Experimental Studies of the Program of Assertive Community Treatment (PACT)
Identifieur interne : 001771 ( Istex/Corpus ); précédent : 001770; suivant : 001772Experimental Studies of the Program of Assertive Community Treatment (PACT)
Auteurs : Andrea C. Herdelin ; Diane L. ScottSource :
- Journal of Disability Policy Studies [ 1044-2073 ] ; 1999-04.
Abstract
The effectiveness of the Program of Assertive Community Treatment (PACT) versus standard inpatient/outpatient treatment was investigated through a meta-analysis. The study included 19 peer-reviewed published articles describing controlled, randomized experiments comparing PACT to standard treatment of individuals with severe mental illness. Treatment was found to have a significant relationship with effectiveness on each of the following six indicators: number of hospital admissions, length of hospital stay, social functioning, symptomatology, patient satisfaction, and cost. The use of PACT was associated with fewer admissions, shorter length of stay, higher social functioning, lower symptomatology, greater patient satisfaction, and lower cost. These findings were challenged, however, by the confounding effect of attrition and the small amount of total variance explained in the effectiveness indicators by the PACT intervention. Future replication studies of PACT using larger sample sizes and standardized measures of benefits and costs appear necessary to justify major shifts in mental health and vocational rehabilitation services and funding policies.
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DOI: 10.1177/104420739901000105
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ISTEX:AAB747D3756B8D3B6F0DF59BA0742ACCCD628727Le document en format XML
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Scott</name><affiliation><mods:affiliation>The Catholic University of America</mods:affiliation></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">ISTEX</idno><idno type="RBID">ISTEX:AAB747D3756B8D3B6F0DF59BA0742ACCCD628727</idno><date when="1999" year="1999">1999</date><idno type="doi">10.1177/104420739901000105</idno><idno type="url">https://api.istex.fr/document/AAB747D3756B8D3B6F0DF59BA0742ACCCD628727/fulltext/pdf</idno><idno type="wicri:Area/Istex/Corpus">001771</idno><idno type="wicri:explorRef" wicri:stream="Istex" wicri:step="Corpus" wicri:corpus="ISTEX">001771</idno></publicationStmt><sourceDesc><biblStruct><analytic><title level="a" type="main" xml:lang="en">Experimental Studies of the Program of Assertive Community Treatment (PACT)</title><author wicri:is="90%"><name sortKey="Herdelin, Andrea C" sort="Herdelin, Andrea C" uniqKey="Herdelin A" first="Andrea C." last="Herdelin">Andrea C. 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Scott</name><affiliation><mods:affiliation>The Catholic University of America</mods:affiliation></affiliation></author></analytic><monogr></monogr><series><title level="j">Journal of Disability Policy Studies</title><idno type="ISSN">1044-2073</idno><idno type="eISSN">1538-4802</idno><imprint><publisher>Sage Publications</publisher><pubPlace>Sage CA: Thousand Oaks, CA</pubPlace><date type="published" when="1999-04">1999-04</date><biblScope unit="volume">10</biblScope><biblScope unit="issue">1</biblScope><biblScope unit="page" from="53">53</biblScope><biblScope unit="page" to="89">89</biblScope></imprint><idno type="ISSN">1044-2073</idno></series><idno type="istex">AAB747D3756B8D3B6F0DF59BA0742ACCCD628727</idno><idno type="DOI">10.1177/104420739901000105</idno><idno type="ArticleID">10.1177_104420739901000105</idno></biblStruct></sourceDesc><seriesStmt><idno type="ISSN">1044-2073</idno></seriesStmt></fileDesc><profileDesc><textClass></textClass><langUsage><language ident="en">en</language></langUsage></profileDesc></teiHeader><front><div type="abstract" xml:lang="en">The effectiveness of the Program of Assertive Community Treatment (PACT) versus standard inpatient/outpatient treatment was investigated through a meta-analysis. The study included 19 peer-reviewed published articles describing controlled, randomized experiments comparing PACT to standard treatment of individuals with severe mental illness. Treatment was found to have a significant relationship with effectiveness on each of the following six indicators: number of hospital admissions, length of hospital stay, social functioning, symptomatology, patient satisfaction, and cost. The use of PACT was associated with fewer admissions, shorter length of stay, higher social functioning, lower symptomatology, greater patient satisfaction, and lower cost. These findings were challenged, however, by the confounding effect of attrition and the small amount of total variance explained in the effectiveness indicators by the PACT intervention. Future replication studies of PACT using larger sample sizes and standardized measures of benefits and costs appear necessary to justify major shifts in mental health and vocational rehabilitation services and funding policies.</div></front></TEI><istex><corpusName>sage</corpusName><author><json:item><name>Andrea C. Herdelin</name><affiliations><json:string>The Catholic University of America</json:string></affiliations></json:item><json:item><name>Diane L. Scott</name><affiliations><json:string>The Catholic University of America</json:string></affiliations></json:item></author><articleId><json:string>10.1177_104420739901000105</json:string></articleId><language><json:string>eng</json:string></language><originalGenre><json:string>research-article</json:string></originalGenre><abstract>The effectiveness of the Program of Assertive Community Treatment (PACT) versus standard inpatient/outpatient treatment was investigated through a meta-analysis. The study included 19 peer-reviewed published articles describing controlled, randomized experiments comparing PACT to standard treatment of individuals with severe mental illness. Treatment was found to have a significant relationship with effectiveness on each of the following six indicators: number of hospital admissions, length of hospital stay, social functioning, symptomatology, patient satisfaction, and cost. The use of PACT was associated with fewer admissions, shorter length of stay, higher social functioning, lower symptomatology, greater patient satisfaction, and lower cost. These findings were challenged, however, by the confounding effect of attrition and the small amount of total variance explained in the effectiveness indicators by the PACT intervention. Future replication studies of PACT using larger sample sizes and standardized measures of benefits and costs appear necessary to justify major shifts in mental health and vocational rehabilitation services and funding policies.</abstract><qualityIndicators><score>7.372</score><pdfVersion>1.4</pdfVersion><pdfPageSize>433 x 675 pts</pdfPageSize><refBibsNative>true</refBibsNative><abstractCharCount>1169</abstractCharCount><pdfWordCount>9226</pdfWordCount><pdfCharCount>55983</pdfCharCount><pdfPageCount>37</pdfPageCount><abstractWordCount>156</abstractWordCount></qualityIndicators><title>Experimental Studies of the Program of Assertive Community Treatment (PACT)</title><refBibs><json:item><host><author></author><title>The PACT model of community-based treatment for persons with severe and persistent mental illnesses: A manual for PACT start -up</title></host></json:item><json:item><author><json:item><name>M. Asberg</name></json:item><json:item><name>S.A. 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Trusty</name></json:item></author><host><volume>154</volume><pages><last>349</last><first>341</first></pages><author></author><title>American Journal of Psychiatry,</title></host><title>Cost-effectiveness evaluation of three approaches to case management for homeless mentally ill clients</title></json:item></refBibs><genre><json:string>research-article</json:string></genre><host><volume>10</volume><publisherId><json:string>DPS</json:string></publisherId><pages><last>89</last><first>53</first></pages><issn><json:string>1044-2073</json:string></issn><issue>1</issue><genre><json:string>journal</json:string></genre><language><json:string>unknown</json:string></language><eissn><json:string>1538-4802</json:string></eissn><title>Journal of Disability Policy Studies</title></host><categories><wos><json:string>social science</json:string><json:string>rehabilitation</json:string></wos><scienceMetrix><json:string>health sciences</json:string><json:string>public health & health services</json:string><json:string>rehabilitation</json:string></scienceMetrix></categories><publicationDate>1999</publicationDate><copyrightDate>1999</copyrightDate><doi><json:string>10.1177/104420739901000105</json:string></doi><id>AAB747D3756B8D3B6F0DF59BA0742ACCCD628727</id><score>0.021709954</score><fulltext><json:item><extension>pdf</extension><original>true</original><mimetype>application/pdf</mimetype><uri>https://api.istex.fr/document/AAB747D3756B8D3B6F0DF59BA0742ACCCD628727/fulltext/pdf</uri></json:item><json:item><extension>zip</extension><original>false</original><mimetype>application/zip</mimetype><uri>https://api.istex.fr/document/AAB747D3756B8D3B6F0DF59BA0742ACCCD628727/fulltext/zip</uri></json:item><istex:fulltextTEI uri="https://api.istex.fr/document/AAB747D3756B8D3B6F0DF59BA0742ACCCD628727/fulltext/tei"><teiHeader><fileDesc><titleStmt><title level="a" type="main" xml:lang="en">Experimental Studies of the Program of Assertive Community Treatment (PACT)</title><title level="a" type="sub" xml:lang="en">A Meta-Analysis</title></titleStmt><publicationStmt><authority>ISTEX</authority><publisher>Sage Publications</publisher><pubPlace>Sage CA: Thousand Oaks, CA</pubPlace><availability><p>SAGE</p></availability><date>1999</date></publicationStmt><sourceDesc><biblStruct type="inbook"><analytic><title level="a" type="main" xml:lang="en">Experimental Studies of the Program of Assertive Community Treatment (PACT)</title><title level="a" type="sub" xml:lang="en">A Meta-Analysis</title><author xml:id="author-1"><persName><forename type="first">Andrea C.</forename><surname>Herdelin</surname></persName><affiliation>The Catholic University of America</affiliation></author><author xml:id="author-2"><persName><forename type="first">Diane L.</forename><surname>Scott</surname></persName><affiliation>The Catholic University of America</affiliation></author></analytic><monogr><title level="j">Journal of Disability Policy Studies</title><idno type="pISSN">1044-2073</idno><idno type="eISSN">1538-4802</idno><imprint><publisher>Sage Publications</publisher><pubPlace>Sage CA: Thousand Oaks, CA</pubPlace><date type="published" when="1999-04"></date><biblScope unit="volume">10</biblScope><biblScope unit="issue">1</biblScope><biblScope unit="page" from="53">53</biblScope><biblScope unit="page" to="89">89</biblScope></imprint></monogr><idno type="istex">AAB747D3756B8D3B6F0DF59BA0742ACCCD628727</idno><idno type="DOI">10.1177/104420739901000105</idno><idno type="ArticleID">10.1177_104420739901000105</idno></biblStruct></sourceDesc></fileDesc><profileDesc><creation><date>1999</date></creation><langUsage><language ident="en">en</language></langUsage><abstract xml:lang="en"><p>The effectiveness of the Program of Assertive Community Treatment (PACT) versus standard inpatient/outpatient treatment was investigated through a meta-analysis. The study included 19 peer-reviewed published articles describing controlled, randomized experiments comparing PACT to standard treatment of individuals with severe mental illness. Treatment was found to have a significant relationship with effectiveness on each of the following six indicators: number of hospital admissions, length of hospital stay, social functioning, symptomatology, patient satisfaction, and cost. The use of PACT was associated with fewer admissions, shorter length of stay, higher social functioning, lower symptomatology, greater patient satisfaction, and lower cost. These findings were challenged, however, by the confounding effect of attrition and the small amount of total variance explained in the effectiveness indicators by the PACT intervention. Future replication studies of PACT using larger sample sizes and standardized measures of benefits and costs appear necessary to justify major shifts in mental health and vocational rehabilitation services and funding policies.</p></abstract></profileDesc><revisionDesc><change when="1999-04">Published</change></revisionDesc></teiHeader></istex:fulltextTEI><json:item><extension>txt</extension><original>false</original><mimetype>text/plain</mimetype><uri>https://api.istex.fr/document/AAB747D3756B8D3B6F0DF59BA0742ACCCD628727/fulltext/txt</uri></json:item></fulltext><metadata><istex:metadataXml wicri:clean="corpus sage not found" wicri:toSee="no header"><istex:xmlDeclaration>version="1.0" encoding="UTF-8"</istex:xmlDeclaration><istex:docType PUBLIC="-//NLM//DTD Journal Publishing DTD v2.3 20070202//EN" URI="journalpublishing.dtd" name="istex:docType"></istex:docType><istex:document><article article-type="research-article" dtd-version="2.3" xml:lang="EN"><front><journal-meta><journal-id journal-id-type="hwp">spdps</journal-id><journal-id journal-id-type="publisher-id">DPS</journal-id><journal-title>Journal of Disability Policy Studies</journal-title><issn pub-type="ppub">1044-2073</issn><publisher><publisher-name>Sage Publications</publisher-name><publisher-loc>Sage CA: Thousand Oaks, CA</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="doi">10.1177/104420739901000105</article-id><article-id pub-id-type="publisher-id">10.1177_104420739901000105</article-id><article-categories><subj-group subj-group-type="heading"><subject>Articles</subject></subj-group></article-categories><title-group><article-title>Experimental Studies of the Program of Assertive Community Treatment (PACT)</article-title><subtitle>A Meta-Analysis</subtitle></title-group><contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Herdelin</surname><given-names>Andrea C.</given-names></name><aff>The Catholic University of America</aff></contrib></contrib-group><contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Scott</surname><given-names>Diane L.</given-names></name><aff>The Catholic University of America</aff></contrib></contrib-group><pub-date pub-type="ppub"><month>4</month><year>1999</year></pub-date><volume>10</volume><issue>1</issue><fpage>53</fpage><lpage>89</lpage><abstract><p>The effectiveness of the Program of Assertive Community Treatment (PACT) versus standard inpatient/outpatient treatment was investigated through a meta-analysis. The study included 19 peer-reviewed published articles describing controlled, randomized experiments comparing PACT to standard treatment of individuals with severe mental illness. Treatment was found to have a significant relationship with effectiveness on each of the following six indicators: number of hospital admissions, length of hospital stay, social functioning, symptomatology, patient satisfaction, and cost. The use of PACT was associated with fewer admissions, shorter length of stay, higher social functioning, lower symptomatology, greater patient satisfaction, and lower cost. These findings were challenged, however, by the confounding effect of attrition and the small amount of total variance explained in the effectiveness indicators by the PACT intervention. Future replication studies of PACT using larger sample sizes and standardized measures of benefits and costs appear necessary to justify major shifts in mental health and vocational rehabilitation services and funding policies.</p></abstract><custom-meta-wrap><custom-meta xlink:type="simple"><meta-name>sagemeta-type</meta-name><meta-value>Journal Article</meta-value></custom-meta><custom-meta xlink:type="simple"><meta-name>search-text</meta-name><meta-value>53 Experimental Studies of the Program of Assertive Community Treatment (PACT)A Meta-Analysis SAGE Publications, Inc.1999DOI: 10.1177/104420739901000105 Andrea C. Herdelin The Catholic University of America Diane L. Scott The Catholic University of America The effectiveness of the Program of Assertive Community Treatment (PACT) versus standard inpatient/outpatient treatment was investigated through a meta-analysis. The study included 19 peer-reviewed published articles describing controlled, randomized experiments comparing PACT to standard treatment of individuals with severe mental illness. Treatment was found to have a significant relationship with effectiveness on each of the following six indicators: number of hospital admissions, length of hospital stay, social functioning, symptomatology, patient satisfaction, and cost. The use of PACT was associated with fewer admissions, shorter length of stay, higher social functioning, lower symptomatology, greater patient satisfaction, and lower cost. These findings were challenged, however, by the confounding effect of attrition and the small amount of total variance explained in the effectiveness indicators by the PACT intervention. Future replication studies of PACT using larger sample sizes and standardized measures of benefits and costs appear necessary to justify major shifts in mental health and vocational rehabilitation services and funding policies. ABSTRACT A meta-analysis was conducted on experimental studies comparing standard treatment (inpatient and outpatient) and assertive community treatment for individuals with severe mental illness. Given the current emphasis by the National Alliance for the Mentally III (NAMI) Campaign to End Discrimination on widespread dissemination and implementation of the Program of Assertive Community Treatment (PACT) model (Allness & Knoedler, 1998), 54 the results of this meta-analysis are timely and may temper the expansive thrust of PACT model implementation in favor of further replications of the model with larger samples and standardized measures of benefits and costs. The authors' intention with this study is to give an objective overview of and direction for ongoing U.S. policy and funding discussions regarding the treatment of severe mental illness. Since the 1950s, major changes have occurred in the treatment of people with mental illness, with the most profound change being the locus of care. Several factors converged over the last few decades to make deinstitutionalization, rather than institutionalization, the norm: 1. Responding to criticism concerning the practice of institutionalizing persons with severe mental illness, Congress established the Joint Commission on Mental Illness and Health in 1955 to study and make recommendations regarding the treatment of this population. 2. Costs of treating patients in institutions had risen dramatically; thus, governmental agencies became more open to finding less costly methods of treatment. 3. Policy changes by the U.S. Department of Health, Education, and Welfare allowed patients to live more easily in the community, rather than solely in institutions. 4. In legislatures and courts, advocates advanced civil rights claims for treatment in the least restrictive environments. 5. New pharmacotherapies were discovered, and use of new drugs, in conjunction with outpatient care, began to be considered as effective methods of treating patients in their homes and communities. 6. In 1963, the Mental Retardation Facilities and Community Mental Health Centers Act was passed (Braun et al., 1981; Marx, Test, & Stein, 1973; Segal, 1995). Regardless of the advances in care (drug therapy, treatment in communities), some major problems have been associated with deinstitutionalization. One problem has been the "revolving door" phenomenon: Patients living in the community often stop taking medications. As a result, the symptoms of mental illness increase and readmission for psychiatric inpatient treatment frequently takes place. This phenomenon happens for several reasons: Persons with severe mental illness often lack the requisite skills and abilities needed to live independently or semi-independently; they rely heavily on emotional, financial, and daily living skills support from family and institutions; and they tend to develop psychiatric symptoms when under stress (Marx et al., 1973; Test, 1992). Additionally, according to Test, "in many cases there [has been] an 55 underestimation and/or misconceptualization of how much and what kinds of help persons with serious mental illnesses need. An even greater problem [has been] that existing services often were not reaching our patients" (p. 154). PACT was designed as an innovative treatment model for counteracting the negative effects of deinstitutionalization while still helping patients live within their communities (Allness & Knoedler, 1998; Test, 1992). Although many factors are now common in community-based mental health treatment programs, several key factors differentiated this treatment from other types: 1. All treatment (e.g., medication, psychotherapy, life skills and social skills training, employment rehabilitation, family psychoeducation, brief hospitalization when needed) is provided by an interdisciplinary team. 2. Treatment is provided in the community and/or home of the patient. 3. Providers exhibit a positive, "can do" attitude toward patients (Allness & Knoedler, 1998, p. 3)-that is, the team makes every effort to help change the environment and to provide any services needed for clients to remain in the community. 4. Treatment and follow-up care are initiated by staff members rather than provided only at the request of the patient. 5. The treatment team is available to the patients 24 hours per day, 7 days per week. These unique features allow for individualized and flexible treatment of patients (Allness & Knoedler, 1998; Test, 1992). PACT has been studied and used extensively in Madison, Wisconsin, and the surrounding Dane County (Marx et al., 1973; Stein & Test, 1980; Test, 1992; Test & Stein, 1980; Weisbrod, 1981; Weisbrod, Test, & Stein, 1980). Originally called Training in Community Living (TCL), this treatment model has been disseminated and adapted for use in many states across the country. As of 1995, 340 assertive community treatment programs existed in 34 states (Deci, Santos, Hiott, Schoenwald, & Dias, 1995). These researchers found variations in the application of the original model. For example, only 71 % of the programs responding to their survey reported that they had 24-hour availability. Studies of variations on the PACT model have been conducted in Chicago (Bond et al., 1990; Witheridge & Dincin, 1985); Kent County, Michigan (Mul- der, 1982); Indiana (Bond, Miller, Krumwied, & Ward, 1988); San Jose, California (Jerrell & Hu, 1989); and St. Louis, Missouri (Morse, Calsyn, Allen, Tempelhoff, & Smith, 1992; Wolff et al., 1997). The model has also been adapted for use and studied in Australia (Hoult, 1986; Hoult, Reynolds, Charbonneau-Powis, Weekes, & Briggs, 1983; Hoult, Rosen, & Reynolds, 1984); 56 the United Kingdom (Knapp et al., 1994; Marks et al., 1994; Muijen, Marks, Connolly, Audini, & McNamee, 1992); and Canada (Lafave, de Souza, & Gerber, 1996). At least two research reviews of PACT have been conducted (Olfson, 1990; Taube, Morlock, Burns, & Santos, 1990). Although these reviews provided useful qualitative reviews of the different aspects of programs employing the PACT model, they were not meta-analyses and thus did not provide quantitative findings regarding the efficacy of PACT versus more standard treatments. The purpose of the research reported here was to analyze the existing research on PACT versus standard mental health treatment to determine if significant effects resulted from PACT interventions. Method Procedure We employed methods discussed by H. M. Cooper (1989) to conduct the meta-analysis. First, we undertook a comprehensive review of the literature through psychology, psychiatry, and social science electronic databases; journal indexes; author and key word searches; ancestral searches; and professional consultation. We found approximately 220 publications regarding community-based mental health treatment. In the majority of these cases, we obtained books or reproductions of articles in order to review entire published studies. Of these, there were approximately 50 empirical articles regarding PACT and PACT-like programs. From this review, we hypothesized that-for several measures-PACT and PACT-like programs would be found to be more effective than more traditional inpatient and/or outpatient treatments. During this process, we created, pre- tested, refined, and computerized a code sheet for use with the studies that contained relevant data (e.g., threats to validity, test statistics, alpha, power, sample size, attrition, design, and details of intervention). Two articles were coded together, then each author coded one article independently and compared the results for consistency in interpreting the reported study data. We then coded the articles, including all operational measures, before determining which measures of effectiveness would be analyzed in this study. Articles' utility was evaluated by creating a list of criteria for inclusion: ~ Utilization of a controlled, randomized experimental design, ~ Utilization of samples composed of patients diagnosed with a wide range of severe mental illnesses rather than just a single diagnosis, 57 ~ Comparison of traditional inpatient/outpatient treatment with treatment modeled on TCL, PACT, or PACT-like programs, ~ Publication in a peer-reviewed journal. Inclusion of only those studies meeting these requirements was done to increase the validity of the meta-analysis findings (Wolf, 1986). This narrowing of the criteria for inclusion yielded 19 studies. Those studies that were published in more than one journal but included the same sample and reported on the experiment were treated as one study and are so noted in the tables included in this article. We also excluded one article that reported on the continued effects of PACT-like treatment after treatment withdrawal. The coding process allowed us to identify the operational measures most commonly used by researchers evaluating the effectiveness of PACT programs in comparison with inpatient treatment. We relied on the researchers' labeling of each study's treatment modality to determine if the study replicated PACT interventions; as with the other measures, there was inconsistency in reporting what actual treatment occurred. Some articles were quite descriptive about treatment staff, methods, and interventions used in their PACT model, whereas others were vague. Likewise, we did not evaluate the conceptual validity of each study's use of a particular outcome measure but instead looked for outcome measures that were found across studies. This variability across the studies is a primary reason for our selection and use of meta-analysis and its incumbent objectivity to evaluate the existing research on PACT programs. The outcome measures employed in the 19 studies varied considerably (and are discussed later in this article) but are reflective of changes in the mental health treatment environment over the years. The measures used were consistent with arguments favoring the deinstitutionalization of persons with mental illness: using fewer inpatient resources to reduce or control costs, increasing patient autonomy, and integrating patient care into communities. After coding, we identified the following operational measures of effectiveness : the number and length of psychiatric inpatient admissions, social functioning, symptomatology, patient satisfaction, and cost. Although 9 of the 19 studies contained a cost measure, only 6 included cost data that could be used for calculation in the meta-analysis. Nevertheless, we determined that cost would remain an outcome measure in this study because cost-effectiveness is a frequent component of current policy discussions regarding the provision of mental health services. A few studies included measures for family burden or relative satisfaction. Because of the minuscule sample sizes associated with such measures, the non- random assignment of participants, and the researchers' apparent inability to 58 contact relatives outside their study locales, we could not trust that such measures would not result in biased findings. Measures dealing with patient participation in mental health and other services, medication compliance, frequency of suicidal gestures, and rates of involvement in the criminal justice system were also not included in this meta-analysis. These measures occurred in only a few studies. We also excluded studies that addressed only a specific mental illness or diagnosis, such as schizophrenia (e.g., Hoult & Reynolds, 1984). Because there were a sufficient number of studies that included a broader range of diagnoses, we believed that such studies could be more easily compared and would result in more generalizable findings. Data Analysis For each of the six operational measures of effectiveness in this meta-analysis (see Tables 1-6 for information summaries), we used test statistics or data reported in the articles to infer or calculate statistical measures. For the studies that included multiple sites, if data were presented in the aggregate for community-based or hospital-based treatment, they were used; otherwise, we collapsed the data for inclusion in the meta-analysis. From the calculated statistic, we determined the probability level, and from this probability level we determined the z score. Once the z score and statistic were determined, the effect size (r) was calculated using formulae presented by H. M. Cooper (1989). The use of standardized measures such as z scores and effect sizes allowed for comparison of different statistical measures. These measures reflect the attrited z score and effect sizes because each measure was calculated with the actual, rather than original, sample size. After calculating the effect size, if the test statistic was a t or F statistic, we converted it into either a Cohen's d or f effect size in order to use it in the computer package GPOWER (Erdfelder & Buchner, 1996). If the test statistic was a chi-square, we assumed r to be equal to w, the effect size measure associated with a chi-square used by this program (H. M. Cooper, 1989). In order to conduct a post hoc power analysis for each statistical test, we input into GPOWER the effect size, sample size, and probability level associated with the statistical test. We often found that the data needed to compute statistics or to determine z scores were not reported. In these cases, if a probability level or the degrees of freedom were reported, then the statistics were inferred from those, effect sizes were calculated, z was inferred, and a post hoc power analysis was performed. For those measures that were reported as not significant but that lacked corre- 59 sponding data, we inferred the probability level to be .5, the effect size to be 0, the z score to be 0, and power to be .5. In some other studies, as previously noted, researchers failed to report an overall score but sometimes included items from the scales with their corresponding levels of significance. Still other studies used multiple indicators to operationalize a measure. For these measures, the overall z, mean effect size, and mean power were calculated. In order to calculate the overall z, we used the Stouffer Combined Test/Adding zs formula (H. M. Cooper, 1989; Wolf, 1986). In this formula, the sum of the corresponding z scores is calculated and then divided by the square root of the number of tests being combined. Similarly, the mean r and mean power were calculated after each r was calculated and each power analysis was carried out. Finally, we found the overall alpha by using the overall z to find the corresponding alpha in the z table. For each outcome measure represented in Tables 1 through 6, we have provided a combined z score, overall alpha, mean r, and mean power, as well as the values for each individual statistical test. Table 7 contains the results of the meta-analysis, including the six operational measures of effectiveness that occurred within the studies examined. Results and Discussion Characteristics of Primary Research Studies The 19 studies included in the meta-analysis ranged from the original 1973 study by Marx et al. to a 1997 study by Wolff et al. that compared three community-based programs (two PACT-like programs and a traditional outpatient psychiatric program). The studies we found that fell into this nearly 25-year span included studies of programs in the United States, Canada, Australia, and Great Britain. The period of time encompassed in the individual studies ranged from 3 months (Merson et al., 1992) to 24 months (Jerrell & Hu, 1989; Quinlivan et al., 1995; Rosenheck, Neale, Leaf, Milstein, & Frisman, 1995). Sample size ranged from a high of 873 (Rosenheck et al., 1995) to a low of 35 (Jerrell & Hu, 1989) and predominantly included the following demographics: - patients ages 18 to 65, . patients of both genders, . racial and ethnic diversity representative of the community from which the sample was drawn, and . covered all psychiatric diagnoses with the exception of organic brain syndrome, mental retardation, and a primary diagnosis of substance addiction. 60 Two studies reflected specific population groups-homeless persons (Wolff et al., 1997) and veterans (Rosenheck et al., 1995)-and multiple treatment sites. Outcome Measures Hospital Admissions. Ten of the 19 studies included a measure for the number of hospital admissions (see Table 1). The analysis of these 10 studies found that type of treatment was significantly related to the number of hospital admissions (z = 5.7902, r = .2846, p = .0000, r2 =.08 1). The total amount of variance in the number of hospital admissions explained by the PACT treatment was 8.1 %. The amount of variance explained in the studies ranged from a high of 61.4% in the earliest study (Stein, Test, & Marx, 1975) to between 5% and 6% in the Bond et al. ( 1988) and Marks et al. (1994) studies. Patients who received community treatment were more likely to avoid hospitalization than those receiving traditional aftercare following hospitalization. Although this measure seems straightforward and was based on data from hospital records, data on admissions were reported in various ways. Some studies reported percentages of patients admitted in different time periods; others reported the percentage of patients admitted over the length of the study or the percentage changes in numbers of patients admitted over time. Few researchers reported their own calculated statistics. In some of the studies, researchers noted the number and length of admissions together, a practice that often obscured the data. We thus found it difficult to determine whether the reported data were based on repeated admissions or on numbers of single patients admitted. Length of Hospital Stay. Fourteen of the studies included a measure of length of hospital stay (see Table 2). There was a significant relationship between length of hospital admission and type of treatment (z = 8.03, r = .2877, p = .0000, r' = .083). Patients receiving assertive community treatment tended to have fewer inpatient days than those in standard treatment. The earliest study, Marx et al. (1973), explained the highest amount of variance ( 100%) in length of hospital stay. This may reflect the innovativeness of the PACT treatment model compared to traditional inpatient hospitalization. Overall, however, length of hospital stay explained only 8.3% of the variance. As with number of hospitalizations, at times we had difficulty in extracting the information necessary for analysis because of the ways these data were reported. Social Functioning. Social functioning (see Table 3), a measure of effectiveness included in 11 of the studies, was operationalized in various ways. Researchers often combined a number of different operational measures of this 61 V) z 0 (7 4 2 0 -< .....J H a. 0 ill w - C) P4 C4 ~ w d w 12 z a4 0 w (A ç..¡.:¡ :5~ 0 U E-< 0 E-< U c~<. 62 % d .~ t c '-' d 9 "'0 c: I.,¡.., 0 ~ s - N'~M— fl i# % ') W WI_ ~~5 o :>.£ c:"'2 .c: V ~ ~s -c ~ c L c '"3=~t: w<_ x v > '- C c ^ c ~ c u ~ -S~E c '" 0 ¡.¡.:: <0:: u 0 I ~ '£ '£ N C ~/j c.> ji o 8 ~ :, ~ ~ '~.. L ~ E ~ ~ .... 0'- '" o...u"'''' ¡.¡.:: E I.,¡.., 0 õ.. v <0:: II W v; c N Ul s ~CQ ° © C [j.! rJ; £i ~ i V v '_' v. ~-- v: ~ C ~c_ l- s S '*- 'G M -5I-Ol,ro ~ vV, 4~ C N t ..g ~.;: E c~s'5~ e-~ti5..[ .. I- L ~ 0 >< " ", E ~T 5E C:bb~~5 h~~~c i~ II _tG t0 ~ CC 4! 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V C > C §rfijc ~ ~ & ~~i'~i flt g 0-0 -c - Ov m ,r0 > U C y u C bA cc ~.v.. ~= '.5p '~ 8 (U C M — fl% © - w m.- ~ S~3 E~j ~i~ji'2 § .E £h ei- #cgl§~-3£ iN , E 88_C ~ '~-c—~o'~~ e58~~ 5 t:'~— ~t — M m-~ 0~-~SSS'~"~ C © - x £1%_ ~ ~. o o N ~ ~ ~· 3~ c0 - ~ #~ l Efl 9* g S 8'~~-s" g ~ g E ~ o ~ o a,~ .5P o h ©18 E #(j § % a.o~·r ° f yB I " u cz ~ ^s.`n. ~ `c~ v O ' ~ `^ V 'C buov--U~3vp~^ * ~ - O 5 > © O'r ~ E g ~g z *.I% Ez ~ )Q+ Ei 16 #£ §( & .-. i· cG ~ y ~ ~ C )t£ m2 E£_* g 1 U ~ E 8'r~p£.£ !~ C4,~'~_c~a~y~,cd mv= C, ~iE s i8 § § C V bf~ U y ~ fX lu - @ 8 5 )5_#§ 5_fi£ W o- R1Q 1.r m , ~ ij 00 zg~ , ji§§I j #( I# l~ 4~ ~ m v7 ~ U i.~" ~A 4J ili #'&< §§ ~§Q# gU r,4 C)V o~—'£ z O &$f 5 z-I <~> M.i2 oc~v ~ en~ 65 C z 5 0 p u Z ~ w ~ < m[ w O ~C/) ~o <~ w O u ~ :::J o H U 66 ;i c M 0> 9 67 z z E: I r<) d 9 d; 0 ~ - r::: .-;: = ~ >---' J3 c b~!~ ~~~ ~ ''8 (1: ~ I- 'i:i >-- 8 (J).~,s:, c >--:.õ (1: v õ- ~ E I- VE ~i i!-!~i~!j-! -~ ~ -~ E~ & ~'1 §lj ioJ >£t ~~ ~p~~<~~ 1"" ~9'õ~~~v~}¿ 'S5 ~.~~~j]~ ,©© u E /5£ Ë #I§e%§y@) ~,~ '5".~..s t;.2 ~.É ~ :: ~ :~~~-!~ !j :.n ~ 't -5 ~ 'õ ~ c ~ J3 E kf 1L2'l£°$j££E ii 9£tBr,1;8 ~~ #I"~#~§£~£ '~Z ,gj°jt*ft'g =~ 'S~'S.~~S ~~ -~'C *-' t 17 #'l~'~ j ~ E ©E i# t #tji12%-%"~f_i.£ )(£~ll.##j(_§§ II 00 0c) 5~-~ 00 r<~3~ '+' ~C CC !j\~-< ~~ ~ S'S'~ 0 ES il<[9§4~~l.j%* II t;.u E ~. i cn U cc U Z 'i:i 0 'i:i E' ¡: ...8 0(5 0 0.. v I- r:::r.t"JvVCo;! ~""'EV::3 ~~.syt:8~..¿Eo~E ~s~~~!~~ h~lik~§f,#j_#I*)I£ to 68 concept. Several researchers operationalized this concept with scales they had created themselves, existing scales they had adapted, single items from scales, or commonsense measures such as amount of alcohol consumed per week (Bond et al., 1990; Bond et al., 1988; Lafave et a]., 1996; Marx et al., 1973; Merson et al., 1992; Morse et al., 1992; Stein & Test, 1980; Stein, Test, & Marx, 1975; Wolff et al., 1997). Some researchers used published scales or instruments, such as Jerrell and Hu (1989), who used the Social Adjustment Scale (Schooler, Weismman, & Hogarty, 1977), Role Functioning Scale (Green & Gracely, 1987), and the Quality of Life Scale (Test & Stein, 1978); and Lafave et al. (1996) who used the Environmental Index (Wing & Brown, 1970) and the Quality of Life Interview (Lehman, 1988) in addition to their own measure. Unfortunately, most researchers did not discuss the validity and reliability of the measures they used. A significant relationship was found between type of treatment and social functioning (z = 5.63, r = .1296, p = .0000, r' = .017). Patients who received assertive community treatment had higher levels of social functioning than patients in more standard treatment. The amount of variance in social functioning explained was highest (8.7%) in the Lafave et al. (1996) study, but overall was only 1.7% for all the studies combined. Symptomatology. Symptomatology (see Table 4) was also operationalized in various ways by the different researchers. Very few researchers reported the validity and reliability measures associated with the instruments they used. Several studies included multiple measures. Marx et al. (1973) used the Short Clinical Rating Scale (French & Heninger, 1970), the Lorr Inpatient Multidimensional Psychiatric Scale (IMPS; Lorr & Klett, 1966), the MACC II Behavioral Adjustment Scale (Elsworth, 1962), the Adjective Check List (Gough & Heilbrun, 1965), parts of the KATZ Adjustment Scale (Katz & Lyerly, 1963), and the Rosenburg Self-Esteem Inventory (Rosenburg, 1965). Stein and Test (1980) used two measures, the Short Clinical Rating Scale and the Rosenburg Self-Esteem Inventory. Hoult et al. (1983) used the Present State Examination (Wing, Cooper, & Sartorius, 1974), the Health Sickness Rating Scale (Luborsky, 1962), and the Brief Psychiatric Rating Scale (Overall & Gorham, 1962). Merson et al. (1992) used the Comprehensive Psychopathological Rating Scale (Asberg, Montgomery, Perris, Schalling, & Sedvall, 1978), the Montgomery and Asberg Depression Rating Scale (Montgomery & Asberg, 1979), and the Brief Scale for Anxiety (Tyrer, Owen, & Cicchetti, 1984). Morse et al. (1992) used the Brief Symptom Inventory (Derogatis & Spencer, 1982), the short form of the Rosenburg Self-Esteem Inventory (Rosenberg, 1979), and an alienation scale for homeless persons (Bahr & Caplow, 1973). Marks et al. (1994) used the Global Assessment Score (Endicott, Spitzer, Fleiss, & Cohen, 1976), the Brief Psychiatric Rating Scale, and the Present State Examination (J. E. Cooper et al., 1972; Wing, Cooper, & Sartorius, 1974; Wing & Sturt, 1978). 69 n u s 8 ~E C F- C" ~ ~ az $ 0 W 1;~ 0 U 6 0 P 5 g 70 fii § . c gg "'t' W 15 9 71 ;i 'a 3 v h E E~ m —§" II ~ a~ a~ p . ~ SSc~~-S~ 8 -8x'igZi o O~N"wflz p ' >`, w p , ~ v~ p. oJ) s.°.. tJJO<1JtJJ"""Of) tJJ~ :1..,`~'_' bA c~ s~ ~: ~ w O C f- w C ~ a.r .~"S~~~~cc~ .s~..Troyf3. o..~ ~~---=- 8 8-5 ~ ~~~~~~~~~ ~ ~ ~= ~ 00 '~ C '? ~ ~5~~9:8..~tJJ5 >.~ ~"9'--' 8'" 8 8 "9 't 0 --5.:: o..gj ~ ~ ~.L:)7n.5~~"2 ~s m-I~/~aBZ&£ jfl§~fdi$I"» .~~~ ~ ~ 8.. = ~.L:);: ~ 'õ.g 8 '~%dz£'££%I ......'- 1-0 ~...... ° 8.- 0.. 0..-5 <1J ¡:: 't 8.. 8 ~ ~p*"2~E~ci.SM w-R1Q v% y ° 4~ ~ vi ~fi&.jggw~~g ,~(~ cC ~ ~. p .""04-v:""ON08~ ......tJJtJJ~....L:)I-o_U8 1-0 <1J 0 :> tJJ tJJ <1J ~ c -r- &.-5 8 .Ç ~ ~ 6 g.~] ~~~:Dt>-<1J""O<1JO;:) t:: ~ 5"'3 'õ "2 ~ 8 ~ ~ bb ~~2~.~t:~~ê1~ rg*°'5lmW<#y% Q" ~ ~ cc O sy.. cc .cn u yV.. iZ. ~ v -~j ~ Q o a~ c 5" 8 t: 0 ~ ~ T3] ~ 8 .S o ""0 ¡:: e-...... tJJ.- 1-0 ~ s'c - ~ 0 0 <1J >-.- <1J ê""2 >< '~c~?c-c:3=~oE'~ 5~~-35~S2:-5g~ )#hE£G)X4£fi .r;o«<°«uz"g ~ tJJ r ¡: g ~ EJ ~ ¡: 0 ,;- II .~ g ô.¡:.e:- -;; ~ E ":Í :: ~s~ ~~~ ~ E ;:) i:î.~ 0 ~.- 0 51 8 ~ .- '--' 9: <1J tJJ ...... ~ 0.. 0 0 8 bb~""O o ""0 ~ 04- = 8 ¡: <1J::s! tJJ.~ ~ ""0 ~.........c:: ~ u O ~ Wn O ^ C ~ ~ C S ~ ~ ? .S 'c t:: 0.. t:: U 3 E .:: ::J ~.~.:: ~ ~ .s u ..... ~ E'is'3~~~ ~E ~ `n ~ ~ ~ W O~ ~ u ~ C a~ ~ vi ~, ° ar ~ ~ E a~ w ,.., ~.' a~ ~S~~E~~M-~S~ ~ ~-2~—'o~t!~'~'e zi#£ikZ(£'I# z~n~~i~,~~-p~'in~ v-£"tfE£y0'E %1%lR_l_©18## .- ~ .- - tJJ ""0 ""0 1-0 ~ tJJ <1J ~'5i ~'s ~~ ,tJJ>-~~I-oI-o<1Jo..~..... ~_£,o~.-oo%5-q~ I#i#1##Jl1?1 72 Several researchers used only one measure of symptomatology. Stein et al. (1975) used the Short Clinical Rating Scale. Jerrell and Hu ( 1989), Lafave et al. (1996), and Wolff et al. (1997) used the Brief Psychiatric Rating Scale (Derogatis & Spencer, 1982; Lukoff, Liberman, & Nuetchterlein, 1986; Overall & Gorham, 1962). Bond et al. (1990) used the Global Assessment Scale. A significant relationship was found between type of treatment and symptomatology (z = 3.95, r = .1023, p = .0000, r2 = .011). Patients receiving assertive community treatment had lower levels of symptomatology than patients in more standard treatment. The total amount of variance in symptomatology explained was only 1.1 %. Patient Satisfaction. Patient satisfaction with services was examined in 8 of the 19 studies (see Table 5). The level of patient satisfaction was measured with standardized instruments and author-created scales. Four studies used clearly identified but different standardized instruments ( Jerrell & Hu, 1989; Lafave et al., 1996; Merson et al., 1992; Morse et al., 1992; Wolff et al., 1997). One of these studies ( Jerrell & Hu) reported only selected items from the standardized scale. Another (Hoult et al., 1983) used selected items from an unidentified scale, and two studies (Bond et al., 1990; Marks et al., 1994) used author-created scales or those assembled from other instruments. The meta-analysis revealed a significant relationship between patient satisfaction and type of treatment (z = 6.7857, r = .3115, p = .0000, r' = .097). Patients receiving assertive community treatment were more satisfied with their treatment than those patients receiving more standard treatment. The amount of variance in patient satisfaction ranged from 3.7% (Jerrell & Hu, 1989) to 27.1% (Marks et al., 1994). Overall, the eight studies explained 9.7% of the variance in patient satisfaction with services. Cost. The final measure of effectiveness included in this meta-analysis was cost (see Table 6). Of the 19 studies, 9 included data on the costs associated with community-based or hospital-based treatment, but only 6 studies were usable. The three studies that did not report enough data to calculate differences between the groups reported only the average costs per group. These costs appeared to be quite similar (Bond et al., 1988; Hoult et al., 1983; Muijen et al., 1992 ) . In three studies, there was no significant difference between the groups on the cost measure (Jerrell & Hu, 1989; Quinlivan et al., 1995; Wolff et al., 1997). One of the three studies that reported significant results noted a significance level of .084 rather than .05, the common cutoff of significance for social science research (Weisbrod et al., 1980). The second study, carried out in Great Britain, found that the PACT-like program was less costly (Knapp et al., 1994). Finally, the study by Rosenheck et al. (1995) revealed a significant difference 73 c./) M u ~ w Cf) x ~ ? z o 5 u 2i: w ~ p ~<1:: ""':¡Cf) iif£ 8.,E..E(1: '3E'' "'" 0 I- v u~ 0 "'0 g: .¿ ~ ~ ~ g: 3~ ~ S "- ~ ~ (1: 'f: v .; v .ê" U v g S ~ ~ 0 S ~ E ~ II ~ o I-~ °<.t:-o..2 ~~ 0 E . fJ') '- '" ~ U is i ~j l i.£ fC . .~ U ~; U ~ y ^~~- 4J ~ p 'y. cC '~ l3 ~"B ~ .ê -;; ~ ~ ~ ~ s < " M _ .;: ~- U C -~ .= C/) "- V "'0 ,- `i' 3 ~"'~5o $O w U 'G v C ~ V; 4J <- '~ 'r' *- z ~ZCF, 2 ~ °:lELy '~ °' 0 C ö g u 0\ ,#5tg~§ 2-° '~~'0~'*- 'Z ~ ~ 0.. E I- '" cj >..~c~n~3·U £flj~ a..~ y v, #'3 -ij0(¡ E "S ~ >. 2~ _, ~~ 5E~-E~ li I>h§t ~~ "'0 -: Q E ~ 1( N ~ ~ ~ `n gS ...c: "~ ~ 8 t C:biJ %jt°; I ~ s~ ~~ :::: ....... (1: (1:..... -;; :i c 2££O)g~ ~o o c e ~ ~ ~.U .5 0 ~~ 00 "'0 "'0 (1: "'0 =- ~ ~ M ~ " ë ~ ';; .2 ¡,.¡.¡ ~~ E5 O ~C s~. ); N ~ O ~j >-::: ~ 0 S~ ~~~5~ I,# £ E © 8~ I.=: ~ 0 ~ u ~ Mg j~ § #.§ 8 r" E V V ,- U ~J g~S~-s e~ «mU7v &b ~ XU750= — ~ v !! ~ So >- E ..... ë. '" B %v 'r 0 ~ u~ © . z 9 U ,~ ..... ~. CXi~§~ 80~~~ ~~ flUJ.%~~ -~ ~~c5M II .it ~ 0 g;-< E'-, i!H~H v 0\ (1: OUV(1: <2~->-u"'o..u ~~ -~3~*;~~ ~£.8~",C:ëC: ~~ ~.5 0(¡4- 0 '5 V 0 u5' E'~ V 'Z iliiij§§ ~ o ~ O(¡ p::: V ~..2 (1: I- 'S (1: b V ~ 0.. 75 ~ m M j c~ M d. t- ,8 -8 t-D ~ ~z ~¡2 ~ 0 ~ ~ O H s! 76 ~i 'c I: C, \0 -~4 .. , E 9 0% ~~.s ce r ~"-~ ~ E i££.z$% b (£ I Ej.= j j-f~# I © ~ ~"'Oc.n<1.)"'CU f qr_- > g% ~ g w z 'm w w gS §E §z& _= ~< ~g W 0 i,j z [[z'i . £ E"=Qj2 « % , W% C XG 8 ji "%'I z < x ." j Q g C '*z ~z o , Q E .- fl . ~£Q £ M c ~ ~i~~~~~~ ~t~EE~cg ~ ~ .~"2 ~ ê '~ ~ ~-c ~~~ ~ E-S C C E fgg 'c'i ~~c-5~~'-'" j §Q f§ ££ § IL .E~'C~~E~S ~~-~ ~E g~-~ _ §##'l h #')I -G Ws I > siv I C< 0z ;- ~! ' ' 21&yI E ~~OE~-E~S ~~C'-.SnC~'J ~Ec-ME~ ~~~.3_~ ~ , z z )I'£ )1 §( 2 § 5> E 5~c~§~~~~ E C,t ~ !!-~~-5§ -~~ ~~ 4 §- ~~.2 v# jje iz'4 x 1-""" (J):: ~.c~o~cE.~n. 0..V) U N 8. 0 o..'~ I- £ W% w' 0Xr @g §j f i% 1 8 j§ S~SO.!E~~ ##'fil 11 1$I 00 o~~E-'¿EE: il.'au.-Evo -0"0bo ~-§Sj~~!'s ~~~0~ ~ 1"'- t': C""" '" ~Og~oS~S~g +« & tl I* E-g " ~r_rxs§g'? ~~ g~~~-2~ 77 between the experimental and control groups: for the experimental groups, PACT treatment was offered in either a neuropsychiatric hospital or a general medical and surgical hospital-based program. This treatment was then compared to the standard Veteran's Administration (VA) inpatient care. For the six studies that contained enough data for use in the meta-analysis, a significant relationship between cost and type of treatment (z = 4.047, r = 1.533, p = .0000, r2 = .024) was found. Assertive community treatment had lower costs than standard treatment. However, the total amount of variance in cost explained by PACT treatment was only 2.4%. The highest amount of variance in cost ( 15.8%) was explained by the Knapp et al. (1994) study. Both the Weisbrod et al. (1980) and Rosenheck et al. (1995) studies explained only 2% of the variance in cost. Outcomes of Combined Probability Tests As stated earlier, in order to assess the overall probability for the six operational measures of effectiveness commonly used in this body of research, we employed two methods: the Stouffer Combined Test and the Fail-safe N (H. M. Cooper, 1989). The Stouffer/Adding zs formula allows one to calculate the probability of "the combined likelihood that the series of results included in the analysis could have been generated by chance if the null hypothesis were true for every study" (H. M. Cooper, 1989, p. 95). Because the Stouffer/Adding zs method might produce a calculation that is an underestimation of the probability of incorrectly rejecting the null hypothesis (a Type I error), Cooper advocates the use of the Fail-safe N method. He stated that this method "answers the question, 'How many comparisons totaling to a null hypothesis confirmation (e.g., zst = 0) would have to be added to the results of the retrieved comparisons in order to change the conclusion that a relation exists?"' (p. 97). In Table 1, the outcome measure of number of hospital admissions has an overall z score of 5.7902 with an associated p of .0000. The Fail-safe N for the measure is 124; thus, 124 more comparisons would be needed to reverse the results found in Table 1. The overall z score for the outcome measure of length of psychiatric hospitalizations is 8.03, a value of z associated with a p of .0000. The Fail-safe N for this measure is 297. For the measure of social functioning, the overall z is equal to 5.63. Although this z is significant at p = .0000, only 118 extra comparisons would be needed to reverse the result. Similarly, for symptomatology, the overall z of 3.95 (p = .0000) has a Fail-safe N of 93. For the measure of patient satisfaction, the overall z score is 6.79, level of significance is .0000, and Fail-safe N is 128. For cost, the findings are significant, with a z score of 4.05, and a p of .0000. The Fail-safe N calculations reveal that only 30 additional studies would reverse the findings. 78 According to H. M. Cooper (1989), one can determine if the Fail-safe N is large enough to conclude that a finding is resistant to unretrieved null results by comparing it to the resistance number: "Rosenthal ( 1979b) suggests that the resistance number equal 5 times the number of retrieved studies plus 10" (p. 97). The Fail-safe N has the most impact for the cost measure. For cost, the 6 studies with usable cost data for this meta-analysis yielded a suggested resistance number of 40 studies; if 9 studies had been used, the resistance number would have been 55. Both figures are well over the calculated Fail-safe N of 30, which suggests that the significance of the findings might easily be reversed if unretrieved or unpublished studies were included. For each of the other five outcome measures, the calculated Fail-safe Ns were well above the resistance number (see Table 7). Effect Size Analysis Effect size is characterized as small (r = .10), medium (r = .30), or large (r = .50) and indicates the degree to which the study findings reveal a relationship between the treatment (independent variable) and the outcome measure (dependent variable; H. M. Cooper, 1989). As shown in Table 7, the effect sizes indicate that there was a small effect for social functioning (r = .1296) and symptomatology (r = .1023). The effect size for cost (r = .1533) was midway between small and medium, whereas those for the number of hospitalizations and length of hospitalizations fell just below a medium size (r = .2846 and r = .2877, respectively). Patient satisfaction had the highest effect size (r = .3115), which would be considered medium. Although small effect sizes are common in the social sciences and are often related to the difficulty in operationalizing and measuring dimensions of human behaviors, the use of a confidence interval can provide a further indication of support for the overall findings. For the number of hospital admissions, the 95% confidence interval was .2806 to .3984; for length of hospital stay, .2104 to .2980 (based on 13 of 14 studies with usable data); for social functioning, .0895 to .2409 (based on 10 of 11 studies with usable data); for symptomatology, .0511 to .1781; for patient satisfaction, .2626 to .4184; and for cost, .0955 to .2055 (based on 6 of 9 studies with usable data). All of these confidence intervals support the rejection of the null hypothesis that there is no relationship between type of treatment and effectiveness (as measured by the six indicators). These effect sizes may reflect the way the data were obtained. For example, patient satisfaction, with the highest effect size, generally was measured through patient self-report. It is not surprising that patients would prefer assertive community treatment to standard treatments; their movement is not restricted, 79 C/) ~g~ ~ O u H O I'¡- M u fi) ~~ ~õ O ~ ~ ~ s ~3 'LD 'g u z (jJ X ê c (jJ u c 2~0 'r 3 £ > E C 5 N E v ~ 3 ~ ...8c:~ (!J U S- . G ~ #z g z ~~ .·`= m 'K 'c ~0 9J S ~. rg # j 0 > ~ C E p c g 3 ~w 3 80 they receive comprehensive and attentive care, and they live close-to-normal lives. Second, the two measures that are the least subjectively defined-number of hospital admissions and length of hospital stay-have the next two highest effect sizes. The medium effect sizes of these measures may reflect the fact that the data were obtained by secondary sources and that these measures were more concretely operationalized than the other four outcome measures. Those outcome measures (social functioning and symptomatology) that were operationalized by researchers generated small effect sizes. Similarly, cost was operationalized differently in the studies; some researchers included direct and indirect costs, while others did not. Effect Size Moderators Regression analysis was performed for each of the six measures to determine if other variables were influencing effect sizes. The variables included in the regression analysis were chosen to alleviate concerns about possible confounding effects due to advances in pharmacology, treatment modalities, and the increasing integration of mental health services into the community that might have occurred during the 25 years since the advent of PACT programs. The following variables were correlated and tested for statistical significance (Pearson r): year, time, initial sample size, attrition rate, type of measure (single or multiple operationalization), locus of randomization (inpatient facility or community), geographic location of study, author-created or standardized scale, and size effect. There were no significant correlations between any of these variables and the outcome measure of patient satisfaction. Interestingly, for the number of hospital admissions, those studies conducted in the earliest years showed higher effect sizes for the number of admissions (r = 0.733, p < .0 16), but the remaining effect size correlations were not significant. The correlation between the earliest years and the number of admissions may reflect closer adherence to the original PACT model, a lower threshold for inpatient admission, and mental health providers' lower level of comfort with community-based treatment for persons with severe mental illness. For length of hospitalization, earlier studies also had larger effect sizes (r = 0.576, p < .039). This may be a reflection of practitioners' bias toward hospital-based treatment. Further, studies that included shorter time periods showed larger effect sizes on length of hospitalization (r = 0.550, p < .052). This finding might be attributed to the fact that shorter time periods constrain the interval during which participants can be measured for inpatient experience. No other correlations with this measure were significant. Higher effect sizes on social functioning were found for composite measures (r = 0.685, p < .02). This indicates that those measures containing several . . '" .. , 81 pooled dimensions are more likely to detect nuances of varying magnitudes than measures made up of only a single dimension. The remainder of the correlations were not significant. For symptomatology, attrition and randomization from an inpatient facility or the community were significantly correlated with effect size. Those studies with higher attrition rates had higher effect sizes (r = 0.742, p < .022). The effect of attrition on symptomatology is quite possibly related to a creaming effect; that is, those patients with the most severe mental illness were most likely to be noncompliant with treatment and difficult to locate if they dropped out of treatment. Therefore, studies with higher attrition rates tended to have higher effect sizes; the participants who were most ill were no longer measured after they were lost to the researchers. Although the correlation between effect size for symptomatology and randomization from an inpatient facility or community was also significant (r = 0.797, p < .003), this finding was based on only 1 of the 11 studies. In the remaining 10 studies, participants were randomized from inpatient facilities. There were no other significant correlations between symptomatology and effect size. For the cost measure, those studies conducted outside the United States showed a higher effect size than those conducted within the United States (r = 0.791, p < .061 ). There was no significant correlation between cost and any of the other variables. Power Analysis Whereas a Type I error was addressed by use of the Fail-safe N, the likelihood of committing a Type II error (failing to reject the null hypothesis when it is false) was addressed by computing the power of the test: The greater the power of the test, the smaller the likelihood of a Type II error. As discussed previously, the test's power was calculated based on the sample size, level of significance, and expected effect size. In an ideal situation, an a priori power analysis would have been performed in order to ensure an adequate sample size for the study. None of the 19 studies reported results of an a priori power analysis. Because we lacked data on power, we used GPOWER to perform post hoc power analyses. As reported in Table 7, all the measures had power above .5 (a medium power), but only one measure, patient satisfaction, had a power (.7939) that would be considered to be large. Thus, patient satisfaction was the measure with the lowest probability of failing to reject the null hypothesis if it was false. For symptomatology (.5199), there was almost an equal chance of failing to reject the null as accepting it if it was false. For hospital admissions (.6650), length of hospital stay (.6379), social functioning (.6108), and cost (.6350), the likelihood of a Type II error was lower. 82 Sensitivity Analysis In this meta-analysis, attrition was viewed as a potential threat to the validity of the findings. Attrition rates for the studies included in this meta-analysis ranged from 0% to 63%. The reasons for attrition included death, incarceration, refusal of services, and researchers' inability to locate the participant. The most frequent causes of attrition were refusal of services and researchers' inability to locate patients. We suspected that the high attrition rates and researchers' lack of specificity regarding attempts to locate missing patients biased the findings of this study. The inclusion of patients who were hard to find and who thus were probably less functional and more symptomatic might have shifted the findings to support more standard treatment modalities. Concern about the possibility of attrition as a threat to inference led us to conduct a sensitivity analysis on the eight studies that provided sample sizes, means, and standard deviations for both the experimental and control groups for the outcome measures. The attrited cases were assigned scores that fell within .25, 1, and 2 standard deviations from the mean of the experimental or control group to which they belonged, and new adjusted means for each group were recalculated. The size of the original experimental or control group standard deviation was adjusted upward by multiplying the proportion or multiple of the original standard deviation that was used to assign scores to the attrited cases by the rate of attrition that had occurred in each group. Following this, the t tests were recomputed to determine if this changed the significance of the reported findings. All eight of the studies on which sufficient data were reported remained either significant or not significant as reported when computed at .25 and 1 standard deviation. Similarly, even at the extreme of 2 standard deviations, only the measure for symptomatology in the study by Wolff et al. (1997) lost statistical significance. Following this analysis, the impact of attrition on the effect size and the amount of variance explained (effect size squared) were calculated (see Table 8). In general, the total amount of variance in the various dependent variables explained by the PACT program was quite limited. With little change after adjusting for attrition, the Stein and Test study (1980) accounted for 4.1 % of the variance in length of hospitalization. The Bond et al. study (1990) accounted for only 4.3% of the variance in length of hospitalization before attrition and 0% after adjusting for attrition. Using days in stable housing as a measure of social functioning, the Wolff et al. study (1997) accounted for 1.2% of the variance before adjusting for attrition and 0% after adjusting for attrition. Similarly, the Wolff study fell to 0% from 14.3% of variance explained on symptomatology when attrition was taken into account. For the cost measure, Knapp et al. (1994) accounted for 15.8% of the variance before attrition; after adjusting for attrition, it accounted for 13.6% to 8.1 % of the variance. 83 r- u ibi W. (~ 8l w N ~7; ~7_ 0 4 ~ ~ < ~7_ < COE--< ~4 - b5 *x ~U3 z l# C-11, z ~ ~ ë2 H > 1 0 (A b ~ oc w 94 >. Mj c c E c I- E 11 y. ~3 '0 v A 84 The Merson et al. (1992), Morse et al. (1992), and Marks et al. ( 1994) studies each accounted for variance in patient satisfaction. Merson et al. initially accounted for 15.8% of the variance, and after adjusting for attrition, accounted for 14.4% to 8.3% of the variance. Before adjusting for attrition, the Morse et al. study accounted for 23.3% of the variance and, after adjusting for attrition, dropped to 20.0% to 10.0% of the variance. Finally, Marks et al. initially accounted for 27.1 % of the variance, but that number fell to 23.5% to 13.3% when adjusted for attrition. Implications of the Findings The results of this study revealed a significant relationship between type of treatment of severe mental illness and effectiveness, as measured by number of hospitalizations, length of hospital stay, social functioning, symptomatology, patient satisfaction, and cost. However, post hoc power analyses indicated that the relationship between these indicators of effectiveness and type of treatment was not completely clear. Only one measure, patient satisfaction, had a significantly large enough power to ensure a degree of safety in accepting the finding, whereas the other five had medium levels of power. For example, the power of the test for symptomatology indicated that it was almost equally possible to reject as accept the null when it was false. This measure is a critical indicator of effectiveness and has been measured by more commonly used and standardized instruments than our other indicators of effectiveness. The amount of variance explained in the effectiveness measures raises another cautionary flag in recommending policy changes that embrace PACT and PACT-like programs over other interventions for persons with severe mental illness. For the six outcome measures, the largest amount of variance was explained by patient satisfaction (9.7%), followed by the number of hospital admissions and length of hospital stay (8.1% and 8.3%, respectively). Cost, social functioning, and symptomatology each explained 2.4%, 1.7%, and 1.1 %, respectively, of the variance. When the numbers were adjusted for attrition, in general, the amount of explained variance fell. In either case, none of these numbers supported abandoning current funding patterns to implement PACT nationwide. This meta-analysis further demonstrates that cost considerations cannot be the sole basis for policy decisions regarding an appropriate type of treatment. Although this meta-analysis found a significant effect size for cost, these results are the most suspect and most easily reversed by unpublished or unretrieved studies. In addition, the post hoc power analysis fell into the medium range. A major concern also was that the effect sizes for this measure were based on sig- 85 nificant findings from only three studies, because six studies had either insignificant results or unusable data. Further, operationalization of this measure lacked consistency. The wisdom of shifting mental health treatment funding based on this small number of studies is questionable. When researchers discussed costs of mental health treatment, they frequently noted that although the cost of inpatient treatment was high, the start-up costs for assertive community treatment often were higher. Thus, total costs were not significantly different in the long run, and policy discussion should focus on where mental health dollars would best be spent, rather than on what type of treatment saves the most money. Finally, patient satisfaction, the strongest measure in the post hoc power analysis, needs to be considered. Patient satisfaction should be factored into arguments about effectiveness and the type of treatment for severe mental illness. The issues of consumer sovereignty and patients' rights, issues that are often debated in the era of managed care, are issues of great importance to all patients, including those patients with severe mental illness. This meta-analysis clearly indicated that patient satisfaction was greater for community treatment. This finding supports a group of patients who often are unable to advocate for humane treatment on their own behalf. However, given the results of this meta-analysis, we concluded that concerns regarding the lack of consistency in operationalizing the outcome measures, the small effect sizes and amounts of variance explained, and the small number of studies reporting a cost savings did not justify shifting funding patterns for mental health treatment. Patient satisfaction notwithstanding, in order to support the enormous start-up costs associated with assertive community treatment, further replication studies with more consistent outcome measures of effectiveness must be conducted. Future researchers need to be consistent in how they define the direct and indirect costs of each type of treatment, the desired level of functioning, symptomatology, and the type of treatment provided. Too precipitous a move to fund PACT nationwide would preclude or limit future research into other promising leads for more effective community-based treatment of persons with serious mental illness. This study did not address the costs and functioning levels associated with vocational rehabilitation programs that operate concurrently with mental health treatment programs; therefore, future research and replication studies must address this type of joint program. However, given the results of this meta-analysis and the low return rate per client for vocational rehabilitation expenditures, we cannot envision a benefit at this time to joining two programs with marginal levels of effectiveness. Any decision in this regard might more prudently await the (hopefully) more definitive findings about the benefits and costs of combined delivery of mental health and vocational rehabilitation ser- 86 vices that is expected to result from the several randomized experiments currently being funded by the Center for Mental Health Services (Cary, 1996). ABOUT THE AUTHORS ANDREA C. HERDELIN and DIANE L. SCOTT are doctoral degree candidates at The Catholic University ojAmerica in Washington, DC. Ms. Herdelin is currently completing her dissertation proposal. Ms. Scott is conducting dissertation research on domestic violence policies and legislation in Virginia alld is a teaclling adjunct for the School ojSocial Work at Florida State University. Address: Andrea C. Herdelin, 221 W. Pine St., Audubon, NJ 08106. AUTHORS'NOTE The authors wish to thank Dr. John Noble, Jr., at The Catholic University of America for his guidance and unfailing support during this project. . ~ ' REFERENCES - - '' , ; ~ ." v:` ' , 'I, References marked with an asterisk indicate studies included in the meta-analysis. Allness, D.J., & Knoedler, W.H. (1998). The PACT model of community-based treatment for persons with severe and persistent mental illnesses: A manual for PACT start -up. Arlington, VA: NAMI Anti-Stigma Foundation. Asberg, M., Montgomery, S.A., Perris, C., Schalling, D., & Sedvall, G. (1978). A comprehensive psychopathological rating scale . Acta Psychiatrica Scandinavica, 271 (Suppl.), 5-29. 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The study included 19 peer-reviewed published articles describing controlled, randomized experiments comparing PACT to standard treatment of individuals with severe mental illness. Treatment was found to have a significant relationship with effectiveness on each of the following six indicators: number of hospital admissions, length of hospital stay, social functioning, symptomatology, patient satisfaction, and cost. The use of PACT was associated with fewer admissions, shorter length of stay, higher social functioning, lower symptomatology, greater patient satisfaction, and lower cost. These findings were challenged, however, by the confounding effect of attrition and the small amount of total variance explained in the effectiveness indicators by the PACT intervention. Future replication studies of PACT using larger sample sizes and standardized measures of benefits and costs appear necessary to justify major shifts in mental health and vocational rehabilitation services and funding policies.</abstract><relatedItem type="host"><titleInfo><title>Journal of Disability Policy Studies</title></titleInfo><genre type="journal">journal</genre><identifier type="ISSN">1044-2073</identifier><identifier type="eISSN">1538-4802</identifier><identifier type="PublisherID">DPS</identifier><identifier type="PublisherID-hwp">spdps</identifier><part><date>1999</date><detail type="volume"><caption>vol.</caption><number>10</number></detail><detail type="issue"><caption>no.</caption><number>1</number></detail><extent unit="pages"><start>53</start><end>89</end></extent></part></relatedItem><identifier type="istex">AAB747D3756B8D3B6F0DF59BA0742ACCCD628727</identifier><identifier type="DOI">10.1177/104420739901000105</identifier><identifier type="ArticleID">10.1177_104420739901000105</identifier><recordInfo><recordContentSource>SAGE</recordContentSource></recordInfo></mods></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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