Who terminates from ACT and why? Data from the National VA Mental Health Intensive Case Management Program.
OBJECTIVE
One of the original principles of assertive community treatment (ACT) is that treatment should be time unlimited. Although termination is not uncommon in ACT, it has not been empirically studied. This study examined termination from a large program based on ACT.


METHODS
This study used national data from the Department of Veterans Affairs Mental Health Intensive Case Management program modeled on ACT to compare veteran characteristics, patterns of service delivery, and early clinical changes among veterans who terminated early (less than one year) and later (one to three years) with those of veterans had not terminated after three years. Bivariate comparisons and multinomial logistic regression analyses were used to identify factors associated with early and later termination.


RESULTS
Among 1,402 veterans enrolled in fiscal years (FY) 2002-2004, 16% terminated early, 26% terminated later, and 57% had not terminated after three years. Compared with those who had not terminated, those who terminated early showed higher suicidality scores, and participants who terminated early and those who terminated later were less likely to have a diagnosis of schizophrenia and were more likely to have lower quality of life at entry. Stronger differentiating effects were observed for program participation. Those who terminated received less intensive services during the first six months of participation and had a weaker therapeutic alliance. Although participants who terminated early showed more violent behavior at follow-up than the other two groups, there were no other differences in early clinical changes.


CONCLUSIONS
Rates of both early and later termination were substantial, and less active participation was a stronger predictor of termination than either patient characteristics or clinical changes. A diagnosis of schizophrenia was associated with continued treatment. Further research is needed to determine the impact of termination on longer-term outcomes.
Mohamed
Somaia
S
Department of Psychiatry, Department of Veterans Affairs (VA) Northeast Program Evaluation Center, 950 Campbell Ave., West Haven, CT 06516, USA. somaia.mohamed@yale.edu
Rosenheck
Robert
R
Cuerdon
Timothy
T
D000328:Adult; D003156:Community Mental Health Services / Q000706:statistics & numerical data*; D016208:Databases, Factual; D003657:Decision Making; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D001523:Mental Disorders / Q000628:therapy*; D008875:Middle Aged; D016312:Treatment Refusal / Q000706:statistics & numerical data; D014481:United States; D014493:United States Department of Veterans Affairs