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Like many people with serious and persistent mental illnesses, Russell Weston, who is charged with shooting and killing two Capitol Hill police officers two months ago, fell through the cracks in the mental health system following hospital discharge.
To bridge this service delivery gap, the National Alliance on Mental Illness (NAMI) announced at a Capitol Hill briefing last month its goal of ensuring that all 50 states and the District of Columbia establish a sufficient number of Programs for Assertive Community Treatment (PACT) to meet the needs of their mentally ill residents by the year 2002. Twenty-five states and the District of Columbia do not have such a program, and only six states (Delaware, Idaho, Michigan, Rhode Island, Wisconsin, and Texas) have an adequate number to serve its mentally ill residents.
Speakers at the press briefing, who included psychiatrists, mental health researchers, and patient advocates, hailed the program as a cost-effective, well-researched, comprehensive treatment model that is worth replicating in communities across the country.
Several congressional representatives including Rep. Marge Roukema (R-N.J.) and Sen. Paul Wellstone (D-Minn.) spoke favorably at the briefing about the PACT initiative.
Wellstone commented, "I support NAMI's work with the PACT model. We need to constantly push forward all types of treatment to meet the needs of the mentally ill. The worst alternative is to warehouse the mentally ill in jails and prisons."
The program is organized as a "hospital without walls" in which a multidisciplinary team provides the bulk of services where the patient lives, works, and socializes. Team members include psychiatrists, social workers, psychiatric nurses, vocational counselors, and occupational therapists who are accessible to patients 24 hours a day, seven days a week, according to social worker Deborah Allness, who has been involved in developing, researching, and disseminating information on the PACT model.
The program's direct service delivery approach differs from that of case management, which links patients to various services, noted Allness. "Having one team provide all the services minimizes the fragmentation and time-consuming coordination inherent in traditional mental health systems."
The model evolved from work by psychiatrists and staff on an inpatient psychiatric unit of a state hospital in Madison, Wis. They noted that the gains made by patients in the hospital did not translate to their lives once they returned to the community. The first PACT began when hospital ward staff moved into the community to provide intensive 24-hour care.
The multidisciplinary team provides essential services, including dispensing atypical antipsychotic and antidepressant medications, mobile crisis intervention, support and education to family members, supportive therapy, cognitive-behavioral therapy, group treatment, and supported employment, especially vocational rehabilitation services within psychiatric programs. The team also teaches behavior skills, according to Allness. The psychiatrist on the team prescribes the medications.
NAMI Executive Director Laurie Flynn lamented, "Despite the program's repeated and unequaled success with 25 years of research-based evidence, its replication in public mental health systems has been agonizingly slow."
Research shows that individuals participating in PACTs fare better than individuals treated primarily in hospital settings. They are less symptomatic and have fewer hospital days, more time in independent living situations, less time unemployed, more income from competitive employment, more positive social relationships and greater satisfaction with life, according to Donald Steinwachs, Ph.D., chair and professor of the department of health policy and management at the Johns Hopkins School of Hygiene and Public Health in Baltimore.
Steinwachs acknowledged that there are significant costs associated with staffing a PACT, but studies in different communities have shown that the costs are no greater than alternatives such as institutional care. Moreover, research by the Department of Veterans Affairs showed cost savings when individuals in long-term psychiatric facilities were transferred to PACTs, noted Steinwachs. Similar findings were also shown in a long-term treatment study of PACT patients.
William Knoedler, M.D., who directed and worked as the team psychiatrist on the PACT model program at Mendota Mental Health Institute in Madison, Wis., until last year, commented, "PACTs' assertive approach helps keep the seriously mentally ill on their medications and involved in therapy, which lessons their symptoms, distress, and disruptions to communities. PACT also has a high staff-to-patient ratio and provides one-stop shopping for the range of services patients needed. As a psychiatrist on the PACT team, I know that if the work is done properly, over 90 percent of my patients will receive and take their medications and progress."
Moreover, "with PACTs, I can use my skills where they are needed the most, treating the persistently mentally ill. I can diagnose, treat, and do crisis and hospital work."
Knoedler continued, "Psychiatrists in PACTs serve as general practitioners in the sense of providing necessary general medical care and being able to work with patients long term, which I find very satisfying."
However, working in a PACT requires the ability to adapt to a nontraditional mental health service model, said Knoedler. "In a sense, it reinvents home care. I have been doing this work for 25 years, and I still spend 30 to 50 percent of my time out in the community in patients' homes and other settings. This is not something a psychiatrist does to get to know the work; this is the nature of the work."
Knoedler also emphasized that the PACT model can be adapted to urban and rural settings.
To assist psychiatrists and mental health administrators in implementing a PACT, Flynn announced a new comprehensive resource manual developed by Knoedler and Allness, The PACT Model of Community-Based Treatment for Persons With Severe and Persistent Mental Illnesses. NAMI has distributed the manual to state Medicaid agencies, state and county mental health authorities, the Health Care Financing Administration (HCFA), legislators and other policymakers, and its grass-roots advocates, according to Flynn.
NAMI also will seek congressional action to replicate the PACT model in every state. One way is to require states receiving federal mental health block grants to provide PACTs. NAMI will also work with HCFA on funding mechanisms.
Information about the new PACT initiative and how to order the manual (see book section) can be found on NAMI's web site at www.nami.org. The cost for each manual is $29.95 for members and $39.95 for nonmembers. Those who wish to order by phone should call NAMI at (703) 524-7600.