Table 1 Summary of included studies

Sample

n = 69

age = 65 or over

n = 60

age = 65 or over

n = 62

age = 65 or over in the first year of research; afterwards minimum age = 60

Study type

RCT

RCT

RCT

Setting

UK /London

As naturalistic as possible.

Home

Austria /Graz

Naturalistic service.

Home

Netherlands/ Rotterdam

In cooperation with an existing health care centre. TAU includes also multidisciplinary ACT teams.

Home

Duration of intervention / Follow up

6 months (0/6)

At baseline, and at 6 months after baseline

12 months (0/3/12)

At baseline, at 3 months after baseline, and at 12 months after baseline

18 months (0/9/18)

At baseline, at 9 months after baseline, and at 18 months after baseline

Intensity

No information

1–2 contacts per week

In crisis situations up to 4 contacts per week.

According to the Guidelines for ACT Teams by SAaMHSA [50].

Intervention

Participants were not currently under psychiatric care.

Intervention group:

All were referred to a psychogeriatric team.

The management plan for each subject on an individual basis was designed by the multidisciplinary team (see below) and implemented by the key worker who was always a doctor. He made no more visits than other team members.

This could include any combination of physical interventions, e.g., prescription of antidepressants, physical review; psychological interventions, e.g., bereavement counselling or psychotherapy, family work; and social interventions, e.g., referral to a day centre, benefit check.

Control group:

General practitioner care. Letters were sent to general practitioners to say that their patient was participating in the study as a control but that this should not affect their management of him or her. The patients could be referred to as needed and they would be accepted by the team as normal if they were referred.

Access to all routine aspects of psychiatric care.

Intervention group:

In addition, all received geriatric home treatment over a 1-year-period. The individual care plan for each participant was designed by the multidisciplinary team (see below) working Mo-Fr 9-5 pm.

Each Participant was visited once or twice a week. In crisis situations, up to four visits a week. Also phone contact with patients and carer. Components of geriatric home treatment were talks about self-esteem, coping resources and medication adherence; encouragement and practical support for the individual to establish and maintain social networks, increase social and leisure activities and cope with tasks of daily living; support of carers; and crisis intervention if required.

Control group:

Conventional psychiatric out-patient care. Individuals had free access to general practitioners and out-patient psychiatrists. They could also be referred to other services. Domiciliary visits were done rarely.

In addition, all participants had an initial meeting with a psychologist for detailed information about all available health and social services and ways to access them.

Intervention group:

ACTE (Assertive Community Treatment for the Elderly), a community-based treatment approach for outpatients whose SMI resulted in difficulties in daily living activities and social functioning often including problems with relationships, physical health, addiction, work, daytime activities and living conditions.

ACT: Individualised services designed by the multidisciplinary team (see below) that provided psychiatric, somatic and rehabilitation treatment in the environment of the patient.

Key features: assertive engagement, small and shared caseload (max. 1:10), based on treatment plan, community based and assertive services on a time unlimited basis with high contact frequency.

Control group:

TAU (Treatment as usual) was provided by three community mental health teams for elderly patients. Two of these teams were for patients with primary psychiatric disorders, one for patients with cognitive disorders. The teams provided regular mental health services including psychiatric care on an outreach basis.

Various disciplines (community mental health nurses, a psychiatrist, and a psychologist) were individually responsible for the patients.

High caseload (more than 25 patients per practitioner).

All clinicians were specialised in treating elderly people.

Team Profession

Community psychiatric nurse, occupational therapist, senior and junior medical staff, social worker, psychologist

Psychiatrist and psychotherapist, psychologist, social worker, psychiatric nurse

Substance-abuse specialist, rehabilitation worker, social worker, psychiatric nurse, nurse specialized in somatic care, community mental health nurse, psychiatrist

Diagnosis

Major Depression

in context with geriatric mental state –AGECAT system

Major Depression

in context with GDS-15 score, GAF 21–60, MMSE > 27 [and living independently]

Severe mental illnesses including schizophrenia spectrum disorders, mood disorders, other disorders plus problems in daily functioning and engaging in treatment in context with Health of the Nation Outcome Scales for elderly people and exclusion of severe cognitive impairment.

Outcome measures

Selfcare(d) questionnaire.

Multidimensional functional assessment.

AGECAT (automatic geriatric examination for computer assisted taxonomy)

Montgomery Asberg depression rating scale.

Blinded follow up

Symptom levels of depression (GDS-15 Geriatric Depression Scale).

Level of functioning (GAF Global Assessment of Functioning Scale).

Level of subjective quality of life (SQOL based on BELP-KF Berlin Quality of Life Profile).

Admissions to nursing homes and days spent there.

Days spent in psychiatric inpatient care.

Costs of care included

intervention, days in nursing homes, days in psychiatric inpatient care.

Not blinded. Self and observer rated

Primary outcome measures:

Number of patients engaged in the first 3 months.

Number of dropouts.

Psychosocial functioning.

Secondary outcome measures:

Number of unmet needs.

Number and Duration of inpatient psychiatric admission.

Number of crisis contacts.

Based on:

HoNOS65+ (Health of the Nation Outcome Scales for elderly people).

CANE, staff member version (Camberwell Assessment of Need for the Elderly).

Measuring the model fidelity of ACT; Measuring the model fidelity of ACTE and TAU 2 years after start with DACTS (Dutch version of the Dartmouth Assertive Community Treatment Scale).

Not blinded

Outcomes

Psychiatric team treatment at home was substantially more effective than general practitioner care alone in treating depression in this disabled elderly population. Significant beneficial follow up effects.

Patients receiving geriatric home treatment had significantly fewer symptoms of depression, better global functioning and a higher SQOL at 3 months and 12 months. Over 1 year they had significantly fewer admissions to nursing homes, spent less time in psychiatric in-patient care, and care costs were significantly lower.

ACTE had better results than TAU with regard to engaging patients into treatment within 3 months and fewer dropouts from treatment.

Improvements but no significant differences in the other primary and secondary outcome variables, which means that ACTE did not produce better outcomes with respect to psychosocial functioning, unmet needs or mental health care use.

Patients allocated to ACTE had significantly more often contact with mental healthcare workers.

Hospital days and crisis contacts:

These variables were not analysed statistically. Very few patients had been admitted or had had crisis contacts.

Model fidelity: TAU teams had lower model fidelity scores, but model fidelity in ACTE was also only moderate.

ACTE scored high on the small and shared caseload and time-unlimited services; maximum scores for community based services and assertive outreach.

Low model fidelity concerning a vocational specialist and consumer provider in the team,

the frequency of contact, the intensity of service, the intake rate,

dual-disorders treatment groups,work with the support system, and

responsibility for crisis services.