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Reviews and Overviews   |    
The Effectiveness of Assertive Community Treatment for Homeless Populations With Severe Mental Illness: A Meta-Analysis
Craig M. Coldwell, M.D., M.P.H.; William S. Bender, M.P.H.
Am J Psychiatry 2007;164:393-399. doi:10.1176/appi.ajp.164.3.393

Abstract

Objective: The purpose of this study was to assess the effectiveness of assertive community treatment in the rehabilitation of homeless persons with severe mental illness using a meta-analysis. Method: A structured literature search identified studies for review. Inclusion criteria were the use of an assertive community treatment-based rehabilitation treatment in an experimental or quasi-experimental model, exclusive treatment of homeless subjects, and follow-up of housing and psychiatric outcomes. Two reviewers independently abstracted data on methodology and outcomes from included studies. The authors calculated effect differences, summary effects and confidence intervals (CIs) for housing, and hospitalization and symptom severity outcomes. Results: Of the 52 abstracts identified, 10 (19%) met inclusion criteria. Of these, six were randomized controlled trials, and four were observational studies, totaling 5,775 subjects. In randomized trials, assertive community treatment subjects demonstrated a 37% (95% CI=18%–55%) greater reduction in homelessness and a 26% (95% CI=7%–44%) greater improvement in psychiatric symptom severity compared with standard case management treatments. Hospitalization outcomes were not significantly different between the two groups. In observational studies, assertive community treatment subjects experienced a 104% (95% CI=67%–141%) further reduction in homelessness and a 62% (95% CI=0%–124%) further reduction in symptom severity compared with pretreatment comparison subjects. Conclusions: Assertive community treatment offers significant advantages over standard case management models in reducing homelessness and symptom severity in homeless persons with severe mental illness.

Abstract Teaser
Figures in this Article

Several evidence-based interventions have demonstrated efficacy in treating severe mental illness (1). The most aggressively studied model of case management is assertive community treatment, derived from the work of Stein and Test (2). Assertive community treatment is distinguished from traditional approaches by the following features: a multidisciplinary team, low client/staff caseloads that enable more intensive contact, community-based services that are directly provided rather than brokered to other organizations, and 24-hour coverage by the treatment team (1–4). The superiority of assertive community treatment compared with other case management models is well documented. A number of studies, including several meta-analyses, demonstrate statistically significant advantages of assertive community treatment in substantially reducing the length and frequency of hospitalization and increasing independent living while moderately improving psychiatric symptoms and quality of life for persons with severe mental illness (4–9). While assertive community treatment is more costly to administer than other case management treatments, studies have found that it is more cost-effective because of a reduced utilization of hospitalization and emergency services (4, 10).

While evidence supports the effectiveness of assertive community treatment in treating persons with severe mental illness, less is known about its effects in specific subpopulations that present particular challenges for engagement or recovery (8). One such subgroup is the homeless mentally ill. The homeless population in all cities of the United States exceeds 200,000, and an estimated 14 million Americans experience at least one episode of homelessness during their lifetime (11, 12). Among these individuals, 20% to 35% suffer from severe mental illness (13). They also experience higher rates of substance abuse and criminal justice involvement (14). As a result, this is a particularly challenging group for the mental health service system to engage and assist.

Identifying a best practice may help to improve the quality of care for the homeless mentally ill. There is no consensus regarding the best treatment; therefore, we sought to determine whether current evidence supports the use of assertive community treatment over other case management models in this population. We conducted a meta-analysis to test the hypothesis that assertive community treatment is more effective than other case management models in reducing homelessness, hospitalization, and symptom severity outcomes in homeless persons with severe mental illness.

+

Study Selection

We performed a standardized search of abstracts in MEDLINE (1966–2003), PubMed (1950–2003), the Cochrane Database of Systematic Reviews, and PsycINFO (1974–2003) databases. The search involved the intersection of the following three topic areas: assertive community treatment (keywords: assertive community treatment or case management or intensive case management), severe mental illness (keywords: severe mental illness or community mental health services or psychotic disorders or schizophrenia), and homelessness (keywords: homeless persons or homeless or homelessness). Citations from two substantial reviews of assertive community treatment or community programs for homeless persons were also examined (8, 15). Several principal investigators were contacted regarding unpublished data. We examined studies for the following inclusion criteria: experimental or observational design; subjects limited to homeless persons with a severe mental illness, but not limited to addictive disorders alone; use of assertive community treatment or an assertive community treatment-based treatment; and report of the outcomes of interest (housing plus hospitalization and/or symptom severity). We set no limits on cohort size or length of follow-up.

+

Data Abstraction

Authors independently used a standardized data abstraction instrument to extract data from the included studies. Abstracted data consisted of the study design, cohort size, treatment versus comparison groups, measurement methods, and effect size with variance for the three outcome variables. Because of heterogeneity of measures across studies, we performed basic data transformation in order to create linearly equatable outcome measures. For example, in creating a homelessness measure, studies reporting days in stable housing during a follow-up period were transformed into days of homelessness by subtracting the published result from the total days in follow-up. When multiple symptom rating measures were available, we selected a measure of positive psychotic symptoms as the best representation of severe mental illness. For one study, we contacted authors to provide supplementary data (16).

+

Data Synthesis

For experimental trials, we compared outcomes of subjects receiving assertive community treatment versus subjects receiving other case management treatments. For observational studies, we compared post-assertive community treatment versus pre-assertive community treatment assessments. In trials with three treatment groups (e.g., assertive community treatment versus two non-assertive community treatment comparison groups), results were aggregated into assertive community treatment and non-assertive community treatment outcomes by calculating a weighted mean and pooled standard deviation from the published data (17–20).

We first calculated study-level raw effect differences with 95% confidence intervals (CIs). For binary outcomes, we calculated risk differences with standard error using methods published by Deeks (21). For continuous outcomes, we used Hedges’ adjusted g to calculate standardized mean differences with standard error (21). Effect differences were illustrated on a continuous scale that compared assertive community treatment subjects with comparison subjects. A study-level difference of 0% indicated no difference in outcome between groups. A positive-effect difference indicated the degree to which the assertive community treatment outcome surpassed the comparison outcome and vice versa.

In order to maximize homogeneity for statistical synthesis (22), results were segregated by study type (randomized controlled trials and observational studies) and outcome (homelessness, hospitalization, and psychiatric symptom rating). This resulted in six subgroups for synthesis.

Assuming that the published measures within each subgroup remained different yet linearly equatable, unbiased estimators of pooled effect size and variance for each subgroup were calculated using fixed effects methods (21). The heterogeneity of studies within each subgroup was then assessed using chi square test of the Q statistic (22). When significant intragroup heterogeneity was discovered, we recalculated summary effects using random effects methods as described by DerSimonian and Laird (21, 23). All calculations were performed using Excel 2000 software.

Publication bias is a potential confounder of any meta-analysis. Following methods described by Petitti (22), we assessed the likelihood of publication bias using a funnel plot displaying study-level effect difference versus cohort size. Because precision to a true effect difference increases with cohort size, a “funnel” with a wide base and narrow vertex is expected. When negative studies go unpublished, one corner of the funnel will be missing.

The standardized search identified 52 abstracts for review. Ten studies met inclusion criteria; they were six randomized controlled trials comparing assertive community treatment with standard case management (3, 18–20, 24, 25) and four observational studies comparing pre- and post-assertive community treatment outcomes (17, 26–28). We excluded publications that were reviews or descriptive accounts that did not include an assertive community treatment-based treatment or that did not report the outcomes of interest (29–43). Study characteristics are shown in Table 1. We note a number of potential limitations in the quality of included studies. Among randomized controlled trials, there is evidence of a gender bias in recruitment (3) as well as differential attrition between treatment groups (3, 19). Elsewhere, an intent-to-treat analysis is not documented (18–19). We are unable to assess the presence or impact of systematic bias in the individual studies created by these limitations.

Assertive community treatment subjects experienced significantly greater success in reducing homelessness in eight out of 10 studies and four out of six randomized trials (Table 2). The summary effect across randomized trials was 37% (95% CI=18%–55%, Z=3.85, p=0.0001), signifying that assertive community treatment subjects, on average, experienced a 37% greater reduction in homelessness compared with standard case management subjects. Across observational studies, subjects averaged more substantial improvement ([104%] 95% CI=67%–141%, Z=5.50, p<0.0001) when compared with baseline housing levels.

On average, assertive community treatment subjects had better hospitalization outcomes; however, this was statistically significant in only one of four randomized trials (Table 3). The summary effect across randomized trials revealed no significant difference in hospitalization between assertive community treatment and standard case management ([10%] 95% CI= -7%–27%, Z=1.17, p=0.24). A single observational study demonstrated better hospitalization outcomes after assertive community treatment ([69%] 95% CI=60%–78%, Z=5.21, p<0.0001).

Assertive community treatment subjects had significant reductions in psychiatric symptom severity beyond that experienced by comparison subjects (Table 4). Study-level effect differences were significant in four out of six studies, including two out of three randomized controlled trials. When combined, assertive community treatment subjects averaged a 26% (95% CI=7%–44%, Z=2.76, p=0.006) further symptom improvement in randomized trials and a borderline significant 62% (95% CI=0%–124%, Z=1.96, p=0.05) greater symptom improvement in observational studies.

Data for the analysis of publication bias is shown in Figure 1. We see a narrowing range of study-level effect differences as cohort size increases. Both negative and positive results are reported in the included studies.

Relative to standard case management or comparison treatments, assertive community treatment is associated with significant improvements in rates of homelessness and levels of psychiatric symptom severity in the homeless mentally ill. The evidence shows that assertive community treatment was statistically equivalent to standard case management in reducing hospitalization.

As previously mentioned, prior meta-analyses examined the effectiveness of assertive community treatment versus other case management in severely mentally ill subjects without a specified housing status. These studies showed robust improvement in housing stability for assertive community treatment subjects. It is not surprising that our study, which specifically examines homeless subjects, replicates this significant advantage. It is likely that the key processes of assertive community treatment provide real advantages in engaging the severely mentally ill and providing social supports that correlate with stable housing (44).

The earlier meta-analyses also showed that assertive community treatment led to better hospitalization and symptom severity outcomes for severely mentally ill subjects. In contrast, we found that assertive community treatment led homeless mentally ill subjects toward statistically significant symptom severity reduction but not hospitalization reduction when compared with standard case management.

We believe that the difference in hospitalization findings can be explained by the heterogeneity of the hospitalization measures used in our meta-analysis. As can be seen in Table 3, included studies reporting “days hospitalized” demonstrated more positive findings, while studies reporting “percent hospitalized” demonstrated more negative findings. This suggests that assertive community treatment subjects were more likely to be hospitalized but, simultaneously, to spend less time in the hospital than comparison subjects.

Because the homeless mentally ill are a population difficult to engage (45), it is possible that a higher hospitalization rate using assertive community treatment could be considered a success in treatment. Fewer days in the hospital may indicate a benefit of assertive community treatment in facilitating shorter stays or reducing rehospitalization. A “percent hospitalized” measure (18, 25) is not capable of making these distinctions. Their inclusion, therefore, limits the interpretation of our hospitalization outcome. In the future, we recommend the use of “days hospitalized” as a more appropriate measure to assess homeless mentally ill subjects.

Our study is affected initially by the limitations of the included studies (Table 1). Four out of 10 studies were observational and reported greater effect differences. Evidence of impaired randomization or interpolation of missing data could bias in favor of assertive community treatment. In contrast, documentation of low fidelity to assertive community treatment or availability of assertive community treatment to comparison subjects from agencies outside of the study could contribute to a type II error. While each of these limitations may bias the results of an individual study, we do not detect a consistent bias across studies. We conclude that there is a low likelihood of systematic bias in the meta-analysis. Regarding a possible publication bias, our meta-analysis includes smaller studies that exhibit both large and small and positive and negative effect differences (Figure 1). We therefore conclude that there is a low likelihood that publication bias affects the meta-analysis.

The meta-analysis also has limitations. The cohort of included studies was small. In order to avoid combining dissimilar entities, studies were then segregated by design and outcome, further limiting the power of the meta-analysis. Regarding the symptom severity outcome measure, studies reported a wide variety of instruments, and an assumption was made that these were linearly equatable. Generalizability must also be interpreted with caution. All subjects had a severe mental illness not limited to an addictive disorder, but variation in diagnostic case-mix was not consistently reported across studies.

Despite these limitations, evidence supports our conclusion that assertive community treatment offers significant advantages over standard case management programs in the care of homeless persons with severe mental illness. The use of assertive community treatment leads to greater improvement in housing stability and symptom reduction early in treatment. While hospitalization appears similar in assertive community treatment and standard case management, differences in hospitalization rate and duration require further study. These findings provide support for policy makers and community program directors to institute assertive community treatment as a best available practice to improve outcomes for the homeless mentally ill.

+Received Sept. 29, 2004; revisions received Feb. 18 and April 20, 2005; accepted June 20, 2005. From the Department of Psychiatry, Dartmouth Medical School, and the Center for Evaluative and Clinical Sciences, Dartmouth College, Hanover, N.H. Address correspondence and reprint requests to Dr. Coldwell, New Hampshire Hospital, 36 Clinton St., Concord, NH 03301; Craig.M.Coldwell@Dartmouth.edu (e-mail).

+Funding for this study was provided by the VA Quality Scholars Fellowship at the White River Junction VA Medical Center, White River Junction, VT.

+The authors thank William B. Weeks, M.D., M.B.A., and Todd A. MacKenzie, Ph.D., for comments on earlier versions of this study.

+CME DISCLOSURE: Dr. Coldwell and Mr. Bender report no competing interests.

+APA policy requires disclosure by CME authors of unapproved or investigational use of products discussed in CME programs. Off-label use of medications by individual physicians is permitted and common. Decisions about off-label use can be guided by scientific literature and clinical experience.

1.Drake RE, Mueser KT, Torrey WC, Miller AL, Lehman AF, Bond GR, Goldman HH, Leff HS: Evidence-based treatment of schizophrenia. Curr Psychiatry Rep 2000; 2:393–397
 
2.Stein LI, Test MA: Alternative to mental hospital treatment, I: conceptual model, treatment program, and clinical evaluation. Arch Gen Psychiatry 1980; 37:392–397
 
3.Lehman AF, Dixon LB, Kernan E, DeForge BR, Postrado LT: A randomized trial of assertive community treatment for homeless persons with severe mental illness. Arch Gen Psychiatry 1997; 54:1038–1043
 
4.Gilbody SM, Petticrew M: Rational decision-making in mental health: the role of systematic reviews. J Ment Health Policy Econ 1999; 2:99–106
 
5.Marshall M, Lockwood A: Assertive community treatment for people with severe mental disorders. Cochrane Database Syst Rev 2003; 2:CD001089
 
6.Gorey KM, Leslie DR, Morris T, Carruthers WV, John L, Chacko J: Effectiveness of case management with severely and persistently mentally ill people. Community Ment Health J 1998; 34:241–250
 
7.Bond GR, McGrew JH, Fekete DM: Assertive outreach for frequent users of psychiatric hospitals: a meta-analysis. J Ment Health Admin 1995; 22:4–16
 
8.Mueser KT, Bond GR, Drake RE, Resnick SG: Models of community care for severe mental illness: a review of research on case management. Schizophr Bull 1998; 24:37–74
 
9.Ziguras SJ, Lyle Stuart GW: A meta-analysis of the effectiveness of mental health case management over 20 years. Psychiatr Serv 2000; 51:1410–1421
 
10.Latimer EA: Economic impacts of assertive community treatment: a review of the literature. Can J Psychiatry 1999; 44:443–454
 
11.The homeless and mental illness. Society 1992; 29. http://weblinks1.epnet.com (accessed July 2004)
 
12.Link BL, Susser E, Stueve A: Lifetime and five-year prevalence of homelessness in the United States. Am J Public Health 1994; 84:1907–1912
 
13.Lehman AF, Cordray DS: Prevalence of alcohol, drug and mental disorders among the homeless: one more time. Contemp Drug Probl 1993; 20:355–383
 
14.Yanos PT, Barrow SM, Tsemberis S: Community integration in the early phase of housing among homeless persons diagnosed with severe mental illness: successes and challenges. Community Ment Health J 2004; 40:133–150
 
15.Morse GA: A review of case management for people who are homeless: implications for practice, policy, and research. http://madnation.cc/documents/morse.htm (accessed June 2003)
 
16.Rosenheck R: Cost-effectiveness of services for mentally ill homeless people: the application of research to policy and practice. Am J Psychiatry 2000; 157:1563–1570
 
17.Lam JA, Rosenheck R: Street outreach for homeless persons with severe mental illness: is it effective? Med Care 1999; 37:894–907
 
18.Clarke GN, Herinckx HA, Kinney RF, Paulson RI, Cutler DL, Lewis K, Oxman E: Psychiatric hospitalizations, arrests, emergency room visits, and homelessness of clients with serious and persistent mental illness: findings from a randomized trial of two ACT programs vs. standard care. Ment Health Serv Res 2000; 2:155–164
 
19.Morse GA, Calsyn RJ, Allen G, Tempelhoff B, Smith R: Experimental comparison of the effects of three treatment programs for homeless mentally ill people. Hosp Community Psychiatry 1992; 43:1005–1010
 
20.Morse GA, Calsyn RJ, Klinkenberg WD, Trusty ML, Gerber F, Smith R, Tempelhoff B, Ahmad L: An experimental comparison of three types of case management for homeless mentally ill persons. Psychiatr Serv 1997; 48:497–503
 
21.Deeks J: Statistical methods programmed in MetaView, version 4. Statistical Methods Working Group, Cochrane Collaboration, 1999. http://www.med.monash.edu.au/healthservices/cochrane/resources/statisticalmethods.pdf (accessed Dec 2003)
 
22.Petitti DB: Meta-Analysis, Decision Analysis, and Cost-Effectiveness Analysis: Methods for Quantitative Synthesis in Medicine, 2nd ed. New York, Oxford University Press, 2000
 
23.DerSimonian R, Laird N: Meta-analysis in clinical trials. Controlled Clin Trials 1986; 7:177–188
 
24.Korr WS, Joseph A: Housing the homeless mentally ill: findings from Chicago. J Soc Serv Res 1995; 21:53–68
 
25.Shern DL, Tsembris S, Anthony W, Lovell AM, Richmond L, Felton CJ, Winarski J, Cohen M: Serving street-dwelling individuals with psychiatric disabilities: outcomes of a psychiatric rehabilitation clinical trial. Am J Public Health 2000; 90:1873–1878
 
26.Morris DW, Warnock JK: Effectiveness of a mobile outreach and crisis services unit in reducing psychiatric symptoms in a population of homeless persons with a severe mental illness. J Okla State Med Assoc 2001; 94:343–346
 
27.Meisler N, Blankertz L, Santos AB, McKay C: Impact of assertive community treatment on homeless persons with co-occurring severe psychiatric and substance use disorders. Community Ment Health J 1997; 33:113–122
 
28.Wasylenki DA, Goering PM, Lemire D, Lindsey S, Lancee W: The Hostel Outreach Program: assertive case management for homeless mentally ill persons. Hosp Community Psychiatry 1993; 44:848–853
 
29.Dixon LB, Krauss N, Kernan E, Lehman AF, DeForge BR: Modifying the PACT model to serve homeless persons with severe mental illness. Psychiatr Serv 1995; 46:684–688
 
30.Worthington JB, Cohen DC: Characteristics of the homeless mentally ill in case management: differentiation using major diagnostic categories. J Soc Distress Homeless 1994; 3:163–173
 
31.Bachrach LL: Research on services for the homeless mentally ill. Hosp Community Psychiatry 1984; 35:910–913
 
32.Burns T, Catty J, Watt H, Wright C, Knapp M, Henderson J: International differences in home treatment for mental health problems. Br J Psychiatry 2002; 181:375–382
 
33.Commander M, Odell S, Sashidharan S: Psychiatric admission for homeless people: the impact of a specialist community mental health team. Psychiatric Bull 1997; 21:260–263
 
34.Nordentoft M, Knudsen HC, Jessen-Petersen B, Krasnik A, Saelan H, Brodersen AM, Treufeldt P, Loppenthin P, Sahl I, Ostergard P: Copenhagen Community Psychiatric Project (CCPP): characteristics and treatment of homeless patients in the psychiatric services after introduction of community mental health centres. Soc Psychiatry Psychiatr Epidemiol 1997; 32:369–378
 
35.Odell S, Commander M: A follow-up study of people with a severe mental illness treated by a specialist homeless team. Psychiatr Bull 1999; 23:139–142
 
36.Drake RE, Yovetich NA, Bebout RR, Harris M, McHugo GJ: Integrated treatment for dually diagnosed homeless adults. J Nerv Ment Dis 1997; 185:298–305
 
37.Susser E, Valencia E, Conover S, Felix A, Tsai W, Wyatt RJ: Preventing recurrent homelessness among mentally ill men: a “critical time” intervention after discharge from a shelter. Am J Public Health 1997; 87:256–262
 
38.Lehman AF, Dixon L, Hoch JS, DeForge B, Kernan E, Frank R: Cost-effectiveness of assertive community treatment for homeless persons with severe mental illness. Br J Psychiatry 1999; 174:346–352
 
39.Wolff N, Helminiak TW, Morse GA, Calsyn RJ, Klinkenberg WD, Trusty ML: Cost-effectiveness evaluation of three approaches to case management for homeless mentally ill clients. Am J Psychiatry 1997; 154:341–348
 
40.Rife JC, First RJ, Greenlee RW, Miller LD, Feichter MA: Case management with homeless mentally ill people. Health Soc Work 1991; 16:58–67
 
41.Solomon P, Draine J: One-year outcomes of a randomized trial of case management with seriously mentally ill clients leaving jail. Eval Rev 1995; 19:256–273
 
42.First RJ, Rife JC, Kraus S: Case management with people who are homeless and mentally ill: preliminary findings from an NIMH demonstration project. Psychosoc Rehab J 1990; 13:87–91
 
43.Rosenheck R, Kasprow W, Frisman L, Liu-Mares W: Cost-effectiveness of supported housing for homeless persons with mental illness. Arch Gen Psychiatry 2003; 60:940–951
 
44.Calsyn RJ, Winter JP: Social support, psychiatric symptoms, and housing: a causal analysis. J Community Psychol 2002; 30:247–259
 
45.Rosenheck RA, Dennis D: Time-limited assertive community treatment for homeless persons with severe mental illness. Arch Gen Psychiatry 2001; 58:1073–1080
 
 
Figure 1. Assessment of Publication Bias Using a Funnel Plot Comparing Cohort Size Versus Effect Difference

Figure 1. Assessment of Publication Bias Using a Funnel Plot Comparing Cohort Size Versus Effect Difference
+

References

1.Drake RE, Mueser KT, Torrey WC, Miller AL, Lehman AF, Bond GR, Goldman HH, Leff HS: Evidence-based treatment of schizophrenia. Curr Psychiatry Rep 2000; 2:393–397
 
2.Stein LI, Test MA: Alternative to mental hospital treatment, I: conceptual model, treatment program, and clinical evaluation. Arch Gen Psychiatry 1980; 37:392–397
 
3.Lehman AF, Dixon LB, Kernan E, DeForge BR, Postrado LT: A randomized trial of assertive community treatment for homeless persons with severe mental illness. Arch Gen Psychiatry 1997; 54:1038–1043
 
4.Gilbody SM, Petticrew M: Rational decision-making in mental health: the role of systematic reviews. J Ment Health Policy Econ 1999; 2:99–106
 
5.Marshall M, Lockwood A: Assertive community treatment for people with severe mental disorders. Cochrane Database Syst Rev 2003; 2:CD001089
 
6.Gorey KM, Leslie DR, Morris T, Carruthers WV, John L, Chacko J: Effectiveness of case management with severely and persistently mentally ill people. Community Ment Health J 1998; 34:241–250
 
7.Bond GR, McGrew JH, Fekete DM: Assertive outreach for frequent users of psychiatric hospitals: a meta-analysis. J Ment Health Admin 1995; 22:4–16
 
8.Mueser KT, Bond GR, Drake RE, Resnick SG: Models of community care for severe mental illness: a review of research on case management. Schizophr Bull 1998; 24:37–74
 
9.Ziguras SJ, Lyle Stuart GW: A meta-analysis of the effectiveness of mental health case management over 20 years. Psychiatr Serv 2000; 51:1410–1421
 
10.Latimer EA: Economic impacts of assertive community treatment: a review of the literature. Can J Psychiatry 1999; 44:443–454
 
11.The homeless and mental illness. Society 1992; 29. http://weblinks1.epnet.com (accessed July 2004)
 
12.Link BL, Susser E, Stueve A: Lifetime and five-year prevalence of homelessness in the United States. Am J Public Health 1994; 84:1907–1912
 
13.Lehman AF, Cordray DS: Prevalence of alcohol, drug and mental disorders among the homeless: one more time. Contemp Drug Probl 1993; 20:355–383
 
14.Yanos PT, Barrow SM, Tsemberis S: Community integration in the early phase of housing among homeless persons diagnosed with severe mental illness: successes and challenges. Community Ment Health J 2004; 40:133–150
 
15.Morse GA: A review of case management for people who are homeless: implications for practice, policy, and research. http://madnation.cc/documents/morse.htm (accessed June 2003)
 
16.Rosenheck R: Cost-effectiveness of services for mentally ill homeless people: the application of research to policy and practice. Am J Psychiatry 2000; 157:1563–1570
 
17.Lam JA, Rosenheck R: Street outreach for homeless persons with severe mental illness: is it effective? Med Care 1999; 37:894–907
 
18.Clarke GN, Herinckx HA, Kinney RF, Paulson RI, Cutler DL, Lewis K, Oxman E: Psychiatric hospitalizations, arrests, emergency room visits, and homelessness of clients with serious and persistent mental illness: findings from a randomized trial of two ACT programs vs. standard care. Ment Health Serv Res 2000; 2:155–164
 
19.Morse GA, Calsyn RJ, Allen G, Tempelhoff B, Smith R: Experimental comparison of the effects of three treatment programs for homeless mentally ill people. Hosp Community Psychiatry 1992; 43:1005–1010
 
20.Morse GA, Calsyn RJ, Klinkenberg WD, Trusty ML, Gerber F, Smith R, Tempelhoff B, Ahmad L: An experimental comparison of three types of case management for homeless mentally ill persons. Psychiatr Serv 1997; 48:497–503
 
21.Deeks J: Statistical methods programmed in MetaView, version 4. Statistical Methods Working Group, Cochrane Collaboration, 1999. http://www.med.monash.edu.au/healthservices/cochrane/resources/statisticalmethods.pdf (accessed Dec 2003)
 
22.Petitti DB: Meta-Analysis, Decision Analysis, and Cost-Effectiveness Analysis: Methods for Quantitative Synthesis in Medicine, 2nd ed. New York, Oxford University Press, 2000
 
23.DerSimonian R, Laird N: Meta-analysis in clinical trials. Controlled Clin Trials 1986; 7:177–188
 
24.Korr WS, Joseph A: Housing the homeless mentally ill: findings from Chicago. J Soc Serv Res 1995; 21:53–68
 
25.Shern DL, Tsembris S, Anthony W, Lovell AM, Richmond L, Felton CJ, Winarski J, Cohen M: Serving street-dwelling individuals with psychiatric disabilities: outcomes of a psychiatric rehabilitation clinical trial. Am J Public Health 2000; 90:1873–1878
 
26.Morris DW, Warnock JK: Effectiveness of a mobile outreach and crisis services unit in reducing psychiatric symptoms in a population of homeless persons with a severe mental illness. J Okla State Med Assoc 2001; 94:343–346
 
27.Meisler N, Blankertz L, Santos AB, McKay C: Impact of assertive community treatment on homeless persons with co-occurring severe psychiatric and substance use disorders. Community Ment Health J 1997; 33:113–122
 
28.Wasylenki DA, Goering PM, Lemire D, Lindsey S, Lancee W: The Hostel Outreach Program: assertive case management for homeless mentally ill persons. Hosp Community Psychiatry 1993; 44:848–853
 
29.Dixon LB, Krauss N, Kernan E, Lehman AF, DeForge BR: Modifying the PACT model to serve homeless persons with severe mental illness. Psychiatr Serv 1995; 46:684–688
 
30.Worthington JB, Cohen DC: Characteristics of the homeless mentally ill in case management: differentiation using major diagnostic categories. J Soc Distress Homeless 1994; 3:163–173
 
31.Bachrach LL: Research on services for the homeless mentally ill. Hosp Community Psychiatry 1984; 35:910–913
 
32.Burns T, Catty J, Watt H, Wright C, Knapp M, Henderson J: International differences in home treatment for mental health problems. Br J Psychiatry 2002; 181:375–382
 
33.Commander M, Odell S, Sashidharan S: Psychiatric admission for homeless people: the impact of a specialist community mental health team. Psychiatric Bull 1997; 21:260–263
 
34.Nordentoft M, Knudsen HC, Jessen-Petersen B, Krasnik A, Saelan H, Brodersen AM, Treufeldt P, Loppenthin P, Sahl I, Ostergard P: Copenhagen Community Psychiatric Project (CCPP): characteristics and treatment of homeless patients in the psychiatric services after introduction of community mental health centres. Soc Psychiatry Psychiatr Epidemiol 1997; 32:369–378
 
35.Odell S, Commander M: A follow-up study of people with a severe mental illness treated by a specialist homeless team. Psychiatr Bull 1999; 23:139–142
 
36.Drake RE, Yovetich NA, Bebout RR, Harris M, McHugo GJ: Integrated treatment for dually diagnosed homeless adults. J Nerv Ment Dis 1997; 185:298–305
 
37.Susser E, Valencia E, Conover S, Felix A, Tsai W, Wyatt RJ: Preventing recurrent homelessness among mentally ill men: a “critical time” intervention after discharge from a shelter. Am J Public Health 1997; 87:256–262
 
38.Lehman AF, Dixon L, Hoch JS, DeForge B, Kernan E, Frank R: Cost-effectiveness of assertive community treatment for homeless persons with severe mental illness. Br J Psychiatry 1999; 174:346–352
 
39.Wolff N, Helminiak TW, Morse GA, Calsyn RJ, Klinkenberg WD, Trusty ML: Cost-effectiveness evaluation of three approaches to case management for homeless mentally ill clients. Am J Psychiatry 1997; 154:341–348
 
40.Rife JC, First RJ, Greenlee RW, Miller LD, Feichter MA: Case management with homeless mentally ill people. Health Soc Work 1991; 16:58–67
 
41.Solomon P, Draine J: One-year outcomes of a randomized trial of case management with seriously mentally ill clients leaving jail. Eval Rev 1995; 19:256–273
 
42.First RJ, Rife JC, Kraus S: Case management with people who are homeless and mentally ill: preliminary findings from an NIMH demonstration project. Psychosoc Rehab J 1990; 13:87–91
 
43.Rosenheck R, Kasprow W, Frisman L, Liu-Mares W: Cost-effectiveness of supported housing for homeless persons with mental illness. Arch Gen Psychiatry 2003; 60:940–951
 
44.Calsyn RJ, Winter JP: Social support, psychiatric symptoms, and housing: a causal analysis. J Community Psychol 2002; 30:247–259
 
45.Rosenheck RA, Dennis D: Time-limited assertive community treatment for homeless persons with severe mental illness. Arch Gen Psychiatry 2001; 58:1073–1080
 
+
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1.
Assertive community treatment is distinguished from standard case management by which of the following?
2.
Which of the following is a demonstrated advantage of assertive community treatment over standard case management:
3.
What is the purpose of the funnel plot used in this study comparing the cohort size and effect difference?
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