Santos A B, Henggeler S W, Burns B J, Arana G W, Meisler N
Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston 29425, USA.
Am J Psychiatry. 1995 Aug;152(8):1111-23. doi: 10.1176/ajp.152.8.1111.
Clinical services for psychiatrically impaired populations have only recently been studied with scientifically valid designs to explore innovations in structure, accessibility, and financing. Health systems reform in the United States has provided the impetus for better defining clinically effective and cost-sensitive models for mental health services. This article reviews assertive community treatment, used for adults with severe mental illnesses, and multisystemic therapy, used for adolescents with serious emotional disturbances, as examples of service system innovations that have been studied with controlled clinical trial designs and have demonstrated efficacy in treating difficult and costly clinical populations.
The authors reviewed the published controlled clinical trials of assertive community treatment and multisystemic therapy, focusing on the clinical and administrative elements that distinguish them from traditional service systems.
A qualitative assessment of these two approaches suggests that they share common elements, with important implications for mental health policy. Specifically, the use of an ecological model of behavior applied to mental health patients is critical to both systems. In addition, therapeutic principles emphasizing pragmatic (outcome-oriented) treatment approaches, home-based interventions, and individualized goals are key elements of their success. Most important, both systems embody a therapeutic philosophy demanding therapist accountability, in which personnel are rewarded for clinical outcomes and therapeutic innovation rather than for following a prescribed plan.
As empirically tested approaches, assertive community treatment and multisystemic therapy provide a scientific foundation for continued reform and serve to illustrate critical elements in designing new community treatment initiatives for behavioral as well as medical conditions.
针对有精神障碍人群的临床服务，直到最近才采用科学有效的设计进行研究，以探索在结构、可及性和融资方面的创新。美国的医疗体系改革为更好地界定精神卫生服务的临床有效且成本敏感的模式提供了动力。本文回顾了用于患有严重精神疾病的成年人的积极社区治疗，以及用于有严重情绪障碍的青少年的多系统治疗，作为服务体系创新的实例，这些创新已通过对照临床试验设计进行研究，并已证明在治疗困难且费用高昂的临床人群方面具有疗效。
作者回顾了已发表的关于积极社区治疗和多系统治疗的对照临床试验，重点关注将它们与传统服务体系区分开来的临床和管理要素。
对这两种方法的定性评估表明，它们具有共同要素，这对精神卫生政策具有重要意义。具体而言，将行为生态模型应用于精神卫生患者对这两种体系都至关重要。此外，强调务实（以结果为导向）治疗方法、居家干预和个性化目标的治疗原则是它们成功的关键要素。最重要的是，这两种体系都体现了一种要求治疗师承担责任的治疗理念，即人员因临床结果和治疗创新而非遵循既定计划而获得奖励。
作为经过实证检验的方法，积极社区治疗和多系统治疗为持续改革提供了科学基础，并有助于阐明为行为及医疗状况设计新的社区治疗举措的关键要素。
