Effectiveness of Integrated Care Including Therapeutic Assertive Community Treatment in Severe Schizophrenia Spectrum and Bipolar I Disorders

Abstract

Objective:The ACCESS treatment model offers assertive community treatment embedded in an integrated care program to patients with psychoses. Compared to standard care and within a controlled study, it proved to be more effective in terms of service disengagement and illness outcomes in patients with schizophrenia spectrum disorders over 12 months. ACCESS was implemented into clinical routine and its effectiveness assessed over 24 months in severe schizophrenia spectrum disorders and bipolar I disorder with psychotic features (DSM-IV) in a cohort study. Method: All 115 patients treated in ACCESS (from May 2007 toOctober 2009) were included in the ACCESS II study. The primary outcome was rate of service disengagement. Secondary outcomes were change of psychopathology, severity of illness, psychosocial functioning, quality of life, satisfaction with care, medication nonadherence, length of hospital stay, and rates of involuntary hospitalization.Results: Only 4 patients (3.4%) disengaged with the service. Another 11 (9.6%) left because they moved outside the catchment area. Patients received a mean of 1.6 outpatient contacts per week. Involuntary admissions decreased from 34.8% in the 2 previous years to 7.8% during ACCESS (P < .001). Mixed models repeatedmeasures analyses revealed significant improvements among all patients in psychopathology (effect size d = 0.64, P < .001), illness severity (d = 0.84, P = .03), functioning level (d = 0.65, P < .001), quality of life (d = 0.50, P < .001), and client satisfaction (d = 0.11, P < .001). At 24 months, 78.3% were fully adherent to medication, compared to 25.2% at baseline (P = .002).Conclusions: ACCESS was successfully implemented in clinical routine and maintained excellent rates of service engagement and other outcomes in patients with schizophrenia spectrum disorders or bipolar I disorder with psychotic features over 24 months.Trial Registration: ClinicalTrials.gov identifier: NCT01888627

Psychotic Symptoms and Attitudes toward Medication Mediate the Effect of Insight on Personal-Social Functions in Patients with Schizophrenia: One-Year Randomized Controlled Trial and Follow-Up

“…The results are in accordance with previous studies reporting that antipsychotic treatment integrated with several components of psychosocial intervention is superior to traditional medication-alone treatments in terms of dealing with several problems (e.g., psychotic symptoms, social functioning, and compliance to medication) simultaneously in the treatment of schizophrenia [1, 23, 25, 27, 29, 48-50]. …”

“…Antipsychotic treatment integrated with several components of psychosocial intervention approaches have been considered beneficial in social functional outcomes for patients with schizophrenia in long-term therapy with antipsychotics [23-29]. The improvements in personal-social function, self-awareness, psychotic symptoms, and attitudes toward medication induced by the mediation effect of treatment methods (combined treatment vs. treatment with medication alone) may interact with each other over time, and whether factors mediating improved insight on improved personal-social functioning are affected by the treatment methods remains unclear.…”

Effectiveness of integrated care including therapeutic assertive community treatment in severe schizophrenia-spectrum and bipolar I disorders: Four-year follow-up of the ACCESS II study

“…In 2007, the ACCESS-model was implemented in routine care and concurrently extended to patients with bipolar disorder with psychotic features (BD), offering continuous and open-ended treatment. Under real-life conditions, the effectiveness of the program was continuously assessed (ACCESS-II-study) [ 6 ]. The 24-month follow-up revealed low service disengagement rates and hospital days as well as improvements in psychopathology, illness severity, functioning level, quality of life, and client satisfaction in both SSD and BD [ 6 ].…”

“…Under real-life conditions, the effectiveness of the program was continuously assessed (ACCESS-II-study) [ 6 ]. The 24-month follow-up revealed low service disengagement rates and hospital days as well as improvements in psychopathology, illness severity, functioning level, quality of life, and client satisfaction in both SSD and BD [ 6 ]. These improvements were similar to those found in ACCESS under research conditions (ACCESS-I-study [ 4 ]).…”

Which routes should psychopharmacological treatment research take in schizophrenia?

“…A German study has highlighted new ways of routine patient care: individual patient care can be improved and deficits can be addressed by integrated care programs (10). Assertive community treatment embedded in an integrated care program proved to be more effective in terms of service disengagement and illness outcomes in patients with schizophrenia (8,9). The implementation of treatment pathways brought about a robust change in efficacy (11).…”