Assertive Community Treatment as Part of Integrated Care Versus Standard Care

Abstract

Article Abstract Objective: The ACCESS trial examined the 12-month effectiveness of continuous therapeutic assertive community treatment (ACT) as part of integrated care compared to standard care in a catchment area comparison design in patients with schizophrenia spectrum disorders treated with quetiapine immediate release. Method: Two catchment areas in Hamburg, Germany, with similar population size and health care structures were assigned to offer 12-month ACT as part of integrated care (n†‰=†‰64) or standard care (n†‰=†‰56) to 120 patients with first- or multiple-episode schizophrenia spectrum disorders (Structured Clinical Interview for DSM-IV Axis I Disorders criteria); multiple-episode patients were restricted to those with a history of relapse due to medication nonadherence. The primary outcome was time to service disengagement. Secondary outcomes comprised medication nonadherence, improvements of symptoms, functioning, quality of life, satisfaction with care from patients†and relatives†perspectives, and service use data. The study was conducted from April 2005 to December 2008. Results: 17 of 120 patients (14.2%) disengaged with service, 4 patients (6.3%) in the ACT and 13 patients (23.2%) in the standard care group. The mean Kaplan-Meier estimated time in service was 50.7 weeks in the ACT group (95% CI, 49.1-52.0) and 44.1 weeks in the standard care group (95% CI, 40.1-48.1). This difference was statistically significant (P†‰=†‰.0035). Mixed models repeated measures indicated larger improvements for ACT compared to standard care regarding symptoms (P†‰<†‰.01), illness severity (P†‰<†‰.001), global functioning (P†‰<†‰.05), quality of life (P†‰<†‰.05), and client satisfaction as perceived by patients and family (both P†‰<†‰.05). Logistic regression analyses revealed that ACT was associated with a higher likelihood of being employed/occupied (P†‰=†‰.001), of living independently (P†‰=†‰.007), and of being adherent with medication (P†‰<†‰.001) and a lower likelihood of persistent substance misuse (P†‰=†‰.027). Conclusions: Compared to standard care, intensive therapeutic ACT as part of integrated care could improve 1-year outcome. Future studies need to address in which settings these improvements can be sustained. Trial Registration: clinicaltrials.gov Identifier: NCT01081418 J Clin Psychiatry © Copyright 2010 Physicians Postgraduate Press, Inc. Submitted: February 9, 2009; accepted June 9, 2009. Online ahead of print: March 23, 2010 (doi:10.4088/JCP.09m05113yel). Corresponding author: Martin Lambert, MD, Psychosis Centre, Department for Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistr 52, 20246 Hamburg, Germany (lambert@uke.uni-hamburg.de).

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