Negative symptoms, anxiety, and depression as mechanisms of change of a 12-month trial of assertive community treatment as part of integrated care in patients with first- and multi-episode schizophrenia spectrum disorders (ACCESS I trial)
- 549 Downloads
Assertive community treatment (ACT) has shown to be effective in improving both functional deficits and quality of life (QoL) in patients with severe mental illness. However, the mechanisms of this beneficial effect remained unclear. We examined mechanisms of change by testing potential mediators including two subdomains of negative symptoms, i.e. social amotivation as well as expressive negative symptoms, anxiety, and depression within a therapeutic ACT model (ACCESS I trial) in a sample of 120 first- and multi-episode patients with a schizophrenia spectrum disorder (DSM-IV). Path modelling served to test the postulated relationship between the respective treatment condition, i.e. 12-month ACT as part of integrated care versus standard care, and changes in functioning and QoL. The final path model resulted in 3 differential pathways that were all significant. Treatment-induced changes in social amotivation served as a starting point for all pathways, and had a direct beneficial effect on functioning and an additional indirect effect on it through changes in anxiety. Expressive negative symptoms were not related to functioning but served as a mediator between changes in social amotivation and depressive symptoms, which subsequently resulted in improvements in QoL. Our results suggest that social amotivation, expressive negative symptoms, depression, and anxiety functioned as mechanisms of change of ACCESS. An integrated and sequential treatment focusing on these mediators may optimise the generalisation effects on functioning as well as on QoL by targeting the most powerful mechanism of change that fits best to the individual patient.
KeywordsMediation Amotivation Quality of life Functioning Negative symptoms Psychosis
Compliance with ethical standards
This study was supported by Astra Zeneca. The sponsor was not involved in designing and conducting the study, analysing as well as interpreting the data or writing up the manuscript.
Conflict of interest
Dr Schmidt and Dr Lange have no conflict of interest to declare. Dr Schöttle has received honoraria from Astra Zeneca. Dr Karow has received honoraria from and serves on speakers boards of Astra Zeneca. Dr Schimmelmann has served as paid speaker for Eli Lilly and Shire. Dr Lambert has received grant/research support from and served on speakers or advisory boards of Astra Zeneca and has received honoraria from Astra Zeneca, Eli Lilly, Janssen-Cilag, and Bristol-Myers Squibb.
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional guides on the care and use of laboratory animals.
- 2.Bechdolf A, Pukrop R, Köhn D, Tschinkel S, Veith V, Schultze-Lutter F, Klosterkötter J (2005) Subjective quality of life in subjects at risk for a first episode of psychosis: a comparison with first episode schizophrenia patients and healthy controls. Schizophr Res 79(1):137–143CrossRefPubMedGoogle Scholar
- 4.Meesters PD, Comijs HC, de Haan L, Smit JH, Eikelenboom P, Beekman ATF, Stek ML (2013) Subjective quality of life and its determinants in a catchment area based population of elderly schizophrenia patients. Schizophr Res 147(2–3):275–280. doi: 10.1016/j.schres.2013.04.030 CrossRefPubMedGoogle Scholar
- 5.Álvarez-Jiménez M, Gleeson JF, Henry LP, Harrigan SM, Harris MG, Killackey E, Bendall S, Amminger GP, Yung AR, Herrman H, Jackson HJ, McGorry PD (2012) Road to full recovery: longitudinal relationship between symptomatic remission and psychosocial recovery in first-episode psychosis over 7.5 years. Psychol Med 42(3):595–606CrossRefPubMedGoogle Scholar
- 9.Kerkemeyer L, Mostardt S, Biermann J, Wasem J, Neumann A, Walendzik A, Jahn R, Bartels C, Falkai P, Brannath W, Breunig-Lyriti V, Mester B, Timm J, Wobrock T (2015) Evaluation of an integrated care program for schizophrenia: concept and study design. Eur Arch Psychiatry Clin Neurosci 265(2):155–162CrossRefPubMedGoogle Scholar
- 10.Karow A, Reimer J, König HH, Heider D, Bock T, Huber C, Lambert M (2012) Cost-effectiveness of 12-month therapeutic assertive community treatment as part of integrated care versus standard care in patients with schizophrenia treated with quetiapine immediate release (ACCESS trial). J Clin Psychiatry 73(3):402–408CrossRefGoogle Scholar
- 11.Lambert M, Bock T, Schöttle D, Golks D, Meister K, Rietschel L, Schimmelmann BG (2010) Assertive community treatment as part of integrated care versus standard care: a 12-month trial in patients with first- and multiple-episode schizophrenia spectrum disorders treated with quetiapine immediate release (ACCESS trial). J Clin Psychiatry 71(10):1313–1323CrossRefPubMedGoogle Scholar
- 21.Gade K, Malzahn D, Anderson-Schmidt H, Strohmaier J, Meier S, Frank J, Schulze TG (2015) Functional outcome in major psychiatric disorders and associated clinical and psychosocial variables: a potential cross-diagnostic phenotype for further genetic investigations? World J Biol Psychiatry 16(4):237–248CrossRefPubMedGoogle Scholar
- 31.Sass H, Wittchen HU, Zaudig M, Houben I (2003) Diagnostische kriterien des diagnostischen und statistischen manuals psychischer störungen. DSM-IV-TR. Hogrefe, GöttingenGoogle Scholar
- 32.Hayes AF (2013) Introduction to mediation, moderation, and conditional process analysis: a regression-based approach. The Guilford Press, New YorkGoogle Scholar
- 38.Brown TA (2006) Confirmatory factor analysis for applied research. The Guilford Press, New YorkGoogle Scholar
- 57.Urben S, Baier V, Mantzouranis G, Pigois E, Graap C, Dutoit F, Cherix-Parchet M, Henz C, Faucherand A, Senent E, Holzer L (2015) Predictors and moderators of clinical outcomes in adolescents with severe mental disorders after an assertive community treatment. Child Psychiatry Hum Dev 46(6):997–1005CrossRefPubMedGoogle Scholar