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)

  • Stefanie J. Schmidt
  • Matthias Lange
  • Daniel Schöttle
  • Anne Karow
  • Benno G. Schimmelmann
  • Martin LambertEmail author
Original Paper


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.


Mediation Amotivation Quality of life Functioning Negative symptoms Psychosis 


Compliance with ethical standards

Financial support

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.

Ethical standards

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.


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Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  • Stefanie J. Schmidt
    • 1
    • 2
  • Matthias Lange
    • 3
  • Daniel Schöttle
    • 3
  • Anne Karow
    • 3
  • Benno G. Schimmelmann
    • 1
    • 4
  • Martin Lambert
    • 3
    Email author
  1. 1.University Hospital of Child and Adolescent Psychiatry and PsychotherapyUniversity of BernBernSwitzerland
  2. 2.Department of Psychiatry and PsychotherapyUniversity of CologneCologneGermany
  3. 3.Department for Psychiatry and Psychotherapy, Psychosis Centre, Centre for Psychosocial MedicineUniversity Medical Centre Hamburg-EppendorfHamburgGermany
  4. 4.University Hospital of Child and Adolescent Psychiatry, Centre for Psychosocial MedicineUniversity Medical Centre Hamburg-EppendorfHamburgGermany

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