Friederike Ruppelt

Effectiveness of Integrated Care Including Therapeutic Assertive Community Treatment in Severe Schizophrenia Spectrum and Bipolar I Disorders: The 24-Month Follow-Up ACCESS II Study

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 to October 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 repeated-measures 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.

Early detection and integrated care for adolescents and young adults with severe psychotic disorders: rationales and design of the Integrated Care in Early Psychosis Study (ACCESS III)

The Integrated Care in Early Psychosis (ACCESS III) Study examined the efficacy and cost‐effectiveness of a combined intervention consisting of strategies to improve early detection and quality of care (integrated care including therapeutic assertive community treatment) in adolescents and young adults in the early phase of a severe psychotic disorder from 2011 to 2014.

Trialog und Psychosenpsychotherapie

ZusammenfassungTrialog meint hier die gleichberechtigte Begegnung von Psychoseerfahrenen, Angehörigen und Therapeuten im Sinne von wechselseitigem Lernen und gegenseitigem Respekt. Diese Idee hat ihren Ursprung in Deutschland in den sog. Psychoseseminaren, hat aber inzwischen auch Bedeutung für andere Krankheitserfahrungen und für andere Ebenen der Begegnung – für psychiatrische Praxis, Antistigmaarbeit, Beschwerdestellen, für Psychiatrieplanung und Qualitätssicherung sowie für Lehre, Tagungen, Fortbildungen und auch für die Forschung. In diesem Beitrag wird der Trialog anhand der Ziele, Erfahrungen und Ergebnisse der Psychoseseminare dargestellt und mit denen der Psychoedukation verglichen. Anschließend wird die Idee des Trialogs mit der Entwicklung der Psychosenpsychotherapie in Beziehung gesetzt: Haben die Erfahrungen des Trialogs auch Relevanz für Psychotherapie? Können nicht nur formale, sondern auch inhaltliche Impulse abgeleitet werden? Kann der Trialog insgesamt die Psychosenpsychotherapie stärken und stützen? In diesem Zusammenhang werden die empirischen Ergebnisse des trialogischen SuSi-Forschungsprojekts zu subjektivem Sinn und Bedeutung von Psychosen dargestellt – ein überraschend eindeutiges Plädoyer für Sinnorientierung und für eine biografiebezogene Psychosenpsychotherapie.Abstract Trialogue in this context is defined as the equal encounter of people with experience of psychoses, relatives and therapists in the sense of reciprocal learning and mutual respect. This concept has its origins in Germany in the so-called psychosis seminars but has now become of importance for experiences with other diseases and for other levels of encounters – for psychiatric practice, anti-stigma work, tribunals, for psychiatry planning and quality assurance, teaching, congresses, further education and also for research. In this article the trialogue will be presented based on the targets, experiences and results of psychosis seminars and compared with the results of psychoeducation. Finally, the concept of trialogue will be placed in context with the development of the psychotherapy of psychoses: are experiences of trialogue also relevant for psychotherapy? Can not only form but also content impulses be derived? Can trialogue strengthen and support the psychotherapy of psychoses as a whole? In this context the empirical results of the trialogue research project SuSi on the subjective meaning and significance of psychoses will be presented showing a surprisingly clear case for sense orientation and for a biography-oriented psychotherapy of psychoses.

Early detection and integrated care for adolescents and young adults with psychotic disorders: the ACCESS III study

The objective of the study was to investigate whether a combined intervention composed of early detection plus integrated care (EDIC) enhances outcomes in patients with early psychosis compared to standard care (SC).

Früherkennung und integrierte Versorgung von Jugendlichen und jungen Erwachsenen mit schweren psychotischen Erkrankungen

This is a prospective 1-year follow-up study comparing a combined intervention consisting of multidimensional early detection strategies with age- and interdisciplinary integrated care (intervention group, n = 120) with standard care (historical control group, n = 105) in adolescents and young adults within the early phase of psychosis. Data at study entry indicate a high complexity and severity of illness. Primary outcome is the 6-month rate of combined symptomatic and functional remission at study endpoint.

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

The ACCESS-model offers integrated care including assertive community treatment to patients with psychotic disorders. ACCESS proved more effective compared to standard care (ACCESS-I study) and was successfully implemented into clinical routine (ACCESS-II study). In this article, we report the 4-year outcomes of the ACCESS-II study. Between May 2007 and December 2013, 115 patients received continuous ACCESS-care. We hypothesized that the low 2-year disengagement and hospitalization rates and significant improvements in psychopathology, functioning, and quality of life could be sustained over 4 years. Over 4 years, only 10 patients disengaged from ACCESS. Another 23 left for practical reasons and were successfully transferred to other services. Hospitalization rates remained low (13.0% in year 3; 9.1% in year 4). Involuntary admissions decreased from 35% in the 2 years prior to ACCESS to 8% over 4 years in ACCESS. Outpatient contacts remained stably high at 2.0–2.4 per week. We detected significant improvements in psychopathology (effect size d = 0.79), illness severity (d = 1.29), level of functioning (d = 0.77), quality of life (d = 0.47) and stably high client satisfaction (d = 0.02) over 4 years. Most positive effects were observed within the first 2 years with the exception of illness severity, which further improved from year 2 to 4. Within continuous intensive 4-year ACCESS-care, sustained improvements in psychopathology, functioning, quality of life, low service disengagement and re-hospitalization rates, as well as low rates of involuntary treatment, were observed in contrast to other studies, which reported a decline in these parameters once a specific treatment model was stopped. Yet, stronger evidence to prove these results is required. Trial registration: Clinical Trial Registration Number: NCT01888627

Comorbidity of chronic somatic diseases in patients with psychotic disorders and their influence on 4-year outcomes of integrated care treatment (ACCESS II study)

BACKGROUND People with psychotic disorders fulfilling criteria of a severe and persistent mental illness (SPMI) display a high risk of somatic comorbidity (SC). METHODS ACCESS II is a prospective, long-term study examining the effectiveness of Integrated Care for people with psychotic disorders fulfilling SPMI criteria. Chronic comorbid somatic disorders were systematically assessed according to ICD-10-GM criteria. Patients treated for ≥4years in ACCESS were categorized as early psychosis (treatment: ≤2years) or non-early psychosis (treatment: >2years) patients. RESULTS Of 187 patients treated in ACCESS for ≥4years (mean age=41.8years, males=44.4%), 145 (77.5%) had SC, (mean=2.1±2.1). Overall, 55 different diseases from 15 different ICD-10-GM disease areas were identified. Prevalence of ≥1 SC (p=0.09) and specific types of SC (p=0.08-1.00) did not differ between early and non-early psychosis patients, but non-early psychosis patients had a higher mean number of SC (2.3±2.2 vs. 1.3±1.3, p=0.002). SC patients had higher rates of comorbid mental disorders (93% vs. 81%, p=0.002), specifically posttraumatic stress disorder (23% vs. 7%, p=0.002), and suicide attempts (43% vs. 19%, p<0.001). At the 4-year endpoint, both patients with and without comorbidity displayed major improvements in psychopathology, severity of illness, functioning, quality of life and satisfaction with care. CONCLUSIONS SC is frequent in patients with severe psychotic disorders, even in the early psychosis phase. The magnitude of the problem underlines the need for regular screening, comprehensive assessment, preventive pharmacotherapy, and targeted SC management.

Early detection and integrated care for adolescents and young adults with severe psychotic disorders: rationales and design of the Integrated Care in Early Psychosis Study (ACCESS III): Integrated care in early psychosis

The Integrated Care in Early Psychosis (ACCESS III) Study examined the efficacy and cost‐effectiveness of a combined intervention consisting of strategies to improve early detection and quality of care (integrated care including therapeutic assertive community treatment) in adolescents and young adults in the early phase of a severe psychotic disorder from 2011 to 2014.