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Effectiveness of an Assertive Community Treatment program for people with severe schizophrenia in mainland China – a 12-month randomized controlled trial

  • Xingwei Luo (a1), Samuel F. Law (a2), Xiang Wang (a1), Jingzheng Shi (a3), Wu Zeng (a4), Xiaoqian Ma (a1), Wendy Chow (a2), Shiyan Liu (a1), Wei Zhao (a1), Xiaoli Liu (a3), Shuqiao Yao (a1) and Michael R. Phillips (a5) (a6)...

Abstract

Background

Assertive Community Treatment (ACT) is an evidence-based treatment program for people with severe mental illness developed in high-income countries. We report the first randomized controlled trial of ACT in mainland China.

Methods

Sixty outpatients with schizophrenia with severe functional impairments or frequent hospitalizations were randomly assigned to ACT (n = 30) or standard community treatment (n = 30). The severity of symptoms and level of social functioning were assessed at baseline and every 3 months during the 1-year study. The primary outcome was the duration of hospital readmission. Secondary outcomes included a pre-post change in symptom severity, the rates of symptom relapse and gainful employment, social and occupational functioning, and quality of life of family caregivers.

Results

Based on a modified intention-to-treat analysis, the outcomes for ACT were significantly better than those of standard community treatment. ACT patients were less likely to be readmitted [3.3% (1/30) v. 25.0% (7/28), Fisher's exact test p = 0.023], had a shorter mean readmission time [2.4 (13.3) v. 30.7 (66.9) days], were less likely to relapse [6.7% (2/30) v. 28.6% (8/28), Fisher's exact test p = 0.038], and had shorter mean time in relapse [3.5 (14.6) v. 34.4 (70.6) days]. The ACT group also had significantly longer times re-employed and greater symptomatic improvement and their caregivers experienced a greater improvement in their quality of life.

Conclusion

Our results show that culturally adapted ACT is both feasible and effective for individuals with severe schizophrenia in urban China. Replication studies with larger samples and longer duration of follow up are warranted.

Copyright

Corresponding author

Author for correspondence: Xiang Wang, E-mail: wang0916xia@gmail.com or wangxiang0916@csu.edu.cn

References

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Allness, DJ and Knoedler, WH (2003) ACT Clients: Whom Is ACT for? In: A Manual for ACT Start-up: Based on the PACT Model of Community Treatment for Persons with Severe and Persistent Mental Illnesses. Arlington, Virginia: NAMI Press.
Andreasen, NC, Flaum, M, Swayze, VWII, Tyrrell, G and Arndt, S (1990) Positive and negative symptoms in schizophreniaA critical reappraisal. Archives of General Psychiatry 47, 615621.
Bertelsen, M, Jeppesen, P, Petersen, L, Thorup, A, Ohlenschlaeger, J, le Quach, P, Christensen, TO, Krarup, G, Jorgensen, P and Nordentof, M (2008) Five-year follow-up of a randomized multicenter trial of intensive early intervention vs standard treatment for patients with a first episode of psychotic illness: the OPUS trial. Archives of General Psychiatry 65, 762771.
Bond, GR and Drake, RE (2015) The critical ingredients of assertive community treatment. World Psychiatry 14, 240242.
Bond, GR, Drake, RE, Muesser, KT and Latimer, E (2001) Assertive community treatment for people with severe mental illness: critical ingredients and impact on patients. Disease Management and Health Outcomes 9, 142159.
Botha, UA, Koen, L, Galal, U, Jordaan, E and Niehaus, DJ (2014) The rise of assertive community interventions in South Africa: a randomized control trial assessing the impact of a modified assertive intervention on readmission rates; a three year follow-up. BMC Psychiatry 14, 56.
Botha, UA, Koen, L, Joska, JA, Hering, LM and Oosthuizen, PP (2010) Assessing the efficacy of a modified assertive community-based treatment programme in a developing country. BMC Psychiatry 10, 73.
Buchanan, RW, Kreyenbuhl, J, Kelly, DL, Noel, JM, Boggs, DL, Fischer, BA., Himelhoch, S, Fang, B, Peterson, E, Aquino, PR, Keller, W and Schizophrenia Patient Outcomes Research Team (PORT) (2010) The 2009 schizophrenia PORT psychopharmacological treatment recommendations and summary statements. Schizophrenia Bulletin 36, 7193.
Burns, T (2010) The rise and fall of assertive community treatment? International Review of Psychiatry 22, 130137.
Chan, SW, Yip, B, Tso, S, Cheng, BS and Tam, W (2009) Evaluation of a psychoeducation program for Chinese clients with schizophrenia and their family caregivers. Patient Education and Counselling 75, 6776.
Chen, H, Phillips, M, Cheng, H, Chen, Q, Chen, X, Fralick, D, Zhang, Y, Liu, M, Huang, J and Bueber, M (2012) Mental health law of the People's Republic of China (English translation with annotations): translated and annotated version of China's new Mental Health Law. Shanghai Archives of Psychiatry 24, 305321.
Chien, WT and Wong, KF (2007) A family psychoeducation group program for Chinese people with schizophrenia in Hong Kong. Psychiatric Services 58, 10031006.
Chow, W, Law, S, Andermann, L, Yang, JA, Leszcz, M, Wong, J and Sadavoy, J (2010) Multi-family psycho-education group for assertive community treatment clients and families of culturally diverse background: a pilot study. Community Mental Health Journal 46, 364371.
Dieterich, M, Irving, CB, Bergman, H, Khokhar, MA, Park, B and Marshall, M (2017) Intensive case management for severemental illness. Cochrane Database of Systematic Reviews (1), Art. No.: CD007906.
Dixon, L (2000) Assertive community treatment: twenty-five years of gold. Psychiatric Services 51, 759765.
Dixon, LB, Dickerson, F, Bellack, AS, Bennett, M, Dickinson, D, Goldberg, RW, Lehman, A, Tenhula, WN, Calmes, C, Pasillas, RM, Peer, J and Kreyenbuhl, J and Schizophrenia Patient Outcomes Research Team (PORT) (2010) Schizophrenia patient outcomes research team (PORT): the 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements. Schizophrenia Bulletin 36, 4870
Erhart, SM, Marder, SR and Carpenter, WT (2006) Treatment of schizophrenia negative symptoms future: prospects. Schizophrenia Bulletin 32, 234237.
Good, BJ and Good, MJ (2012) Significance of the 686 Program for China and for global mental health. Shanghai Archives of Psychiatry 24, 175177.
Guan, LL, Liu, J, Wu, XM, Chen, DF, Wang, X, Ma, N, Wang, Y, Good, B, Ma, H, Yu, X and Good, MJ (2015) Unlocking patients with mental disorders who were in restraints at home: a national follow-up study of China's new public mental health initiatives. PLoS ONE 10, e0121425.
Guy, W (1976) Clinical global impressions. In: ECDEU Assessment Manual for Psychopharmacology, Rockville, MD, U.S. Department of Health, Education, and Welfare, 218222.
Issakidis, C, Sanderson, K, Teesson, M, Johnston, S and Buhrich, N (1999) Intensive case management in Australia: a randomized controlled trial. Acta Psychiatrica Scandinavica 99, 360367.
Ito, H, Setoya, Y and Suzuki, Y (2012) Lessons learned in developing community mental health care in East and South East Asia. World Psychiatry 11, 186190.
Ito, J, Oshima, I, Nishio, M, Sono, T, Suzuki, Y, Horiuchi, K, Niekawa, N, Ogawa, M, Setoya, Y, Hisanaga, F, Kouda, M and Tsukada, K (2011) The effect of assertive community treatment in Japan. Acta Psychiatrica Scandinavica 123, 398401.
Kay, SR, Fiszbein, A and Opler, LA (1987) The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia Bulletin 13, 261276.
Kim, TW, Jeong, JH, Kim, YH, Kim, Y, Seo, HJ and Hong, SC (2015) Fifteen-month follow up of an assertive community treatment program for chronic patients with mental illness. BMC Health Services Research 15, 388.
Liem, SK and Lee, CC (2013) Effectiveness of assertive community treatment in Hong Kong among patients with frequent hospital admissions. Psychiatric Services 64, 11701172.
Liu, J, Ma, H, He, YL, Xie, B, Xu, YF, Tang, HY, Li, M, Hao, W, Wang, XD, Zhang, MY, Ng, CH, Goding, M, Fraser, J, Herrman, H, Chiu, HF, Chan, SS, Chiu, E and Yu, X (2011) Mental health system in China: history, recent service reform and future challenges. World Psychiatry 10, 210216.
Low, L, Tan, YY, Lim, BL, Poon, WC and Lee, C (2013) Effectiveness of assertive community management in Singapore. Annals of the Academy of Medicine, Singapore 42, 125132.
Mansfield, AK, Keitner, GI and Dealy, J (2015) The family assessment device: an update. Family Process 54, 8293.
Mausbach, BT, Harvey, PD, Goldman, SR, Jeste, DV and Patterson, TL (2007) Development of a brief scale of everyday functioning in persons with serious mental illness. Schizophrenia Bulletin 33, 13641372.
Monroe-DeVita, M, Teague, GB and Moser, LL (2011) The TMACT: a new tool for measuring fidelity to assertive community treatment. Journal of American Psychiatric Nurses Association 17, 1729.
Murray, CJ and Lopez, AD (1996) Evidence-based health policy – lessons from the global burden of disease study. Science 274, 740743.
Phillips, MR (2004) Mental health in China: challenges and options for the 21st century. Chinese Journal of Neurology and Psychiatry 30, 110.
Phillips, MR (2013). Can China's new mental health law substantially reduce the burden of illness attributable to mental disorders? The Lancet 381, 19641966.
Phillips, MR, Chen, HH, Diesfeld, K, Xie, B, Cheng, HG, Mellsop, G and Liu, XH (2013) China's new mental health law: reframing involuntary treatment. American Journal of Psychiatry 170, 588591.
Phillips, MR, Zhang, J, Shi, Q, Song, Z, Ding, Z, Pang, S, Li, X, Zhang, Y and Wang, Z (2009) Prevalence, treatment, and associated disability of mental disorders in four provinces in China during 2001–05: an epidemiological survey. The Lancet 373, 20412053.
Salyers, MP, McGuire, AB, Rollins, AL, Bond, GR, Mueser, KT and Macy, VR (2010) Integrating assertive community treatment and illness management and recovery for consumers with severe mental illness. Community Mental Health Journal 46, 319329.
Salyers, MP and Tsemberis, S (2007) ACT and recovery: integrating evidence-based practice and recovery orientation on assertive community treatment teams. Community Mental Health Journal 43, 619641.
Sono, T, Oshima, I and Ito, J (2008) Family needs and related factors in caring for a family member with mental illness: adopting assertive community treatment in Japan where family caregivers play a large role in community care. Psychiatry and Clinical Neuroscience 62, 584590.
The WHOQOL Group (1998) Development of the World Health Organization WHOQOL-BREF quality of life assessment. Psychological Medicine 28, 551558.
Tianmei, S, Liang, S, Yun'ai, S, Chenghua, T, Jun, Y, Jia, C, Xueni, L, Qi, L, Yantao, M, Weihua, Z and Hongyan, Z (2011) The Chinese version of the personal and social performance scale (PSP): validity and reliability. Psychiatry Research 185, 275279.
Tse, S, Ran, MS, Huang, Y and Zhu, S (2013) Mental health care reforms in Asia: the urgency of now: building a recovery-oriented, community mental health service in China. Psychiatric Services 64, 613616.
Wang, CY, Xiang, YT, Weng, YZ, Bo, QJ, Chiu, HF, Chan, SS, Lee, EH and Ungvari, GS (2010) Cigarette smoking in patients with schizophrenia in China: prospective, multicentre study. Australian and New Zealand Journal of Psychiatry 44, 456462.
Wang, X, Zhang, W, Ma, N, Guan, L, Law, SF, Yu, X and Ma, H (2016) Adherence to antipsychotic medication by community-based patients with schizophrenia in China: a cross-sectional study. Psychiatric Services 67, 431437.
Winter, JP and Calsyn, RJ (2000) The Dartmouth assertive community treatment scale (DACTS). A generalizability study. Evaluation Review 24, 319338.
World Health Organization (1988) WHO psychiatric Disability Assessment Schedule (WHO/DAS): With A Guide to its use. Geneva: WHO.
Xiang, YT, Yu, X, Sartorius, N, Ungvari, GS and Chiu, HF (2012) Mental health in China: challenges and progress. The Lancet 380, 17151716.
Xiong, W and Phillips, MR (2016) Translated and annotated version of the 2015–2020 national mental health work plan of the People's Republic of China. Shanghai Archives of Psychiatry 28, 417.
Xu, JF, Yu, FH and Wang, J (2013) Analyzing the hospitalization expense and management status of severe mental illness. Chinese Health Economics 32, 5356.
Zhang, J, Wieczorek, WF, Jiang, C, Zhou, L, Jia, S, Sun, Y, Jin, S and Conwell, Y (2002) Studying suicide with psychological autopsy: social and cultural feasibilities of the methodology in China. Suicide and Life-Threat Behavior 32, 370379.
Zhao, W, Law, S, Luo, X, Chow, W, Zhang, J, Zhu, Y, Liu, S, Ma, X, Yao, S and Wang, X (2015) First adaptation of a family-based ACT model in mainland China: a pilot project. Psychiatric Services 66, 438441.

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