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.

The Rasikajy civilization in northeast Madagascar: a pre-European Chinese community?

Archaeological excavations in northern Madagascar during the first half of the 20th century have revealed the presence of a former prosperous civilisation known as the Rasikajy civilisation. Little is known about the origin of this civilisation and how and when they first arrived in Madagascar. The most striking evidence for the Rasikajy civilisation comes from excavations at a necropolis in Vohemar located along the northeast coast, where more than 600 tombs containing spectacular objects were unearthed in the 1940s (Vernier & Millot 1971). The findings in the tombs included, amongst others, Chinese ceramics, silver and gold jewellery, iron weapons, glassware, bronze mirrors and chlorite-schist objects (ibid.). The latter objects were produced from chlorite schist mined at quarries in northern and eastern Madagascar and there is evidence that jewellery and iron objects were also produced by the Rasikajy from locally available raw material. Chlorite-schist objects have not only been found in coastal sites in Madagascar, but also in the Comores and eastern Africa suggesting an active engagement of the Rasikajy in western Indian Ocean trade. Our re-evaluation of published literature on archaeological sites in northern Madagascar indicates that the majority of Chinese ceramics found in the tombs at Vohemar dates from the 15th and first half of the 16th century with some dating back to the 14th century or earlier. Our comparative analysis of burial objects at Vohemar shows that locally produced chlorite-schist tripod vessels exhibit remarkable resemblances to ancient Chinese bronze ritual tripod vessels. The objects encountered in the tombs and their positions with respect to the body indicate that the Rasikajy practiced burial rites similar to those practised in the past in China. Our re-evaluation of the literature suggests that communities with Chinese roots were present in northeastern Madagascar prior to the arrival of the first Europeans in 1500 and participated in the Indian Ocean trade network. The demise of the Rasikajy civilisation seems to have occurred in the second half of the 16th century when production of chlorite-schist objects ceased. It is still unclear why this occurred.