The fidelity score of the DACTS model showed that the six teams had implemented ACT moderately successfully, but that treatment for dual disorder had been implemented relatively unsuccessfully.
Although the patients’ psychosocial functioning improved significantly over time, the gains seem to have been concentrated mainly in the first months of treatment; later on, the level of functioning appeared to stabilize. Despite this early improvement, two factors indicate a need for long-term ACT: patients’ level of functioning over time, and the risk that their lack of motivation for treatment will cause their situation to worsen. It should also be stated that the significant improvement in psychosocial functioning was restricted to men, although the non-significant results for women may have been a product of the sample size.
Our analysis also showed that the level of psychosocial functioning was significantly hampered by substance abuse, age over 30, low level of education (either no education, or elementary school only), and problems with motivation for treatment. In that these patient characteristics were associated with significantly more problematic functioning over time, our results confirmed earlier findings on treatment outcome in other patients with a severe mental illness (Dixon 1999
; Drake et al. 1993
; Batel 2000
; Greenfield et al. 2006
; Lauronen et al. 2007
; Gerlach 2002
; Roberts et al. 2000
). Our finding that older patients had higher HoNOS total scores may have been due to the fact that the duration of mental illness (Jenner 2003
) or of untreated psychosis was longer in these patients, each a factor that has been associated with worse prognosis (Singh 2007
Our study further demonstrated that the pattern with which these variables were associated with psychosocial outcome was different between men and women. The differences between the sexes’ levels of psychosocial functioning—women tending to have fewer psychosocial problems over time, but also improving less—may have been due to a floor effect.
However, the fact that substance abuse had more adverse consequences for women than for men may have been because women seemed more prone to perilous activities, such as turning to prostitution as a means to earn the money they needed to support their substance use. This led to problems regarding physical health and daily living conditions, and is in line with previous research by RachBeisel et al. (1999
), who suggested that substance abuse among women is associated with increased risks for physical health problems and sexually transmitted diseases.
The third difference between men and women, problems with motivation for treatment, also resulted in a higher risk (i.e., stronger association) for psychosocial problems in women than in men, which may be related to more disruptive behavior, and which therefore leads women to have more problems with motivation for treatment.
For men, risk factors were being aged 30 or older, low level of education, and substance abuse. This is in agreement with findings that older patients had poorer global functioning (Roberts et al. 2000
), and may indicate that these patients are more at risk of neglecting their personal care than women are. These findings also supplement those of Gur et al. (1996
) by showing more specifically how the clinical features of patients with a severe mental illness are moderated by aging and gender.
The association with low level of education may indicate that such patients have more difficulty managing or coping with problems in their lives. Neisser et al. (1996
) showed that because educational level was moderately highly correlated with intelligence, it may also reflect a patient’s ability to make use of any services on offer, and to foresee the consequences of their behavior. Because a low level of education may also lead to greater isolation from the labour market (Wolbers 2000
), it may also complicate rehabilitation.
Bhugra et al. (1997
) showed that non-western ethnicity was associated with poorer treatment outcome, a finding we were unable to replicate, due possibly to differences in outcome assessment: whereas Bhugra et al. used employment status, we defined outcome more broadly in terms of psychosocial functioning as measured by the HoNOS. Our study therefore suggests that, in terms of psychosocial functioning over time, non-western immigrants do not differ from other patients.
Limitations of the Study
We should acknowledge two limitations of the present study. The first concerns the design. Because this was a naturalistic follow-up study that used routine outcome-monitoring data, we had no information on other factors that may have co-determined the outcomes, such as negative symptoms, lack of awareness of symptoms, and duration of untreated psychosis. Neither does the design make it possible to draw any causal inferences, although Shrier et al. (2007
) suggests that, like randomized controlled trials, an observational study design can also contribute to evidence-based research.
The second limitation concerns the small number of women in the analyses, which was a product of the substantial overrepresentation of male patients in the ACT teams. We therefore checked non-significant results for the female patients to see if they were similar in magnitude (β) and direction to those in the larger group. Although non-significant results may indicate that the sample size was not enough for purposes of comparing the groups, the differences in magnitude or direction we found here indicate that the results were not explained solely by sample size.