The Illness Management and Recovery program: rationale, development, and preliminary findings

Getting by, getting back, and getting on: Matching mental health services to consumers' recovery goals

OBJECTIVE

The goal of this study was to better understand mental health recovery from the point of view of mental health consumers to identify opportunities for practice improvements that closely align services with consumer goals and consumer-preferred outcomes.

METHOD

As part of an exploratory study of recovery, semistructured interviews were conducted with 177 integrated health plan members diagnosed with schizophrenia, schizoaffective disorder, bipolar disorder, or affective psychosis. Transcripts of in-depth interviews were coded using Atlas.ti, and definitions of recovery were further subcoded. A qualitative analysis using a modified grounded theory approach and constant comparative method identified common themes and less common but potentially important recovery-related experiences and perspectives.

RESULTS

Three primary and 2 cross-cutting themes emerged. "Getting by" meant coping and meeting basic needs. "Getting back" meant learning to live with mental illness. "Getting on" meant living a life where mental illness was no longer prominent. Regaining control and recouping losses were cross-cutting themes.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Mental health recovery is complex and dynamic; individuals' recovery goals can be expected to change over time. Person-centered care must accommodate changing consumer priorities, services must be flexible and responsive, and outcomes need to match consumers' objectives. Clinicians can assist in (a) identifying recovery goals, (b) monitoring progress toward and recognizing movement away from goals, (c) tailoring support to different phases/stages, and (d) supporting transitions between phases/stages. (PsycINFO Database Record

Treatment Attrition of Probationers With Mental Illness From an Enhanced Day Reporting Center

Treatment completion is an important outcome for both mental health and criminal justice agencies tasked with managing offenders with mental illness in the community. Previous research has shown that greater degrees of criminogenic risk factors (e.g., specific criminal history variables) predict treatment non-completion among legally mandated populations. However, most studies were conducted with offenders without mental illness. In this study, demographic (e.g., age, gender), clinical (e.g., psychiatric diagnosis), and criminogenic risk factors (measured using the Level of Service Inventory-Revised [LSI-R]) were compared by treatment completion status using 167 probationers with mental illness treated at an enhanced day reporting center. Bivariate and multivariate (i.e., forward entry logistic regression) analyses revealed that while the LSI-R total score was unrelated to treatment completion, higher scores on the LSI-R Alcohol and Drug use subscale (odds ratio [OR] = 1.25, 95% confidence interval [CI] = [1.01, 1.54]) and older age (OR = 1.04, 95% CI = [1.00, 1.09]) were significantly predictive of non-completion.

Theory of mind correlates with clinical insight but not cognitive insight in patients with schizophrenia

Research on the relationship between insight and social cognition, in particular Theory of Mind (ToM), in schizophrenia has yielded mixed findings to date. Very few studies, however, have assessed both clinical insight and cognitive insight when examining their relationships with ToM in schizophrenia. The current study thus investigated the relationship between clinical insight, cognitive insight, and ToM in a sample of 56 patients with schizophrenia and 30 healthy controls. Twenty-seven patients were classified as low in clinical insight according to their scores on the 'insight' item (G12) of the Positive and Negative Syndrome Scale (PANSS). Moreover, cognitive insight and ToM were assessed with the Beck Cognitive Insight Scale (BCIS) and the Yoni task, respectively. The results indicated that patients with poor clinical insight performed worse on tasks of second-order cognitive and affective ToM, while the ToM performance of patients with high clinical insight was equivalent to that of healthy controls. Furthermore, while clinical insight was correlated with ToM and clinical symptoms, cognitive insight did not correlate with clinical insight, ToM, or clinical symptoms. Clinical insight thus appears to be an important factor related to ToM in schizophrenia.

Effectiveness of illness management and recovery (IMR) in the Netherlands: a randomised clinical trial

BACKGROUND

Illness Management and Recovery (IMR) is intended to provide a structured psychosocial programme that helps to manage the disabling effects of severe mental illnesses such as schizophrenia and bipolar disorders. It is curriculum based and aims to improve different aspects of illness management and recovery through interventions such as goal-setting, psycho-education, coping and social skills training. Its overall aim is to improve illness outcomes and support subjective and objective recovery. To date there have been four RCTs on IMR; as these yielded mixed results, further research is needed. Our hypotheses aim to test the interrelatedness assumed in Mueser's Conceptual Framework for IMR for the many aspects of illness management, illness management outcomes and recovery.

METHODS/DESIGN

This randomised multi-centre, single-blinded clinical trial is intended to compare IMR with treatment as usual for 200 outpatient clients with a severe and persistent mental illness (SMI). We will investigate whether IMR leads to better illness management, fewer symptoms and fewer relapses, and also to better subjective and objective recovery. The primary outcome measure is the score on the client version of the Illness Management and Recovery Scale. Secondary outcome measures are the clinician version of the Illness Management and Recovery scale, measures of illness management, coping, symptoms, the number of relapses, and measures of recovery. Measurement will take place before randomisation, and 12 and 18 months after randomisation.

DISCUSSION

Overall, our study has the following strengths: 1.) our use of an RCT design in a country where the earlier RCTs on IMR were not conducted; 2.) the fact that participants will consist not only of people with a diagnosis of schizophrenia, but also of those with various types of SMI; 3.) our inclusion of 200 participants; and 4.) the fact that we will explore the working mechanisms described in Mueser's Conceptual Framework for IMR. Finally, 5.) because the RCT will be conducted in everyday clinical practice, we believe that the generalisability of our results will be good.

TRIAL REGISTRATION

The Netherlands National Trial Register (identifier: NTR 5033 ). Date registered: 13 January 2015.

Working therapeutically with deaf people recovering from trauma and addiction

OBJECTIVE

This article reviews what is known about behavioral health treatment of deaf persons with comorbid trauma and addiction.

METHOD

We discuss how to work therapeutically with deaf people with comorbid trauma and addiction, both through a review of the literature and through clinical observations of the authors. The article also includes the personal stories of two people-a Deaf peer specialist and a hearing psychiatrist-who share their humbling stories about the recovery process for deaf people and the challenges of learning to become an effective Deaf mental health care provider.

FINDINGS

Deaf people report higher rates of mental health problems than the general population. Although initial empirical work with the deaf population suggests high rates of posttraumatic stress disorder (PTSD) and substance use disorder (SUD), little is known about the rates of comorbid PTSD/SUD or how to effectively address this comorbidity in treatment.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Substantial work is needed to raise awareness of comorbid PTSD/SUD and provide treatment tools to agencies and providers who work with deaf clients, infusing trauma-informed care into deaf SUD services and SUD treatment into deaf mental health care. Fortunately, several endeavors are on the horizon to disseminate assessment and treatment tools to work with deaf people recovering from trauma and addiction.

A Qualitative Study of Client-Clinician Text Exchanges in a Mobile Health Intervention for Individuals With Psychotic Disorders and Substance Use

OBJECTIVE

Mobile health (mHealth) approaches have the potential to transform prevention, wellness, and illness management for people with dual diagnosis consisting of co-occurring mental illness and substance use disorders by providing timely and cost-effective interventions in clients' natural environments. However, little is known about how clients interact with mHealth interventions to manage their illness. This qualitative study explored the content of mobile phone text messages between clients with dual diagnosis and a clinician who engaged them in daily assessment and intervention text exchanges.

METHODS

Seventeen participants with psychotic disorders and substance use were enrolled in a 12-week single-arm trial of an mHealth intervention focusing on illness management. The clinician (i.e., mobile interventionist) sent daily text messages to participants' privately owned mobile phones to assess their medication adherence and clinical status. The clinician provided other illness management and wellness suggestions flexibly, in response to participants' needs and preferences. In this qualitative study we conducted a thematic analysis of the client-clinician text exchanges that occurred over the course of the intervention.

RESULTS

Seven major content themes in client-clinician text message exchanges were identified: mental health symptoms; mental health coping strategies; mental health treatment and management; lifestyle behaviors; social relationships and leisure activities; motivation and personal goal setting; and independent living. Participants were interested in discussing strategies for coping with mental health symptoms (e.g., cognitive restructuring, social support) and health behavior change (e.g., increased physical activity, dietary changes).

CONCLUSIONS

Our findings suggest that client-centered text messaging has the potential to be an important component of illness management for people with dual diagnosis. This approach is able to offer coping strategies that are tailored to clients' needs and preferences in real time when help is needed.

An Integrative Psychotherapy Approach to Foster Community Engagement and Rehabilitation in Schizophrenia: A Case Study Illustration

This case study illustrates the use of a long-term integrative psychotherapy approach with a middle- aged man with chronic schizophrenia and a mood disorder. The case of "Holst" describes a man with a history of insecure attachment and trauma who later went on to contract a serious chronic illness, precipitating the onset of psychotic symptoms, depression, and chronic suicidal ideation, resulting in multiple hospitalizations. Combining metacognition-oriented therapy with elements of cognitive behavioral therapy and psychiatric rehabilitation, this approach fostered significantly improved community functioning and attainment of personal goals over time. Through the journey of therapy, the patient also developed a more coherent narrative about his life, established a stable sense of self, and became an active agent in the world. This case illustration demonstrates that these three different approaches can be used in a sequential and complementary fashion to foster recovery in the midst of serious physical and mental illness.

From recovery programs to recovery-oriented practice? A qualitative study of mental health professionals' experiences when facilitating a recovery-oriented rehabilitation program

INTRODUCTION

The recovery model has influenced mental health services and fostered new standards for best practice. However, knowledge about how mental health care professionals (HCPs) experience recovery-oriented programs is sparse.

AIM/QUESTION

This paper explores HCPs' experiences when facilitating a recovery-oriented rehabilitation program. The research question is how do HCPs experience a change in their attitude and practice when applying recovery-oriented programs?

METHODS

This paper draws on semi-structured in-depth qualitative interviews conducted with 16 HCPs experienced in facilitating a recovery-oriented rehabilitation program in either the USA or Denmark.

RESULTS

Three themes emerged from the HCPs' reflections on changes in attitudes and practices: "Hopeful Attitude" captures a change in the HCPs' attitude toward a more positive view on the future for clients' living with mental illness; "A New Focus in the Dialogue With Clients" thematizes how the HCPs focus more on the individual's own goal for recovery rather than disease-induced goals in the dialog with clients; "A Person-Centered Role" comprises a shift in the professional role whereby the HCPs value the client's own ideas in addition to the professional's standards.

CONCLUSION

This study supports the theory of the recovery model by its empirical findings and indications that when facilitating a recovery-oriented program, HCPs experience recovery-oriented changes in their attitude toward life with mental illness, and it alters their professional practice toward a stronger focus on client's own goals during treatment. More studies are needed to further clarify how changes in HCPs' attitudes translate into changes in mental health practices.

Planning Patient-Centered Health Homes for Medicaid Psychiatric Patients at Greatest Risk for Intensive Service Use

This study identified characteristics of Medicaid psychiatric patients at risk of hospitalizations and emergency department (ED) visits to identify their service delivery needs. A total of 4,866 psychiatrists were randomly selected from the AMA Physician Masterfile; 62 % responded, 32 % met eligibility criteria and reported on 1,625 Medicaid patients. Patients with schizophrenia, substance use disorders, suicidal and violent ideation/behavior, and psychotic, substance use, or manic symptoms were at high risk for intensive service use, along with homeless and incarcerated patients. Patients with schizophrenia or psychotic symptoms represented 37 % of patients, but used 73 % of all hospital days and 61 % of all ED visits. Patients with substance use problems comprised 21 % of patients, but used nearly half of all ED visits. Our findings highlight opportunities to enhance treatments and interventions, and inform the development of patient-centered health homes to address the needs of patients at high risk for intensive service use.

Behavioral activation therapy for return to work in medication-responsive chronic depression with persistent psychosocial dysfunction

OBJECTIVE

Chronic depression is associated with significant impairment in work functioning, relationships, and health. Such impairment often persists following medication-induced remission of depressive symptoms. We adapted and tested Behavioral Activation therapy with a goal of return to work (BA-W) in subjects with chronic depression who had responded to medication treatment but remained unemployed.

METHOD

Sixteen adults aged 18-65 with DSM-IV diagnosed Dysthymic Disorder or chronic Major Depression were recruited from clinical trials taking place at the New York State Psychiatric Institute between 4/2009 and 12/2012 and enrolled in 12 weeks of individual manual-driven BA-W. Functioning was measured at intake, post-treatment and at 24 week follow-up.

RESULTS

Eighty-seven percent (n=14) of subjects completed the full 12 weeks of BA-W. Hours of work related activity (p<.005, d=0.83), hours of paid work (p<.0003, d=0.54), and work productivity (p<.0004, d=-0.48) increased significantly over the study period. Earned income increased post-treatment (p=.068) with significant changes by 24 week follow-up (p=.011). Secondary outcomes including behavioral avoidance (p<.004, d=-0.56), and global functioning (p<.0003, d=1.42) were also significantly improved post-treatment. Effect sizes, including for outcomes with non-significant changes, were generally in the range of 0.5-0.8.

CONCLUSIONS

This pilot study provides preliminary evidence of the efficacy of a work-targeted psychotherapy to remediate vocational impairment in subjects with chronic depression. Data suggests that further testing of BA-W using a randomized controlled trial is warranted and may represent a significant advance in treatment for the residual disability present after successful pharmacotherapy.

Interaction between 5-HTTLPR genotype and cognitive stress vulnerability on sleep quality: effects of sub-chronic tryptophan administration

BACKGROUND

Abundant evidence suggests that allelic variation in the serotonin transporter-linked polymorphic region (5-HTTLPR) influences susceptibility to stress and its affective consequences due to brain serotonergic vulnerability. Based on recent assumptions, the present study examined whether the 5-HTTLPR genotype may also interact with a vulnerability to chronic stress experience (conceptualized by trait neuroticism) in order to influence sleep quality and, additionally, whether this is influenced by brain serotonergic manipulations.

METHODS

In a well-balanced experimental design, homozygous S-allele (n = 57) and L-allele (n = 54) genotypes with high and low chronic stress vulnerability (neuroticism) were first assessed for general past sleep quality during a month before onset of the experiment. Then subjects were assessed for sleep quality following 7 days of tryptophan (3.0g/day) or placebo intake.

RESULTS

Although high neuroticism was significantly related to a higher frequency of stressful life events and daily hassles, it did not interact with the 5-HTTLPR genotype on general past sleep quality. However, as expected, a 7 day period of tryptophan administration was exclusively associated with better sleep quality scores in the S'/S' genotype with high trait neuroticism.

CONCLUSIONS

Current findings suggest that 5-HTTLPR does not directly interact with stress vulnerability in order to influence sleep quality. Instead, based on current and previous findings, it is suggested that the S'/S' 5-HTTLPR genotype promotes the risk for stress-related sleep disturbances because of an increased susceptibility to the depressogenic consequences of stress. Accordingly, by way of reducing depressive symptomatology, tryptophan augmentation may particularly improve sleep quality in stress-vulnerable individuals carrying the 5-HTTLPR S-allele.

Focusing on psychiatric patients' strengths: A new vision on mental health care in Iran

BACKGROUND

Identifying and using the strengths of patients, in practice, is a new territory. Today, the need to educate nurses and psychiatric patients about positive psychology in practice and the importance of understanding and focusing on strengths is clear. However, little is known about the strengths the psychiatric patients use and experience. Thus, this study has been designed and conducted in order to understand how people with psychiatric disorders demonstrate their strengths.

MATERIALS AND METHODS

In the present study, 13 semi-structured, qualitative interviews with patients and 2 focus groups with nurses were carried out. In addition, a qualitative content analysis was used to identify significant strengths.

RESULTS

Based on the results, the four main strengths consisted of: Finding a meaning in daily living, work as enduring strength, entertaining activities, and positive relationship. Patients also reported that health care providers rarely focused on patients' strengths, and experts confirmed these findings. Our findings indicate that patients' own strengths are a pivotal factor in getting through their illness from their perspective.

CONCLUSIONS

Despite the enduring legacy of pessimism regarding psychiatric patients, these people have a repertoire of strengths. Nurses should, therefore, have a greater focus on eliciting and nourishing psychiatric patients' strengths in their care. It is suggested that the theoretical and practical aspects of patients' strengths be incorporated in nursing school curricula.

Individual Psychotherapy and Changes in Self-Experience in Schizophrenia: A Qualitative Comparison of Patients in Metacognitively Focused and Supportive Psychotherapy

OBJECTIVE

Deficits in metacognition, or the ability to form complex ideas about self and others, may be a root cause of dysfunction in schizophrenia. Accordingly, forms of psychotherapy have been proposed to address metacognitive deficits. This study explored whether metacognitively focused individual psychotherapy can affect self-experience by conducting narrative interviews of patients with a schizophrenia spectrum disorder enrolled in either metacognitively oriented psychotherapy (n = 12) or supportive psychotherapy (n = 13) in a naturalistic setting.

METHOD

Participants in both groups completed a narrative interview consisting of questions that focused on perceptions and process of psychotherapy and its impact on outcomes. Interviews were audiotaped, transcribed, and coded using an inductive process informed by grounded theory.

RESULTS

Qualitative analyses revealed all participants reported psychotherapy led to improvements in self-esteem and the ability to think more clearly and set meaningful goals. The group receiving metacognitively oriented therapy, in contrast to those receiving supportive therapy, reported being able to integrate their current experiences into the larger narratives of their lives and an increased experience of sense of agency and the ability to understand and manage pain.

CONCLUSIONS

Results provide evidence that metacognitively oriented psychotherapy may promote subjective forms of recovery.

Being in a process of transition to psychosis, as narrated by adults with psychotic illnesses acutely admitted to hospital

To assist in improving early interventions for psychosis, this study explored how adult people narrated their experience of becoming psychotic, and how contact with mental health personnel was established. Narrative interviews were conducted with 12 participants with psychotic illnesses recruited from acute psychiatric wards. The interviews were content analysed. Participants described being in a process of transition to psychosis as follows: experiencing changes as well-known signs of psychosis, experiencing sudden unexpected changes as signs of psychosis and experiencing unidentified changes as signs of illness. Our results show that participants and their close others who knew the signs of psychosis established a dialogue with mental health personnel and were better equipped to prevent and mitigate the psychosis. Our results demonstrate that participants who did not perceive the signs of psychosis and did not have other people to advocate for them were at risk for delayed treatment, poor communication and coercive interventions. Furthermore, participants who did not know the signs of psychosis perceived these changes as deterioration in their health and awareness of illness. We suggest that participants' experiential knowledge of transitioning to psychosis and an awareness of illness can be used to improve the communication during interventions for psychosis.

A Case-Series Evaluation of a Brief, Psycho-Social Approach Intended for the Prevention of Relapse in Psychosis

There is a wealth of research into relapse prevention in psychosis; however, specific research into the effectiveness of short-term, self-management strategies aimed to prevent relapse is lacking. This pilot study aimed to evaluate the effects of Sorensen’s ‘Relapse Prevention in Schizophrenia and Other Psychoses’ manual-based therapy (Sorensen, 2006b) with 11 participants in one UK National Health Service Trust. The intervention was delivered over four sessions and interviews were conducted pre and post intervention. The effect of the intervention on measures of hopelessness, perceived control over internal states, and satisfaction were recorded using validated questionnaires at one week, one month and two months follow-up, supported by measures taken from visual analogue scales. Data analysis revealed significant improvements on hopelessness, perceived control over internal states, and satisfaction at one week follow-up, although these results were not maintained at one and two months follow-up. Additionally, the attrition rate meant that results lacked statistical power at one and two months follow-up. The study also considered the clinical significance of the research findings with the Jacobson-Truax (Jacobson & Truax, 1991) method for measuring reliable change. A substantial number of clients attained clinically significant changes with regards to hopelessness and perceived control over internal states. Future research is required in order to evaluate the use of self-management strategies to prevent relapse. It would be valuable to repeat the current study with the additional use of booster sessions in order to assess whether the positive impacts on hopelessness and perceived control over illness can be maintained at the longer term follow up.

A systematic review of self-management health care models for individuals with serious mental illnesses

OBJECTIVE

The general medical health of individuals with serious mental illnesses is compromised relative to those without serious mental illnesses. To address this health disparity, numerous integrated care strategies are being employed from the system level to the level of individual patients. However, self-management of health care, a strategy considered an integral aspect of typical care, has been infrequently included in interventions for this population. Despite reservations about the capacity of those with serious mental illnesses to self-manage health care, a subset of new interventions focused on general medical health in this population has tested whether models including self-management strategies have empirical support. To understand whether these models are supported, the authors reviewed the evidence for self-management models.

METHODS

This systematic review examined collaborative and integrated care models that include self-management components for individuals with serious mental illnesses.

RESULTS

Across the 14 studies identified in this review, promising evidence was found that individuals with serious mental health issues can collaborate with health professionals or be trained to self-manage their health and health care. The evidence supports the use of mental health peers or professional staff to implement health care interventions. However, the substantial heterogeneity in study design, types of training, and examined outcomes limited conclusions about the comparative effectiveness of existing studies.

CONCLUSIONS

This review found preliminary support that self-management interventions targeting the general medical health of those with serious mental illnesses are efficacious, but future work is needed to determine what elements of training or skills lead to the most salient changes.

Feasibility, acceptability, and preliminary efficacy of a smartphone intervention for schizophrenia

The FOCUS smartphone intervention was developed to provide automated real-time/real-place illness management support to individuals with schizophrenia. The system was specifically designed to be usable by people with psychotic disorders who may have cognitive impairment, psychotic symptoms, negative symptoms, and/or low reading levels. FOCUS offers users both prescheduled and on-demand resources to facilitate symptom management, mood regulation, medication adherence, social functioning, and improved sleep. In this study, 33 individuals with schizophrenia or schizoaffective disorder used FOCUS over a 1-month period in their own environments. Participants were able to learn how to use the intervention independently, and all but one participant completed the trial successfully and returned the smartphones intact. Completers used the system on 86.5% of days they had the device, an average of 5.2 times a day. Approximately 62% of use of the FOCUS intervention was initiated by the participants, and 38% of use was in response to automated prompts. Baseline levels of cognitive functioning, negative symptoms, persecutory ideation, and reading level were not related to participants' use of the intervention. Approximately 90% of participants rated the intervention as highly acceptable and usable. Paired samples t tests found significant reductions in psychotic symptoms, depression, and general psychopathology, after 1 month of FOCUS use. This study demonstrated the feasibility, acceptability, and preliminary efficacy of the FOCUS intervention for schizophrenia and introduces a new treatment model which has promise for extending the reach of evidence-based care beyond the confines of a physical clinic using widely available technologies.

Self-management and bipolar disorder--a clinician's guide to the literature 2011-2014

This review provides clinicians and individuals with bipolar disorder (BD) with an overview of evidence-based skills shown to be effective in BD and amenable to self-management including psychoeducation; monitoring moods, medications, and social function; sleep hygiene; setting goals and relapse plans; and healthy lifestyles (physical activity, healthy eating, weight loss and management, medical comorbidities). Currently available self-management resources for BD are summarized by mode of delivery (workbooks, mobile technologies, internet, and peer-led interventions). Regardless of the self-management intervention/topic, the research suggests that personally tailored interventions of longer duration and greater frequency may be necessary to achieve the maximal benefit among individuals with BD. Means to support these self-management interventions as self-sustaining identities are critically needed. Hopefully, the recent investment in patient-centered research and care will result in best practices for the self-management of BD by mode of delivery. Since self-management of BD should complement rather than replace medical care, clinicians need to partner with their patients to incorporate and support advances in self-management for individuals with BD.

Rasch analysis of the illness management and recovery scale-clinician version

RATIONALE, AIMS AND OBJECTIVES

The illness management and recovery scale-clinician version (IMRS-C) is a measure of outcomes thought to be important indicators of progress for consumers participating in illness management and recovery (IMR). Prior research has examined the psychometric properties of the IMRS-C; extant research supports certain aspects of the scale's reliability (test-retest) and validity (sensitivity to interventions). Analyses based on Rasch provide certain advantages and have not been applied to the IMRS-C.

METHOD

This study used an archival IMRS database including responses regarding 697 participants with severe mental illness from a variety of community-based settings. Rasch analyses were utilized to determine item functioning and utility of the IMRS-C.

RESULTS

Results of Rasch analyses using the IMRS-C as one unidimensional scale were problematic. Analyses grouping items into three separate scales measuring recovery, management and biological vulnerability were more promising, but the third scale had other limitations.

CONCLUSIONS

Results suggest that the items included in the IMRS-C can form two screeners, one for recovery and one for management; items regarding biological vulnerability were inadequate. The assessment could be supplemented by more refined measures of coping/self-management and recovery constructs.

Strong subjective recovery as a protective factor against the effects of positive symptoms on quality of life outcomes in schizophrenia

BACKGROUND

Interest in recovery from schizophrenia has been growing steadily, with much of the focus on remission from psychotic symptoms and a return to functioning. Less is known about the experience of subjective recovery and its relationships with other important outcomes, such as quality of life and the formation and sustenance of social connections. This study sought to address this gap in knowledge by examining the links between self perceived recovery, symptoms, and the social components of quality of life.

METHODS

Sixty eight veterans with schizophrenia-spectrum disorders who were participating in a study of cognitive remediation and work were concurrently administered the Recovery Assessment Scale, Positive and Negative Syndrome Scale, and the Heinrichs-Carpenter Quality of Life Scale (QLS).

RESULTS

Linear regression analyses demonstrated that subjective recovery moderated the relationship between positive symptoms and both QLS intrapsychic foundations scores and QLS instrumental role functioning after controlling for negative symptoms. Further examination of this interaction revealed that for individuals with substantial positive symptoms, higher levels of subjective recovery were associated with better instrumental role functioning and intrapsychic foundational abilities.

CONCLUSION

Greater self perceived recovery is linked with stronger quality of life, both in regards to the cognitive and affective bases for socialization and active community involvement, even in the presence of substantial psychotic symptoms. Clinical implications of these findings are discussed.

Perceptions of behavioral health care among veterans with substance use disorders: results from a national evaluation of mental health services in the Veterans Health Administration

Understanding patients' perceptions of care is essential for health care systems. We examined predictors of perceptions of behavioral health care (satisfaction with care, helpfulness of care, and perceived improvement) among veterans with substance use disorders (SUD; n = 1,581) who participated in a phone survey as part of a national evaluation of mental health services in the U.S. Veterans Health Administration. In multivariate analyses, SUD specialty care utilization and higher mental health functioning were associated positively with all perceptions of care, and comorbid schizophrenia, bipolar, and PTSD were associated positively with multiple perceptions of care. Perceived helpfulness of care was associated with receipt of SUD specialty care in the prior 12 months (adjusted OR = 1.77, p<.001). Controlling for patient characteristics, satisfaction with care exhibited strong associations with perceptions of staff as supportive and empathic, whereas perceived improvement was strongly linked to the perception that staff helped patients develop goals beyond symptom management. Survey responses that account for variation in SUD patients' perceptions of care could inform and guide quality improvement efforts with this population.

Recovery and severe mental illness: description and analysis

The notion of recovery has been embraced by key stakeholders across Canada and elsewhere. This has led to a proliferation of definitions, models, and research on recovery, making it vitally important to examine the data to disentangle the evidence from the rhetoric. In this paper, first we ask, what do people living with severe mental illness (SMI) say about recovery in autobiographical accounts? Second, what do they say about recovery in qualitative studies? Third, from what we have uncovered about recovery, can we learn anything from quantitative studies about proportions of people leading lives of recovery? Finally, can we identify interventions and approaches that may be consistent or inconsistent with the grounded notions of recovery unearthed in this paper? We found that people with mental illness frequently state that recovery is a journey, characterized by a growing sense of agency and autonomy, as well as greater participation in normative activities, such as employment, education, and community life. However, the evidence suggests that most people with SMI still live in a manner inconsistent with recovery; for example, their unemployment rate is over 80%, and they are disproportionately vulnerable to homelessness, stigma, and victimization. Research stemming from rehabilitation science suggests that recovery can be enhanced by various evidence-based services, such as supported employment, as well as by clinical approaches, such as shared decision making and peer support. But these are not routinely available. As such, significant systemic changes are necessary to truly create a recovery-oriented mental health system.

Mental health reform at a systems level: widening the lens on recovery-oriented care

This paper is an initial attempt to collate the literature on psychiatric inpatient recovery-based care and, more broadly, to situate the inpatient care sector within a mental health reform dialogue that, to date, has focused almost exclusively on outpatient and community practices. We make the argument that until an evidence base is developed for recovery-oriented practices on hospital wards, the effort to advance recovery-oriented systems will stagnate. Our scoping review was conducted in line with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (commonly referred to as PRISMA) guidelines. Among the 27 papers selected for review, most were descriptive or uncontrolled outcome studies. Studies addressing strategies for improving care quality provide some modest evidence for reflective dialogue with former inpatient clients, role play and mentorship, and pairing general training in recovery oriented care with training in specific interventions, such as Illness Management and Recovery. Relative to some other fields of medicine, evidence surrounding the question of recovery-oriented care on psychiatric wards and how it may be implemented is underdeveloped. Attention to mental health reform in hospitals is critical to the emergence of recovery-oriented systems of care and the realization of the mandate set forward in the Mental Health Strategy for Canada.

Chronic disease self-management interventions for adults with serious mental illness: a systematic review of the literature

OBJECTIVE

While there is strong evidence in support of chronic disease self-management programs, much less is available with regard to individuals living with serious mental illness (SMI). The objectives of this review are to identify and appraise chronic disease self-management studies tested with samples of US adults living with SMI. We include an appraisal of methodological quality of the chronic disease self-management (CDSM) studies that met our final criteria.

METHODS

Systematic search methods were utilized to identify intervention studies published before 2012 that describe CDSM outcomes for adults with SMI.

RESULTS

Eighteen unduplicated articles were identified that included outcomes of CDSM studies, while 10 met all inclusion criteria. Favorable treatment effects were observed for adults with SMI across 10 studies that took place in different types of clinical settings. CDSM studies that met all search criteria had a wide range of methodological quality, indicating that this is a nascent field of study.

CONCLUSIONS

Given the high chronic disease burden experienced by individuals with SMI combined with our nations health care reform, emphasis on self-management to improve population health, coupled with advancing the quality of research to evaluate CDSM programs for adults with SMI, is critically needed.

Occupational functioning in early non-affective psychosis: the role of attributional biases, symptoms and executive functioning

Aims. Occupational functioning is severely impaired in people with psychosis. Social cognition has recently been found to be a stronger predictor of functioning than neurocognition. This study is the first to investigate if externalizing attributional biases that are typically associated with psychosis play a role in the vocational pathways of people with early psychosis. Methods. A cross-sectional design was used. Fifty participants with early psychosis were recruited from a cohort of 144 participants of the Lambeth Early Onset randomized control trial at 18-month follow-up. Information on occupational functioning was obtained using case notes and interview. Severity of symptoms was assessed and participants completed measures on attributional style and executive functioning. Results. Although executive functioning and positive symptoms were associated with poor occupational functioning, an externalizing attributional style for failures and reduced engagement in occupational activities during the previous 18 months emerged as the only predictors of poor occupational functioning at 18-month follow-up. Conclusions. An externalizing attributional bias is associated with poor occupational functioning. Further research is needed to investigate the direction of this relationship and whether attributional biases mediate the impact of symptoms and cognitive impairment on functioning.

Integrated IMR for psychiatric and general medical illness for adults aged 50 or older with serious mental illness

OBJECTIVES

Self-management is promoted as a strategy for improving outcomes for serious mental illness as well as for chronic general medical conditions. This study evaluated the feasibility and effectiveness of an eight-month program combining training in self-management for both psychiatric and general medical illness, including embedded nurse care management.

METHODS

Participants were 71 middle-aged and older adults (mean age=60.3 ± 6.5) with serious mental illness and chronic general medical conditions who were randomly assigned to receive integrated Illness Management and Recovery (I-IMR) (N=36) or usual care (N=35). Feasibility was determined by attendance at I-IMR and nurse sessions. Effectiveness outcomes were measured two and six months after the intervention (ten- and 14-month follow-ups) and included self-management of psychiatric and general medical illness, participation in psychiatric and general medical encounters, and self-reported acute health care utilization.

RESULTS

I-IMR participants attended 15.8 ± 9.5 I-IMR and 8.2 ± 5.9 nurse sessions, with 75% attending at least ten I-IMR and five nurse sessions. Compared with usual care, I-IMR was associated with greater improvements in participant and clinician ratings for psychiatric illness self-management, greater diabetes self-management, and an increased preference for detailed diagnosis and treatment information during primary care encounters. The proportion of I-IMR participants with at least one psychiatric or general medical hospitalization decreased significantly between baseline and ten- and 14-month follow-ups.

CONCLUSIONS

I-IMR is a feasible intervention for this at-risk group and demonstrated potential effectiveness by improving self-management of psychiatric illness and diabetes and by reducing the proportion of participants requiring psychiatric or general medical hospitalizations.

Uses and abuses of recovery: implementing recovery-oriented practices in mental health systems

An understanding of recovery as a personal and subjective experience has emerged within mental health systems. This meaning of recovery now underpins mental health policy in many countries. Developing a focus on this type of recovery will involve transformation within mental health systems. Human systems do not easily transform. In this paper, we identify seven mis-uses ("abuses") of the concept of recovery: recovery is the latest model; recovery does not apply to "my" patients; services can make people recover through effective treatment; compulsory detention and treatment aid recovery; a recovery orientation means closing services; recovery is about making people independent and normal; and contributing to society happens only after the person is recovered. We then identify ten empirically-validated interventions which support recovery, by targeting key recovery processes of connectedness, hope, identity, meaning and empowerment (the CHIME framework). The ten interventions are peer support workers, advance directives, wellness recovery action planning, illness management and recovery, REFOCUS, strengths model, recovery colleges or recovery education programs, individual placement and support, supported housing, and mental health trialogues. Finally, three scientific challenges are identified: broadening cultural understandings of recovery, implementing organizational transformation, and promoting citizenship.

Illness management and recovery: a review of the literature

OBJECTIVE

Illness Management and Recovery (IMR) is a standardized psychosocial intervention that is designed to help people with severe mental illness manage their illness and achieve personal recovery goals. This literature review summarizes the research on consumer-level effects of IMR and articles describing its implementation.

METHODS

In 2011, the authors conducted a literature search of Embase, MEDLINE, PsycINFO, CINAHL, and the Cochrane Library by using the key words "illness management and recovery," "wellness management and recovery," or "IMR" AND ("schizophrenia" OR "bipolar" OR "depression" OR "recovery" OR "mental health"). Publications that cited two seminal IMR articles also guided further exploration of sources. Articles that did not deal explicitly with IMR or a direct adaptation were excluded.

RESULTS

Three randomized-controlled trials (RCTs), three quasi-controlled trials, and three pre-post trials have been conducted. The RCTs found that consumers receiving IMR reported significantly more improved scores on the IMR Scale (IMRS) than consumers who received treatment as usual. IMRS ratings by clinicians and ratings of psychiatric symptoms by independent observers were also more improved for the IMR consumers. Implementation studies (N=16) identified several important barriers to and facilitators of IMR, including supervision and agency support. Implementation outcomes, such as participation rates and fidelity, varied widely.

CONCLUSIONS

IMR shows promise for improving some consumer-level outcomes. Important issues regarding implementation require additional study. Future research is needed to compare outcomes of IMR consumers and active control groups and to provide a more detailed understanding of how other services utilized by consumers may affect outcomes of IMR.

Development and Usability Testing of FOCUS: A Smartphone System for Self-Management of Schizophrenia

OBJECTIVE

Mobile Health (mHealth) approaches can support the rehabilitation of individuals with psychiatric conditions. In the current article, we describe the development of a smartphone illness self-management system for people with schizophrenia.

METHODS

The research was conducted with consumers and practitioners at a community-based rehabilitation agency. Stage 1: 904 individuals with schizophrenia or schizoaffective disorder completed a survey reporting on their current use of mobile devices and interest in mHealth services. Eight practitioners completed a survey examining their attitudes and expectations from an mHealth intervention, and identified needs and potential obstacles. Stage 2: A multidisciplinary team incorporated consumer and practitioner input and employed design principles for the development of e-resources for people with schizophrenia to produce an mHealth intervention. Stage 3: 12 consumers participated in laboratory usability sessions. They performed tasks involved in operating the new system, and provided "think aloud" commentary and post-session usability ratings.

RESULTS

570 (63%) of survey respondents reported owning a mobile device and many expressed interest in receiving mHealth services. Most practitioners believed that consumers could learn to use and would benefit from an mHealth intervention. In response, we developed a smartphone system that targets medication adherence, mood regulation, sleep, social functioning, and coping with symptoms. Usability testing revealed several design vulnerabilities, and the system was adapted to address consumer needs and preferences accordingly.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Through a comprehensive development process, we produced an mHealth illness self-management intervention that is likely to be used successfully, and is ready for deployment and systemic evaluation in real-world conditions.

Negative symptoms and depression predict lower psychological well-being in individuals with schizophrenia

Previous studies have demonstrated that negative symptoms are linked to lower rates of recovery in individuals with schizophrenia when recovery is defined objectively in terms of symptom remission, vocational outcome, and social functioning. In the current study, we followed up these prior investigations by examining the other aspect of recovery, the subjective component, to determine whether negative symptoms predict lower self-reported well-being. Participants included 56 individuals with schizophrenia and 33 controls who completed self-report measures of psychological, social, and emotional well-being. Individuals with schizophrenia also completed a battery of symptom measures. Results indicated that individuals with schizophrenia self-reported lower psychological well-being than controls in relation to all 6 domains assessed: autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and self-acceptance. However, there were no differences between groups on global self-reported emotional or social well-being. In addition, negative symptoms and depression were found to be significant predictors of psychological well-being among individuals with schizophrenia. These findings indicate that lower psychological well-being may be characteristic of individuals in the chronic phase of schizophrenia, particularly those with negative symptoms and/or depression. Implications for recovery-focused psychosocial programs are discussed.

The psychometric properties of the Illness Management and Recovery scale in a large American public mental health system

The Illness Management and Recovery (IMR) scale was created to measure recovery outcomes produced by the IMR program. However, many other mental health care programs are now designed to impact recovery-oriented outcomes, and the IMR has been identified as a potentially valuable measure of recovery-oriented mental health outcomes. The purpose of this study was to examine the psychometric properties and structural validity of the IMR clinician scale within a variety of therapeutic modalities other than IMR in a large multiethnic sample (N=10,659) of clients with mental illness from a large U.S. county mental health system. Clients completed the IMR on a single occasion. Our estimates of internal consistency were stronger than those found in previous studies (α=0.82). The scale also related to other measures of theoretically similar constructs, supporting construct and criterion validity claims. Additionally, confirmatory factor analyses supported the multidimensional representation of the IMR clinician scale. The three-factor model of illness self-management and recovery was represented by dimensions of recovery, management, and substance use. These reliable psychometric properties support the use of both the original one-factor and revised three-factor models to assess illness self-management and recovery among a broad spectrum of clients with mental illness.

Development and validation of a mental health subscale from the Quality of Well-Being Self-Administered

PURPOSE

The purpose of this study was to create and validate a mental health subscale for the Quality of Well-Being Self-Administered (QWB-SA).

METHODS

The QWB-SA and other measures such as the Profile of Mood States (POMS), Medical Outcomes Study 36 Item Short Form (SF-36), EuroQOL 5D (EQ-5D), and Health Utilities Index Mark 2 (HUI) were administered to three samples: a general population (N = 3,844), a non-psychiatric medical population (N = 535), and a psychiatric population (N = 915). Independent expert ratings of which items represented the construct of mental health were used along with psychometric methods to develop and validate a 10-item QWB-SA mental health scale.

RESULTS

The mental health scale demonstrated high internal consistency (Cronbach's alpha = 0.827-0.842) and strong correlations with other measures of mental health, such as the POMS (r = -0.77), mental health scale from the SF-36 (r = 0.72), EQ-5D mood item (r = 0.61), and HUI Emotion Scale (r = 0.59). It was not highly correlated with measures of physical health. Among the psychiatric population, the new mental health scale was moderately correlated with indicators of psychiatric problem severity.

CONCLUSIONS

It is now possible to report outcomes and relationships with mental health in studies that use the QWB-SA. This new mental health subscale can also be used with the large volume of previously collected data using the QWB-SA to examine the impact of illnesses and interventions on mental health-related quality of life.

Family interventions in Schizophrenia: promise and pitfalls over 30 years

The stress of living with unpredictable, disturbing schizophrenic symptoms can erode interpersonal relationships. Stressful family interactions are associated with poorer prognosis. Several investigators have developed educational or more intensive skills-based family programs to increase illness knowledge and improve prognosis in schizophrenia. An extensive body of research supports the benefits of participating in family-based treatments for schizophrenia, especially those of longer duration and emphasizing skill development, in reducing relapse rates. In spite of the data, these programs are underimplemented and underutilized. Barriers to their use likely arise from patients, relatives, and mental health professionals. Newer programs, which include novel engagement strategies, target subpopulations with poor prognoses, or use innovative technologies, may make these programs more accessible to a wider range of families. Engaging individuals with schizophrenia and their loved ones in a collaborative effort to design new, more consumer-driven family interventions is warranted.

Evaluating the effectiveness of an integrated community continuum of care program for individuals with serious mental illness

OBJECTIVE

To evaluate effectiveness of an "Continuum of Care Program" (CCCP) for persons with serious mental health conditions in reducing inpatient use, and building a continuum of integrated care that enhanced employment and residential stability. The program combined components of Assertive Community Treatment with a comprehensive wrap-around program.

METHODS

A cohort of 1154 individuals admitted to four outpatient CCCPs between December 2003 and May 31 2004 was identified and followed for 1 year. Outcome measures included clinical functioning level, drug/alcohol use, employment, residential arrangement and inpatient use. Regression was employed to explain changes in outcomes between baseline and follow-up as a function of services.

RESULTS

Statistically significant changes were seen over a 1-year period in all outcomes. Housing, employment and mental health improved, whereas inpatient utilization and level of care need increased. Older individuals receiving higher levels of care at baseline and those with higher case management and medical service utilization reported higher inpatient use. Outcomes also varied by provider suggesting the contribution of workforce differences to outcomes.

CONCLUSIONS

Although significant, changes in outcomes were small. Outcome effectiveness was mixed and generally unrelated to services. These findings imply that significant changes in outcomes may require several years to obtain.

Controlled clinical trial of a self-management program for people with mental illness in an adult mental health service - the Optimal Health Program (OHP)

Objective. The objective of this study was to evaluate the effect and cost-effectiveness of a self-management intervention, delivered as part of routine care in an adult mental health service. Method. In a community mental health setting, routine care was compared with routine care plus a nine-session intervention (the Optimal Health Program) using a non-randomised controlled design. Adult (18–65 years) consumers of mental health services in the Australian Capital Territory were eligible for participation. Results. The Optimal Health Program was associated with significant improvements in health and social functioning as measured by the Health of the Nation Outcome Scale (average change relative to control: –3.17; 95% CI –4.49 to –1.84; P < 0.001). In addition, there was a reduction in hospital admissions in the treatment group (percentage of time in hospital reduced from 3.20 to 0.82; P = 0.07). This translated into a net cost saving of over AU$6000 per participant per year (uncertainty range AU$744 to AU$12 656). Conclusions. This study shows promising results for incorporating a self-management program into routine care to improve the health and social functioning of mental health consumers in a cost-effective manner. What is known about the topic? Current literature supports the efficacy of structured self-management programs for chronic conditions such as diabetes (type 1 and 2) and asthma, but there remains limited evidence that self-management programs improve outcomes for people with mental illness. What does this paper add? This study adds to the body of evidence supporting self-management as a cost-effective adjunct to routine care in mental health services. What are the implications for practitioners? Our study supports the feasibility of clinicians delivering cost-effective self-management programs as part of routine mental health service delivery.

Assessing recovery from schizophrenia as an individual process. A review of self-report instruments

OBJECTIVE

Studies investigating indicators of recovery from schizophrenia yielded two concepts of recovery. The first is the reduction of psychiatric symptoms and functional disabilities ('clinical recovery'), while the second describes the individual adaptation process to the threat posed to the individual sense of self by the disorder and its negative consequences ('personal recovery'). Evidence suggests that both perceptions contribute substantially to the understanding of recovery and require specific assessment and therapy. While current reviews of measures of clinical recovery exist, measures of personal recovery have yet to be investigated. Considering the steadily growing literature on recovery, this article gives an update about existing measures assessing personal recovery.

METHOD

A literature search for instruments was performed using Medline, Embase, PsycINFO&PSYNDEXPlus, ISI Web of Knowledge, and Cochrane Library. Inclusion criteria were: (1) quantitative self-report measures; (2) specifically developed for adults with schizophrenia or schizoaffective disorder or at least applied to individuals suffering from severe mental illness; (3) empirically tested psychometric properties and/or published in a peer-reviewed, English-language journal. Instruments were evaluated with regard to psychometric properties (validity and reliability) and issues of application (user and administrator friendliness, translations).

RESULTS

Thirteen instruments met the inclusion criteria. They were individually described and finally summarized in a table reflecting the pros and cons of each instrument. This may enable the reader to make an evidence-based choice for a questionnaire for a specific application.

CONCLUSION

The Recovery Assessment Scale is possibly the best currently available measure of personal recovery when all evaluation criteria are included. However, the ratings listed in the current paper depended on the availability of information and the quality of available reports of previous assessment of the measurement properties. Considering the significant amount of information lacking and inconsistent findings, further research on the reviewed measures is perhaps more important than the development of new measures of personal recovery.

Long-Term Effects of Brief Acceptance and Commitment Therapy for Psychosis

A previous report explored the impact of a brief (four session) acceptance and commitment therapy (ACT) intervention as compared with treatment as usual (TAU) on rehospitalization over 4 months in a sample of 80 inpatients with psychosis. The present study extended the follow-up period to 1 year and used a more sophisticated survival analysis to take previous hospitalization and length of the current hospitalization into account. Those in the ACT condition showed reduced hospitalization as compared to those in TAU at 4 months post discharge and again at 1 year post discharge. A test of proportionality of hazard showed that survival curves continued to diverge in the 5- to 12-month postdischarge period after adjusting for differences in the 0 to 4 month period. Future directions are discussed.