Implementing Illness Management and Recovery Within Assertive Community Treatment: A Pilot Trial of Feasibility and Effectiveness

The illness management and recovery program: a contribution to recovery-oriented secondary mental health services

BACKGROUND

In recent decades, mental health services have been challenged to offer evidence-based practices (EBPs) that are person-centered, human rights- and recovery-oriented. The Illness Management and Recovery (IMR) program aims to promote recovery and enhance individuals' ability to live well. Investigating the IMR program from the perspective of mental health practitioners is crucial to improve recovery-oriented care and optimize program delivery.

METHODS

This study aimed to develop knowledge whether IMR, as an EBP, can function as a recovery-oriented practice (ROP) within secondary mental health care services. Seven focus groups were conducted, each consisting of two to eight mental health practitioners with different professional backgrounds and experiences. Altogether, 36 practitioners from five mental health hospitals and district psychiatric centers in Norway participated. Reflexive thematic analysis was used to analyze the data.

RESULTS

The results show that IMR (a) actively facilitates the alignment of coping mechanisms with patients' lives, and (b) emphasizes a recovery-oriented approach in the delivery of services. Mental health practitioners perceive IMR as inherently recovery-oriented. Although ROPs and EBPs are often considered to function in opposition, to the practitioners in our study they were neither contradictory nor mutually exclusive but complementary and with the potential to bring out the best in each other to support patients' recovery processes.

CONCLUSION

IMR, as an evidence-based, recovery-oriented program, bridges psychiatry and mental health recovery. However, challenges arise from its illness-oriented approach and language, as well as its emphasis on individual recovery aspects. While IMR underscores the social aspects of recovery, it is essential to highlight the social, and societal factors in individuals' recovery processes within the program.

The Comparison of Four Models of Community Psychiatry-A Systematic Review and Preliminary Meta-Analysis of the ACT Model

BACKGROUND

The aim of this systematic review and preliminary meta-analysis is to summarize the effectiveness of selected models of community psychiatry: community mental health center, flexible assertive community treatment, community mental health team and assertive community treatment.

METHODS

In order to determine the results of therapeutic interventions, comparison of symptom severity, level of functioning, use of institutional care, quality of life/well-being/recovery and satisfaction at baseline and during follow-up was conducted. Thirty-seven quantitative studies were selected, grouped according to the study model and compared in terms of positive, neutral and negative impact on patients according to efficacy factors. Additionally, a preliminary random-effects meta-analysis was performed on 11 studies to investigate the effectiveness of assertive community treatment.

RESULTS

Review shows the overall positive results of the selected models. The best documented effects were an increase in the level of functioning and a reduction in institutional care. The number of articles collected indicates that community mental health center and assertive community treatment are better researched than community mental health team and flexible assertive community treatment models. Meta-analysis on assertive community treatment studies showed significant pooled effect sizes for domains of functioning, quality of life, hospitalizations and symptom severity.

CONCLUSIONS

The community mental health center and assertive community treatment are most likely to indicate efficiency and safety. The community mental health team and flexible assertive community treatment models should be explored in future studies. Results of the preliminary meta-analysis provide further evidence for the effectiveness of assertive community treatment.

A systematic review of influences on implementation of supported self-management interventions for people with severe mental health problems in secondary mental health care settings

PURPOSE

There is robust evidence for offering supported self-management interventions for people with severe mental illness (SMI) throughout secondary mental health services, but their availability remains patchy. The aim of this systematic review is to synthesise the evidence on barriers and facilitators to implementing self-management interventions for people with SMI in secondary mental health care settings.

METHODS

The review protocol was registered with PROSPERO (CRD42021257078). Five databases were searched to identify relevant studies. We included full-text journal articles with primary qualitative or quantitative data on factors which affect the implementation of self-management interventions for people with SMI in secondary mental health services. The included studies were analysed using narrative synthesis, using the Consolidated Framework for Implementation Research and an established taxonomy of implementation outcomes.

RESULTS

Twenty-three studies from five countries met eligibility criteria. The barriers and facilitators identified in the review were mainly on the organisational level, but included some individual-level influences. Facilitators included high feasibility, high fidelity, a strong team structure, sufficient number of staff, support from colleagues, staff training, supervision, the presence of an implementation champion and adaptability of the intervention. Barriers to implementation include high staff turnover, staff shortage, lack of supervision, lack of support for staff delivering the programme, staff struggling with their increased workload, a lack of senior clinical leadership, and programme content perceived as irrelevant.

CONCLUSION

The findings from this research suggest promising strategies to improve implementation of self-management interventions. For services providing support for people with SMI, organisational culture should be considered, as well as the adaptability of interventions.

Effects of empowerment-based illness management on the medication adherence and recovery of persons with schizophrenia: A systematic review and meta-analysis

Medication adherence and recovery rates are <50% among persons with schizophrenia; therefore, this health concern needs attention. Empowerment is a vital element for behavioural change, but previous studies have presented different results and lack specific connotations about empowerment. Therefore, this study systematically reviewed and meta-analysed the effects of empowerment-based illness management on the medication adherence and recovery of persons with schizophrenia. The databases searched included the PROSPERO registration network, Cochrane Library, PubMed, Embase, CINAHL, PsycAricle, and Airiti Library. The research steps were based on PRISMA. RoB 2.0 was used for article quality evaluation, the effect size was calculated using RevMan software, and the random-effect model and standardized mean differences (SMD) were established. Eight randomized controlled trials (RCTs) involving 859 participants were used to investigate the effect of empowerment on medication adherence. The trials involved the use of effective strategies as inducing medication motivation, promoting self-medication management, and providing support resources. A moderate effect was observed (SMD = 0.58, 95% CI 0.18-0.99). Ten RCTs involving 1473 participants were used to investigate the effect of empowerment on recovery. These trials involved the use of such effective strategies as using self-strength, connecting external forces, understanding personal needs, and overcoming self-stigma. A moderate effect was observed (SMD = 0.55, 95% CI 0.10-0.99). Empowerment in illness management can effectively promote the medication adherence and recovery of persons with schizophrenia. In the future, nurses can use self-strength care to promote medication motivation and connect internal and external forces to assist a person's medication adherence and recovery.

Organisational change to integrate self-management into specialised mental health services: Creating collaborative spaces

INTRODUCTION

Self-management support for schizophrenia has become expected practice leaving organisations to find ways for feasible implementation. Self-management support involves a foundational cultural shift for traditional disease-based services, new ways of clients-providers working together, coupled with delivering a portfolio of tools and techniques. A new model of self-management support embedded into traditional case management services, called SET for Health (Self-management Engaging Together for Health),  was designed and tailored to make such services meaningfully accessible to clients of a tertiary care centre. This paper describes the proof of concept demonstration efforts, the successes/challenges, and initial organisational changes.

METHOD

An integrated knowledge translation approach was selected as a means to foster organisational change grounded in users' daily realities. Piloting the model in two community case management programmes, we asked two questions: Can a model of self-management support be embedded in existing case management and delivered within routine specialised mental health services? What organisational changes support implementation?

RESULTS

Fifty-one clients were enroled. Indicators of feasible delivery included 72.5% completion of self-management plans in a diverse sample, exceeding the 44% set minimum; and an attrition rate of 21.6%, less than 51% set maximum. Through an iterative evaluation process, the innovation evolved to a targeted hybrid approach revolving around client goals and a core set of co-created reference tools, supplemental tools and resources. Operationalisation by use of tools was implemented to create spaces for client-provider collaborations. Monitoring of organisational changes identified realignment of practices. Changes were made to procedures and operations to further spread and sustain the model.

CONCLUSION

This study demonstrated how self-management support can be implemented, within existing resources, for routine delivery of specialised services for individuals living with schizophrenia. The model holds promise as a hybrid option for supporting clients to manage their own health and wellness.

Reliability and validity of the Mental Health Self-management Questionnaire among Chinese patients with mood and anxiety disorders

BACKGROUND

Self-management plays an important role in promoting and restoring mental health for individuals with mental health issues. However, there is no valid and reliable Chinese tool assessing the self-management behaviors of people with mood and anxiety disorders. This study aimed to develop a Chinese version of the Mental Health Self-management Questionnaire (MHSQ-C) and to verify its psychometric properties.

METHODS

A total of 440 potential participants were recruited by convenience sampling from June to August 2020. Item analysis and analyses of internal consistency, test-retest reliability, content validity, construct validity and criterion validity were performed.

RESULTS

Data from 326 participants were used. Three factors obtained via principal component analysis and varimax rotation explained 53.68% of the total variance. The average content validity index was 0.99. The Cronbach's α coefficient (total: 0.874, clinical: 0.706, empowerment: 0.818, vitality: 0.830) and test-retest reliability (ICC: total: 0.783, 95% confidence interval (CI) [0.616, 0.882], clinical: 0.525, 95% CI [0.240, 0.725], empowerment: 0.786, 95% CI [0.622, 0.884], vitality: 0.748, 95% CI [0.564, 0.862]) were good. The MHSQ-C was well correlated with the Partners in Health scale and showed no floor or ceiling effect.

DISCUSSION

The MHSQ-C is a reliable and valid tool to evaluate the self-management strategies of patients with mood and anxiety disorders.

Longitudinal changes in personal recovery in individuals with psychotic disorders through hospitalisation in a psychiatric ward: preliminary findings

BACKGROUND

This study aimed to investigate whether personal recovery indices in individuals with psychotic disorders would change through hospitalisation in a psychiatric ward and to identify factors associated with these changes.

METHODS

Participants underwent assessments for personal recovery using the Questionnaire about the Process of Recovery, Recovery Assessment Scale, and Self-Identified Stage of Recovery Part A and B; clinical symptoms using the Positive And Negative Syndrome Scale; self-efficacy using the General Self-Efficacy Scale; and self-esteem using the Rosenberg Self-Esteem Scale at baseline and before hospital discharge. Wilcoxon signed-rank tests were administered for longitudinal comparisons between baseline and follow-up. Spearman's rank correlation tests were conducted to assess correlations of longitudinal changes in personal recovery with baseline values of personal recovery as well as baseline values or changes in the Positive And Negative Syndrome Scale, General Self-Efficacy Scale, and Rosenberg Self-Esteem Scale.

RESULTS

Thirty-four individuals with psychotic disorders completed the assessments. The average duration of the current hospitalisation was 81.9 days (SD, 15.3; median, 85.0; range, 51-128 days). No significant changes were observed in personal recovery, self-efficacy, and self-esteem, although clinical symptoms significantly improved. Significant correlations were found between positive changes in the Recovery Assessment Scale and improvements in negative symptoms; between positive changes in the General Self-Efficacy Scale and those in personal recovery assessed with the Questionnaire about the Process of Recovery, Recovery Assessment Scale, and Self-Identified Stage of Recovery part A; and between positive changes in the Rosenberg Self-Esteem Scale and those in the Self-Identified Stage of Recovery part B.

CONCLUSION

This study revealed longitudinal relationships between changes in personal recovery and amelioration of negative symptoms or enhancement of self-efficacy and self-esteem through moderate length of hospitalisation in individuals with psychotic disorders. Considering the small sample size in this study, further studies with a larger sample size are needed to confirm the present finding.

TRIAL REGISTRATION

The protocol of this study is registered in the UMIN Clinical Trials Registry (UMIN-CTR; ID: UMIN000035131 ).

Assessing Implementation Strategy Reporting in the Mental Health Literature: A Narrative Review

Inadequate implementation strategy reporting restricts research synthesis and replicability. We explored the implementation strategy reporting quality of a sample of mental health articles using Proctor et al.'s (Implement Sci 8:139, 2013) reporting recommendations. We conducted a narrative review to generate the sample of articles and assigned a reporting quality score to each article. The mean article reporting score was 54% (range 17-100%). The most reported domains were: name (100%), action (82%), target (80%), and actor (67%). The least reported domains included definition (6%), temporality (26%), justification (34%), and outcome (37%). We discuss limitations and provide recommendations to improve reporting.

Effects of Illness Management and Recovery: A Multicenter Randomized Controlled Trial

There have been inconsistent findings in the literature with respect to the efficacy of Illness Management and Recovery (IMR) in the psychosocial treatment of people with schizophrenia or other severe mental illnesses. This study aimed to comprehensively investigate the effectiveness of IMR, including the impact of completion and fidelity. In this randomized controlled trial (RCT), 187 outpatients received either IMR plus care as usual (CAU) or only CAU. Multilevel modeling was implemented to investigate group differences over an 18-month period, comprising 12 months of treatment and six months of follow-up. The primary outcome was overall illness management, which was assessed using the client version of the IMR scale. Secondary outcomes included measures regarding illness management, clinical, personal, and functional recovery, and hospitalizations. The interviewers were blinded to group allocation. This clinical trial was registered with the Netherlands Trial Register (NL4931, NTR5033). Patients who received IMR showed statistically significant improvement in self-reported overall illness management (the primary outcome). Moreover, they showed an improvement in self-esteem, which is a component of personal recovery. There were no effects within the other questionnaires. There were also no statistically significant between-group differences in terms of hospitalizations. Patients in both groups showed statistically significant improvement in clinician-rated overall illness management, social support, clinical and functional recovery, and self-stigma over time. IMR completion was associated with stronger effects. High IMR fidelity was associated with self-esteem. This study confirms the efficacy of IMR in overall illness self-management. To our knowledge, this is the first RCT on IMR to explore the impact of fidelity on treatment efficacy. Future studies should further establish efficacy in personal recovery. To improve efficacy, it appears important to promote IMR completion and fidelity.

Implementing illness management and recovery within assertive community treatment teams: A qualitative study

OBJECTIVE

The study purpose was to assess the feasibility, advantages/disadvantages, and factors that hinder or facilitate the implementation of illness management and recovery (IMR) within assertive community treatment (ACT) teams.

METHOD

A qualitative study was conducted with 11 ACT teams that implemented IMR. We conducted semistructured individual interviews with 17 persons enrolled in services and 55 ACT staff in individual and focus groups. Questions were designed to assess perceptions of IMR implementation, effects of IMR, staff training considerations, and recommendations. Data were analyzed using an inductive, consensus-building, thematic analysis, which included multiple research staff reviewing interview transcripts and field notes, developing and refining a codebook, constructing data summaries, and thematic synthesis.

RESULTS

The analysis revealed six major themes: (a) a generally positive fit exists between the two models and population served, (b) both people with serious mental illness and staff benefited from ACT + IMR, (c) ACT teams encountered significant implementation barriers, (d) relationships and engagement with participants facilitated implementation, (e) taking a flexible approach to IMR and ACT improved implementation, and (f) programs should focus on greater integration of IMR within ACT teams.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

While there can be barriers to implementing IMR within ACT teams, there is generally a positive fit, it is feasible to implement, and it offers meaningful benefits. ACT teams should improve their recovery orientation by more widespread implementation of IMR. Future research on ACT + IMR should include mixed-methods approaches, implementation methodologies to identify barriers and facilitators, and idiographic measures that capture the individualized recovery goals of people with serious mental illness. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Self-management interventions for people with severe mental illness: systematic review and meta-analysis

BACKGROUND

Self-management is intended to empower individuals in their recovery by providing the skills and confidence they need to take active steps in recognising and managing their own health problems. Evidence supports such interventions in a range of long-term physical health conditions, but a recent systematic synthesis is not available for people with severe mental health problems.AimsTo evaluate the effectiveness of self-management interventions for adults with severe mental illness (SMI).

METHOD

A systematic review of randomised controlled trials was conducted. A meta-analysis of symptomatic, relapse, recovery, functioning and quality of life outcomes was conducted, using RevMan.

RESULTS

A total of 37 trials were included with 5790 participants. From the meta-analysis, self-management interventions conferred benefits in terms of reducing symptoms and length of admission, and improving functioning and quality of life both at the end of treatment and at follow-up. Overall the effect size was small to medium. The evidence for self-management interventions on readmissions was mixed. However, self-management did have a significant effect compared with control on subjective measures of recovery such as hope and empowerment at follow-up, and self-rated recovery and self-efficacy at both time points.

CONCLUSION

There is evidence that the provision of self-management interventions alongside standard care improves outcomes for people with SMI. Self-management interventions should form part of the standard package of care provided to people with SMI and should be prioritised in guidelines: research on best methods of implementing such interventions in routine practice is needed.Declaration of interestsNone.

Sixth Kraepelin Symposium-Understanding and Treating Cognitive Impairment and Depression in Schizophrenia and Affective Disorders

The Sixth Kraepelin Symposium was held at the Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich in October 2018, covering reports from 12 working groups (Keith H. Nuechterlein, Ph.D., University of California, Los Angeles; Kim T. Mueser, Ph.D., Center for Psychiatric Rehabilitation, Boston University, U.S.A.; Dominic Dwyer, Ph.D, Hospital LMU, Munich; David Fowler, Ph.D. University of Sussex, Brighton, U.K.; Martin Hautzinger, Ph.D., University of Tübingen; Nikolaos Koutsouleris, M.D., Hospital LMU, Munich; Stephan Leucht, M.D., Technical University Munich, Munich; David Miklowitz, Ph.D., UCLA School of Medicine, Los Angeles. U.S.A.; Cornelius Schüle, M.D., Hospital LMU, Munich; Florian Seemüller. M.D., kbo-Lech-Mangfall Clinics for Psychiatry and Psychotherapy, Garmisch Partenkirchen; Carla Torrent, Ph.D., Institute of Neuroscience, University of Barcelona, Barcelona, Spain.) from the United States and Europe on understanding and treating cognitive impairment and depression in schizophrenia and affective disorders. Current psychological interventions to improve outcome in schizophrenia and affective disorder such as cognitive remediation, illness management, psychoeducational and cognitive therapy were focused on, as were evidence-based psychological and pharmacological treatment options, guidelines for treating cognitive deficits and depression in schizophrenia, Cochrane-meta-analysis of acute therapies, relapse prevention as well as supported withdrawal from medication. Prevention of cognitive dysfunction and symptom exacerbation was approached in terms of machine learning methods to revisit Kraepelin's illness distinctions, application of new strategies in order to increase the rate of social recovery in patients with first-episode psychosis as well as in terms of state of the art psychosocial interventions for bipolar disorder in adolescents. Finally, the dissemination of information to consumers and the contribution to the reduction of stereotypes in psychiatry was also part of the symposiums aims.

Distribution and Correlates of Assertive Community Treatment (ACT) and ACT-Like Programs: Results From the 2015 N-MHSS

OBJECTIVE

The study examined the availability and characteristics of assertive community treatment (ACT) programs across mental health treatment facilities in the United States.

METHODS

Prevalence and correlates of facilities that reported offering ACT, broadly defined as intensive community services for serious mental illness provided by multidisciplinary teams in the clients' natural settings and including both ACT and "ACT-like" programs, were examined by using data from the National Mental Health Services Survey. Availability of services essential to the ACT model in these facilities was also examined.

RESULTS

Of the 12,826 surveyed facilities, 13.4% reported offering ACT, with significant variability among states. Of the facilities with ACT, 19.2% reported offering all core ACT services. Few facilities offered peer support, employment, and housing services. Compared with programs at facilities that did not offer all core ACT services, facilities with ACT programs that offered these services had higher odds of being publicly owned (odds ratio [OR]=2.12, 95% confidence interval [CI]=1.64-2.74) and of receiving federal (OR=3.60, CI=2.17-5.98) or grant funding (OR=1.87, CI=1.45-2.41). Facilities with ACT that offered all core services also had higher odds of offering other services important to individuals with serious mental disorders.

CONCLUSIONS

Substantial differences existed in availability of ACT and ACT-like programs among states, with evidence of a large unmet need overall, even when a very broad and inclusive definition of ACT was used. Few ACT programs offered all core services. Legislative, administrative, and funding differences may explain some of the variability.