Mental illness and well-being: the central importance of positive psychology and recovery approaches

Measuring the performance of the Mental Health Continuum-Short Form (MHC-SF) in a primary care youth mental health service

Objectives

Mental health is regarded as more than the absence of mental health difficulties, with clinical and research focus moving towards measurement of well-being. The Mental Health Continuum-Short Form (MHC-SF) was developed to assess overall and emotional, social and psychological well-being. Little is known about the use of the MHC-SF with young people engaging with mental health services. The current pilot study sought to examine the performance of the MHC-SF in an Irish primary care youth mental health service for 12–25 year olds.

Methods

A sample of 229 young people (female n=143; male n=85, unknown n=1) aged 12–24 years (M=15.87, SD=2.51) who completed the MHC-SF prior to commencing their first intervention session in Jigsaw participated in this study. The psychometric properties of the MHC-SF were investigated using confirmatory factor analysis (CFA) and Cronbach’s alpha for internal consistency.

Results

CFA supported the three-factor structure of the MHC-SF for emotional, social, and psychological well-being, and very good internal consistency was observed.

Conclusion

Findings provide evidence for the psychometric properties of the MHC-SF in a primary care youth mental health setting, and suggest that the MHC-SF’s three-factor structure is valid for use in this context. Limitations and recommendations for future research are discussed.

A Meta-Analysis of the Efficacy of Case Management for Substance Use Disorders: A Recovery Perspective

Background: Case management is a client-centered approach to improve the coordination and continuity of service delivery, especially for persons with substance use disorders (SUD) and multiple and complex support needs. This intervention supports individuals by helping them identify needed services, facilitate linkage with services, and promote participation and retention in services. However, it is questionable whether case management is equally effective in promoting recovery and aspects of personal functioning. The objective was to conduct an updated meta-analysis and to assess whether case management was more effective than treatment as usual (TAU) among persons with SUD for improving treatment-related (e.g., successful linkage with and retention in treatment) as well as personal functioning outcomes (e.g., substance use). Methods: This meta-analysis focuses on randomized controlled trials (RCTs) that included persons with alcohol or drug use disorders and compared case management with TAU. To be eligible, interventions had to meet core case management functions as defined in the literature. We conducted searches of the following databases to May 2017: the Cochrane Drugs and Alcohol Specialized Register, CENTRAL, PubMed, Embase, CINAHL, and Web of Science. Also, reference lists of retrieved publications were scanned for relevant (un)published studies. Results: The overall effect size for case management compared to TAU across all outcome categories and moments was small and positive (SMD = 0.18, 95% CI 0.07-0.28), but statistically significant. Effects were considerably larger for treatment tasks (SMD = 0.33, 95% CI 0.18-0.48) than for personal functioning outcomes (SMD = 0.06, 95% CI -0.02 to 0.15). The largest effect sizes were found for retention in substance abuse treatment and linkage with substance abuse services. Moderator effects of case management models and conditions were assessed, but no significant differences were observed. Conclusions: The primary results from earlier meta-analyses were supported: case management is more effective than TAU conditions for improving outcomes, but this effect is significantly larger for treatment-related tasks than for personal functioning outcomes. Case management can be an important supplement to available services for improving linkage and retention, although further research is needed to assess its potential for supporting recovery from a longitudinal perspective.

Validation of the Mental Health Continuum-Short Form and the dual continua model of well-being and psychopathology in an adult mental health setting

OBJECTIVE

The growing evidence for the dual continua model of psychopathology and well-being has important implications for measuring outcomes in mental health care. The aim of the current study is to validate a measure of well-being as well as the dual continua model in adults with mood, anxiety, personality, and developmental disorders.

METHODS

472 adult psychiatric outpatients filled out the Mental Health Continuum-Short Form (MHC-SF) and the Outcome Questionnaire before start of treatment.

RESULTS

Confirmatory factor analyses (CFA) confirmed the three-factor structure of emotional, psychological, and social well-being of the MHC-SF. The dual continua model had the best fit in the complete sample and the different diagnostic groups.

CONCLUSION

The MHC-SF is a reliable and valid instrument to measure well-being in the psychiatric population. Although relatively high correlations between psychopathology and well-being exist, the results underline the importance to measure well-being in addition to psychopathology in mental health care.

Consumer and staff perspectives of the implementation frequency and value of recovery and wellbeing oriented practices

Background

Despite advances in our understanding of what mental health systems and services can do to enhance recovery and wellbeing outcomes for people seeking support, there is limited evidence demonstrating that this body of work has translated successfully into mental health service practice. The Collaborative Recovery Model (CRM) is a practice framework that has been designed to support application of recovery and wellbeing oriented principles and practices within mental health service delivery. The aims of this study were to assess consumer and staff perceptions of implementation frequency during service engagement and the value of this approach for assisting recovery within a setting where the CRM approach had been adopted.

Methods

The setting was a large Australian community managed mental health organisation. The study involved a cross-sectional analysis of consumer (n = 116) and staff practitioner (n = 62) perspectives. A series of paired sample t-tests assessed for differences between consumer and staff perceptions of the: (i) importance of key practice elements for assisting recovery, and the (ii) frequency that key practice elements are utilised during engagement sessions. Spearman's r correlational analysis explored associations between importance, frequency and helpfulness of sessions.

Results

Key practice elements of the model were applied during service interactions at a high level and perceived by the majority of consumers and staff participants as being important or very important for assisting recovery. Significant moderate correlations were found between the extent that practice elements were valued and the level at which they were applied. Higher levels of implementation of CRM practices were associated with higher ratings of perceived session helpfulness. The strongest association was between 'encouragement to set tasks to complete between support visits' and perceived helpfulness.

Conclusions

Consumer and staff responses revealed that the key practice elements of the CRM were frequently implemented during service engagement interactions and were seen as valuable for assisting recovery. The level of agreement between raters suggests firstly, that the key practice elements were apparent and able to be rated as occurring, and secondly that the CRM approach is seen as responsive to consumer needs. The results have implications for translating recovery and wellbeing oriented knowledge into mental health service practice.

Changes in percentages of perceived met needs for care over time in a Canadian longitudinal cohort

There is a paucity of research on determinants associated with changes in perceived met needs for care over time. This study used a longitudinal cohort to explore changes in percentages of perceived met needs over time and to identify its related determinants. Data analyzed was from a longitudinal community-based survey. A total of 150 participants received at least one type of help both at baseline and a 2-year follow-up. Multivariate analyses were used. Perceived met needs of the study sample slightly increased over time. People who had a higher percentage of met needs at baseline were less likely to have an increase in percentage of perceived met needs at the 2-year follow-up, whereas, those who had a higher value of wellbeing and an increase in the value of mental wellbeing over time, were associated with an increase in the percentage of met needs at the 2-year follow-up. Determinants associated with changes in percentages of perceived met needs could be the target for improving perceived need for mental health care. Findings of this study indicate the need for longitudinal studies in perceived need for mental health services.

Barriers and facilitators of effective health education targeting people with mental illness: a theory-based ethnographic study

BACKGROUND

Health education is particularly important for people with mental illness because they are at higher risk of becoming overweight or obese and developing type 2 diabetes than are members of the general population. However, little is known about how to provide health education activities that promote engagement and motivation among people with mental illness.

METHODS

This study used ethnographic methods to examine barriers and facilitators of effective health education targeting people with mental illness by applying the concept of flow as a theoretical framework. Flow refers to immersion in an activity and is related to motivation. Data were collected through participant observation during eight health-educating activities and were thematically analysed using the concept of flow. Fieldwork was carried out between May and July 2015 in Denmark.

RESULTS

Barriers to flow included: 1) information overload, particularly of biomedical rationales for behaviour change; 2) a one-size-fits-all approach that failed to address the needs and preferences of the target group; and 3) one-way communication allowing little time for reflection. Educators promoted a state of flow when they spoke less and acted outside of a traditional expert role, thus engaging participants in the activity. Flow was facilitated when educators were attentive and responsive to people with mental illness, and when they stimulated reflection about health and health behaviour through open-ended questions, communication tools and in small group exercises.

CONCLUSIONS

This study suggests that more focus should be paid to training of educators in terms of skills to involve and engage people with mental illness in health education activities.

'The only chance of a normal weight life': A qualitative analysis of online forum discussions about bariatric surgery

Background

The only effective weight loss treatment for severe obesity is bariatric surgery, with Roux-en-Y gastric bypass being the most common method. Patients often have unrealistic expectations of surgery and expect a “miracle cure” even though the procedure requires major lifelong lifestyle changes. Most patients access information about the procedure online, and come into contact with others who have had the surgery.

Objective

The objective of this study was to describe shared values, feelings, and thoughts among visitors to a web-based forum for those undergoing bariatric surgery.

Methods

In this cross-sectional observation study using qualitative contents analysis, the material consisted of an online discussion forum thread about bariatric surgery, with 498 posts. These were saved in a document, read and re-read. Through coding of meaningful units of text, themes were established.

Results

Four themes were constructed during data analysis: a) A new life—anticipating dramatic changes of body and mind; b) Negotiating the system and playing the waiting game; c) A means to an end—managing the pre-operative diet; and d) Managing the attitudes of others. Posters described the process of bariatric surgery as a journey, riddled with roadblocks, setbacks and trials, but also with joy and expectations of a new life.

Conclusion

Professionals who encounter this group should be aware of their need for support throughout the process, and investigate the possibility of both pre- and postoperative support groups, either online or face-to-face. The results also show that the posters on the forum had very high, and often unrealistic, expectations on how the surgery would change their lives. It is important for those who encounter this group before surgery to be aware of this tendency and to take measures to ensure that patients undergo the surgery with realistic expectations.

B-positive: a randomized controlled trial of a multicomponent positive psychology intervention for euthymic patients with bipolar disorder - study protocol and intervention development

BACKGROUND

Bipolar disorder (BD) is characterized by recurrent (hypo)manic and depressive episodes, alternating with euthymic states in which patients are relatively symptom free. Besides clinical recovery, it is important to also strive for improvement of mental well-being and personal recovery. One prominent field focussing on the improvement of well-being is positive psychology. However, studies assessing the effects of positive psychology or personal recovery interventions for people with BD are scarce and have used weak methodological designs. The study described in this protocol article aims to assess the effectiveness of a multicomponent positive psychology intervention ("Living well with bipolar disorder") adjusted for people with BD in the euthymic phase to improve well-being and personal recovery.

METHOD

The study concerns a pragmatic randomized multicenter trial. The principle objective of the study is to assess whether the positive psychology intervention offered to BD patients in remission in addition to usual care (CAU) is more effective than CAU. The study will include 112 participants randomized to either the experimental condition receiving the intervention in addition to CAU or the control condition receiving CAU. The study population are patients with BD I or II in the euthymic phase. The inclusion criteria are 1) diagnosis of BD I or BD II, 2) between the ages of 18-65, 3) four or more supportive sessions in the last year, and 4) only residual depressive or manic symptoms. Patients are excluded if they are in a depressive or manic episode, have current addiction problems or have optimal levels of well-being. Measurements take place at baseline, post-intervention and follow-up 6 and 12 months from baseline. Outcomes of measures include positive well-being, personal recovery, psychopathology, self-compassion, positive relationships, dampening of positive affect and relapse.

DISCUSSION

The outlined study will be the first RCT examining the effects of a multicomponent positive psychology intervention for patients with bipolar disorder. Several limitations, including generalizability of the results and possible attrition issues, are discussed in advance.

TRIAL REGISTRATION

This study has been registered in the Netherlands Trial Register ( NTR6729 ) on 12 October 2017.

A randomized controlled trial of three smartphone apps for enhancing public mental health

Many smartphone applications (apps) for mental health (MHapps) are available to the public. However, few have been the subject of a randomized controlled trial (RCT), and the change processes that are hypothesized to mediate claimed effects have not been previously studied. This RCT compared the efficacy of three publicly available MHapps to a waitlist control condition in a community sample, in which no MHapp was provided. The three MHapps included cognitive behavioural therapy (CBT) toolkit app MoodKit, mood tracking app MoodPrism, and CBT strategy app MoodMission. Participants were randomly allocated to each condition, completed a baseline assessment, downloaded their allocated MHapp, and completed a second assessment 30 days later, with n = 226 included in final analyses (81% female; M age = 34 years). Compared to the control condition, all MHapp groups experienced increases in mental wellbeing, MoodKit and MoodMission groups experienced decreases in depression, and no groups experienced effects on anxiety. Mediated regressions revealed that increasing coping self-efficacy, rather than emotional self-awareness or mental health literacy, was the underlying process contributing to effects on mental health for all three MHapps. MHapps appear to be an effective solution for improving public mental health, notably by improving users' confidence in their ability to cope.

Promoting well-being in psychosis

BACKGROUND

Traditionally, treatment of psychosis has focused on the amelioration of psychopathology and return to adequate functioning: clinical recovery although there is growing recognition of the importance of subjective experiences associated with recovery: personal recovery. Positive psychiatry extends the focus of psychiatric treatment to go beyond the reduction of psychiatric symptoms and and improvement of functional disability to promote the attainment of well-being.

AIM

This article examined the conceptualization of well-being from the context of treatment for psychosis, its relationship with clinical recovery and highlighted some of challenges and implications for mental health services in promoting well-being.

DISCUSSION

Recovery from psychosis is a complex and individual process, where well-being is more than just the absence of mental illness. Clinical and personal recovery processes may contribute to well-being although further longitudinal studies are required. A recent framework for understanding well-being in psychosis helps address the lack of consensus in this field. There is a considerable overlap between the indicators of well-being in this model and the CHIME framework for personal recovery. Thus, interventions targeting personal recovery processes may be a potential way to promote well-being. Current mental health services face a considerable challenge if they are to fulfill the dual role of reducing psychopathology and/or disability whilst concurrently addressing personal recovery to promote well-being. The attainment of well-being may not only be a desirable treatment goal in recovery-orientated mental health services but also a potential protective factor against serious mental illness.

Personal recovery within positive psychiatry

BACKGROUND

One goal within positive psychiatry is to support the personal recovery of persons with mental illness and providing opportunities for well-being.

AIM

The current article aims to introduce readers to the concept of personal recovery and the potential and importance of recovery-oriented services and measures.

METHODS

A literature review was conducted to help consider the domains of 'personal recovery', 'recovery-oriented services/interventions', and 'measures'. A database search was complemented with a web-based search. Both medical subject heading (MESH) terms and free-text search terms were used.

RESULTS

Literature from research journals, grey literature, and websites were included. Within this context, recovery does not refer to a cure but involves a process in which a person acts as an agent to develop new goals and meaning in life, despite and beyond limitations posed by the illness and its consequences. A positive focus on recovery is in sharp contrast to historical deterministic and pessimistic concepts of mental illnesses. Recovery-oriented services such as peer support, assertive community treatment, supported employment/education/housing, illness self-management, and decreasing self-stigma are highlighted. A review of 27 measures that focus on personal recovery and promotion of well-being are also discussed.

CONCLUSIONS

The literature overview presents perspectives and knowledge of how to develop positive psychiatry, how mental health services and their partner organizations may become more recovery oriented and help persons reach well-being and a better quality of life. This study is limited to a narrative review and may precede future systematic reviews.

Implementation of a Positive Technology Application in Patients With Eating Disorders: A Pilot Randomized Control Trial

Background: Positive psychological interventions (PPIs) have been suggested to produce benefits in patients with eating disorders (ED) by improving well-being, which might act as a buffer of the harmful effects caused by the disorder. Best Possible Self (BPS) is a PPI which consists of writing and envisioning a future where everything has turned out in the best possible way. In this regard, positive technology (PT) can be of considerable benefit as it allows to implement specific PPIs that have already shown efficacy.

Objective: This study tested the preliminary efficacy of the BPS exercise implemented through a PT application and carried out for 1 month, in improving positive functioning measures, compared to a control condition, in patients with ED. Follow-up effects were also explored at 1 and 3 months later.

Methods: This is a pilot randomized controlled trial, with two experimental conditions. Participants were 54 outpatients, who were receiving ongoing specialized treatment in ED services. 29 participants were randomly allocated to the BPS intervention and 25 to the control exercise. The sample was composed mostly by females and the mean age was 27 years. In the intervention group, participants had to write about their BPS. In the control group participants had to write about their daily activities. The exercise was conducted through the Book of Life, which is a PT application that allows users to add multimedia materials to the written content. Measures of future expectations, affect, dispositional optimism, hope and self-efficacy were assessed at different time frames.

Results: Findings showed that all participants improved over time and there were no statistically significant differences between conditions on the specific measures. These effects were not influenced by prior levels of ED severity. Within-group effect sizes indicate a greater benefit for the participants in the BPS condition, compared to the control condition, on nearly all the measures.

Conclusion: Results indicated that PT produced modest improvements in patients with EDs that are receiving current treatment for ED. More empirical attention is needed to explore the potential benefits of PPIs as supporting tools in the prevention and treatment of EDs.

Trial registration: clinicaltrails.gov Identifier: NCT03003910, retrospectively registered December 27, 2016.

A narrative meta-synthesis of how people with schizophrenia experience facilitators and barriers in using antipsychotic medication: Implications for healthcare professionals

BACKGROUND

It is recognized that people who are diagnosed with schizophrenia often do not fully adhere with their antipsychotic prescription. The vast majority of previous research on the topic of medical adherence is limited to quantitative research methods, and in particular, to determining correlations.

OBJECTIVES

The present review was designed to describe how people who are diagnosed with schizophrenia experience and narrate pharmacological treatment with antipsychotic medication.

DESIGN

A narrative meta-synthesis.

DATA SOURCES/REVIEW METHOD

A search was conducted in three databases, PubMed, CINAHL and PsycINFO, to identify qualitative original research. Nine articles met the criteria for inclusion and were subjected to a qualitative interpretive meta-synthesis.

RESULTS

The findings showed that patients were uninformed about medication but valued talks about medication with professionals. The findings also demonstrated that patients are motivated to take medication in order to gain stability in their life and to be able to participate in life activities and in relationships. Good support, both from relatives and professionals, also motivates them to continue taking medication. The obstacles were side-effects, pressure and compulsion, and rigid organizations.

CONCLUSIONS

We advise professionals to adopt a person-centered approach to healthcare when encountering these patients and to transform the language used to describe patients from terms denoting compliance and adherence to terms denoting cooperation and alliance. Labeling patients as compliant or non-adherent may risk fortifying preconception of patients as static beings and obscure the patients' individual recovery process.

Quality of life in bipolar disorder: towards a dynamic understanding

BACKGROUND

Although quality of life (QoL) is receiving increasing attention in bipolar disorder (BD) research and practice, little is known about its naturalistic trajectory. The dual aims of this study were to prospectively investigate: (a) the trajectory of QoL under guideline-driven treatment and (b) the dynamic relationship between mood symptoms and QoL.

METHODS

In total, 362 patients with BD receiving guideline-driven treatment were prospectively followed at 3-month intervals for up to 5 years. Mental (Mental Component Score - MCS) and physical (Physical Component Score - PCS) QoL were measured using the self-report SF-36. Clinician-rated symptom data were recorded for mania and depression. Multilevel modelling was used to analyse MCS and PCS over time, QoL trajectories predicted by time-lagged symptoms, and symptom trajectories predicted by time-lagged QoL.

RESULTS

MCS exhibited a positive trajectory, while PCS worsened over time. Investigation of temporal relationships between QoL and symptoms suggested bidirectional effects: earlier depressive symptoms were negatively associated with mental QoL, and earlier manic symptoms were negatively associated with physical QoL. Importantly, earlier MCS and PCS were both negatively associated with downstream symptoms of mania and depression.

CONCLUSIONS

The present investigation illustrates real-world outcomes for QoL under guideline-driven BD treatment: improvements in mental QoL and decrements in physical QoL were observed. The data permitted investigation of dynamic interactions between QoL and symptoms, generating novel evidence for bidirectional effects and encouraging further research into this important interplay. Investigation of relevant time-varying covariates (e.g. medications) was beyond scope. Future research should investigate possible determinants of QoL and the interplay between symptoms and wellbeing/satisfaction-centric measures of QoL.

Impact of parents' substance misuse on children: an update

We review how research over the past decade both supports existing knowledge about the risk factors that children in the UK affected by parental substance misuse face, and adds to our knowledge about the protective factors, protective processes and evidence of resilience which can reduce the likelihood that children will experience poor outcomes. Further research is needed to understand what areas of resilience are most important to target and how other variables, such as gender or age, may influence how protective factors affect the development of resilience. Longitudinal research is also needed to better understand how an individual's resilience may change over time. Finally, there remain many considerable challenges which practitioners, service providers, commissioners and policy makers face in better meeting the needs of this population of children.

Preparing master-level mental health nurses to work within a wellness paradigm: Findings from the eMenthe project

Mental health promotion remains an important component of mental health nursing practice. Supporting wellness at both the individual and societal levels has been identified as one of the key tenets of mental health promotion. However, the prevailing biomedical paradigm of mental health education and practice has meant that many nurses have not been equipped to incorporate a wellness perspective into their mental health practice. In the present study, we report on an exploratory study which details the knowledge, skills, and attitudes required by master-level mental health nurses to practice within a wellness paradigm from the perspective of three groups of key stakeholders: (i) service users and family members (n = 23); (ii) experienced mental health nurses (n = 49); and (iii) master-level mental health nursing students (n = 37). The findings, which were reported from individual and focus group interviews across five European countries, suggested a need to reorientate mental health nursing education to include a focus on wellness and resilience to equip mental health nurses with the skills to work within a strengths-based, rather than a deficits-based, model of mental health practice. Key challenges to working within a wellness paradigm were identified as the prevailing dominance of the biomedical model of cause and treatment of mental health problems, which focusses on symptoms, rather than the holistic functioning of the individual, and positions the person as passive in the nurse-service user relationship.

What keeps nurses happy? Implications for workforce well-being strategies

AIM

The aim of this article is to present selected findings from a doctoral study on the subjective well-being and subjective experience of mental health problems in UK mental health nurses. Here the concept of 'nurses' well-being' is explored.

METHOD

Data were drawn from a survey of 237 mental health nurses about their mental health and well-being and from interviews with 27 mental health nurses with personal experience of mental health problems and high subjective well-being.

RESULTS

While nurses' subjective well-being is relatively low, some use strategies to support their well-being in and outside the workplace. Activities outside work that improved their wellbeing were physical exercise, mindfulness practice, spending time in nature and listening to music. Well-being was associated with clear boundaries between home and work life, regular clinical supervision and translating learning from work with patients to nurses' own lives.

CONCLUSION

Healthcare employers' staff health and well-being strategies should be informed by nurses' insights into what works for them. This may mean offering opportunities to take part in well-being activities. There are also opportunities to improve staff well-being through shared initiatives open to nurses and patients, and through an inclusive and empowering approach to staff engagement.

Psychometric properties and population norms of the positive mental health instrument in a representative multi-ethnic Asian population

Background

Measures of mental well-being and positive mental health (PMH) have been largely developed and used in Western populations, however, data on representative Asian communities are lacking. Using data from a population sample, this study sought to establish psychometric properties and norms of the PMH Instrument (PMH-I), a measure of positive mental health developed in Singapore.

Methods

We conducted a nationally representative survey among 1925 adults aged 18–79 years of Chinese, Malay, Indian or other ethnicity. Participants reported socio-demographic characteristics and completed the PMH-I along with measures of health-related quality of life (HRQoL) and psychological distress. Construct validity of the PMH-I was assessed using confirmatory factor analysis and concurrent validity was tested through correlation with other psychological measures. Normative PMH values and differences in population subgroups were estimated.

Results

The six-factor-higher-order structure of the PMH-I comprising six subscales of general coping, emotional support, spirituality, interpersonal skills, personal growth and autonomy and global affect was confirmed. Concurrent validity was shown through significant positive correlation of the total PMH score and its subscales with HRQoL and an inverse correlation with psychological distress. Weighted age, gender and ethnicity-specific norms were derived for the Singapore population. Total PMH was significantly higher in participants aged over 40 years as compared with 18–29 year olds and in non-Chinese ethnic groups as compared with Chinese. These differences were observed for all PMH-I subscales, with the exception of emotional support and interpersonal skills score differences by age. In contrast, gender, marital status, and education level were significantly associated with some of the subscales, but not with total PMH.

Conclusions

These results support the psychometric properties of the PMH-I in a multi-ethnic Asian population sample. The generalizable population-based norms support the application of the PMH-I for measuring mental health and assessing its determinants within the Singapore general population.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0487-9) contains supplementary material, which is available to authorized users.

Towards partnerships in mental healthcare

We consider key facets of the concept of mental health recovery and how they are reflected in other concepts that run through the emerging focus on public mental healthcare. We widen the scene to portray the niche into which recovery fits and show how it and recent research indicate why psychiatrists should use the social sciences more widely to complement neuroscience.

Becoming a recovery-oriented practitioner

Professional practice explicitly focused on supporting the recovery of those it serves is broadly backed by an emerging profile of necessary knowledge, key skills and innovative collaborations, although there is no universally accepted practice ‘model’. This article outlines these components and discusses the associated need for change in the culture of provider organisations along with implementation of wider social and economic policies to support peoples' recovery and social inclusion. This is a values-led approach supported by persuasive advocacy and international endorsement but still in need of further development, systematic evaluation and confirmatory evidence.

An evidence-based approach to routine outcome assessment

Routine use of Health of the Nation Outcome Scales (HoNOS) has not produced the anticipated benefits for people using mental health services. Four HoNOS-specific reasons for this are: low relevance to clinical decision-making; not reflecting service user priorities; being staff-rated; and having a focus on deficits. More generally, the imposition of a centrally chosen measure on the mental health system leads to a clash of cultures, since frontline workers do not need a standardised measure to treat individuals. A better approach might be to use research from the emerging academic discipline of implementation science to inform the routine use of a standardised measure that is chosen by the people who will use it and hence is more concordant with existing clinical processes. This is illustrated using a case study of successful implementation of the Camberwell Assessment of Need (CAN) in community mental health services across Ontario, Canada.

‘Forensic service user’: transitional identity or life sentence?

It has been suggested that a recovery-focused approach and treatment under the Mental Health Act are mutually exclusive, hence the limited applicability of ‘recovery’ in forensic psychiatry. This is heightened if recovery is seen as a ‘model’ that does or does not fit, and lessened if seen as ‘values-in-action’ that need reinterpretation in context.

Severe and enduring eating disorders: recognition and management

Patients with severe and enduring eating disorders (SEED) may constitute a specific group. It is proposed that patients with anorexia nervosa (SEED-AN) or bulimia nervosa (SEED-BN) that requires the regular attention of a multidisciplinary team and is of a duration known to have a low recovery rate should be included in the SEED group. These patients present with a combination of severe symptoms and long-term illness, and may experience serious chronic physical sequelae (e.g. osteoporosis and renal failure), marked social isolation and stigma. Their carers suffer from the stress of caring for them over a prolonged period. Symptoms, treatment and crisis management of SEED-AN are discussed. SEED is a relatively recently described area of eating disorders psychiatry that requires research and service development so that patients and carers are helped to cope with very serious chronic, but not incurable, conditions.

Learning Objectives

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Understanding ‘recovery’

The principles of recovery have been supported by UK mental health policy and have been incorporated into policy in several countries worldwide. In this article we examine the ideas, principles and definitions of recovery and their origins. Personal recovery is contrasted with clinical recovery and the nature and development of the recovery movement is outlined. The principal factors influencing personal recovery are hope, control and opportunity. In an accompanying article we discuss the implications of these principles for training and practice.

Life satisfaction and happiness associated with depressive symptoms among university students: a cross-sectional study in Korea

BACKGROUND

This cross-sectional study investigated the impact of life satisfaction and happiness, as well as the prevalence and correlates of depressive symptoms in a large sample of university students.

METHODS

We included 2338 students at 6 universities in 1 metropolitan city and 2 provinces of Korea. Depressive symptoms were assessed by the Beck Depression Inventory, and scores of 16 or higher were categorized as the presence of depression. Various sociodemographic, life satisfaction, happiness, and clinical factors (alcohol consumption and sleep quality) were measured. According to the presence of depression, sociodemographic, life satisfaction, happiness, and clinical characteristics were compared using statistical analyses. Further, a logistic regression model was constructed to examine the impact of life satisfaction, happiness, and clinical factors on depression.

RESULTS

Among participants, 13.4% were identified as having depression. Life satisfaction and happiness were associated with a lower risk of depression, while hazardous alcohol drinking and poor sleep quality were related to a higher risk of depression. In addition, female gender, subjective body shape as obese, and insufficient pocket money were found to be significant correlates of depressive symptoms.

CONCLUSIONS

This study demonstrated possible risk and protective factors of underlying depressive symptoms. Especially, our findings suggest that improvement in life satisfaction and happiness would be important in the prevention and management of depression. Our findings may contribute to developing specialized mental health programs for prevention, screening, and treatment of depression among university students.

Exploration of Lower Frequency EEG Dynamics and Cortical Alpha Asymmetry in Long-term Rajyoga Meditators

BACKGROUND

Rajyoga meditation is taught by Prajapita Brahmakumaris World Spiritual University (Brahmakumaris) and has been followed by more than one million followers across the globe. However, rare studies were conducted on physiological aspects of rajyoga meditation using electroencephalography (EEG). Band power and cortical asymmetry were not studied with Rajyoga meditators.

AIMS

This study aims to investigate the effect of regular meditation practice on EEG brain dynamics in low-frequency bands of long-term Rajyoga meditators.

SETTINGS AND DESIGN

Subjects were matched for age in both groups. Lower frequency EEG bands were analyzed in resting and during meditation.

MATERIALS AND METHODS

Twenty-one male long-term meditators (LTMs) and same number of controls were selected to participate in study as par inclusion criteria. Semi high-density EEG was recorded before and during meditation in LTM group and resting in control group. The main outcome of the study was spectral power of alpha and theta bands and cortical (hemispherical) asymmetry calculated using band power.

STATISTICAL ANALYSIS

One-way ANOVA was performed to find the significant difference between EEG spectral properties of groups. Pearson's Chi-square test was used to find difference among demographics data.

RESULTS

Results reveal high-band power in alpha and theta spectra in meditators. Cortical asymmetry calculated through EEG power was also found to be high in frontal as well as parietal channels. However, no correlation was seen between the experience of meditation (years, hours) practice and EEG indices.

CONCLUSION

Overall findings indicate contribution of smaller frequencies (alpha and theta) while maintaining meditative experience. This suggests a positive impact of meditation on frontal and parietal areas of brain, involved in the processes of regulation of selective and sustained attention as well as provide evidence about their involvement in emotion and cognitive processing.

Recovery capital pathways: Modelling the components of recovery wellbeing

BACKGROUND

In recent years, there has been recognition that recovery is a journey that involves the growth of recovery capital. Thus, recovery capital has become a commonly used term in addiction treatment and research yet its operationalization and measurement has been limited. Due to these limitations, there is little understanding of long-term recovery pathways and their clinical application.

METHODS

We used the data of 546 participants from eight different recovery residences spread across Florida, USA. We calculated internal consistency for recovery capital and wellbeing, then assessed their factor structure via confirmatory factor analysis. The relationships between time, recovery barriers and strengths, wellbeing and recovery capital, as well as the moderating effect of gender, were estimated using structural equations modelling.

RESULTS

The proposed model obtained an acceptable fit (χ² (141, N=546)=533.642, p<0.001; CMIN/DF=3.785; CFI=0.915; TLI=0.896; RMSEA=0.071). Findings indicate a pathway to recovery capital that involves greater time in residence ('retention'), linked to an increase in meaningful activities and a reduction in barriers to recovery and unmet needs that, in turn, promote recovery capital and positive wellbeing. Gender differences were observed.

CONCLUSIONS

We tested the pathways to recovery for residents in the recovery housing population. Our results have implications not only for retention as a predictor of sustained recovery and wellbeing but also for the importance of meaningful activities in promoting recovery capital and wellbeing.

Joining, belonging, and re-valuing: A process of meaning-making through group participation in a mental health lifestyle intervention

BACKGROUND

Balancing Everyday Life (BEL), a new group-based intervention for mental health service users, was implemented in Sweden. Mental health service users often experience group interventions as meaningful, but knowledge of the process of meaning-making in a group is lacking.

AIM

To explore participants' perceptions of the group in the Balancing Everyday Life (BEL) lifestyle intervention; specifically, personal experiences of what brings meaning when participating in a group.

METHODS

This qualitative Grounded Theory study included 26 interviews with 19 BEL participants.

RESULTS

A process of meaning-making in a group was constructed: Joining with others: from feeling alone to connected, A sense of belonging: mutual support and understanding, and Re-valuing Self: respect and self-worth. No longer feeling alone contributed to meaning. Peers and group leaders were considered important parts of the group, and participants appreciated feeling understood, respected, and helping others.

CONCLUSION

The proposed process of meaning-making, as well as 'Joining' as a unique step, seems to be new contributions which could help practitioners when organizing groups. Overcoming fear of joining could break a cycle of isolation and lead to connecting and belonging. The value of participants finding purpose through helping others should be further explored.

Quality of Life Among People with Psychiatric Disabilities: Does Day Centre Attendance Make a Difference?

The purpose was to investigate (i) how people with psychiatric disabilities who attend day centres experience their quality of life (QoL) compared to non-attendees, (ii) differences in QoL between those who attend meeting place-oriented centres and those who attend work-oriented centres, (iii) possible correlates of QoL among day centre attendees. Ninety-three day centre attendees and 82 non-attendees completed questionnaires addressing QoL and selected correlates. No group difference was found regarding QoL. Factors related with a good QoL were high levels of self-mastery and motivation. Thus, promoting day centre attendees' self-mastery and motivation might enhance their QoL.

Genealogies of recovery: The framing of therapeutic ambitions

The notion of recovery has become prominent in mental healthcare discourse in the UK, but it is often considered as if it were a relatively novel notion, and as if it represented an alternative to conventional treatment and intervention. In this paper, we explore some of the origins of the notion of recovery in the early 20th century in movements such as Alcoholics Anonymous and Recovery Inc. Whilst these phenomena are not entirely continuous with recovery in the present day, some important antecedents of the contemporary notion can be detected. These include the focus on the sufferers' interior space as a key theatre of operations and the reinforcement and consolidation of medical ways of seeing the condition without any immediate medical supervision of the actors being necessary. This has resonance with many contemporary examples of recovery in practice where the art of living with a mental health condition is emphasised without the nature of the psychopathological condition itself being challenged.

Beliefs in social inclusion: Invariance in associations among hope, dysfunctional attitudes, and social inclusion across adolescence and young adulthood

Social disability in youth is an important precursor of long-term social and mental health problems. Social inclusion is a key policy driver and fits well within a new paradigm of health and well-being rather than illness-oriented services, yet little is known about social inclusion and its facilitators for "healthy" young people. We present a novel exploratory structural analysis of social inclusion using measures from 387 14- to 36-year-olds. Our model represents social inclusion as comprising social activity and community belonging, with both domains predicted by hopeful and dysfunctional self-beliefs but hopefulness more uniquely predicting social inclusion in adolescence. We conclude that social inclusion can be modeled for meaningful comparison across spectra of development, mental health, and functioning.

Protocol for a mixed studies systematic review on the implementation of the recovery approach in adult mental health services

INTRODUCTION

Recovery is integral to mental health planning in G-8 countries including Canada. A recovery-oriented approach to care aims to promote personal empowerment, illness self-management and a life beyond services for people with serious mental illness (SMI), while reducing the financial burden associated with mental illness. Although there is a growing body of literature on recovery, no synthesis of research on the implementation of recovery into mental health services exists.

OBJECTIVES

The objective is to conduct a mixed studies systematic review on the operationalisation of recovery into mental health services for adults with SMI. It will inform the transformation of Canadian services to a recovery orientation, but may be applicable to other countries.

METHODS AND ANALYSIS

Seven databases including PubMed, Ovid Medline, Ovid Embase, Ovid PsycInfo, CINAHL, the Cochrane Library and Scopus will be searched for peer-reviewed empirical studies published from 1998 to December 2016. Systematic reviews and studies using quantitative, qualitative and mixed methodologies will be included. Secondary searches will be conducted in reference lists of all selected full text articles. Handsearches will also be performed in the tables of contents of three recovery-focused journals for the last 5 years. International experts in the field will be contacted for comments and advice. Data extraction will include identification and methodological synthesis of each study; definition of recovery; information on recovery implementation; facilitators and barriers and study outcomes. A quality assessment will be conducted on each study. The data will be synthesised and a stepwise thematic analysis performed.

ETHICS AND DISSEMINATION

Ethics approval is not required for this knowledge synthesis. Findings will be disseminated through knowledge translation activities including: (1) a 1-day symposium; (2) presentations in national and international conferences and to local stakeholders; (3) publications in peer-reviewed journals; (4) posts on the organisational websites.

Psychometric properties of the short Warwick Edinburgh mental well-being scale (SWEMWBS) in service users with schizophrenia, depression and anxiety spectrum disorders

Background

To establish the validity and reliability of the Short Warwick Edinburgh Mental Well-being Scale (SWEMWBS) in service users with schizophrenia, depression and anxiety spectrum disorders in Singapore and estimate SWEMWBS scores across socio-demographic and the three psychiatric diagnostic groups in the sample.

Methods

This secondary analysis was conducted using data from a study among outpatients of a tertiary psychiatric hospital. In addition to the SWEMWBS, socio-demographic data and current psychiatric diagnosis were collected. Service users were also administered the Global Assessment of Functioning (GAF), Patient Health Questionnaire (PHQ)-8, Generalised Anxiety Disorder (GAD)-7, Satisfaction with Life Scale (SWLS) and the Positive Mental Health (PMH) instrument. The SWEMWBS was tested for factorial validity, reliability and convergent and divergent validity.

Results

In total, 350 service users with a mean (SD) age of 39.1 (11.1) years were included in this study of which 39.4%, 38.9% and 21.7% had schizophrenia, depression and anxiety spectrum disorders, respectively. The single factor structure of the SWEMWBS was confirmed by confirmatory factor analysis (CFI = 0.969, TLI = 0.954, RMSEA = 0.029). The internal consistency reliability was high (Cronbach’s alpha = 0.89). The convergent and divergent validity testing revealed that the SWEMWBS scores had significant moderate to high positive correlations with GAF, SWLS and PMH scores and moderate negative correlations with (PHQ)-8 and (GAD)-7 scores. SWEMWBS scores were higher in married participants (22.2 (5.4) versus never married: 20.7 (5.3) and divorced/separated/widowed: 20.4 (5.1), p = 0.049) and among those with schizophrenia (22.8 (5.5) versus depression:19.6 (4.7) and anxiety spectrum disorders 20.9 (5.2), p < 0.001).

Conclusion

These results demonstrate adequate validity and reliability of the SWEMWBS in people with schizophrenia, depression and anxiety spectrum disorders in Singapore.

Development and Initial Validation of a Multidimensional Scale Assessing Subjective Well-Being: The Well-Being Scale (WeBS)

Numerous scales currently exist that assess well-being, but research on measures of well-being is still advancing. Conceptualization and measurement of subjective well-being have emphasized intrapsychic over psychosocial domains of optimal functioning, and disparate research on hedonic, eudaimonic, and psychological well-being lacks a unifying theoretical model. Lack of systematic investigations on the impact of culture on subjective well-being has also limited advancement of this field. The goals of this investigation were to (1) develop and validate a self-report measure, the Well-Being Scale (WeBS), that simultaneously assesses overall well-being and physical, financial, social, hedonic, and eudaimonic domains of this construct; (2) evaluate factor structures that underlie subjective well-being; and (3) examine the measure's psychometric properties. Three empirical studies were conducted to develop and validate the 29-item scale. The WeBS demonstrated an adequate five-factor structure in an exploratory structural equation model in Study 1. Confirmatory factor analyses showed that a bifactor structure best fit the WeBS data in Study 2 and Study 3. Overall WeBS scores and five domain-specific subscale scores demonstrated adequate to excellent internal consistency reliability and construct validity. Mean differences in overall well-being and its five subdomains are presented for different ethnic groups. The WeBS is a reliable and valid measure of multiple aspects of well-being that are considered important to different ethnocultural groups.

Users' Adoption of Mental Health Apps: Examining the Impact of Information Cues

BACKGROUND

Numerous mental health apps have been developed and made available to users on the current app market. Users may find it difficult and overwhelming to select apps from the hundreds of choices that are available in the app marketplace. Clarifying what information cues may impact a user's selection and adoption of mental health apps is now a critical and pressing issue.

OBJECTIVE

The aim of this study was to investigate the impact of information cues on users' adoption of anxiety apps using observational data from the Android app market.

METHODS

A systematic search of anxiety apps was conducted on the Android app store by using keywords search. The title and metadata information of a total of 274 apps that met our criteria were collected and analyzed. Three trained researchers recorded the app rankings from the search results page on different dates and Web browsers.

RESULTS

Our results show that ratings (r=.56, P<.001) and reviews (r=.39, P<.001) have significant positive correlations with the number of installs, and app prices have significant negative correlations with installs (r=-.36). The results also reveal that lower-priced apps have higher ratings (r=-.23, P<.001) and a greater number of app permission requests (r=.18, P=.002) from the device. For app titles, we found that apps with titles related to symptoms have significantly lower installs than apps with titles that are not related to symptoms (P<.001).

CONCLUSIONS

This study revealed a relationship between information cues and users' adoption of mental health apps by analyzing observational data. As the first of its kind, we found impactful indicators for mental health app adoptions. We also discovered a labeling effect of app titles that could hinder mental health app adoptions and which may provide insight for future designs of mental health apps and their search mechanisms.

The effect of a mindfulness-based intervention in cognitive functions and psychological well-being applied as an early intervention in schizophrenia and high-risk mental state in a Chilean sample: study protocol for a randomized controlled trial

BACKGROUND

According to the projections of the World Health Organization, 15% of all disabilities will be associated with mental illnesses by 2020. One of the mental disorders with the largest social impacts due to high personal and family costs is psychosis. Among the most effective psychological approaches to treat schizophrenia and other psychotic disorders at the world level is cognitive behavioral therapy. Recently, cognitive behavioral therapy has introduced several tools and strategies that promote psychological processes based on acceptance and mindfulness. A large number of studies support the effectiveness of mindfulness in dealing with various mental health problems, including psychosis. This study is aimed at determining the efficiency of a mindfulness-based program in increasing cognitive function and psychological well-being in patients with a first episode of schizophrenia and a high risk mental state (those at risk of developing an episode of psychosis).

METHODS AND DESIGN

This is an experimentally designed, multi-center randomized controlled trial, with a 3-month follow-up period. The study participants will be 48 patients diagnosed with schizophrenia (first episode) and 48 with a high-risk mental state, from Santiago, Chile, aged between 15 and 35 years. Participants will be submitted to a mindfulness-based intervention (MBI), which will involve taking part in eight mindfulness workshops adapted for people with psychosis. Workshops will last approximately 1.5 hours and take place once a week, over 8 weeks. The primary outcome will be the cognitive function through Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) and the secondary outcome will be psychological well-being measured by self-reporting questionnaires.

DISCUSSION

The outcomes of this trial will add empirical evidence to the benefits and feasibility of MBIs for the psychotherapeutic treatment of patients with schizophrenia and high-risk mental states in reducing cognitive impairment in attention, working memory, and social cognition, as well as increasing the psychological well-being by empowering the patients' personal resources in the management of their own symptoms and psychotic experiences.

TRIAL REGISTRATION

ISRCTN registration number ISRCTN24327446 . Registered on 12 September 2016.

Goal Setting Among People Living with Mental Illness: A Qualitative Analysis of Recovery Camp

People living with mental illness (consumers) often experience difficulty in achieving life goals, particularly those important for their recovery. An innovative approach to address consumers' goals for recovery can be found in the form of therapeutic recreation (TR) initiatives. Recovery Camp is a five-day TR program, bringing together people with a serious mental illness, undergraduate health students, and staff members. This article aims to examine the types of goals set by consumers in the context of Recovery Camp, and to what extent the self-identified goals were attained. The consumers (n  =  27) were invited to set goals that they wished to achieve during the week. On the final day of Recovery Camp, each participant rated the degree to which they felt that each of their goals was achieved or not. The goals were themed using content analysis, revealing four key themes: connectedness, developing healthy habits, challenging oneself, and recovery. All goals were, to some extent, attained. The results suggest people with a mental illness are able to both set and evaluate the self-identified goals in the context of a TR initiative. A collaborative recovery approach indicates that goal planning should be undertaken in direct consultation with the consumer.

Transitions from biomedical to recovery-oriented practices in mental health: a scoping review to explore the role of Internet-based interventions

Background

The Internet is transforming mental health care services by increasing access to, and potentially improving the quality of, care. Internet-based interventions in mental health can potentially play a role in transitions from biomedical to recovery-oriented research and practices, but an overview of what this may entail, current work, and issues that need addressing, is lacking. The objective of this study is to describe Internet-based recovery-oriented interventions (referred to as e-recovery) and current research, and to identify gaps and issues relevant to advancing recovery research and practices through opportunities provided by the Internet.

Methods

Five iterative stages of a scoping review framework were followed in searching and analyzing the literature. A recovery framework with four domains and 16 themes was used to deductively code intervention characteristics according to their support for recovery-oriented practices. Only Internet-based interventions used in conjunction with ongoing care were included.

Results

Twenty studies describing six e-recovery interventions were identified and originated in Australia, Finland, the Netherlands, Norway and USA. The domain supporting personal recovery was most clearly reflected in interventions, whereas the last three domains, i.e., promoting citizenship, organizational commitment and working relationship were less evident. Support for the formulation and follow-up of personal goals and preferences, and in accessing peer-support, were the characteristics shared by most interventions. Three of the six studies that employed a comparison group used randomization, and none presented definitive findings. None used recovery-oriented frameworks or specific recovery outcome measures. Four of the interventions were specific to a diagnosis.

Conclusion

Research about how technologies might aid in illuminating and shaping recovery processes is in its formative stages. We recommend that future e-recovery research and innovation attend to four dimensions: evidence-supported interventions, new knowledge about personal recovery, values-based approaches and Internet as a facilitator for organizational transformation. The incremental changes facilitated by e-recovery may help propel a shift in mental health care toward recovery-oriented practices.

First-person experiences of recovery in co-occurring mental health and substance use conditions

Purpose

The purpose of this paper is to explore and describe experiences of recovery among people with co-occurring mental health and substance use conditions (co-occurring conditions) in a rural community in Norway.

Design/methodology/approach

In-depth individual interviews with eight persons with co-occurring conditions were conducted, audiotaped, transcribed and analysed using a phenomenological approach. This study is part of a research project investigating recovery orientation of services in a Norwegian district.

Findings

The analysis yielded four dimensions of recovery: feeling useful and accepted; coming to love oneself; mastering life; and emerging as a person. Insecure and inadequate housing and limited solutions to financial problems were described as major obstacles to recovery.

Research limitations/implications

Further research into the facilitation of recovery as defined by persons with concurrent disorders is needed, particularly regarding the facilitation of community participation.

Practical implications

This study supports an increased focus on societal and community factors in promoting recovery for persons with co-occurring conditions, as well as service designs that allow for an integration of social services and health care, and for collaboration among services.

Social implications

The results suggest that the community can aid recovery by accepting persons with co-occurring conditions as fellow citizens and welcoming their contributions.

Originality/value

The paper provides an enhanced understanding of how persons with co-occurring conditions may experience recovery.