Integrating wellness, recovery, and self-management for mental health consumers

Co-Production of a Flexibly Delivered Relapse Prevention Tool to Support the Self-Management of Long-Term Mental Health Conditions: Co-Design and User Testing Study

BACKGROUND

Supported self-management interventions, which assist individuals in actively understanding and managing their own health conditions, have a robust evidence base for chronic physical illnesses, such as diabetes, but have been underused for long-term mental health conditions.

OBJECTIVE

This study aims to co-design and user test a mental health supported self-management intervention, My Personal Recovery Plan (MyPREP), that could be flexibly delivered via digital and traditional paper-based mediums.

METHODS

This study adopted a participatory design, user testing, and rapid prototyping methodologies, guided by 2 frameworks: the 2021 Medical Research Council framework for complex interventions and an Australian co-production framework. Participants were aged ≥18 years, self-identified as having a lived experience of using mental health services or working in a peer support role, and possessed English proficiency. The co-design and user testing processes involved a first round with 6 participants, focusing on adapting a self-management resource used in a large-scale randomized controlled trial in the United Kingdom, followed by a second round with 4 new participants for user testing the co-designed digital version. A final round for gathering qualitative feedback from 6 peer support workers was conducted. Data analysis involved transcription, coding, and thematic interpretation as well as the calculation of usability scores using the System Usability Scale.

RESULTS

The key themes identified during the co-design and user testing sessions were related to (1) the need for self-management tools to be flexible and well-integrated into mental health services, (2) the importance of language and how language preferences vary among individuals, (3) the need for self-management interventions to have the option of being supported when delivered in services, and (4) the potential of digitization to allow for a greater customization of self-management tools and the development of features based on individuals' unique preferences and needs. The MyPREP paper version received a total usability score of 71, indicating C+ or good usability, whereas the digital version received a total usability score of 85.63, indicating A or excellent usability.

CONCLUSIONS

There are international calls for mental health services to promote a culture of self-management, with supported self-management interventions being routinely offered. The resulting co-designed prototype of the Australian version of the self-management intervention MyPREP provides an avenue for supporting self-management in practice in a flexible manner. Involving end users, such as consumers and peer workers, from the beginning is vital to address their need for personalized and customized interventions and their choice in how interventions are delivered. Further implementation-effectiveness piloting of MyPREP in real-world mental health service settings is a critical next step.

Effects of a Self-Guided Transdiagnostic Smartphone App on Patient Empowerment and Mental Health: Randomized Controlled Trial

BACKGROUND

Mental disorders impact both individuals and health systems. Symptoms and syndromes often remain undetected and untreated, resulting in chronification. Besides limited health care resources, within-person barriers such as the lack of trust in professionals, the fear of stigmatization, or the desire to cope with problems without professional help contribute to the treatment gap. Self-guided mental health apps may support treatment seeking by reducing within-person barriers and facilitating mental health literacy. Digital mental health interventions may also improve mental health related self-management skills and contribute to symptom reduction and the improvement of quality of life.

OBJECTIVE

This study aims to investigate the effects of a self-guided transdiagnostic app for mental health on help seeking, reduced stigma, mental health literacy, self-management skills, mental health symptoms, and quality of life using a randomized controlled design.

METHODS

Overall, 1045 participants (recruited via open, blinded, and web-based recruitment) with mild to moderate depression or anxiety-, sleep-, eating-, or somatization-related psychopathology were randomized to receive either access to a self-guided transdiagnostic mental health app (MindDoc) in addition to care as usual or care as usual only. The core features of the app were regular self-monitoring, automated feedback, and psychological courses and exercises. The coprimary outcomes were mental health literacy, mental health-related patient empowerment and self-management skills (MHPSS), attitudes toward help seeking, and actual mental health service use. The secondary outcomes were psychopathological symptom burden and quality of life. Data were collected at baseline and 8 weeks and 6 months after randomization. Treatment effects were investigated using analyses of covariance, including baseline variables as predictors and applying multiple imputation.

RESULTS

We found small but robust between-group effects for MHPSS (Cohen d=0.29), symptoms burden (Cohen d=0.28), and quality of life (Cohen d=0.19) 8 weeks after randomization. The effects on MHPSS were maintained at follow-up. Follow-up assessments also showed robust effects on mental health literacy and preliminary evidence for the improvement of help seeking. Predictors of attrition were lower age and higher personality dysfunction. Among the non-attritors, predictors for deterioration were less outpatient treatment and higher initial symptom severity.

CONCLUSIONS

A self-guided transdiagnostic mental health app can contribute to lasting improvements in patient empowerment. Symptoms of common mental disorders and quality of life improved faster in the intervention group than in the control group. Therefore, such interventions may support individuals with symptoms of 1 or more internalizing disorders, develop health-centered coping skills, prevent chronification, and accelerate symptom improvement. Although the effects for individual users are small and predictors of attrition and deterioration need to be investigated further, the potential public health impact of a self-guided intervention can be large, given its high scalability.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00022531; https://drks.de/search/de/trial/DRKS00022531.

Complementary and Alternative Medicine (CAM) Use Among Mental Health Consumers

Understanding integrative approaches to mental health care can improve the responsiveness of the mental health system. Complementary and alternative medicine (CAM) use is on the rise. Research documents that many mental health consumers use CAM. This exploratory study attempts to advance awareness of CAM in mental health by examining mental health consumers' usage of CAM, their experiences in discussing CAM use with providers, and how CAM use relates to mental health recovery. Results show that 72% of the sample uses such methods, and CAM use is associated with recovery. About 54% of respondents feel CAM combined with medication is more effective than medication alone, and many endorse positive beliefs about CAM. Most consumers shared CAM use with their providers, but when they did not, the main reasons were fear of provider judgment and provider attitudes being a deterrent.

Yoga perspective on personal excellence and well-being

The discussions on conceptualization, operationalization, measures, and means of well-being (WB) and personal excellence (PE) are dynamic and debatable. Therefore, this study aims to coin a perspective of PE based on the Patanjali Yoga Sūtra (PYS). For this, professional, psychological, philosophical, and yogic perspectives of WB and PE are analyzed to derive a viable yogic framework for PE. The WB and the consciousness-based constructs of PE are discussed in terms of psychic tensions (PTs) (nescience, egoism, attachment, aversion, and love for life), yogic hindrances (YHs) (illness, apathy, doubt, procrastination, laziness, over somatosensory indulgence, delusion, inability, and unstable progress), psychosomatic impairments (pain, despair, tremors, arrhythmic breath), and yogic aids (wellness, intrinsic motivation, faith, role punctuality, physical activity, sensory control, clarity, competence, and sustainable progress). The PYS operationalizes PE as the dynamic level of WB and self-awareness until one attains Dharmamegha Samādhi (super consciousness). Lastly, Ashtanga Yoga (AY) is discussed as a universal principle, process, and practice for thinning PTs, vanishing YHs, empowering holistic WB, awakening extrasensory potentials, advancing self-awareness, and PE. This study will be a pioneering base for further observational and interventional studies to develop measures and personalized protocols for PE.

Early recognition method for patients with schizophrenia or bipolar disorder in community mental health care: Illness insight, self-management and control

AIMS AND OBJECTIVE

To investigate how participating in the early recognition method treatment strategy affect illness insight and management, in patients with schizophrenia or bipolar disorder in community mental healthcare.

BACKGROUND

The current practice in mental healthcare focus on shared decision-making and self-managing capacity, but poor insight is a predictor of poor adherence and dropout. Engagement in illness management and recovery predict the treatment response.

DESIGN

Semi-structured interviews with a phenomenological-hermeneutic approach.

METHODS

We conducted 36 semi-structured interviews with 26 patients. The interviews were conducted before and after participating in the intervention using the early recognition method strategy. The analysis was based on Ricoeur's theory of interpretation: Naive reading, structural analysis, interpretation and discussion. The COREQ checklist was used as reporting guideline.

RESULTS

The experience of participating in treatment as usual and early recognition method revealed two main themes. The first theme 'patient care' describes how dialogue and collaboration increase awareness of the illness and how to gain control. The second theme 'insight and experience' describes how illness affects personality and self-image, and how insight entails control and self-confidence.

CONCLUSION

Managing life with severe mental illness is complex and challenging. However, the experience of guidance, support and collaboration between patient and nurse are essential to improve these circumstances.

RELEVANCE TO CLINICAL PRACTICE

A systematic approach to the patient' symptoms, as in the early recognition method strategy, enhances knowledge of the individual patient' symptoms, both for nurse and patient. A knowledge that is significant for meeting individual treatment needs. Therefore, applying this strategy is likely to enhance collaboration and improve treatment outcome.

Self-Management in Anxiety and Depression: A Psychometric Evaluation of a Questionnaire

Objective: To examine the underlying factor structure and psychometric properties of the Assessment of Self-management in Anxiety and Depression (ASAD) questionnaire, which was specifically designed for patients with (chronic) anxiety and depressive disorders. Moreover, this study assesses whether the number of items in the ASAD can be reduced without significantly reducing its precision. Methods: The ASAD questionnaire was completed by 171 participants across two samples: one sample comprised patients with residual anxiety or depressive symptoms, while the other consisted of patients who have been formally diagnosed with a chronic anxiety or depressive disorder. All participants had previously undergone treatment. Both exploratory (EFA) and confirmatory factor analyses (CFA) were conducted. Internal consistency and test-retest reliability were also assessed. Results: Both EFA and CFA indicated three solid factors: Seeking support, Daily life strategies and Taking ownership [Comparative Fit Index = 0.80, Tucker Lewis Index = 0.78, Root Mean Square Error of Approximation = 0.09 (CI 0.08-1.00), Standardized Root Mean Square Residual = 0.09 (χ2 = 439.35, df = 168)]. The ASAD was thus reduced from 45 items to 21 items, which resulted in the ASAD-Short Form (SF). All sub-scales had a high level of internal consistency (> α = 0.75) and test-retest reliability (ICC > 0.75). Discussion: The first statistical evaluation of the ASAD indicated a high level of internal consistency and test-retest reliability, and identified three distinctive factors. This could aid patients and professionals' assessment of types of self-management used by the patient. Given that this study indicated that the 21-item ASAD-SF is appropriate, this version should be further explored and validated among a sample of patients with (chronic or partially remitted) anxiety and depressive disorders. Alongside this, to increase generalizability, more studies are required to examine the English version of the ASAD within other settings and countries.

Personal narratives of learning self-management: Lessons for practice based on experiences of people with serious mental illness

INTRODUCTION

Clinicians are challenged to deliver self-management interventions in recovery-oriented services for individuals living with serious mental illnesses. Little is known about how people learn self-management skills and questions remain about how best to deliver support. To offer insights for delivery, this research describes the lived experiences of learning self-management and the meaning of those experiences within recovery journeys and the context of health-care delivery.

METHODS

Design followed van Manen's approach of phenomenology through an occupational therapist's lens. Using purposeful criterion sampling until saturation, 25 adults with psychosis experiences (8-40 years) from six community-based specialised mental health programs were interviewed. Conceptual maps were cocreated depicting key learning experiences, intersections with services, and recommendations. Data reduction, reconstruction and explication of meaning occurred concurrently, and multiple strategies were used to transparently support an open, iterative, reflexive process.

FINDINGS

Participants described eight essential tasks to live well, learned often serendipitously, taking up to 15-30 years to find the right combination of supports and self-management strategies to achieve what they felt was a life of quality. Self-management needs were not routinely addressed by services and extended beyond illness or crisis management while participants grappled with emotions, self-concept, relationships, and occupational issues. Participants asked providers to "teach us to teach ourselves"; "invite clients" to the decision table; and deal directly with emotions of fear, shame, and trust with respect to self and relationships. Findings challenge conventional conceptualisations of self-management to consider clients living interdependent lives with tasks performed in context, dynamically influenced by complex personal, socio-ecological relationships.

CONCLUSIONS

Participants' narratives compel increasing access to strategic personalised self-management learning opportunities as an effort to shorten the prolonged recovery paths. Findings offer ways providers can understand and address eight self-management learning tasks from the perspective of lived experiences. Self-management was enmeshed with recovery, health, and building a life.

Whole Health Action Management: A Randomized Controlled Trial of a Peer-Led Health Promotion Intervention

OBJECTIVE

Adults with serious mental illness have high rates of general medical comorbidity and encounter challenges in dealing with multiple health conditions. Chronic illness self-management programs may help them more effectively cope with comorbid illnesses, especially when instructors are certified peer specialists. This study assessed the longitudinal effectiveness of a peer-delivered health promotion program.

METHODS

Community mental health program clients in Georgia and Illinois with serious mental illness and health impairments were randomly assigned to receive either Whole Health Action Management (WHAM), a medical illness self-management program led by peer specialists, or care as usual, resulting in a sample of N=139 (WHAM N=68, control N=71). Assessments were conducted at study baseline and at 3 and 6 months. Generalized estimating equations were used to examine change over time in the primary outcome of patient activation and secondary outcomes of general health, hope, and employment.

RESULTS

Longitudinal analysis indicated that compared with control participants, WHAM participants demonstrated significantly greater improvement over time in patient activation for health care. Intervention participants also demonstrated greater improvement in their self-assessed general health, overall hopefulness, and paid employment. Reactions to the WHAM program were positive, with 97% reporting being very or somewhat satisfied, and almost two-thirds (63%) reporting that their health was better than before they joined the program.

CONCLUSIONS

The WHAM program improved patient activation, perceived general medical health, hopefulness, and likelihood of paid employment among people with serious mental illness and co-occurring medical conditions. Results suggest that peer-delivered health self-management education is effective and well received by participants.

Randomized Trial of a Mobile Personal Health Record for Behavioral Health Homes

OBJECTIVE

Behavioral health homes, which provide onsite primary medical care in mental health clinics, face challenges in integrating information across multiple health records. This study tested whether a mobile personal health record application improved quality of medical care for individuals treated in these settings.

METHODS

This randomized study enrolled 311 participants with a serious mental illness and one or more cardiometabolic risk factors across two behavioral health homes to receive a mobile personal health record application (N=156) or usual care (N=155). A secure mobile personal health record (mPHR) app provided participants in the intervention group with key information about diagnoses, medications, and laboratory test values and allowed them to track health goals. The primary study outcome was a chart-derived composite measure of quality of cardiometabolic and preventive services.

RESULTS

At 12-month follow-up, participants in the mPHR group maintained high quality of care (70% of indicated services at baseline and at 12-month follow-up), in contrast to a decline in quality for the usual-care group (71% at baseline and 67% at follow-up), resulting in a statistically significant but clinically modest differential impact between the groups. No differences between the study groups were found in secondary self-reported outcomes, including delivery of chronic illness care, patient activation, and quality of life related to mental or general medical health.

CONCLUSIONS

Use of a mPHR app was associated with a statistically significant but clinically modest differential benefit for quality of medical care among individuals with serious mental illness and comorbid cardiometabolic conditions.

Expert by Experience Involvement in Mental Health Research: Developing a Wellbeing Brochure for People with Lived Experiences of Mental Illness

This is a process paper that describes the development of a wellbeing brochure, shared between university researchers, a consumer research advocate, and fully informed by people who are living with mental illness (experts by experience). The purpose of this brochure was to provide strategies for maintaining wellbeing for EBEs, after attending a psychosocial intervention. Brochure development was guided by a mixed-methods research design, using a survey and focus group. The findings illustrate five key themes in EBEs strategies for maintaining wellbeing: good sleep hygiene, regular physical activity, maintaining a healthy lifestyle, relaxation techniques and social support. This process paper demonstrates how collaborating with experts by experience represents a valuable approach for developing mental health research and resources.

Assistive technology and schizophrenia

Purpose

Assistive technology (AT) has been highlighted as a tool that can support self-management for people living with schizophrenia. A gap in the literature exists regarding the views held by the stakeholders involved in the health care of an individual living with schizophrenia regarding the potential use of AT to enable the self-management of this condition. The purpose of this paper is to explore how individuals living with schizophrenia, their relatives and their mental health care professionals view AT as a tool to facilitate self-management.

Design/methodology/approach

This mixed methods research paper will discuss the findings of the second stage of a two-stage research study. The paper will discuss the findings of questionnaires that were disseminated to service users living with schizophrenia, their relatives and the health-care professionals of a community mental health service in the Greater Dublin area.

Findings

The results indicate that the introduction of AT for the self-management of schizophrenia would be accepted by key stakeholders.

Research limitations/implications

As AT continues to develop, it is clear from the findings presented in this paper that the main stakeholder groups involved in the care of an individual living with schizophrenia are amenable to the use of AT to facilitate the self-management of this condition. Further research is required to explore correct policing and management of its implementation.

Originality/value

This study is the first study of its kind within an Irish context to explore the use of assistive technology as a tool for self-management from the perspective of those experiencing schizophrenia, their relatives and the health-care professionals working alongside them.

Joining forces to improve psychosocial care for people with cognitive deficits across diagnoses: social health as a common framework

Cognitive deficits such as memory problems have a major impact on independence in daily life and participation in society in several populations, such as people with dementia, brain injury (i.e. stroke) or a severe mental illness such as schizophrenia. Similarities in the impact on participation and well-being have resulted in the development of comparable psychosocial interventions across populations, aiming to support people to adapt to cognitive deficits or by adapting the environment. These interventions are developed separately, without using the expertise in other fields. We argue that each of the fields and the field of psychosocial care in general would benefit from closer collaboration on development and evaluation of innovative psychosocial interventions. Collaboration has been complicated by the use of different care models and theoretical frameworks, each with their own terminology. The concept of social health - the ability to participate in work or other meaningful activities and to feel healthy despite a condition - translates to the leading care models within the fields of dementia, brain injury and severe mental illness. The concept of social health provides a common language and framework. In this paper, we elaborate on strategies for collaboration using examples of interventions to improve social health.

Internet-based interventions to support recovery and self-management: A scoping review of their use by mental health service users and providers together

BACKGROUND

Internet-based interventions can make self-management and recovery-oriented information and tools more accessible for people experiencing severe mental illness, including psychosis. The aim of this scoping review was to identify and describe emerging joint uses of these Internet-based interventions by service users experiencing psychosis and mental health workers. It also investigated how using these Internet-based interventions influenced interactions between service users and workers and whether recovery-oriented working practices were elicited.

METHODS

A scoping review method was used. Iterative review stages included identifying the review question, a comprehensive search including searching six electronic databases to locate relevant studies, selecting studies, charting the data, and collating and reporting the results. Rigour of the scoping review was enhanced by using an appraisal tool to evaluate the quality of included studies, and by using a published template for systematic description of interventions.

RESULTS

Fifteen papers about eleven Internet-based interventions that focused on self-management and/or recovery were identified. Interventions were web-based, mobile-device based, or both. The eleven interventions were used by service users either with their usual mental health workers, or with mental health workers employed in a research project. Emerging evidence suggested that jointly using an Internet-based intervention could support a positive sense of working together. However, mismatched expectations and poor integration of Internet-based interventions into service systems could also negatively influence interactions, leading to mistrust. The interventions demonstrated potential to elicit recognised recovery-oriented practices, specifically understanding service users' values and supporting their goal striving.

CONCLUSIONS

The use of Internet-based interventions focused on self-management and recovery in mental health services by service users and workers jointly demonstrates potential to support working together and recovery-oriented practice. Given that the quality of relationships is critical in recovery-oriented practice, greater focus on human support in Internet-based interventions is needed in future research and practice.

The service-seeking profiles of youth reporting a legal mandate or perceived coercion for substance use treatment

INTRODUCTION

There is paucity of research on treatment-related coercion in youth: most research focuses on adult populations and legally mandated treatment. This study aims to examine the service-seeking profiles of youth with substance misuse issues who report a legal mandate or perceived coercion to enter treatment.

METHODS

Differences between youth who were legally mandated and not legally mandated, and differences between youth reporting high and low perceived coercion, were examined for demographic characteristics, mental health and substance use profiles, motivation, and readiness to change.

RESULTS

Compared to participants reporting low perceived coercion, those experiencing high perceived coercion reported more substance use problems, greater mental health needs, and greater external and introjected motivation. Legally mandated youth reported fewer mental health issues, lower identified motivation, and greater readiness to change than those reporting no legal mandate.

DISCUSSION

Many youth who present for substance use services report experiencing a sense of coercion, which suggests the potential importance of considering youth-centered strategies for involving youth in treatment planning and the development of treatment goals. Youth seeking treatment also have multiple intersecting needs which may benefit from a collaborative and integrative approach.

Patients’ perspectives about the design of a mobile application for psychotic disorders

Aim

Based on the design of applications for psychotic disorders illness self-management, this study aimed to understand patients’ patterns of technology usage, as well as their expectations and requirements concerning the design of an app for rehabilitation and illness management purposes. It also aimed to identify guidelines for mobile application development for this population.

Method

After a literature review, a questionnaire was developed, focused on behaviours and opinions about technology usage. It was applied, through a cross-sectional study, to a sample of 102 users of mental health services with psychotic disorders (62% men; with ages between 22 and 66 years old).

Results

Nearly 59% of the participants were willing to download an app for illness self-management, and 51% evaluated as essential the self-management of their mental health condition. However, correlation analysis revealed that the more years with mental illness, the less importance is given to an app for this purpose.

Conclusion

The use of mobile technologies seems to the have potential to empower individuals with mental health problems, especially younger ones and those in early disease stages. Concerns about privacy/security should be considered, as well as simple screening designs and texts. The results also reveal the importance of user participatory design.

Spiritual Openness, Revisiting a Potentially Important Aspect of Spirituality: Scale Review and Revision

Religiousness and spirituality (R/S) exert important influences on individuals across a range of domains. Spiritual Openness is theoretically linked with the personality trait of Openness to Experience, suggesting promise for future research. Using responses from 366 undergraduates on the Spiritual Experience Index-Revised (SEI-R: subscales of Spiritual Openness and Spiritual Support), analyses evaluated and revised the SEI-R, deleting poor items and generating a 10-item measure. The new SEI-S exhibits better psychometric properties and reduced participant burden, and subscales displayed a curvilinear relationship in which increases in Spiritual Openness showed a trade-off in levels of Spiritual Support.

Development of a peer-supported, self-management intervention for people following mental health crisis

BACKGROUND

A documented gap in support exists for service users following discharge from acute mental health services, and structured interventions to reduce relapse are rarely provided. Peer-facilitated self-management interventions have potential to meet this need, but evidence for their effectiveness is limited. This paper describes the development of a peer-provided self-management intervention for mental health service users following discharge from crisis resolution teams (CRTs).

METHODS

A five-stage iterative mixed-methods approach of sequential data collection and intervention development was adopted, following the development and piloting stages of the MRC framework for developing and evaluating complex interventions. Evidence review (stage 1) included systematic reviews of both peer support and self-management literature. Interviews with CRT service users (n = 41) regarding needs and priorities for support following CRT discharge were conducted (stage 2). Focus group consultations (n = 12) were held with CRT service-users, staff and carers to assess the acceptability and feasibility of a proposed intervention, and to refine intervention organisation and content (stage 3). Qualitative evaluation of a refined, peer-provided, self-management intervention involved qualitative interviews with CRT service user participants (n = 9; n = 18) in feasibility testing (stage 4) and a pilot trial (stage 5), and a focus group at each stage with the peer worker providers (n = 4).

RESULTS

Existing evidence suggests self-management interventions can reduce relapse and improve recovery. Initial interviews and focus groups indicated support for the overall purpose and planned content of a recovery-focused self-management intervention for people leaving CRT care adapted from an existing resource: The personal recovery plan (developed by Repper and Perkins), and for peer support workers (PSWs) as providers. Participant feedback after feasibility testing was positive regarding facilitation of the intervention by PSWs; however, the structured self-management booklet was underutilised. Modifications to the self-management intervention manual and PSWs' training were made before piloting, which confirmed the acceptability and feasibility of the intervention for testing in a future, definitive trial.

CONCLUSIONS

A manualised intervention and operating procedures, focusing on the needs and priorities of the target client group, have been developed through iterative stages of intervention development and feedback for testing in a trial context. Trial Registration ISRCTN01027104 date of registration: 11/10/2012.

Development of a peer-supported, self-management intervention for people following mental health crisis

BACKGROUND

A documented gap in support exists for service users following discharge from acute mental health services, and structured interventions to reduce relapse are rarely provided. Peer-facilitated self-management interventions have potential to meet this need, but evidence for their effectiveness is limited. This paper describes the development of a peer-provided self-management intervention for mental health service users following discharge from crisis resolution teams (CRTs).

METHODS

A five-stage iterative mixed-methods approach of sequential data collection and intervention development was adopted, following the development and piloting stages of the MRC framework for developing and evaluating complex interventions. Evidence review (stage 1) included systematic reviews of both peer support and self-management literature. Interviews with CRT service users (n = 41) regarding needs and priorities for support following CRT discharge were conducted (stage 2). Focus group consultations (n = 12) were held with CRT service-users, staff and carers to assess the acceptability and feasibility of a proposed intervention, and to refine intervention organisation and content (stage 3). Qualitative evaluation of a refined, peer-provided, self-management intervention involved qualitative interviews with CRT service user participants (n = 9; n = 18) in feasibility testing (stage 4) and a pilot trial (stage 5), and a focus group at each stage with the peer worker providers (n = 4).

RESULTS

Existing evidence suggests self-management interventions can reduce relapse and improve recovery. Initial interviews and focus groups indicated support for the overall purpose and planned content of a recovery-focused self-management intervention for people leaving CRT care adapted from an existing resource: The personal recovery plan (developed by Repper and Perkins), and for peer support workers (PSWs) as providers. Participant feedback after feasibility testing was positive regarding facilitation of the intervention by PSWs; however, the structured self-management booklet was underutilised. Modifications to the self-management intervention manual and PSWs' training were made before piloting, which confirmed the acceptability and feasibility of the intervention for testing in a future, definitive trial.

CONCLUSIONS

A manualised intervention and operating procedures, focusing on the needs and priorities of the target client group, have been developed through iterative stages of intervention development and feedback for testing in a trial context. Trial Registration ISRCTN01027104 date of registration: 11/10/2012.

Service Users' Perceptions of an Outreach Wellbeing Service: A Social Enterprise for Promoting Mental Health

Inadequate provision and limited access to mental healthcare has been highlighted with the need to offer more contemporary ways to provide clinically effective interventions. This study aimed to present an insight into service users' perceptions of an outreach Wellbeing Service (WBS), providing psychological therapy in social settings. Descriptive and thematic analysis was undertaken of 50 returned surveys. Comparison of initial and final mental health measures demonstrated a significant improvement in all outcomes with 96% of participants reporting being helped by attending. Participants were assisted to rebuild social connections in a safe and supportive environment and were facilitated to become more self-determining as their resourcefulness to self-manage was cultivated. Situated within different settings within the community, the WBS offers a workable example of a novel approach to supporting and promoting citizens to become more resilient and lead a more fulfilling and independent life in the community.

Mental Ill Health, Recovery and the Family Assemblage

The recovery approach is now among the most influential paradigms shaping mental health policy and practice across the English-speaking world. While recovery is normally presented as a deeply personal process, critics have challenged the individualism underpinning this view. A growing literature on "family recovery" explores the ways in which people, especially parents with mental ill health, can find it impossible to separate their own recovery experiences from the processes of family life. While sympathetic to this literature, we argue that it remains limited by its anthropocentricity, and therefore struggles to account for the varied human and nonhuman entities and forces involved in the creation and maintenance of family life. The current analysis is based on an ethnographic study conducted in Australia, which focused on families in which the father experiences mental ill health. We employ the emerging concept of the "family assemblage" to explore how the material, social, discursive and affective components of family life enabled and impeded these fathers' recovery trajectories. Viewing families as heterogeneous assemblages allows for novel insights into some of the most basic aspects of recovery, challenging existing conceptions of the roles and significance of emotion, identity and agency in the family recovery process.

Self-management in young adults with bipolar disorder: Strategies and challenges

BACKGROUND

Early adoption of effective self-management strategies for bipolar disorder (BD) results in better clinical outcomes and increased quality of life. Therefore, facilitation of these strategies in young adults who are early in their illness course is vital. However, an understanding of self-management practices and needs of young adults with BD is lacking. This study explores young adult's perspectives of disorder self-management practices and challenges.

METHODS

Young adults with BD completed an online survey about disorder management strategies and challenges. Self-management was investigated through self-report and ratings of literature-derived strategies. Results were analysed using descriptive statistics and qualitative thematic analysis.

RESULTS

Eighty-nine participants aged 18-30 (M=24.4; SD=3.9) completed the survey. Adherence to treatment, disorder psychoeducation, and sleep-management were the strategies rated most helpful. Six participant-reported self-management strategies were identified (1) Maintaining a healthy lifestyle; (2) Treatment attendance and adherence; (3) Participation in meaningful activities; (4) Engagement with social support; (5) Meditation and relaxation practices; and (6) Symptom monitoring. The most common self-management challenges experienced by young adults concerned the nature of the disorder, interpersonal relationships, and stigma.

LIMITATIONS

Participants likely represent a sub-set of young adults engaged with healthcare and therefore may not be representative of the population.

CONCLUSIONS

Strategies reported vital by those successfully managing their disorder are not adequately utilised by young adults with BD. Both differences in strategy use and perceived self-management challenges represent important areas of clinical support and intervention. This increased understanding will help facilitate self-management skill development in this population.

Young adults' experiences of seeking online information about diabetes and mental health in the age of social media

BACKGROUND

The Internet is a primary source of health information for many. Since the widespread adoption of social media, user-generated health-related content has proliferated, particularly around long-term health issues such as diabetes and common mental health disorders (CMHDs).

OBJECTIVE

To explore perceptions and experiences of engaging with health information online in a sample of young adults familiar with social media environments and variously engaged in consuming user-generated content.

METHODS

Forty semi-structured interviews were conducted with young adults, aged 18-30, with experience of diabetes or CMHDs. Data were analysed following a thematic networks approach to explore key themes around online information-seeking and content consumption practices.

RESULTS

Although participants primarily discussed well-rehearsed approaches to health information-seeking online, particularly reliance on search engines, their accounts also reflected active engagement with health-related content on social media sites. Navigating between professionally produced websites and user-generated content, many of the young adults seemed to appreciate different forms of health knowledge emanating from varied sources. Participants described negotiating health content based on social media practices and features and assessing content heuristically. Some also discussed habitual consumption of content related to their condition as integrated into their everyday social media use.

CONCLUSION

Technologies such as Facebook, Twitter and YouTube offer opportunities to consume and assess content which users deem relevant and useful. As users and organizations continue to colonize social media platforms, opportunities are increasing for health communication and intervention. However, how such innovations are adopted is dependent on their alignment with users' expectations and consumption practices.

Social media as a space for support: Young adults' perspectives on producing and consuming user-generated content about diabetes and mental health

Social media offer opportunities to both produce and consume content related to health experiences. However, people's social media practices are likely to be influenced by a range of individual, social and environmental factors. The aim of this qualitative study was to explore how engagement with user-generated content can support people with long-term health conditions, and what limits users' adoption of these technologies in the everyday experience of their health condition. Forty semi-structured interviews were conducted with young adults, aged between 18 and 30 years, with experience of diabetes or a common mental health disorder (CMHD). We found that the online activities of these young adults were diverse; they ranged from regular production and consumption ('prosumption') of health-related user-generated content to no engagement with such content. Our analysis suggested three main types of users: 'prosumers'; 'tacit consumers' and 'non-engagers'. A key determinant of participants' engagement with resources related to diabetes and CMHDs in the online environment was their offline experiences of support. Barriers to young adults' participation in online interaction, and sharing of content related to their health experiences, included concerns about compromising their presentation of identity and adherence to conventions about what content is most appropriate for specific social media spaces. Based on our analysis, we suggest that social media do not provide an unproblematic environment for engagement with health content and the generation of supportive networks. Rather, producing and consuming user-generated content is an activity embedded within individuals' specific health experiences and is impacted by offline contexts, as well as their daily engagement with, and expectations, of different social media platforms.

Challenges encountered in the conduct of Optimal Health: A patient-centered comparative effectiveness study of interventions for adults with serious mental illness

BACKGROUND

The aim of patient-centered comparative effectiveness research is to conduct stakeholder-driven investigations that identify which interventions are most effective for which patients under specific circumstances. Conducting this research in real-world settings comes with unique experiences and challenges. We provide the study design, challenges confronted, and the solutions we devised for Optimal Health, a stakeholder-informed patient-centered comparative effectiveness study focused on the needs of seriously mentally ill individuals receiving case management services in community mental health centers across Pennsylvania.

METHODS

Optimal Health, supported by the Patient-Centered Outcomes Research Institute, is a cluster-randomized trial of two evidence-based interventions for improving health and wellness across 11 provider sites. Participants were followed for 18-24 months, with repeated measurements of self-reported health status and activation in care and administrative measurements of primary and specialty health service utilization. Health-related quality of life, engagement in care, and service utilization are to be compared via random effects mixed models. Stakeholders were, and continue to be, engaged via focus groups, interviews, and stakeholder advisory board meetings. A learning collaborative model was used to support shared learning and implementation fidelity across provider sites.

RESULTS

From 1 November 2013 through 15 July 2014, we recruited 1229 adults with serious mental illness, representing 85.1% of those eligible for study participation. Of these, 713 are in the Provider-Supported arm of the study and 516 in Patient Self-Directed Care. Across five data collection time points, we retained 86% and 83% of the participants in the Provider-Supported and Self-Directed arms, respectively.

LESSONS LEARNED

Lessons learned relate to estimation of the size of our study population, the value of multiple data sources, and intervention training and implementation. The use of historical claims data can lead to an overestimation of eligible participants and, subsequently, a reduced study sample and an imbalance between intervention arms. Disruptions in continuity of care in real-world settings can pose challenges to on-site self-report data collection, although the inclusion of multiple data sources in study design can improve data completeness. Geographic dispersion of rural provider sites and staff turnover can lead to training and intervention fidelity challenges that can be overcome with the use of a "train-the-trainer" model, "wellness champions," and the use of a Learning Collaborative approach. Stakeholder engagement in mitigating these challenges proved to be critical to study progress.

CONCLUSION

Conducting real-world patient-centered comparative effectiveness research in healthcare systems that care for seriously mentally ill persons is an important yet challenging undertaking, one which requires flexibility in identifying potential adaptations within all major study phases. Advice from a wide range of stakeholders is critical in development of successful strategies.

Disease Burden Among Individuals with Severe Mental Illness in a Community Setting

This study examines the prevalence of comorbid physical health conditions within a community sample of individuals with severe mental illness (SMI), compares them to a matched national sample without SMI, and identifies which comorbidities create the greatest disease burden for those with SMI. Self-reported health status, co-morbid medical conditions and perceived disease burden were collected from 203 adults with SMI. Prevalence of chronic health conditions was compared to a propensity-matched sample without SMI from the National Comorbidity Survey-Replication (NCS-R). Compared to NCS-R sample without SMI, our sample with SMI had a higher prevalence of seven out of nine categories of chronic health conditions. Chronic pain and headaches, as well as the number of chronic conditions, were associated with increased disease burden for individuals with SMI. Further investigation of possible interventions, including effective pain management, is needed to improve the health status of this population.

Profiles of Recovery from Mood and Anxiety Disorders: A Person-Centered Exploration of People's Engagement in Self-Management

Context: A shift toward person-centered care has been occurring in services provided to people with mood and anxiety disorders. Recovery is recognized as encompassing personal aspects in addition to clinical ones. Guidelines now recommend supporting people's engagement in self-management as a complementary recovery avenue. Yet the literature lacks evidence on how individualized combinations of self-management strategies used by people relate to their clinical and personal recovery indicators.

Objectives: The aims of this study were to identify profiles underlying mental health recovery, describe the characteristics of participants corresponding to each profile, and examine the associations of profiles with criterion variables.

Method: 149 people recovering from anxiety, depressive, or bipolar disorders completed questionnaires on self-management, clinical recovery (symptom severity), personal recovery (positive mental health), and criterion variables (personal goal appraisal, social participation, self-care abilities, coping).

Results: Latent profile analysis (LPA) revealed three profiles. The Floundering profile included participants who rarely used self-management strategies and had moderately severe symptoms and the lowest positive mental health. The Flourishing profile was characterized by frequent use of self-empowerment strategies, the least severe symptoms, and the highest positive mental health. Participants in the Struggling profile engaged actively in several self-management strategies focused on symptom reduction and healthy lifestyle. They concomitantly reported high symptom severity and moderately high positive mental health. The study revealed that Floundering was associated with higher probabilities of being a man, being single, and having a low income. People in the Flourishing profile had the most favorable scores on criterion variables, supporting the profiles' construct validity.

Discussion: The mixed portrait of Struggling participants on recovery indicators suggests the relationship between health engagement and recovery is more intricate than anticipated. Practitioners should strive for a holistic understanding of their clients' self-management strategies and recovery indicators to provide support personalized to their profile. While people presenting risk factors would benefit from person-centered support, societal efforts are needed in the long term to reduce global health inequalities. The integration of constructs from diverse fields (patient-centered care, chronic illness, positive psychology) and the use of person-oriented analysis yielded new insights into people's engagement in their health and well-being.

Changing practice to support self-management and recovery in mental illness: application of an implementation model

Health services introducing practice changes need effective implementation methods. Within the setting of a community mental health service offering recovery-oriented psychosocial support for people with mental illness, we aimed to: (i) identify a well-founded implementation model; and (ii) assess its practical usefulness in introducing a new programme for recovery-oriented self-management support. We reviewed the literature to identify implementation models applicable to community mental health organisations, and that also had corresponding measurement tools. We used one of these models to inform organisational change strategies. The literature review showed few models with corresponding tools. The Promoting Action on Research Implementation in Health Services (PARIHS) model and the related Organisational Readiness to Change Assessment (ORCA) tool were used. The PARIHS proposes prerequisites for health service change and the ORCA measures the extent to which these prerequisites are present. Application of the ORCA at two time points during implementation of the new programme showed strategy-related gains for some prerequisites but not for others, reflecting observed implementation progress. Additional strategies to address target prerequisites could be drawn from the PARIHS model. The PARIHS model and ORCA tool have potential in designing and monitoring practice change strategies in community mental health organisations. Further practical use and testing of implementation models appears justified in overcoming barriers to change.

Self-Management Strategies in Recovery From Mood and Anxiety Disorders

Mood and anxiety disorders are the most prevalent mental disorders. People with such disorders implement self-management strategies to reduce or prevent their symptoms and to optimize their health and well-being. Even though self-management strategies are known to be essential to recovery, few researchers have examined them. The aim of this study is to explore strategies used by people recovering from depressive, anxiety, and bipolar disorders by asking 50 of them to describe their own strategies. Strategies were classified according to dimensions of recovery: social, existential, functional, physical, and clinical. Within these themes, 60 distinct strategies were found to be used synergistically to promote personal recovery as well as symptom reduction. Findings highlight the diversity of strategies used by people, whether they have depressive, anxiety, or bipolar disorders. This study underscores the importance of supporting self-management in a way that respects individual experience.

Depression Awareness and Self-Management Through the Internet: Protocol for an Internationally Standardized Approach

Background

Depression incurs significant morbidity and confers increased risk of suicide. Many individuals experiencing depression remain untreated due to systemic and personal barriers to care. Guided Internet-based psychotherapeutic programs represent a promising means of overcoming such barriers and increasing the capacity for self-management of depression. However, existing programs tend to be available only in English and can be expensive to access. Furthermore, despite evidence of the effectiveness of a number of Internet-based programs, there is limited evidence regarding both the acceptability of such programs and feasibility of their use, for users and health care professionals.

Objective

This paper will present the protocol for the development, implementation, and evaluation of the iFightDepression tool, an Internet-based self-management tool. This is a cost-free, multilingual, guided, self-management program for mild to moderate depression cases.

Methods

The Preventing Depression and Improving Awareness through Networking in the European Union consortium undertook a comprehensive systematic review of the available evidence regarding computerized cognitive behavior therapy in addition to a consensus process involving mental health experts and service users to inform the development of the iFightDepression tool. The tool was implemented and evaluated for acceptability and feasibility of its use in a pilot phase in 5 European regions, with recruitment of users occurring through general practitioners and health care professionals who participated in a standardized training program.

Results

Targeting mild to moderate depression, the iFightDepression tool is based on cognitive behavioral therapy and addresses behavioral activation (monitoring and planning daily activities), cognitive restructuring (identifying and challenging unhelpful thoughts), sleep regulation, mood monitoring, and healthy lifestyle habits. There is also a tailored version of the tool for young people, incorporating less formal language and additional age-appropriate modules on relationships and social anxiety. The tool is accompanied by a 3-hour training intervention for health care professionals.

Conclusions

It is intended that the iFightDepression tool and associated training for health care professionals will represent a valuable resource for the management of depression that will complement existing resources for health care professionals. It is also intended that the iFightDepression tool and training will represent an additional resource within a multifaceted approach to improving the care of depression and preventing suicidal behavior in Europe.

Optimizing delivery of recovery-oriented online self-management strategies for bipolar disorder: a review

OBJECTIVES

Self-management is emerging as a viable alternative to difficult-to-access psychosocial treatments for bipolar disorder (BD), and has particular relevance to recovery-related goals around empowerment and personal meaning. This review examines data and theory on BD self-management from a recovery-oriented perspective, with a particular focus on optimizing low-intensity delivery of self-management tools via the web.

METHODS

A critical evaluation of various literatures was undertaken. Literatures on recovery, online platforms, and self-management in mental health and BD are reviewed.

RESULTS

The literature suggests that the self-management approach aligns with the recovery framework. However, studies have identified a number of potential barriers to the utilization of self-management programs for BD and it has been suggested that utilizing an online environment may be an effective way to surmount many of these barriers.

CONCLUSIONS

Online self-management programs for BD are rapidly developing, and in parallel the recovery perspective is becoming the dominant paradigm for mental health services worldwide, so research is urgently required to assess the efficacy and safety of optimization methods such as professional and/or peer support, tailoring and the development of 'online communities'.

Self-efficacy and quality of life among people with bipolar disorder

People with bipolar disorders report a lower quality of life than the general population does, and few mutable factors associated with health-related quality of life (HRQoL) among people with bipolar disorders have been identified. Using a cross-sectional design, these analyses examined whether self-efficacy was associated with mental and physical HRQoL in a sample of 141 patients with bipolar disorder who completed baseline assessments for two randomized controlled trials. Multiple linear regression analyses indicated that higher levels of self-efficacy were associated with higher mental and physical HRQoL, after controlling for demographic factors and clinical factors (including mood symptoms, comorbid medical conditions, and substance use). Future research should examine whether targeted treatments that aim to improve self-efficacy (such as self-management interventions) lead to improvements in HRQoL among people with bipolar disorder and other serious mental illnesses.

Effectiveness of the chronic disease self-management program for persons with a serious mental illness: a translation study

Evaluation of evidence-based interventions in new settings and new populations is the hallmark of successful translation. We evaluated the Chronic Disease Self-Management Program in persons with serious mental illness who were receiving care through Michigan Community Mental Health Services (N = 139). At 6-months, participants demonstrated improvements in health indicators (fatigue, quality of life, sleep, depression, health distress, and days health bad) and health behaviors (medical adherence and communication with doctor). The program was successfully administrated in a "real world" setting and continues to be used. In addition, the program appears to be an effective resource for people with serious mental illness.

Effectiveness of a peer-led self-management programme for people with schizophrenia: protocol for a randomized controlled trial

AIM

To determine the effectiveness of a peer-led self-management programme for people with schizophrenia in reducing psychotic symptom severity, hospital readmission and psychiatric consultation and in enhancing cognition, empowerment, functioning level, medication adherence, perceived recovery, quality of life and social support.

BACKGROUND

Several self-management programmes have been developed to empower patients with severe mental illness in achieving recovery. Research suggests that peer-led self-management programmes have positive effects on patient recovery. However, the existing evidence is inconclusive, due to a lack of credible evidence and long-term follow-up evaluations.

DESIGN

A stratified randomized controlled trial will be conducted at six community mental health rehabilitation centres

METHODS

A sample of 242 adults with schizophrenia will be recruited. A peer-led self-management programme, comprising six 2-hour sessions, will be implemented in the intervention group and a standard rehabilitation programme in the control group. Outcomes will be measured at baseline, postintervention and at the 6- and 12-month follow-ups. The measures will include cognition, empowerment, functioning level, medication adherence, perceived recovery, quality of life, social support, symptom severity, hospital readmission and psychiatric consultation. A mixed effects model will be used to analyse the results. Semi-structured interviews will be conducted to explore the peer-trainers' and participants' perspectives on the programme. Research Ethics Committee approval was obtained in December 2011 and funding was obtained in January 2012.

CONCLUSION

This study will provide evidence on the effectiveness of a peer-led self-management programme for patient recovery. It will identify a clinically useful and potentially effective intervention that incorporates empowerment concept.

Improving propensity for patient self-advocacy through wellness recovery action planning: results of a randomized controlled trial

A fundamental aspect of successful illness self-management for people with serious mental illnesses is the ability to advocate for themselves in health and rehabilitation settings. This study reports findings from a randomized controlled trial comparing propensity for patient self-advocacy among those who received a peer-led mental illness self-management intervention called Wellness Recovery Action Planning (WRAP) and those who received usual care. Outcomes were self-reported engagement in self-advocacy with service providers, and the relationship between patient self-advocacy and other key recovery outcomes. In a multivariable analysis, at immediate post-intervention and 6-month follow-up, WRAP participants were significantly more likely than controls to report engaging in self-advocacy with their service providers. Higher self-advocacy also was associated with greater hopefulness, better environmental quality of life, and fewer psychiatric symptoms among the intervention group. These findings provide additional support for the positive impact of peer-led illness self-management on mental health recovery.

Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis

BACKGROUND

No systematic review and narrative synthesis on personal recovery in mental illness has been undertaken.

AIMS

To synthesise published descriptions and models of personal recovery into an empirically based conceptual framework.

METHOD

Systematic review and modified narrative synthesis.

RESULTS

Out of 5208 papers that were identified and 366 that were reviewed, a total of 97 papers were included in this review. The emergent conceptual framework consists of: (a) 13 characteristics of the recovery journey; (b) five recovery processes comprising: connectedness; hope and optimism about the future; identity; meaning in life; and empowerment (giving the acronym CHIME); and (c) recovery stage descriptions which mapped onto the transtheoretical model of change. Studies that focused on recovery for individuals of Black and minority ethnic (BME) origin showed a greater emphasis on spirituality and stigma and also identified two additional themes: culturally specific facilitating factors and collectivist notions of recovery.

CONCLUSIONS

The conceptual framework is a theoretically defensible and robust synthesis of people's experiences of recovery in mental illness. This provides an empirical basis for future recovery-oriented research and practice.

Use of 'chronic disease self-management strategies' in mental healthcare

PURPOSE OF REVIEW

Medical care for chronic conditions imposes a substantial burden on healthcare systems designed originally for acute illness or injury. The notion of chronic disease self-management (CDSM) has been developed as a means of encouraging individuals with chronic conditions to self-manage their own health. It is known that successful chronic disease management reduces hospital admission rates and improves patients' quality of life. Although recognized widely by other medical disciplines, it is beginning to have an impact on psychiatric practice; therefore, a review of how the CDSM approach is implemented in psychiatry is timely.

RECENT FINDINGS

The move toward self-management in general medicine can be seen by and large as a holistic approach that encourages the person to work in partnership with health professionals to improve outcomes and assist patients to better manage their healthcare needs. One of the defining features of CDSM approaches is the active collaboration between the patient and the healthcare professional. Five mechanisms that demonstrate such active collaboration are self-directed care, illness management and recovery, shared decision-making, joint crisis planning and wellness planning. Their use in psychiatry is discussed.

SUMMARY

The key feature of CDSM approaches is an active collaboration between healthcare professionals and healthcare consumers. It is a fundamental shift away from traditional active expert/passive patient treatment modes. Each of the five approaches discussed exemplifies the active participation in treatment planning by both consumers and mental health professionals.

Smoking cessation in persons with serious mental illnesses: the experience of successful quitters

OBJECTIVE

The purpose of the study was to better understand the experiences of persons with serious mental illnesses who have quit smoking.

METHODS

Former smokers with serious mental illnesses who had been abstinent for at least 4 months participated in an individually-administered structured interview about their motivation to quit smoking and the strategies that they used to quit. Participants also were asked about their willingness to assist peers in smoking cessation.

RESULTS

The sample of 78 successful quitters had been abstinent from smoking for an average of 7.4 (±8.6) years after smoking for a mean of 25.3 (±11.4) years; the mean peak quantity of cigarettes smoked was 1.5 (± 1.1) packs per day. The primary reason for quitting smoking was health concerns, endorsed by 57 (73%) of respondents. Additional reasons included the cost of cigarettes (55, 71%); advice from a doctor (42, 54%); advice from others (50, 64%). The main methods that participants cited as enabling them to quit were social support from friends or family (cited by 45, 58%); direction from a doctor (36, 46%); use of nicotine replacement therapy (NRT) (24, 31%); and the advice of friends who had quit (18, 23%). Only a small proportion of the sample had received smoking cessation treatment other than NRT. A large portion of the sample indicated that they would be willing to serve in peer helping roles for smoking cessation.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Persons with serious mental illnesses are able to successfully quit smoking despite extensive histories of heavy smoking. For practitioners, this study also emphasizes the importance of smoking cessation programming that is relevant and easily accessible to people with serious mental illnesses. Importantly, former smokers living with mental illnesses indicated a willingness to be involved in helping others quit, and should be utilized in formal smoking cessation efforts aimed at their peers.