How do recovery-oriented interventions contribute to personal mental health recovery? A systematic review and logic model

Effective provider communication for personal agency in mental health recovery: A cross-sectional study on Japanese users' perspectives

WHAT IS KNOWN ON THE SUBJECT?: Recovery-oriented practices in community-based mental health services are of increasing importance. The recovery journey of individuals with mental illness starts with a sense of agency, and a therapeutic relationship with the providers who support them is a prerequisite. In Japan, the construction of community-based integrated care systems for individuals with mental illness is positioned as a priority health issue, with communication with familiar individuals being particularly important for recovery in Japanese and Asian cultures. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study is the first to examine effective communication factors for personal agency in the recovery of individuals with mental illness, focusing on addressing uncertainty about treatment choices and dissatisfaction with decision-making, and considering the user's personal recovery journey. In recovery-oriented practice, it is important to prioritize addressing the emotional aspects of decision-making alongside the mental illness condition, supporting users' self-determination in their unique recovery journeys. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The findings emphasized the need to actively engage with users' perspectives and emotions, emphasize shared life planning, and foster a therapeutic relationship based on partnership. Providers should approach dialogue as carefully as medication prescriptions, prioritizing the establishment of an effective therapeutic relationship with the user. These characteristics are essential for developing a strong therapeutic relationship and effectively facilitating users' recovery. The findings are applicable not only to nurses but to all mental health service providers, contributing to the advancement of recovery-oriented practice.

ABSTRACT

INTRODUCTION: Recovery-oriented practice in community-based mental health services is crucial for individuals with mental illness, with communication with familiar individuals being important for recovery in Japanese and Asian cultures.

AIM

This study aimed to examine effective communication factors for personal agency in recovery by investigating the association between perceived support provided through communication and personal agency of individuals with mental illness.

METHOD

A cross-sectional study was conducted among community-dwelling Japanese mental health service users, assessing subjective agency, decisional conflict, staff support for personal recovery, activation for mental health self-management, demographic variables and living difficulties. Multiple linear regression analysis identified factors predicting subjective agency, revealing characteristics of effective provider communication for recovery.

RESULTS

Data from 222 users were analysed, revealing negative correlations between uncertainty about treatment choices and ineffective decision-making with higher subjective agency, while staff support for personal recovery positively correlated with higher subjective agency.

DISCUSSION

In recovery-oriented practice, prioritizing users' emotional experiences during decision-making and supporting their self-determination in their unique recovery journeys is crucial.

IMPLICATIONS FOR PRACTICE

Providers should approach dialogue as carefully as medication prescriptions, prioritizing therapeutic partnerships with users. The findings extend beyond nursing to all mental health service providers, advancing the theory of recovery-oriented practice.

Effectiveness of a needs-tailored nurse-led recovery program for community-dwelling people with schizophrenia: a cluster-randomized controlled trial

BACKGROUND

Meeting people's needs is positively correlated with their recovery. However, recovery services rarely include nurse-led programs tailored to the needs of these people. This study aimed to evaluate the effectiveness of a new needs-tailored recovery program by using a cluster-randomized controlled trial design.

METHODS

We conducted a parallel randomized controlled trial in two community psychiatric departments, employing nurse-level clustering for intervention delivery and selecting participants through convenience sampling. The participants were people diagnosed with schizophrenia that were receiving homecare services. The experimental group (n = 82) received needs-tailored recovery program for six months. The control group (n = 82) received traditional homecare. Data were collected at baseline, post-intervention, and the three-month follow-up (the study ran from February to December 2021). The outcomes were recovery, needs, hope, empowerment, psychotic symptoms, and medication adherence. We used repeated measures ANOVA tests to examine the effect of the group × time interaction.

RESULTS

The participants in the experimental group demonstrated statistically significant improvements in recovery, hope, and medication adherence compared to the control group, both immediately post-intervention and at the three-month follow-up. Moreover, they exhibited statistically significant reductions in needs compared to the control group at the three-month follow-up (p < .05). While the interaction effect for psychotic symptoms was not significant, the time effect was significant (p < .05). No significant interaction or time effect was observed for empowerment.

CONCLUSION

The findings increase our understanding of recovery-oriented care that prioritizes therapeutic alliance, integrated needs assessment, individual goals, hope, and empowerment.

TRIAL REGISTRATION

The Clinicaltrials.gov identifier NCT05304780 retrospectively registered on 03/31/2022.

Implementation of the Recovery Model and Its Outcomes in Patients with Severe Mental Disorder

BACKGROUND

The recovery model assumes that the patient can experience personal growth even while maintaining symptoms of a mental disorder. In order to achieve this recovery, the practices of professionals must also change. However, in our setting, there are limited data on the implementation of practices based on the recovery model and their effect on personal recovery.

OBJECTIVE

To describe the association between professionals' practices and patients' personal recovery.

METHODS

An observational and cross-sectional study in which the Recovery Self-Assessment (RSA) was used to assess the degree of implementation of the different practices and the Recovery Assessment Scale (RAS) was used to assess the personal recovery of 307 patients with severe mental disorders.

RESULTS

Patients attended by professionals who followed the recovery model obtained a greater personal recovery (p < 0.001, d = 1.10). The dimension associated with greater recovery was that of working toward life goals. The least implemented dimensions had to do with offering treatment options and patient participation in decision-making. This study was conducted in accordance with STROBE (STrengthening the Reporting of OBservational studies in Epidemiology).

CONCLUSIONS

Although this is a cross-sectional study that does not allow us to establish causal relationships, it shows that the model with which mental health professionals work is associated with patients' chances of recovery. We therefore consider that it is important to foster the implementation of practices based on the recovery model within mental health care.

Embedding Recovery Principles in Staff Orientation: A New Way of Delivering Multidisciplinary Mental Health Orientation

PURPOSE

Recovery-focused mental health treatment continues to grow, yet staff are often uncertain how best to define and implement it. As a quality assurance activity, we examined the effect of a novel orientation program embedded with a recovery framework structure, philosophy, and content, together with true lived experience codesign, on knowledge of recovery principles and acceptability.

METHOD

Staff of a new sub-acute adolescent mental health inpatient center completed a 6-week orientation in early 2020. Recovery processes of connectedness, hope and optimism, identity, meaning, and empowerment were mapped to session topics and the structure, design, and philosophy of the program.

RESULTS

Mean knowledge scores improved from pre- to post-assessment and most (≥70%) participants reported topics as relevant, impactful, and would recommend. Approximately all (95%) comments were positive.

CONCLUSION

Findings suggest that person-centered orientations that embed a recovery framework are promising for mental health staff orientation. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].

The impact of reduced routine community mental healthcare on people from minority ethnic groups during the COVID-19 pandemic: qualitative study of stakeholder perspectives

BACKGROUND

Enduring ethnic inequalities exist in mental healthcare. The COVID-19 pandemic has widened these.

AIMS

To explore stakeholder perspectives on how the COVID-19 pandemic has increased ethnic inequalities in mental healthcare.

METHOD

A qualitative interview study of four areas in England with 34 patients, 15 carers and 39 mental health professionals from National Health Service (NHS) and community organisations (July 2021 to July 2022). Framework analysis was used to develop a logic model of inter-relationships between pre-pandemic barriers and COVID-19 impacts.

RESULTS

Impacts were largely similar across sites, with some small variations (e.g. positive service impacts of higher ethnic diversity in area 2). Pre-pandemic barriers at individual level included mistrust and thus avoidance of services and at a service level included the dominance of a monocultural model, leading to poor communication, disengagement and alienation. During the pandemic remote service delivery, closure of community organisations and media scapegoating exacerbated existing barriers by worsening alienation and communication barriers, fuelling prejudice and division, and increasing mistrust in services. Some minority ethnic patients reported positive developments, experiencing empowerment through self-determination and creative activities.

CONCLUSIONS

During the COVID-19 pandemic some patients showed resilience and developed adaptations that could be nurtured by services. However, there has been a reduction in the availability of group-specific NHS and third-sector services in the community, exacerbating pre-existing barriers. As these developments are likely to have long-term consequences for minority ethnic groups' engagement with mental healthcare, they need to be addressed as a priority by the NHS and its partners.

Integrating Subjective Recovery and Stigma Resistance in Individuals with Schizophrenia: A Narrative Review and Theoretical Integration

Stigmatised attitudes are known to be associated with negative outcomes in schizophrenia, yet there is little focus on the role of stigma in the recovery process. Attempts to develop interventions to reduce self-stigma in schizophrenia have not been found effective. This paper presents a theoretical integration based on a narrative review of the literature. PsycINFO, Medline and Embase databases were searched up to the 11th December 2023. Studies were included if they were: i) empirical studies using qualitative, quantitative or mixed methods studies investigating mental health stigma; ii) included participants based in the United Kingdom, fluent in English, between the ages of 16 and 70, meeting criteria for a schizophrenia spectrum diagnosis. Fourteen studies were included. In Part 1, we propose a novel theoretical model derived from a synthesis of service-user perspectives on the relationship between stigma and schizophrenia. Stigmatised attitudes were commonly perceived to be caused by a lack of education and further exacerbated by disinformation primarily through the media and cultural communities. Stigma led to negative self-perceptions, negative emotional responses, social isolation and increased symptom severity, ultimately acting as a barrier to recovery. In Part 2, we identify several factors that ameliorate the impact of stigma and promote clinical and subjective recovery among service-users: education, empowerment, self-efficacy, self-acceptance, hope and social support. We argue that the notion of stigma resistance may be helpful in developing new interventions aimed at promoting recovery in individuals with schizophrenia. Wider implications are discussed and recommendations for future research and practice are explored.

Ontological insecurity of inattentiveness: Conceptualizing how risk management practices impact on patient recovery when admitted to an acute psychiatric hospital

Risk management which assesses and mitigates risks such as suicide and violence is under scrutiny, particularly within psychiatric inpatient settings. Restrictive practices, which result from risk assessment, such as observations, physical restraint and ward seclusion can impact negatively on patient recovery, hindering abilities to develop a meaningful life that emphasizes purpose, hope and autonomy, despite experiencing mental distress. Yet, less is known about the impact from the patient's perspective when first admitted to hospital, a period which among other reasons may come with increasing risk management practices owing to the clinical uncertainties about patient risks. In this grounded theory study, we explore the impact on recovery, interviewing 15 adult participants with patient experiences of being in an acute hospital. The main theme of the study, termed a core category with a grounded theory, was identified as "ontological insecurity of inattentiveness". This highlighted a staff inattentiveness with involving patients with risk management and explaining the purposes of the practice, which raised insecurities about what was happening to the patients when admitted to hospital. Four subcategories support the core category; discounting the patients' experiences to gain a meaningful grasp of risk management, ambiguity about risk management rules, particularly the reasons around their use, forebodingness to the hospital environment and, management from afar, with patients feeling scrutinized from observations without a voice to offer different views. It is hoped these findings will add to the field of patient involvement in psychiatric inpatient settings, proposing attempts to raise understanding and inclusivity of risk management, starting when first admitted to hospital.

Personal recovery in first-episode psychosis: Beyond clinical and functional recovery

BACKGROUND

The concept of personal recovery after psychotic illness focuses more on patients' social and existential needs compared to traditional outcome measures including clinical and functional recovery. This research aims to contribute to a broad framework on (personal) recovery and associated factors.

METHODS

Data from 203 persons with symptomatic remission of their first-episode psychosis from the ongoing HAMLETT study were analyzed. To determine the relative importance of several biological, clinical, psychological, and social factors in explaining personal recovery as measured by the Recovery Assessment Scale (RAS), partial Spearman correlations (controlling for clinical recovery (PANSS) and functional recovery (WHODAS 2.0)) and a bootstrapped multiple regression were performed. Indirect effects on personal recovery within these factors, clinical recovery, and functional recovery were explored using a regularized partial correlation network.

RESULTS

Of the factors that explained personal recovery beyond the effects of clinical and functional recovery, social support was the strongest predictor, followed by self-esteem, internalized stigma, and insecure attachment, collectively explaining 48.2 % of the variance. Anhedonia/apathy showed a trend towards a negative correlation. Age at onset, sex, early trauma/neglect, cognition, and being married/cohabiting did not significantly correlate with personal recovery. The network (n = 143) was consistent with these findings and indicated possible mediation pathways for early trauma/neglect, insecure attachment, cognition, and being married/cohabiting.

CONCLUSIONS

Personal recovery is an important addition to traditional measures of outcome after psychosis. Various quality of life indicators, such as self-esteem and social support, explain variance in personal recovery over clinical and functional recovery.

Effectiveness of Community-Based Rehabilitation (CBR) Centers for Improving Physical Fitness for Community-Dwelling Older Adults: A Systematic Review and Meta-Analysis

To synthesise the best available evidence for the effectiveness of interventions delivered in community-based rehabilitation (CBR) centers on physical fitness, for community-dwelling older adults living in Asian countries. This study is a systematic review and meta-analysis. Seven English and two Chinese electronic databases were searched for randomised controlled trials (RCTs) and quasi-experimental studies that were conducted by centers providing CBR. Independent reviewers screened, quality-appraised and extracted data. The primary outcome was physical fitness measured by validated assessment tools, including the Timed Up and Go Test (TUG), gait speed, hand grip strength, Functional Reach Test (FRT), and one-leg standing test. Assessments of activity of daily living and quality of life using tools including the Barthel Index, Short Form (SF)-12, and SF-36 were secondary outcomes. After screening 5,272 studies, 29 studies were included (16 RCTs, 13 quasi-experimental studies) from four countries. Meta-analyses found that CBR programs significantly decreased TUG time (mean difference [MD], -1.89 seconds; 95% confidence interval [95% CI], -2.84 to -0.94; I2=0%; Z=3.90, p<0.0001), improved gait speed (MD, 0.10 m/s; 95% CI, 0.01-0.18; I2=0%; Z=2.26, p=0.02), and increased one-leg standing time (MD, 2.81 seconds; 95% CI, 0.41-5.22; I2=0%; Z=2.29, p=0.02). Handgrip strength and FRT showed no statistically significant improvement in the meta-analyses. CBR may improve aspects of physical fitness for older adults in Asian countries. However, variability in intervention components and measurement tools reduced the ability to pool individual studies. Further trials are required with robust designs including standardised measures of physical fitness.

Creating "an oasis of hope, inclusion and connection": students and stakeholders' experiences of a pilot Recovery College

BACKGROUND

Recovery Colleges are an innovative approach to promoting personal recovery for people experiencing mental illness.

AIMS

This study was to explore experiences of students, supporters, staff, educators and external stakeholders (i.e. partner organisations) of a pilot Recovery College in the Australian Capital Territory (ACTRC), and the impact of participation in the College for students and supporters.

METHODS

ACTRC students, supporters, staff and educators, and external stakeholders were invited to participate in a mixed-method evaluation via an online survey, interviews and/or focus groups. The survey included questions regarding experiences and recovery-orientation of the College environment, and for students and supporters only, satisfaction with the College. Qualitative data from interviews and focus groups was inductively coded, thematically analysed and triangulated with survey responses.

RESULTS

The findings suggest that the ACTRC provides a safe space, promotes meaningful connections within and beyond the college, and offers steppingstones supporting recovery and growth. Participants spoke positively about cross institutional partnerships and collaboration with several organisations within the ACT.

CONCLUSIONS

This evaluation reiterates the role of Recovery Colleges as an innovative approach to promoting personal recovery for people living with mental illness. Adequate resourcing and collaboration are essential in realising the value of co-production whilst ensuring sustainability.

"A bit lost"-Living with attention deficit hyperactivity disorder in the transition between adolescence and adulthood: an exploratory qualitative study

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) begins in childhood and in many cases persists into adulthood. The transition from adolescence to adulthood for young people with ADHD is a vulnerable time and can be associated with comorbid conditions and unfavorable outcomes. Thus, further studies are needed to explore the characteristics of the transition period in emerging adulthood. The overall aim of this study was to gain increased knowledge of emerging adults' experience of living with ADHD in the transition from adolescence to adulthood. This is a follow-up from a previous qualitative study that examined how young people experience receiving and living with a diagnosis of ADHD.

METHOD

The study has a qualitative retrospective design. Seven participants were included in this study using a purposive sampling method. We re-invited the same participants who were interviewed in 2015-2016 and conducted in-depth interviews. The data were subjected to Malterud's systematic text condensation (STC).

RESULTS

Four crosscutting themes were identified from our analysis: (1) low level of knowledge about ADHD and treatment options; (2) barriers to seeking and accessing help; (3) developing self-help strategies; and (4) a preference to discontinued medication use.

CONCLUSION

The participants emphasized a need for more information about ADHD in transition phases and support, both from professionals and peers, about finding ways to live meaningful lives. The treatment they had been offered was particularly linked to symptom reduction and medication use. A more appropriate focus would have been linked to how they, as citizens, could gain knowledge and skills to live meaningful lives with ADHD.

The Wisdom of Hindsight: Allies Reflections on Their Role in Supporting the Implementation of Expert by Experience Positions in Academia

Experts by experience involvement in mental health education has consistently demonstrated positive attitudinal outcomes including a greater appreciation for recovery-focused practice. Mental health academic allies have played a crucial role in supporting implementation of expert by experience academic positions. To date the inclusion of their views in research is limited. The aim of this study was to explore and present allies' reflections on their involvement in supporting expert by experience academic roles in relation to "hindsight" and "foresight." A qualitative descriptive design was used, involving in-depth semi-structured interviews with allies who had supported the implementation of academic roles for experts by experience. Participants described the wisdom of hindsight. Based on their own experiences they emphasised the importance of, laying the groundwork, facilitating a supportive environment, contributing to meaningful, credible, and sustainable roles, and vision for the future as key to successful implementation. They also described a vision for the expansion of expert by experience roles in mental health education in the future. Allies' reflections suggest the importance of preparation to facilitate a smooth as possible implementation process and enhance the likelihood of successful outcomes. The transition to recovery-focused mental health services requires the attitudes of health professionals to change. The potential of experts by experience to influence attitudinal change can be enhanced by understanding the experiences and reflections of academic allies.

When Distance Becomes Closeness: Distance Learning as a Meaningful Learning Opportunity During the COVID-19 Pandemic

The National School for Mental Health Rehabilitation, Integration, and Recovery in Israel developed responses to academic, pedagogical, and emotional needs that arose during the first wave of the COVID-19 pandemic. Despite reduced activity during the outbreak, the school continued all regular courses remotely and created new online workshops. In this article, we review the school's adjustment from being change agents on the frontal level to change agents on the virtual level, through descriptive and qualitative findings. We use the learning from success approach to examine development and implementation processes. The large number of participants who suddenly had access to distance learning and their highly positive responses indicated the creation of opportunities alongside the challenges we faced. To the best of our knowledge, this is the first description and analysis of the challenges, opportunities, and outcomes of a recovery-oriented online academic facility during a pandemic.

A blended module (STAIRS) to promote functional and personal recovery in patients with a major depressive disorder in remission: study protocol of a concurrent mixed methods randomized controlled trial

BACKGROUND

Despite the availability of a wide variety of evidence-based treatments for major depressive disorder (MDD), many patients still experience impairments in their lives after remission. Programs are needed that effectively support patients in coping with these impairments. The program Storytelling and Training to Advance Individual Recovery Skills (STAIRS) was developed to address this need and combines the use of peer contact, expert-by-experience guidance, family support and professional blended care. The aim of the planned study is (1) to assess the efficacy of the STAIRS program in patients with remitted MDD, (2) to investigate patients' subjective experiences with STAIRS, and (3) to evaluate the program's cost-effectiveness.

METHODS

A concurrent mixed-methods randomized controlled trial design will be used. Patients aged between 18 and 65 years with remitted MDD (N = 140) will be randomized to either a group receiving care as usual (CAU) + the STAIRS-program or a control group receiving CAU + some basic psychoeducation. Quantitative efficacy data on functional and personal recovery and associated aspects will be collected using self-report questionnaires at the start of the intervention, immediately following the intervention, and at the six-month follow-up. Insights into patients' experiences on perceived effects and the way in which different program elements contribute to this effect, as well as the usability and acceptability of the program, will be gained by conducting qualitative interviews with patients from the experimental group, who are selected using maximum variation sampling. Finally, data on healthcare resource use, productivity loss and quality of life will be collected and analysed to assess the cost-effectiveness and cost-utility of the STAIRS-program.

DISCUSSION

Well-designed recovery-oriented programs for patients suffering from MDD are scarce. If efficacy and cost-effectiveness are demonstrated with this study and patients experience the STAIRS program as usable and acceptable, this program can be a valuable addition to CAU. The qualitative interviews may give insights into what works for whom, which can be used to promote implementation.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov on 1 July 2021, registration number NCT05440812.

Interventions promoting recovery from depression for patients transitioning from outpatient mental health services to primary care: Protocol for a scoping review

INTRODUCTION

Patients with severe Major Depressive Disorder (MDD) have an increasing risk of new psychiatric hospitalizations following each new episode of depression highlighting the recurrent nature of the disorder. Furthermore, patients are not fully recovered at the end of their treatment in outpatient mental health services, and residual symptoms of depression might explain why patients with MDD have a high risk of relapse. However, evidence of methods to promote recovery after discharge from outpatient mental health services is lacking. The proposed scoping review aims to systematically scope, map and identify the evidence and knowledge gaps on interventions that aims to promote recovery from MDD for patients transitioning from outpatient mental health services to primary care.

MATERIALS AND METHODS

The proposed scoping review will follow the latest methodological guidance by the Joanna Briggs Institute (JBI) in tandem with the Preferred Reporting Items for Systematic reviews and Meta-Analysis-extension for Scoping Reviews (PRISMA-ScR) checklist. The review is ongoing. Four electronic databases (Medline via PubMed, PsycINFO, CINAHL, and Sociological Abstracts) were systematically searched from 20 January 2022 till 29 March 2022 using keywords and text words. The review team consists of three independent screeners. Two screeners have completed the initial title and abstract screening for all studies retrieved by the search strategy. Currently, we are in the full text screening phase. Reference lists of included studies will be screened, and data will be independently extracted by the review team. Results will be analyzed qualitatively and quantitatively.

DISCUSSION

The chosen methodology is based on the use of publicly available information and does not require ethical approval. Results will be published in an international peer reviewed scientific journal, at national and international conferences and shared with relevant authorities.

REGISTRATION

A pre-print has been registered at the medRxiv preprint server for health sciences (doi.org/10.1101/2022.10.06.22280499).

Exploring Patients' Feeling of Being Coerced During Psychiatric Hospital Admission: A Qualitative Study

Various coercive measures can be used to legally compel a person suffering from psychiatric disorder to undergo treatment. However, evidence suggests that patients' feeling of being coerced is not determined solely by their being submitted to formal coercion. This study aimed to explore voluntary and involuntary patients' experience of coercion during psychiatric hospitalisation and to identify which factors, from their perspective, most affected it. We chose a qualitative design inspired by a hermeneutic-phenomenological approach. Participants were purposively selected from six psychiatric hospitals in Switzerland. Maximum variation sampling was used to ensure the inclusion of patients with different levels of perceived coercion and different admission statuses. In-depth, semi-structured interviews were co-conducted by a research psychologist and a service-user researcher. The transcribed data underwent thematic analysis. All twelve interviewed patients described the hospitalisation as an experience of loss of control over their life due to either external or internal pressures. During the process, perceptions of these pressures varied and sometimes overlapped, leading some patients to describe their admission as a form of simultaneous protection and violation. The balance between these two contradictory feelings was affected by a variety of contextual and relational factors, as well as by the meaningfulness of the experience and the patient's subsequent satisfaction with it. Increasing policy-makers' and clinicians' awareness about the main factors influencing patients' experience of loss of control is of paramount importance in order to develop skills and strategies able to address them, reinforcing patients' empowerment, reducing their feeling of coercion and improving their well-being.

Value of gym-based group exercise versus usual care for young adults receiving antipsychotic medication: study protocol for the multicenter randomized controlled Vega trial

BACKGROUND

Exercise is recommended to protect physical health among people with severe mental illness and holds the potential to facilitate long-term recovery. An inclusive exercise community provides an opportunity for life skill training and social connectedness and may reduce the experience of loneliness and internalized stigmatization which together may improve personal recovery. Using a pragmatic randomized design, we aim to examine the effectiveness of a gym-based exercise intervention tailored to young adults in antipsychotic treatment (i.e., Vega Exercise Community) compared to usual care. It is hypothesized that the Vega Exercise Community will be superior to usual care for personal recovery at four months.

METHODS

The trial will be conducted at four sites in Denmark from which 400 participants, aged 18 to 35 years, who are in current treatment with antipsychotic medications for the management of schizophrenia spectrum or affective disorders, will be recruited. Participants will be randomized (2:1) to Vega Exercise Community or usual care. Vega Exercise Community includes three weekly group-based exercise sessions hosted in commercial functional training centers delivered by certified Vega instructors. After four months, participants in Vega Exercise Community will be randomized (1:1) to minimal versus extended support with regards to sustained physical activity. Data will be collected at baseline, four, six and 12 months. The primary outcome is personal recovery assessed by Questionnaire about the Process of Recovery at four months. Behavioral symptoms, health-related quality of life, metabolic health, and program costs will be evaluated to further determine the effectiveness and cost-effectiveness of the Vega Exercise Community. Finally, the quality of life and physical and mental health of the participants' primary relative will be evaluated.

DISCUSSION

The results of this trial may have important implications for health, sustained physical activity, and recovery for individuals in treatment with antipsychotics. Given the pragmatic design, positive results may readily be implemented by mental health care professionals to promote exercise as an integrated part of treatment of severe mental illness.

TRIAL REGISTRATION

Clinical Trials.gov (NCT05461885, initial registration June 29th, 2022). WHO Universal Trial Number (UTN): U1111-1271-9928.

Toward an Experience-Based Model of Recovery and Recovery-Oriented Practice in Mental Health and Substance Use Care: An Integration of the Findings from a Set of Meta-Syntheses

A model of recovery and recovery-oriented practice has been developed based on three previously published meta-syntheses of experiences and processes of mental health and substance use recovery. The model integrates the findings of these three meta-syntheses into three components: experiences of recovery, processes of recovery-oriented practice, and social and material capital. The experiences of recovery involve being, doing, and accessing and are viewed as embedded in the processes of recovery. The processes of recovery-oriented practice aim to mobilize and apply various forms of capital to support the recovery journey. Social and material capital, in turn, constitute the context in which recovery occurs and requires mobilization for the individual and the service system. The model is grounded in the principles of well-being, person-centeredness, embedding, self-determination, and the interdependency of human living. The model is both descriptive and explanatory, as it depicts the experiential and processual aspects of recovery and recovery-oriented practice and their interrelationships. The model as a framework needs to be elaborated further through application in practice and research, especially for understanding how experiences, processes and practices interact over time, and how they are affected by access to material and social capital.

Association between childhood maltreatment and social functioning in individuals with affective disorders: A systematic review and meta-analysis

OBJECTIVE

Childhood maltreatment has been linked to impairments in social functioning and social cognition in adults with affective disorders. However, conclusions have been limited by inconsistent findings across different maltreatment subtypes and social domains. We conducted a systematic review and meta-analysis to quantify associations between childhood maltreatment (overall and subtypes - physical, emotional and/or sexual abuse, and/or physical and/or emotional neglect) and different domains of social functioning and social cognition in adults with affective disorders (bipolar disorder or major depressive disorder). We also examined effect moderators and mediators of these associations.

METHODS

A systematic search was performed on 12.12.2022 which identified 29 studies included in qualitative synthesis (n = 3022 individuals with affective disorders), of which 27 (n = 2957) were pooled in meta-analyses. Across studies, five social functioning and five social cognition domains were examined, of which four domains of social functioning and two domains of social cognition had sufficient data for meta-analysis (PROSPERO CRD42022288976).

RESULTS

Social functioning: childhood maltreatment was associated with lower global social functioning (r = -0.11 to -0.20), poorer interpersonal relations (r = -0.18 to -0.33), and with aggressive behaviour (r = 0.20-0.29) but was unrelated to vocational functioning. Emotional abuse and emotional neglect showed the largest magnitudes of effect. Social cognition: there was no meta-analytic evidence of associations between maltreatment and social cognition domains. Exploratory moderation analyses did not identify any consistent moderators. Narrative synthesis identified attachment style as possible moderator, and sensory patterns, anxiety, and depressive symptoms as possible mediators between childhood maltreatment and social outcomes. Overall, the available evidence was limited, particularly in relation to social cognition.

CONCLUSIONS

Adults with affective disorders are at risk of social functioning difficulties after childhood maltreatment exposure, an effect observed across multiple maltreatment subtypes, social functioning domains, and diagnoses. Addressing social functioning problems may benefit maltreated adults with both bipolar disorder and major depressive disorder.

Development of mental health first-aid guidelines for depression: a Delphi expert consensus study in Argentina and Chile

BACKGROUND

Depression is one of the most common mental health problems worldwide and, while prevalence rates in Latin America are relatively high, most people who meet the criteria for diagnosis do not receive treatment. Family and friends of a person with depression can play an important role in supporting a person to seek and engage with treatment. However, many people do not have the necessary skills or confidence to help. English-language mental health first aid guidelines have been developed to support people to provide such help. The aim of this study was to culturally adapt these guidelines for Chile and Argentina.

METHODS

A Delphi expert consensus study was conducted with two expert panels, one of people with lived experience of depression (either their own or as a carer; n = 26) and one of health professionals (n = 29). Overall, 172 statements from the English-language guidelines were translated and compiled into a questionnaire. Participants were asked to rate statements based on how essential or important those statements were for Chile and Argentina and to suggest new statements if necessary.

RESULTS

Data were obtained over two survey rounds. Consensus was achieved on 172 statements. A total of 137 statements were adopted from the English-language guidelines, whereas 35 new endorsed statements were generated from panel suggestions. There were similarities between the English-language guidelines and those for Chile and Argentina. The adapted guidelines did not include some of the items from the English-language guidelines related to commenting on a person's strengths or making judgements about their character, and also incorporated new items related to the incorporation of sociocultural considerations as causes of depression and attention to inequities in mental health.

CONCLUSIONS

The significant number of new items underscores the importance of undertaking a careful process of cultural adaptation. Further research on dissemination and incorporation of the guidelines into the Mental Health First Aid training course for Chile and Argentina is still required.

A Community Navigation Scale for Persons With Serious Mental Illnesses

OBJECTIVE

The recovery paradigm in the context of serious mental illnesses pertains to several characteristics of community functioning, adjustment, and integration, among other constructs. Additional rating scales would be beneficial for measuring various facets of community functioning for research that is recovery oriented as opposed to symptom focused. The Community Navigation Scale was developed as part of the Opening Doors to Recovery project to address several aspects of navigating community resources.

METHODS

After item development, the 21-item Community Navigation Scale was used across two studies with 340 participants who had serious mental illnesses. Factor analysis revealed three potential factors, and subscales were computed.

RESULTS

The social and physical well-being subscale (seven items, Cronbach's α=0.82) addressed community involvement, volunteering, finding enjoyable activities, and engaging in positive health behaviors. The accessing external resources subscale (nine items, Cronbach's α=0.80) tapped one's ability to obtain needed resources, ranging from medications to housing and from small appliances to classes in the community. The home and self-maintenance subscale (five items, Cronbach's α=0.73) measured abilities around shopping, cooking, cell phone use, house cleaning, and personal grooming and hygiene. Initial validity of the subscales was suggested through correlations with the Multnomah Community Ability Scale (r=0.65, 0.55, and 0.41 for social and physical well-being, accessing external resources, and home and self-maintenance, respectively).

CONCLUSIONS

The Community Navigation Scale assesses dimensions of community functioning among persons with serious mental illnesses and may add to the array of research and clinical measures pertinent to recovery outcomes. Additional research on its psychometric properties is warranted.

Remote cognitive assessment in severe mental illness: a scoping review

Many individuals living with severe mental illness, such as schizophrenia, present cognitive deficits and reasoning biases negatively impacting clinical and functional trajectories. Remote cognitive assessment presents many opportunities for advancing research and treatment but has yet to be widely used in psychiatric populations. We conducted a scoping review of remote cognitive assessment in severe mental illness to provide an overview of available measures and guide best practices. Overall, 34 studies (n = 20,813 clinical participants) were reviewed and remote measures, psychometrics, facilitators, barriers, and future directions were synthesized using a logic model. We identified 82 measures assessing cognition in severe mental illness across 11 cognitive domains and four device platforms. Remote measures were generally comparable to traditional versions, though psychometric properties were infrequently reported. Facilitators included standardized procedures and wider recruitment, whereas barriers included imprecise measure adaptations, technology inaccessibility, low patient engagement, and poor digital literacy. Our review identified several remote cognitive measures in psychiatry across all cognitive domains. However, there is a need for more rigorous validation of these measures and consideration of potentially influential factors, such as sex and gender. We provide recommendations for conducting remote cognitive assessment in psychiatry and fostering high-quality research using digital technologies.

Factors associated with personal recovery among psychiatric nursing home residents

WHAT IS KNOWN ABOUT THE SUBJECT?: Poor recovery will cause harm to the quality of life and well-being of residents and that the scope of influence includes the self, family and society. No study to date has investigated empowerment and the other multiple factors associated with personal recovery among psychiatric nursing home residents. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: The factors associated with personal recovery are empowerment, social support and global functioning. This pioneer study contributes new evidence that personal recovery is mainly predicted by empowerment, social support and global function, with empowerment exhibiting the highest predictive value. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Strengthening empowerment in mental health nursing may contribute more to the personal recovery of psychiatric nursing home residents than improving global function or social support. Mental health professionals should shift to empowerment-oriented care to improve individuals' personal recovery, such as offering more opportunities to achieve autonomy, encouraging individuals' involvement in decision-making and promoting individuals' motivation for achieving their goals. ABSTRACT: Introduction Individuals diagnosed with mental illness have a need for recovery. No study to date has investigated empowerment and the other multiple factors associated with personal recovery among psychiatric nursing home residents. Aim The study aimed to identify the factors associated with personal recovery among psychiatric nursing home residents. Methods This was a cross-sectional study with convenience sampling. Participants were recruited from a psychiatric nursing home in Northern Taiwan between April and June 2018. Data were collected through self-reported, structured questionnaires with verified reliability and validity. Descriptive and hierarchical regression analyses were performed. The present study followed the STROBE guidelines. Results The study included 158 participants. The factors associated with recovery according to bivariate associations were religious belief, psychotic symptoms, global function, social support and empowerment. In the hierarchical regression, empowerment, social support and global function were the main predictive factors of recovery, with the explained variation reaching 40.8%. Empowerment exhibited the highest predictive value for the recovery. Implications for clinical practice Strengthening empowerment in mental health nursing may contribute more to the personal recovery of psychiatric nursing home residents than improving global function or social support.

Innovations in community-based mental health care: an overview of meta-analyses

In the last four decades, mental health services for people with Severe Mental Illness (SMI) have seen asylums replaced by a balanced model of Community Mental Healthcare (CMH). Innovative approaches and strategies in the field of CMH have been extensively researched. However, this research has been hampered by issues limiting their capacity to inform clinicians and policymakers. We conducted an overview of meta-analyses of the effectiveness of innovative CMH models focussing on clinical and psychosocial outcomes in comparisons with standard care in adults with SMI. Based on the 12 eligible studies, we appraised, synthesised and graded the resulting evidence. There was moderate quality evidence that case management, Early Intervention Services (EIS) and caregiver-directed interventions were superior to standard care in reducing hospital admission. In relation to psychosocial outcomes, EIS showed high quality evidence of a small effect on global functioning. There was moderate quality evidence for a similar effect of Intensive Case Management, and for a large effect of family intervention. For quality of life, both EIS and self-management education had a small effect, with moderate quality. The level of research about effective CMH models is therefore substantial. However, several gaps related to innovative CMH not yet covered in meta-analytic synthesis, need to be filled.

Using photovoice to explore women's experiences of a women-only prevention and recovery care service in Australia

Women should be able to access mental health services that are safe, free from harassment and abuse. Yet, research indicates that women experiencing mental health issues are often not safe in mixed gender environments, and especially in inpatient settings. This qualitative study draws on a photo-elicitation method ('photovoice') and semi-structured interviews to explore women's experiences of a sub-acute women-only prevention and recovery care (PARC) service in Australia. Twelve women experiencing mental health issues were recruited via an aftercare peer support group for recent service participants. The women took photographs guided by the central question: 'What were your experiences of a women-only prevention and recovery care service?' They then shared these photographs with the researchers and each other, and described them in detail. Four key themes were identified by thematic analysis of the photovoice visual and narrative data: (a) Only women can understand what women go through; (b) I feel safer with no men around due to my history of trauma; (c) This environment feels safe, making it easier to talk and (d) Staff are accessible and make time for me to talk about difficult topics. Woven throughout the women's narratives was the expressed desire to feel safe and supported during the process of recovering. Aspects of service delivery that contributed to these feelings and facilitated shared support were also valued in this setting. These findings indicate that access to women-only services and peer support are not only valued by women experiencing mental health issues, but need to be more widely available to support their recovery. They also underline the importance of a trauma-informed approach for improving the gender sensitivity of services.

The impacts of implementing recovery innovations: a conceptual framework grounded in qualitative research

Background

Implementing mental health recovery into services is a policy priority in Canada and globally. To that end, a 5 year study was undertaken with seven organisations providing mental health and housing services to people living with a mental health challenge to implement guidelines for the transformation of services and systems towards a recovery-orientation. Multi-stakeholder implementation teams were established and a facilitated process guided teams to choosing and planning for the implementation of one recovery innovation. The recovery innovations chosen were hiring peer support workers, Wellness Recovery Action Planning (WRAP), a family support group, and staff recovery training.

Methods

This study reports on data collected at the post-implementation stage. 90 service users, service providers, family members, managers, other actors and knowledge users participated in 41 group, individual or dyad semi-structured interviews. The interview guides included open-ended questions eliciting participants’ impressions regarding the impact of implementing the innovation on service users, service providers and organisations. We applied a collaborative qualitative content analysis approach in NVivo12 to coding and interpreting the data generated from these questions.

Results

Eighteen impacts of implementing recovery innovations from the perspectives of diverse stakeholder groups were identified. Three impacts of working as an implementation team member and as part of a research project were also identified. Impacts were developed into a conceptual framework organised around four overall categories of impact: Ways of being, Ways of interacting, Ways of thinking, and Ways of operating and doing business.

Conclusions

The IMpacts of Recovery Innovations (IMRI) framework version 1 can assist researchers, evaluators and decision-makers identify, explore and understand impact in the context of recovery innovations. The framework helps fill a gap in conceptualising service and organisation-level impacts. Future research is needed to validate the framework and map it to existing methods for studying impact.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00559-2.

Minds@Work: A New Manualized Intervention to Improve Job Tenure in Psychosis Based on Scoping Review and Logic Model

Introduction A significant proportion of people experiencing psychosis are unemployed, despite a strong desire to work. Current supported employment programs appear effective in helping them obtain employment, yet job tenure remains an arduous challenge. The objective of this study was to review the literature and model the results to inform the development of a new manualized group psychosocial intervention-'Minds@Work'-aimed specifically at improving job tenure in psychosis. Methods The study was registered on the Open Science Framework platform ( https://osf.io/he68z ). The literature was searched in Medline, Embase, PsycInfo and Cochrane Library databases for studies examining predictors of job tenure in psychosis and existing occupational psychosocial interventions. Data were extracted using a pre-established form and synthesized using logic models. Results A total of 94 studies were included and their findings were modeled using different categories: intervention typologies, mechanisms of action, predictors of job tenure, outcomes and contextual factors. The 'Minds@Work' program was built based on these modeled findings and aimed to target specific predictors of job tenure while addressing some of the limitations of existing interventions. The program uses evidence-based techniques and is divided into 9 modules covering 4 themes: positive psychology (motivation, character strengths, self-compassion), neurocognitive remediation (attention, memory, problem-solving), cognitive biases training (jumping to conclusions, defeatists beliefs, theory of mind, attributional styles) and socioemotional coping skills (emotion regulation, communication). Conclusions Once validated, this new program is meant to be used either as a stand-alone intervention or integrated in supported employment initiatives, by employment specialists or healthcare workers.

Methodologies to Advance a "Science of How": Identifying and Engaging Intervention Targets and Outcomes

OBJECTIVE

Although implementation science has taken hold in many areas of psychiatric services research, a need remains for developing effective, low-cost interventions for specific subpopulations with mental health conditions. The experimental therapeutics approach has gained momentum as a framework for developing effective interventions. However, few studies have taken steps to rigorously apply experimental therapeutics. This article provides a blueprint for applying this approach.

METHODS

A focused literature review was conducted to document the frequency of the application of experimental therapeutics among articles published between 2011 and 2021 in some of the American Psychiatric Association's journals. Independently of the review, the authors delineated a four-component approach for applying experimental therapeutics in research and present practical, innovative strategies to advance psychiatric services research.

RESULTS

The four-component approach includes outlining prerequisites, identifying target mechanisms, proposing intervention strategies to address target mechanisms, and using advanced analytic methods. The strategies described for each component are not exhaustive; rather, they suggest promising avenues for research that can lead to more effective interventions and deeper understanding of how, and for whom, an intervention works.

CONCLUSIONS

The application of experimental therapeutics in psychiatric services research can lead to increased development, refinement, and implementation of effective interventions for specific populations or conditions.

The Role of Peer Support in Recovery from Psychiatric Symptoms: A Moderation Analysis

Social support theory has been postulated as underlying peer support and recovery programs. However, there is limited understanding of the underlying theoretical mechanism of peer support and recovery programs. The current study examines how the relationship between psychiatric symptoms and personal recovery depends on social support, as well as assessing the level at which social support influences personal recovery. A sample of 65 adults in a peer support and recovery program were surveyed in a northeastern city in the U.S. The interaction between psychiatric symptoms and peer support on recovery was significant. When peer support is low or average, there is a significant positive relationship between psychiatric symptoms and recovery. There was no significant relationship between psychiatric symptoms and recovery when peer support was high. Peer support and recovery programs may have to assess the level of support needed and tailor the support to the recovery needs.

Recovery beyond clinical improvement - Recovery outcomes measured for people with bipolar disorder between 1980 and 2020

BACKGROUND

Outcome measurement in bipolar disorder (BD) traditionally focused on clinical improvement without considering other domains. Improvement trajectories in clinical and social-functional domains are different and can simultaneously appear in one while not in other domains. Measuring personal recovery (PR) has become a priority internationally. This review explored the shift in research investigating operational recovery definitions and underpinning factors of recovery in BD over the past four decades.

METHODS

Studies defining recovery domains (other than clinical recovery) in BD were systematically reviewed; operational recovery definitions and factors assessed in association with recovery were thematically categorised and integrated in a narrative synthesis.

RESULTS

Thirty-three studies, comprising 3638 participants from 19 countries were included. Identified operational recovery definition themes included i) PR ii) social-functional (SFR), and iii) occupational-residential (ORR) recovery. Examined factors were grouped as demographic, clinical and psychosocial factors. Predominantly demographic factors were linked to ORR and clinical factors to SFR. Depressive symptomatology was the only clinical factor associated with PR. Research investigating psychosocial factors in PR is emerging and has showed that resilience and appraisals of mood seem to be associated with PR.

LIMITATIONS

Studies not available in English or examining functioning without defining recovery were excluded.

CONCLUSIONS

Earlier operational recovery definitions of ORR and SFR were often arbitrary and inconsistent, and predominantly focused on clinical and demographic underpinning factors. While research attempts to follow the significant policy shifts towards personalised care by measuring what matters to individuals and exploring broader underpinning psychosocial factors, it is still lagging behind.

The interplay between psychopathological symptoms: transdiagnostic cross-lagged panel network model

BACKGROUND

Recent paradigm shifts suggest that psychopathology manifests through dynamic interactions between individual symptoms.

AIMS

To investigate the longitudinal relationships between symptoms in a transdiagnostic sample of patients with psychiatric disorders.

METHOD

A two-wave, cross-lagged panel network model of 15 nodes representing symptoms of depression, (social) anxiety and attenuated psychotic symptoms was estimated, using baseline and 1-year follow-up data of 222 individuals with psychiatric disorders. Centrality indices were calculated to determine important predictors and outcomes.

RESULTS

Our results demonstrated that the strongest relationships in the network were between (a) more suicidal ideation predicting more negative self-view, and (b) autoregressive relationships of social anxiety symptoms positively reinforcing themselves. Negative self-view was the most predictable node in the network as it had the highest 'in-expected influence' centrality, and may be an important transdiagnostic outcome symptom.

CONCLUSIONS

The results give insight into longitudinal interactions between symptoms, which interact in ways that do not adhere to broader diagnostic categories. Our results suggest that self-view can also be a transdiagnostic outcome of psychopathology rather than just a predictor, as is normally posited, and may especially have an important relationship with suicidal ideation. Overall, our study demonstrates the dynamic complexity of psychopathology, and further supports the importance of investigating symptom interactions of different psychopathological dimensions over time and across disorders.

Measuring mental health recovery: Cross-cultural adaptation of the 15-item Questionnaire about the Process of Recovery in Spain (QPR-15-SP)

Mental health services need reliable and valid instruments to measure mental health recovery outcomes, and the only available one in Spanish is arduous. Adapting an instrument is more efficient than creating a new one as it enables international comparison research. The aim of this study was to conduct a cross-cultural adaptation of the 15-item Questionnaire about the Process of Recovery. Fifty-four participants engaged in a five-stage systematic and standardized process carried out from November 2019 to November 2020. Professional translators (n = 4) from the Translation Service Center for Foreign Languages of the Universidad de Alcalá participated in the direct translation, synthesis and back translation stages, and mental health professionals (n = 33) and service users (n = 17) from the Hospital Regional Universitario de Málaga and the Hospital Universitario Virgen de la Victoria in Andalucía (Spain), with an average of 19.2 (SD 12.86) years of experience in mental health, participated in the committee of experts and pilot debriefing stages. Additionally, legibility was assessed. Out of the 15-items of the questionnaire, three (20%) were equal amongst translations, three items (20%) of the back translations matched the original questionnaire and discrepancies identified were adapted accordingly. Seven items (46.7%) were approved online by experts and consensus of alternative translations was reached for the rest. The average time spent completing the questionnaire by service users during the face-to-face pilot was 4.12 min (SD 2.25). Internal consistency obtained was ω = 0.95 and α = 0.91. Debriefing findings reported the questionnaire as comprehensible (97.1%), adequate in wording (91.2%), formal in language (55.9%) and adequate in terms of length (100%). The questionnaire scored 65.53, 'normal' readability, on the Inflesz scale. The adapted instrument has conceptual, linguistic, cultural and metric equivalence to the original instrument.

'It was the deepest level of companionship': peer-to-peer experience of supporting community-dwelling older people with depression - a qualitative study

BACKGROUND

There is an ample body of literature examining the experiences and outcomes of peer support services for mental health recovery in western countries. However, formal peer support is only recently adapted and piloted to alleviate depression among older people, and little is known about how the peer-to-peer model might be lived out in the older Chinese population. This qualitative study investigated peer supporters' (PS) perspectives of their roles and experiences of rendering formal peer support to community-dwelling older adults at risk of or living with depression in Hong Kong.

METHODS

The study adopted a qualitative design. Five semi-structured focus groups were conducted with 27 trained peer supporters between ages 54-74 (21 females and 6 males) who had provided peer-to-peer support to older adults at risk of or living with depression in the community for at least 12 months. Thematic analysis was employed to derive content and meanings from the focus group transcripts.

RESULTS

Participants' mean age was 61.9 years; two-thirds of them were retired and the rest still engaged in part-time or full-time employment. Four themes were identified in relations to the roles and experiences in rendering the peer support services: (1) peerness in health and age-related lived experiences; (2) companionship, social and emotional ties beyond formal support; (3) meaningful roles to facilitate older people's functional ability; and (4) hopes and actions against the undesirable outcomes of aging. Being a PS might provide meaningful roles for persons in transition to or living in late adulthood, and enable community-dwelling older adults with depression to maintain functional ability. On the other hand, defining the concept of 'peer' beyond the shared experience of mental distress, ensuring a healthy boundary between the peers and the service users, maintaining a careful balance between time-limited formal support and stable social ties, and providing self-management training and on-going support appear crucial.

CONCLUSIONS

This study of PS' perspectives and experiences offer insights into the age-specific dimension of the peer relationship. Despite the promising effects it might offer, careful implementation of peer support among older adults is warranted to safeguard against the ensuing loss of meaningful social ties and the potential emotional distress.

The significant mediators between depression and mental health recovery among community-dwelling people with a diagnosed mental disorder

To investigate the mediating roles of community integration and positive thinking on the relationship between depression and mental health recovery among community dwelling people with mental disorders in South Korea. A cross-sectional, descriptive study was utilized. Data were collected from 167 community-dwelling people with mental disorders who did not use the day program at community mental health centers. Data were collected from November 20, 2018, to February 15, 2019. Both community integration and positive thinking were found to mediate the effects of depression on mental health recovery. The mediating effect of positive thinking was significantly greater than that of community integration. This study added evidence for a significant multiple mediating effect of community integration and positive thinking on the relationship between depression and mental health recovery in community-dwelling people with mental disorders. Although the consumer-centered recovery paradigm of people with mental health difficulties is of global importance, little research has been conducted on mental health recovery among community-dwelling people with mental disorders who do not use the day program at community mental health centers. It was found that community integration and positive thinking mediated the effects of depression on mental health recovery, with positive thinking mediating this relationship the most. Thus, these results suggest a specific direction of community mental health services to promote mental health recovery for people with mental disorders who do not have access to community mental health services.

Part III: Recovery-Oriented Practices in Community Mental Health and Substance Abuse Services: A Meta-Synthesis

In recent decades, recovery-oriented practice has become the major approach in mental health and substance abuse care, especially in community mental health and substance abuse services. Various models of recovery-oriented practice have come to form the basis of the integration of this approach in service settings. The study aims to elucidate the characteristics of recovery-oriented practice as experienced by participants in the practice. The method used was a qualitative meta-synthesis that integrated the findings from thirty-four empirical papers published by one research group. Four meta-themes were developed: (a) helping and supporting, (b) collaborating and relating, (c) identity integration in practice, and (d) generating hope through nurturing and helping. These themes emphasize the value of relationships and connectedness, contextuality, and resources that can be mobilized in practice. The results emphasize the need to incorporate the elements in the four major themes as “working capital” for practitioners to realize recovery-oriented practice. The concepts of personal, social, and economic capital as working capital are elaborated, drawing from the meta-themes as the basis for recovery-oriented practice in mental health and substance abuse services.

Why Do People with Severe Mental Illness Have Poor Cardiovascular Health?-The Need for Implementing a Recovery-Based Self-Management Approach

People with severe mental illness (SMI) die significantly earlier than their well counterparts, mainly due to preventable chronic conditions such as cardiovascular disease (CVD). Based on the existing research, this perspective paper summarises the key contributors to CVD in people with SMI to better target the areas that require more attention to reduce, and ultimately resolve this health inequity. We discuss five broad factors that, according to current international evidence, are believed to be implicated in the development and maintenance of CVD in people with SMI: (1) bio-psychological and lifestyle-related factors; (2) socio-environmental factors; (3) health system-related factors; (4) service culture and practice-related factors; and (5) research-related gaps on how to improve the cardiovascular health of those with SMI. This perspective paper identifies that CVD in people with SMI is a multi-faceted problem involving a range of risk factors. Furthermore, existing chronic care or clinical recovery models alone are insufficient to address this complex problem, and none of these models have identified the significant roles that family caregivers play in improving a person’s self-management behaviours. A new framework is proposed to resolve this complex health issue that warrants a collaborative approach within and between different health and social care sectors.

Designed and created for a veteran by a veteran: A pilot study of caring cards for suicide prevention

INTRODUCTION

This pilot study investigates feasibility and acceptability of Caring Cards, a suicide prevention intervention inspired by Caring Contacts and the Recovery Model, where Veteran peers create cards that are sent to Veterans recently discharged from a VA psychiatric hospitalization for suicide risk.

METHODS

Caring Cards consists of: (1) a weekly outpatient group where Veterans (card makers) create cards, and (2) sending cards to recently discharged Veterans (card recipients). Feasibility for card makers was measured by attendance; acceptability (satisfaction) was examined. Card recipients were sent one caring card, one week post-discharge. Feasibility for recipients was measured by the percentage of Veterans that met eligibility and follow-up response rate; acceptability (satisfaction) was examined.

RESULTS

Caring Cards is feasible and acceptable. The outpatient group had a higher attendance rate (81%) compared with other clinic groups. The percentage of eligible card recipients was 61%. Of these, 69% were reached for follow-up and 50% provided follow-up responses. Card makers and recipients both expressed positive experiences with Caring Cards.

CONCLUSION

Caring Cards is a low-intensity, feasible, and acceptable intervention with potential benefits for both Veteran card makers and recipients. Additional research is needed to determine the efficacy of Caring Cards as a suicide prevention intervention.

A journey of living well: a participatory photovoice study exploring recovery and everyday activities with people experiencing mental illness

BACKGROUND AND AIM

Engagement in everyday activities has been identified as an important element in personal recovery from the experience of mental illness and a key priority for service-users. This study explored the role of everyday activities in recovery.

METHOD

This study used a photovoice participatory research. Twenty-one participants experiencing mental illness were recruited from a community-managed mental health service in Melbourne, Australia. Data collection included individual interviews and photovoice courses. The courses included group discussions and required participants to take photographs about their everyday activities that support recovery. A lived experience co-facilitator contributed to development and delivery of the course. The interviews and group discussions were transcribed verbatim and analysed using constant comparative methods.

RESULTS

Recovery as a "journey of living well" was identified as the central theme that encompasses three interlinked categories: (1) living a life on hold; (2) choosing to recover; and (3) learning and navigating strategies.

CONCLUSIONS

The findings suggest that recovery involves a range of experiences embedded in people's everyday lives. Recovery-oriented practice should provide opportunities for engagement in meaningful activities, to help consumers identify their potential and strategies to live well, and to adopt co-production at all levels.

PhotoVoice: An Ideal Methodology for Use within Recovery-Oriented Mental Health Research

At the heart of recovery-orientated mental health care and the Patient and Public Involvement (PPI) movement, is the inclusion of experts by experience as collaborators on mental health research projects. However, embedding Public and Patient Involvement (PPI) can be challenging in academic institutions that have long-standing researcher-as-expert structures in place. PhotoVoice is a collaborative, participant-centric community-based methodology that has potential to overcome some of the challenges encountered within Public and Patient Involvement (PPI). This discursive paper describes what PhotoVoice is, why it was developed, it's application in research and its alignment to recovery principles. Thereby arguing that PhotoVoice is an ideal methodology for use within recovery-orientated research.

Factors influencing the implementation of mental health recovery into services: a systematic mixed studies review

BACKGROUND

Countries around the world have committed in policy to transforming their mental health services towards a recovery orientation. How has mental health recovery been implemented into services for adults, and what factors influence the implementation of recovery-oriented services?

METHODS

This systematic mixed studies review followed a convergent qualitative synthesis design and used the best-fit framework synthesis method. Librarians ran searches in Ovid- MEDLINE, Ovid-EMBASE, Ovid-PsycInfo, EBSCO-CINAHL Plus with Full Text, ProQuest Dissertations and Theses, Cochrane Library, and Scopus. Two reviewers independently screened studies for inclusion or exclusion using DistillerSR. Qualitative, quantitative, and mixed methods peer-reviewed studies published since 1998 were included if they reported a new effort to transform adult mental health services towards a recovery orientation, and reported findings related to implementation experience, process, or factors. Data was extracted in NVivo12 to the 38 constructs of the Consolidated Framework for Implementation Research (CFIR). The synthesis included a within-case and a cross-case thematic analysis of data coded to each CFIR construct. Cases were types of recovery-oriented innovations.

RESULTS

Seventy studies met our inclusion criteria. These were grouped into seven types of recovery-oriented innovations (cases) for within-case and cross-case synthesis. Themes illustrating common implementation factors across innovations are presented by CFIR domain: Intervention Characteristics (flexibility, relationship building, lived experience); Inner Setting (traditional biomedical vs. recovery-oriented approach, the importance of organizational and policy commitment to recovery-transformation, staff turnover, lack of resources to support personal recovery goals, information gaps about new roles and procedures, interpersonal relationships), Characteristics of Individuals (variability in knowledge about recovery, characteristics of recovery-oriented service providers); Process (the importance of planning, early and continuous engagement with stakeholders). Very little data from included studies was extracted to the outer setting domain, and therefore, we present only some initial observations and note that further research on outer setting implementation factors is needed.

CONCLUSION

The CFIR required some adaptation for use as an implementation framework in this review. The common implementation factors presented are an important starting point for stakeholders to consider when implementing recovery-oriented services.

Exploration of recovery of people living with severe mental illness (SMI) in low/middle-income countries (LMICs): a scoping review

OBJECTIVE

To examine the literature on how recovery of people with severe mental illness (SMI) is conceptualised in low/middle-income countries (LMICs), and in particular what factors are thought to facilitate recovery.

DESIGN

Scoping review.

DATA SOURCES AND ELIGIBILITY

We searched 14 electronic databases, hand searched citations and consulted with experts during the period May-December 2019. Eligible studies were independently screened for inclusion and exclusion by two reviewers. Unresolved discrepancies were referred to a third reviewer.

DATA EXTRACTION AND SYNTHESIS

All bibliographical data and study characteristics were extracted using a data charting form. Selected studies were analysed through a thematic analysis emerging from extracted data.

RESULTS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram offers a summary of the results: 4201 titles, 1530 abstracts and 109 full-text articles were screened. Ten articles were selected for inclusion: two from Turkey, two from India, and one each from China, Swaziland, Indonesia, Egypt, South Africa and Vietnam. Although most studies used qualitative methods, data collection and sampling methods were heterogeneous. One study reported on service provider perspectives while the rest provided perspectives from a combination of service users and caregivers. Three themes emerged from the data analysis. First, studies frame recovery as a personal journey occurring along a continuum. Second, there was an emphasis on social relationships as a facilitator of recovery. Third, spirituality emerged as both a facilitator and an indicator of recovery. These themes were not mutually exclusive and some overlap exists.

CONCLUSION

Although there were commonalities with how high-income countries describe recovery, we also found differences in conceptualisation. These differences in how recovery was understood reflect the importance of framing the personal recovery concept in relation to local needs and contextual issues found in LMICs. This review highlighted the current sparse evidence base and the need to better understand recovery from SMI in LMICs.

System-level barriers to personal recovery in mental health: qualitative analysis of co-productive narrative dialogues between users and professionals

BACKGROUND

No co-productive narrative synthesis of system-level facilitators and barriers to personal recovery in mental illness has been undertaken.

AIMS

To clarify system-level facilitators and barriers to personal recovery of people with mental illness.

METHOD

Qualitative study guided by thematic analysis. Data were collected through one focus group, which involved seven service users and three professionals. This group had 11 meetings, each lasting 2 h at a local research institute, between July 2016 to January 2018.

RESULTS

The analysis yielded three themes: barriers inhibiting positive interaction within personal relationship networks, roots of barriers from mental health systems and the social cultural context, and possible solutions to address the roots. Barriers were acknowledged as those related to sense of safety, locus of control within oneself and reunion with self. The roots of barriers were recognised within mental health services, including system without trauma sensitivity, lack of advocacy support and limited access to psychosocial approaches. Roots from social cultural context were also found. There were no narratives relating to facilitators. A possible solution was to address the roots from systems. Social cultural change was called for that makes personalised goals most valued, with an inclusive design that overcomes stigma, to achieve an open and accepting community.

CONCLUSIONS

The analysis yielded system-level barriers specific to each recovery process. Roots of barriers that need transformation to facilitate personal recovery were identified within mental health services. Social interventions should be further explored to translate the suggested social cultural changes into action.

Personal Recovery in People With a Psychotic Disorder: A Systematic Review and Meta-Analysis of Associated Factors

Background: Personal recovery (PR) is a subjective, multidimensional concept, and quantitative research using PR as an outcome is rapidly increasing. This systematic review is intended to support the design of interventions that contribute to PR in psychotic disorders, by providing an overview of associated factors and their weighted importance to PR: clinical factors, social factors, and socio-demographic characteristics are included, and factors related to the concept of PR (organized into CHIME dimensions). Methods: A systematic literature search was conducted from inception to March 2020. Quantitative studies that had used a validated questionnaire assessing the concept of PR were included. Mean effect sizes for the relationship between PR-scale total scores and related factors were calculated using meta-analyses. Sources of heterogeneity were examined using meta-regression tests. Results: Forty-six studies, that used (a total of) eight PR measures, showed that in clinical factors, affective symptoms had a medium negative association with PR-scale total scores (r = -0.44, 95%CI -0.50 to -0.37), while positive, negative and general symptoms had small negative correlations. No association was found with neuro-cognition. Social factors (support, work and housing, and functioning) showed small positive correlations. Gender and age differences had barely been researched. Large associations were found for PR-scale total scores with the CHIME dimensions hope (r = 0.56, 95%CI 0.48-0.63), meaning in life (r = 0.48, 95%CI 0.38-0.58) and empowerment (r = 0.53, 95%CI 0.42-0.63); while medium associations were found with connectedness (r = 0.34, 95%CI 0.43-0.65) and identity (r = 0.43, 95%CI 0.35-0.50). Levels of heterogeneity were high, sources included: the variety of PR measures, variations in sample characteristics, publication bias, variations in outcome measures, and cultural differences. Discussion: Most interventions in mental healthcare aim to reduce symptoms and improve functioning. With regard to stimulating PR, these interventions may benefit from also focusing on enhancing hope, empowerment, and meaning in life. The strength of these findings is limited by the challenges of comparing separate CHIME dimensions with questionnaires assessing the concept of PR, and by the high levels of heterogeneity observed. Future research should focus on the interaction between elements of PR and clinical and social factors over time.

Factors impacting the implementation of a psychoeducation intervention within the mental health system: a multisite study using the consolidation framework for implementation research

BACKGROUND

Despite a strong evidence base and policy recommendation supporting the implementation of psychoeducation interventions within the mental health system, equitable access for many service users and family members has not been achieved. To enhance translation, developing an evidence-base around the factors that influence implementation of interventions is critical.

METHODS

The aim of the study was to explore the factors influencing implementation of a group cofacilitated recovery focused psychoeducation intervention. The study design was explorative qualitative descriptive, involving the collection of data through individual and focus group interviews with key stakeholders (n = 75) involved with the implementation within 14 mental health sites in the Republic of Ireland. The Consolidation Framework for Implementation Research (CFIR) was used as a conceptual framework to guide data collection and analysis.

RESULTS

Key enablers and barriers were identified across all CFIR domains of the framework with some factors (depending on context) being both an enabler and a barrier. Important factors in the outer setting domain included structural stability within national systems and the peer payment system, while the extent of a recovery-oriented culture, leadership, implementation readiness, and buy-in were influential factors in the inner setting. The characteristics of the intervention in terms of design, evidence-base and adaptability also shaped the intervention's implementation as did the knowledge, beliefs and self-efficacy of facilitators. In terms of processes, implementation was influenced by the degree of engagement of key individuals who championed and supported the programme. The results highlight that while some of the barriers were specific to the programme, many reflected systemic and structural challenges within health services more generally.

CONCLUSION

Findings from this study provide an enhanced understanding of the different layers of determinants to implementation of an intervention. Overcoming challenges will involve positive and ongoing engagement and collaboration across the full range of stakeholders that are active within each domain, including policy and operational levels. The quality of leadership at each domain level is of crucial importance to successful implementation.

Narrative Matters: Mental health recovery - considerations when working with youth

BACKGROUND

Youth mental health and well-being is of increasing concern to practitioners and policy-makers. Youth experiencing mental health problems face many barriers in accessing care and often have different needs to those of adults experiencing mental health problems. In order to adequately respond to the needs of young people aged 12-25, it is necessary to understand, from their perspective, their diverse needs and their different realities, using a global health approach and through participation in the development of mental health services and care. There are documented difficulties in implementing a recovery-oriented practice approach that have led to misapplications, misunderstandings and critiques. That said, there is little research or discussion on mental health recovery by and for young people and young adults.

PURPOSE

To help child and adolescent mental health practitioners better assess the pertinence of the mental health recovery model in their practice, a focus on the emergence of the model can be helpful in order to adapt the current conceptions of mental health recovery for work with youth.

CONCLUSION

Child and adolescent mental health professionals might want to consider the following three suggestions - consider developmental processes, focus on hope and create strong community ties.