Julie Williams

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

BACKGROUNDnNo systematic review and narrative synthesis on personal recovery in mental illness has been undertaken.nnnAIMSnTo synthesise published descriptions and models of personal recovery into an empirically based conceptual framework.nnnMETHODnSystematic review and modified narrative synthesis.nnnRESULTSnOut 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.nnnCONCLUSIONSnThe conceptual framework is a theoretically defensible and robust synthesis of peoples experiences of recovery in mental illness. This provides an empirical basis for future recovery-oriented research and practice.

What does recovery mean in practice? A qualitative analysis of international recovery-oriented practice guidance.

OBJECTIVESnRecovery is a multifaceted concept, and the need for operationalization in practice has been identified. Although guidance on recovery-oriented practice exists, it is from disparate sources and is difficult to apply. The aims of the study were to identify the key characteristics of recovery-oriented practice guidance on the basis of current international perspectives and to develop an overarching conceptual framework to aid the translation of recovery guidance into practice.nnnMETHODSnA qualitative analysis of 30 international documents offering recovery-oriented practice guidance was conducted. Inductive, semantic-level, thematic analysis was used to identify dominant themes. Interpretive analysis was then undertaken to group the themes into practice domains.nnnRESULTSnThe guidance documents were diverse; from six countries-the United States, England, Scotland, Republic of Ireland, Denmark, and New Zealand-and varied in document type, categories of guidance, and level of service user involvement in guidance development. The emerging conceptual framework consists of 16 dominant themes, grouped into four practice domains: promoting citizenship, organizational commitment, supporting personally defined recovery, and working relationship.nnnCONCLUSIONSnA key challenge for mental health services is the lack of clarity about what constitutes recovery-oriented practice. The conceptual framework contributes to this knowledge gap and provides a synthesis of recovery-oriented practice guidance.

International differences in understanding recovery: systematic review.

AIMSnMental health policy internationally varies in its support for recovery. The aims of this study were to validate an existing conceptual framework and then characterise by country the distribution, scientific foundations and emphasis in published recovery conceptualisations.nnnMETHODSnUpdate and modification of a previously published systematic review and narrative synthesis of recovery conceptualisations published in English.nnnRESULTSnA total of 7431 studies were identified and 429 full papers reviewed, from which 105 conceptualisations in 115 papers were included and quality assessed using established rating scales. Recovery conceptualisations were identified from 11 individual countries, with 95 (91%) published in English-speaking countries, primarily the USA (47%) and the UK (25%). The scientific foundation was primarily qualitative research (53%), non-systematic literature reviews (24%) and position papers (12%). The conceptual framework was validated with the 18 new papers. Across the different countries, there was a relatively similar distribution of codings for each of five key recovery processes.nnnCONCLUSIONSnRecovery as currently conceptualised in English-language publications is primarily based on qualitative studies and position papers from English-speaking countries. The conceptual framework was valid, but the development of recovery conceptualisations using a broader range of research designs within other cultures and non-majority populations is a research priority.

How much physical activity do people with schizophrenia engage in? A systematic review, comparative meta-analysis and meta-regression

OBJECTIVEnPhysical activity (PA) improves health outcomes in people with schizophrenia. It is unclear how much PA people with schizophrenia undertake and what influences PA participation. We conducted a meta-analysis to investigate PA levels and predictors in people with schizophrenia.nnnMETHODnMajor databases were searched from inception till 02/2016 for articles measuring PA (self-report questionnaire (SRQ) or objective measure (e.g. accelerometer)) in people with schizophrenia, including first episode psychosis (FEP). A random effects meta-analysis and meta-regression analysis were conducted.nnnRESULTSn35 studies representing 3453 individuals with schizophrenia (40.0years; 64.0% male) were included. Engagement in light PA was 80.44min (95% CI 68.32-92.52, n=2658), 47.1min moderate-vigorous PA (95% CI 31.5-62.8, n=559) and 1.05min (95% CI 0.48-1.62, n=2533) vigorous PA per day. People with schizophrenia engaged in significantly less moderate (hedges g=-0.45, 95% CI -0.79 to -0.1, p=0.01) and vigorous PA (g=-0.4, 95% CI -0.60 to -0.18) versus controls. Higher light to moderate, but lower vigorous PA levels were observed in outpatients and in studies utilizing objective measures versus SRQ. 56.6% (95% CI 45.8-66.8, studies=12) met the recommended 150min of moderate physical activity per week. Depressive symptoms and older age were associated with less vigorous PA in meta-regression analyses.nnnCONCLUSIONSnOur data confirm that people with schizophrenia engage in significantly less moderate and vigorous PA versus controls. Interventions aiming to increase PA, regardless of intensity are indicated for people with schizophrenia, while specifically increasing moderate-vigorous PA should be a priority given the established health benefits.

How sedentary are people with psychosis? A systematic review and meta-analysis

OBJECTIVEnSedentary behavior (SB) is an independent risk factor for cardiovascular disease and mortality. We conducted a meta-analysis to investigate SB levels and predictors in people with psychosis.nnnMETHODnMajor electronic databases were searched from inception till 09/2015 for articles measuring SB with a self-report questionnaire (SRQ) or objective measure (e.g. accelerometer) in people with psychosis, including schizophrenia spectrum and bipolar disorders. A random effects meta-analysis and meta regression analysis were conducted.nnnRESULTSnThirteen studies were eligible including 2033 people with psychosis (mean age 41.3years (range 25.1-60), 63.2% male (range 35-89%), body mass index 28.7 (range 25.9-32.1). The trim and fill analysis demonstrated people with psychosis spent 660.8min (95% CI 523.2-798.4, participants=2033) or 11.0h (95% CI 8.72-13.3) per day being sedentary. Objective measures of SB recorded significantly higher levels (p<0.001) of SB (12.6h per day, 95% CI 8.97-16.2, studies=7, participants=254) compared to self-report SB (6.85h per day, 95% CI 4.75-8.96, studies=6, participants=1779). People with psychosis engaged in significantly more SB than controls (g=1.13, 95% CI 0.496-1.77, P<0.001, n psychosis=216, n controls=159) equating to a mean difference of 2.80 (95% CI 1.47-4.1) hours per day. Multivariate meta-regression confirmed that objective measurement of SB predicted higher levels of sedentariness.nnnCONCLUSIONSnPeople with psychosis engage in very high levels of sedentary behavior in their waking day and current SRQ may underestimate SB. Given that SB is an independent predictor of cardiovascular disease, future interventions specifically targeting the prevention of SB are warranted.

Measures of Personal Recovery: A Systematic Review

OBJECTIVE Mental health systems internationally have adopted a goal of supporting recovery. Measurement of the experience of recovery is, therefore, a priority. The aim of this review was to identify and analyze recovery measures in relation to their fit with recovery and their psychometric adequacy. METHODS A systematic search of six data sources for articles, Web-based material, and conference presentations related to measurement of recovery was conducted by using a defined search strategy. Results were filtered by title and by abstract (by two raters in the case of abstracts), and the remaining papers were reviewed to identify any suitable measures of recovery. Measures were then evaluated for their fit with the recovery processes identified in the CHIME framework (connectedness, hope, identity, meaning, and empowerment) and for demonstration of nine predefined psychometric properties. RESULTS Thirteen measures of personal recovery were identified from 336 abstracts and 35 articles. The Recovery Assessment Scale (RAS) was published most, and the Questionnaire About the Process of Recovery (QPR) was the only measure to have all items map to the CHIME framework. No measure demonstrated all nine psychometric properties. The Stages of Recovery Instrument demonstrated the most psychometric properties (N=6), followed by the Maryland Assessment of Recovery (N=5), and the QPR and the RAS (N=4). Criterion validity, responsiveness, and feasibility were particularly underinvestigated properties. CONCLUSIONS No recovery measure can currently be unequivocally recommended, although the QPR most closely maps to the CHIME framework of recovery and the RAS is most widely published.

Measures of the recovery orientation of mental health services: systematic review

PurposeThe review aimed to (1) identify measures that assess the recovery orientation of services; (2) discuss how these measures have conceptualised recovery, and (3) characterise their psychometric properties.MethodsA systematic review was undertaken using seven sources. The conceptualisation of recovery within each measure was investigated by rating items against a conceptual framework of recovery comprising five recovery processes: connectedness; hope and optimism; identity; meaning and purpose; and empowerment. Psychometric properties of measures were evaluated using quality criteria.ResultsThirteen recovery orientation measures were identified, of which six met eligibility criteria. No measure was a good fit with the conceptual framework. No measure had undergone extensive psychometric testing and none had data on test–retest reliability or sensitivity to change.ConclusionsMany measures have been developed to assess the recovery orientation of services. Comparisons between the measures were hampered by the different conceptualisations of recovery used and by the lack of uniformity on the level of organisation at which services were assessed. This situation makes it a challenge for services and researchers to make an informed choice on which measure to use. Further work is needed to produce measures with a transparent conceptual underpinning and demonstrated psychometric properties.

Recovery grows up

Health Service and Population Research Department, Institute of Psychiatry, London, UKIntroductionRecovery has come of age. The recoveryapproach has gained traction in mental health policythroughout the English-speaking world, and – at least rhetorically – within mental healthsystems internationally (Slade et al., 2008). But with age comes responsibility. An idea caninitiate change, but that change must work in practice if it is to be sustained.This special issue on recovery marks a shift from ideology to empirical investigation. Thestudies report dataaddressingimportant questions.Webeginbyidentifying someideologicalstatements made by recovery proponents, and reviewing recent evidence relating to thesebeliefs. We then consider some of the scientific challenges in investigating recovery.“Recovery is a process, not just an outcome”A valid understanding of recovery must be grounded in lived experience. Todd and col-leagues (2012) explore the meaning of recovery for people with bipolar disorder, adding togrowingevidence basedonself-managementinthisgroup(Jones etal.,2011).Theirfindingsmake clear that the key dimensions of personal recovery differ from traditional clinicalpreoccupations.To clarify what personal recovery means, a systematic review was undertaken to collateand synthesise published frameworks and models of recovery (Leamy et al., 2011). A totalof 97 papers from 13 different countries which offered new conceptualisations of recoverywere identified. The types of papers included qualitative studies, narrative literaturereviews, book chapters, consultation documents reporting the use of consensus methods,opinion pieces, editorials, quantitative studies, as well as papers which combined differentmethods.Empirical studies recruited participants from a range of settings including commu-nity mental health teams and facilities, self-help groups, consumer-operated mental healthservices and supported housing facilities. The majority of studies used inclusion criteriathat covered any diagnosis of severe mental illness.A modified narrative synthesis of these papers showed that recovery can be thought of (a)as a journey which varies from one person to another, (b) as inter-linking sets of processes,

REFOCUS Trial: protocol for a cluster randomised controlled trial of a pro-recovery intervention within community based mental health teams

BackgroundThere is a consensus about the importance of recovery in mental health services, but the evidence base is limited.Methods/DesignA two centre, cluster randomised controlled trial. Participants are community-based mental health teams, and service users aged 18-65 years with a primary clinical diagnosis of psychosis. In relation to the REFOCUS Manual researchintorecovery.com/refocus, which describes a 12-month, pro-recovery intervention based on the REFOCUS Model, the objectives are: (1) To establish the effectiveness of the intervention described in the REFOCUS Manual; (2) To validate the REFOCUS Model; (3) To establish and optimise trial parameters for the REFOCUS Manual; and (4) To understand the relationship between clinical outcomes and recovery outcomes. The hypothesis for the main study is that service users in the intervention arm will experience significantly greater increases in measures of personal recovery (as measured by the QPR) compared to service users receiving care from control teams. The hypothesis for the secondary study is that black service users in the intervention arm will experience significantly greater increases in measures of personal recovery (as measured by the QPR) and client satisfaction (as measured by the CSQ) compared to Black service users receiving care from control teams.The intervention comprises treatment as usual plus two components: recovery-promoting relationships and working practices. The control condition is treatment as usual. The primary outcme is the Process of Recovery Questionnaire (QPR). Secondary outcomes are satisfaction, Goal setting - Personal Primary Outcome, hope, well-being, empowerment, and quality of life. Primary outcomes for the secondary study will be QPR and satisfaction. Cost data will be estimated, and clinical outcomes will also be reported (symptomatology, need, social disability, functioning).29 teams (15 intervention and 14 control) will be randomised. Within each team, 15 services users will be randomly chosen, giving a total sample of 435 service users (225 in intervention and 210 in control). Power for the main study: 336 service users will give power to detect a medium effect size of 0.4 (alpha 0.05, power = 0.8) on both QPR sub-scales. Power for the secondary study: 89 participants will give power to detect an effect size of 0.67 on both QPR sub-scales and on CSQ. A range of approaches are used to minimise bias, although service users and clinicians cannot be blinded.DiscussionThis cluster-RCT will evaluate a pro-recovery intervention in community mental health teams.Trial registrationISRCTN: ISRCTN02507940

Supporting recovery in patients with psychosis through care by community-based adult mental health teams (REFOCUS): a multisite, cluster, randomised, controlled trial

BACKGROUNDnMental health policy in many countries is oriented around recovery, but the evidence base for service-level recovery-promotion interventions is lacking.nnnMETHODSnWe did a cluster, randomised, controlled trial in two National Health Service Trusts in England. REFOCUS is a 1-year team-level intervention targeting staff behaviour to increase focus on values, preferences, strengths, and goals of patients with psychosis, and staff-patient relationships, through coaching and partnership. Between April, 2011, and May, 2012, community-based adult mental health teams were randomly allocated to provide usual treatment plus REFOCUS or usual treatment alone (control). Baseline and 1-year follow-up outcomes were assessed in randomly selected patients. The primary outcome was recovery and was assessed with the Questionnaire about Processes of Recovery (QPR). We also calculated overall service costs. We used multiple imputation to estimate missing data, and the imputation model captured clustering at the team level. Analysis was by intention to treat. This trial is registered, number ISRCTN02507940.nnnFINDINGSn14 teams were included in the REFOCUS group and 13 in the control group. Outcomes were assessed in 403 patients (88% of the target sample) at baseline and in 297 at 1 year. Mean QPR total scores did not differ between the two groups (REFOCUS group 40·6 [SD 10·1] vs control 40·0 [10·2], adjusted difference 0·68, 95% CI -1·7 to 3·1, p=0·58). High team participation was associated with higher staff-rated scores for recovery-promotion behaviour change (adjusted difference -0·4, 95% CI -0·7 to -0·2, p=0·001) and patient-rated QPR interpersonal scores (-1·6, -2·7 to -0·5, p=0·005) at follow-up than low participation. Patients treated in the REFOCUS group incurred £1062 (95% CI -1103 to 3017) lower adjusted costs than those in the control group.nnnINTERPRETATIONnAlthough the primary endpoint was negative, supporting recovery might, from the staff perspective, improve functioning and reduce needs. Implementation of REFOCUS could increase staff recovery-promotion behaviours and improve patient-rated recovery.nnnFUNDINGnNational Institute for Health Research.