Victoria Bird

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

BACKGROUND No systematic review and narrative synthesis on personal recovery in mental illness has been undertaken. AIMS To synthesise published descriptions and models of personal recovery into an empirically based conceptual framework. METHOD Systematic review and modified narrative synthesis. RESULTS Out of 5208 papers that were identified and 366 that were reviewed, a total of 97 papers were included in this review. The emergent conceptual framework consists of: (a) 13 characteristics of the recovery journey; (b) five recovery processes comprising: connectedness; hope and optimism about the future; identity; meaning in life; and empowerment (giving the acronym CHIME); and (c) recovery stage descriptions which mapped onto the transtheoretical model of change. Studies that focused on recovery for individuals of Black and minority ethnic (BME) origin showed a greater emphasis on spirituality and stigma and also identified two additional themes: culturally specific facilitating factors and collectivist notions of recovery. CONCLUSIONS The conceptual framework is a theoretically defensible and robust synthesis of peoples experiences of recovery in mental illness. This provides an empirical basis for future recovery-oriented research and practice.

Early intervention services, cognitive–behavioural therapy and family intervention in early psychosis: systematic review

Background Early intervention services for psychosis aim to detect emergent symptoms, reduce the duration of untreated psychosis, and improve access to effective treatments. Aims To evaluate the effectiveness of early intervention services, cognitive–behavioural therapy (CBT) and family intervention in early psychosis. Method Systematic review and meta-analysis of randomised controlled trials of early intervention services, CBT and family intervention for people with early psychosis. Results Early intervention services reduced hospital admission, relapse rates and symptom severity, and improved access to and engagement with treatment. Used alone, family intervention reduced relapse and hospital admission rates, whereas CBT reduced the severity of symptoms with little impact on relapse or hospital admission. Conclusions For people with early psychosis, early intervention services appear to have clinically important benefits over standard care. Including CBT and family intervention within the service may contribute to improved outcomes in this critical period. The longer-term benefits of this approach and its component treatments for people with early and established psychosis need further research.

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

OBJECTIVES Recovery 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. METHODS A 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. RESULTS The 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. CONCLUSIONS A 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.

AIMS Mental 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. METHODS Update and modification of a previously published systematic review and narrative synthesis of recovery conceptualisations published in English. RESULTS A 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. CONCLUSIONS Recovery 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.

Development of action representation during adolescence

During adolescence the body undergoes many physical changes. These changes necessitate an updating of internal models of action. Here, we tested the hypothesis that internal models undergo refinement between adolescence and adulthood. We investigated the chronometry of executed and imagined hand actions, which relies on internal models, in 40 adolescents (24 males; mean age 13.1 years) and 33 adults (15 males; mean age 27.5 years). In two different motor imagery tasks, the time it took each participant to execute a hand movement was compared with the time it took them to imagine making that movement. For all participants, movement execution time significantly correlated with movement imagery time. However, there was a significant increase in the execution-imagery time correlation between adolescence and adulthood. Cognitive-motor efficiency per se did not change as indexed by both similar execution and imagery times on both tasks for the adolescents and adults. That it was only the correlation between imagined and executed actions that changed with age suggests that the developmental change was specific to generating accurate motor images and not a result of general cognitive improvement with age. The results support the notion that aspects of internal models are refined during adolescence. We suggest that this refinement may be facilitated by the development of parietal cortex during adolescence.

Determinants, self-management strategies and interventions for hope in people with mental disorders: Systematic search and narrative review

Developing a recovery focus in mental health services is a policy goal internationally, and hope is a central component of recovery. Yet determinants of hope of people with mental disorders are not well known, nor are strategies and interventions that increase hope. This study aims to systematically summarise the available evidence to fill four relevant knowledge gaps: (1) hope scales used in psychiatric research, (2) determinants of hope, (2) hope-fostering self-management strategies, and (3) interventions to increase hope for people with mental disorders. We conducted a systematic literature search in April 2011 and a narrative synthesis of publications including qualitative and quantitative studies. Results for the first time provide a comprehensive overview of existing evidence and identify important scientific knowledge gaps: (1) Hope scales used do slightly vary in focus but are overall comparable. (2) Most published research used cross-sectional designs resulting in a high number of potential determinants of hope. No studies prospectively investigated the influence of these determinants. (3) Hope fostering self-management strategies of people with mental disorders were described in qualitative studies only with experimental studies completely missing. (4) While some recovery oriented interventions were shown to increase hope as a secondary outcome, there are no successful interventions specifically aimed at increasing hope. This review provides the basis for both practical and research recommendations: The five most promising candidate interventions to improve hope in people with mental disorders are (i) collaborative strategies for illness management, (ii) fostering relationships, (iii) peer support, (iv) helping clients to assume control and to formulate and pursue realistic goals, and (v) specific interventions to support multiple positive factors such as self-esteem, self-efficacy, spirituality and well-being. These may serve to directly improve care and to develop theory-based models and testable interventions to improve hope in mental health as well as in allied fields.

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.

Case identification of depression in patients with chronic physical health problems: a diagnostic accuracy meta-analysis of 113 studies

BACKGROUND Depression is more likely in patients with chronic physical illness, and is associated with increased rates of disability and mortality. Effective treatment of depression may reduce morbidity and mortality. The use of two stem questions for case finding in diabetes and coronary heart disease is advocated in the Quality and Outcomes Framework, and has become normalised into primary care. AIM To define the most effective tool for use in consultations to detect depression in people with chronic physical illness. DESIGN Meta-analysis. METHOD The following data sources were searched: CENTRAL, CINAHL, Embase, HMIC, MEDLINE, PsycINFO, Web of Knowledge, from inception to July 2009. Three authors selected studies that examined identification tools and used an interview-based ICD (International Classification of Diseases) or DSM (Diagnostic and statistical Manual of Mental Disorders) diagnosis of depression as reference standard. At least two authors independently extracted study characteristics and outcome data and assessed methodological quality. RESULTS A total of 113 studies met the eligibility criteria, providing data on 20,826 participants. It was found that two stem questions, PHQ-9 (Patient Health Questionnaire), the Zung, and GHQ-28 (General Health Questionnaire) were the optimal measures for case identification, but no method was sufficiently accurate to recommend as a definitive case-finding tool. Limitations were the moderate-to-high heterogeneity for most scales and the facts that few studies used ICD diagnoses as the reference standard, and that a variety of methods were used to determine DSM diagnoses. CONCLUSION Assessing both validity and ease of use, the two stem questions are the preferred method. However, clinicians should not rely on the two-questions approach alone, but should be confident to engage in a more detailed clinical assessment of patients who score positively.

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.

Pharmacological interventions for people with depression and chronic physical health problems: systematic review and meta-analyses of safety and efficacy.

BACKGROUND Antidepressant drugs are widely used in the treatment of depression in people with chronic physical health problems. AIMS To examine evidence related to efficacy, tolerability and safety of antidepressants for people with depression and with chronic physical health problems. METHOD Meta-analyses of randomised controlled efficacy trials of antidepressants in depression in chronic physical health conditions. Systematic review of safety studies. RESULTS Sixty-three studies met inclusion criteria (5794 participants). In placebo-controlled studies, antidepressants showed a significant advantage in respect to remission and/or response: selective serotonin reuptake inhibitors (SSRIs) risk ratio (RR) = 0.81 (95% CI 0.73-0.91) for remission, RR = 0.83 (95% CI 0.71-0.97) for response; tricyclics RR = 0.70 (95% CI 0.40-1.25 (not significant)) for remission, RR = 0.55 (95% 0.43-0.70) for response. Both groups of drugs were less well tolerated than placebo (leaving study early due to adverse effects) for SSRIs RR = 1.80 (95% CI 1.16-2.78), for tricyclics RR = 2.00 (95% CI 0.99-3.57). Only SSRIs were shown to improve quality of life. Direct comparisons of SSRIs and tricyclics revealed no advantage for either group for remission, response, effect size or tolerability. Effectiveness studies suggest a neutral or beneficial effect on mortality for antidepressants in participants with recent myocardial infarction. CONCLUSIONS Antidepressants are efficacious and safe in the treatment of depression occurring in the context of chronic physical health problems. The SSRIs are probably the antidepressants of first choice given their demonstrable effect on quality of life and their apparent safety in cardiovascular disease.