BACKGROUND/RATIONALE:
The President's New Freedom Commission on Mental Health has called for a transformation of the mental health system to partner with consumers of those services in delivering effective interventions focused on recovery, and the Department of Veterans Affairs (VA) has developed a Mental Health Strategic Plan to address these recommendations. One promising approach is to implement Illness Management and Recovery (IMR), a structured curriculum to help mental health consumers manage their illnesses and pursue goals related to recovery from mental illness. Although IMR is based on practices shown to be effective in controlled research, effectiveness of the comprehensive package of IMR has only been studied in 3 randomized trials. None of those trials included an active attention control, and none of them were focused on veterans.

OBJECTIVE(S):
Although IMR is based on practices shown to be effective in controlled research, effectiveness of the comprehensive package of IMR has been demonstrated in only three randomized, controlled trials. Each of those had a weak control group (treatment as usual) and none included veterans. The primary objective of this study was to test the effectiveness of IMR in veterans with schizophrenia or schizoaffective disorder, compared to an active control group (problem solving intervention). Our primary focus was to examine the impact of the IMR intervention on consumer outcomes related to illness self-management and recovery.

METHODS:
This was a randomized, controlled trial comparing IMR to a problem solving group, in the context of ongoing usual mental health treatment in veterans with schizophrenia or schizoaffective disorder. Assessment included semi-structured interviews and standardized measures at baseline, 9 months, and 18 months to assess illness self-management (e.g., symptoms), objective indicators of recovery (e.g., role functioning), and subjective indicators of recovery (e.g., perceptions of well-being). Assessments included client self-report as well as interviewer, clinician, and informant ratings. In addition, electronic medical records were accessed to determine the impact of IMR on other service utilization (inpatient and emergency services). Fidelity of the intervention was assessed with a newly developed scale - the IMR Treatment Integrity Scale (IT-IS).

FINDINGS/RESULTS:
Recruitment was more difficult than expected. We were unable to recruit the target of 200 veterans with schizophrenia/schizoaffective disorder in the time frame allotted. We expanded recruitment to a local community mental health center and were able to recruit and randomize 118 consumers to either IMR or a problem solving group. Attendance rates for both groups were low. Of those randomized to IMR, the mean attendance was 25% of total sessions, with 14% of the sample attending no IMR groups. For problem solving groups, the mean attendance was 19% of total sessions, with 21% of the sample attending no problem solving groups.

We developed the IT-IS instrument to be able to assess the degree to which the groups in the study were following the IMR model (McGuire et al., in press). Working with Kim Mueser, developer of IMR, we created a 13-item scale (with 3 optional items) to be completed by trained raters on the basis of audiotaped sessions. Independent raters scored tapes of IMR (n = 60) and the problem solving group (n = 20). The IT-IS showed excellent inter-rater reliability. A factor analysis supported a one-factor model with good internal consistency. The scale successfully differentiated between IMR and problem solving groups.

Follow-up interviews at 9 months were completed with 81 participants. Initial analyses focused on comparing groups (as randomized) between baseline and nine months using repeated measures analyses of variance (ANOVAs). There were significant time effects for improvement in symptoms as rated by interviews using the Positive and Negative Syndrome Scale (PANSS), F (1,79) = 23.95, p < .001. The total sample improved from a mean of 75.4 (16.2) to a mean of 67.6 (17.0). There were trends (p = .09) for improvements over time in client self ratings of illness management and recovery (IMR rating scale) and the recovery assessment scale. However, there were no groupXtime interactions.

IMPACT:
Preliminary outcomes suggest that while consumers showed improvements over time, there may not be a significant advantage for IMR over a problem-solving intervention. Future analyses are needed to better understand potential impact on service utilization, and reasons for lack of attendance and the impact that may have on consumer outcome. One important product from this work is the development of a psychometrically sound clinician-level fidelity scale that can be used for training and monitoring in the implementation of IMR.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Tsai J, Salyers MP, McGuire AB. A cross-sectional study of recovery training and staff attitudes in four community mental health centers. Psychiatric Rehabilitation Journal. 2011 Mar 8; 34(3):186-93. [view]
2. Salyers MP, McGuire AB, Kukla M, Fukui S, Lysaker PH, Mueser KT. A randomized controlled trial of illness management and recovery with an active control group. Psychiatric services (Washington, D.C.). 2014 Aug 1; 65(8):1005-11. [view]
3. Frankel RM, Salyers MP, Bonfils KA, Oles SK, Matthias MS. Agenda setting in psychiatric consultations: an exploratory study. Psychiatric Rehabilitation Journal. 2013 Sep 1; 36(3):195-201. [view]
4. McGuire AB, Stull LG, Mueser KT, Santos M, Mook A, Rose N, Tunze C, White LM, Salyers MP. Development and reliability of a measure of clinician competence in providing illness management and recovery. Psychiatric services (Washington, D.C.). 2012 Aug 1; 63(8):772-8. [view]
5. McGuire AB, Kukla M, Green A, Gilbride D, Mueser KT, Salyers MP. Illness management and recovery: a review of the literature. Psychiatric services (Washington, D.C.). 2014 Feb 1; 65(2):171-9. [view]
6. McGuire AB, Bonfils KA, Kukla M, Myers L, Salyers MP. Measuring participation in an evidence-based practice: illness management and recovery group attendance. Psychiatry Research. 2013 Dec 30; 210(3):684-9. [view]
7. Matthias MS, Salyers MP, Frankel RM. Re-thinking shared decision-making: context matters. Patient education and counseling. 2013 May 1; 91(2):176-9. [view]

Center Products

1. Salyers MP, McGuire AB. Assessing IMR Fidelity. 2011 Sep 19. [view]
2. Salyers MP, McGuire AB. Training and Site Visit in Assessing IMR Fidelity. 2011 Sep 19. [view]

Conference Presentations

1. Salyers MP. ACT/IDDT: Practical Issues of Implementation. Paper presented at: Illinois Department of Human Services, Division of Mental Health / Illinois Mental Health Collaborative for Access and Choice Evidence Based Practices Conference; 2010 Apr 22; Champaign, IL. [view]
2. Salyers MP. Illness Management and Recovery. Paper presented at: Behavioral Health Institute Summer Assembly; 2011 Aug 18; Hot Springs, AR. [view]
3. Salyers MP. Illness Management and Recovery Workshop: Implementing in the Netherlands. Paper presented at: Saxion University of Applied Sciences Assembly; 2010 May 27; Deventer, Holland. [view]
4. Salyers MP. Illness Management and Recovery: A Method for Recovery Oriented Care. Paper presented at: Saxion University of Applied Sciences Assembly; 2010 May 28; Deventer, Holland. [view]
5. Salyers MP. Implementing evidence-based practices for adults with severe mental illness. Paper presented at: Behavioral Health Institute Summer Assembly; 2011 Aug 18; Hot Springs, AR. [view]
6. Salyers MP. Implementing Supported Employment in the US. Paper presented at: Israeli Association of Psychiatric Rehabilitation Workshop; 2010 May 3; Yehud, Israel. [view]
7. Salyers MP. Ingredients of Recovery Oriented Assertive Community Treatment. Paper presented at: Illinois Department of Human Services, Division of Mental Health / Illinois Mental Health Collaborative for Access and Choice Evidence Based Practices Conference; 2010 Apr 21; Champaign, IL. [view]
8. Salyers MP. Recovery Oriented Services for Adults with Severe Mental Illness. Paper presented at: University of Haifa Assembly; 2010 May 5; Haifa, Israel. [view]

DRA: Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational
Keywords: Depression, Schizophrenia
MeSH Terms: none