14. Recovery: the business case

This paper makes the Business Case for supporting recovery. We believe that this should be informed by three types of data: evaluative research (such as randomised controlled trials); the perceived benefits for service users – what might be termed ‘customer satisfaction’; and best evidence about value for money. Some of the ImROC 10 key challenges have a very strong research base. For example, there is substantially more randomised controlled trial evidence supporting the value of peer support workers (challenge 8) than exists for any other mental health professional group, or service model. Similarly, the scientific evidence for supporting self-management (challenge 1) is compelling. Other challenges have a strong evidence base indicating that they improve people’s experience of services. The positive experiences of students at Recovery Colleges (challenge 3) and the beneficial impact on experience of more involvement in safety planning (challenge 6) are clear

Mental illness and well-being:the central importance of positive psychology and recovery approaches

Background: A new evidence base is emerging, which focuses on well-being. This makes it possible for health services to orientate around promoting well-being as well as treating illness, and so to make a reality of the long-standing rhetoric that health is more than the absence of illness. The aim of this paper is to support the re-orientation of health services around promoting well-being. Mental health services are used as an example to illustrate the new knowledge skills which will be needed by health professionals.Discussion: New forms of evidence give a triangulated understanding about the promotion of well-being in mental health services. The academic discipline of positive psychology is developing evidence-based interventions to improve well-being. This complements the results emerging from synthesising narratives about recovery from mental illness, which provide ecologically valid insights into the processes by which people experiencing mental illness can develop a purposeful and meaningful life. The implications for health professionals are explored. In relation to working with individuals, more emphasis on the person's own goals and strengths will be needed, with integration of interventions which promote well-being into routine clinical practice. In addition, a more societally-focussed role for professionals is envisaged, in which a central part of the job is to influence local and national policies and practices that impact on well-being.Summary: If health services are to give primacy to increasing well-being, rather than to treating illness, then health workers need new approaches to working with individuals. For mental health services, this will involve the incorporation of emerging knowledge from recovery and from positive psychology into education and training for all mental health professionals, and changes to some long-established working practices

Measuring Recovery in Mental Health Services

An international policy goal is to orientate mental health services around the support of "recovery": the development of new meaning and purpose in one's life, irrespective of the presence or absence of symptoms of mental illness. Current progress towards a recovery orientation in mental health services is summarized, indicating that pro-recovery policy is in advance of both scientific evidence and clinical practice. Key evaluation challenges are outlined, and indicators of a recovery focus are described. These include quality standards, consumer-clinician interaction styles, and belief and discourse markers. This underpins a proposal for a new approach to service evaluation, which combines attainment of objectively-valued social roles and of subjective-valued personal goals. This approach has applicability as a methodology both for clinical trials and routine practice

Everyday Solutions for Everyday Problems:How Mental Health Systems Can Support Recovery

People who experience mental illness can be viewed as either fundamentally different than, or fundamentally like, everyone else in society. Recovery-oriented mental health systems focus on commonality. In practice, this involves an orientation toward supporting everyday solutions for everyday problems rather than providing specialist treatments for mental illness related problems. This change is evident in relation to help offered with housing, employment, relationships, and spirituality. Interventions may contribute to the process of striving for a life worth living, but they are a means, not an end. Mental health systems that offer treatments in support of an individual's life goals are very different than those that treat patients in their best interests. The strongest contribution of mental health services to recovery is to support everyday solutions to everyday problems. </p

Impact of supported employment on service costs and income of people with mental health needs

Background: A 12-month study of UK supported employment providers found that 77 (54.6%) of the participants in the study remained unemployed, 32 (22.7%) got jobs and 32 (22.7%) retained the jobs they held at the outset. Aims: To explore the impact of moving into employment on service use, earnings, benefits and tax allowances claimed. Methods: Service use and frequency were measured at baseline and 12 months. Comparisons paid particular attention to the differences between people entering work and those who remained unemployed. Costs were analysed from a government perspective (excluding earnings) and a societal perspective (excluding welfare benefits and taxes). Results: People who entered work reduced their consumption of mental health services (p<0.001). However, use of supported employment increased (p=0.04), in contrast to falling use by people who remained unemployed (p<0.001) and those who had been working for more than one year (p=0.002). The increase in earnings for those entering work (p=0.02) was not offset by a similar reduction in benefits. Conclusion: This indicates that mental health services may make savings as a result of their clients engaging in paid work. It raises questions about the optimal nature and organization of employment support for this service user group

Development and evaluation of an Individualised Outcome Measure (IOM) for randomised controlled trials in mental health

Predefined, researcher-selected outcomes are routinely used as the clinical end-point in randomised controlled trials (RCTs); however, individualised approaches may be an effective way to assess outcome in mental health research. The present study describes the development and evaluation of the Individualised Outcome Measure (IOM), which is a patient-specific outcome measure to be used for RCTs of complex interventions. IOM was developed using a narrative review, expert consultation and piloting with mental health service users (n=20). The final version of IOM comprises two components: Goal Attainment (GA) and Personalised Primary Outcome (PPO). For GA, patients identify one relevant goal at baseline and rate its attainment at follow-up. For PPO, patients choose an outcome domain related to their goal from a predefined list at baseline, and complete a standardised questionnaire assessing the chosen outcome domain at baseline and follow-up. A feasibility study indicated that IOM had adequate completion (89%) and acceptability (96%) rates in a clinical sample (n=84). IOM was then evaluated in an RCT (ISRCTN02507940). GA and PPO components were associated with each other and with the trial primary outcome. The use of the PPO component of IOM as the primary outcome could be considered in future RCTs

Need for information in a representative sample of outpatients with schizophrenia disorders

Background: providing adequate information and involving patients in treatment has become an essential component of mental health care. Despite this, research regarding the extent to which this need has been met in clinical services is still scarce. Aims: To investigate the need for information about psychiatric condition and treatment among outpatients with schizophrenia disorders and how this need is associated with service use, adjusting for sociodemographic and clinical characteristics. Methods: Need for information for information about condition and treatment was assessed using the corresponding domain in the Camberwell Assessment of Need (CAN), in a representative sample of 401 schizophrenia outpatients in Santos, Brazil. Hierarchical logistic regression was used to investigate the association of information as a reported need and as an unmet need with service use variables, adjusting for sociodemographic and clinical characteristics. Results: Need for information was reported by 214 (53.4%) patients, being met in 101 (25.2%) and unmet in 113 (28.2%). Hierarchical regression indicated a significant association of a reported need with higher age of onset, family monitoring medication use last year and lower education level, which was the only associated with an unmet need. Conclusion: Information was a commonly reported need and which was often unmet, showing no significant association with service use. Greater attention should be given by mental health services to information provision

Using Peer Support in Developing Empowering Mental Health Services (UPSIDES): Background, rationale and methodology

BACKGROUND: Peers are people with lived experience of mental illness. Peer support is an established intervention in which peers offer support to others with mental illness. A large proportion of people living with severe mental illness receive no care. The care gap is largest in low- and middle-income countries, with detrimental effects on individuals and societies. The global shortage of human resources for mental health is an important driver of the care gap. Peers are an under-used resource in global mental health. OBJECTIVES: To describe rationale and methodology of an international multicentre study which will scale-up peer support for people with severe mental illness in high-, middle-, and low-income countries through mixed-methods implementation research. METHODS: UPSIDES is an international community of research and practice for peer support, including peer support workers, mental health researchers, and other relevant stakeholders in eight study sites across six countries in Europe, Africa, and Asia. During the first two years of UPSIDES, a series of qualitative studies and systematic reviews will explore stakeholders' perceptions and the current state of peer support at each site. Findings will be incorporated into a conceptual framework to guide the development of a culturally appropriate peer support intervention to be piloted across all study sites. All intervention and study materials will be translated according to internationally recognised guidelines.Expected Impact: UPSIDES: will leverage the unique expertise of people with lived experience of mental illness to strengthen mental health systems in high-, middle- and low-income countries. UPSIDES will actively involve and empower service users and embed patient-centeredness, recovery orientation, human rights approaches, and community participation into services. The focus on capacity-building of peers may prove particularly valuable in low-resource settings in which shortages of human capital are most severe.https://agh.ubiquitypress.com/articles/10.5334/aogh.2435