Description of the condition
The term severe mental illness (SMI) is generally used to describe a condition or group of conditions that causes people to have a severe and often long-term impairment in psychological and social functioning. Although there is no internationally agreed definition of SMI, there is wide consensus regarding that of the National Institute of Mental Health (NIMH) (Schinnar 1990; Dieterich 2010). This definition is based on three criteria: i. diagnosis of non-organic psychosis or personality disorder; ii. duration, characterised as involving ’prolonged illness’ and ’long term treatment’, and operationalised as a two-year or longer history of mental illness or treatment; and iii. disability, moderate impairment in work and non-work activities, and mild impairment in basic needs (National Institute of Mental Health 1987; Ruggeri 2000). A survey conducted in Europe in 1999 put the total population-based annual prevalence of SMI at approximately two per thousand (Ruggeri 2000).
Schizophrenia is an illness heavily contributing to the numbers of people considered severely mentally ill. The median lifetime morbid risk for schizophrenia is 7.2 per 1000 persons and, generally, the prevalence of schizophrenia ranges from four to seven per 1000 persons, depending on the type of prevalence estimate used (Warner 1995; Saha 2005; McGrath 2008). Schizophrenia is responsible for 1.1% of the disability-adjusted life-years worldwide (Picchioni 2007). Although the clinical presentation of schizophrenia varies widely among affected individuals and even within the same individual at different phases of the illness, schizophrenia as per the definition of the World Health Organization (WHO) is characterised by disruptions in thinking, affecting language, perception and the sense of self. It often includes psychotic experiences and can impair functioning (WHO 2013).
Description of the intervention
Pharmacological interventions, which are used to manage symptoms, comprise the main treatment modality for people with schizophrenia and other SMI. In recent years, however, it has become clear that medication alone is not sufficient as it tends to produce only limited improvement in social functioning and quality of life (Drake 2009; Kern 2009; Dixon 2010). Psychosocial treatments that enable people with schizophrenia and other SMI to cope with the disabling aspects of their illnesses are therefore a necessary complementary intervention.
Over the past decade several systematic efforts have been made to identify evidence-based psychosocial interventions for people with schizophrenia (Drake 2009; Dixon 2010). Examples of these interventions include systematic approaches to medication management, assertive community treatment, relapse prevention programmes and supported employment (Drake 2009).
The aims of psychosocial interventions are numerous. Often they may be intended to improve one or more of the following outcomes: to decrease the person’s mental vulnerability; reduce the impact of stressful events and situations; decrease distress and disability; minimise symptoms; improve quality of life; reduce relapses; improve coping skills; and involve the person's relatives (NICE 2009).
As treatment for people with schizophrenia and SMI in general requires the integration of different levels of care and different types of intervention to support independence, quality of life, personal well-being and social participation (Drake 2001; Freese 2001; Davidson 2006), most psychosocial interventions can be classified as multimodal. A multimodal intervention is defined as one that comprises two or more specific psychological or psychosocial interventions in a systematic and programmed way, with the aim of producing a benefit over and above that which might be achieved by a single intervention (NICE 2009). They are also often subsumed under the general term 'rehabilitation' (Almerie 2011).
Illness management and recovery (IMR) is a multimodal curriculum-based standardised programme that evolved out of this growing knowledge that psychosocial treatments which enable persons with schizophrenia and other SMI to cope with the disabling aspects of their illness and achieve personal goals are a necessary complement to pharmacological interventions. The impetus for developing the IMR programme initially arose at a Robert Wood Johnson Foundation Consensus Conference of US National Institutes of Mental Health staff, services researchers, advocates and the schizophrenia Patient Outcomes Research Team in Baltimore, USA, in 1997, where it was suggested that the various psychosocial interventions available for helping people manage their symptoms and prevent relapses needed to be consolidated into a single standardised programme for study and dissemination (Mueser 2006). To meet this need, the IMR programme was developed as part of the National Implementing Evidence-Based Practices Project, between 2000 and 2002, as an evidence-based practice based on the principles of recovery to help people with SMI. By collecting the evidence of different empirically supported practices, including psychoeducation, relapse prevention, behaviour training to improve medication adherence, coping skills training and social training, IMR was developed as a full-ranged rehabilitation programme and consolidated into a single standardised programme for study and dissemination (Mueser 2006; Dalum 2011). By relating to the concept of recovery, the care tradition of IMR is an orientation to psychiatric illness which holds that individuals are more than the sum of their symptoms and that a mental illness is only one aspect of a multidimensional sense of self, capable of identifying, choosing and pursuing personally meaningful goals and aspirations (Davidson 2006). Hence, IMR was developed in order to help people with schizophrenia and other SMI learn how to manage their illness more effectively in the context of pursuing their personal goals, and to acquire the knowledge and skills to manage their disorder independently (Mueser 2006).
There are currently three versions of the manual for IMR, which reflects a steady development of the intervention. A draft from 2003 was first developed into the August 2006 version (Gingerich 2006), and in 2010 an additional optional module on healthy lifestyles was developed into the second revised edition of the manual (Gingerich 2010), The latest version is from November 2011, and includes several key improvements, while existing modules have been expanded (Gingerich 2011)
The target groups for IMR are: people with schizophrenia, schizoaffective disorder, bipolar disorder and severe depression. The intervention is organised into 11 curriculum topic areas: recovery strategies, practical facts about mental illness, the stress-vulnerability model, building social support, using medication effectively, drug and alcohol use, reducing relapses, healthy lifestyle, coping with stress, coping with problems and symptoms, and getting your needs met in the mental health system.
The curriculum topic areas are taught using a combination of educational, motivational and cognitive-behavioural teaching strategies. In order to help people apply the information and skills that they learn in the sessions to their day-to-day lives, the participant and the practitioner collaborate to develop homework assignments at the end of each session. Every session follows the same routine, and sessions generally last between 45 and 60 minutes; however, it is possible to conduct more frequent, brief sessions, such as meeting for 20 to 30 minutes two or three times a week. The whole programme follows a structured pattern, with educational handouts and practitioners’ guidelines for each topic area. In each session of the programme, practitioners should follow up on the progress of participants towards their personal recovery goals.
IMR can be provided in an individual or group format, and generally lasts between 8 and 11 months, involving a series of weekly sessions where mental health practitioners help the participants to develop personalised strategies for managing their mental illness and moving forward in their lives. With participants’ consent, significant others (e.g., family, friends) are encouraged to be involved in supporting participants while they learn self-management strategies and pursue their personal goals. The participants can share their educational handouts with their significant others, practice specific learned skills and invite their significant others to participate in some of the sessions.
How the intervention might work
The IMR programme integrates specific, empirically supported strategies for teaching illness self-management into a cohesive treatment package based on two theoretical models: the transtheoretical model and the stress-vulnerability model (Mueser 2006; Dalum 2011). The transtheoretical model assumes that human change develops over a series of stages that can be motivated (Derisley 2002; Norcross 2011). By motivating people through the structured course of the IMR programme, the assumption is that people can succeed more easily in achieving their personal recovery goals. The stress-vulnerability model builds on the assumption that the course of SMI is determined by an interaction between biological vulnerability, stress and coping. The aim, therefore, of IMR is to empower people and teach them skills to interrupt the circle of stress and vulnerability that can lead to poor functioning and relapse (Das 2001; Goh 2010).
Why it is important to do this review
Research increasingly suggests that the IMR programme has beneficial effects on outcomes such as illness self-management, global functioning, knowledge of illness, distress related to symptoms and goal orientation (Mueser 2006; Hassan-Ohayon 2007; Lewitt 2009; Fujita 2010), and that it can be implemented in a routine metal health treatment setting with a high fidelity to the programme curriculum (Salyers 2009a; Salyers 2009b). A growing number of countries have ongoing studies on IMR, and the implementation process is well developed in some parts of the USA. Sweden and Denmark have also started the implementation process in parts of their community mental health services(Dalum 2011; Färdig 2011). Presently, however, there are no systematic reviews evaluating the benefits and harms of IMR for people with SMI.