The relationship between clinical and recovery dimensions of outcome in mental health

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Abstract

Background

Little is known about the empirical relationship between clinical and personal recovery.

Aims

To examine whether there are separate constructs of clinical recovery and personal recovery dimensions of outcome, how they change over time and how they can be assessed.

Method

Standardised outcome measures were administered at baseline and one-year follow-up to participants in the REFOCUS Trial (ISRCTN02507940). An exploratory factor analysis was conducted and a confirmatory factor analysis assessed change across time.

Results

We identified three factors: patient-rated personal recovery, patient-rated clinical recovery and staff-rated clinical recovery. Only the personal recovery factor improved after one year. HHI, CANSAS-P and HoNOS were the best measures for research and practice.

Conclusions

The identification of three rather than two factors was unexpected. Our findings support the value of concurrently assessing staff and patient perceptions of outcome. Only the personal recovery factor changed over time, this desynchrony between clinical and recovery outcomes providing empirical evidence that clinical recovery and personal recovery are not the same. We did not find evidence of a trade-off between clinical recovery and personal recovery outcomes. Optimal assessment based on our data would involve assessment of hope, social disability and patient-rated unmet need.

Introduction

Recovery, defined as “a way of living a satisfying, hopeful, and contributing life even with any limitations caused by illness” (Anthony, 1993), has an increasing empirical evidence base (e.g. Law and Morrison, 2014). However, it is also clear that the term ‘recovery’ has been used in different ways. The literature contains at least four types of frameworks to understand recovery from mental health problems and these can be summarised as follows: Clinical recovery generally refers to clinical outcomes, professionally rated by the presence of symptoms of illness. In this context recovery refers generally to the absence of disease or cure (Torgalsboen, 2013) with schizophrenia-related disorders, and underpins epidemiological research (Austin et al., 2013). The concept of Personal recovery which has emerged from the consumer movement in the past 20 years has a number of characteristics which focus on outcomes important to the recovering individual and distinguish it from more clinically based models: Recovery is individually defined, through an understanding of narrative and founded on the concept of an individual's journey of growth and personal development. This form of recovery focuses mostly on social success and individually defined forms of progress, rather than symptom control. Dealing with stigma (Deegan, 1988) and the development of self-confidence and hope (Corrigan and Watson, 2006) are critical elements of the process. Some authors (Frese et al., 2001) have noted the potential for conflict between evidence based medicine approaches and the recovery approach, given that many with the highest levels of disability often reject the evidence. The authors argue for an integrated model which recognises the need for structured support at times of greatest need, which must give way to greater autonomy as the individual's disability improves.

Internationally, mental health systems are transforming services to promote a recovery focus (Mental Health Commission of Canada, 2015). Therefore we need to develop clarity about how this approach to mental health work is measured and healthcare professionals need guidance to inform their clinical decision-making and actions (Le Boutillier et al., 2015a and Le Boutillier et al., 2015b). However, empirical research in the field of personal recovery is at an early stage of development and there is an obvious challenge in reducing an individual's recovery to a set of domains for systematic analysis across groups (Slade, 2009). The unpredictability of outcomes, with or without treatment, suggests that finding simple associations between these factors may be difficult. It may be that approaches which use multiple sources to define a multi-faceted approach to defining recovery are needed and this fits with qualitative research which showed that recovery could occur in three domains (biomedical, psychological and social) and could be complete or partial (Henderson, 2010). The evidence base indicates that clinical and recovery measures assess different aspects of outcome. There is a developing literature concerned with the different concepts of recovery and many studies have analysed concepts of recovery beyond symptomatology. Law and Morrison (2014) used a Delphi approach to establish consensus about the meaning of recovery among individuals with experience of psychosis and went on to consider implications for clinical practice. Attempting to find an approach which encompasses service user, professional and political considerations, Whitley and Drake (2010) proposed five superordinate dimensions of recovery and identified lay, professional, and systemic resources that promote each dimension. The empirical analysis by Gordon et al. (2014) produced five core dimensions to the concept of recovery and these authors noted the potential value of an agreed set of dimensions for recovery, which could potentially be used to inform service provision and outcomes. Gould et al. (2013) considered the important relationship between recovery and aspects of individual goal attainment.

The aim of this study was to investigate the relationship between clinical outcomes, which relate to illness and deficit amelioration; and recovery outcomes, which relate to subjective experiences such as hope and empowerment. Objective 1 was to identifying groupings of outcome domains. Objective 2 explored how the identified groupings change over time. Objective 3 was to identify the most informative standardised measure for each grouping.

Section snippets

Sample and setting

The REFOCUS Trial was a cluster RCT evaluating a pro-recovery team level intervention (Bird et al., 2011). It took place in adult community mental health teams in two sites: South London and Maudsley NHS Foundation Trust (SLaM) and 2gether NHS Foundation Trust (2gether). Pooled data from both arms were used in the current study. A total of 27 participating teams (18 SLaM, 9 2gether) were recruited, comprising 13 Recovery teams (4 control, 9 intervention), four Psychosis teams (2 control, 2

Results

The initial study sample included 403 patients, of whom 258 (64%) were male, 309 (77%) single and 210 (53%) white British. The highest level of education achieved was: no qualification or GCSE 206 (52%), A-level or higher qualification 192 (48%). Mean age was 44 years (sd = 11) and mean total use of mental health services at time of trial was mean 16 years (sd = 11). Table 1 summarises the scores on the rating scales at baseline and follow-up.

Table 2 shows the number (percentage) of cases with

Discussion

This study compares patient-rated and staff-rated outcomes over one year. Factor analysis of baseline data produced three factors. Factor 1 – interpreted as Patient-rated personal recovery – comprised four patient-rated measures of recovery, empowerment, wellbeing and hope. Factor 2 — interpreted as Patient-rated clinical recovery, comprised two patient-rated measures of health-related quality of life and unmet need, and a researcher-rated measure of symptomatology. The BPRS has been included

Role of funding source

This work was funded by a grant from the UK National Institute for Health Research (NIHR). The NIHR had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Contributors

Drs. Macpherson, Slade and Pesola conceived the idea and methodology of this study. Drs. Le Boutillier, Bird and Williams were involved in subject recruitment and staff and patient rating assessments. Dr. Pesola conducted the statistical analyses and all authors contributed to and have approved the final manuscript.

Conflict of interest

The authors have no competing financial interests to declare in relation to the current work.

Acknowledgments

This article presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research (PGfAR) Programme (Grant Reference Number RP-PG-0707-10040), and in relation to the NIHR Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and [Institute of Psychiatry, Psychology & Neuroscience] King's College London. The project will be published in full in the NIHR PGfAR journal. The views expressed

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