The Mental Health Recovery Measure Can Be Used to Assess Aspects of Both Customer-Based and Service-Based Recovery in the Context of Severe Mental Illness

Is your doctor measuring your mental health recovery? Even know there is such a thing?

The Mental Health Recovery Measure Can Be Used to Assess Aspects of Both Customer-Based and Service-Based Recovery in the Context of Severe Mental Illness

Albino J. Oliveira-Maia^1,2,3,4*‡, Carina Mendonça^5†‡, Maria J. Pessoa⁵, Marta Camacho² and Joaquim Gago^3,4

• ¹Champalimaud Clinical Centre, Champalimaud Centre for the Unknown, Lisboa, Portugal
• ²Champalimaud Research, Champalimaud Centre for the Unknown, Lisboa, Portugal
• ³Department of Psychiatry and Mental Health, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
• ⁴Department of Psychiatry and Mental Health, NOVA School of Medicine – Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
• ⁵Department of Psychiatry and Mental Health, Centro Hospitalar Cova da Beira, Covilhã, Portugal

Within clinical psychiatry, recovery from severe mental illness (SMI) has classically been defined according to symptoms and function (service-based recovery). However, service-users have argued that recovery should be defined as the process of overcoming mental illness, regaining self-control and establishing a meaningful life (customer-based recovery). Here, we aimed to compare customer-based and service-based recovery and clarify their differential relationship with other constructs, namely needs and quality of life. The study was conducted in 101 patients suffering from SMI, recruited from a rural community mental health setting in Portugal. Customer-based recovery and function-related service-based recovery were assessed, respectively, using a shortened version of the Mental Health Recovery Measure (MHRM-20) and the Global Assessment of Functioning score. The Camberwell Assessment of Need scale was used to objectively assess needs, while subjective quality of life was measured with the TL-30s scale. Using multiple linear regression models, we found that the Global Assessment of Functioning score was incrementally predictive of the MHRM-20 score, when added to a model including only clinical and demographic factors, and that this model was further incremented by the score for quality of life. However, in an alternate model using the Global Assessment of Functioning score as the dependent variable, while the MHRM-20 score contributed significantly to the model when added to clinical and demographic factors, the model was not incremented by the score for quality of life. These results suggest that, while a more global concept of recovery from SMI may be assessed using measures for service-based and customer-based recovery, the latter, namely the MHRM-20, also provides information about subjective well-being. Pending confirmation of these findings in other populations, this instrument could thus be useful for comprehensive assessment of recovery and subjective well-being in patients suffering from SMI.

Introduction

Recovery is a concept that cuts across medicine, with particular importance in the context of chronic disease. Clinical definitions of recovery are generally related to reduction or remission of symptoms and return to pre-morbid or full levels of functioning. However, these definitions are variable according to disease or disorder and, frequently, consensus definitions are difficult to obtain. In the contexts of clinical psychiatry, mental health policy and psychiatric research, the concept of recovery from severe mental illness (SMI) has become increasingly relevant (Slade, 2010). This is particularly true for conditions such as schizophrenia, where recovery is very heterogeneous (Lieberman et al., 2008), since there are arguments that stigma and negative stereotyping are self-fulfilling attitudes directly resulting from a misconception of a very limited potential for recovery (Liberman and Kopelowicz, 2005).

The conceptualization of recovery has been challenging for psychiatric disorders, in part because different groups use the term differently. Clinical psychiatry has traditionally defined recovery based on symptoms and several dimensions of function (service-based, objective, or clinical recovery – SBR), while consumer movements advocate for recovery to be defined as the process that involves overcoming mental illness, regaining self-control and establishing a meaningful and fulfilling life (customer-based, subjective, or personal recovery – CBR) (Schrank and Slade, 2007). In patients suffering from schizophrenia, recovery has many predicting factors, including socio-demographic variables, among others (Westermeyer and Harrow, 1984; Wieselgren et al., 1996). Specifically, age and functional status at onset, better cognitive functioning at stabilization, shorter duration of psychosis and early remission seem to best predict functional SBR (Robinson et al., 2004; Lambert et al., 2008). While there is less data for CBR, it has been proposed that subjective well-being at onset and marital satisfaction are associated with increased subjective recovery (Lambert et al., 2008; Tse et al., 2014). In any case, the concept of CBR has gained increasing relevance, given the movements toward promotion of patient-centered medicine and patient engagement in healthcare (Barello et al., 2012; Mullins et al., 2012; Domecq et al., 2014; Richards et al., 2015).

Unfortunately, lack of precision in the definition of these constructs and their dimensions has lead to variable use of these terms within the literature. In fact, CBR has been directly or indirectly equated to other measures of subjective experience, such as quality-of-life (QoL) (Roe et al., 2011), and the degree to which CBR and SBR are separable constructs is not consensual (Resnick et al., 2004; Andresen et al., 2010; Lloyd et al., 2010; Roe et al., 2011, 2012; Norman et al., 2013; Stanhope et al., 2013). To address this question empirically, as we propose here, stringent conceptualizations of these recovery constructs have been considered by several authors. Specifically it has been proposed that the distinction between CBR and SBR should result from the methods according to which the two constructs and their respective measurement instruments are defined and derived (Campbell-Orde et al., 2005; Andresen et al., 2010). According to these conceptualizations, CBR is considered to be recovery defined by users/patients and measured by instruments developed according to the accounts of users/patients (e.g., focus groups, qualitative analysis of patient interviews). SBR, on the other hand, is recovery defined by service providers and experts, and is measured using instruments developed according to the expertise of service providers and experts (Schrank and Slade, 2007). Nevertheless, this approach to distinguish recovery constructs is questionable, and there has been insufficient empirical work to support the distinction between the two.

Here, we set out to clarify the relationship between CBR and SBR constructs in a population of patients with SMI. Since there are no validated instruments for measurement of CBR in Portuguese patients with SMI, we initially translated and validated the Mental Health Recovery Measure (MHRM) (Bullock and Young, 2003; Young and Bullock, 2005) for use in this patient population. This instrument was chosen because it is one of only two self-rated measures of CBR according to the stringent definition presented above (Campbell-Orde et al., 2005; Andresen et al., 2010), i.e., it was developed according to the accounts of service-users. Furthermore, the MHRM has several versions with excellent psychometric properties (Bullock and Young, 2003; Young and Bullock, 2005; Chang et al., 2013; Armstrong et al., 2014) and has been successfully translated and validated into other languages (van Nieuwenhuizen et al., 2014). Once this instrument was validated, we proceeded to compare customer-based and service-based recovery and clarify their differential relationship with other constructs, namely needs and subjective QoL. The four constructs were assessed simultaneously using either clinician-reported (SBR and needs) and/or self-reported (CBR, needs and subjective QoL) measures.