Introduction
Methods
Study design
Participants
Mental health professionals | 19 |
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Gender, Male | 4 (21%) |
Discipline | |
Trainee psychiatrist | 7 (37%) |
Support worker | 3 (16%) |
Nurse | 4 (21%) |
Psychologist | 2 (10%) |
Vocational worker | 2 (10%) |
Non-professional support staff (in Italian ‘OSS’ – these staff have a qualification in health and social care) | 1 (5%) |
Mean (SD) months working in mental health Work setting | 137 (122.2) |
Community multidisciplinary team | 14 (56%) |
Supported housings | 4 (16%) |
Day Centre | 6 (24%) |
Other | 1 (4%) |
Assessments
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Personal and social functioning was assessed using the Personal and Social Functioning Scale (FPS) [46, 47] which examines four main areas: socially useful activities (including work and study), personal and social relationships (including relationships with family), self-care and hygiene, disturbing and aggressive behaviour. The total score ranges from 1 to 100 with higher numbers indicating better functioning.
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Psychopathology and social functioning were assessed using the Health of the Nation Outcome Scale (HoNOS) [48, 49] which consists of 12 items covering 4 areas (behaviours that impact negatively on the person and/or others; problems with managing day to day activities; symptoms of mental ill-health that distress or limit the person; social, housing and/or occupational problems that limit autonomy). Scores are given on 5-point Likert scale (0 = no problem; 4 = very severe problem). The total score is the sum for all items, thus ranging from 0 to 48, with a higher value reflecting greater severity of psychopathology or lower functioning.
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Functional autonomy was assessed using the Monitoring of the Path of Rehabilitation (MPR) [50]. This tool provides an assessment of the person's ability to perform independently various activities of daily living [51] including self-care, housework, shopping, cooking, using public transport, accessing community activities (social, leisure), engaging in occupational activities, and managing physical and mental health. The total mean score ranges from 0 to 12, with higher scores indicating greater functional autonomy.
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Needs for care were assessed using the Italian version of the Camberwell Assessment of Need (CAN) staff version [52, 53], which comprises 22 items grouped into four domains (health, basic, service, and functioning). Each item was assessed as 0 = no problem, 1 = no⁄moderate problem (met need), 2 = current severe problem (unmet need). The number of needs (scores of 1 or 2) and unmet needs (scores of 2) is aggregated over the 22 items and the ratio of met:unmet needs calculated.
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Personal recovery process and recovery goals were assessed using the Italian version of the MHRS [54, 55]. MHRS was developed via participatory action research involving researchers, service users, mental health professionals, and informal caregivers. Its purpose is to facilitate and monitor the process of personal recovery. The MHRS comprises a 10-point star-shaped visual schema where each point corresponds to a life dimension, with these further grouped into four dimensions: physical and mental health (managing mental health, self-care, addictive behaviour); activities and functioning (living skills, work, responsibilities); self-image (identity and self-esteem, trust and hope); networks (social networks, relationships). Through discussion with their key professional, service users are supported to rate their progress on each domain on a ten-point ‘Scale of Change’, which describes five steps in the recovery process, each sub-divided into two phases as follows:
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Stuck (phases 1–2): feeling unable to cope with the problem or not being able to accept help for it.
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Accepting help (phases 3–4): the desire to get away from the problem and the hope that someone/something can intervene to assist.
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Believing (phases 5–6): starting to believe in the possibility of change, starting to do things to achieve personal goals and accepting help from others.
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Learning (phases 7–8): actively trying things out and learning through trial and error with support.
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Self-reliance (phases 9–10): being able to achieve and manage the desired goal/s without support.
Statistical analysis
Power of the study
Results
Service user participants’ socio-demographic and clinical characteristics at recruitment
Women (N = 10) | Men (N = 15) | Total (N = 25) | P-value | |
---|---|---|---|---|
Sociodemographic and clinical characteristics | ||||
Mean (SD) age in years | 41.8 (12.1) | 40.7 (8.6) | 41.1 (9.9) | 0.786 |
Marital status | - | |||
Single | 7 (70.0%) | 12 (80.0%) | 19 (76.0%) | |
Partnered | 3 (30.0%) | 3 (20.0%) | 6 (24.0%) | |
Educational achievement | - | |||
Lower education (primary/middle school only) Higher education (high school/further education) | 7 (70.0%) 3 (30.0%) | 6 (40.0%) 9 (60.0%) | 13 (52.0%) 12 (48.0%) | |
Work | - | |||
Employed | 2 (20.0%) | 2 (13.3%) | 4 (16.0%) | |
Unemployed | 1 (10.0%) | 9 (60.0%) | 10 (40.0%) | |
Supported employment | 2 (20.0%) | 1 (6.7%) | 3 (12.0%) | |
Student | 1 (10.0%) | 1 (6.7%) | 2 (8.0%) | |
Homemaker | 1 (10.0%) | 0 (0.0%) | 1 (4.0%) | |
Retired | 3 (30.0%) | 2 (13.3%) | 5 (20.0%) | |
Housing | - | |||
Alone | 1 (10.0%) | 0 (0.0%) | 1 (4.0%) | |
With family/partner | 5 (50.0%) | 8 (53.3%) | 13 (52.0%) | |
Supported housings | 11 (40.0%) | 7 (46.7%) | 11 (44.0%) | |
Primary clinical diagnosis | - | |||
Schizophrenia | 2 (20.0%) | 6 (40.0%) | 8 (32.0%) | |
Other psychosis (schizoaffective disorder, delusional disorder) | 4 (40.0%) | 5 (33.3%) | 9 (36.0%) | |
Affective disorders (bipolar affective disorder, depression) | 2 (20.0%) | 0 (0.0%) | 2 (8.0%) | |
Other diagnoses (e.g. personality disorders) | 2 (20.0%) | 4 (26.6%) | 6 (24.0%) | |
Mean (SD) years of contact with community mental health service | 16.3 (8.7) | 15.9 (8.4) | 16.0 (8.4) | 0.902 |
Psychiatric admission in the last year | - | |||
No admission | 7 (70.0%) | 11 (73.3%) | 18 (72.0%) | |
1 voluntary admission | 3 (30.0%) | 3 (20.0%) | 6 (24.0%) | |
1 involuntary admission | 0 (0.0%) | 1 (6.7%) | 1 (4.0%) | |
Mean (SD) length in months of admissions in the last year | 55.7 (28.2) | 23 (3.5) | 37.0 (24.0) | 0.064 |
Physical health comorbidity (e.g. dyslipidemia, hypothyroidism) | 5 (50.0%) | 3 (20.0%) | 8 (32.0%) | - |
Substance misuse or gambling problem | 3 (30.0%) | 9 (60.0%) | 12 (48.0%) | - |
Rating scale assessments | ||||
Mean (SD) functioning (FPS) [0, very severe dysfunction; 90 very good functioning] | 62.1 (20.3) | 46.2 (17.1) | 53 (19.7) | 0.046 |
Mean (SD) psychopathology and social functioning (HoNOS) [0 = no problems at all; 48 = severe problems in all areas] | 11.4 (6.5) | 13.4 (4.8) | 12.6 (5.5) | 0.386 |
Mean (SD) functional autonomy (MPR) [0 = non-autonomous; 12 = fully autonomous] | 9.2 (1.3) | 8.3 (1.5) | 8.7 (1.5) | 0.108 |
Total, met and unmet needs (CAN) [0 = no problem, 1 = no ⁄ moderate problem (met need), 2 = current severe problem (unmet need)] | ||||
Ratio met/unmet ≥ 1 indicates more needs are met than unmet | ||||
Total mean (SD) needs | 7.9 (5.0) | 11.4 (3.9) | 10.8 (4.5) | 0.095 |
Total (SD) met needs | 5.6 (3.7) | 8.6 (3.7) | 7.7 (3.7) | |
Total (SD) unmet needs | 2.3 (2.9) | 2.9 (2.7) | 3.0 (0.54) | 0.184 |
Ratio met/unmet needs | 2.4 | 3.0 | 2.6 | 0.347 - |
Functioning, psychopathology, functional autonomy and care needs at recruitment
Differences in men and women’s recovery
Women (N = 10) | Men (N = 15) | Total (N = 25) | P-value | |
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Total mean (SD) MHRS scale of change | 7.0 (1.5) n = 9 | 5.6 (1.2) | 6.1 (1.5) n = 24 | 0.018 |
Physical and mental health | 7.7 (1.3) | 5.8 (1.5) | 6.6 (1.7) | 0.003 |
Managing mental health | 6.6 (1.6) | 5.5 (1.7) | 5.8 (1.8) | 0.115 |
Self-care | 8.0 (1.8) | 6.1 (2.4) | 6.7 (2.3) | 0.040 |
Addictive behavior | 8.5 (2.3) | 5.9 (3.5) | 7.0 (3.4) | 0.050 |
Activities and functioning | 7.6 (1.9) n = 9 | 5.7 (1.2) | 6.4 (1.7) n = 24 | 0.022 |
Living skills | 7.0 (2.2) | 5.3 (1.5) | 6.0 (2.0) | 0.029 |
Work | 6.8 (3.2) n = 9 | 4.5 (1.3) | 5.5 (2.4) n = 24 | 0.021 |
Responsibilities | 9.1 (2.0) | 7.3 (2.5) | 8.1 (2.3) | 0.050 |
Self -image | 6.6 (1.9) | 5.6 (1.5) | 6.0 (1.7) | 0.175 |
Identity and self-esteem | 6.6 (1.8) | 5.5 (1.7) | 6.0 (1.8) | 0.126 |
Trust and hope | 6.6 (2.0) | 5.7 (1.7) | 6.9 (1.9) | 0.253 |
Networks | 5.9 (1.9) | 5.0 (1.9) | 5.4 (1.9) | 0.264 |
Social networks | 6.5 (2.7) | 4.5 (1.5) | 5.5 (2.2) | 0.029 |
Relationships | 5.3 (2.4) | 5.5 (2.8) | 5.5 (2.6) | 0.878 |
Recruitment | 6-month follow-up | |||||
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Women (N = 10) | Men (N = 15) | Total (N = 25) | Women (N = 10) | Men (N = 15) | Total (N = 25) | |
Area/s of intervention | ||||||
Physical and mental health | 3 (30.0%) | 8 (53.3%) | 11 (44.0%) | 2 (20.0%) | 12 (85.7%) | 14 (70.0%) |
Managing mental health | 2 (20.0%) | 3 (20.0%) | 5 (20.0%) | 1 (16.7%) | 4 (28.6%) | 5 (25.0%) |
Self-care | 1 (10.0%) | 4 (26.7%) | 5 (20.0%) | 1 (16.7%) | 4 (28.6%) | 5 (25.0%) |
Addictive behavior | 0 (0.0%) | 1 (6.7%) | 1 (4.0%) | 0 (0.0%) | 4 (28.6%) | 4 (20.0%) |
Activities and functioning | 5 (50.0%) | 13 (86.7%) | 18 (72.0%) | 4 (40.0%) | 12 (85.7%) | 16 (80.0%) |
Living skills | 1 (10.0%) | 3 (20.0%) | 4 (16.0%) | 2 (33.3%) | 3 (21.4%) | 5 (25.0%) |
Work | 4 (40.0%) | 8 (53.3%) | 12 (48.0%) | 2 (33.3%) | 7 (50.0%) | 9 (45.0%) |
Responsibilities | 0 (0.0%) | 2 (13.3%) | 2 (8.0%) | 0 (0.0%) | 2 (14.3%) | 2 (10.0%) |
Self-image | 1 (10.0%) | 2 (13.3%) | 3 (12.0%) | 2 (33.3%) | 1 (7.1%) | 3 (15.0%) |
Identity and self-esteem | 1 (10.0%) | 1 (6.7%) | 2 (8.0%) | 2 (33.3%) | 1 (7.1%) | 3 (15.0%) |
Trust and hope | 0 (0.0%) | 1 (6.7%) | 1 (4.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
Networks | 8 (80.0%) | 4 (26.7%) | 12 (48.0%) | 3 (30.0%) | 7 (50.0%) | 10 (50.0%) |
Social networks | 3 (30.0%) | 2 (13.3%) | 5 (20.0%) | 1 (16.7%) | 4 (28.6%) | 5 (25.0%) |
Relationships | 5 (50.0%) | 2 (13.3%) | 7 (28.0%) | 2 (33.3%) | 3 (21.4%) | 5 (25.0%) |
Change in socio-demographic, clinical characteristics, functioning, psychopathology and functional autonomy from recruitment to 6 months follow up
Recruitment Women (N = 10) | 6 month follow up Women (N = 10) | p-value paired t-test | Recruitment Men (N = 15) | 6 month follow up Men (N = 15) | p-value paired t-test | |
---|---|---|---|---|---|---|
Sociodemographic and clinical characteristics | ||||||
Marital status | ||||||
Single | 7 (70.0%) | 5 (50.0%) | - | 12 (80.0%) | 11 (73.3%) | |
Partnered | 3 (30.0%) | 5 (50.0%) | 3 (20.0%) | 4 (26.7%) | - | |
Education | ||||||
Lower education (primary/middle school) | 7 (70.0%) | - | 6 (40.0%) | - | ||
Higher education (high school/ further education) | 3 (30.0%) | 7 (70.0%) 3 (30.0%) | 9 (60.0%) | 6 (40.0%) 9 (60.0%) | ||
Work | ||||||
Employed | 2 (20.0%) | 2 (20.0%) | - | 2 (13.3%) | 3 (20.0%) | - |
Unemployed | 1 (10.0%) | 0 (0.0%) | 9 (60.0%) | 5 (33.3%) | ||
Supported employment | 2 (20.0%) | 3 (30.0%) | 1 (6.7%) | 4 (26.7%) | ||
Student | 1 (10.0%) | 1 (10.0%) | 1 (6.7%) | 1 (6.7%) | ||
Homemaker | 1 (10.0%) | 1 (10.0%) | 0 (0.0%) | 0 (0.0%) | ||
Retired | 3 (30.0%) | 3 (30.0%) | 2 (13.3%) | 2 (13.3%) | ||
Housing | 1 (10.0%) | 2 (20.0%) | - | 0 (0.0%) | 0 (0.0%) | |
Alone | 5 (50.0%) | 5 (50.0%) | 8 (53.3%) | 7 (46.7%) | ||
With family/partner Supported accommodation | 4 (40.0%) | 3 (30.0%) | 7 (46.7%) | 8 (53.3%) | ||
Substance misuse or gambling problem | 3 (30.0%) | 3 (30.0%) | - | 9 (60.0%) | 9 (60%) | - |
Assessments | ||||||
Mean (SD) functioning (FPS) [0, very severe dysfunction; 90 very good functioning] | 62.1 (20.3) | 66.0 (15.9) | 0.311 | 46.2 (17.1) | 51.3 (16.3) | 0.013 |
Mean (SD) psychopathology and social functioning (HoNOS) [0 = no problems at all; 48 = severe problems in all areas] | 11.4 (6.5) | 8.1 (4.1) | 0.086 | 13.4 (4.8) | 10.7 (4.7) | 0.003 |
Mean (SD) functional autonomy (MPR) [0 = non-autonomous; 12 = fully autonomous] | 9.2 (1.3) | 9.9 (1.4) | 0.013 | 8.3 (1.5) | 9.0 (1.5) | 0.042 |
Total, met and unmet needs (CAN) [0 = no problem, 1 = no ⁄ moderate problem (met need), 2 = current severe problem (unmet need)] | ||||||
Ratio met/unmet ≥ 1 indicates more needs are met than unmet | 7.1 (4.6) n = 9 | 5.9 (3.7) | 0.315 | 11.4 (3.9) | 10.3 (4.4) | 0.164 |
Total mean (SD) needs | 5.0 (3.4) n = 9 | 5.2 (3.4) | 0.760 | 8.5 (3.7) | 8.5 (4.2) | 0.939 |
Total (SD) met needs | 2.1 (3.0) n = 9 | 0.7 (1.3) | 0.182 | 2.9 (2.7) | 1.9 (1.8) | 0.087 |
Total (SD) unmet needs Ratio met/unmet needs | 2.4 | 7.4 | - | 2.9 | 4.5 | - |
Mean (SD) Process of Change (MHRS) score [1–2 Stuck, 3–4 Accepting help, 5–6 Believing, 7–8 Learning, 9–10 Self-reliance] | 7.2 (1.5) | 7.6 (1.6) n = 8 | 0.245 | 5.6 (1.2) | 6.1 (1.1) | 0.006 |
Mean (SD) MHRS physical and mental health | 7.7 (1.4) | 7.9 (1.4) | 0.776 | 5.8 (1.5) | 6.4 (1.2) | 0.018 |
Managing mental health | 6.6 (1.7) | 7.3 (1.9) n = 9 | 0.023 | 5.5 (1.7) | 6.2 (1.4) | 0.052 |
Self-care | 7.8 (1.7) | 8.0 (1.7) n = 9 | 0.347 | 6.1 (2.4) | 6.8 (2.2) | 0.102 |
Addictive behavior | 8.9 (2.1) | 8.2 (3.0) n = 9 | 0.493 | 4.5 (1.5) | 4.9 (1.8) | 0.068 |
Mean (SD) MHRS activities and functioning | 7.9 (1.7) | 8.1 (1.6) | 0.049 | 5.7 (6.3) | 6.3 (1.1) | 0.009 |
Living skills | 7.2 (2.2) | 7.6 (1.8) n = 9 | 0.195 | 5.3 (1.5) | 5.9 (1.6) | 0.036 |
Work | 7.4 (2.9) | 7.8 (2.9) n = 8 | 0.197 | 6.1 (2.4) | 6.8 (2.2) | 0.023 |
Responsibilities | 9.3 (1.0) | 9.2 (1.0) n = 9 | 0.347 | 4.5 (1.3) | 5.1 (1.4) | 0.015 |
Mean (SD) MHRS self-image | 6.7 (2.0) | 7.3 (1.9) | 0.102 | 5.6 (1.5) | 6.1 (1.6) | 0.100 |
Identity and self-esteem | 6.7 (1.9) | 7.0 (1.9) n = 9 | 0.347 | 5.5 (1.7) | 6.1 (1.6) | 0.027 |
Trust and hope | 6.7 (2.1) | 7.6 (2.1) n = 9 | 0.086 | 5.7 (1.7) | 6.0 (1.9) | 0.512 |
Mean (SD) MHRS networks | 6.3 (1.6) | 6.9 (1.9) | 0.255 | 5.0 (1.9) | 5.5 (2.0) | 0.019 |
Social networks | 7.0 (2.3) | 7.3 (1.9) n = 9 | 0.608 | 4.5 (1.5) | 4.9 (1.8) | 0.028 |
Relationships | 5.6 (2.4) | 6.4 (2.5) n = 9 | 0.198 | 5.3 (1.5) | 5.9 (1.6) | 0.033 |