Is self-management ready for the mental health mainstream?

Self-management interventions are well established approaches for long-term physical health conditions such as diabetes and asthma.

However, when it comes to mental health, self-management is not yet widely implemented, and the evidence base has not yet been systematically reviewed.

What is self-management?

Self-management covers a range of approaches such as psychoeducation, setting goals for maintaining recovery or developing an action plan for management of symptoms. According to the authors of this review:

Self-management interventions aim to equip someone with skills to manage symptoms, relapse and improve overall functioning.

Self-management may also include a psychosocial component when they are delivered in groups either by peers or clinicians.

Where are they offered?

Well, essentially across the board, but not in a very consistent way. Implementation has been behind for mental health compared with physical health. Some examples of co-produced and co-designed interventions can be found in the third sector. Co-designed, peer-led or peer-support interventions focusing on recovery and maintaining good mental health are often delivered locally in the community.

Aims of the review

The authors of this review aimed to evaluate the effectiveness of self-management interventions for people with severe mental illness (Lean et al, 2019). They focused on assessing the impact of self-management interventions on a broad range of outcomes related to mental health.

Self-management interventions combine knowledge with experience of one’s own mental health to maintain good mental health and prevent relapse.

Methods

The authors conducted a systematic review and meta-analysis that included randomised controlled trials only.

Participants

Participants were adults who had severe mental health problems (schizophrenia spectrum disorders, bipolar disorder, major depression or studies with mixed populations of people with these diagnoses, including people with a “personality disorder”) and who used secondary mental health services.

Intervention

In order to be clear about what self-management was, the authors followed the following criteria by Mueser (2002):

Psychoeducation about mental illness and its treatment (in order to make informed decisions about care);
Recognition of early warning signs of relapse and development of a relapse prevention plan;
Coping skills for dealing with persistent symptoms.

Comparison

Comparisons were treatments as usual (as defined by the study authors) or active controls.

Outcomes

Outcomes were: symptomatic recovery, relapse (defined as hospital readmission), self-rated recovery, empowerment, hope, self-efficacy, functioning and quality of life. Effect sizes (Hedges’ g) were calculated for outcomes both at post-test and at follow-up.

Self-management: finding an approach that works to protect and maintain one’s mental health.

Results

Description of included studies

Thirty-seven randomised controlled trials (5,790 participants) were included in the review, two of these were not included in the meta-analysis because they lacked the right kind of data.

Diagnoses included: schizophrenia spectrum disorder (n=18 studies); bipolar disorder (n=7 studies); mixed (schizophrenia, psychosis, bipolar, major depressive disorder and personality disorder in contact with secondary mental health services) (n=12 studies). Most interventions (n=25 studies) were delivered in groups by clinicians, with only five using a peer-to-peer delivery model. A minority (n=5 studies) were delivered individually, either online, by a clinician or peer-to-peer.

Risk of bias

Risk of performance bias was high except in one study, but blinding study personnel is difficult in the context of complex interventions. Nine studies had a high risk of bias or reporting bias (i.e. selective reporting of outcomes) and 18 were unclear.

Overall, self-management seems to convey a number of benefits across the people assessed in the studies included in this review.

Symptoms

There was a small but significant on symptoms (SMD= -0.43, 95% CI [-0.63 to -0.22]) at post treatment and a large effect at follow-up (SMD= -0.88; 95% CI [-1.19 to -0.57]).

Readmission/relapse

There were no effects on re-admission at post-treatment (SMD= 0.84, 95% CI [0.48 to 1.46] or follow-up SMD=0.75, 95% CI [0.51 to 1.08])
The mean number of admissions was reduced (SMD= -0.92, 95% CI [-1.63 to -0.21])
There was also a small effect on length of admission post-treatment (SMD= -0.26, 95% CI [-0.50 to -0.02]), with a larger effect at follow-up (SMD= -0.68, 95% CI [-1.10 to -0.25]).

Self-rated recovery

There was a moderate effect following treatment: SMD= -0.62; 95% CI [-1.03 to -0.22]) and a large effect at follow up (SMD= -0.81; 95% CI [-1.40 to -0.22]).

Empowerment

After finishing treatment, there was no effect on empowerment (SMD= -1.44; 95% CI [-2.97 to 0.08], but at follow-up there was a small effect (SMD= -0.25; -0.43 to -0.07).

Hope

There was no effect on hope at the end of treatment (SMD= -0.18; 95% CI [-0.38 to 0.01]) but at follow-up there was a small effect (SMD= -0.24; [-0.46 to -0.02]).

Self-efficacy

At follow-up, self-management improved self-efficacy (SMD=-0.38; 95% CI [-0.62 to -0.15]). Only one study provided data at follow-up and found a significant result.

Functioning

Self-management had a moderate effect on functioning at the end of treatment (SMD= -0.56; 95% CI [-0.85 to -0.28]) versus control. At follow-up, a large effect size was observed (SMD= -0.90; 95% CI [-1.34 to -0.45]).

Quality of life

After the intervention, there was a small but significant effect of self-management on quality of life (SMD= -0.23; 95% CI [-0.37 to -0.10]) and this continued at follow up (SMD= -0.25, 95%CI [-0.37 to -0.12]).

Overall, self-management interventions had a positive effect on the symptoms of severe mental illness.

Conclusions

Overall, positive effects on mental health symptoms
No effect on readmission, but effects were found on the length of re-admission and the number of readmissions
The authors found positive effects versus control on factors such as hope, empowerment, functioning, quality of life and recovery.

What is interesting is that the effects on functioning, quality of life and recovery increase over time rather than reduce. It would be interesting to explore this effect was observed, does more time allow for self-management techniques to be more embedded in daily life or are there other factors that drive these results?

Self-management had a positive effect on functioning, quality of life and recovery for people with severe mental illness, and this effect increased over time.

Strengths and limitations

The strengths of this review are clear. It is a high-quality systematic review that used robust methods and included a broad range of clinical populations and assessed a broad range of health outcomes.
The findings are highly applicable to clinical practice and policy makers.
No lived experience involvement was sought in this review, which the authors’ note was a limitation. They point out that this would have been helpful when reviewing a definition of self-management as well as choosing outcomes.
The definition of self-management was perhaps drawn from a narrow psychiatric perspective, which might have less salience to the priorities of people with lived experience of severe mental illness (SMI). There is scope here to enhance the relevance of research on self-management in SMI to include a broader definition that incorporates the behaviours and practices that people can engage with to promote and improve physical as well as mental health. For example, self-management can also encompass action that can lead to healthier lifestyle choices, and help people to meet their social, emotional and psychological needs. A broader and more inclusive approach to self-management acknowledges that there are significant health inequalities between people with SMI and the general population leading to a mortality gap whereby people with SMI die 20 to 25 years younger. Efforts to improve health and prevent further ill health in people with SMI are likely to be achieved by developing health strategies that focus on improving mental and physical health together. The UKRI Closing the Gap Network is one high profile UK initiative looking to understand how to close the mortality gap between people with SMI and the general population.

Implications for future research

The authors highlight that future research should consider cost-effectiveness of interventions and large trials that look at readmission and service use data.
There would also be scope to explore what service level factors (e.g. type of clinician, intensity and duration of interventions) and patient level characteristics (e.g. age, gender, type of diagnosis, social and economic status) might impact on the effectiveness of self-management interventions. While future trials might help to address these questions, it is also possible that using methods such as meta-regression and individual participant data meta-analysis could more readily and swiftly unpick which types of self-management interventions work and who they work best for. Learning about how best to tailor self-management interventions for people with SMI will have significant implications for their successful implementation.
From a third-sector research and implementation perspective, there is scope to explore how data from ongoing service delivery and pilots can be further harnessed. Perhaps improved research practices can be implemented in collaboration with academia to allow for better ongoing evaluation of what is being delivered on the ground, which can in return offer relevant information on implementation.

The reviewers suggest that future research should consider cost-effectiveness of interventions and large trials that look at readmission and service use data.

Implications for practice

It is great to see this first systematic review of self-management for severe mental illness. This on its own highlights that there might be a slow, but steady, shift going on in practice and research where the focus is increasingly on offering services that are co-produced and help empower people to reach the goals they want in life. It would be interesting to see how we, with appropriate implementation studies, can now move forward and embed self-management in services.

Co-design has to be a key part of developing self-management interventions.

Conflicts of interest

Josefien Breedvelt works for the Mental Health Foundation. The Mental Health Foundation receives funding to deliver peer-support and self-management programmes in the community. Josefien is not involved in the delivery of these interventions, but has led on several evaluations assessing how self-management was implemented and perceived by the community. Views expressed in this blog are not necessarily those from the Mental Health Foundation and the blog is written in a personal capacity.

Links

Primary paper

Lean M, Fornells-Ambrojo M, Milton A, Lloyd-Evans B, Harrison-Stewart B, Yesufu-Udechuku A, Kendall T, Johnson S. (2019) Self-management interventions for people with severe mental illness: systematic review and meta-analysis. The British Journal of Psychiatry. Cambridge University Press; :1–9. https://doi.org/10.1192/bjp.2019.54

Other references

Mueser KT, Corrigan PW, Hilton DW, Tanzman B, Schaub A, Gingerich S, et al. Illness Management and Recovery: a review of the research. Psychiatr Serv 2002; 53: 1272–84.

The Mental Elf