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PSYCHIATRIC SERVICES ♦ http://psychservices.psychiatryonline.org ♦ October 2002 Vol. 53 No. 10
11227722
I
n recent years, interest in identify-
ing and implementing evidence-
based practices for mental health
services has been growing (1,2). Crite-
ria used to determine whether a prac-
tice is supported by research typically
include all of the following: standard-
ized interventions examined in studies
that use experimental designs, similar
research findings obtained from dif-
ferent investigators, and objective as-
sessment of broadly accepted impor-
tant outcomes, such as reducing symp-
toms and improving social and voca-
tional functioning (3,4). On the basis
of these criteria, several psychosocial
treatments for persons with severe
mental illness are supported by evi-
dence, including assertive community
treatment (5), supported employment
(6), family psychoeducation (7), and
integrated treatment for mental illness
and concomitant substance abuse (8).
The standardization and dissemination
of evidence-based practices is expect-
ed to improve outcomes for the broad-
er population of people who use men-
tal health services (9).
In this article, we examine the re-
search that supports interventions for
helping people collaborate with pro-
fessionals in managing their mental
illness while pursuing their personal
recovery goals. We begin by defining
illness management. Next, we discuss
Illness Management and
Recovery: A Review
of the Research
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Dr. Mueser is with the departments of psychiatry and community and family medicine at
the Dartmouth Medical School and the New Hampshire–Dartmouth Psychiatric Research
Center, Main Building, 105 Pleasant Street, Concord, New Hampshire 03301 (e-mail,
kim.t.mueser@dartmouth.edu). Dr. Corrigan is with the University of Chicago Center for
Psychiatric Rehabilitation in Tinley Park, Illinois. Mr. Hilton is with the Office of Policy and
Planning of the New Hampshire Division of Behavioral Health in Concord. Ms. Tanzman
is director of Adult Community Mental Health Services at the Vermont Department of De-
velopmental and Mental Health Services in Waterbury. Dr. Schaub is with the department
of psychiatry and psychotherapy at the University of Munich. Ms. Gingerich is a social
worker in Narberth, Pennsylvania. Dr. Essock is with the Division of Health Services Re-
search of the Mount Sinai School of Medicine of New York University in New York City. Dr.
Tarrier is with the School of Psychiatry and Behavioural Sciences at the the University of
Manchester in England. Ms. Morey resides in Blacksburg, Virginia. Dr. Vogel-Scibilia is
with the Western Psychiatric Institute and Clinic in Pittsburgh. Dr. Herz is with the de-
partment of psychiatry at the University of Rochester in New York.
Illness management is a broad set of strategies designed to help individ-
uals with serious mental illness collaborate with professionals, reduce
their susceptibility to the illness, and cope effectively with their symp-
toms. Recovery occurs when people with mental illness discover, or re-
discover, their strengths and abilities for pursuing personal goals and de-
velop a sense of identity that allows them to grow beyond their mental ill-
ness. The authors discuss the concept of recovery from psychiatric disor-
ders and then review research on professional-based programs for help-
ing people manage their mental illness. Research on illness management
for persons with severe mental illness, including 40 randomized con-
trolled studies, indicates that psychoeducation improves people’s knowl-
edge of mental illness; that behavioral tailoring helps people take med-
ication as prescribed; that relapse prevention programs reduce symptom
relapses and rehospitalizations; and that coping skills training using cog-
nitive-behavioral techniques reduces the severity and distress of persist-
ent symptoms. The authors discuss the implementation and dissemina-
tion of illness management programs from the perspectives of mental
health administrators, program directors, people with a psychiatric ill-
ness, and family members. (Psychiatric Services 53:1272–1284, 2002)
Focusing on
Evidence-
Based
Practices
the concept of recovery and the role
of illness management in aiding the
recovery process. We then review re-
search on illness management pro-
grams, and we conclude by consider-
ing issues involved in the dissemina-
tion and implementation of these
programs.
Defining illness management
The practice in medicine of profes-
sionals teaching persons with medical
diseases and their families about the
diseases in order to improve adher-
ence to recommended treatments
and to manage or relieve persistent
symptoms and treatment side effects
has a long history (10–12). Education-
based approaches are especially com-
mon in the treatment of chronic ill-
nesses such as diabetes, heart disease,
and cancer. In the mental health field,
didactic methods for educating peo-
ple have been referred to as psychoe-
ducation (13–15). Other methods, es-
pecially cognitive-behavioral strate-
gies, have also been used to help peo-
ple learn how to manage their mental
illnesses more effectively.
People with psychiatric disorders
can be given information and taught
skills by either professionals or peers
to help them take better care of
themselves. Although the goals of
professional-based and peer-based
teaching are similar, we distinguish
between them for practical reasons.
Professional-based intervention is
conducted in the context of a thera-
peutic relationship in which the
teacher—or the organization to
which the teacher belongs, such as a
community mental health center—is
responsible for the overall treatment
of the individual’s psychiatric disor-
der. In contrast, peer-based interven-
tion is conducted in the context of a
relationship in which the teacher—or
the organization to which the teacher
belongs, such as a peer support cen-
ter—usually does not have formal re-
sponsibility for the overall treatment
of the individual’s disorder. Given this
distinction, the relationship between
a professional and the person with a
mental illness may be perceived as hi-
erarchical, because the professional
assumes responsibility for the per-
son’s treatment, whereas the relation-
ship between a peer and the person
with a mental illness is less likely to be
perceived as hierarchical, because the
peer does not assume such responsi-
bility. This distinction is crucial among
individuals with psychiatric disorders
who have advocated for self-help and
peer-based services as alternatives to,
or in addition to, traditional profes-
sional-based services (16–18).
Another reason for distinguishing
interventions delivered by profes-
sionals from those provided by peers
is that most professionals do not have
serious psychiatric disorders—in con-
trast, by definition, to peers. Thus
when teaching others how to manage
their mental illness, peers are able to
convey the lessons they have learned
from personal experience, whereas
professionals cannot. This places
peers in a unique position of being
able to teach “self” management skills
to other persons with a mental illness.
To recognize these differences, we
propose a distinction between profes-
sional-based services and peer-based
services aimed at helping people deal
with their psychiatric disorders. We
define illness management as profes-
sional-based interventions designed
to help people collaborate with pro-
fessionals in the treatment of their
mental illness, reduce their suscepti-
bility to relapses, and cope more ef-
fectively with their symptoms. We
suggest that illness self-management
be used to refer to peer-facilitated
services aimed at helping people cope
more effectively with their mental ill-
ness and facilitating people’s ability to
take care of themselves. In this article
we focus on the substantial body of
controlled research addressing the ef-
fectiveness of illness management.
Although a variety of illness self-man-
agement programs have been devel-
oped (19–22), rigorous controlled re-
search evaluating the effects of these
programs has not been completed.
Recovery
Illness management programs have
traditionally provided information
and taught strategies for adhering to
treatment recommendations and
minimizing symptoms and relapses.
However, many programs go beyond
this focus on psychopathology and
strive to improve self-efficacy and
self-esteem and to foster skills that
help people pursue their personal
goals. Enhanced coping and the abil-
ity to formulate and achieve goals are
critical aspects of rehabilitation and
are in line with the recent emphasis
on recovery in the mental health self-
help movement. We briefly address
the relevance of illness management
to recovery here.
According to Anthony (23), “Recov-
ery involves the development of new
meaning and purpose in one’s life as
one grows beyond the catastrophic ef-
fects of mental illness.” Recovery
refers not only to short-term and long-
term relief from symptoms but also to
social success and personal accom-
plishment in areas that the person de-
fines as important (24–26). Recovery
has been conceptualized as a process,
as an outcome, and as both (27–30).
What is critical about recovery is the
personal meaning that each individual
attaches to the concept. Common
themes of recovery are the develop-
ment of self-confidence, of a self-con-
cept beyond the illness, of enjoyment
of the world, and of a sense of well-be-
ing, hope, and optimism (31–34).
Critical to people’s developing
hope for the future and formulating
personal recovery goals is helping
them gain mastery over their symp-
toms and relapses. Basic education
about mental illness facilitates their
ability to regain control over their
lives and to establish more collabora-
tive and less hierarchical relationships
with professionals (16,35–37). Al-
though relapses and rehospitaliza-
tions are important learning opportu-
nities (38–40), prolonged periods of
severe symptoms can erode a person’s
sense of well-being, and avoiding the
disruption associated with relapses is
a common recovery goal (30,41). Im-
provement in coping with symptoms
and the stresses of daily life is anoth-
er a common theme of recovery, be-
cause such improvement allows peo-
ple to spend less time on their symp-
toms and more time pursuing their
goals (27,30,42). Thus illness man-
agement and recovery are closely re-
lated, with illness management fo-
cused primarily on minimizing peo-
ple’s symptoms and relapses and re-
covery focused primarily on helping
people develop and pursue their per-
sonal goals.
PSYCHIATRIC SERVICES ♦ http://psychservices.psychiatryonline.org ♦ October 2002 Vol. 53 No. 10
11227733
Research on illness management
Although illness management and re-
covery are intertwined, almost all the
available treatment research pertains
to illness management. Thus we con-
fined our research review to studies
of illness management programs. Be-
cause extensive research has been
conducted on illness management,
we confined our review to random-
ized clinical trials. We also limited our
review to programs that addressed
schizophrenia, bipolar disorder, and
the general group of severe or serious
mental illnesses, excluding studies
that focused on major depression or
borderline personality disorder. Stud-
ies included in this review were iden-
tified through a combination of
strategies, including literature search-
es on PsycINFO and MEDLINE, in-
spection of previous reviews, and
identification of studies presented at
conferences.
With respect to outcomes, we ex-
amined the effects of different inter-
ventions on two proximal outcomes
and three distal outcomes. The proxi-
mal outcomes are knowledge of men-
tal illness and using medication as pre-
scribed. The distal outcomes are re-
lapses and rehospitalizations, symp-
toms, and social functioning or other
aspects of quality of life. Distal out-
comes are of inherent interest be-
cause they are defined in terms of the
nature of the mental illness and asso-
ciated problems. Proximal outcomes
are of interest because they are relat-
ed to important distal outcomes.
Specifically, knowledge of mental ill-
ness is critical to the involvement of
people with psychiatric disorders as
informed decision makers in their
own treatment (14,15). Using medica-
tion as prescribed is important be-
cause medications are effective for
preventing symptom relapses and re-
hospitalizations for persons with se-
vere mental illness (43,44), yet many
people do not take medications (45),
and nonadherence accounts for a sig-
nificant proportion of relapses and in-
patient treatment costs (46). Although
adherence to medication regimens is
important in and of itself, illness man-
agement approaches involve forming
partnerships between clinicians and
persons with a mental illness in order
to determine the services each person
needs, including medication, and re-
specting patients’ rights to make deci-
sions about their own treatment (36).
The literature review was divided
into five areas: broad-based psychoed-
ucation programs, medication-focused
programs, relapse prevention, coping
skills training and comprehensive pro-
grams, and cognitive-behavioral treat-
ment of psychotic symptoms.
Broad-based psychoeducation
programs
Most broad-based programs, summa-
rized in Table 1, provided informa-
tion to people about their mental ill-
ness, including symptoms, the stress-
vulnerability model, and treatment.
Among the four controlled studies, all
but one (47) provided at least eight
sessions of psychoeducation. Follow-
up periods ranged from ten days (15)
to two years (48). Three of the con-
trolled studies found that psychoedu-
cation improved knowledge about
mental illness (15,47,48); one did not
(49). In two studies, improved knowl-
edge had no effect on taking medica-
tion as prescribed (47,49); one study
reported improved adherence (48).
In summary, research on broad-
based psychoeducation indicates that
it increases participants’ knowledge
about mental illness but does not af-
fect the other outcomes studied. This
finding may not be surprising: similar
didactic information given to families
of persons with schizophrenia has
been found to increase their knowl-
edge but not to affect their behavior
(50,51). The reason for this may be
that didactic information does not
consider beliefs and illness represen-
tations already held by recipients
(52). Nevertheless, psychoeducation
remains important because access to
information about mental illness is
crucial to people’s ability to make in-
formed decisions about their own
treatment, and psychoeducation is
the foundation for more comprehen-
sive programs (as reviewed below).
Medication-focused programs
Studies that strove to foster collabora-
tion between people with a mental ill-
ness and professionals regarding tak-
ing medication used psychoeduca-
tional or cognitive-behavioral ap-
proaches or a combination of the two.
Psychoeducation about medication
involves providing information about
the benefits and the side effects of
medication and teaching strategies
for managing side effects, so that peo-
ple can make informed decisions
about taking medication. These pro-
grams, summarized in Table 2, tend-
ed to be brief, with only two of eight
programs (53,54) lasting more than
one or two sessions. Three studies
conducted posttreatment-only fol-
low-up assessments (55–57), and five
studies conducted follow-ups after
the end of treatment (53,54,58–60).
Most of the studies reported that par-
ticipants increased their knowledge
about medication. However, three
studies reported no group differences
in taking medication as prescribed
(56,59,60); a fourth study reported
improvements (53); and a fifth study
reported deterioration in taking med-
ication (54). The three studies that
found no differences in taking med-
ication as prescribed compared dif-
ferent psychoeducational methods
(56,59,60). Only one study that as-
sessed medication adherence includ-
ed a no-treatment control group (54);
this study found that clients who re-
ceived psychoeducation were more
likely than clients who received no
psychoeducation to discontinue med-
ication. A somewhat disconcerting
finding was reported in the only other
study with a no-treatment control
group (58). This study found that psy-
choeducation increased clients’ in-
sight into their illness but also in-
creased clients’ suicidality; psychoed-
ucation had no influence on other
symptoms or on relapse rates. In
summary, research on the effects of
psychoeducation about medication
indicates that it improves knowledge
about medication, but little evidence
indicates that it improves taking med-
ication as prescribed or affects other
areas of functioning.
Cognitive-behavioral programs that
focused on medication used one of
several techniques: behavioral tailor-
ing, simplifying the medication regi-
men, motivational interviewing, or
social skills training. Behavioral tai-
loring involves working with people
to develop strategies for incorporat-
ing medication into their daily rou-
tine—for example, placing medica-
PSYCHIATRIC SERVICES ♦ http://psychservices.psychiatryonline.org ♦ October 2002 Vol. 53 No. 10
11227744
tion next to one’s toothbrush so it is
taken before brushing one’s teeth
(61). Behavioral tailoring may also in-
clude simplifying the medication reg-
imen, such as taking medication once
or twice a day instead of more often.
Motivational interviewing, based on
the approach developed for the treat-
ment of substance abuse (62), in-
volves helping people articulate per-
sonally meaningful goals and explor-
ing how medication may be useful in
achieving those goals. Social skills
training involves teaching people
skills to improve their interactions
with prescribers, such as how to dis-
cuss medication side effects (63).
Cognitive-behavioral programs for
medication are summarized in Table
3. All four studies of behavioral tailor-
ing found improvements in taking
medication as prescribed (61,64–66),
as did the one study that evaluated
the effect of simplifying the medica-
tion regimen (67). One study of moti-
vational interviewing (68) also report-
ed an increase in taking medication as
prescribed, as well as fewer symp-
toms and relapses and improved so-
cial functioning. One broad-based
cognitive-behavioral program also re-
ported lower rates of rehospitaliza-
tion (69). The two studies that exam-
ined social skills training were limit-
ed. One of these studies found that
skills training had no effect on knowl-
edge about medication, but medica-
tion adherence was not directly as-
sessed (70). The other study showed
that psychoeducation and skills train-
ing improved knowledge and social
skills in medication-related interac-
tions, but it did not assess taking med-
ication as prescribed (71).
Thus controlled research, which has
focused mainly on individuals with
schizophrenia, provides the strongest
support for the effects of cognitive-be-
havioral methods (chiefly, behavioral
tailoring) for increasing their taking of
medication as prescribed, whereas
psychoeducation alone has limited, if
any, impact. The strong effects of be-
havioral tailoring on taking medica-
tion, compared with the weak effects
of psychoeducation, suggest that
memory problems, which are common
in schizophrenia (72), may interfere
with taking medication as prescribed
and that behavioral tailoring may work
by helping people develop their own
cues to take medication, thereby com-
pensating for cognitive impairments.
Most of the programs reviewed
were response-based, with little effort
made to understand the psychology
of why people did not take medica-
tion as prescribed. This is very differ-
ent from the theoretical position in
health psychology, in which complex
models such as the health belief mod-
el and the theory of planned action
have been developed to understand
health-related behavior. Preliminary
studies investigating medication self-
administration have used the concept
of psychological reactance, which is a
motivational state that can develop
when a person perceives a threat to
his or her personal freedom (73). In
an analogue study, reactance-prone
individuals rated themselves as being
less likely to take medication if their
freedom of choice was restricted,
whereas no effect of freedom of
choice was seen in non–reactance-
prone participants (74). In a study of
PSYCHIATRIC SERVICES ♦ http://psychservices.psychiatryonline.org ♦ October 2002 Vol. 53 No. 10
11227755
TTaabbllee 11
Randomized controlled trials of broad-based psychoeducation programs
Reference
Goldman and
Quinn (15)
Bäuml et al. (48)
MacPherson et
al. (47)
Merinder et al.
(49)
Treatment and duration
Psychoeducation and
standard care; 25 hours
a week for three weeks
Psychoeducation and
standard care; eight ses-
sions over three months
Three sessions of psy-
choeducation; one ses-
sion of psychoeducation;
standard care; one or
three weekly psychoe-
duction sessions
Psychoeducation and
standard care; eight ses-
sions
Outcomes
Knowledge
Psychoeducation
better than stan-
dard care
Psychoeducation
better than stan-
dard care
Three sessions of
psychoeducation
better than one
session of psychoe-
ducation better
than standard care
No group differ-
ences
Not taking med-
ication as pre-
scribed
—
Psychoeducation
better than stan-
dard care
No group differ-
ences
No group differ-
ences
Patients
N=60, all
with schizo-
phrenia
N=163, all
with schizo-
phrenia
N=64, all
with schizo-
phrenia
N=46, all
with schizo-
phrenia
Comments
Highly compre-
hensive educa-
tional program
Separate psy-
choeducation
groups for rela-
tives
Participants were
hospitalized
Separate psy-
choeducation
groups for rela-
tives
Other
Psychoeducation
better than stan-
dard care for neg-
ative symptoms;
no group differ-
ences in distress
Psychoeducation
better than stan-
dard care in hos-
pitalizations
Three sessions of
psychoeducation
better than one
session of psy-
choeducation and
better than stan-
dard care for in-
sight
—
people with schizophrenia or
schizoaffective disorder, individuals
with higher psychological reactance
who perceived taking medication as a
threat to their freedom of choice
were less likely to have taken medica-
tion as prescribed in the past (75).
Motivational interviewing may pro-
vide one strategy for improving peo-
PSYCHIATRIC SERVICES ♦ http://psychservices.psychiatryonline.org ♦ October 2002 Vol. 53 No. 10
11227766
TTaabbllee 22
Randomized controlled trials of psychoeducation programs focused on medication
Reference
Seltzer et al. (53)
Munetz and
Roth (60)
Streicker et al.
(54)
Brown et al. (56)
Kleinman et al.
(59)
Kuipers et al.
(57)
Angunawela and
Mullee (55)
Owens et al. (58)
Treatment and duration
Psychoeducation and
standard care; nine ses-
sions
Formal (written) psy-
choeducation and infor-
mal (oral) psychoeduca-
tion; one session
Psychoeducation and
standard care; ten ses-
sions
Oral psychoeducation on
medication and oral and
written psychoeducation
on medication; oral psy-
choeducation on med-
ication and side effects;
and oral and written
psychoeducation on
medication and side ef-
fects; two sessions
Psychoeducation with
and without a review
session; one or two ses-
sions
Structured psychoedu-
cation and unstructured
psychoeducation; one
session
Information leaflets and
standard care; one ses-
sion
Psychoeducation and
standard care; 15-
minute video and infor-
mation booklets
Outcomes
Knowledge
No group
differences
Informal psy-
choeducation
better than
formal psy-
choeducation
Psychoedu-
cation better
than stan-
dard care
All groups
improved.
No group
differences
Both groups
improved.
No group
differences
Both groups
improved.
No group
differences
Information
leaflets and
standard care
—
Not taking
medication as
prescribed
Psychoeduca-
tion better
than standard
care
No group dif-
ferences
Psychoeduca-
tion better
than standard
care
No group dif-
ferences
No group dif-
ferences
—
—
—
Patients
N=100,
66% with
schizo-
phrenia
N=25,
88%
with
schizo-
phrenia
N=75,
“mostly
schizo-
phrenia”
N=30,
all
with
schizo-
phrenia
N=40,
all with
schizo-
phrenia
N=60,
55% with
schizo-
phrenia
N=249,
21%
with
schizo-
phrenia
N=114,
all with
schizo-
phrenia
Comments
Both groups had
high levels of
knowledge
Brief intervention.
Younger partici-
pants retained
more information
than older ones
Peer counseling
included in pro-
gram
Brief intervention
Brief intervention
Brief intervention
Brief intervention.
People with schiz-
ophrenia learned
less than people
with affective and
personality disor-
ders
Very brief inter-
vention
Other
Psychoeducation
better than stan-
dard care on fear
about medication
No group differ-
ences in relapses
No group differ-
ences in hospital-
izations
All groups report-
ed fewer side ef-
fects at posttreat-
ment
No group differ-
ences in hospital-
izations
—
—
No group differ-
ences in relapse
rates. Psychoedu-
cation better than
standard care for
insight, but psy-
choeducation not
better than stan-
dard care for sui-
cidality
Follow-up
Five
months
Two
months
35 weeks
Posttreat-
ment as-
sessment
only
Six
months
Posttreat-
ment as-
sessment
only
Four
weeks af-
ter distri-
bution of
leaflets
One year
TTaabbllee 33
Randomized controlled trials of cognitive-behavioral programs focused on medication
Reference
Boczkowski
et al. (61)
Dekle and
Christensen
(70)
Kelly and
Scott (66)
Eckman et al.
(1)
Razali and
Yahya (67)
Lecompte
and Pele (69)
Azrin and Te-
ichner (64)
Kemp et al.
(68)
Cramer and
Rosenheck
(65)
Treatment and duration
Psychoeducation;
behavioral tailoring
and standard care;
one session
Psychoeducation and
social skills training;
general health instruc-
tion; and standard care;
12 weekly sessions
Home psychoeducation
and behavioral tailoring;
clinic psychoeducation
and behavioral tailoring;
home and clinic psy-
choeducation and be-
havioral tailoring; and
standard care; home
three sessions, clinic two
Psychoeducation and
social skills training;
supportive group thera-
py; two weekly sessions
for six months
Psychoeducation and
simplifying regimen;
and standard care; one
session
Cognitive-behavioral
therapy versus unstruc-
tured conversation
Psychoeducation; be-
havioral tailoring; and
behavioral tailoring with
client and family; one
session
Psychoeducation, moti-
vational interviewing,
and nonspecific coun-
seling; four to six ses-
sions
Behavioral tailoring
and standard care; one
session plus monthly
checks
Outcomes
Knowledge
—
Psychoeducation
and social skills
training equal to
general health
instruction and
better than stan-
dard care
—
Psychoeducation
and social skills
training better
than supportive
group therapy
—
—
—
—
—
Not taking med-
ication as pre-
scribed
Behavioral tailor-
ing better than
psychoeducation
and equal to stan-
dard care
—
Psychoeducation
and behavioral
tailoring better
than standard care
—
—
Cognitive-behav-
ioral therapy su-
perior in aftercare
appointments
Both medication
guidelines groups
better than psy-
choeducation
Psychoeducation
and motivational
interviewing bet-
ter than nonspe-
cific counseling
Behavioral tailor-
ing better than
standard care
Patients
N=36,
all
with
schizo-
phrenia
N=18,
55%
with
schizo-
phrenia
N=414,
64%
with
schizo-
phrenia
N=41,
all
with
schizo-
phrenia
N=165,
all with
schizo-
phrenia
N=64,
all with
schizo-
phrenia
N=39,
54%
with
schizo-
phrenia
N=74,
58%
with
schizo-
phrenia
N=60,
32% with
schizo-
phrenia
Comments
Brief treatment
Small sample size
Three experimen-
tal groups com-
bined into one
group for analysis
Social skills train-
ing addressed
medication-related
issues and symp-
tom management
Families included
when available.
Participants se-
lected for nonad-
herence
Guidelines includ-
ed psychoeduca-
tion, behavioral
therapy, and other
advice on taking
medication. Brief
treatment
Better social func-
tioning for psy-
choeducation and
motivational inter-
viewing group
Brief treatment
Other
Psychoeducation
and behavioral
tailoring better
than standard
care in symptoms
and rehospitaliza-
tions
Psychoeducation
and social skills
training better
than supportive
group therapy in
social skills
Psychoeducation
and simplifying
regimen better
than standard
care in rehospi-
talizations
Cognitive-behav-
ioral therapy su-
perior in rehospi-
talizations
—
Psychoeducation
and motivational
interviewing su-
perior in relapses
and symptoms
—
Follow-
up
Three
months
Post-
treat-
ment
assess-
ment
only
Six
months
One
year
One
year
One
year
Two
months
18
months
Six
months
PSYCHIATRIC SERVICES ♦ http://psychservices.psychiatryonline.org ♦ October 2002 Vol. 53 No. 10
11227777
ple’s understanding of medication
and addressing their concerns about
taking medication, while respecting
their decision about whether or not to
use medication. However, only one
controlled study has evaluated the ef-
fects of motivational interviewing on
taking medication as prescribed, and
this study is in need of replication.
Relapse prevention
Controlled studies of relapse preven-
tion programs are summarized in Table
4. Relapse prevention programs focus
on teaching people how to recognize
environmental triggers and early warn-
ing signs of relapse and taking steps to
prevent further symptom exacerba-
tions (76–81). These programs also
teach stress management skills. Be-
cause a person may not be fully aware
that a relapse is happening (82,83), two
of the five relapse prevention pro-
grams included groups to train rela-
tives to help in the identification of
early warning signs of relapse (76,78).
The five studies of relapse preven-
tion programs all showed decreases in
relapse or rehospitalization. These
findings are consistent with the find-
ings of a large, uncontrolled study of
370 people with severe mental illness
in which teaching the early warning
signs of relapse was associated with
better outcomes, including fewer re-
lapses and rehospitalizations and low-
er treatment costs (84). This benefit
of involving relatives in relapse pre-
vention programs is consistent with
research that shows that family inter-
vention is effective in preventing re-
lapses (7).
Coping skills training and
comprehensive programs
Controlled studies of coping skills
training and comprehensive programs
are summarized in Table 5. Coping
programs aim to increase people’s
ability to deal with symptoms or stress
or with persistent symptoms (85–90).
Comprehensive programs incorporate
a broad array of illness management
strategies, including psychoeducation,
relapse prevention, stress manage-
ment, coping strategies, and goal set-
ting and problem solving (91–94).
The four studies of coping skills
were quite different, both in the meth-
ods employed and in the targets of the
intervention. Leclerc and colleagues
(85) taught an integrative coping skills
approach based on Lazarus and Folk-
man’s model of coping (95,96), which
emphasizes the importance of cogni-
tive appraisal in perceiving threat.
Lecomte and colleagues (86) ad-
dressed general coping skills through
building up participants’ sense of em-
powerment. Schaub (87) and Schaub
and Mueser (88) taught skills for man-
aging stress and persistent symptoms,
combined with basic psychoeducation
about schizophrenia. Despite the dif-
ferences in the programs, all the cop-
ing skills programs employed cogni-
tive-behavioral techniques and pro-
duced uniformly positive results in re-
ducing symptom severity. Thus re-
search evidence shows that coping
skills training is effective.
PSYCHIATRIC SERVICES ♦ http://psychservices.psychiatryonline.org ♦ October 2002 Vol. 53 No. 10
11227788
TTaabbllee 44
Randomized controlled trials of relapse prevention programs
Reference
Buchkramer
et al. (76,77)
Herz et al.
(78)
Perry et al.
(79)
Lam et al.
(80)
Scott et al.
(81)
Treatment and duration
Relapse prevention;
social skills training;
standard care; ten
weekly sessions
Relapse prevention and
standard care; weekly
groups for 18 months
Relapse prevention and
standard care; seven to
12 sessions
Relapse prevention and
standard care; six
months, 12 to 20 ses-
sions
Relapse prevention and
standard care; six
months
Outcomes
Relapse or
rehospitalization
Relapse prevention
better than social
skills training but
equal to standard care
Relapse prevention
better than standard
Relapse prevention
better than standard
care in manic relapses
Relapse prevention
better than standard
care
Relapse prevention
better than standard
care
Patients
N=66,
all with
schizo-
phrenia
N=82,
all with
schizo-
phrenia
N=69,
all with
bipolar
disorder
N=25,
all with
bipolar
disorder
N=42,
all with
bipolar
disorder
Comments
Relatives’ groups provided
Relatives’ groups provided
Participants selected after
manic episode
Fewer antipsychotics pre-
scribed at follow-up for
relapse prevention group
Other
—
—
Relapse prevention
better than standard
care in social adjust-
ment and work
Relapse prevention
better than standard
care in social function-
ing and coping strate-
gies
Relapse prevention
better than standard
care in symptoms and
functioning
Follow-
up
Two to
five
years
Post-
treat-
ment as-
sess-
ment
only
18
months
One
year
Six
months,
weekly
sessions
TTaabbllee 55
Randomized controlled trials of coping skills training and comprehensive programs
Refer-
ence
Leclerc
et al.
(85)
Lecomte
et al.
(86)
Schaub
(87)
Schaub
and
Mueser
(88)
Atkinson
et al.
(91)
Hogarty
et al.
(92,93)
Hornung
et al.
(94)
Treatment and duration
Coping skills and problem
solving and standard care;
24 sessions over 12 weeks
Self-esteem and empower-
ment group and standard care;
12 weeks
Coping-oriented therapy and
unstructured discussion group;
24 sessions over 2.5 months
Coping-oriented therapy and
supportive therapy; 16 sessions
over three months
Psychoeducation and problem
solving and standard care; 20
weeks
Personal therapy and support-
ive therapy; 94 sessions over
three years
Psychoeducation; psychoeduca-
tion and problem solving; psy-
choeducation and key person
counseling; psychoeducation,
problem solving, and key per-
son counseling; and standard
care; psychoeducation, ten ses-
sions; problem solving, 15 ses-
sions; key person counseling, 20
sessions
Outcomes
Relapse or
rehospitalization
—
—
No group differences
—
—
Participants living
with families: person-
al therapy better than
supportive therapy.
Participants living in-
dependently equal to
supportive therapy
and better than per-
sonal therapy
Psychoeducation,
problem solving, and
key person counseling
better than other
groups in hospitaliza-
tions
Patients
N=99,
all
with
schizo-
phrenia
N=95,
all
with
schizo-
phrenia
N=20,
all
with
schizo-
phrenia
N=156,
all with
schizo-
phrenia
N=146,
all with
schizo-
phrenia
N=151,
all with
schizo-
phrenia
N=191,
all with
schizo-
phrenia
Comments
60% of partici-
pants were from
long-stay wards
Self-esteem and
empowerment
group improved
more in coping
skills
Relatives’ groups
provided. Two-
year follow-up
under way
Psychoeducation
and problem
solving better
than standard
care in social
functioning, so-
cial networks,
quality of life
Half of partici-
pants living at
home received
family therapy
Other
Coping skills and problem
solving better than standard
care in delusions, hygiene,
self-esteem. No group dif-
ferences in negative symp-
toms
Self-esteem and empower-
ment group better than
standard care in psychotic
symptoms. No group differ-
ences in negative symptoms
Coping-oriented therapy
better than unstructured
discussion group in knowl-
edge of illness, social con-
tacts, well-being, self-confi-
dence, hospitalization. Cop-
ing-oriented therapy equal
to unstructured discussion
group in symptoms, leisure
time, coping
Coping-oriented therapy
better than supportive ther-
apy in symptom severity,
negative symptoms, anxiety-
depression
Personal therapy better
than supportive therapy in
social adjustment
—
Follow-up
Six
months
Six
months
Post-treat-
ment as-
sessment
only
One year
Three
months
Post-treat-
ment as-
sessment
only
Five years
PSYCHIATRIC SERVICES ♦ http://psychservices.psychiatryonline.org ♦ October 2002 Vol. 53 No. 10
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The three studies of comprehen-
sive programs—that is, those using a
broad range of techniques—are
somewhat difficult to compare be-
cause they differed in the clinical
methods used. Atkinson and cowork-
ers (91) evaluated a program that
combined morning educational pre-
sentations and afternoon sessions in
which problem solving was applied to
the educational topics. Hogarty and
associates (92,93) evaluated the ef-
fects of personal therapy, a broad-
based approach incorporating psy-
choeducation, stress management,
and development of adaptive coping
skills to promote social reintegration,
and compared these effects with the
effects of supportive therapy. They
found that personal therapy prevent-
ed relapses only for people living with
families. However, people receiving
personal therapy improved in social
functioning, whether they were living
at home or not. Hornung and col-
leagues (94) examined the effects of
different combinations of psychoedu-
cation, problem-solving training, and
key-person counseling (such as coun-
seling family members) and found
that people who received all three had
fewer relapses over five years. These
three studies suggest that comprehen-
sive programs improve the outcome
of schizophrenia, but the differences
between programs preclude any de-
finitive conclusions about which ap-
proaches may be most effective.
Cognitive-behavioral treatment
of psychotic symptoms
Over the past 50 years, since the ear-
ly work of Beck (97), cognitive-behav-
ioral therapy has been used to help
clients with psychotic symptoms cope
more effectively with the distress as-
sociated with symptoms or to reduce
symptom severity. Cognitive-behav-
ioral approaches to psychosis include
teaching coping skills, such as distrac-
tion techniques to reduce preoccupa-
tion with symptoms (98), and modify-
ing clients’ dysfunctional beliefs
about the illness, the self, or the envi-
ronment (99). In recent years, several
manuals have been developed for
cognitive-behavioral therapy for psy-
chosis (100–102).
Over the past decade, eight con-
trolled studies of time-limited cogni-
tive-behavioral therapy for psychosis
have been conducted—six in Eng-
land (89,90,103–112), one in Canada
(113), and one in Italy (114). Because
several comprehensive reviews of this
research (115), including two meta-
analyses (116,117), have recently
been published, we do not review the
results of these studies in detail here.
The consistent finding across these
studies has been that cognitive-be-
havioral treatment is more effective
than supportive counseling or stan-
dard care in reducing the severity of
psychotic symptoms. Furthermore,
studies that assess negative symp-
toms, such as social withdrawal and
anhedonia, also report beneficial ef-
fects from cognitive-behavioral thera-
py on these symptoms.
Summary of research
The results of controlled research indi-
cate that when illness management is
conceptualized as a group of specific
interventions, it is an evidence-based
practice. The core components of ill-
ness management and the evidence
supporting them can be summarized as
follows. With respect to the more prox-
imal outcomes, three studies (15,47,
48) found that psychoeducation was ef-
fective at increasing knowledge about
mental illness, and a fourth (49) did
not. Similarly, all four studies of behav-
ioral tailoring found that it was effec-
tive in improving the taking of medica-
tion as prescribed (61,64–66). In terms
of the more distal outcomes, all five
studies of training in relapse preven-
tion found that it reduced relapses and
rehospitalizations (76–81), all four
studies of teaching coping skills found
that it reduced the severity of symp-
toms (85–88), and all eight studies of
cognitive-behavioral treatment of per-
sistent psychotic symptoms reported
that it reduced the severity of psychot-
ic symptoms (89,103,107–109,112–
114). Although some studies of coping
skills training differed in the symptoms
they targeted, they all employed time-
limited, cognitive-behavioral interven-
tions. Thus psychoeducation, behav-
ioral tailoring for medication, training
in relapse prevention, and coping skills
training employing cognitive-behav-
ioral techniques are strongly supported
components of illness management.
Confidence in these findings is bol-
stered by the fact that the majority of
the studies cited above were based on
treatment manuals, and all except the
studies by Schaub (87) and Schaub and
Mueser (88) and the study by Tarrier
and colleagues (89,112) were conduct-
ed by different groups of investigators.
The three studies of comprehensive
illness management (91–94) suggest
emerging evidence of the effective-
ness of such programs. Improvements
were seen in several important areas,
such as social adjustment (92,93) and
quality of life (91). However, the dif-
ferences between the components of
the programs and their target out-
comes preclude the drawing of any
definitive conclusions about them.
Although the results of these studies
support several components of illness
management, the studies’ limitations
should be acknowledged. First, most
research has focused on persons with
schizophrenia, which limits the find-
ings’ generalizability. Second, few
replications of standardized interven-
tions have been published. Third,
most research examines the effects of
teaching illness management, with less
attention paid to recovery. Although
coping and symptom relief are impor-
tant aspects of recovery (27,30,42), lit-
tle controlled research has examined
the effect of interventions on the
broader dimensions of recovery, such
as developing hope, meaning, and a
sense of purpose in one’s life.
Implementation and
dissemination issues
Strategies for implementing and dis-
seminating evidence-based practices
are critical to keeping these practices
from languishing on the academic
shelf and yielding little effect in rou-
tine mental health settings. Some ill-
ness management strategies, including
psychoeducation, behavioral tailoring
to address willingness to take medica-
tion as prescribed, relapse prevention
skills, and cognitive-behavioral treat-
ment of persistent symptoms, are
available in some settings, but no em-
pirically supported programs are in
widespread use. Generic strategies for
implementing new psychiatric treat-
ment and rehabilitation programs
have been described elsewhere (118).
We consider implementation and dis-
semination issues from the perspec-
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11228800
tives of four stakeholders: mental
health system administrators, program
directors, people with mental illness,
and family members of people with
mental illness. As virtually no con-
trolled data are available on specific
strategies for disseminating and imple-
menting new programs, the recom-
mendations provided below are based
on the experiences of the authors and
other reports in the literature.
Mental health system
administrators
Several issues are relevant for admin-
istrators attempting to implement ill-
ness management approaches, in-
cluding the selection or development
of manuals, monitoring adherence to
the model, policies and procedures,
and funding.
Although the research supports sev-
eral practices for teaching illness man-
agement, the specific components
have not previously been conceptual-
ized and standardized as a unitary
package or manual, except in the con-
text of comprehensive programs that
go well beyond what the evidence
supports. The availability of a treat-
ment manual is critical for broad-scale
implementation of a practice. The
identification of critical practice com-
ponents for illness management, sup-
ported by research, may facilitate the
development of such a manual.
Policies supporting illness manage-
ment as a core capacity in a service sys-
tem are important for implementing
such programs (119). These policies
include the development of program
standards that identify illness manage-
ment as a specific service modality and
require it as a necessary capacity in
contracts with service providers and
managed care entities. Compared with
other evidence-based practices, illness
management services are not expen-
sive, nor do they require major organi-
zational restructuring to implement.
In fact, clinicians routinely work to
help people with mental illness im-
prove their capacity to manage their
illness and achieve their personal
goals. The identification and standard-
ization of core ingredients of illness
management will allow clinicians to do
what they are already trying to do in a
more organized, systematic, and ef-
fective manner.
Both the clinic and the rehabilita-
tion options in state Medicaid plans
can be used to support illness man-
agement services if the services are
led by traditionally credentialed staff.
When partnerships are sought be-
tween clinical staff and peer facilita-
tors as leaders in teaching illness
management skills, available re-
sources must support curriculum de-
velopment and implementation must
include ways to accomplish this ex-
pansion. Although research has not
examined the effects of partnerships
between professionals and peers in
providing illness management skills,
the overlap in curriculum between
the programs reviewed here and
peer-based illness self-management
programs (20) suggests that such col-
laborations should be considered.
Many states that have implemented
these initiatives have used combina-
tions of federal block grant funds,
Community Action Grants from the
Center for Mental Health Services,
and legislatively appropriated county
and state funds.
The continuity of an illness man-
agement program is strengthened by
the development of a leadership
group that meets regularly and is
composed of people with mental ill-
ness, their family members, mental
health service providers, and mental
health service administrators. Such a
group can review the progress of the
program, develop evaluation plans,
assist in addressing system barriers,
and create policies as needed to sup-
port the program. Finally, such a
group can facilitate the regular meet-
ing of providers of illness manage-
ment training to share teaching expe-
riences, provide mutual support, and
assist in curriculum refinement.
Mental health program directors
Program directors need to select a
curriculum that successfully inte-
grates psychosocial and medical ap-
proaches to illness management. If
the approach that is adopted involves
people with psychiatric disorders as
peer educators, a variety of policies
and procedures need to be in place.
These include supporting the em-
ployment of peers, practices that sup-
port reasonable accommodations for
employees with disabilities, and su-
pervision to help ensure appropriate
boundaries between staff, peer-staff,
and the people with mental illness
who are the focus of treatment.
Another consideration is whom to
target for illness management. Many
program directors extend the oppor-
tunity to anyone who wants to attend,
regardless of symptoms or rehabilita-
tion status, on the grounds that desire
to participate is the most important
criterion for selection.
Program directors may find it help-
ful to integrate illness management
principles throughout their organiza-
tion. Case managers, therapists, crisis
clinicians, and prescribing psychia-
trists all have important roles in help-
ing people use skills and in reinforcing
management concepts. As with other
service initiatives, the effect of illness
management education is enhanced
when the organization adopts its prin-
ciples widely. Offering ongoing train-
ing rather than one-time courses can
enhance the impact of illness manage-
ment education. In addition, teaching
a curriculum in short segments that
are often repeated can be successful.
People with mental illness and
their family members
The potential effect of illness manage-
ment initiatives on people with mental
illness is significant. Although the
benefits of learning how to manage
one’s illness and make progress to-
ward recovery are compelling, people
report that recovery is hard work
(26,120). The switch from being a pas-
sive recipient of care to an active part-
ner is very challenging. People with
psychiatric disorders and their rela-
tives may feel justifiably ambivalent
about these approaches (121). For ex-
ample, a person learning about ways
that others cope with symptoms may
consider it a personal failure if he or
she uses these methods but continues
to experience symptoms. Programs
that adopt fail-safe principles, such as
unconditional support, zero exclusion,
and easy reentry, support individuals’
own recoveries and prevent people
from internalizing a sense of failure.
Family members may be con-
cerned that educational approaches
will be used in lieu of established
medical and psychosocial treatments.
Family members may consider the
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PSYCHIATRIC SERVICES ♦ http://psychservices.psychiatryonline.org ♦ October 2002 Vol. 53 No. 10
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idea of recovery unrealistic, or they
may be concerned that their relative
is not ready to assume a more respon-
sible role in treatment. Whether or
not the person lives with relatives,
relatives are likely to have a signifi-
cant, although perhaps a subtly per-
ceived, role in their family member’s
attitude toward recovery. Thus it is
critical that the family understand
and be involved in illness manage-
ment education and that they appre-
ciate its relevance to recovery.
Conclusions
It is now widely recognized that peo-
ple with mental illness can participate
actively in their own treatment and
can become the most important
agents of change for themselves. Ill-
ness management skills, ranging from
greater knowledge of psychiatric ill-
ness and its treatment to coping skills
and relapse prevention strategies,
play a critical role in people’s recovery
from mental illness. Research on ill-
ness management has thus far fo-
cused on programs developed and
run by professionals. This research
provides support for illness manage-
ment programs and guidance on their
effective components. Similar re-
search on peer-based illness self-
management programs may inform
professional-based services and lead
to collaborative efforts. ♦
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