INDIANAPOLIS, IN—The paradigm of schizophrenia treatment through most of the 20th century was a relatively simple one. The disease could be managed with drugs or therapy, many times on an inpatient basis at a hospital facility, but therapy provided little hope. The idea of recovery—that a patient suffering from schizophrenia could conquer their disease to the point where they could function autonomously and successfully—was not considered.

But as mental health has embraced a recovery mode of healthcare, more and more people with severe mental health disorders are being told that they can become a vital member of their community and that healthcare systems can help them achieve that. As more physicians begin using tools focused on management and recovery, it has become imperative that those tools be evaluated and best practices identified and disseminated.

A study currently underway at the Indianapolis VA Medical Center is looking at the methods that modern physicians are using when treatingschizophreniawiththe purposeof demonstratingthosemethods’effectiveness.

Illness Management Recovery

The current recovery model and treatment techniques being used in VA were developed nearly 15 years ago by researchers combing through the medical literature in a search for best practices. “It was developed as part of a national project to implement evidence-based mental health practices,” said Michelle Salyer, PhD, principal investigator of the Indianapolis study. “There was a group that was pulled together in the late 90s through Dartmouth using SAMHSA funding. They wanted to see what the best practices were in the literature to help people with severe mental illness treat their disease better.”

The result was called Illness Management Recovery (IMR). IMR is a nine month structured curriculum taught to schizophrenia patients using educational, motivational, and cognitive-behavioral techniques. It incorporates five evidence-based practices: education about mental illness, strategies for increasing medication adherence, skills training to enhance social support, relapse prevention planning, and coping skills training.

“Using IMR, you teach patients more self-management skills, and focus a lot on what the person wants out of their life,” Salyer stated. “You’re talking about recovery with the patient and getting them thinking about recovery as something that’s possible. And then you’re using that to help them learn the new skills that they need or learn new facts about mental illness or their medication. It’s a self-motivating kind of a program.”

The skills a patient learns include coping strategies that might work for them. For example, if a patient was hearing voices, the clinician would ask them what strategies have worked in the past to help them deal with the voices. The physician would discuss medication, any side effects the patient has been having, and the possibility of either increasing dosage or trying another approach.

“Are they sleeping at night? Using caffeine? Smoking? Are they using other drugs? Talking about those other factors that might increase your symptoms or your problems and how you might manage those areas to handle the voices better,” Salyer said. “They might discuss other coping strategies. Some people wear headphones. Now so many people have the little earphones or Bluetooth® and use them as distractions.”

In short, the IMR toolkit is one focused on the very practical matters of living and coping with schizophrenia and it extensively incorporates the thoughts and needs of the individual patient—something that VA is seeking to do across its entire system.

Testing the Toolkit

The lingering question about IMR—and the question that Salyer’s study, titled Illness Management and Recovery in Veterans with Severe Mental Illness, is asking—is whether the curriculum is effective as a whole. While each separate piece of the curriculum has been proven to work, no one has yet tested the method in its entirety. “When they were putting it together [in the late 90s], the IMR tool-kit itself didn’t have a lot of evidence as a whole package, but the pieces of it did,” she explained.

The trial that Salyer is overseeing has recruited 200 patients suffering from schizophrenia who are being treated in the VA system. Half are getting IMR, which is offered in small groups once a week. The control group receives more traditional therapy. “Also in the control, they participate in a problem-solving group. They meet once a week so we can control for the extra attention. They just come and talk about current day issues and get more group support.”

Researchers will follow the patients over a nine-month period, after which there will be nine months of follow-up. Researchers will return to the patients nine months after that and evaluate how they are dealing with their illness, and whether there are any discernable differences between the groups. Assessment will include illness self-management; objective indicators of recovery, such as role functioning; and subjective indicators of recovery, such as perceptions of well being. Investigators will also access electronic medical records to determine the impact of IMR on other service utilization, as well as comparing costs.

PiecesoftheIMRpackagearebeingusedacrossVAanditisonthelistofrequiredtreatmentoptionsforVArehabilitationandrecoverycenters focused on patients with severe mental illness. “Each of those, to be certified, has to offer IMR and recovery or something like it—a curriculum-based approach to helping people learn more about illness-based management,” Salyer declared. “Currently, we don’t know how many centers are doing IMR, if they are doing it to full fidelity to the model, or if they are using the full toolkit.”

Salyer and her colleagues are getting ready to submit a grant proposal to VA to see if they can start identifying who across VA is using the IMR approach, to what extent are they using it, and what barriers or facilitators they are seeing in their work.

Define Recovery

Whether or not the full IMR toolkit will hold up under examination, the transformation in how schizophrenia is seen by the medical community and by those suffering from the disease is undeniable.

“The message I was sent in graduate school was that once you got a diagnosis of schizophrenia, you might not have a normal life. You may not be able to work or have a family or have your own home,” Salyer said. “The message now is that’s not necessarily true and that a lot of people can recover from the effects of mental illness.”

That message has sunk in for those struggling with the illness, who now feel like they can play an active part in helping steer the course of their own treatment. “We get people thinking about what they want from their life, what are they excited about. We get them to be more engaged in treatment. We get them wanting to manage the illness, because they have something to look forward to.”

That “something” can be different for each person, highlighting another major change in how people think, not only about treating mental illness, but also about recovery in general. “Recovery is different for each person,” Salyer declared. “Some people are really interested in social relationships, other people want a job, and others want to volunteer.”

Letting the patient define what recovery means to them is another way the IMR system puts control in the hands of the consumer, Salyer noted. “It’s another form of shared decision-making. How do you, as a person with schizophrenia, talk with your doctor so that your treatment is not just based on the published evidence, but also on your values and personal preferences? There’s a lot of work being done on coming up with tools to help with that.”

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