How people manage their chronic condition when not under direct medical supervision makes a difference in their quality of life, their health, and their utilization of the health care system—and such self-management can be both time-consuming and complex. While health care providers routinely educate patients about understanding medical conditions, diagnoses, and treatment options, self-management is defined as the tasks that individuals must undertake to live well with 1 or more chronic conditions.1These tasks include having the confidence to deal with the medical and emotional management of their condition.
Self-management programs are an effective complement to the work provided by clinicians. While variation exists regarding the implementation of self-management programs in terms of program location, staffing, and the extent of personal interaction between self-management coaches and patients, the overall objective of self-management programs is to change behavior.
These changes allow patients to effectively cope with their chronic conditions—many of which can be progressive and debilitating—by learning healthier ways to live, gaining confidence and motivation to manage their health, and feeling more positive about their lives.
Making behavior changes is difficult, and the changes are often hard to maintain. For behavior change to occur, patient education alone is not sufficient. Having the confidence to make the change is critical. This confidence can be translated to self-efficacy—the belief that one is capable of attaining certain goals.
Self-efficacy can be enhanced through specific self-management tools and techniques, such as skills mastery through the achievement of action plans; modeling, which allows self-management program participants to see people like themselves helping others and being successful; reinterpretation of beliefs; and social persuasion. All self-management programs are built on 3 important underlying skills: action planning, problem solving, and decision making. Evidence-based self-management programs stress that for action plans to be effective, they must2,3:
• Reflect what the patient really wants to do
• Be specific about what is to be accomplished, how much, how often, when, and where
• Be realistic in what can be achieved successfully
• Incorporate problem-solving and decision-making techniques that allow for adjustments when issues arise that might interfere with the action plan
The Chronic Disease Self-Management Program (CDSMP) is the most extensively tested peer-led self-management program designed to address the needs of persons who have a wide range of chronic medical conditions, such as diabetes mellitus, arthritis, chronic pain, and HIV infection.2-4 As with all self-management programs, the CDSMP enhances regular treatment and disease-specific education. The program consists of 6 structured small-group sessions that focus on a set of self-management tasks that have been found to be common across chronic conditions, including becoming a better self-manager, increasing healthy behaviors, and using the health care system effectively.
The elements of the intervention, grounded in self-efficacy theory, include regular action planning and feedback, modeling of behaviors and problem solving, reinterpretation of symptoms, and self-tailoring (ie, making your own plans based on what you have learned), so choices are based on the preferences and voice of the patient (see the Table for key subjects covered by the CDSMP).
Self-management and mental health
Efforts to improve the treatment of more common mental health conditions, such as depression, often incorporate elements of the chronic illness care model that support the improvement in self-efficacy.5 By implementing behavioral changes, the patient is better prepared for crises and relapse prevention. Allowing mental health patients to assume a greater role in decision making and self-management is a main theme described by proponents of recovery.
The recovery model is based on understanding personal meaning; attending to personal experiences, contexts, and meanings; building better patient-clinician partnerships; and creating integrated, self-management support structures. Both recovery and self-management stress wellness by removing the blame for the disease or condition from the patient and empowering him or her to take control of his or her life and health. In fact, self-management of psychiatric illnesses has become a central tenet of patient-directed mental health treatment.6,7
One of the most widely circulated programs that expands mental health recovery and consumer movements to include self-management is the Wellness Recovery Action Plan (WRAP).8 WRAP is patient-directed and centers on identifying internal and external resources for facilitating recovery. Using presentations, demonstrations, interactive discussions, and related activities, WRAP facilitators teach participants that to successfully recover from mental illness, they must be determined to get better, manage illness, take action, face problems, and make choices. WRAP facilitators assist participants in creating a personal “Wellness Toolbox” that consists of simple and easily accessible strategies, such as healthy diet, exercise, sleep, and meeting life and vocational goals, in addition to the identification of “early warning signs” and how to effectively manage a crisis situation.
Over the past several years, a number of other well-established, peer-led mental health recovery programs have incorporated self-management concepts. In the mid-1990s, Building Recovery of Individual Dreams and Goals through Education and Support (BRIDGES)9 began to involve peers in teaching courses on recovery and in facilitating ongoing support groups promoting overall wellness.
Similarly, the National Alliance on Mental Illness (NAMI) Peer-to-Peer program10 uses peers to assist persons with mental illness to establish and maintain their recovery through a unique, experimental consumer education and learning program (NAMI 2005). The Vet-to-Vet Peer Support program11 and the Massachusetts Peer Educators Project stress that meetings should encourage, validate, and support recovery in an ongoing fashion.
To help individuals gain the skills needed to lead more peaceful and productive lives, Abraham Low Self-Help Systems (the result of a merger of Recovery International and the Abraham Low Institute) also provide a safe place to talk about life’s struggles with others who have had similar experiences.
As with medical self-management interventions, peer-led mental health programs use the power and influence of peer networks to model physical and social functioning and further build self-efficacy. Peer-led self-management programs are increasingly becoming part of mainstream care delivery in the public mental health system. More than half of state Medicaid programs reimburse peers who provide these evidence-based services. In the context of peer support, self-management allows mental health consumers to become active participants in their health care, leading them to an overall sense of well-being despite their illnesses.
Medical disease self-management among persons with serious mental illness
Research shows that persons with serious mental illness are at elevated risk for a wide range of chronic medical conditions that contribute to increased morbidity and premature death.12,13 Compared with the general population, persons with serious mental illness die about 25% earlier. More specifically, 60% of premature deaths in persons with schizophrenia are due to medical conditions, such as cardiovascular, pulmonary, and infectious diseases.13
Modifiable risk factors, such as physical inactivity, poor diet, smoking and other drug use, problems with medication adherence, and limited health literacy, increase the incidence of illness. At the same time, individuals with serious mental illness face a series of barriers to effectively manage their illness and access appropriate health care. Persons with serious mental illness experience greater social challenges that include unemployment, homelessness, incarcerations, victimization/trauma, poverty, and social exclusion. Consequently, it is particularly important for these persons to acquire the skills to self-manage both their chronic medical conditions and their mental illness.
The Health and Recovery Peer (HARP) program is an adaptation of the CDSMP. It is the first fully peer-led program specifically designed to be delivered by, and to, mental health consumers.
To adapt the CDSMP for mental health consumers, modifications that address potential gaps in health literacy and cognitive limitations were made, and peer coaching sessions were added to personalize the program and reinforce each group session. Materials emphasizing the connection between the mind and body, the importance of coordinating information and medications between primary care providers and mental health clinicians, and the need to consider a mental health advanced directive were also added. The diet and exercise sections were adapted to address high rates of poverty and social disadvantage in this population, and interactive cooking and exercise classes were added.
In a pilot trial, participants in the HARP program showed significant improvement in patient activation (a measure of an individual’s self-management capacity) and in using primary care medical services.12 These benefits appeared greatest in populations with financial and social disadvantage. A multisite, randomized trial of the intervention is now under way in Georgia.
The role of mental health providers in promoting self-management
Interactions with patients should be structured to identify problems from a patient perspective and to design real-life solutions through goal setting, problem solving, action plans, and regular feedback. Sharing responsibilities with patients and emphasizing the vital role patients play in improving health-related habits and self-managing their health conditions are key, regardless of diagnoses. One study found that 4 months after participating in the CDSMP, patients with diabetes mellitus showed significant improvements in eating breakfast, mental stress, aerobic activities, shortness of breath, and pain.12 These improvements continued after 1 year and resulted in increased physician utilization and decreased hospitalizations.
Over the past 20 years, self-management programs have yielded significant, measurable improvements in long-term health benefits, patient outcomes, quality of life, and utilization of health care resources for patients with many different chronic conditions, including diabetes mellitus, heart disease, lung disease, HIV infection, arthritis, autoimmune disorders, and mental illness. These programs have targeted a variety of populations in the United States and abroad.4,14-16 Self-management support assists patients as they take greater ownership of their care: patients are encouraged to live with their physical and mental health conditions long-term and full of hope.
Building on this approach, community mental health centers and other specialty providers are increasingly using peers to promote group work and mutual support to enable patients with mental health problems to draw on each other’s experiences regarding both mental health and general wellness. Mental health clinicians can also link patients to other established community self-management interventions located in health departments, health care organizations, and local non-profits. Through patient self-management, mental health clinicians can transfer the focus from managing symptoms to allowing patients to live well in the context of their mental illness and medical comorbidities. And, patient peers can help model behaviors aimed at improving both physical and mental health.
Dr Sterling is Health Education Consultant in the department of health policy and management, Rollins School of Public Health, Emory University, Atlanta. Dr Druss is Professor and Rosalyn Carter Chair in Mental Health in the department of health policy and management, Rollins School of Public Health, Emory University. Dr Lorig is Professor in the department of medicine and Director of the Patient Education Research Center, department of medicine, Stanford University, Stanford, Calif. The authors report no conflicts of interest concerning the subject matter of this article.
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