Effects of IMR: a randomized controlled trial 131 addition, multiplicity adjustments are not considered appropriate for more exploratory secondary analyses (63, 71). Therefore, we suggest that the present interpretation of our findings may be relevant. Strengths and Limitations Our study has five main strengths. First, our sample size was relatively large and we used a complete set of outcomes. This allowed for rigorous measurement of the IMR effects. Second, we thoroughly investigated the impact of completion rates. Third, to our knowledge, this is the first RCT on IMR to assess the impact of fidelity. Fourth, this is the first RCT on IMR to find effects on personal recovery. Finally, given the natural setting of the current investigation, our results can be assumed to have good generalizability. In addition to these substantial strengths, this study had several limitations. First, there was suboptimal IMR implementation, with approximately half of the IMRparticipants completing the program; furthermore, IMR fidelity was only fair to moderate for almost half of the IMR participants. For example, skills training using role play was applied at a low rate within the evaluated interventions. This suboptimal IMR implementation may have led to an underestimation of the outcomes. Second, since we aimed to comprehensively explore the effects of IMR, we examined numerous secondary outcome measures. Therefore, with reference to alpha inflation, the statistically significant result regarding self-esteem can be disputed. Third, when completing the clinician version of the IMR scale and the Service Engagement Scale, clinicians were not blinded to their patients’ experimental conditions. Since we used self-score questionnaires, the patients were not blinded to the treatment condition. However, all interviewers were blinded to the condition. Fourth, in measuring the impact of fidelity, we could only utilize the fidelity scores of the 68 participants in the 15 IMR groups. This limits the generalizability of our results. Fifth, most of the enrolled participants had relatively few problems in the three domains of addiction, medication adherence, and insight at baseline; therefore, there was little room for improvement within these domains. Conclusions In the current study, we observed positive results with respect to the client version of the IMR scale. Our results support the effectiveness of IMR in overall illness selfmanagement. This finding was confirmed within our secondary analysis among IMR completers. However, we observed negative results for five specific components of illness management. Therefore, our findings suggest that IMR is a non-specific intervention for illness self-management.
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