General discussion 193 fidelity in the present study. In another study, the results regarding lower scoring items on the IT-IS were quite similar (23). The similarities among the results of these three studies support generalization. This provides direction for IMR to improve mental efforts in clinical practice, namely, to improve some cognitive-behavioral skills, especially the use of role-playing, modeling, and home assignments, as these are crucial for implementing otherwise poorly implemented elements. IMR in a broader context A systematic review and meta-analysis of 37 studies on self-management interventions, including nine studies on IMR (24%), found positive effects on symptoms and hospital length of stay, as well as on functioning and multiple components of personal recovery, such as hope, empowerment, and self-efficacy (2). Several of the effects on self-management interventions reported in this review and meta-analysis were found in only some of seven RCTs on IMR, including our own RCT (Table 2). Three of the six RCTs that assessed symptoms reported significant IMR effects on this domain (4-6), and one of three RCTs found effects on hospital length of stay (6). In addition, only two of six RCTs found effects on functional recovery (4, 6) and only one of four on personal recovery (3). However, five of these seven RCTs found effects on overall illness self-management as measured using the IMR scale, of which three RCTs found effects on both versions of the IMR scales (4-6), one RCT found effects only on the client version (3) and one other RCT only on the clinician version of the IMR scale (7). Therefore, the most consistent effect of IMR was overall illness self-management. Two RCTs on IMR found no effects at all (8-10, 12), probably due to very low completion rates (Chapter 5). Several aspects were not assessed in all seven RCTs. Therefore, a wellconducted review and meta-analysis of IMR is needed. We suggest that the results of the mentioned review and meta-analysis on self-management (2) can be considered as potential outcomes of IMR, which were only partially realized in the current study. However, as indicated in our study, proper implementation of IMR seems necessary to achieve more effects (Chapter 5). IMR and its theoretical framework Our results on the association between illness management and personal recovery, found using structural equation modeling (SEM) and mediation analysis (Chapters 4 and 7), are supported by previous findings. An earlier review and meta-analysis showed that self-management treatment conditions of people with SMI had a significant effect compared with control on subjective recovery measures such as hope and empowerment (2). Hope and empowerment are components of the CHIME conceptual framework for personal recovery, as are connectedness, identity, and meaning in life (24). Moreover, these results were consistent with
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