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Cited by 34Mental Health and Patient InvolvementOccupational Therapy Practice and ResearchPsychiatric care and mental health services

Exploring mediators of the recovery process over time among mental health service users, using a mixed model regression analysis based on cluster RCT data

Open access
Argentzell, Elisabeth, Bäckström, Martin, Lund, Kristine, Eklund, Mona·2020·BMC Psychiatry
DOI 10.1186/s12888-020-02924-2PMC PMC7602343
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Abstract

Background: Personal recovery is associated with many significant health-related factors, but studies exploring associations between activity factors and personal recovery among service users are scarce. The aims of this study were hence to; 1) investigate if various aspects of activity may mediate change in recovery while also acknowledging clinical, sociodemographic and well-being factors; 2) explore the effects of two activity-based interventions, Balancing Everyday Life (BEL) or standard occupational therapy (SOT), on personal recovery among service users. Methods: Two-hundred-and-twenty-six service users were included in a cluster RCT, 133 from BEL units and 93 from SOT units. Participants commonly had a diagnosis of mood disorder and the mean age was 40. Instruments used targeted activity, mastery and functioning. A mixed-model regression analysis was employed. Results: The model tested was whether selected variables could be used to mediate the change in recovery from the start to a six-month follow-up after intervention. Participants’ personal recovery increased after treatment and increased further at the follow-up. The general level of recovery was negatively related to a diagnosis of depression/anxiety, both before and after treatment, but depressed/anxious service users still increased their recovery. There were no significant relations between recovery and sex or age. The interactions between change in recovery and changes in depression/anxiety, satisfaction with activities, sex, and age were all non-significant. All possible treatment mediators included were related to change in recovery, the strongest being occupational engagement and mastery, followed by activity satisfaction and symptoms. Mediation was shown by the decrease in the effect of the time factor (from intervention start to completion) when the covariates were introduced. In all cases the time variable was still significant. When testing a model with all variables simultaneously as covariates, occupational engagement and mastery were strongly significant. There was no difference between interventions regarding recovery improvement. Conclusion: The treatments were equally beneficial and were effective regardless of gender, age and diagnosis. Those who gained most from the treatment also gained in feelings of mastery and activity engagement. Activity engagement also moderated the level of recovery. To enhance recovery, interventions should facilitate meaningful activities and gaining control in life. Trial registration: The study was registered with ClinicalTrials.gov. Reg. No. NCT02619318. Retrospectively registered: December 2, 2015.

AI snapshot

Written from the paper’s full text.

TL;DR

This secondary analysis of a cluster RCT found that personal recovery increased among 226 mental health service users from baseline to six-month follow-up, with no difference between Balancing Everyday Life (BEL) and standard occupational therapy (SOT). Activity engagement and mastery were the strongest mediators of recovery change.

Key findings

  • Recovery increased from a mean of 52.45 at baseline to 56.09 after treatment and 57.68 at six-month follow-up (both increases p < 0.001; M2 vs M3 p < 0.05). There was no significant BEL vs SOT main effect, F(1,214.5) = 0.154, p > .05, and no interaction, F(2,348.6) = 0.151, p > 0.05.
  • In models with one covariate at a time, all tested mediators were related to recovery change; the strongest were activity engagement (F = 206.2, p < 0.001) and mastery (F = 177.2, p < 0.001), followed by activity satisfaction (F = 79.7, p < 0.001) and symptoms (F = 47.6, p < 0.001).
  • In the simultaneous model, activity engagement (F = 59.00, p < 0.001) and mastery (F = 57.70, p < 0.001) remained strong unique mediators; activity satisfaction (F = 9.72, p < 0.001) and symptoms (F = 4.46, p = 0.035) were weaker, while activity level, activity balance, and functioning were not significant. The time effect became non-significant, F(2,280.1) = 1.62.
  • Depression/anxiety diagnosis was related to lower recovery overall, F(1,213.1) = 14.19, p < 0.001, but there were no significant relations with sex or age and no baseline moderation by depression/anxiety, activity satisfaction, sex, or age. Activity engagement moderated follow-up recovery, F(2,318.6) = 4.38, p = .013, B = .42, t(328.8) = 2.92, p = 0.004.

Methods

  • Secondary analysis of a cluster RCT including 226 service users (133 from BEL units, 93 from SOT units) in Swedish outpatient and community-based mental health settings; mean age was 40, and participants commonly had mood disorder diagnoses. Data were collected at baseline, after the 16-week intervention, and at six-month follow-up.
  • Mixed-model regression analysis in SPSS used time as a within-subject factor and mediators/moderators as between-subject fixed factors, with compound symmetry for within-subject variance. Mediation was inferred from a reduction in the time effect when covariates were introduced.
  • Measures included POES for activity engagement, SDO-OB for activity level/satisfaction/balance, QPR-Swe for personal recovery, Pearlin Mastery Scale for self-mastery, and GAF for functioning and symptom severity.

Limitations

  • The paper states that only the English QPR has been tested for test-retest stability, although the Swedish QPR has shown sensitivity to change; the exact participation rate could not be calculated because of gatekeepers and unsatisfactory administrative routines, weakening external validity; dropout left the SOT group somewhat underpowered; the longitudinal design cannot demonstrate clear cause and effect; and because several possible interactions were tested, the significant activity-engagement moderation needs replication.
  • Evident from the text: blinding was not possible in the cluster design, although allocation concealment and other bias-counteracting actions were used.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1186/s12888-020-02924-2

Cites

41 of 41 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

0 of 49 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    In all cases the time variable was still significant.

    “In all cases the time variable was still significant.”
    Quote in the paperSubstantial claim
  • Findingown data

    Depressed/anxious service users still increased their recovery.

    “but depressed/anxious service users still increased their recovery.”
    Quote in the paperNot a substantial claim
  • Findingown data

    There were no significant relations between recovery and sex or age.

    “There were no significant relations between recovery and sex or age.”
    Quote in the paperNot a substantial claim
  • Findingown data

    The strongest mediators of change in recovery were occupational engagement and mastery, followed by activity satisfaction and symptoms.

    “All possible treatment mediators included were related to change in recovery, the strongest being occupational engagement and mastery, followed by activity satisfaction and symptoms.”
    Quote in the paperSubstantial claim
  • Findingown data

    The general level of recovery was negatively related to a diagnosis of depression/anxiety, both before and after treatment.

    “The general level of recovery was negatively related to a diagnosis of depression/anxiety, both before and after treatment, but depressed/anxious service users still increased their recovery.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 40
  • Classified as probably not a substantial claim. 38

  • May combine two claims.

    Findingown data

    Participants' personal recovery increased after treatment and increased further at the six-month follow-up.

    “Participants’ personal recovery increased after treatment and increased further at the follow-up.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The interactions between change in recovery and changes in depression/anxiety, satisfaction with activities, sex, and age were all non-significant.

    “The interactions between change in recovery and changes in depression/anxiety, satisfaction with activities, sex, and age were all non-significant.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    All variables were correlated.

    “All variables were correlated (see Table 2).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The strongest mediators were activity engagement and mastery, followed by activity satisfaction and symptoms; weaker effects were found for activity level, activity balance and psychosocial functioning.

    “The strongest mediators were activity engagement and mastery, followed by activity satisfaction and symptoms. Somewhat weaker effects were found for activity level, activity balance and psychosocial functioning.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The participants were service users from 37 different units.

    “The participants were service users from 37 different units.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The change in recovery was significant (F(2, 351.6) = 30.54, p < 0.001), with mean recovery increasing from 52.45 to 56.09 and then to 57.68.

    “the change was significant F (2, 351.6) = 30.54, p < 0.001; the mean of recovery increased from 52.45, to 56.09, (p < 0.001), and then to 57.68 (p < 0.001)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The treatment effect on recovery was significant for all tested mediators, and the relationships were positive.

    “The treatment effect on recovery was significant for all tested mediators, and the relationships were in all cases positive.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The strongest effects on recovery were from activity engagement and mastery, while activity level and symptoms showed weaker effects.

    “The strongest effects on recovery were from activity engagement and mastery, while activity level and symptoms showed weaker effects.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    When all mediators were included, the change in recovery was not significant (F(2, 280.1) = 1.62), with corrected means 55.4, 56.6, and 56.5 at the three time points.

    “In this model, when all mediators were included, the change in recovery was not significant F (2, 280.1) = 1.62, and the corrected mean values were 55.4, 56.6, and 56.5 for recovery at the three time points.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Although there was a difference in recovery at the start between users diagnosed with depression/anxiety and other diagnostic groups, and that difference remained over time, the group with depression/anxiety increased their recovery and benefitted from treatment to the same extent as those without such a diagnosis.

    “The current findings further showed that, although there was a difference in recovery at the start between users diagnosed with depression/anxiety and the other diagnostic groups, and that difference remained over time, the group with a diagnosis of depression/anxiety increased their recovery and benefitted from treatment to the same extent as those without such a diagnosis.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    From baseline to 16 weeks, dropout was 33 (25%) in BEL and 13 (14%) in SOT, a statistically significant difference (p=0.047).

    “From baseline to 16 weeks there were 33 dropouts (25%) the BEL group and 13 (14%) in the SOT group, which was a statistically significant difference (p = 0.047).”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    The BEL intervention seemed to enhance activity and key recovery tenets over time.

    “Qualitative studies from that project show that the intervention seemed to enhance activity and key recovery tenets over time [23, 24].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [23] Lund K, Argentzell E, Leufstadius C, Tjörnstrand C, Eklund M. Joining, belonging, and re-valuing: a process of meaning-making through group participation in a mental health lifestyle intervention. Scand J Occup Ther. 2017;26(1):55–68. source

      Not checked in the free run.

    • cites [24] Lund K, Hultqvist J, Bejerholm U, Argentzell E, Eklund M. Group leader and participant perceptions of balancing everyday life, a groupbased lifestyle intervention for mental health service users. Scand J Occup Ther. 2019;6:462–73.

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    Between the 16-week measurement and the six-month follow-up, dropout was 11 (8%) in BEL and 10 (11%) in SOT, not statistically significant (p=0.527).

    “Between the 16-week measurement and the six-month follow-up another 11 participants (8%) in the BEL group and 10 (11%) in the SOT group dropped out, which was not a statistically significant difference (p = 0.527).”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Everyday activity experiences, within and beyond mental health care, shape personal recovery processes.

    “A more recent study [19], using the CHIME framework to analyze the daily life of people with severe mental illness, found that everyday activity experiences, within and beyond mental health care, shape personal recovery processes [19].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [19] Piat M, Seida K, Sabetti J. Understanding everyday life and mental health recovery through CHIME. Ment Health Soc Incl. 2017;21(5):271–9. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Allocation concealment was ensured by an independent research colleague handling the randomization procedure.

    “In order to ensure allocation concealment and prevent bias, the randomization procedure was handled by an independent research colleague.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Personal recovery is associated with satisfaction with daily activities as well as activity level.

    “a quantitative study by Eklund and Tjörnstrand [20] found that personal recovery was associated with satisfaction with daily activities as well as activity level.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] Eklund M, Tjörnstrand C. Associations between occupational and social interaction factors and well-being among people with psychiatric disabilities living in supported housing in Sweden. J Occup Sci. 2019;27(1):54–68. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Activity engagement and forms of disengagement play an important role in the recovery process.

    “The results showed that activity engagement, and also forms of disengagement, played an important role in the recovery process.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [18] Sutton D, Hocking CS, Smythe LA. A phenomenological study of occupational engagement in recovery from mental illness. Can J Occup Ther. 2012;79(3):142–50. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    POES has good internal construct validity and inter-rater agreement.

    “The POES instrument has been found to have good internal construct validity and inter-rater agreement engagement [31, 32].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [31] Bejerholm U, Hansson L, Eklund M. Profiles of occupational engagement among people with schizophrenia: instrument development, content validity, inter-rater reliability, and internal consistency. Br J Occup Ther. 2006;69(2):58–68. source

      Not checked in the free run.

    • cites [32] Bejerholm U, Lundgren-Nilsson A. Rasch analysis of the profiles of occupational engagement in people with severe mental illness (POES) instrument. Health Qual Life Outcomes. 2015;13:130. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    CHIME is lacking a dimension of activity as part of the recovery journey.

    “Also, the prominent recovery framework CHIME is lacking a dimension of activity as a part of the recovery journey [9].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [9] Leamy MBV, Le Boutillier C, et al. Conceptual framework for personal recovery in mental health systematic review and narrative synthesis. Br J Psychiatry. 2011;199(6):445–52. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Sole reduction of symptoms does not necessarily result in higher personal recovery.

    “Furthermore, studies have shown that sole reduction of symptoms (i.e. clinical recovery) does not necessarily result in higher personal recovery [6, 7].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [6] Law H, Shryane N, Bentall RP, Morrison AP. Longitudinal predictors of subjective recovery in psychosis. Br J Psychiatry. 2016;209(1):48–53. source

      Not checked in the free run.

    • cites [7] Resnick S, Rosenheck RA, Lehman AF. An exploratory analysis of correlates of recovery. Psychiatr Serv. 2004;55(5):540–7. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The BEL program has positive effects on activity engagement, activity level and activity balance, as well as on symptom severity and level of functioning.

    “The program has been evaluated in an RCT [22] showing positive effects on activity engagement, activity level and activity balance, as well as on symptom severity and level of functioning.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [22] Eklund M, Tjörnstrand C, Sandlund M, Argentzell E. Activity outcomes of balancing everyday life (BEL) for people with psychiatric disorders. BMC Psychiatry. 2017;17:363. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    SDO has good internal consistency and construct validity.

    “The original SDO, without the balance questions, has shown good internal consistency and construct validity [26].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [26] Eklund M, Backstrom M, Eakman A. Psychometric properties and factor structure of the 13-item satisfaction with daily occupations scale when used with people with mental health problems. Health Qual Life Outcomes. 2014;12(1):7. source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductown data

    The settings were assigned to BEL or SOT by cluster randomization in blocks of four, with two randomized to BEL and two to SOT.

    “The settings were assigned to the BEL or SOT intervention by cluster randomization. During 2012–2015, eligible settings were successively grouped in blocks of four units, from which two were randomized to the BEL intervention and two to SOT.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    Sample size was based on a power analysis on the SDO: 82 participants per group to detect a difference of 0.5 with 80% power at p<0.05; presuming 25% attrition, 120 participants per group were sought.

    “Using the means and standard deviations from a previous study [27] we arrived at 82 participants in each group to detect a difference on the SDO of 0.5 with 80% power at p < 0.05. Presuming 25% attrition, we sought to include 120 participants from BEL setting and the same number from SOT settings.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [27] Eklund M, Hansson L, Ahlqvist C. The importance of work as compared to other forms of daily occupations for wellbeing and funtioning among persons with long-term mental illness. Community Ment Health J. 2004;40:465–77. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Pearlin Mastery Scale Swedish version has good psychometric properties in terms of reliability and validity.

    “The Swedish version used in the current study has shown good psychometric properties in terms of reliability and validity [38].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [38] Argentzell E, Leufstadius C, Eklund M. Factors influencing subjective perceptions of everyday occupations: comparing day Centre attendees with non-attendees. Scand J Occup Ther. 2012;19:68–77. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    SDO-OB balance questions showed satisfactory construct validity.

    “The balance questions, added later, were tested separately and showed satisfactory construct validity [33].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [33] Eklund M, Argentzell E. Perception of occupational balance by people with mental illness: a new methodology. Scand J Occup Ther. 2016;23(4):304–13. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    GAF is considered reliable and valid.

    “GAF has been used extensively and is considered reliable and valid [41].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [41] Vatnaland T, Vatnaland J, Friis S, Opjordsmoen S. Are GAF scores reliable in routine clinical use? Acta Psychiatr Scand. 2007;115(4):326–30. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Activity engagement is an important dimension of recovery.

    “The authors concluded that activity engagement is an important dimension of the recovery.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [2] Doroud N, Fossey E, Fortune T. Recovery as an occupational journey: a scoping review exploring the links between occupational engagement and recovery for people with enduring mental health issues. Aust Occup Ther J. 2015;62:378–92. source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductcitation

    QPR-Swe 16-item one-factor Swedish version has good internal consistency and satisfactory construct validity.

    “For this study the QPR-Swe was used, which is a 16-item one-factor version in the Swedish language with good internal consistency and satisfactory construct validity [36].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [36] Argentzell E, Hultqvist J, Neil S, Eklund M. Measuring personal recovery - psychometric properties of the Swedish questionnaire about the process of recovery (QPR-Swe). Nord J Psychiatry. 2017;71(7):529–35. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A diagnosis of depression and/or anxiety is related to negative ratings of subjective well-being factors such as quality of life.

    “Research indicates that a diagnosis of depression and/or anxiety is related to negative ratings of subjective well-being factors such as quality of life [29, 30].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [29] Johansson S, Bejerholm U. The role of empowerment and quality of life in depression severity among unemployed people with affective disorders receiving mental healthcare. Disabil Rehabil. 2017;39(18):1807–13. source

      Not checked in the free run.

    • cites [30] Eklund M, Backstrom M, Lissner L, Bjorkelund C, Sonn U. Daily activities mediate the relationship between personality and quality of life in middle-aged women. Qual Life Res. 2010;19(10):1477–86. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    CHIME is one of the most prominent and well-used frameworks for personal recovery in mental health services and research.

    “CHIME currently is one of the most prominent and well-used frameworks for personal recovery in mental health services and research [10], including the current study.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] van Weeghel J, van Zelst C, Boertien D, Hasson-Ohayon I. Conceptualizations, assessments, and implications of personal recovery in mental illness: a scoping review of systematic reviews and meta-analyses. Psychiatric Rehabil J. 2019;42(2):169–81. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    The results were almost identical when models were estimated using deletion of persons with only baseline data, though power was somewhat lower.

    “We also estimated the same models using deletion of persons for whom data was obtained only at baseline. The results were almost identical, even if power was somewhat lower.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Reliable GAF ratings require training of raters.

    “Reliable GAF ratings require training of the raters [40]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [40] Startup M, Jackson MC, Bendix S. The concurrent validity of the global assessment of functioning (GAF). Br J Clin Psychol. 2002;41(4):417–22. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Activity engagement cultivates meaning in life for people with psychiatric disabilities.

    “Activity engagement cultivates meaning in life for people with psychiatric disabilities [17], which has generated an interest in activity-based approaches within mental health care and research, including investigation of recovery from an activity perspective.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [17] Argentzell E, Håkansson C, Eklund M. Experience of meaning in everyday occupations among unemployed people with severe mental illness. Scand J Occup Ther. 2012;19:49–58. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning

    Blinding was not possible in a cluster design, so other actions were performed to counteract bias: allocation concealment, treatment allocation not specified to the data collector, identical information letter, and not revealing treatment.

    “Since blinding was not possible in a cluster design, other actions were performed to counteract bias. As stated above, allocation concealment was ensured, and treatment allocation was not specified to the data collector. Also, efforts were made to treat all participants similarly, such as providing an identical information letter, not revealing whether the treatment was BEL or SOT.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The treatments were equally beneficial and were effective regardless of gender, age and diagnosis.

    “The treatments were equally beneficial and were effective regardless of gender, age and diagnosis.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    The different factors in CHIME possibly interact with activity engagement.

    “The choice of this specific framework was also based on the fact that the different factors in CHIME possibly interact with activity engagement [2], although this needs to be further investigated.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [2] Doroud N, Fossey E, Fortune T. Recovery as an occupational journey: a scoping review exploring the links between occupational engagement and recovery for people with enduring mental health issues. Aust Occup Ther J. 2015;62:378–92. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Engaging in meaningful and valued occupations supports recovery through fostering the CHIME factors of connectedness, hope, identity, meaning, and empowerment.

    “The study showed that engaging in meaningful and valued occupations seemed to support recovery through fostering the CHIME factors of connectedness, hope, identity, meaning, and empowerment.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [2] Doroud N, Fossey E, Fortune T. Recovery as an occupational journey: a scoping review exploring the links between occupational engagement and recovery for people with enduring mental health issues. Aust Occup Ther J. 2015;62:378–92. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    These variables were not based on the service users' self-reports but were rated by research assistants.

    “This is noteworthy, since these variables were not based on the service users’ self-reports but were rated by research assistants.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Both of the activity-based occupational therapy based treatments were successful, and they seem to have been equally beneficial for men and women, for people of various ages and for various diagnostic groups when aiming at increasing recovery.

    “Since no support was found for moderators or type of intervention, one can conclude that both of the activity-based occupational therapy based treatments were successful, and they seem to have been equally beneficial for men and women, for people of various ages and for various diagnostic groups when aiming at increasing recovery.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Using the QPR to measure recovery in this study can be seen as a strength, since it aligns well with CHIME.

    “Using the QPR [34] to measure recovery in this study can be seen as a strength, since it aligns well with CHIME, one of the most-used frameworks for personal recovery in mental health services today [10].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [34] Neil ST, Kilbride M, Pitt L, Nothard S, Welford M, Sellwood W, et al. The questionnaire about the process of recovery (QPR): a measurement tool developed in collaboration with service users. Psychosis. 2009;1(2):145–55. source

      Not checked in the free run.

    • cites [10] van Weeghel J, van Zelst C, Boertien D, Hasson-Ohayon I. Conceptualizations, assessments, and implications of personal recovery in mental illness: a scoping review of systematic reviews and meta-analyses. Psychiatric Rehabil J. 2019;42(2):169–81. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    In order to enhance the recovery process, interventions within mental health care should facilitate engagement in personally meaningful and desired activities and support the target groups' possibilities to create control and independence in daily life.

    “These results indicate that in order to enhance the recovery process, interventions within mental health care should facilitate engagement in personally meaningful and desired activities and support the target groups´ possibilities to create control and independence in daily life.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Few existing interventions in mental health services today focus explicitly on both these aspects.

  • May combine two claims.

    Study design and conductcitation

    Although the Swedish version of QPR has shown sensitivity to change, only the English version has been tested for test-retest stability, which may be seen as a limitation of this study.

    “Firstly, it should be mentioned that although the Swedish version of QPR has shown sensitivity to change [36], only the English version has been tested for test-retest stability [34], which may be seen as a limitation of this study.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [36] Argentzell E, Hultqvist J, Neil S, Eklund M. Measuring personal recovery - psychometric properties of the Swedish questionnaire about the process of recovery (QPR-Swe). Nord J Psychiatry. 2017;71(7):529–35. source

      Not checked in the free run.

    • cites [34] Neil ST, Kilbride M, Pitt L, Nothard S, Welford M, Sellwood W, et al. The questionnaire about the process of recovery (QPR): a measurement tool developed in collaboration with service users. Psychosis. 2009;1(2):145–55. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    The identified mediators must be seen as aspects of the general improvement the mental health service users reached; the study could not demonstrate any clear cause and effect.

    “Another study limitation includes that although this was a longitudinal study, the identified mediators must be seen as aspects of the general improvement the mental health service users reached. This study could thus not demonstrate any clear cause and effect.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Previous qualitative research shows that being more active in daily life and participating in the surrounding community were important factors for personal recovery.

    “That would be in agreement with previous qualitative research showing that being more active in daily life and participate in the surrounding community were important factors for personal recovery [9, 17, 19].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [9] Leamy MBV, Le Boutillier C, et al. Conceptual framework for personal recovery in mental health systematic review and narrative synthesis. Br J Psychiatry. 2011;199(6):445–52. source

      Not checked in the free run.

    • cites [17] Argentzell E, Håkansson C, Eklund M. Experience of meaning in everyday occupations among unemployed people with severe mental illness. Scand J Occup Ther. 2012;19:49–58. source

      Not checked in the free run.

    • cites [19] Piat M, Seida K, Sabetti J. Understanding everyday life and mental health recovery through CHIME. Ment Health Soc Incl. 2017;21(5):271–9. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Premisecitation

    According to theory, recovery is the ultimate criterion for treatment outcome in mental health care, and can hardly be viewed as a factor causing the phenomena addressed through the mediators.

    “According to theory, however, recovery is the ultimate criterion for treatment outcome in mental health care [9], and can hardly be viewed as a factor causing the phenomena addressed through the mediators.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [9] Leamy MBV, Le Boutillier C, et al. Conceptual framework for personal recovery in mental health systematic review and narrative synthesis. Br J Psychiatry. 2011;199(6):445–52. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Empowerment, a construct with similarities with mastery, is one of the components in the recovery framework CHIME.

    “Empowerment, a construct with similarities with mastery, is one of the components in the recovery framework CHIME [9].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [9] Leamy MBV, Le Boutillier C, et al. Conceptual framework for personal recovery in mental health systematic review and narrative synthesis. Br J Psychiatry. 2011;199(6):445–52. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationown data

    In order to enhance the recovery process, interventions should facilitate engagement in personally meaningful activities and support service users' possibilities to create control and independence in daily life.

    “These results indicate that in order to enhance the recovery process, interventions should facilitate engagement in personally meaningful activities and support service users’ possibilities to create control and independence in daily life.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Few existing interventions in mental health services today focus explicitly on both these aspects.

  • May combine two claims.

    Premisecitation

    Only a few specific manual-based occupational therapy interventions and well-controlled outcome studies exist.

    “Occupational therapy would be the nearest existing alternative, but although it has a long history in mental health care, only a few specific manual-based occupational therapy interventions and well-controlled outcome studies exist [21].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [21] Kirsh B, Martin L, Hultqvist J, Eklund M. Occupational therapy interventions in mental health: a literature review in search of evidence. Occup Ther in Ment Health. 2019;35(2):109–56.. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    The relations between recovery and activity level and activity balance align with research showing that creating balance between different everyday activities boosts the recovery process for people with mental illness.

    “The relations between recovery and the service users’ reports on activity level and activity balance also align with research showing that creating balance between different everyday activities boosts the recovery process for people with mental illness [17].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] Argentzell E, Håkansson C, Eklund M. Experience of meaning in everyday occupations among unemployed people with severe mental illness. Scand J Occup Ther. 2012;19:49–58. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationown data

    The CHIME framework would benefit from more clearly highlighting the importance of engaging in satisfying activities in the recovery process.

    “The results from the current study suggest that the CHIME framework would benefit from more clearly highlighting the importance of engaging in satisfying activities in the recovery process.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Tse and colleagues' recovery instrument differed from the one used in the current study and their study did not look specifically at moderators.

    “However, their recovery instrument differed from the one used in the current study and their study did not look specifically at moderators.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13] Tse S, Davidson L, Chung K, Ng KL, Yu CH. Differences and similarities between functional and personal recovery in an Asian population: a cluster analytic approach. Psychiatry. 2014;77(1):41–56. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Symptom reduction is generally regarded as clinical recovery, but earlier research has highlighted that it can be important for personal recovery, though decreased symptoms are not the primary focus for the overall personal recovery journey.

    “Symptom reduction is generally regarded as clinical recovery, but earlier research has also highlighted that it can be important for personal recovery, though decreased symptoms are not the primary focus for the overall personal recovery journey [8].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Lim M, Li Z, Hea X. An Asian study on clinical and psychological factors associated with personal recovery in people with psychosis. BMC Psychiatry. 2019;19:256. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    Both types of treatment seemed to have an effect on recovery.

    “Both types of treatment seemed to have an effect on recovery, but this study also sheds light on possible reasons for this change.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    The activity-based treatments seem to have been equally beneficial for men and women, and for older and younger clients.

    “With respect to increased recovery, we could not find any support for moderators when addressing gender, age and diagnostic group; the activity-based treatments seem to have been equally beneficial in relation to increased recovery for men and women, and for older and younger clients.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    The finding that increased recovery co-varied with increased engagement in activity is in agreement with both qualitative and quantitative research, suggesting a well-established connection between these phenomena.

    “The finding that increased recovery co-varied with increased engagement in activity is in agreement with both qualitative [2, 19, 43] and quantitative [20] research, suggesting a well-established connection between these phenomena.”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [2] Doroud N, Fossey E, Fortune T. Recovery as an occupational journey: a scoping review exploring the links between occupational engagement and recovery for people with enduring mental health issues. Aust Occup Ther J. 2015;62:378–92. source

      Not checked in the free run.

    • cites [19] Piat M, Seida K, Sabetti J. Understanding everyday life and mental health recovery through CHIME. Ment Health Soc Incl. 2017;21(5):271–9. source

      Not checked in the free run.

    • cites [43] Kelly SL, Brunero S. An occupational perspective of the recovery journey in mental health. British J Occup Ther. 2010;73(3):129–35. source

      Not checked in the free run.

    • cites [20] Eklund M, Tjörnstrand C. Associations between occupational and social interaction factors and well-being among people with psychiatric disabilities living in supported housing in Sweden. J Occup Sci. 2019;27(1):54–68. source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductreasoning

    The exact participation rate could not be calculated, which weakens the study's external validity.

    “Further, the exact participation rate could not be calculated. The reason for this was use of gatekeepers and dissatisfactory administrative routines when registering non-participants. This weakens the study’s external validity.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Earlier research comparing BEL and SOT shows that BEL was more effective in several respects, such as improved activity engagement and better psychosocial functioning.

    “Although SOT and BEL seemed to enhance recovery equally well in the current study, earlier research comparing BEL and SOT shows that BEL was more effective in several respects, such as improved activity engagement and better psychosocial functioning [22].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] Eklund M, Tjörnstrand C, Sandlund M, Argentzell E. Activity outcomes of balancing everyday life (BEL) for people with psychiatric disorders. BMC Psychiatry. 2017;17:363. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationcitation

    BEL is effective in several respects and can be viewed as a recommended activity-based intervention.

    “Research on BEL so far thus supports that BEL is effective in several respects and can be viewed as a recommended activity-based intervention.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] Eklund M, Tjörnstrand C, Sandlund M, Argentzell E. Activity outcomes of balancing everyday life (BEL) for people with psychiatric disorders. BMC Psychiatry. 2017;17:363. source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductnone given

    There was participant dropout over time, which made this study somewhat underpowered with respect to the SOT group.

    “Also, as expected, there was participant dropout over time, which made this study somewhat underpowered with respect to the SOT group.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Mediation was shown by the decrease in the effect of the time factor when covariates were introduced one by one; the time variable remained significant, suggesting only partial mediation.

    “Mediation was shown by the decrease in the effect of the time factor when the covariates were introduced one by one. In all cases the time variable was still significant, suggesting only partial mediation.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning

    One of seven possible moderators, activity engagement, revealed a significant effect, but the fact that several possible interactions were tested makes replication very important.

    “Finally, one of seven possible moderators, activity engagement, revealed a significant effect, but the fact that several possible interactions were tested makes replication very important.”
    Quote in the paperNot a substantial claim
62 of 62

  • The paper relies on this without support.

    There is no consensus regarding factors that may mediate change in recovery scores.

    “Although the recovery concept is considered important to incorporate within mental health, there is still no consensus regarding factors that may mediate change in recovery scores.”

  • The paper relies on this without support.

    Quantitative studies exploring various aspects of activity that may mediate change in recovery are lacking.

    “Qualitative studies show that various aspects of activity are of importance for the recovery process [2]; however, quantitative studies exploring various aspects of activity that may mediate change in recovery are lacking.”

  • The paper relies on this without support.

    Many service users have limited activity engagement in their daily lives.

    “This focus is however important as many service users have limited activity engagement in their daily lives.”

  • The paper relies on this without support.

    BEL and SOT are occupational therapy treatments.

    “Since BEL and SOT are occupational therapy treatments, it is interesting to note that there was a relation between recovery and the extent to which service users were satisfied with their everyday activities.”

  • The paper relies on this without support.

    Few existing interventions in mental health services today focus explicitly on both these aspects.

    “Few existing interventions in mental health services today focus explicitly on both these aspects.”

  • The paper relies on this without support.

    Occupational therapy would be the nearest existing alternative.

    “Occupational therapy would be the nearest existing alternative, but although it has a long history in mental health care, only a few specific manual-based occupational therapy interventions and well-controlled outcome studies exist [21].”
6 of 6

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Argentzell et al. reported activity engagement, mastery, satisfaction and symptom severity as the strongest mediators of changes in personal recovery following the BEL intervention.

    “They reported activity engagement, mastery, satisfaction and symptom severity as the strongest mediators of changes in personal recovery following the intervention.”

    From Contributions of a time use perspective in community mental health practice: a scoping review (2024) · cites this paper as [46]

    The Results section ranks activity engagement and mastery as the strongest mediators, followed by activity satisfaction and symptoms. The Discussion says satisfaction and symptom severity did not uniquely contribute to recovery change, so calling all four the strongest mediators overstates the finding. The analysis also covered both BEL and standard occupational therapy, not BEL alone. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

Statistics recomputed

Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.

  • ConsistentF(1, 214.5) = 0.154reported p > .05 · recomputed p = .695

    “F (1,214.5) = 0.154, p > .05”

  • ConsistentF(2, 348.6) = 0.151reported p > .05 · recomputed p = .860

    “F (2, 348.6) = 0.151, p > .05”

  • ConsistentF(2, 351.6) = 30.54reported p < .001 · recomputed p < .001

    “F (2, 351.6) = 30.54, p < .001”

  • ConsistentF(2, 318.6) = 4.38reported p = .013 · recomputed p = .013

    “F (2, 318.6) = 4.38, p = .013”

  • Consistentt(328.8) = 2.92reported p = .004 · recomputed p = .004

    “t (328.8) = 2.92, p = .004”

5 of 5

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Discussion calls significant covariates non-contributors

    Major

    The discussion says activity satisfaction and symptom severity did not uniquely contribute in the combined model, whereas Table 3 reports both as significant. The sentence also calls its list of five variables "Three possible mediators."

  • Results identify the wrong fourth significant covariate

    Minor

    The text names activity level among the four significant covariates in the combined model. Table 3 marks activity level non-significant and activity satisfaction significant.

  • Conclusion denies a reported moderator

    Minor

    The conclusion says no support was found for moderators, but the results report significant moderation by activity engagement.

  • Reported number of participating units conflicts with the unit flow

    Minor

    The results say participants came from 37 units, but the selection account says 29 units were randomized and one then withdrew, leaving 28.

4 of 4

Cites

Flagged first, then by citations

1 of the 42 references couldn’t be matched to a known paper.

Research works printed but not linked: 3

  1. National Board of Health and Welfare. National guidelines for psychosocial interventions for people with schizophrenia or similar conditions, 2018 - support for governing and management. Stockholm: In Swedish: Nationella riktlinjer för vård och stöd vid schizofreni och schizofreniliknande tillstånd. Stöd för styrning och ledning; 2018.
  2. Eklund M, Tjornstrand C, Sandlund M, Argentzell E. Effectiveness of balancing everyday life (BEL) versus standard occupational therapy for activity engagement and functioning among people with mental illness - a cluster RCT study. BMC Psychiatry. 2017;17(1):363. · DOI · Paper page
  3. Argentzell E, Eklund M. Vardag i Balans. En manual för kursledare, version 2 [Balancing Everyday Life. Manual for course leaders, version 2]; 2017.

Cited by

Sorted by citations

Related

Authors
Argentzell, E., Bäckström, M., Lund, K., & Eklund, M.
Affiliations
Lund University (SE)
Corresponding author
Argentzell, Elisabeth
ORCID
Venue
BMC Psychiatry
Publisher
Springer Science and Business Media LLC
Published
2020-10-30
Volume
20
Issue
1
Pages
520-520
ISSN
1471-244X (ISSN-L)
DOI
10.1186/s12888-020-02924-2
PMC
PMC7602343
OpenAlex
W3096537202
Semantic Scholar
44c5d36239e4b55d61b40ee05912ea918c128bd9
Cited by
34
References
42
Citations by year
2026: 5 · 2025: 7 · 2024: 5 · 2023: 10 · 2022: 4 · 2021: 3
FWCI
4.44
Type
journal article
Language
en
Open access
Licence
Locations
  • BMC Psychiatry (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • Lund University Publications (Lund University) (submittedVersion)
Funders
Swedish Research Council (Reg. No. K2014-99X-20067-09-4)
Topics
  • Health Sciences › Health Professions › General Health Professions › Mental Health and Patient Involvement
  • Health Sciences › Health Professions › Occupational Therapy › Occupational Therapy Practice and Research
  • Social Sciences › Psychology › Clinical Psychology › Psychiatric care and mental health services
Keywords
personal recovery, mental health service users, mood disorders, occupational therapy, activity-based intervention, mediation analysis, occupational engagement, mastery, activity satisfaction, anxiety and depression, recovery over time
MeSH terms
Adult, Humans, Mental Health Services, Occupational Therapy, Regression Analysis

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-10.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-10.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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