Stages of recovery from depression in relation to clinical outcomes and consumer recovery processes

Benjamin C. Y. Low, Kokkwang Lim, Meiyin Wong, Sayleong Ooi, Lindsay G. Oades, Chee Khong Yap


Background: Research on consumer-defined recovery from mental illness has been critiqued for a lack of quantitative evidence and conceptual clarity that has impeded further development of recovery-oriented services. This is especially true when it comes to models of the stages of recovery from mental illness. Qualitative studies have produced 20 distinct stage models with significant similarities but limited quantitative validation. The present study tests the convergent validity of one promising model in relation to psychosocial functioning, depression symptoms, and the processes that are thought to underpin consumer-defined recovery.

Methods: Eighty-eight patients with depressive symptoms were recruited. Patient-rated and clinician-rated measures were used to assess participants’ current stage of recovery, depressive symptoms, psychosocial functioning, and their level of attainment on the processes of recovery.

Results: Higher stages of recovery were associated with better depression symptoms, participant and clinician rated functioning, and several recovery processes that were repeatedly identified by past research. The effect sizes were consistently large.

Conclusions: Evidence of convergent validity was found for the model under study. Together with previous research, results suggest that the model may be a promising description of the recovery process and could inform the development of recovery-oriented services.


Consumer recovery, Recovery model, Recovery stages, Depression, Psychosocial functioning, CHIME

Full Text:



Australian Health Ministers’ Advisory Council. A National Framework for Recovery-Oriented Mental Health Services. Australia: Commonwealth of Australia, 2013. Available at:$File/recovgde.pdf. Accessed on 4 September 2017.

Mental Health Commission. A Vision for a Recovery Model in Irish Mental Health Services. Dublin: Mental Health Commission, 2005. Available at: discpapvforarecmod.pdf. Accessed 4 September 2017.

Mental Health Commission. Blueprint for Mental Health Services in New Zealand: How things need to be. Wellington: Mental Health Commission, 1998. Available at: notebook/nbbooks.nsf/0/0E6493ACAC236A394C25678D000BEC3C/%24file/Blueprint_for_mental_health_services.pdf. Accessed 4 September 2017.

National Institute for Mental Health in England. NIMHE Guiding Statement on Recovery. United Kingdom: Department of Health. Available at: Accessed on 4 September 2017.

Standing Committee on Social Affairs, Science, and Technology. Out of the Shadows at Last: Transforming mental health, mental illness, and addiction services in Canada. Canada: The Senate, 2006. Available at: collections/collection_2011/sen/yc17-0/YC17-0-391-2- 1-eng.pdf. Accessed on 4 September 2017

The Carter Center. The President’s New Freedom Commission on Mental Health: Transforming the Vision. Georgia: The Carter Center, 2003. Available at: 1701.pdf. Accessed 4 September 2017.

Slade M, Leamy M, Bacon F, Janosik M, Le Boutillier C, Williams C, et al. International differences in understanding recovery: Systematic review. Epidemiol Psychiatr Sc. 2012;21:353-64.

Andresen R, Caputi P, Oades LG. Do clinical outcome measures assess consumer-defined recovery? Psychiatry Res. 2010;177:309-17.

Anthony B. Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psycho Rehab J. 1993;16(4):11-23.

Donelly M, Scott D, McGilloway S, O’Neill T, Williams J, Slade M. Patient outcomes: What are the best methods for measuring recovery from mental illness and capturing feedback from patients in order to inform service improvement?. United Kingdom: Bamford Implementation Rapid Review Scheme, 2011. Available at: http://www. Accessed 8 September 2017.

Andresen R, Oades L, Caputi P. The experience of recovery from schizophrenia: Towards an empirically validated stage model. Aust N Z J Psychiatry. 2003;37:586-94.

Davidson L, Roe D, Andres-Hyman R, Ridgway P. Applying stages of change models to recovery from serious mental illness: Contributions and limitations. Isr J of Psychiatry and Relat Sci. 2010;47(3):213-21.

Leamy M, Bird V, Boutillier CL, Williams J, Slade M. Conceptual framework for personal recovery in mental health: Systematic review and narrative synthesis. Br J Psychiatry. 2011;199:445-54.

Copic V, Deane FP, Crowe TP, Oades LG. Hope, meaning and responsibility across stages of recovery for individuals living with an enduring mental illness. Australian J Rehab Counselling. 2015;17(2):61-73.

Andresen R, Oades LG, Caputi P. Psychological Recovery: Beyond mental illness. West Sussex: John Wiley & Sons; 2011: 190.

Bird V, Leamy M, Tew J, Le Boutillier C, Williams J, Slade M. Fit for purpose? Validation of a conceptual framework for personal recovery with current mental health consumers. Aust N Z J Psychiatry. 2014;48(7):644-53.

Brijnath B. Applying the CHIME recovery framework in two culturally diverse Australian communities: Qualitative results. Int J Soc Psychiatry. 2015;61(7):660-7.

Petros R, Solomon P, Linz S, DeCesaris M, Hanrahan NP. Autovideography: The lived experience of recovery for adults with serious mental illness. Psychiatr Q. 2016;87:417-26.

Stuart SR, Tansey L, Quayle E. What we talk about when we talk about recovery: A systematic review and best-fit framework synthesis of qualitative literature. J Ment Health. 2017;26 (3):291-304.

Roberts G, Wolfson P. The rediscovery of recovery: open to all. B J Psych Adv. 2004;10:37-49.

World Health Organization & World Organization of Family Doctors. Integrating mental health into primary care: A global perspective, 2012. Available at: mentalhealth_PHC_2008.pdf. Accessed on 16 July 2018.

Kroenke K, Spitzer R, Williams W. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606-16.

Cameron IM, Crawford JR, Lawton K, Reid IC. Psychometric comparison of PHQ-9 and HADS for measuring depression in primary care. Br J Gen Pract. 2008;58:32-6.

Lowe B, Unutzer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment outcomes with the Patient Health Questionnaire-9. Med Care. 2004;42(12):1194-201.

Sung SC, Low CCH, Fung DSS, Chan YH. Screening for major and minor depression in a multiethnic sample of Asian primary care patients: A comparison of the nine-item Patient Health Questionnaire (PHQ-9) and the 16-item Quick Inventory of Depressive Symptomatology – Self-Report (QIDS-SR16). Asia Pac Psychiatry. 2013;5:249-58.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed, text revised. Washington, DC: American Psychiatric Association; 2000: 943.

Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensional scale of perceived social support. J Pers Assessment. 1998;52:30-41.

Hardan-Khalil K, Mayo AM. Psychometric properties of the multidimensional scale of perceived social support. Clin Nurse Spec. 2015;29(5):258-61.

Vaingankar JA, Abdin E, Chong SA. Exploratory and confirmatory factor analyses of the Multidimensional Scale of Perceived Social Support in patients with schizophrenia. Compr Psychiatry. 2012;53:286-91.

Snyder CR, Sympson SC, Ybasco FC, Borders TF, Babyak MA, Higgins RL. Development and validation of the state hope scale. J Pers Soc Psychol. 1996;70(2):321-35.

McKay EA, Seeman MV. A scale to measure the impact of a schizophrenic illness on an individual’s self-concept. Arch Psychiatr Nurs. 1998;12(1):41-9.

Scheier MF, Wrosch C, Baum A, Cohen S, Martire LM, Matthews KA, et al. The Life Engagement Test: Assessing purpose in life. J Behav Med. 2006;29(3):291-8.

Clarke J, Proudfoot J, Birch M, Whitton AE, Parker G, Manicavasgar V, et al. Effects of mental health self-efficacy on outcomes of a mobile phone and web intervention for mild-to-moderate depression, anxiety, and stress: Secondary analysis of a randomised controlled trial. BMC Psychiatry. 2014;14:272-82.

Cohen J. Statistical Power Analysis for the Behavioural Sciences. 2nd ed. New York: Routledge; 1988: 567.

Cassar J, Ross J, DahneJ, Ewer P, Teesson M, Hopko D, et al. Therapist tips for the brief behavioural activation therapy for depression – revised (BATD-R) treatment manual practical wisdom and clinical nuance. Clinical Psychologist. 2016;20:46-53.

Luoma JB, Hayes SC, Walser RD. Learning ACT: An acceptance and commitment therapy skills training manual for therapists. Oakland, CA: New Harbinger Publications; 2007: 304.