Is personal recovery in schizophrenia predicted by low cognitive insight?

Schizophrenia: Communication Disorders and Role of the Speech-Language Pathologist

PURPOSE

This clinical focus article aims to provide a comprehensive overview of schizophrenia and understanding of communication disorders resulting from its psychopathology. Schizophrenia is a spectrum disorder with varying levels of symptom expression. It is characterized by positive and negative symptoms that can cause communication disorders of different severity levels. Communication difficulties manifest as a range of symptoms such as alogia, disorganized speech, and impaired social communication. These challenges may result in receptive and expressive language deficits that lead to misunderstandings, reduced social interactions, and difficulties expressing thoughts and emotions effectively. The purpose of this clinical focus article is to explore the role of the speech-language pathologist (SLP) in assessing and treating communication disorders presented in schizophrenia.

CONCLUSIONS

In order to understand the role of the SLP in assessing and treating communication disorders in schizophrenia, it is imperative to understand the overall course, etiology, assessment, and treatment consideration of this condition. SLPs can provide services in the areas of social skills training and community-based intervention contexts.

Exploring Personal Recovery in Schizophrenia: The Role of Mentalization

Recovery is a broadly debated concept in the field of psychiatry research and in schizophrenia. Our study aims to understand the correlation between personal recovery from schizophrenia and factors such as mentalization, disability, quality of life, and antipsychotic side effects; Methods: Participants with schizophrenia (according to DSM-5 criteria) were consecutively recruited from the Psychiatry Unit of the University of Catania, Italy. Participants were assessed with the Recovery Assessment Scale (RAS), the Multidimensional Mentalizing Questionnaire (MMQ), the brief version of the WHO Disability Assessment Schedule (WHO-DAS), the EuroQoL-5 dimensions-5 levels, the Insight Orientation Scale (IOS) and the Glasgow Antipsychotic Side Effect Scale (GASS); Results: 81 patients were included. Our findings showed a positive correlation between RAS total scores and MMQ scores, especially in "good mentalizing" subdomains. IOS scores also had a positive association with RAS and MMQ scores. In contrast, poor mentalizing abilities negatively correlated with WHO-DAS 2.0 scores. While antipsychotic side effects influenced functioning, they did not impact perceived recovery. Conclusions: The study's results identified potential predictors of personal recovery from schizophrenia. These findings could contribute to creating tailored interventions to facilitate the recovery process.

Defining recovery in schizophrenia: A review of outcome studies

Schizophrenia is a chronic disorder with a heterogenous course and different ways in which recovery is measured or perceived. Recovery in schizophrenia is a complex process that it can be defined either from a clinical perspective focused on sustained symptom and functional remission, or from a patient-focused one, as a self-broadening process aimed at living a meaningful life beyond mental illness. Until now, studies analysed these domains separately, without examining their mutual relations and changes over time. Therefore, this meta-analysis aimed to examine the relationship of global measures of subjective recovery with each of the components of clinical recovery such as symptom severity and functioning, in patients with schizophrenia spectrum disorders. The results showed that the association between different indicators of personal recovery and remission are weak and inverse (^dIG⁺ = -0.18, z = -2.71, p < 0.01), however, this finding is not substantial according to the sensitivity indicators. With respect to functionality and personal recovery, there was a moderate relationship (^dIG⁺ = 0.26, z = 7.894, p < 0.01) with adequate sensitivity indices. In addition, a low consensus exists between subjective measures that are more related to the patient's perspective and clinical measures based on experts and clinician's viewpoint.

Predictors of personal recovery for individuals with schizophrenia spectrum disorders living in the community

INTRODUCTION

Personal recovery is a complex construct frequently used as outcome measure in people with schizophrenia spectrum disorders. This study examined potential predictors of personal recovery using the two most common assessment tools for people with schizophrenia spectrum disorders living in the community: the Chinese version of the Questionnaire about the Process of Recovery and the Chinese version of the Recovery Assessment Scale.

METHODS

Ninety-one individuals (57 women) diagnosed with schizophrenia spectrum disorders participated in the study (mean age: 47.41 ± 9.41 years). All participants lived in the community and received community psychiatric services. The participants were evaluated via interviews, questionnaires and standardized assessments. Potential predictors included four domains: personal, disease-related, functional and social. Stepwise multiple linear regression was used to analyse the potential predictors of the recovery and recovery assessment scale.

RESULTS

Resilience and social support were the only significant predictors of the Chinese versions of the Questionnaire about the Process of Recovery and Chinese version of the Recovery Assessment Scale. The primary predictor of the Chinese version of the Questionnaire about the Process of Recovery was social support from family and institutional staff. Conversely, resilience was the major predictor of the Chinese version of the Recovery Assessment Scale.

DISCUSSION

For people with schizophrenia spectrum disorders living in the community, social support and resilience significantly predicted personal recovery. Age, educational level, disease-related and functional factors were not significant predictors of personal recovery. Therefore, it is important to develop successful personal recovery-oriented practices that enhance resilience and promote social support.

Neurocognitive correlates of the varied domains of outcomes at 20 year follow-up of first-episode psychosis

Little is known about long-term outcomes of the first episode of psychosis (FEP) other than in the symptomatic domain. We hypothesised that cognitive impairment is associated with poorer multi-domain outcomes at a long-term follow-up of FEP patients. We followed-up 172 FEP patients for a mean of 20.3 years. Ten outcome dimensions were assessed (symptomatic, functional and personal recovery, social disadvantage, physical health, suicide attempts, number of episodes, current drug use, chlorpromazine equivalent doses (CPZ), and schizophrenia/schizoaffective disorder final diagnosis). Cognition was assessed at follow-up. Processing speed and verbal memory deficits showed significant associations with poor outcomes on symptomatic, social functioning, social disadvantage, higher number of episodes, and higher CPZ. Significant associations were found between visual memory impairments were significantly associated with low symptomatic and functional recovery, between attentional deficits and a final diagnosis of schizophrenia/schizoaffective disorder, and between social cognition deficits and poor personal recovery.Lower cognitive global scores were significantly associated with all outcome dimensions except for drug abuse and physical status. Using multiple outcome dimensions allowed for the inclusion of the patients' perspective and other commonly neglected outcome measures. Taken together, cognitive impairment in FEP patients is strongly related to poor performance on several outcome dimensions beyond symptomatic remission.

Is clinical insight a determinant factor of subjective recovery in persons living with schizophrenia or schizoaffective disorders?

Good clinical insight is predictive of clinical recovery in schizophrenia (i.e. symptomatic remission and functional improvement). However, the recent subjective recovery paradigm (i.e. the self-identity reconstruction process with and beyond psychosis) questioned the relevance of seeking patients' awareness of their medically-defined illness. This study aimed to assess the relationship between clinical insight and subjective recovery in individuals with psychotic disorders. Sixty-seven outpatients diagnosed with schizophrenia or schizoaffective disorder were assessed for clinical insight using the Scale to assess Unawareness of Mental Disorder (SUMD) and for self-rated subjective recovery using the Recovery Assessment Scale (RAS). Among all dimensions of insight, only the unawareness of current symptoms was significantly associated with RAS total score, with illness duration as the only moderating factor. On the final regression model, unawareness of current symptoms was confirmed as the strongest of six factors explaining all together 44% of the subjective recovery variance, whereas clinical insight taken as an independent multidimensional construct did not significantly participate in explaining subjective recovery. Our study highlights the weak and only partial implication of clinical insight in subjective recovery, and invites clinicians to consider the patients' meaning making process of morbid experiences in order to build a self-directed and medically-supported recovery.

Latent Profiles of Premorbid Adjustment in Schizophrenia and Their Correlation with Measures of Recovery

Premorbid adjustment (PA) has classically been defined as psychosocial functioning in the areas of education, occupation, social and interpersonal relationships prior to evidence of characteristic positive symptomatology. It is a concept which possesses ample evidence regarding its predictive nature for the course of Schizophrenia. The study aimed to analyze the latent profiles of premorbid adjustment and their relationship with symptomatology, functionality, subjective recovery, stigma resistance and years of untreated psychosis. Latent class analysis (LCA) was used to elaborate a solution of three premorbid adjustment profiles in a sample of 217 patients diagnosed with Schizophrenia from Public Mental Health Centers in the city of Arica, Chile. The results show that premorbid adjustment was significantly correlated with recovery indicators and that latent profiles of better premorbid adjustment predict better outcomes in subjective recovery and stigma resistance. The results show that premorbid adjustment not only has implications for the severity of the disorder, but that psychosocial functioning prior to psychosis affects the patient’s subjectivity, the representation of the disorder and the recovery process.

Easier Said Than Done: The Challenge to Teach "Personal Recovery" to Mental Health Professionals Through a Short, Targeted and Structured Training Programme

This study assesses the effectiveness of our short Personal Recovery Training Program (PRTP) for mental health professionals. Fifty-two healthcare professionals from Italian mental health services and forty students in psychiatric rehabilitation completed the Recovery Knowledge Inventory (RKI) pre- and post-training, divided into two groups: the PRTP (N = 45) and the Family Psychoeducational Training Program (FPTP; N = 47). Participants' understanding of personal recovery improved more significantly for those in the PRTP than for those in the FPTP group in two domains, "Roles and responsibilities" and "Non-linearity of the recovery process"; the FPTP group showed a significant improvement in the "Role of self-definition and peers in recovery" domain. Two consumers were involved in the PRTP and represented a resource to help participants understand the personal recovery process. Our findings indicate that a brief PRTP supported by consumers can improve staff and students' recovery orientation. The translation of the training into clinical practice remains unevaluated.

The relationship between clinical recovery and personal recovery among people living with schizophrenia: A serial mediation model and the role of disability and quality of life

OBJECTIVE

We examine the relationship between two perspectives on recovery from schizophrenia: clinical recovery and personal recovery. Clinical recovery emphasizes an individual's psychiatric symptoms and functioning, whereas personal recovery emphasizes adaptation to one's illness that includes taking responsibility for one's recovery, establishing an identity apart from the illness, and finding meaning, purpose, and hope in life.

METHODS

Using serial mediation analysis, we examine the relationship between clinical and personal recovery in the context of two potential mediators, disability and quality of life. Study participants were 356 people with a diagnosis of schizophrenia and living with family in Changsha City of Hunan Province, China.

RESULTS

Although clinical recovery was modestly associated with personal recovery (r = 0.27, p < 0.001), subsequent serial mediation analysis showed that clinical recovery is not directly related to personal recovery when accounting for disability and quality of life. Clinical recovery was a significant predictor of disability, which predicted quality of life and personal recovery. Among the three mediation paths, quality of life accounted for most of the mediation effect (54%), followed by disability (24%), and disability and quality of life serially (22%). We discuss the implications of these findings for theory development, intervention, and future research.

Effects of Adherence to Pharmacological Treatment on the Recovery of Patients with Schizophrenia

The aim of this study was to evaluate the effects of adherence to antipsychotic treatment on the recovery of patients with schizophrenia in northern Chile. One hundred and fifty-one patients diagnosed with schizophrenia completed the Drug Attitude Inventory (DAI-10), Positive and Negative Syndrome Scale for Schizophrenia (PANSS), Recovery Assessment Scale (RAS-24), sociodemographic information, and clinical and treatment characteristics of patients with schizophrenia. Multivariate analysis with multiple linear regression was then performed to identify variables that were potentially associated with the recovery assessment (variable criterion). A significant association was found between adherence to antipsychotic medication and the Willing to Ask for Help dimension of Recovery (β = 0.239, p = 0.005). Association of clinical and socio-demographic variables with recovery were identified: negative symptoms with Personal Confidence and Hope (β = -0.341, p = 0.001) and Goal and Success Orientation (β = -0.266, p = 0.014); cognitive symptoms with Willing to Ask for Help (β = -0.305, p = 0.018) and no domination by symptoms (β = -0.351, p = 0.005); marital status with reliance on others (β = -0.181, p = 0.045); age with Personal Confidence and Hope (β = -0.217, p = 0.021), Goal and Success Orientation (β = -0.296, p = 0.003), and no domination by symptoms (β = 0.214, p = 0.025). Adherence has a positive relationship with personal recovery in this sample of Chilean patients with schizophrenia.

Exploring factors associated with personal recovery in bipolar disorder

BACKGROUND

Personal recovery is increasingly recognized as important outcome for people with bipolar disorder (BD), but research addressing associated factors of personal recovery in this group remains scarce. This study aimed to explore the association of sociodemographic variables, social participation, psychopathology, and positive emotion regulation with personal recovery in BD.

METHODS

Baseline data from a randomized controlled trial and survey data were combined (N = 209) and split into a training (n = 149) and test sample (n = 60). Block-wise regression analyses and model training were used to determine the most relevant predictors. The final parsimonious model was cross-validated in the test sample.

RESULTS

In the final parsimonious model, satisfaction with social roles (β = .442, p < .001), anxiety symptoms (β = -.328, p < .001), manic symptoms (β = .276, p < .001), and emotion-focused positive rumination (β = .258, p < .001) were independently associated with personal recovery. The model explained 57.3% variance in personal recovery (adjusted R²  = .561) and performed well in predicting personal recovery in the independent test sample (adjusted R²  = .491).

CONCLUSIONS

Our findings suggest that especially social participation, anxiety and positive rumination might be relevant treatment targets when aiming to improve personal recovery.

PRACTITIONER POINTS

Personal recovery is considered an increasingly important outcome for people with chronic mental health conditions, including bipolar disorder. We found that anxiety and manic symptoms as well as positive rumination and social participation were independently associated with personal recovery in bipolar disorder. Therefore, these outcomes might be relevant treatment targets when aiming to improve personal recovery in bipolar disorder. Possible interventions to improve these outcomes are discussed, including supported employment and vocational rehabilitation for social participation and exercising with savoring strategies to increase positive rumination.

Longitudinal changes in personal recovery in individuals with psychotic disorders through hospitalisation in a psychiatric ward: preliminary findings

BACKGROUND

This study aimed to investigate whether personal recovery indices in individuals with psychotic disorders would change through hospitalisation in a psychiatric ward and to identify factors associated with these changes.

METHODS

Participants underwent assessments for personal recovery using the Questionnaire about the Process of Recovery, Recovery Assessment Scale, and Self-Identified Stage of Recovery Part A and B; clinical symptoms using the Positive And Negative Syndrome Scale; self-efficacy using the General Self-Efficacy Scale; and self-esteem using the Rosenberg Self-Esteem Scale at baseline and before hospital discharge. Wilcoxon signed-rank tests were administered for longitudinal comparisons between baseline and follow-up. Spearman's rank correlation tests were conducted to assess correlations of longitudinal changes in personal recovery with baseline values of personal recovery as well as baseline values or changes in the Positive And Negative Syndrome Scale, General Self-Efficacy Scale, and Rosenberg Self-Esteem Scale.

RESULTS

Thirty-four individuals with psychotic disorders completed the assessments. The average duration of the current hospitalisation was 81.9 days (SD, 15.3; median, 85.0; range, 51-128 days). No significant changes were observed in personal recovery, self-efficacy, and self-esteem, although clinical symptoms significantly improved. Significant correlations were found between positive changes in the Recovery Assessment Scale and improvements in negative symptoms; between positive changes in the General Self-Efficacy Scale and those in personal recovery assessed with the Questionnaire about the Process of Recovery, Recovery Assessment Scale, and Self-Identified Stage of Recovery part A; and between positive changes in the Rosenberg Self-Esteem Scale and those in the Self-Identified Stage of Recovery part B.

CONCLUSION

This study revealed longitudinal relationships between changes in personal recovery and amelioration of negative symptoms or enhancement of self-efficacy and self-esteem through moderate length of hospitalisation in individuals with psychotic disorders. Considering the small sample size in this study, further studies with a larger sample size are needed to confirm the present finding.

TRIAL REGISTRATION

The protocol of this study is registered in the UMIN Clinical Trials Registry (UMIN-CTR; ID: UMIN000035131 ).

What matters: Factors impacting the recovery process among outpatient mental health service users

OBJECTIVE

Understanding factors that promote and hinder the recovery process for people living with serious mental illness remains of critical importance. We examine factors, including limited literacy, associated with mental health recovery among public mental health service users.

METHOD

This study uses data from a mixed-methods, service-user informed project focused on the impact of limited literacy in the lives of people with serious mental illness. Data from structured interviews evaluate perceptions of recovery as assessed with the Recovery Assessment Scale (RAS). Regression models examine factors related to recovery controlling for sociodemographic factors, literacy, neurocognition, mental health status, perceived social support, and stigma.

RESULTS

Despite bivariate relationships between RAS and limited literacy, the full models suggest that other factors account for this relationship. These include mental health status, higher social support, higher self-reported community status, and higher stigma consciousness, as well as race for some models.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Our findings that social support and perceptions of community status are associated with higher scores on the RAS echo prior work demonstrating the importance of social connection and context in mental health recovery. Though literacy was not a predictor of recovery, further research should examine the relationship between literacy and recovery given the deep literature on literacy on health outcomes. In order to better support people in the recovery process it is important that more research is done to examine the complex relationship between stigma consciousness and recovery as well as understand the racial disparities that exist within the recovery subscales. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Personal Recovery in People With a Psychotic Disorder: A Systematic Review and Meta-Analysis of Associated Factors

Background: Personal recovery (PR) is a subjective, multidimensional concept, and quantitative research using PR as an outcome is rapidly increasing. This systematic review is intended to support the design of interventions that contribute to PR in psychotic disorders, by providing an overview of associated factors and their weighted importance to PR: clinical factors, social factors, and socio-demographic characteristics are included, and factors related to the concept of PR (organized into CHIME dimensions). Methods: A systematic literature search was conducted from inception to March 2020. Quantitative studies that had used a validated questionnaire assessing the concept of PR were included. Mean effect sizes for the relationship between PR-scale total scores and related factors were calculated using meta-analyses. Sources of heterogeneity were examined using meta-regression tests. Results: Forty-six studies, that used (a total of) eight PR measures, showed that in clinical factors, affective symptoms had a medium negative association with PR-scale total scores (r = -0.44, 95%CI -0.50 to -0.37), while positive, negative and general symptoms had small negative correlations. No association was found with neuro-cognition. Social factors (support, work and housing, and functioning) showed small positive correlations. Gender and age differences had barely been researched. Large associations were found for PR-scale total scores with the CHIME dimensions hope (r = 0.56, 95%CI 0.48-0.63), meaning in life (r = 0.48, 95%CI 0.38-0.58) and empowerment (r = 0.53, 95%CI 0.42-0.63); while medium associations were found with connectedness (r = 0.34, 95%CI 0.43-0.65) and identity (r = 0.43, 95%CI 0.35-0.50). Levels of heterogeneity were high, sources included: the variety of PR measures, variations in sample characteristics, publication bias, variations in outcome measures, and cultural differences. Discussion: Most interventions in mental healthcare aim to reduce symptoms and improve functioning. With regard to stimulating PR, these interventions may benefit from also focusing on enhancing hope, empowerment, and meaning in life. The strength of these findings is limited by the challenges of comparing separate CHIME dimensions with questionnaires assessing the concept of PR, and by the high levels of heterogeneity observed. Future research should focus on the interaction between elements of PR and clinical and social factors over time.

Co-occurring Deficits in Clinical and Cognitive Insight in Prolonged Schizophrenia-Spectrum Disorders: Relationship to Metacognitive Deficits

People diagnosed with schizophrenia have been broadly observed to experience deficits in clinical and cognitive insight; however, less is understood about how these deficits are related. One possibility is that these deficits co-occur among people when other deficits in cognition are present, such as in executive function, social cognition, and metacognition, which may either promote the development of both forms of poor insight or allow one to negatively influence the other. To explore this possibility, we conducted a cluster analysis using assessments of clinical and cognitive insight among 95 adults with a schizophrenia spectrum disorder. As predicted, this analysis yielded a group with concurrently poor clinical and cognitive insight (n = 36). Additional groups were found with concurrently good clinical and cognitive insight (n = 28) and poor clinical insight and good cognitive insight (n = 31). Groups were then compared on assessments of executive function, social cognition, and metacognition. The group with concurrently lower levels of cognitive and clinical insight had significantly poorer metacognition relative to the other groups. In particular, they tended to form more fragmented and less integrated ideas about themselves and others. No differences were found for executive function or social cognition. The result may suggest that while clinical and cognitive insight is partially orthogonal phenomena, relatively lower levels of metacognition, or difficulties forming integrated ideas about oneself and others, maybe a condition leading to the confluence of lower clinical and cognitive insight. Interventions targeting metacognition may be of particular use for this group.

Does the Beck Cognitive Insight Scale predict change in delusional beliefs?

OBJECTIVES

The Beck Cognitive Insight Scale (BCIS) is composed of two subscales, self-reflectiveness and self-certainty, assessing reflectiveness and openness to feedback, and mental flexibility. Delusions have previously been associated with low cognitive insight. The aim of this study was to determine whether changes in BCIS scores predict changes in delusional beliefs.

METHODS

The study is a secondary analysis of a previously published randomized controlled trial. All participants had a psychotic disorder diagnosis and received treatment as usual, with half of them also receiving the cognitive restructuring intervention 'Michael's game'. Participants were assessed at three different times: at baseline (T1), at 3 months (T2), and at 9 months (T3). Cognitive insight was measured with the BCIS, belief flexibility with the Maudsley assessment of delusions schedule (MADS), and psychotic symptoms with the Brief Psychiatric Rating Scale (BPRS).

RESULTS

A total of 172 participants took part in the trial. After using generalized estimating equation (GEE) modelling, we observed (1) significant main effects of BCIS self-certainty and Time and (2) significant Time × BCIS self-certainty and Time × treatment group interaction effects on belief flexibility. Improvements in self-certainty (i.e., decrease in scores) were associated with more changes in conviction over time, more accommodation, improved ability in ignoring or rejecting a hypothetical contradiction and increased use of verification of facts. Medication and BPRS total scores were controlled for in the GEE analyses at their baseline values.

CONCLUSIONS

Overall improvement in BCIS self-certainty scores over time predicted better treatment outcomes as assessed with MADS items.

PRACTITIONER POINTS

Treatments for patients with psychosis should focus on improving cognitive insight as this seems to improve overall treatment outcomes and recovery. The Beck Cognitive Insight Scale can be used to measure changes during treatment and can predict treatment outcomes.

Essential Elements That Contribute to the Recovery of Persons With Severe Mental Illness: A Systematic Scoping Study

Introduction: There is an increasing emphasis on recovery-oriented care in the design and delivery of mental health services. Research has demonstrated that recovery-oriented services are understood differently depending on the stakeholders involved. Variations in interpretations of recovery lead to challenges in creating systematically organized environments that deliver a consistent recovery-oriented approach to care. The existing evidence on recovery-oriented practice is scattered and difficult to apply. Through this systematic scoping study, we aim to identify and map the essential elements that contribute to recovery outcomes for persons living with severe mental illness. Methods: We used the Arksey & O'Malley framework as our guiding approach. Seven key databases (MEDLINE, PubMed, CINAHL/EBSCO, EMBASE, ProQuest, PsycINFO, and Google Scholar) were searched using index terms and keywords relating to recovery and severe mental illness. To be included, studies had to be peer-reviewed, published after 1988, had persons with severe mental illness as the focal population, and have used recovery in the context of mental health. The search was conducted in August 2018 and last updated in February 2020. Results: Out of 4,496 sources identified, sixty (n = 60) sources were included that met all of the selection criteria. Three major elements of recovery that emerged from the synthesis (n = 60) include relationships, sense of meaning, and participation. Some sources (n = 20) highlighted specific elements such as hope, resilience, self-efficacy, spirituality, social support, empowerment, race/ethnicity etc. and their association with the processes underpinning recovery. Discussion: The findings of this study enable mental health professionals to incorporate the identified key elements into strategic interventions to facilitate recovery for clients with severe mental illness, and thereby facilitate recovery-oriented practice. The review also documents important gaps in knowledge related to the elements of recovery and identifies a critical need for future studies to address this issue.

Subjective Recovery in Patients with Schizophrenia and Related Factors

Subjective recovery is a personally perceived recovery involving other factors beyond clinical recovery. This study aims at investigating the factors related to subjective recovery in patients with schizophrenia living in Turkey. This study assessed 120 clinically stable outpatients with schizophrenia or schizoaffective disorder using the clinical and psychosocial scales. Gender, type of the diagnosis of disease, and age of the illness onset were found to be correlated with the subjective recovery. Subjective recovery was significantly correlated with CGI-S (r = - 0.25), total PANSS score (r = - 0.29), global assessment of functioning (r = 0.27), social functioning (r = 0.43), internalized stigma (r = - 0.38), self-esteem (r = 0.56), depression (r = - 0.59), and hopelessness (r = - 0.55). Hopelessness and self-esteem were found to be predictive of the subjective recovery explaining 52% of the variance. It can be argued that efforts to promote hope and self-esteem contribute to the subjective recovery.

Recovery and its correlates in patients with schizophrenia

Little information is available from India, on psychological recovery in patients with schizophrenia. Accordingly, this study aimed to evaluate the correlates and stages of the psychological recovery of patients with schizophrenia. 100 patients, in clinical remission, were evaluated on Stages of Recovery Instrument (STORI), Functional Social Support Questionnaire, WHO Quality of life-BREF, Ways of Coping Checklist, Internalised Stigma of Mental Illness Scale, Scale to Assess Unawareness of Mental Disorder and Knowledge of mental illness scale. Majority of the patients (N = 50) belonged to the stage-5 (Growth), and this was followed by those in the stage-4 (stage of rebuilding; N = 22) and stage-3 (stage of preparation; N = 16) of recovery. A higher stage of recovery was associated with lower stigma in all the domains except stigma resistance. Higher use of confrontative coping and accepting responsibility was associated with a higher score in the awareness stage of recovery. In terms of insight, higher awareness about the effect of medication was associated with a higher stage of recovery. Higher disability in the domain of self-care was seen in the lower stage of recovery. Better quality of life in the physical health domain was associated with being in a higher stage of recovery. To conclude, findings of the present study suggest that stigma plays a significant role in determining the outcome in the form of personal recovery. These findings suggest that to organize the services to promote personal recovery, clinicians should not only aim at symptom amelioration but also must focus on stigma to promote psychological recovery.

Italian Investigation on Mental Health Workers' Attitudes Regarding Personal Recovery From Mental Illness

This study aimed to investigate attitudes toward personal recovery in a sample of 436 healthcare professionals and students of psychiatric rehabilitation techniques through the Italian version of the recovery knowledge inventory (RKI). The sample in our study showed a good global orientation toward recovery. Statistically significant differences were found among mental health professionals based on gender difference, professional role, and level of experience. Women seemed more inclined to accept users' decision-making processes, including therapeutic risk-taking. Nurses seemed more cautious in considering the users able to "live beyond their illness". Professionals with fewer than 15 years of experience had more favorable attitudes and expectations than the more experienced respondents. Students had more optimistic expectations regarding recovery than nurses and social workers. Academic curriculum development for students and training courses for mental health professionals could further improve the homogeneity in attitudes and skills in the support of users' "unique" recovery processes.

Satisfaction and Needs in Serious Mental Illness and Autism Spectrum Disorder: The REHABase Psychosocial Rehabilitation Project

OBJECTIVE

The REHABase project is a French observational, prospective, and multicenter cohort study of serious mental illness and autism spectrum disorder (ASD), launched in 2016 for a planned minimum duration of 15 years. The aim is to characterize the care and quality-of-life needs of participants. This article presents initial results from data collection.

METHODS

Psychosocial, cognitive, and functional data were collected at baseline, annually, and after rehabilitation care. Data from the baseline evaluation on diagnoses, medications, well-being, insight, life satisfaction, and care needs are presented. The clinical profiles of REHABase participants with serious mental illness or ASD were assessed in relation to their level of satisfaction with life and well-being in nine life dimensions and their needs, according to their stage of recovery in a five-stage model.

RESULTS

Baseline data were collected for 1,397 participants between January 2016 and August 2018. Main diagnoses were schizophrenia spectrum disorder (49%); ASD (13%); and personality (12%), bipolar (9%), and major depressive (6%) disorders. More than 50% of participants reported needs for care or interventions in four of nine dimensions: employment, cognitive functioning, symptom management, and interpersonal relationships. Nearly half of participants were not in the active stages of recovery (stages 4 and 5), and even those considered to have reached the final stage continued to require help in several areas.

CONCLUSIONS

Most participants had already received psychiatric care for several years, and most remained dissatisfied with their social and emotional life and their psychological well-being.

Modeling variables associated with personal recovery among service users with mental disorders using community-based services

BACKGROUND

Mental health research is evolving toward the identification of conceptual models and associated variables, which may provide a better understanding of personal recovery, given its importance for individuals affected by mental disorders (MDs).

AIMS

This article evaluated personal recovery in a sample of adults with MDs using an adapted conceptual framework based on the Andersen behavioral model, which evaluates predisposing, enabling and needs factors in service use.

METHODS

The study design was cross-sectional and included 327 mental health service users recruited across four local health service networks in Quebec (Canada). Data were collected using seven standardized instruments and participant medical records. Structural equation modeling was performed.

RESULTS

Quality of life (QOL), an enabling factor, was most strongly associated with personal recovery. Health behavior variables associated with recovery included the following: use of alcohol services, having a family physician, consulting a psychologist, use of food banks, consulting fewer professionals and not using drug services. Regarding needs factors, higher numbers of needs, lower severity of unmet health, social and basic needs and absence of mood disorders were also associated with personal recovery. No predisposing factors emerged as significant in the model.

CONCLUSION

Findings suggest that QOL, needs variables and comprehensive service delivery are important in personal recovery. Services should be individualized to the health, social and basic needs of service users, particularly those with mood disorders or co-occurring mental health/substance use disorders.

The impact of affective symptoms on personal recovery of patients with severe mental illness

BACKGROUND

Clinical recovery is often defined as remission of symptoms. Personal recovery is described as growing beyond the catastrophic effects of mental illness, sometimes despite ongoing symptoms.

AIMS

To examine the relationship between the severity of clinical symptom domains and personal recovery in patients with severe mental illness (SMI).

METHODS

Symptom severity and personal recovery of 105 outpatients with SMI at Mentrum, part of Arkin Institute for Mental Health in Amsterdam, the Netherlands, were assessed using the Brief Psychiatric Rating Scale-Expanded Version (BPRS-E) and the Mental Health Recovery Measure (MHRM). Correlation and regression analyses were used to investigate the associations.

RESULTS

The multiple regression analysis showed that only affective symptoms significantly predicted personal recovery, whereas neither positive nor negative symptom severity added to the explained variance in the model.

CONCLUSION

The association between affective symptoms and personal recovery in patients with SMI implies that treatment of affective symptoms may advance personal recovery, and/or support of personal recovery may improve mood, whereas focussing on treatment of psychotic symptoms might not be the key to personal recovery. More research is needed to elucidate causal interrelations.

The Relationship Between Clinical and Personal Recovery in Patients With Schizophrenia Spectrum Disorders: A Systematic Review and Meta-analysis

Patients describe experiencing personal recovery despite ongoing symptoms of psychosis. The aim of the current research was to perform a meta-analysis investigating the relationship between clinical and personal recovery in patients with schizophrenia spectrum disorders. A comprehensive OvidSP database search was performed to identify relevant studies. Correlation coefficients of the relationship between clinical and personal recovery were retrieved from primary studies. Meta-analyses were performed, calculating mean weighted effect sizes for the association between clinical and personal recovery, hope, and empowerment. Additionally, associations between positive, negative, affective symptoms, general functioning, and personal recovery were investigated. The results show that heterogeneity across studies was substantial. Random effect meta-analysis of the relationship between symptom severity and personal recovery revealed a mean weighted correlation coefficient of r = -.21 (95% CI = -0.27 to -0.14, P < .001). We found the following mean weighted effect size for positive symptoms r = -.20 (95% CI = -0.27 to -0.12, P < .001), negative symptoms r = -.24 (95% CI = -0.33 to -0.15, P < .001), affective symptoms r = -.34 (95% CI = -0.44 to -0.24, P < .001) and functioning r = .21 (95% CI = -0.09 to 0.32, P < .001). The results indicate a significant small to medium association between clinical and personal recovery. Psychotic symptoms show a smaller correlation than affective symptoms with personal recovery. These findings suggest that clinical and personal recovery should both be considered in treatment and outcome monitoring of patients with schizophrenia spectrum disorders.

The impact of cognitive insight, self-stigma, and medication compliance on the quality of life in patients with schizophrenia

Impaired quality of life (QoL) is a common and clinically relevant feature of schizophrenia. In the present study, we attempted to formulate a model of QoL in the chronic stage of schizophrenia by including key variables-namely cognitive insight, self-stigma, insight into treatment, and medication compliance-that were proposed as its significant predictors in previous studies. We employed structural equation modeling (SEM) to simultaneously test the associations between these variables. A total of 170 community-dwelling patients with schizophrenia participated in this study. Cognitive insight, self-stigma, insight into treatment, medication compliance, and QoL were assessed through self-reporting. Symptoms were rated by interviewers. The influences of cognitive insight, stigma, insight into treatment, and medication compliance on QoL were supported using SEM. Our findings indicated that cognitive insight had a significant, positive, and direct effect on both self-stigma and insight into treatment; in contrast, it had a negative and direct effect on medication compliance. Notably, no evidence indicated a direct effect of cognitive insight on QoL. Thus, individuals with high cognitive insight reported low QoL because of stigma, low medication compliance, and their increased insight into treatment. In contrast, cognitive insight might indirectly ameliorate QoL mediated by the effect of insight into treatment on medication compliance. The findings provide additional support of the links between cognitive and clinical insight, self-stigma, medication compliance, and QoL in those with schizophrenia and suggest the need for screening and intervention services appropriate for this high-risk population.

Insight in schizophrenia spectrum disorders: relationship with behavior, mood and perceived quality of life, underlying causes and emerging treatments

Poor insight in schizophrenia is prevalent across cultures and phases of illness. In this review, we examine the recent research on the relationship of insight with behavior, mood and perceived quality of life, on its complex roots, and on the effects of existing and emerging treatments. This research indicates that poor insight predicts poorer treatment adherence and therapeutic alliance, higher symptom severity and more impaired community function, while good insight predicts a higher frequency of depression and demoralization, especially when coupled with stigma and social disadvantage. This research also suggests that poor insight may arise in response to biological, experiential, neuropsychological, social-cognitive, metacognitive and socio-political factors. Studies of the effects of existing and developing treatments indicate that they may influence insight. In the context of earlier research and historical models, these findings support an integrative model of poor insight. This model suggests that insight requires the integration of information about changes in internal states, external circumstances, others' perspectives and life trajectory as well as the multifaceted consequences and causes of each of those changes. One implication is that treatments should, beyond providing education, seek to assist persons with schizophrenia to integrate the broad range of complex and potentially deeply painful experiences which are associated with mental illness into their own personally meaningful, coherent and adaptive picture.

Long-term outcomes of Metacognitive Narrative Psychotherapy for people diagnosed with schizophrenia

OBJECTIVES

This study investigated long-term outcomes of Metacognitive Narrative Psychotherapy. Previous studies have shown the approach to be effective in enhancing recovery and metacognition in people with a diagnosis of schizophrenia.

DESIGN

A 2-year longitudinal follow-up case study design.

METHODS

Eight people with a diagnosis of schizophrenia received an average of 52 sessions over 13-26 months. Follow-up interviews were conducted and self-report measures administered at approximately 2 years (22-30 months) post-completion of therapy.

RESULTS

The majority of participants demonstrated reliable improvement from pre-treatment to 2-year follow-up on one or more of the outcome measures with some variation in patterns of improvement.

CONCLUSIONS

This study provides the first evidence that therapeutic gains in recovery and metacognition during Metacognitive Narrative Psychotherapy for people with a diagnosis of schizophrenia can be maintained at 2-year follow-up. Larger, controlled trials are warranted to ascertain the most important factors contributing to the facilitation and maintenance of gains over time.

PRACTITIONER POINTS

Research demonstrates the value of longer-term psychotherapy for patients with more severe and longer-term difficulties resulting from psychotic spectrum disorders. Metacognitive Narrative Psychotherapy has been demonstrated to facilitate improvement in a proportion of patients who present with a diagnosis of schizophrenia. Components of Metacognitive Narrative Psychotherapy can be incorporated into a range of therapeutic approaches for the benefit of patients.

The impact of an empowerment intervention on people with schizophrenia: Results of a randomized controlled trial

AIMS

The aim of the study was to assess what empowerment intervention has on people with schizophrenia.

METHODS

A randomized controlled trial was carried out between November 2015 and May 2016 involving 112 participants who had been diagnosed with schizophrenia. Patients, who were 18 years and above diagnosed with Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-V) schizophrenia or schizoaffective disorder from the outpatient mental health clinics in Jordan, were randomly assigned to take part in an intervention that consisted of receiving 6 weeks' worth of information booklets, with face to face discussions, while receiving their usual medication or allocated treatment as usual. The participants were assessed at baseline, immediately after the intervention and at 3-month follow-up. The primary outcome was a change in the helplessness score. Secondary outcomes were psychiatric symptoms, recovery rate, empowerment and quality of life.

RESULTS

This study showed that people with schizophrenia in the intervention group showed more improvement in the helplessness score immediately post-intervention ( F = 74.53, p < .001) and at 3-month follow-up ( F = 75.56, p < .001), they reported significant improvements in all secondary outcomes.

CONCLUSION

This study indicated that the empowering intervention was an effective intervention when integrated with treatment as usual.

Association between family history of psychiatric disorders and long-term outcome in schizophrenia - The Northern Finland Birth Cohort 1966 study

Family history of psychiatric disorders has been associated with impaired outcome in schizophrenia, but very few studies have investigated its long-term social and occupational outcome. We investigated the association of family history of psychiatric disorders, especially psychosis, with long-term social, occupational, clinical and global outcome in schizophrenia. The study sample comprises of the Northern Finland Birth Cohort 1966. Cohort members with psychosis were detected by Finnish national registers. Altogether 69 individuals with schizophrenia spectrum diagnosis participated, mean age 43, after on average 17 years since onset of illness. The information regarding family history of psychiatric disorders were gathered from registers and interviews. A Strauss-Carpenter Outcome Scale, PANSS and SOFAS were conducted to assess the outcome. Results showed that the family history of any psychiatric disorder was associated with more severe positive and emotional symptoms in PANSS. The family history of psychosis was not associated with outcomes. These findings suggest that family history of psychiatric disorders has a small association with outcome in schizophrenia. Despite family history of psychosis being a strong risk factor for schizophrenia, after years of illness it does not seem to affect outcome.

An integrative model of the impairments in insight in schizophrenia: emerging research on causal factors and treatments

INTRODUCTION

Poor insight, or unawareness of some major aspect of mental illness, is a major barrier to wellness when it interferes with persons seeking out treatment or forming their own understanding of the challenges they face. One barrier to addressing impaired insight is the absence of a comprehensive model of how poor insight develops.

AREAS COVERED

To explore this issue we review how poor insight is the result of multiple phenomena which interfere with the construction of narrative accounts of psychiatric challenges, rather than a single social or biological cause. Expert commentary: We propose an integrative model of poor insight in schizophrenia which involves the interaction of symptoms, deficits in neurocognition, social cognition, metacognition, and stigma. Emerging treatments for poor insight including therapies which focus on the development of metacognition are discussed.

Psychometric properties of the recovery measurement in homeless people with severe mental illness

OBJECTIVE

The Recovery Assessment Scale (RAS) is one of the most widely used measurements of recovery in mental health research. To date, no data have been available concerning the psychometric characteristics of the RAS in homeless people with severe mental illness. The aim of this study was to provide new data regarding the psychometric properties of the RAS in homeless people with schizophrenia and bipolar disorder.

METHODS

This multi-center study was conducted in 4 French cities. In addition to the RAS, data on sociodemographic information, disease severity using the Modified Colorado Symptom Index - MCSI, and the number of mental health comorbidities, care characteristics and quality of life (S-QoL-18) were collected. The RAS was tested for construct validity, reliability, external validity, sensitivity to change and acceptability.

RESULTS

Six hundred fifty-eight homeless patients participated in this study. The five-factor structure was confirmed by confirmatory factor analysis (RMSEA = 0.043, CFI = 0.95, NFI = 0.94 and SRMR = 0.063). The internal item consistency (from 0.40 to 0.80) and reliability (Cronbach's alpha from 0.79 to 0.87) were satisfactory for all dimensions. External validity testing revealed that the dimension scores were correlated significantly with the MCSI and S-QoL 18 scores. Significant associations with age, disease severity, psychiatric comorbidities and care characteristics showed good discriminant validity. The percentage of missing data (< 14.4%) and sensitivity to change were satisfactory.

CONCLUSIONS

Our study demonstrated the satisfactory acceptability and psychometric properties of the RAS, supporting its use as a mean of recovery measurement for homeless patients.

Relationship between cognitive insight and subjective quality of life in outpatients with schizophrenia

BACKGROUND

The concept of cognitive insight refers to the cognitive processes involved in patients' re-evaluation of their anomalous experiences and of their misinterpretations. The purpose of the present study was to examine the relationship between cognitive insight and subjective quality of life in patients with schizophrenia to further shed light on the nature of cognitive insight and its functional correlates in schizophrenia.

METHODS

Seventy-one stable outpatients with schizophrenia were evaluated for cognitive insight and subjective quality of life using the Beck Cognitive Insight Scale (BCIS) and the Schizophrenia Quality of Life Scale Revision 4 (SQLS-R4). The symptoms of schizophrenia were also assessed. Pearson's correlation analysis and partial correlation analysis that controlled for the severity of symptoms were performed to adjust for the possible effects of symptoms.

RESULTS

The self-reflectiveness subscale score of the BCIS had significant positive correlations with the SQLS-R4 psychosocial domain and total SQLS-R4 scores, indicating that the higher the level of cognitive insight, the lower the subjective quality of life. In partial correlation analysis controlling for symptoms, the BCIS self-reflectiveness subscale score still had a significant correlation with the SQLS-R4 psychosocial domain score. The correlation coefficient between the BCIS self-reflectiveness and total SQLS-R4 scores was reduced to a nonsignificant statistical tendency.

CONCLUSION

The results of our study suggest that cognitive insight, particularly the level of self-reflectiveness, is negatively associated with the level of subjective quality of life in outpatients with schizophrenia and that this relationship is not wholly due to the confounding effect of symptoms. Future studies are necessary to explore possible mediating and moderating factors and to evaluate the effects of therapeutic interventions on the relationship.