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Tous-Espelosin M, Pavon C, Elizagarate E, Sampedro A, Maldonado-Martín S. As We Were and As We Should Be, Combined Exercise Training in Adults With Schizophrenia: CORTEX-SP Study Part II. Scand J Med Sci Sports 2024; 34:e14707. [PMID: 39054763 DOI: 10.1111/sms.14707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 07/03/2024] [Accepted: 07/16/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVE To determine the changes in health-related quality of life (HRQoL) and sleep quality following a supervised combined exercise (EX) program compared to a Treatment-As-Usual (TAU) and to analyze the relationship between the differences in cardiorespiratory fitness (CRF) and HRQoL domains in people with schizophrenia (SZ). METHODS The SZ (n = 112, 41.3 ± 10.4 year) was randomly assigned into a TAU control group (n = 53) or EX-group (n = 59, 3 days/week). The 36-item Short-Form Health Survey questionnaire assessed HRQoL and the sleep quality analysis (accelerometry). RESULTS After the intervention (20 weeks), physical functioning (∆ = 12.9%), general health (∆ = 15.3%), mental health (∆ = 8.3%), physical component summary (PCS) (∆ = 5.1%), and sleep efficiency (∆ = 1.9%) increased (p < 0.05) in the EX, with no significant changes in the TAU for any domains studied. There were significant differences between groups whose EX showed improvements (p < 0.05) compared to TAU in physical functioning, general health, PCS, and sleep efficiency. A greater CRF was associated with better values in physical functioning, role-physical, bodily pain, general health, vitality, and PCS after the exercise program in SZ. CONCLUSIONS A 20-week supervised combined exercise intervention program for SZ increased sleep efficiency and physical functioning, general and mental health, and PCS scores. This could lead to a critical HRQoL change from how they were to how they should be. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03509597.
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Affiliation(s)
- Mikel Tous-Espelosin
- Society, Sports, and Physical Exercise Research Group, GIzartea, Kirola eta Ariketa Fisikoa Ikerkuntza Taldea (GIKAFIT), Department of Physical Education and Sport, Faculty of Education and Sport-Physical Activity and Sport Sciences Section, University of the Basque Country (UPV/EHU), Vitoria-Gasteiz, Spain
- Physical Activity, Exercise, and Health Group, Bioaraba Health Research Institute, Vitoria-Gasteiz, Spain
| | - Cristóbal Pavon
- New Therapies in Mental Health Group, Bioaraba Health Research Institute, Vitoria-Gasteiz, Spain
- Osakidetza Basque Health Service, Araba Mental Health Network, Psychiatric Hospital of Alava, Vitoria-Gasteiz, Spain
- Department of Medicine, Faculty of Health Sciences, University of Deusto, Bilbao, Spain
| | - Edorta Elizagarate
- New Therapies in Mental Health Group, Bioaraba Health Research Institute, Vitoria-Gasteiz, Spain
- Osakidetza Basque Health Service, Araba Mental Health Network, Psychiatric Hospital of Alava, Vitoria-Gasteiz, Spain
| | - Agurne Sampedro
- Department of Psychology, Faculty of Health and Sciences, University of Deusto, Bilbao, Spain
| | - Sara Maldonado-Martín
- Society, Sports, and Physical Exercise Research Group, GIzartea, Kirola eta Ariketa Fisikoa Ikerkuntza Taldea (GIKAFIT), Department of Physical Education and Sport, Faculty of Education and Sport-Physical Activity and Sport Sciences Section, University of the Basque Country (UPV/EHU), Vitoria-Gasteiz, Spain
- Physical Activity, Exercise, and Health Group, Bioaraba Health Research Institute, Vitoria-Gasteiz, Spain
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Myers EJ, Abel DB, Mickens JL, Russell MT, Rand KL, Salyers MP, Lysaker PH, Minor KS. Meta-analysis of the relationship between metacognition and disorganized symptoms in psychosis. Schizophr Res 2024; 264:178-187. [PMID: 38154360 DOI: 10.1016/j.schres.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 10/10/2023] [Accepted: 12/10/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVE Disorganized symptoms show associations with metacognitive deficits in psychosis. However, the magnitude of this relationship is unclear. This meta-analysis aimed to 1) quantify relationships between metacognition and both disorganized symptoms and disorganized speech; and 2) examine moderators of these relationships (e.g., metacognition type, neurocognition). METHOD A literature search was conducted using PsycINFO, Web of Science, PubMed, and EMBASE databases. English-language studies measuring disorganized symptoms and metacognition (i.e., introspective accuracy, metacognitive beliefs, or metacognitive capacity) in psychosis were included. Random effects meta-analyses were conducted using Pearson's r. RESULTS Meta-analysis of 20 studies (n = 1490) resulted in a significant negative medium correlation between disorganized symptoms and metacognition (r = -0.332, 95 % CI [-0.423, -0.235]). Magnitude was moderated by metacognition type. A significant negative small correlation between disorganized speech and metacognition (r = -0.173, 95 % CI [-0.254, -0.089], n = 1470) was observed, with no significant moderators. CONCLUSIONS Results clarify the magnitude of the relationships between metacognition and both disorganized symptoms and disorganized speech. Significant relationships may indicate conceptual links, yet the different magnitudes may reflect a distinction between disorganized symptoms and speech. The moderator finding highlights that metacognitive capacity has an especially strong link to disorganized symptoms and underscores the need for careful distinction between types of metacognition in future work.
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Affiliation(s)
- Evan J Myers
- Department of Psychology, Indiana University - Purdue University Indianapolis, 402 N Blackford St., LD 124, Indianapolis, IN 46202, United States.
| | - Danielle B Abel
- Department of Psychology, Indiana University - Purdue University Indianapolis, 402 N Blackford St., LD 124, Indianapolis, IN 46202, United States.
| | - Jessica L Mickens
- Department of Psychology, Indiana University - Purdue University Indianapolis, 402 N Blackford St., LD 124, Indianapolis, IN 46202, United States.
| | - Madisen T Russell
- Department of Psychology, Indiana University - Purdue University Indianapolis, 402 N Blackford St., LD 124, Indianapolis, IN 46202, United States.
| | - Kevin L Rand
- Department of Psychology, Indiana University - Purdue University Indianapolis, 402 N Blackford St., LD 124, Indianapolis, IN 46202, United States.
| | - Michelle P Salyers
- Department of Psychology, Indiana University - Purdue University Indianapolis, 402 N Blackford St., LD 124, Indianapolis, IN 46202, United States.
| | - Paul H Lysaker
- Richard L. Roudebush VA Medical Center, Department of Psychiatry, 1481 W. 10th St., Indianapolis, IN 46202, United States; Department of Psychiatry, Indiana University School of Medicine, 355 W. 16th St., Indianapolis, IN 46202, United States.
| | - Kyle S Minor
- Department of Psychology, Indiana University - Purdue University Indianapolis, 402 N Blackford St., LD 124, Indianapolis, IN 46202, United States.
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Ponce-Correa F, Caqueo-Urízar A, Berrios R, Escobar-Soler C. Defining recovery in schizophrenia: A review of outcome studies. Psychiatry Res 2023; 322:115134. [PMID: 36871410 DOI: 10.1016/j.psychres.2023.115134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/07/2023]
Abstract
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.
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Affiliation(s)
- Felipe Ponce-Correa
- Programa Doctorado en Psicología, Escuela de Psicología y Filosofía, Facultad de Ciencias Sociales y Jurídicas, Universidad de Tarapacá, Avenida 18 de Septiembre N 2222, Casilla 7-D, Arica, Chile
| | | | - Raúl Berrios
- Departamento de administración, Facultad de administración y economía, Universidad de Santiago de Chile, Chile
| | - Carolang Escobar-Soler
- Programa Doctorado en Psicología, Escuela de Psicología y Filosofía, Facultad de Ciencias Sociales y Jurídicas, Universidad de Tarapacá, Avenida 18 de Septiembre N 2222, Casilla 7-D, Arica, Chile
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Saavedra J, Brzeska J, Matías-García JA, Arias-Sánchez S. Quality of life and psychiatric distress in people with serious mental illness, the role of personal recovery. Psychol Psychother 2023; 96:525-541. [PMID: 36786401 DOI: 10.1111/papt.12451] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 12/28/2022] [Accepted: 02/02/2023] [Indexed: 02/15/2023]
Abstract
OBJECTIVES When considering the personal recovery of people with serious mental illness (SMI), it is essential to examine their reported psychiatric distress and quality of life (QoL). However, there is no consolidated model in the literature that clearly relates these variables. In this study we first analysed the relationships between QoL, psychiatric distress and recovery, and several sociodemographic variables. Second, we analysed the linear effects of psychiatric distress and recovery on QoL. Third, and most important, we tested two hypotheses that considered personal recovery as a moderator or mediator of the relationship between psychiatric distress and QoL. DESIGN AND METHODS 234 volunteers with a diagnosis of SMI completed three self-report questionnaires, The Recovery Assessment Scale-24, The World Health Organization QoL and the Clinical Outcomes in Routine Evaluation-Outcome Measure, which showed very good levels of validity and reliability. The PROCESS macro for SPSS developed by Hayes (Introduction to mediation, moderation, and conditional process analysis: A regression-based approach, The Guilford Press, 2022) was applied using the Bootstrap method to verify our moderation and mediation hypotheses. RESULTS We found a negative linear effect of psychiatric distress on QoL, as well as a positive effect of recovery on said variable. Our results do not confirm the moderating effect of recovery on the relationship between distress and QoL. However, we do confirm the second hypothesis; recovery functioned as a mediating variable between psychiatric distress and QoL. CONCLUSIONS These findings allow us to reflect on how personal recovery affect the relationship between psychiatric distress and QoL and discuss its theoretical and practical implications as public policies.
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Affiliation(s)
- Javier Saavedra
- Department of Experimental Psychology, University of Seville, Sevilla, Spain
| | - Joanna Brzeska
- Department of Experimental Psychology, University of Seville, Sevilla, Spain
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Zhang J, Wang R, Xue Y. Deconstructing Mechanisms of Abnormal Categorical Perception of Emotional Facial Expressions in Schizophrenia Patients. Psychiatry Investig 2022; 19:991-999. [PMID: 36588433 PMCID: PMC9806511 DOI: 10.30773/pi.2022.0215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/25/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE The current study aims to find out the potential reasons why most schizophrenia patients have a relatively low sensitivity to the classification of emotional facial expressions. METHODS By using an emotional categorical perception task, eighty-three schizophrenia patients and seventy-one healthy adults are provided with morphed emotional continuums with two emotional facial expressions (a positive emotional valence: happy; a negative emotional valence: sad). RESULTS Through comparing the difference between schizophrenia patients and healthy adults in the processes of estimating facial expressions with ambiguous emotions, we find that the pattern of emotional categorical perception for schizophrenia patients is significantly different from that of healthy controls when they process signals on the local facial areas. Compared to healthy people, schizophrenia patients have a significantly separate classification pattern in processing emotional signals between the eyes and mouth regions. It indicates that compared to healthy adults, schizophrenia patients have larger conflicts in integrating emotional signals from different facial areas. To overcome conflicts, more cognitive resources are required. Unfortunately, the lack of cognitive resources leads to the failure of integration, which further increases the difficulty of estimating facial expressions with ambiguous emotions, and finally leads to the relatively low sensitivity of emotional facial expressions classification. CONCLUSION To sum up, the deficit of abnormal perceptions of emotional facial expressions in schizophrenia patients results from an integrated deficit of signals on facial areas.
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Affiliation(s)
- Jian Zhang
- School of Psychology, Guizhou Normal University, Guiyang, China
| | - Ruomin Wang
- Department of Economics, University of Illinois Urbana-Champaign, Urbana, IL, USA
| | - Yunzhen Xue
- Department of Humanities and Social Science, Shanxi Medical University, Taiyuan, China
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Erdoğan E, Demir S. The Effect of Solution Focused Group Psychoeducation Applied to Schizophrenia Patients on Self-Esteem, Perception of Subjective Recovery and Internalized Stigmatization. Issues Ment Health Nurs 2022; 43:944-954. [PMID: 35708992 DOI: 10.1080/01612840.2022.2083735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The study examined the effect of Solution-Focused Group Psychoeducation on self-esteem, subjective perception of recovery, and internalized stigma among patients with schizophrenia 39 patients with schizophrenia were recruited based design of the randomized control-group with pretest and posttest. The patients completed the "Rosenberg Self-Esteem Scale (RSES)", "Subjective Recovery Assessment Scale (SubRAS)", and "Internalized Stigma of Mental Illness (ISMI) Scale" in pretest and posttest. After the psychoeducation, ISMI scores decreased in the intervention group (p < 0.001) but increased in the control group (p = 0.599). The posttest RSES score was lower in the intervention group compared to the control group (p = 0.001). A statistically significant difference was found between the pretest and posttest SRAS scores of the intervention group when compared to the control group (p = 0.018). After the psychoeducation, intervention group' self-esteem and subjective perception of recovery increased, while the severity of internalized stigma decreased.
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Affiliation(s)
- Esra Erdoğan
- Mental Health and Diseases Hospital, Samsun, Turkey
| | - Satı Demir
- Faculty of Health Sciences Nursing Deparment, Gazi University, Ankara, Turkey
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Austin SF, Hjorthøj C, Baagland H, Simonsen E, Dam J. Investigating personal and clinical recovery processes in people with first episode psychosis. Early Interv Psychiatry 2022; 16:1102-1111. [PMID: 34825487 DOI: 10.1111/eip.13258] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 10/04/2021] [Accepted: 11/07/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Schizophrenia is a serious mental illness characterized by a range of symptoms such as distortions in reality, emotional abnormalities and deficits in cognition. Recovery from severe mental illness can be conceptualized in a number of ways. Clinical recovery has a focus on symptoms and functioning whilst personal recovery describes the process of developing new meaning and purpose in life beyond mental illness. OBJECTIVE This longitudinal study examined the relationship between clinical and personal recovery processes within a group of people with first episode psychosis (FEP) receiving early intervention treatment over a period of up to 2 years. METHODS The study sequentially recruited people with FEP that accepted into early intervention treatment. Participants were evaluated at baseline, 12 months and completion of treatment for clinical and personal recovery. RESULTS A total of 51 participants were recruited, completed treatment and assessments. Modest but significant correlations (r = 0.38-0.51) were found between personal recovery and certain aspects of clinical recovery (negative symptoms and functioning). Improvements in functioning (vocational and social activities) predicted both personal and clinical recovery whilst negative symptoms predicted attaining clinical recovery. Reductions in negative symptoms (global, apathy and anhedonia) during treatment were associated with moving towards personal recovery. Psychotic symptoms were not significantly associated with the attainment of clinical or personal recovery. CONCLUSIONS Results indicated that clinical and personal recovery are interdependent and complementary processes. Mental health services may need implement interventions that simultaneously target clinical and personal recovery processes in order to meet the treatment needs of people with psychosis.
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Affiliation(s)
- Stephen F Austin
- Psychiatric Research Unit, Psychiatry Region Zealand, Denmark.,Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Carsten Hjorthøj
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Erik Simonsen
- Psychiatric Research Unit, Psychiatry Region Zealand, Denmark.,Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Dam
- Psychiatric Center North Zealand, Hillerød, Denmark
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Skar-Fröding R, Clausen H, Šaltytė Benth J, Ruud T, Slade M, S Heiervang K. Associations between personal recovery and service user-rated versus clinician-rated clinical recovery, a cross-sectional study. BMC Psychiatry 2022; 22:42. [PMID: 35042494 PMCID: PMC8764788 DOI: 10.1186/s12888-022-03691-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/31/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND This study examined the relationship between service user-rated personal recovery and clinician-rated and service user-rated clinical recovery. The relationships between different subdomains of clinical recovery and personal recovery were also assessed. METHODS In total, 318 mental health service users with a psychosis diagnosis and their clinicians from 39 sites across Norway completed standardized questionnaires regarding personal recovery, clinical symptoms and psychosocial functioning. Regression models were used to investigate the relationship between personal and clinical recovery. RESULTS Overall, clinical recovery was positively associated with personal recovery, when rated both by service users and by clinicians. Personal recovery was associated with lower levels of depression, self-harm and problems with relationships when rated by the service users. Among the subdomains rated by the clinicians, personal recovery was associated with fewer problems with relationships and higher aggressiveness. CONCLUSIONS These findings suggest that affective symptoms are associated with personal recovery, indicating the need for greater focus on depression treatment among people with psychosis. Improving social connections is of importance for personal recovery, and might be an area where clinicians and service users can meet and find agreement on important treatment goals.
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Affiliation(s)
- Regina Skar-Fröding
- R&D Department, Division of Mental Health Services, Akershus University Hospital, P.O. box 1000, 1478, Lørenskog, Norway.
| | - Hanne Clausen
- R&D Department, Division of Mental Health Services, Akershus University Hospital, P.O. box 1000, 1478, Lørenskog, Norway
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders and Mental Health Division, Innlandet Hospital Trust, Brumunddal, Norway
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Torleif Ruud
- R&D Department, Division of Mental Health Services, Akershus University Hospital, P.O. box 1000, 1478, Lørenskog, Norway
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway
| | - Mike Slade
- School of Health Sciences, Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Kristin S Heiervang
- R&D Department, Division of Mental Health Services, Akershus University Hospital, P.O. box 1000, 1478, Lørenskog, Norway
- Centre for Medical Ethics, Faculty of Medicine, University of Oslo, Oslo, Norway
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Rodriguez KM, Von Mach T, Spivak S, Mojtabai R, Cullen BA. Assessing Self-reported Recovery in a Community Psychiatry Setting. J Psychiatr Pract 2021; 27:466-471. [PMID: 34768270 PMCID: PMC8597913 DOI: 10.1097/pra.0000000000000590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study examined demographic and diagnostic characteristics associated with self-reported recovery in patients with serious mental illness. METHODS Patient demographics and diagnoses were obtained from a retrospective review of charts from 981 patients attending a community psychiatry outpatient program between January 2015 and December 2016. All patients completed the Recovery Assessment Scale-Revised (RAS-R), a self-report recovery questionnaire consisting of 5 subscales, approximately every 6 months. Generalized estimating equation models were used to assess change in RAS-R scores over time and to test for associations with demographic characteristics, clinical diagnoses, and appointment adherence. RESULTS RAS-R scores increased among all demographic and diagnostic groups during the study period. A primary diagnosis of a psychotic disorder (including schizophrenia) was associated with higher 2-year average RAS-R total scores and scores on the Personal Confidence and Hope, Goal and Success Orientation, and Not Dominated by Symptoms subscales. African American race was associated with higher 2-year average scores on the Personal Confidence and Hope subscale. Increasing age was associated with higher total RAS-R scores and multiple subscale scores. No significant associations were found between sex or appointment adherence and RAS-R total scores or any of the subscale scores. CONCLUSIONS While certain demographic and diagnostic groups were associated with higher RAS-R scores, study results suggest that time in treatment is itself associated with higher self-reported recovery among all demographic groups. Age, race, and diagnosis were all associated with higher scores on the Personal Confidence and Hope subscale, highlighting the need for individualized treatment that takes multiple patient characteristics into account.
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Resilience in severe mental disorders: correlations to clinical measures and quality of life in hospitalized patients with major depression, bipolar disorder, and schizophrenia. Qual Life Res 2021; 31:507-516. [PMID: 34173172 DOI: 10.1007/s11136-021-02920-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To evaluate resilience in severe mental disorders and correlate it with clinical measures and quality of life. METHODS Resilience (Resilience Scale, RS) and quality of life (WHOQOL-BREF questionnaire) were prospectively evaluated in a sample of 384 hospitalized patients diagnosed with severe mental disorders (depression, bipolar disorder and schizophrenia). Clinical outcomes were measured using the Global Assessment of Functioning Scale (GAF), Clinical Global Impression (CGI), Cumulative Illness Rating Scale (CIRS), Hamilton Scale-Depression (HAM-D), Young Mania Rating Scale (YMRS), and Brief Psychiatric Rating Scale (BPRS). RESULTS Resilience measure showed a difference between the three clinical groups analyzed in the study, with lower scores in depressed patients than in bipolar disorder or schizophrenia patients. There was a trend toward a correlation between resilience and depressive symptoms (Hamilton Scale-Depression; P = 0.052; rs = - 0.163). The scores in the resilience scale's personal competence domain presented a tendency of association with general psychiatric symptoms (Brief Psychiatric Rating Scale; P = 0.058; r = - 0.138). There was a significantly positive association between resilience and all domains of quality of life (r = 0.306-0.545; P < 0.05). Sociodemographic data like age, education, intelligence quotient, sex, and marital status were associated with resilience. CONCLUSION Depressive patients had low scores on the resilience scale compared to patients with other disorders. Resilience was positively associated with quality of life. Therefore, it deserves special attention, as it promotes more positive outcomes and improves patients' quality of life with severe mental disorders.
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Rakitzi S, Georgila P, Becker-Woitag AP. The Recovery Process for Individuals With Schizophrenia in the Context of Evidence-Based Psychotherapy and Rehabilitation. EUROPEAN PSYCHOLOGIST 2021. [DOI: 10.1027/1016-9040/a000400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Abstract. This systematic review aimed to evaluate the efficacy of Cognitive Behavioral Therapy (CBT), META Cognitive Therapy (MCT), Metacognitive Training (MCTR), Metacognitive Reflection and Insight Therapy (MERIT), of various rehabilitation programs and of recovery programs in schizophrenia. Medline/Pubmed was searched for studies published in English from January 2010 to August 2018, which were screened against inclusion criteria by two reviewers. The methodological quality of the included studies was evaluated by two independent raters, which are the Effective Public Health Practice Project (EPHPP) quality assessment tool for quantitative studies and the fidelity criteria. The study included 41 RCTs and 12 case studies with n = 3,059 persons with schizophrenia. Cognitive Behavioral Therapy (CBT) proved to be superior in terms of the improvement of primary and secondary outcomes. MCT decreased positive symptoms and improved metacognitive capacity and insight. MCTR reduced positive symptoms and socially disruptive behavior. MERIT improved metacognitive capacity and insight. Rehabilitation programs were efficacious in the improvement of cognition, symptoms, and functional outcome. The recovery programs enhanced illness-management knowledge, attitudes toward medication and insights related to negative symptoms. It is recommended to combine the above evidence based psychotherapeutic interventions. Limitations of this systematic review are discussed toward the end of the essay. Some important factors have to be considered in the future have been mentioned.
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Affiliation(s)
| | - Polyxeni Georgila
- Psychiatric Department for Adults, General Hospital G. Gennimatas, Athens, Greece
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Milasan LH, Bingley AF, Fisher NR. The big picture of recovery: a systematic review on the evidence of photography-based methods in researching recovery from mental distress. Arts Health 2020; 14:165-185. [PMID: 33252304 DOI: 10.1080/17533015.2020.1855453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background: In the context of a growing body of literature on incorporating visual media in researching well-being and mental health, this systematic review examined the evidence of using photography-based research methods in exploring recovery from mental distress, their outcomes, but also limitations and challenges encountered by researchers.Methodology: Six cross-disciplinary electronic databases (CINAHL, MEDLINE, Web of Science, Scopus, PsycINFO, Arts & Humanities) were systematically searched resulting in a total of 15 qualitative and mixed-methods studies included in a thematic synthesis.Results: Photo-elicitation and photovoice were identified as the main photographic methods employed in recovery research along with less common, but nonetheless creative, techniques. Four key themes were identified through thematic analysis in photography-based recovery studies: enhanced understanding, collaboration and empowerment, situatedness, and storytelling. The results of this review revealed photography as a valuable methodological tool with potential to contribute to conceptualising recovery from the stance of research participants, but also facilitate and support their recovery processes.Conclusions: Recovery research can benefit from the use of photographic methods that are widely accessible, versatile, and interactive. They may offer mental health researchers alternative ways to explore individuals' perspective on recovery in ways that are creative, empowering, and supportive of their recovery.
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Affiliation(s)
- Lucian H Milasan
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancashire, UK
| | - Amanda F Bingley
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancashire, UK
| | - Naomi R Fisher
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancashire, UK
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Argentzell E, Bäckström M, Lund K, Eklund M. Exploring mediators of the recovery process over time among mental health service users, using a mixed model regression analysis based on cluster RCT data. BMC Psychiatry 2020; 20:520. [PMID: 33126873 PMCID: PMC7602343 DOI: 10.1186/s12888-020-02924-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 10/19/2020] [Indexed: 01/05/2023] Open
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.
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Affiliation(s)
- Elisabeth Argentzell
- Lund University, Department of Health Sciences, the Mental Health, Activity and Participation (MAP) group, Box 157, 221 00, Lund, Sweden.
| | - Martin Bäckström
- grid.4514.40000 0001 0930 2361Lund University, Department of Psychology, Box 213, 221 00 Lund, Sweden
| | - Kristine Lund
- grid.4514.40000 0001 0930 2361Lund University, Department of Health Sciences, the Mental Health, Activity and Participation (MAP) group, Box 157, 221 00 Lund, Sweden
| | - Mona Eklund
- grid.4514.40000 0001 0930 2361Lund University, Department of Health Sciences, the Mental Health, Activity and Participation (MAP) group, Box 157, 221 00 Lund, Sweden
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Temesgen WA, Chien WT, Valimaki MA, Bressington D. Predictors of subjective recovery from recent-onset psychosis in a developing country: a mixed-methods study. Soc Psychiatry Psychiatr Epidemiol 2020; 55:1187-1199. [PMID: 32222874 DOI: 10.1007/s00127-020-01853-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 02/28/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE This study was conducted to: (a) investigate the levels and progress of subjective recovery from recent-onset psychosis; (b) examine its predictive factors and; (c) describe perceived challenges and opportunities affecting recovery. The findings were expected to help inform recovery-oriented psychiatric care in low-income, particularly African, countries. METHODS This sequential explanatory mixed-methods study involved 263 service users with recent-onset psychosis from Northwestern Ethiopia. For the quantitative part, a 9-month longitudinal study approach was employed with three time point measurements over 9 months. Predictor variables for subjective recovery from recent-onset psychosis were identified by hierarchical multiple linear regression tests. Following the quantitative survey, individual qualitative interviews were conducted with 19 participants. Interview data were transcribed and thematically analysed. RESULTS High mean subjective recovery scores were recorded throughout the study (Questionnaire about the Process of Recovery score ranging from 44.17 to 44.65). Quality of life, internalized stigma, disability, hopelessness, satisfaction with social support, and central obesity were significant predictors of subjective recovery across the three time points. Participants' perceived challenges and opportunities affecting their recovery were categorized into four themes. CONCLUSION In Ethiopia, a low percentage of individuals with SMIs initiate psychiatric treatment and many discontinue this to attend spiritual healing. In this study, the Ethiopian SMI patients engaged consistently in psychiatric treatment indicated high mean subjective recovery scores. Devising mechanisms to integrate the psychiatric treatment and spiritual healing sectors are suggested. Approaches to improve quality of life, functioning, hope, internalized stigma and provide need-based social support are suggested.
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Affiliation(s)
- Worku Animaw Temesgen
- School of Nursing, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, SAR, China.
| | - Wai Tong Chien
- Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong, SAR, China
| | - Maritta Anneli Valimaki
- School of Nursing, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, SAR, China
| | - Daniel Bressington
- School of Nursing, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, SAR, China
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15
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İpçi K, Yildiz M, İncedere A, Kiras F, Esen D, Gürcan MB. Subjective Recovery in Patients with Schizophrenia and Related Factors. Community Ment Health J 2020; 56:1180-1187. [PMID: 32277339 DOI: 10.1007/s10597-020-00616-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 04/06/2020] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Kübra İpçi
- Department of Psychosocial Rehabilitation, Kocaeli University Institute of Health Science, Izmit, Kocaeli, Turkey
| | - Mustafa Yildiz
- Department of Psychosocial Rehabilitation, Kocaeli University Institute of Health Science, Izmit, Kocaeli, Turkey.
- Department of Psychiatry, Kocaeli University School of Medicine, Umuttepe, 41001, Izmit, Kocaeli, Turkey.
| | - Aysel İncedere
- Department of Psychosocial Rehabilitation, Kocaeli University Institute of Health Science, Izmit, Kocaeli, Turkey
| | - Fatma Kiras
- Department of Psychiatry, Kocaeli University School of Medicine, Umuttepe, 41001, Izmit, Kocaeli, Turkey
| | - Duygu Esen
- Department of Psychiatry, Kocaeli University School of Medicine, Umuttepe, 41001, Izmit, Kocaeli, Turkey
| | - Mehmet B Gürcan
- Department of Psychiatry, Kocaeli University School of Medicine, Umuttepe, 41001, Izmit, Kocaeli, Turkey
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Factors influencing subjective recovery of people with recent-onset psychosis: A cross-sectional study in a low-income sub-Saharan country. Psychiatry Res 2020; 287:112282. [PMID: 30853117 DOI: 10.1016/j.psychres.2019.01.107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 12/11/2018] [Accepted: 01/21/2019] [Indexed: 01/23/2023]
Abstract
People with psychosis were traditionally believed to have a chronic deteriorating condition with no hope of recovery. Recent studies have shown varied levels of recovery across countries. However, evidence from low-income, particularly African countries is scant. This study aimed to investigate levels of subjective recovery of people with recent-onset psychosis and identify its influencing factors. A cross-sectional study was conducted among 263 outpatients with recent-onset psychosis in a low-income country, Ethiopia. Psychiatric outpatients were randomly selected, and assessed by a set of questionnaires measuring their psychosocial, clinical and physical health conditions. Hierarchical multiple regression tests were used to identify factors influencing subjective recovery. The level of subjective recovery was found to be high, with a mean Questionnaire about the Process of Recovery score of 44.17. Individuals with higher quality of life were found to have significantly better subjective recovery level. Hopeless and centrally obese individuals were found to have significantly lower level of subjective recovery. Despite the limitations associated with a cross sectional study design, the results suggest that individuals with recent-onset psychosis in Ethiopia may have a better level of subjective recovery than those in high-income countries and their recovery is influenced by quality of life, hopelessness and central obesity.
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17
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Kukla M, Lysaker PH. Metacognition over time is related to neurocognition, social cognition, and intrapsychic foundations in psychosis. Schizophr Res Cogn 2020; 19:100149. [PMID: 31832339 PMCID: PMC6889797 DOI: 10.1016/j.scog.2019.100149] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 04/12/2019] [Accepted: 05/02/2019] [Indexed: 01/26/2023]
Abstract
Core impairments underlying schizophrenia encompass several domains, including disruptions in metacognition, neurocognition, social cognition, and intrapsychic foundations. Little is known about how these phenomena change over time and whether changes co-occur. The current study sought to address these gaps and examine the relationships between these cognitive domains across a 12 month period in adults with schizophrenia. Seventy-five adult outpatients with schizophrenia spectrum disorders were enrolled in a randomized trial comparing two cognitive interventions designed to improve work performance. Cognitive outcomes were measured at baseline, a 6-month follow-up and a 12-month follow-up. Multilevel linear modeling was used to understand the longitudinal relationships between metacognition and social cognition, neurocognition, and intrapsychic foundations across the 12-month follow-up. Metacognition significantly improved across 12 months. Improvements in overall neurocognition were significantly associated with increases in the metacognition domains of self-reflectivity and mastery across time. Improvements in social cognition over time were associated with improvements in total metacognition and the metacognitive domain of mastery. Improvements in intrapsychic foundations scores over 12 months were significantly associated with improvements in overall metacognition, self-reflectivity, and mastery. In conclusion, over time, improvements in metacognition across domains co-occur with other core cognitive and social capacities in persons with schizophrenia. As persons became better able to form integrated senses of themselves and adaptively use this knowledge, improvements in neurocognition, social cognition, and intrapsychic foundations were also present.
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Affiliation(s)
- Marina Kukla
- HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, 1481 W. 10th Street, Indianapolis, IN, USA
- Indiana University-Purdue University Indianapolis, Department of Psychology, 402 N. Blackford St., Indianapolis, IN 46202, USA
| | - Paul H. Lysaker
- Roudebush VA Medical Center, 1481 W. 10th Street, Indianapolis, IN 46202, USA
- Indiana University School of Medicine, 340 W. 10th Street, Suite 6200, Indianapolis, IN 46202, USA
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18
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Erim BR, Boztaş H, Yıldız M, Uygun E. The Factors Affecting the Relationship between Remission Status and Employment in Chronic Schizophrenia Patients. Psychiatry Investig 2019; 16:860-867. [PMID: 31684714 PMCID: PMC6877458 DOI: 10.30773/pi.2019.0087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 08/23/2019] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE Symptomatic remission have substantial effects in long-term schizophrenia outcome, but exact determinants of the employment. In this study, the relationship between employment and symptomatic remission in chronic schizophrenia patients and other factors related to employment were investigated. METHODS 100 patients interviewed were evaluated by the Positive and Negative Syndrome Scale (PANSS), Functional Recovery Scale in Schizophrenia (FROGS), Global Assessment of Functioning (GAF), Quality of Life Scale (QoL) and Subjective Recovery Assessment Scale (SubRAS). Sociodemographic variables, clinical features, antipsychotic dose and past working history obtained from patient interviews were investigated. RESULTS The patients of 40% who participate in the study were symptomatic remission, but only 53.5% of these patients weren't employed. Young age, especially, -regardless of the onset of illness- working a job in the past, low and moderate use CPED (equivalent doses according to chlorpromazine), shorter disease duration, symptomatic remission was found to be closely related to employment. While QoL, FROGS, GAF, and SubRAS total scores of employment group were higher than the unemployment group, PANSS total scores in the unemployment group were higher than that of the employment group. There was a high correlation between the scales and employment status. CONCLUSION Employment status was closely related with the remission status. This study supports that symptomatic remission alone is not decisive for employment. It was found that younger age, past working history (before or after the disease), low and intermediate CPED antipsychotic use and shorter duration of disease were closely related to employment with symptomatic remission.
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Affiliation(s)
- Burcu Rahşan Erim
- Department of Psychiatry, Faculty of Medicine, Bolu Abant Izzet Baysal University, Bolu, Turkey
| | - Hamid Boztaş
- Department of Psychiatry, Faculty of Medicine, Bolu Abant Izzet Baysal University, Bolu, Turkey
| | - Mustafa Yıldız
- Department of Psychiatry, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Ersin Uygun
- Department of Psychiatry, Bakirkoy Research and Training Hospital for Psychiatric and Neurological Diseases University of Health Sciences, Istanbul, Turkey
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Lim M, Li Z, Xie H, Tan BL, Lee J. An Asian study on clinical and psychological factors associated with personal recovery in people with psychosis. BMC Psychiatry 2019; 19:256. [PMID: 31438913 PMCID: PMC6704510 DOI: 10.1186/s12888-019-2238-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 08/14/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Despite the rising recognition of personal recovery, there is a lack of research on personal recovery in individuals with psychosis in Singapore. This study aims to evaluate the psychometric properties of the QPR-15 using the CHIME personal recovery framework and to examine its associations with clinical recovery factors. METHODS Sixty-six stable outpatients were recruited and assessed at two time points approximately 2 weeks apart. Convergent validity was examined through Spearman correlations with scores on CHIME-related psychological factors: connectedness (Ryff subscale- positive relations with others), hope (Herth Hope Index- abbreviated), identity (Ryff subscale- self-acceptance, Internalized Stigma of Mental Illness- Brief), meaning (World Health Organization Quality of Life Assessment-Brief Form), empowerment (Empowerment Scale). Pearson's correlation was used to examine the test-retest reliability, while Cronbach's alpha was used to examine internal consistency. The initial factor structure was evaluated via principal component analysis, Velicer's minimum average partial (MAP) criteria, parallel analysis, and a scree plot. Spearman correlations and hierarchical multiple linear regression (controlling for age and gender) were employed to examine the association of clinical (symptoms and functioning) and psychological factors with the QPR-15. RESULTS The QPR-15 demonstrated convergent validity with all CHIME-related psychological factors (rs ranged from 0.472 to 0.687). Internal consistency was excellent (Cronbach's alpha = 0.934), and test-retest reliability was adequate (r = 0.708). Initial factor structure evaluations revealed a one-factor model. Correlations of clinical factors with the QPR-15 were mostly low (rs ranged from - 0.105 to - 0.544) but significant, except for depressive symptoms (CDSS: rs = - 0.529 to - 0.544), while correlations were moderate for psychological factors. Clinical factors significantly explained 28.3-31.8% of the variance of the QPR-15. Adding psychological factors significantly increased the model variance at baseline (∆ adjusted R2 = 0.369, F change < 0.001) and at time point 2 (∆ adjusted R2 = 0.208, F change < 0.001). CONCLUSION Our results provide preliminary evidence that the QPR-15 has adequate psychometric properties in Singapore and encompasses the CHIME personal recovery framework. In addition, our results suggest that clinical recovery and personal recovery are not substitutes for each other but rather are complementary, thereby promoting a more holistic evaluation of recovery in people with psychosis. Implications are discussed.
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Affiliation(s)
- Madeline Lim
- 0000 0004 0469 9592grid.414752.1Research Division, Institute of Mental Health, Singapore, Singapore
| | - Ziqiang Li
- 0000 0004 0469 9592grid.414752.1Department of Nursing, Institute of Mental Health, Singapore, Singapore
| | - Huiting Xie
- 0000 0004 0469 9592grid.414752.1Department of Nursing, Institute of Mental Health, Singapore, Singapore
| | - Bhing Leet Tan
- 0000 0004 0469 9592grid.414752.1Department of Occupational Therapy, Institute of Mental Health, Singapore, Singapore ,0000 0004 1790 4399grid.486188.bSingapore Institute of Technology, Singapore, Singapore
| | - Jimmy Lee
- Research Division, Institute of Mental Health, Singapore, Singapore. .,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore. .,Department of Psychosis, Institute of Mental Health, 10 Buangkok View, Singapore, 539747, Singapore.
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20
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Van Patten R, Lee EE, Daly R, Twamley E, Tu XM, Jeste DV. Assessment of 3-dimensional wisdom in schizophrenia: Associations with neuropsychological functions and physical and mental health. Schizophr Res 2019; 208:360-369. [PMID: 30773419 PMCID: PMC6788800 DOI: 10.1016/j.schres.2019.01.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 01/14/2019] [Accepted: 01/19/2019] [Indexed: 12/13/2022]
Abstract
Recent decades have seen growing empirical research in wisdom as a complex, trait-based psychological characteristic. Wisdom has been shown to possess individual and societal benefits through associations with health and well-being, but it has not yet been evaluated in people with schizophrenia (PwS). In the current study, we administered a widely used, validated 3-dimensional wisdom scale that includes three interrelated dimensions: cognitive, reflective, and affective. We examined group differences in wisdom, as well as relationships between wisdom and sociodemographics, clinical symptoms, neurocognitive and functional performance, and mental and physical health in 65 stable adult outpatients with chronic schizophrenia or schizoaffective disorder and 96 non-psychiatric comparison participants (NPCPs). Results showed that PwS had lower wisdom scores than NPCPs and that wisdom moderated relationships between diagnostic group and neurocognitive and functional performance; PwS with higher levels of wisdom demonstrated better cognitive performance than did PwS with lower levels of wisdom. In addition, wisdom was positively correlated with performances on multiple neurocognitive tasks in PwS, but not in NPCPs. Finally, reflective wisdom - representing accurate/unbiased introspection and perspective-taking - correlated with all mental health variables in PwS. Our results were limited by a cross-sectional design, but suggest that wisdom, especially reflective wisdom, may be associated with better cognitive performance and better physical and mental health in PwS. It is conceivable that interventions to enhance wisdom may have broad cognitive and mental and physical health benefits in individuals with chronic psychotic disorders.
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Affiliation(s)
- Ryan Van Patten
- Department of Psychiatry, University of California San Diego, La Jolla, CA, United States; Sam and Rose Stein Institute for Research on Aging, University of California San Diego, La Jolla, CA, United States; Veterans Affairs San Diego Healthcare System, San Diego, CA, United States
| | - Ellen E Lee
- Department of Psychiatry, University of California San Diego, La Jolla, CA, United States; Sam and Rose Stein Institute for Research on Aging, University of California San Diego, La Jolla, CA, United States
| | - Rebecca Daly
- Department of Psychiatry, University of California San Diego, La Jolla, CA, United States; Sam and Rose Stein Institute for Research on Aging, University of California San Diego, La Jolla, CA, United States
| | - Elizabeth Twamley
- Department of Psychiatry, University of California San Diego, La Jolla, CA, United States; Sam and Rose Stein Institute for Research on Aging, University of California San Diego, La Jolla, CA, United States; Veterans Affairs San Diego Healthcare System, San Diego, CA, United States
| | - Xin M Tu
- Department of Psychiatry, University of California San Diego, La Jolla, CA, United States; Sam and Rose Stein Institute for Research on Aging, University of California San Diego, La Jolla, CA, United States
| | - Dilip V Jeste
- Department of Psychiatry, University of California San Diego, La Jolla, CA, United States; Sam and Rose Stein Institute for Research on Aging, University of California San Diego, La Jolla, CA, United States; Department of Neurosciences, University of California San Diego, La Jolla, CA, United States.
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Lysaker PH, Minor KS, Lysaker JT, Hasson-Ohayon I, Bonfils K, Hochheiser J, Vohs JL. Metacognitive function and fragmentation in schizophrenia: Relationship to cognition, self-experience and developing treatments. SCHIZOPHRENIA RESEARCH-COGNITION 2019; 19:100142. [PMID: 31828019 PMCID: PMC6889776 DOI: 10.1016/j.scog.2019.100142] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 03/13/2019] [Accepted: 03/25/2019] [Indexed: 12/26/2022]
Abstract
Bleuler suggested that fragmentation of thought, emotion and volition were the unifying feature of the disorders he termed schizophrenia. In this paper we review research seeking to measure some of the aspects of fragmentation related to the experience of the self and others described by Bleuler. We focus on work which uses the concept of metacognition to characterize and quantify alterations or decrements in the processes by which fragments or pieces of information are integrated into a coherent sense of self and others. We describe the rationale and support for one method for quantifying metacognition and its potential to study the fragmentation of a person's sense of themselves, others and the relative place of themselves and others in the larger human community. We summarize research using that method which suggests that deficits in metacognition commonly occur in schizophrenia and are related to basic neurobiological indices of brain functioning. We also present findings indicating that the capacity for metacognition in schizophrenia is positively related to a broad range of aspects of psychological and social functioning when measured concurrently and prospectively. Finally, we discuss the evolution and study of one therapy that targets metacognitive capacity, Metacognitive Reflection and Insight Therapy (MERIT) and its potential to treat fragmentation and promote recovery.
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Affiliation(s)
- Paul H Lysaker
- Roudebush Veteran Affairs Medical Center, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kyle S Minor
- Indiana University-Purdue University at Indianapolis, Indianapolis, IN, USA
| | | | | | - Kelsey Bonfils
- VA Pittsburgh Healthcare System, Mental Illness Research, Education, & Clinical Center (MIRECC), Pittsburgh, PA, USA.,Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Jenifer L Vohs
- Indiana University School of Medicine, Indianapolis, IN, USA
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Factors influencing subjective recovery of people with recent-onset psychosis: A cross-sectional study in a low-income Sub-Saharan country. Psychiatry Res 2019; 274:421-429. [PMID: 30875619 DOI: 10.1016/j.psychres.2019.02.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
People with psychosis were traditionally believed to have a chronic deteriorating condition with no hope of recovery. Recent studies have shown varied levels of recovery across countries. However, evidence from low-income, particularly African countries is scant. This study aimed to investigate levels of subjective recovery of people with recent-onset psychosis and identify its influencing factors. A cross-sectional study was conducted among 263 outpatients with recent-onset psychosis in a low-income country, Ethiopia. Psychiatric outpatients were randomly selected, and assessed by a set of questionnaires measuring their psychosocial, clinical and physical health conditions. Hierarchical multiple regression tests were used to identify factors influencing subjective recovery. The level of subjective recovery was found to be high, with a mean Questionnaire about the Process of Recovery score of 44.17. Individuals with higher quality of life were found to have significantly better subjective recovery level. Hopeless and centrally obese individuals were found to have significantly lower level of subjective recovery. Despite the limitations associated with a cross sectional study design, the results suggest that individuals with recent-onset psychosis in Ethiopia may have a better level of subjective recovery than those in high-income countries and their recovery is influenced by quality of life, hopelessness and central obesity.
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23
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Clesse C, Lighezzolo-Alnot J, Dumand I, Salime S, Savini C, Decker M. Globalisation des politiques de santé et psychiatrie française : enjeux et impacts. EVOLUTION PSYCHIATRIQUE 2018. [DOI: 10.1016/j.evopsy.2017.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Van Eck RM, Burger TJ, Vellinga A, Schirmbeck F, de Haan L. The Relationship Between Clinical and Personal Recovery in Patients With Schizophrenia Spectrum Disorders: A Systematic Review and Meta-analysis. Schizophr Bull 2018; 44:631-642. [PMID: 29036720 PMCID: PMC5890469 DOI: 10.1093/schbul/sbx088] [Citation(s) in RCA: 132] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Robin Michael Van Eck
- Arkin Institute for Mental Health, Amsterdam, The Netherlands
- Department of Psychiatry, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Thijs Jan Burger
- Arkin Institute for Mental Health, Amsterdam, The Netherlands
- Department of Psychiatry, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Astrid Vellinga
- Arkin Institute for Mental Health, Amsterdam, The Netherlands
- Mentrum, part of Arkin, Amsterdam, The Netherlands
| | - Frederike Schirmbeck
- Arkin Institute for Mental Health, Amsterdam, The Netherlands
- Department of Psychiatry, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Lieuwe de Haan
- Arkin Institute for Mental Health, Amsterdam, The Netherlands
- Department of Psychiatry, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Untreated illness and recovery in clients of an early psychosis intervention program: a 10-year prospective cohort study. Soc Psychiatry Psychiatr Epidemiol 2018; 53:171-182. [PMID: 29188310 DOI: 10.1007/s00127-017-1464-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 11/22/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To investigate whether duration of untreated psychosis (DUP) and duration of untreated illness (DUI) are associated with measures of both subjective and objective recovery 10 years after a first episode of psychosis. METHODS A cohort of 65 clients from an early psychosis intervention program completed a battery of outcome measures 10 years following initial treatment for first-episode psychosis (FEP). The outcomes of interest were self-perceived recovery scores (Maryland Assessment of Recovery in People with Serious Mental Illness Scale) and occupational activity, defined as engagement in work and/or school on a full/part-time basis. Multiple linear and logistic regression analyses were used to estimate the associations between DUP and DUI with each measure of recovery, adjusting for potential confounding factors. RESULTS We did not find a statistically significant association between DUP and either occupational activity (OR = 1.26, 95% CI 0.81-1.95) or self-perceived recovery score (β = - 0.73, 95% CI - 2.42 to 0.97). However, we found a significant negative association between DUI and self-perceived recovery score (β = - 0.52, 95% CI - 0.87 to - 0.16). CONCLUSIONS Our findings suggest that DUI may have a stronger influence than DUP on recovery from FEP at 10-year follow-up. This suggests the potential value in targeted interventions for people with a long DUI to increase the likelihood of achieving recovery after the first episode of psychosis.
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Shadmi E, Gelkopf M, Garber-Epstein P, Baloush-Kleinman V, Doudai R, Roe D. Routine patient reported outcomes as predictors of psychiatric rehospitalization. Schizophr Res 2018; 192:119-123. [PMID: 28499767 DOI: 10.1016/j.schres.2017.04.049] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/27/2017] [Accepted: 04/30/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Patient reported outcome measures (PROMs) are increasingly used to measure psychiatric service consumers' progress and to provide feedback to consumers and providers. We tested whether PROMs can predict and be used to identify groups at high risk for future hospitalization. METHODS A total of 2842 Israeli users of psychiatric rehabilitation services reported on their quality of life (QoL) and the effect of symptoms on their daily functioning. Survey data were linked with information on psychiatric hospitalization 6 and 12months after survey completion. Variables associated with each of the outcomes were tested for significance and entered into a multivariate logistic regression model. Prediction scores were developed to identify the highest-risk groups according to each model. RESULTS QoL was found to be a significant predictor of future hospitalization within 6months (odds ratio [OR]=0.71, 95% CI: 0.59-0.86), and self-report of the impact of symptoms on functioning significantly predicted 12-month hospitalization (OR=0.83, 95% CI: 0.74-0.93), controlling for known risk factors. Positive predictive values for the 6- and 12-month risk scores were 31.1 and 40.4, respectively, for the 10% highest risk categories. CONCLUSIONS Reports of psychiatric service consumers on their QoL and on the effect of symptoms on their functioning significantly predict of future hospitalization risk, beyond other well-known risk factors. PROMs can identify consumers at high risk for future hospitalization and thus direct interventions for those at highest risk.
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Affiliation(s)
- Efrat Shadmi
- The Cheryl Spencer Department of Nursing, University of Haifa, Mount Carmel 31905, Israel; Center for Community Mental Health, Research, Practice and Policy, Faculty of Social Welfare and Health Sciences, University of Haifa, Mount Carmel 31905, Israel.
| | - Marc Gelkopf
- Center for Community Mental Health, Research, Practice and Policy, Faculty of Social Welfare and Health Sciences, University of Haifa, Mount Carmel 31905, Israel; Department of Community Mental Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Mount Carmel 31905, Israel
| | - Paula Garber-Epstein
- Center for Community Mental Health, Research, Practice and Policy, Faculty of Social Welfare and Health Sciences, University of Haifa, Mount Carmel 31905, Israel
| | - Vered Baloush-Kleinman
- Department of Rehabilitation, Mental Health Services, Ministry of Health, Jerusalem, Israel
| | - Ronit Doudai
- Department of Rehabilitation, Mental Health Services, Ministry of Health, Jerusalem, Israel
| | - David Roe
- Center for Community Mental Health, Research, Practice and Policy, Faculty of Social Welfare and Health Sciences, University of Haifa, Mount Carmel 31905, Israel; Department of Community Mental Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Mount Carmel 31905, Israel
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de Pinho L, Pereira A, Chaves C, Batista P. Quality of Life Scale and symptomatology of schizophrenic patients – A systematic review. EUROPEAN JOURNAL OF PSYCHIATRY 2018. [DOI: 10.1016/j.ejpsy.2017.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Popolo R, Smith E, Lysaker PH, Lestingi K, Cavallo F, Melchiorre L, Santone C, Dimaggio G. Metacognitive profiles in schizophrenia and bipolar disorder: Comparisons with healthy controls and correlations with negative symptoms. Psychiatry Res 2017; 257:45-50. [PMID: 28719831 DOI: 10.1016/j.psychres.2017.07.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 07/05/2017] [Accepted: 07/10/2017] [Indexed: 02/06/2023]
Abstract
While deficits in metacognition, or the ability to notice and reflect upon mental states has been observed in schizophrenia and linked with poorer concurrent and future function, it is unknown whether these deficits are unique to schizophrenia. Accordingly, this study assessed metacognition using the Metacognitive Assessment Scale-Abbreviated (MAS-A) and the Metacognitions Questionnaire- 30 (MCQ-30) among 26 adults with schizophrenia, 23 with bipolar disorder and 23 healthy controls. Symptom levels of the psychiatric groups were assessed with the Brief Psychiatric Rating Scale. ANCOVA controlling for age and education revealed that the schizophrenia group had lower scores on the MAS-A total and its subscales compared to the bipolar group and healthy controls. The bipolar disorder group also had lower MAS-A scores than the healthy control group. No group differences were found for the MCQ-30. Examination of symptom correlates revealed MAS-A scores were most commonly related to negative symptoms in both clinical groups. The total score and need for control subscale of MCQ-30 was related to total symptomatology and positive symptoms in patients with bipolar disorder. Correlations between the two measures of metacognition revealed that higher MAS-A scores were significantly related to lower scores on the Need to Control Thoughts MCQ-30 subscale.
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Affiliation(s)
- Raffaele Popolo
- Center for Metacognitive Psychotherapy, Rome, Italy; Studi Cognitivi, Modena, Italy
| | - Elizabeth Smith
- Department of Psychology, Indiana State University, Terre Haute, IN, USA
| | - Paul H Lysaker
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA; Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA.
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Fleury MJ, Grenier G, Bamvita JM. Associated and mediating variables related to quality of life among service users with mental disorders. Qual Life Res 2017; 27:491-502. [DOI: 10.1007/s11136-017-1717-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2017] [Indexed: 11/24/2022]
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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; 71:529-535. [PMID: 28696806 DOI: 10.1080/08039488.2017.1346144] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Personal recovery, defined as an individual process towards meaning, is an important target within mental health services. Measuring recovery hence requires reliable and valid measures. The Process of Recovery Questionnaire (QPR) was developed for that purpose. AIMS The aim was to develop a Swedish version of the QPR (QPR-Swe) and explore its psychometric properties in terms of factor structure, internal consistency, construct validity and sensitivity to change. METHODS A total of 226 participants entered the study. The factor structure was investigated by Principal Component Analysis and Scree plot. Construct validity was addressed in terms of convergent validity against indicators of self-mastery, self-esteem, quality of life and self-rated health. RESULTS A one-factor solution of QPR-Swe received better support than a two-factor solution. Good internal consistency was indicated, α = 0.92, and construct validity was satisfactory. The QPR-Swe showed preliminary sensitivity to change. CONCLUSIONS The QPR-Swe showed promising initial psychometric properties in terms of internal consistency, convergent validity and sensitivity to change. The QPR-Swe is recommended for use in research and clinical contexts to assess personal recovery among people with mental illness.
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Affiliation(s)
- Elisabeth Argentzell
- a Department of Health Sciences , Mental Health, Activity and Participation (MAP), Lund University , Lund , Sweden
| | - Jenny Hultqvist
- a Department of Health Sciences , Mental Health, Activity and Participation (MAP), Lund University , Lund , Sweden
| | - Sandra Neil
- b Department of Clinical Psychology , Cromwell House Community Mental Health Team, Greater Manchester West NHS Foundation Trust , Manchester , UK
| | - Mona Eklund
- a Department of Health Sciences , Mental Health, Activity and Participation (MAP), Lund University , Lund , Sweden
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Leonhardt BL, Huling K, Hamm JA, Roe D, Hasson-Ohayon I, McLeod HJ, Lysaker PH. Recovery and serious mental illness: a review of current clinical and research paradigms and future directions. Expert Rev Neurother 2017; 17:1117-1130. [PMID: 28885065 DOI: 10.1080/14737175.2017.1378099] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Recovery from serious mental illness has historically not been considered a likely or even possible outcome. However, a range of evidence suggests the courses of SMI are heterogeneous with recovery being the most likely outcome. One barrier to studying recovery in SMI is that recovery has been operationalized in divergent and seemingly incompatible ways: as an objective outcome versus a subjective process. Areas covered: This paper offers a review of recovery as a subjective process and recovery as an objective outcome; contrasts methodologies utilized by each approach to assess recovery; reports rates and correlates of recovery; and explores the relationship between objective and subjective forms of recovery. Expert commentary: There are two commonalities of approaching recovery as a subjective process and an objective outcome: (i) the need to make meaning out of one's experiences to engage in either type of recovery and (ii) there exist many threats to engaging in meaning making that may impact the likelihood of moving toward recovery. We offer four clinical implications that stem from these two commonalities within a divided approach to the concept of recovery from SMI.
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Affiliation(s)
- Bethany L Leonhardt
- a Department of Psychiatry , Indiana University School of Medicine , Indianapolis , IN , USA.,b Midtown Community Mental Health , Eskenazi Health , Indianapolis , IN , USA
| | - Kelsey Huling
- c School of Psychological Sciences , University of Indianapolis , Indianapolis , IN , USA
| | - Jay A Hamm
- b Midtown Community Mental Health , Eskenazi Health , Indianapolis , IN , USA
| | - David Roe
- d Department of Community Mental Health, Faculty of Social Welfare and Health Sciences , University of Haifa , Haifa , Israel
| | | | - Hamish J McLeod
- f Institute of Health and Wellbeing, College of Medical Veterinary and Life Sciences , University of Glasgow , Glasgow , UK
| | - Paul H Lysaker
- a Department of Psychiatry , Indiana University School of Medicine , Indianapolis , IN , USA.,g Department of Psychiatry , Richard L. Roudebush Veteran Affairs Medical Center , Indianapolis , IN , USA
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Morera T, Pratt D, Bucci S. Staff views about psychosocial aspects of recovery in psychosis: A systematic review. Psychol Psychother 2017; 90:1-24. [PMID: 27239949 DOI: 10.1111/papt.12092] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 10/09/2015] [Indexed: 11/29/2022]
Abstract
PURPOSE Mental health services remain largely set up to improve patient outcomes through symptom alleviation, but patient views of recovery are broader than symptom remission. Clinicians influence the nature of treatment patients received, but their views about recovery remain poorly understood. The aim of this study was to systematically review the literature examining staff views about psychosocial aspects of recovery in psychosis. METHOD We systematically searched the PsycInfo, EMBASE, MEDLINE, and CINAHL databases. Of the 6,225 articles identified, 15 met inclusion criteria for review. RESULTS The studies reviewed showed a relatively inconsistent picture. Although there was evidence of staff endorsing psychosocial views of recovery, the majority of studies suggested staff endorsed biomedical models of recovery in psychosis and emphasized the importance of pharmacological, over psychosocial, and interventions. CONCLUSIONS The reviewed studies showed that biomedical views about recovery prevail among multidisciplinary mental health staff, despite recent advancements in patients' broader conceptualization of recovery. Clinical implications are discussed. PRACTITIONER POINTS The psychosocial model of recovery has become widely accepted and now underpins most international recovery policies. Despite a dearth in research, existing studies indicate that mental health staff subscribe to biomedical models of recovery in psychosis, with more emphasis on pharmacological, over psychosocial, and interventions. Robust research targeting staff views about recovery in psychosis is needed.
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Affiliation(s)
- Tirma Morera
- School of Psychological Sciences, The University of Manchester, UK
| | - Daniel Pratt
- School of Psychological Sciences, The University of Manchester, UK
| | - Sandra Bucci
- School of Psychological Sciences, The University of Manchester, UK
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Loos S, Clarke E, Jordan H, Puschner B, Fiorillo A, Luciano M, Ivánka T, Magyar E, Krogsgaard-Bording M, Østermark-Sørensen H, Rössler W, Kawohl W, Mayer B, Slade M. Recovery and decision-making involvement in people with severe mental illness from six countries: a prospective observational study. BMC Psychiatry 2017; 17:38. [PMID: 28114913 PMCID: PMC5260092 DOI: 10.1186/s12888-017-1207-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 01/16/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Clinical decision-making is the vehicle of health care provision, and level of involvement predicts implementation and satisfaction. The aim of this study was to investigate the impact of decision-making experience on recovery. METHODS Data derived from an observational cohort study "Clinical decision making and outcome in routine care for people with severe mental illness" (CEDAR). Adults (aged 18-60) meeting standardised criteria for severe mental illness were recruited from caseloads of outpatient and community mental health services in six European countries. After consenting, they were assessed using standardised measures of decision-making, clinical outcome and stage of recovery at baseline and 1 year later. Latent class analysis was used to identify course of recovery, and proportional odds models to investigate predictors of recovery stage and change. RESULTS Participants (n = 581) clustered into three stages of recovery at baseline: Moratorium (N = 115; 19.8%), Awareness/Preparation (N = 145; 25.0%) and Rebuilding/Growth (N = 321; 55.2%). Higher stage was cross-sectionally associated with being male, married, living alone or with parents, and having better patient-rated therapeutic alliance and fewer symptoms. The model accounted for 40% of the variance in stage of recovery. An increased chance of worse outcome (change over 1 year to lower stage of recovery) was found for patients with active involvement compared with either shared (OR = 1.84, 95% CI 1.15-2.94) or passive (OR = 1.71, 95% CI = 1.00-2.95) involvement. Overall, both process (therapeutic relationship) and outcome (symptomatology) are cross-sectionally associated with stage of recovery. CONCLUSIONS Patient-rated decision-making involvement and change in stage of recovery are associated. Joint consideration of decision practise within the recovery process between patient and clinician is supposed to be a useful strategy to improve clinical practice (ISRCTN registry: ISRCTN75841675. Retrospectively registered 15 September 2010).
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Affiliation(s)
- Sabine Loos
- Section Process-Outcome Research, Department of Psychiatry II, Ulm University, Ludwig-Heilmeyer-Str. 2, D-89312, Günzburg, Germany.
| | - Eleanor Clarke
- 0000 0001 2322 6764grid.13097.3cKing’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Harriet Jordan
- 0000 0001 2322 6764grid.13097.3cKing’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Bernd Puschner
- 0000 0004 1936 9748grid.6582.9Section Process-Outcome Research, Department of Psychiatry II, Ulm University, Ludwig-Heilmeyer-Str. 2, D-89312 Günzburg, Germany
| | - Andrea Fiorillo
- 0000 0001 0790 385Xgrid.4691.aDepartment of Psychiatry, University of Naples SUN, Naples, Italy
| | - Mario Luciano
- 0000 0001 0790 385Xgrid.4691.aDepartment of Psychiatry, University of Naples SUN, Naples, Italy
| | - Tibor Ivánka
- 0000 0001 1088 8582grid.7122.6Department of Psychiatry, University of Debrecen Medical Centre, Debrecen, Hungary
| | - Erzsébet Magyar
- 0000 0001 1088 8582grid.7122.6Department of Psychiatry, University of Debrecen Medical Centre, Debrecen, Hungary
| | - Malene Krogsgaard-Bording
- 0000 0004 0646 7349grid.27530.33Unit for Psychiatric Research, Aalborg Psychiatric Hospital, Aalborg University Hospital, Aalborg, Denmark
| | - Helle Østermark-Sørensen
- 0000 0004 0646 7349grid.27530.33Unit for Psychiatric Research, Aalborg Psychiatric Hospital, Aalborg University Hospital, Aalborg, Denmark
| | - Wulf Rössler
- 0000 0004 1937 0650grid.7400.3Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Wolfram Kawohl
- 0000 0004 1937 0650grid.7400.3Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Benjamin Mayer
- 0000 0004 1936 9748grid.6582.9Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Mike Slade
- 0000 0001 2322 6764grid.13097.3cKing’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
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Lim MWZ, Remington G, Lee J. Personal Recovery in Serious Mental Illness: Making Sense of the Concept. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2017. [DOI: 10.47102/annals-acadmedsg.v46n1p29] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Traditionally, clinicians and healthcare users alike use the term “recovery” to imply a return to a premorbid state. This form of clinical recovery is objective, measureable and is a clear health outcome. In the past decade, an alternative to clinical recovery, also known as personal recovery, has gained traction in mental health and has impacted numerous mental health systems. Originally, personal recovery was conceptualised as an individually unique ongoing process for individuals with serious mental illness that emphasises on growth and potential for recovery, but it has also been proposed to be a clinical outcome for mental health professionals. In this commentary, we discuss the differences in the 2 models of recovery and attempt to illustrate the concepts behind personal recovery so as to clarify its usage in people with serious mental illnesses.
Key words: Post-traumatic growth, Resilience, Stigma
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Affiliation(s)
| | - Gary Remington
- Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, Canada
| | - Jimmy Lee
- Research Division, Institute of Mental Health, Singapore
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Recovery assessment scale: Examining the factor structure of the German version (RAS-G) in people with schizophrenia spectrum disorders. Eur Psychiatry 2016; 41:60-67. [PMID: 28049083 DOI: 10.1016/j.eurpsy.2016.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 10/16/2016] [Accepted: 10/22/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The recovery framework has found its way into local and national mental health services and policies around the world, especially in English speaking countries. To promote this process, it is necessary to assess personal recovery validly and reliably. The Recovery Assessment Scale (RAS) is the most established measure in recovery research. The aim of the current study is to examine the factor structure of the German version of the RAS (RAS-G). METHODS One hundred and fifty-six German-speaking clients with schizophrenia or schizoaffective disorder from a community mental health service completed the RAS-G plus measures of recovery attitudes, self-stigma, psychotic symptoms, depression, and functioning. A confirmatory factor analysis of the original 24-item RAS version was conducted to examine its factor structure, followed by reliability and validity testing of the extracted factors. RESULTS The CFA yielded five factors capturing 14 items which showed a substantial overlap with the original subscales Personal Confidence and Hope, Goal and Success Orientation, Willingness to Ask for Help, Reliance on Others, and No Domination by Symptoms. The factors demonstrated mean to excellent reliability (0.59-0.89) and satisfactory criterial validity by positive correlations with measures of recovery attitudes and functioning, and negative correlations with measures of self-stigma, and psychotic and depressive symptoms. CONCLUSIONS The study results are discussed in the light of other studies examining the factor structure of the RAS. Overall, they support the use of the RAS-G as a means to promote recovery oriented services, policies, and research in German-speaking countries.
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Kaite CP, Karanikola MN, Vouzavali FJD, Koutroubas A, Merkouris A, Papathanassoglou EDE. The experience of Greek-Cypriot individuals living with mental illness: preliminary results of a phenomenological study. BMC Psychiatry 2016; 16:343. [PMID: 27716117 PMCID: PMC5053043 DOI: 10.1186/s12888-016-1051-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 09/24/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Research evidence shows that healthcare professionals do not fully comprehend the difficulty involved in problems faced by people living with severe mental illness (SMI). As a result, mental health service consumers do not show confidence in the healthcare system and healthcare professionals, a problem related to the phenomenon of adherence to therapy. Moreover, the issue of unmet needs in treating individuals living with SMI is relared to their quality of life in a negative way. METHODS A qualitative methodological approach based on the methodology of van Manen phenomenology was employed through a purposive sampling of ten people living with SMI. The aim was to explore their perceptions and interpretations regarding: a) their illness, b) their self-image throughout the illness, c) the social implications following their illness, and d) the quality of the therapeutic relationship with mental health nurses. Participants were recruited from a community mental health service in a Greek-Cypriot urban city. Data were collected through personal, semi-structured interviews. RESULTS Several main themes were identified through the narratives of all ten participants. Main themes included: a) The meaning of mental illness, b) The different phases of the illness in time, c) The perception of the self during the illness, d) Perceptions about the effectiveness of pharmacotherapy, e) Social and personal consequences for participants following the diagnosis of mental illness, f) Participants' perceptions regarding mental health professionals and services and g) The therapeutic effect of the research interview on the participants. CONCLUSIONS The present study provides data for the enhancement of the empathic understanding of healthcare professionals regarding the concerns and particular needs of individuals living with SMI, as well as the formation of targeted psychosocial interventions based on these needs. Overall, the present data illuminate the necessity for the reconstruction of the provided mental healthcare in Cyprus into a more recovery- oriented approach in order to address personal identity and self-determination issues and the way these are related to management of pharmacotherapy. Qualitative studies aiming to further explore issues of self-identity during ill health and its association with adherence to therapy, resilience and self-determination, are also proposed.
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Affiliation(s)
- Charis P. Kaite
- Department of Nursing, School of Health Sciences, Cyprus University of Technology, 15, Vragadinou str, 3041 Limassol, Cyprus
| | - Maria N. Karanikola
- Department of Nursing, School of Health Sciences, Cyprus University of Technology, 15, Vragadinou str, 3041 Limassol, Cyprus
| | - Foteini J. D. Vouzavali
- Department of Nursing, Vocational High School of Nurse Assistants & Laboratory Instructor, Technological Educational Institute of Athens, Cholargos, Athens, Greece
| | - Anna Koutroubas
- Children’s Hospital “A & P Kyriakou” Oncology Department, Athens, Greece
| | - Anastasios Merkouris
- Department of Nursing, School of Health Sciences, Cyprus University of Technology, 15, Vragadinou str, 3041 Limassol, Cyprus
| | - Elizabeth D. E. Papathanassoglou
- Faculty of Nursing, University of Alberta, 5–262 Edmonton Clinic Health Academy (ECHA), 11405-87th Ave., Edmonton, AB T6G 1C9 Canada
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Kukla M, Whitesel F, Lysaker PH. An Integrative Psychotherapy Approach to Foster Community Engagement and Rehabilitation in Schizophrenia: A Case Study Illustration. J Clin Psychol 2015; 72:152-63. [PMID: 26636563 DOI: 10.1002/jclp.22248] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This case study illustrates the use of a long-term integrative psychotherapy approach with a middle- aged man with chronic schizophrenia and a mood disorder. The case of "Holst" describes a man with a history of insecure attachment and trauma who later went on to contract a serious chronic illness, precipitating the onset of psychotic symptoms, depression, and chronic suicidal ideation, resulting in multiple hospitalizations. Combining metacognition-oriented therapy with elements of cognitive behavioral therapy and psychiatric rehabilitation, this approach fostered significantly improved community functioning and attainment of personal goals over time. Through the journey of therapy, the patient also developed a more coherent narrative about his life, established a stable sense of self, and became an active agent in the world. This case illustration demonstrates that these three different approaches can be used in a sequential and complementary fashion to foster recovery in the midst of serious physical and mental illness.
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Affiliation(s)
- Marina Kukla
- Center for Health Information and Communication, Health Services Research and Development.,Richard L. Roudebush VA Medical Center.,Indiana University-Purdue University Indianapolis, Department of Psychology
| | | | - Paul H Lysaker
- Richard L. Roudebush VA Medical Center.,Indiana University School of Medicine
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Luther L, Lysaker PH, Firmin RL, Breier A, Vohs JL. Intrinsic motivation and amotivation in first episode and prolonged psychosis. Schizophr Res 2015; 169:418-422. [PMID: 26386901 DOI: 10.1016/j.schres.2015.08.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 08/26/2015] [Accepted: 08/31/2015] [Indexed: 10/23/2022]
Abstract
The deleterious functional implications of motivation deficits in psychosis have generated interest in examining dimensions of the construct. However, there remains a paucity of data regarding whether dimensions of motivation differ over the course of psychosis. Therefore, this study examined two motivation dimensions, trait-like intrinsic motivation, and the negative symptom of amotivation, and tested the impact of illness phase on the 1) levels of these dimensions and 2) relationship between these dimensions. Participants with first episode psychosis (FEP; n=40) and prolonged psychosis (n=66) completed clinician-rated measures of intrinsic motivation and amotivation. Analyses revealed that when controlling for group differences in gender and education, the FEP group had significantly more intrinsic motivation and lower amotivation than the prolonged psychosis group. Moreover, intrinsic motivation was negatively correlated with amotivation in both FEP and prolonged psychosis, but the magnitude of the relationship did not statistically differ between groups. These findings suggest that motivation deficits are more severe later in the course of psychosis and that low intrinsic motivation may be partially independent of amotivation in both first episode and prolonged psychosis. Clinically, these results highlight the importance of targeting motivation in early intervention services.
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Affiliation(s)
- Lauren Luther
- Indiana University-Purdue University Indianapolis, Department of Psychology, 402 N., Blackford St., LD 124, Indianapolis, IN 46202, USA.
| | - Paul H Lysaker
- Roudebush VA Medical Center, Research Dept. Mail code (151), 1481 W. 10th St., Indianapolis, IN 46219, USA; Indiana University School of Medicine, 340 West 10th Street, Suite 6200, Indianapolis, IN 46202, USA.
| | - Ruth L Firmin
- Indiana University-Purdue University Indianapolis, Department of Psychology, 402 N., Blackford St., LD 124, Indianapolis, IN 46202, USA.
| | - Alan Breier
- Indiana University School of Medicine, 340 West 10th Street, Suite 6200, Indianapolis, IN 46202, USA; Prevention and Recovery Center for Early Psychosis, Midtown Community Mental Health Centers, Wishard Hospital, 720 Eskenazi Avenue, Indianapolis, IN 46202, USA; Larue D. Carter Memorial Hospital, IU Psychotic Disorders Research Program, 2601 Cold Spring Rd, Indianapolis, IN 46222,USA
| | - Jenifer L Vohs
- Indiana University School of Medicine, 340 West 10th Street, Suite 6200, Indianapolis, IN 46202, USA; Prevention and Recovery Center for Early Psychosis, Midtown Community Mental Health Centers, Wishard Hospital, 720 Eskenazi Avenue, Indianapolis, IN 46202, USA; Larue D. Carter Memorial Hospital, IU Psychotic Disorders Research Program, 2601 Cold Spring Rd, Indianapolis, IN 46222,USA.
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39
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Vancampfort D, Guelinckx H, Probst M, Stubbs B, Rosenbaum S, Ward PB, De Hert M. Health-related quality of life and aerobic fitness in people with schizophrenia. Int J Ment Health Nurs 2015. [PMID: 26215311 DOI: 10.1111/inm.12145] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The purpose of this cross-sectional study was to investigate whether aerobic fitness contributes to the health-related quality of life (HRQoL) in people with schizophrenia, while adjusting for other previously-established contributory factors. Thirty-four male (34.1 ± 12.0 years) and 13 female (34.3 ± 9.2 years) participants performed a submaximal Astrand-Rhyming cycle ergometer test and completed the 36-item Short-Form Health Survey, the International Physical Activity Questionnaire, and the Psychosis Evaluation tool for Common Use by Caregivers. After controlling for age and sex, illness duration (12.4 ± 11.2 years, r(2) = 0.38, P < 0.001), fewer positive (9.3 ± 4.3, r(2) = 0.30, P = 0.006) and cognitive (8.4 ± 3.8, r(2) = 0.28, P = 0.011) symptoms, and higher aerobic fitness (34.5 ± 8.7 ml O2 min(-1) kg(-1), r(2) = 0.36, P = 0.001) were found to be independent significant predictors of physical HRQoL (mean score 66.6 ± 18.5). However, when all variables were included in the same regression model, only illness duration (P = 0.004) and positive symptoms (P = 0.045) remained significant predictors, while there was a trend (P < 0.10) for age and aerobic fitness. The final model explained 54% of the variability in physical HRQoL. No significant correlates for mental HRQoL (54.9 ± 18.5) were found. People with schizophrenia might improve their physical HRQoL by improving their aerobic fitness. Mental health nurses should assist in facilitating improvements in aerobic fitness through facilitating physical activity participation in patients with schizophrenia.
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Affiliation(s)
- Davy Vancampfort
- Department of Rehabilitation Sciences, KU Leuven - University of Leuven, Leuven, Belgium.,Department of Neurosciences, KU Leuven - University of Leuven, Kortenberg, Belgium
| | - Hannes Guelinckx
- Department of Rehabilitation Sciences, KU Leuven - University of Leuven, Leuven, Belgium
| | - Michel Probst
- Department of Rehabilitation Sciences, KU Leuven - University of Leuven, Leuven, Belgium.,Department of Neurosciences, KU Leuven - University of Leuven, Kortenberg, Belgium
| | - Brendon Stubbs
- School of Health and Social Care, University of Greenwich, London, UK
| | - Simon Rosenbaum
- School of Psychiatry, University of New South Wales, Schizophrenia Research Unit
| | - Philip B Ward
- School of Psychiatry, University of New South Wales, Schizophrenia Research Unit
| | - Marc De Hert
- Department of Rehabilitation Sciences, KU Leuven - University of Leuven, Leuven, Belgium.,School of Health and Social Care, University of Greenwich, London, UK
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40
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Massé M, Lecomte T. Metacognitive profiles in individuals with a first episode of psychosis and their relation to social functioning and perceived social support. Schizophr Res 2015; 166:60-4. [PMID: 26116327 DOI: 10.1016/j.schres.2015.05.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 05/08/2015] [Accepted: 05/11/2015] [Indexed: 11/28/2022]
Abstract
Poorer metacognitive abilities are recognized as strong predictors of social functioning deficits in individuals with schizophrenia, but have not been studied in relation to perceived social support. Furthermore, traditional measures of metacognition fail to consider ecological aspects such as the interaction between thinking of one's own or other's mind, and mastery. As a constellation, these abilities may influence domains of social functioning and perceived social support differently. Therefore, this study aimed to establish whether distinct metacognitive profiles exist within a population of individuals with a first psychotic episode, and to determine how such profiles influence individual domains of social functioning and perceived social support. Participants (n=50) were recruited from two early psychosis outpatient clinics in Montreal, Canada. Demographic information, social functioning and perceived social support were measured using self-reported questionnaires, and metacognition was scored from the transcripts of a semi-structured interview designed to avoid leading responses. Cluster analysis revealed three distinct metacognitive profiles: (1) overall better abilities; (2) poor abilities on thinking of one's own and other's mind, but better mastery; and (3) overall poorer abilities. Analyses showed significant differences between profiles only for self-reported intimacy and independent living abilities, with the second profile showing better abilities than the third. Profiles did not simply represent consistently higher or lower functioning across subscales. Although mastery was predictive of social functioning, the ability to think in an increasingly complex manner of one's self and others did not seem to improve functioning in individuals with a first episode of psychosis.
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Affiliation(s)
- Marjolaine Massé
- Université de Montréal, Department of Psychology, C-358, 90 Vincent d'Indy Street, C.P. 6128, Succ. Centre-Ville, Montreal, QC H3C 3J7, Canada
| | - Tania Lecomte
- Université de Montréal, Department of Psychology, C-358, 90 Vincent d'Indy Street, C.P. 6128, Succ. Centre-Ville, Montreal, QC H3C 3J7, Canada.
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41
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Relationships over time of subjective and objective elements of recovery in persons with schizophreni. Psychiatry Res 2015; 228:14-9. [PMID: 25920806 DOI: 10.1016/j.psychres.2015.03.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 01/02/2015] [Accepted: 03/12/2015] [Indexed: 11/20/2022]
Abstract
Recovery from schizophrenia involves both subjective elements such as self-appraised wellness and objective elements such as symptom remission. Less is known about how they interact. To explore this issue, this study examined the relationship over the course of 1 year of four assessments of symptoms with four assessments of self-reports of subjective aspects of recovery. Participants were 101 outpatients with schizophrenia. Symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS) while subjective recovery was assessed with the Recovery Assessment Scale (RAS). Separate Pearson's or Spearman's rank's correlation coefficients, calculated at all four measurement points, revealed the total symptom score was linked with lower levels of overall self-recovery at all four measurement points. The PANSS emotional discomfort subscale was linked with self-reported recovery at all four measurement points. RAS subscales linked to PANSS total symptoms at every time point were Personal confidence and hope, Goal and success orientation, and No domination by symptoms. Results are consistent with conceptualizations of recovery as a complex process and suggest that while there may be identifiably different domains, changes in subjective and objective domains may influence one another.
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