Overlap and Mutual Distinctions Between Clinical Recovery and Personal Recovery in People With Schizophrenia in a One-Year Study

Factors associated with recovery during schizophrenia and related disorders: A review of meta-analysis

BACKGROUND

The spectrum of schizophrenia disorders (SSD) is a severe mental disorder. It is one of the main medical causes of disability that generates high health and social costs.

OBJECTIVE

To analyze the factors associated with clinical recovery (CR) (symptomatic remission-SR and functional recovery-FR) and personal recovery (PR) in people diagnosed with SSD.

METHODS

14 meta-analyses focused on recovery were reviewed following the PRISMA model statements. 95 % of CI was established.

RESULTS

Shorter Duration of Untreated Psychosis (Zr = 0.24, [0.17, 0.30]) and total Duration of Untreated Illness (Zr = 0.34, [0.20, 0.48]) were related to greater SR and general functioning, respectively. Resilience was the variable with the greatest effect on FR (Zr = 0.67, [0.63, 0.71]). Premorbid adjustment (Zr = 0.34, [0.18, 0.49]) and physical intervention (Zr = 0.71, [0.55, 0.86]) had the greatest effect on occupational and social functioning, respectively. Less severe affective symptoms were related to greater PR (Zr = 0.46, [0.42, 0.50]). There are differences between affective SR and the other types of SR (Zr(SR-A - SR-) = 0.13, Qb = 6.51, p = 0.011), (Zr(SR-A - SR+) = 0.20, Qb = 8.52, p = 0.004), (Zr(SR-A - SR) = 0.18, Qb = 19.29, p = 0.0001). In all, resilience was associated with greater recovery (Zr = 0.67, [0.53, 0.80]), with the global effect being greater on PR than on CR (Zr(PR-CR) = 0.07, Qb = 3.45, p = 0.05).

CONCLUSIONS

Resilience was the variable most strongly associated with recovery. Symptomatic or functional improvement obtained less statistical weight.

Psychotherapy on an Acute Psychiatric Ward: Preliminary Findings From a Controlled Study

This study investigated the efficacy of psychotherapy during hospitalization on an acute psychiatric ward. A controlled trial was conducted to assess the effects of Metacognitive Reflection and Insight Therapy (MERIT) upon metacognition and psychiatric symptoms. Data from 40 inpatient women were analysed. Findings included significant interaction effects between group (intervention or control group) and time (preintervention and postintervention) in regard to the metacognitive abilities and general psychiatric symptoms. Participating in MERIT seems to improve one's ability to use reflective knowledge to cope with psychological challenges and to improve symptomatology level.

Long-term Changes in Personal Recovery and Quality of Life Among Patients With Schizophrenia Spectrum Disorders and Different Durations of Illness: A Meta-analysis

BACKGROUND AND HYPOTHESIS

In schizophrenia spectrum disorders (SSD) personal recovery and subjective quality of life (S-QOL) are crucial and show conceptual overlap. There is limited knowledge about how these outcomes change over time. Therefore, we investigated changes in personal recovery or S-QOL for patients with SSD. We specifically focused on the influence of the patients' durations of illness (DOI) on changes in personal recovery and S-QOL.

STUDY DESIGN

We included 46 studies investigating longitudinal changes in quantitative assessments of personal recovery or S-QOL for patients with SSD. Outcomes were categorized in overall personal recovery, overall S-QOL connectedness, hope and optimism, identity, meaning in life, and empowerment. We evaluated effect sizes of change between baseline and follow-up assessments. We also evaluated potential moderating effects, including DOI on these changes in outcomes.

STUDY RESULTS

We found small improvements of overall personal recovery and S-QOL, but marginal or no improvement over time in the other more specific outcome domains. Patients without a schizophrenia diagnosis, a younger age, and more recent publications positively influenced these changes. We found no significant influence of DOI on the changes in any outcome domain.

CONCLUSIONS

Improvement in personal recovery or S-QOL of people with SSD is modest at best. However, these studies did not fully capture the personal narratives or nonlinear process of recovery of an individual. Future research should focus on how to shift from a clinical to more person-oriented approach in clinical practice to support patients in improving their personal process of recovery.

REVIEW PROTOCOL REGISTRATION

CRD42022377100.

Personal recovery in first-episode psychosis: Beyond clinical and functional recovery

BACKGROUND

The concept of personal recovery after psychotic illness focuses more on patients' social and existential needs compared to traditional outcome measures including clinical and functional recovery. This research aims to contribute to a broad framework on (personal) recovery and associated factors.

METHODS

Data from 203 persons with symptomatic remission of their first-episode psychosis from the ongoing HAMLETT study were analyzed. To determine the relative importance of several biological, clinical, psychological, and social factors in explaining personal recovery as measured by the Recovery Assessment Scale (RAS), partial Spearman correlations (controlling for clinical recovery (PANSS) and functional recovery (WHODAS 2.0)) and a bootstrapped multiple regression were performed. Indirect effects on personal recovery within these factors, clinical recovery, and functional recovery were explored using a regularized partial correlation network.

RESULTS

Of the factors that explained personal recovery beyond the effects of clinical and functional recovery, social support was the strongest predictor, followed by self-esteem, internalized stigma, and insecure attachment, collectively explaining 48.2 % of the variance. Anhedonia/apathy showed a trend towards a negative correlation. Age at onset, sex, early trauma/neglect, cognition, and being married/cohabiting did not significantly correlate with personal recovery. The network (n = 143) was consistent with these findings and indicated possible mediation pathways for early trauma/neglect, insecure attachment, cognition, and being married/cohabiting.

CONCLUSIONS

Personal recovery is an important addition to traditional measures of outcome after psychosis. Various quality of life indicators, such as self-esteem and social support, explain variance in personal recovery over clinical and functional recovery.

A good life with psychosis: rate of positive outcomes in first-episode psychosis at 10-year follow-up

BACKGROUND

More knowledge about positive outcomes for people with first-episode psychosis (FEP) is needed. An FEP 10-year follow-up study investigated the rate of personal recovery, emotional wellbeing, and clinical recovery in the total sample and between psychotic bipolar spectrum disorders (BD) and schizophrenia spectrum disorders (SZ); and how these positive outcomes overlap.

METHODS

FEP participants (n = 128) were re-assessed with structured clinical interviews at 10-year follow-up. Personal recovery was self-rated with the Questionnaire about the Process of Recovery-15-item scale (total score ⩾45). Emotional wellbeing was self-rated with the Life Satisfaction Scale (score ⩾5) and the Temporal Experience of Pleasure Scale (total score ⩾72). Clinical recovery was clinician-rated symptom-remission and adequate functioning (duration minimum 1 year).

RESULTS

In FEP, rates of personal recovery (50.8%), life satisfaction (60.9%), and pleasure (57.5%) were higher than clinical recovery (33.6%). Despite lower rates of clinical recovery in SZ compared to BD, they had equal rates of personal recovery and emotional wellbeing. Personal recovery overlapped more with emotional wellbeing than with clinical recovery (χ2). Each participant was assigned to one of eight possible outcome groups depending on the combination of positive outcomes fulfilled. The eight groups collapsed into three equal-sized main outcome groups: 33.6% clinical recovery with personal recovery and/or emotional wellbeing; 34.4% personal recovery and/or emotional wellbeing only; and 32.0% none.

CONCLUSIONS

In FEP, 68% had minimum one positive outcome after 10 years, suggesting a good life with psychosis. This knowledge must be shared to instill hope and underlines that subjective and objective positive outcomes must be assessed and targeted in treatment.

Patients' awareness of recovery mediates the link between clinical and level of functional remission in schizophrenia to a larger extent in those treated with long-acting antipsychotics

Background

Clinical remission is a step towards functional remission for subjects with schizophrenia. While recovery is both a subjective personal journey and a clinical outcome to be targeted, data on patient self-rated outcomes are scarce.

Objectives

(i) To determine the extent to which the association between clinical and functional remission is mediated by the subjective experience of recovery as reported by patients versus their relatives or their psychiatrist and (ii) to assess differences according to treatment, specifically with oral antipsychotics only versus long-acting injectable antipsychotics (LAIs).

Design

Clinical observational study.

Methods

Community-dwelling participants with schizophrenia enrolled in the EGOFORS cohort (N = 198) were included. Clinical symptoms and remission were assessed using the Positive and Negative Syndrome Scale. Functional remission was assessed with the Functional Remission of General Schizophrenia Scale. Awareness of recovery was assessed with one question 'What percentage of recovery do you think you have now (from 0% - no recovery - to 100% - full recovery)?', asked of the patient, also of the patient's close relative, and the psychiatrist. We used mediation analyses, taking into account the type of pharmacological treatment.

Results

Remission criteria and perceived remission measures were significantly correlated, both within and between groups (r > 0.330). The patient's awareness of recovery mediated the relationship between clinical remission and level of functional remission, while the level of recovery according to psychiatrists or close relatives did not. The direct effect of clinical remission on the level of functional remission became non-significant when taking into account the mediator (patients' awareness of recovery) in the group of patients with LAI (t = 1.5, p = 0.150) but not in the group of patients with other treatments (t = 3.1, p = 0.003).

Conclusion

Patients with LAIs may be more efficient in reporting their level of functional remission. Higher patient awareness could be an interesting candidate to explain this. However, as the study was cross-sectional, such a proposal should be tested with a more specifically designed protocol, such as a long-term cohort.

Self-esteem in stabilized individuals with chronic schizophrenia: association with residual symptoms and cognitive functioning

Low self-esteem is regarded as a barrier to recovery from schizophrenia and the identification of factors affecting this psychological characteristic may help to implement effective therapeutic interventions. To this end, the present study aimed to assess whether residual symptoms of the disorder and performance on a comprehensive neuropsychological test battery might differently impact self-esteem among 70 stabilized outpatients with chronic schizophrenia from public outpatient mental health services. Self-esteem inter-correlated with the severity of overall symptomatology, affective and negative symptoms, with premorbid intelligence, and with performance in the domains of verbal learning and memory, visual memory, working memory, and verbal fluency. Residual affective symptoms, premorbid intelligence, and female sex predicted poorer self-esteem in multiple linear regression analysis. The findings of this study implicate that next to psychological interventions therapeutic strategies that specifically target affective symptoms of schizophrenia may have a beneficial impact on patients' self-esteem.

Systematic review and meta-analysis on predictors of prognosis in patients with schizophrenia spectrum disorders: An overview of current evidence and a call for prospective research and open access to datasets

BACKGROUND

Schizophrenia spectrum disorders (SSD) have heterogeneous outcomes. If we could predict individual outcome and identify predictors of outcome, we could personalize and optimize treatment and care. Recent research showed that recovery rates tend to stabilize early in the course of disease. Short- to medium- term treatment goals are most relevant for clinical practice.

METHODS

We performed a systematic review and meta-analysis to identify predictors of outcome ≤1 year in prospective studies of patients with SSD. For our meta-analysis risk of bias was assessed with the QUIPS tool.

RESULTS

178 studies were included for analysis. Our systematic review and meta-analysis showed that the chance of symptomatic remission was lower in males, and in patients with longer duration of untreated psychosis, more symptoms, worse global functioning, more previous hospital admissions and worse treatment adherence. The chance of readmission was higher for patients with more previous admissions. The chance of functional improvement was lower in patients with worse functioning at baseline. For other proposed predictors of outcome, like age at onset and depressive symptoms, limited to no evidence was found.

DISCUSSION

This study illuminates predictors of outcome of SSD. Level of functioning at baseline was the best predictor of all investigated outcomes. Furthermore, we found no evidence for many predictors proposed in original research. Possible reasons for this include the lack of prospective research, between-study heterogeneity and incomplete reporting. We therefore recommend open access to datasets and analysis scripts, enabling other researchers to reanalyze and pool the data.

Exploring the Personal Recovery Construct in Bipolar Disorders: Definition, Usage and Measurement. A Systematic Review

Personal recovery from psychiatric disorders is a journey toward a satisfying and hopeful life despite the possible persistence of symptoms. This concept has gained interest and become an increasingly important goal in mental health care programmes. Personal Recovery is well described in the context of severe mental illnesses in general, but little is known about this journey in bipolar disorders and the factors underlying it. A systematic review was conducted according to the PRISMA recommendations, focusing on studies exploring personal recovery in bipolar disorder specifically. The latter have integrated a comprehensive approach to the concept, the existing means of measurement or have explored the levers of recovery in care. Twenty-four articles were selected, including seven qualitative, 12 observational, and five interventional studies. The Bipolar Recovery Questionnaire was the only scale developed de novo from qualitative work with bipolar people. Personal recovery did not correlate very closely with symptomatology. Some elements of personal recovery in bipolar disorder were similar to those in other severe mental illnesses: meaning in life, self-determination, hope, and low self-stigma. Specific levers differed: mental relationships with mood swings, including acceptance and decrease in hypervigilance, and openness to others, including trust and closeness. The studies highlighted the role of caregiver posture and the quality of communication within care, as well as the knowledge gained from peers. The choice to exclude articles not focused on bipolar disorder resulted in the provision of very specific information, and the small number of articles to date may limit the scope of the evidence. New components of personal recovery in bipolar disorder emerged from this review; these components could be taken into account in the construction of care tools, as well as in the caregiving posture. Strengthening skills of openness to others could also be a central target of recovery-focused care.