Recovery in Schizophrenia: What Consumers Know and Do Not Know

Defining recovery in schizophrenia: A review of outcome studies

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

Assessment of the treatment needs of community recovery Services in Spain: From the perspective of service users, families, and mental health professionals

Profile of Community Recovery Services users has changed over the years and has become more diverse. To explore the evolution of treatment needs, this study aimed to identify users' needs, from the point of view of different agents implicated in the recovery process. We explored the consistency between the agents using the focus group technique. We defined four groups (n = 58): service users, family members, professionals, and referring professionals. We pre-identified topics related to recovery, such as illness-related losses, imaginary of CRS, expectations, activities, and life goals. All agents recognised losses related to the mental illness, the need for carrying activities out of the Community Recovery Services, and for including families in the recovery process. The groups differed in some areas, such as the identification of activities that should be encouraged, or the importance of promoting vital expectations. Our findings suggest that it is important to identify the needs of different agents involved in the recovery process. There is consistency in the service users' needs, but there are some differences that need to be considered. Interventions should be personalised, covering functional, cognitive, and relational losses related to the mental illness.

The processes involved in the establishment of user-provider partnerships in severe psychiatric illnesses: a scoping review

PURPOSE

With the rising relevance of person-centred care, initiatives towards user-led decision making and designing of care services have become more frequent. This designing of care services can be done in partnership, but it is unclear how. The aim of this scoping review was to identify for mental health services, what user-provider partnerships are, how they arise in practice and what can facilitate or hinder them.

METHODS

A scoping review was conducted to obtain a broad overview of user provider partnerships in severe mental illness. Data was inductively analysed using a conventional content analysis approach, in which meaning was found in the texts.

RESULTS

In total, 1559 titles were screened for the eligibility criteria and the resulting 22 papers found relevant were analysed using conventional content analysis. The identified papers had broad and differing concepts for user-provider partnerships. Papers considered shared decision making and user-involvement as partnerships. Mechanisms such as open communication, organisational top-down support and active participation supported partnerships, but professional identity, power imbalances and stress hindered them. Users can be impeded by their illness, but how to deal with these situations should be formalised through contracts.

CONCLUSION

The field of research around user-provider partnerships is scattered and lacks consensus on terminology. A power imbalance between a user and a provider is characteristic of partnerships in mental healthcare, which hinders the necessary relationship building allowing partnerships to arise. This power imbalance seems to be closely linked to professional identity, which was found to be difficult to change.

Shared decision making in a semi-secluded chronic psychiatric ward: The reflective lifeworld experiences of patients with schizophrenia or schizoaffective disorders and nursing staff

BACKGROUND

Shared decision making (SDM) enhances recovery-oriented mental healthcare, but literature predominately focuses on doctor-patient collaboration leaving the role of mental health nurses (MHN's) underexposed.

AIM

This study describes the experiences of patients with schizophrenia or schizoaffective disorder with SDM in a semi-secluded psychiatric facility, and the attitudes toward SDM by MHN's.

METHOD

A hermeneutic phenomenological design.

RESULTS

Seven patients and six MHN's were interviewed. Although MHNs were skeptical to utilize SDM, and patients often feel omitted, investing in inter-human contact increased the therapeutic alliance.

CONCLUSION

Tailored plan making and attainable goal setting, building trust, and providing hope are important incentives to enhance SDM.

Living beyond the limitation: Rehabilitation, life and productivity of individuals with schizophrenia in South-West Nigeria

INTRODUCTION

Schizophrenia, the most chronic and stigmatized form of mental illness, can be described as a brain disorder that affects an individual's cognition. Individuals with schizophrenia exhibit socially unacceptable symptoms that affect their psychosocial lives. They suffer from reduced productivity due to the debilitating effect of the illness, and the negative symptoms impede their employability; such symptoms and effects aggravate the stigma around mental illness. However, when rehabilitation is successfully achieved, so is productivity, and this decreases the associated stigma. Thus, this study describes the rehabilitation experiences and productivity of individuals with schizophrenia in South-West Nigeria.

METHODS AND ANALYSIS

A descriptive qualitative approach with semi-structured interviews was used to gather information from mental health service users. The discharged users in this study received in-hospital or outpatient rehabilitation care at four outpatient units within two specialist mental health-care facilities in South-West Nigeria. These facilities offer vocational training and rehabilitation services for individuals with schizophrenia. Twenty-nine mental health service users were interviewed. The data from the interviews were independently analysed by two researchers through a content analysis approach using NVIVO version 11. The researchers compared the results of the analysis and reached an agreement on the conclusion.

FINDINGS AND RECOMMENDATIONS

The rehabilitation services availed by patients in the research setting are of three types. Some attend occupational rehabilitation to learn a trade; they depend on professionals for the choice of skill but at a cost that is not affordable to many. Some stay in rehabilitation units linked to the hospital, rendering their services at a cost, and their living expenses and skill acquisition processes are based on the remuneration they get from the services rendered to the institution. Others depend on their family members' efforts to afford rehabilitation services but set up on job by family or employed in family business. The mental health service users in this study who offered their services to the institutions were able to make informed decisions and showed better performance with their chosen occupation than those who depended on their family or health professionals for the choice of rehabilitation service or vocational career. Therefore, this study concludes that prioritizing mental health facility users' preferences in terms of productive activities (sales, services, vocation) or rehabilitation goals should be encouraged.

How Early Life Adversities Influence Later Life Family Interactions for Individuals with Schizophrenia in Outpatient Treatment: A Qualitative Analysis

Many individuals diagnosed with schizophrenia state that family relationships are a primary facilitator of their recovery. However, they also report higher rates of early life adversities, typically in their family environments. We used modified Grounded Theory on 20 semi-structured, in-depth interviews with adults (half ethnic minorities, half women) diagnosed with schizophrenia or schizoaffective disorder and receiving treatment at an urban psychiatric outpatient clinic to investigate how early life adversities influence later life family interactions. Approximately half of participants did not mention early life adversities and described positive family interactions and perceived supportive involvement in their illness. The other half of participants experienced abusive and/or unstable childhood homes that many explicitly linked to limited family interactions and perceived absence of support for their illness. These findings suggest that limited familial interactions following early life adversities may reflect resilient boundary setting, and indicate the value of considering these adversities before incorporating families in care.

Quality of Life in Schizophrenia: What is Important for Persons with Schizophrenia in India?

BACKGROUND

Quality of life (QOL) is a multidimensional construct and is increasingly recognized as an important outcome measure. Schizophrenia runs a chronic course and is a disabling mental disorder. Assessment of QOL using currently available scales for schizophrenia may not be culturally relevant.

METHODS

In phase one, patients with schizophrenia using psychiatric rehabilitation services, caregivers, and mental health professionals were interviewed qualitatively to identify factors that are important for QOL of patients. In phase two, 40 patients with schizophrenia were recruited consecutively from the outpatient department and asked to rate the importance/relevance of the above items for QOL on a Likert scale.

RESULTS

Themes that emerged were work, family's understanding about illness, stigma, financial issues, social life, social standing, religion and spirituality, medications, physical health, mental health and symptoms, recreation and leisure, and independent living. Work and family's understanding of illness were considered as moderately or very important by all patients in phase two.

CONCLUSIONS

Work is very important for all patients with schizophrenia for their QOL. The themes derived from this study could guide the development of a scale for QOL that is relevant to the Indian context.

[Shared decision-making in acute psychiatric medicine : Contraindication or a challenge?]

BACKGROUND

The concept of shared decision-making (SDM) has existed since the 1990s in multiple fields of somatic medicine but has only been poorly applied in psychiatric clinical routine despite broad acceptance and promising outcomes in clinical studies on its positive effects.

MATERIALS AND METHODS

The concept itself and its practicability in mental health are carefully assessed and strategies for its future implementation in psychiatric medicine are presented in this article. Ongoing clinical studies probing some of those strategies are further outlined.

RESULTS AND DISCUSSION

On top of the ubiquitous shortage of time in clinical routine, psychiatrists report their concern about patients' limited abilities in sharing decisions and their own fear of potentially harmful decisions resulting from a shared process. Misinterpretation of shared decision-making restricting the health care professional to rather an informed choice scenario and their own adhesion to the traditional paternalistic decision-making approach further add to SDM's underutilization. Those hurdles could be overcome by communication skill workshops for all mental health care professionals, including nursing personnels, psychologists, social workers and physicians, as well as the use of decision aids and training courses for patients to motivate and empower them in sharing decisions with the medical staff. By this, the patient-centered treatment approach demanded by guidelines, carers and users could be further facilitated in psychiatric clinical routine.

Are we getting any better at staying better? The long view on relapse and recovery in first episode nonaffective psychosis and schizophrenia

Relapse in, and recovery from, schizophrenia has been acknowledged since the disease was first described. In this review the authors summarize the long-term (>100 years) data on relapse and recovery in schizophrenia by reviewing the extant older and modern relevant literature. The authors systematically question the utility of pharmacological and nonpharmacological interventions, with an emphasis on first episode nonaffective psychosis. The method used is a narrative review of earlier meta-analytic and systematic reviews. Antipsychotic medication discontinuation studies suggest a role for prophylactic maintenance treatment in the majority of people with schizophrenia, despite recent debate on this subject. The authors conclude that long-term outcomes, including relapse and recovery rates, have improved in the last 100 years, though prospectively identifying those people who do not require long-term antipsychotic treatment has not yet been possible. Data also suggests that interventions and outcomes during the first 5 years of the disease can influence the long-term schizophrenia trajectory.

The impact of a short-term cohousing initiative among schizophrenia patients, high school students, and their social context: A qualitative case study

Background

A number of programs have been developed to promote the contact between adolescents and mentally-ill patients, in order to break the stigma, improve understanding, promote mental health and prevent substance abuse. The aim of this study was to describe the experience of patients with schizophrenia, high school students, and their social context, participating in a short-term cohousing initiative.

Methods

A qualitative case-study approach was implemented. Patients with schizophrenia from the San Juan de Dios Psychiatric Hospital, female students from Almen High School, and participants from their social context (parents, hospital staff, and teachers) were included, using purposeful sampling. Data were collected from 51 participants (15 patients, nine students, 11 hospital staff, six teachers, 10 parents) via non-participant observation, focus groups, informal interviews, researchers’ field notes and patients’ personal diaries and letters. A thematic analysis was performed.

Results

The themes identified included a) learning to live together: students and patients participate and learn together; b) the perception of the illness and the mentally-ill: the barrier between health and disease is very slim, and society tends to avoid contact with those who are ill; c) change: a transformation takes place in students, in their self-perception, based on the real and intense nature of the experience; d) a trial and an opportunity: patients test their ability to live outside the hospital; e) discharge and readmission: discharge is experienced as both a liberation and a difficulty, whereas relapse and readmission are experienced as failures.

Conclusions

Our findings can help us to better understand schizophrenia and encourage a more positive approach towards both the illness and those who suffer from it. These results may be used for the development of cohousing programs in controlled environments.

Shared decision making in mental health: the importance for current clinical practice

OBJECTIVES

We reviewed the literature on shared decision making (regarding treatments in psychiatry), with a view to informing our understanding of the decision making process and the barriers that exist in clinical practice.

METHODS

Narrative review of published English-language articles.

RESULTS

After culling, 18 relevant articles were included. Themes identified included models of psychiatric care, benefits for patients, and barriers. There is a paucity of published studies specifically related to antipsychotic medications.

CONCLUSIONS

Shared decision making is a central part of the recovery paradigm and is of increasing importance in mental health service delivery. The field needs to better understand the basis on which decisions are reached regarding psychiatric treatments. Discrete choice experiments might be useful to inform the development of tools to assist shared decision making in psychiatry.