Identifying the facilitators and processes which influence recovery in individuals with schizophrenia: a systematic review and thematic synthesis

Association between social support and the severity of positive symptoms in rural community-dwelling patients with schizophrenia during the COVID-19 pandemic

BACKGROUND

This study examined the association between social support and the severity of positive symptoms in rural community-dwelling schizophrenia patients during the COVID-19 pandemic.

METHOD

The cross-sectional study included 665 rural community-dwelling schizophrenia patients investigated during the COVID-19 pandemic. Social support was measured using the Social Support Rating Scale, and positive symptoms were assessed using the Positive Scale extracted from the Positive and Negative Syndrome Scale. Multiple linear regression was adopted to examine the association of social support with positive symptoms.

RESULT

The scores for total social support, subjective support, objective support and the use of social support were 28.3 ± 5.9, 16.4 ± 5.2, 6.5 ± 1.4 and 5.4 ± 2.8, respectively. Total social support (β = -0.08, 95%CI: -0.13 to -0.02, P < 0.01) and subjective social support (β = -0.10, 95%CI: -0.16 to -0.04, P < 0.01) were significantly and negatively associated with the Positive Scale score after adjustment for confounders. Objective social support (β = 0.11, 95%CI: -0.10 to 0.32, P = 0.31) and the use of social support (β = -0.03, 95%CI: -0.14 to 0.07, P = 0.53) were not significantly associated with the Positive Scale score.

CONCLUSION

The study confirmed the importance of social support, especially subjective support, provided to rural community-dwelling schizophrenia patients during the COVID-19 pandemic. This support should be addressed and strengthened for such patients in emergent events.

Psychosocial interventions promoting personal recovery in people with schizophrenia: a scoping review protocol

INTRODUCTION

Personal recovery is an important aspect for many individuals diagnosed with schizophrenia, as people can live rich, fulfilling lives despite ongoing symptoms. Prior reviews have found several factors to be associated with personal recovery, but a comprehensive overview of the psychosocial interventions aimed at improving personal recovery in schizophrenia is needed.

METHODS AND ANALYSIS

Key terms relating to personal recovery and psychosocial interventions to promote personal recovery will be searched for in the following databases: PubMed, EMBASE, PsycINFO, CINAHL, MEDLINE, Google Scholar, Web of Science Core Collection and Cochrane. Additionally, a simple search for grey literature will be conducted in The Networked Digital Library of Theses and Dissertations. Two reviewers will individually screen and extract the data, and the selection of sources will be documented in a Preferred Reporting Items for Systematic reviews and Meta-Analyses flow chart. A content analysis will be conducted on the data, and the findings will be presented in tables, and narratively synthesised. Lastly, research gaps will be identified, and recommendations for future research will be proposed.

ETHICS AND DISSEMINATION

Ethics approval was not required for the development or publishing of this protocol. Findings will be disseminated through conferences, meeting with patient organisations and consumers, and published in a peer-reviewed scientific journal.

Examining the Prevalence and Forms of Leveraged Treatment Pressure and Its Relationship to Personal Recovery: A Canadian Cross-Sectional Study

Across jurisdictions, the use of 'leverage' to promote adherence to mental health treatment is widespread. However, little research exists on the possible association between the application of leverage and personal recovery. We examined the prevalence of various forms of leverage in a Canadian context and compared these rates with those in other jurisdictions. Additionally, we examined the relationship between two prominent forms of leverage (financial and housing) and the experience of personal recovery. Structured interviews were conducted with people receiving community-based mental health care in Toronto, Canada. Rates of overall leverage in our sample were similar to rates reported in other jurisdictions. Personal recovery was negatively associated with financial leverage but was not associated with housing leverage. Our results highlight the importance of separately examining the relationship of specific forms of leverage and personal recovery and raise questions for future research about the possible effect of financial leverage on recovery.

Discrepancies between self and caregiver perceptions of agency in first-episode psychosis

Personal agency-a key element of recovery from psychotic disorders-is formed and maintained in large part through interactions with others. Interactions with caregivers are particularly important in first-episode psychosis (FEP), as these interactions form the foundations for lifelong caregiving relationships. The present study examined shared understandings of agency (operationalized as efficacy to manage symptoms and social behaviors) within families affected by FEP. Individuals with FEP (n = 46) completed the Self-Efficacy Scale for Schizophrenia (SESS) and measures of symptom severity, social functioning, social quality of life, stigma, and discrimination. Caregivers (n = 42) completed a caregiver version of the SESS assessing perceptions of their affected relative's self-efficacy. Self-rated efficacy was higher than caregiver-rated efficacy in all domains (positive symptoms, negative symptoms, and social behavior). Self- and caregiver-rated efficacy correlated only in the social behavior domain. Self-rated efficacy was most associated with lower depression and stigmatization, whereas caregiver-rated efficacy was most associated with better social functioning. Psychotic symptoms did not relate to self- or caregiver-rated efficacy. Individuals with FEP and caregivers have discrepant perceptions of personal agency, perhaps because they base perceptions of agency on different sources of information. These findings highlight specific targets for psychoeducation, social skills training, and assertiveness training to develop shared understandings of agency and facilitate functional recovery.

Factors associated with personal recovery among psychiatric nursing home residents

WHAT IS KNOWN ABOUT THE SUBJECT?: Poor recovery will cause harm to the quality of life and well-being of residents and that the scope of influence includes the self, family and society. No study to date has investigated empowerment and the other multiple factors associated with personal recovery among psychiatric nursing home residents. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: The factors associated with personal recovery are empowerment, social support and global functioning. This pioneer study contributes new evidence that personal recovery is mainly predicted by empowerment, social support and global function, with empowerment exhibiting the highest predictive value. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Strengthening empowerment in mental health nursing may contribute more to the personal recovery of psychiatric nursing home residents than improving global function or social support. Mental health professionals should shift to empowerment-oriented care to improve individuals' personal recovery, such as offering more opportunities to achieve autonomy, encouraging individuals' involvement in decision-making and promoting individuals' motivation for achieving their goals. ABSTRACT: Introduction Individuals diagnosed with mental illness have a need for recovery. No study to date has investigated empowerment and the other multiple factors associated with personal recovery among psychiatric nursing home residents. Aim The study aimed to identify the factors associated with personal recovery among psychiatric nursing home residents. Methods This was a cross-sectional study with convenience sampling. Participants were recruited from a psychiatric nursing home in Northern Taiwan between April and June 2018. Data were collected through self-reported, structured questionnaires with verified reliability and validity. Descriptive and hierarchical regression analyses were performed. The present study followed the STROBE guidelines. Results The study included 158 participants. The factors associated with recovery according to bivariate associations were religious belief, psychotic symptoms, global function, social support and empowerment. In the hierarchical regression, empowerment, social support and global function were the main predictive factors of recovery, with the explained variation reaching 40.8%. Empowerment exhibited the highest predictive value for the recovery. Implications for clinical practice Strengthening empowerment in mental health nursing may contribute more to the personal recovery of psychiatric nursing home residents than improving global function or social support.

Bringing Psychology Students Closer to People with Schizophrenia at Pandemic Time: A Study of a Distance Anti-stigma Intervention With In-presence Opportunistic Control Group

Psychology students are a target population to increase the likelihood that Persons With Schizophrenia (PWS) will receive evidence-based psycho-social interventions in the future. The willingness of future psychologists to care for PWS can be supported through anti-stigma educational interventions. During the pandemic, university education was delivered largely at-distance, which was later combined with in-presence education. This study explored whether an At-Distance Educational Intervention (ADEI), addressing stigma in schizophrenia via scientific evidence and testimony: would improve psychology students' views of PWS, at the one-month post intervention re-assessments; would be more effective of the same In-Presence Educational Intervention (IPEI). ADEI was delivered online to students of two Master's degrees in Psychology at the University of Campania "Luigi Vanvitelli", Caserta, Italy. IPEI was administered to a similar group of 76 students in the pre-pandemic era. Participants completed an anonymous questionnaire about their views on schizophrenia before the intervention (two three-hour sessions one week apart) and one month after its completion. Compared to their pre-intervention assessments, at post-intervention reassessments the 65 ADEI students were: more confident in the recovery and the usefulness of psychological therapies; surer of the PWS awareness and capability to report health problems to professionals; more skeptical about PWS dangerousness, social distance, and affective difficulties; more uncertain on the opportunity to discriminate PWS in hospital and psychology practices. ADEI was more effective than IPEI in five of the ten dimensions analyzed and similarly effective in the remaining others. ADEI may represent a valuable alternative to IPEI for improving future psychologists' view of PWS.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40737-022-00308-1.

Comparing the social networks of service users with long term mental health needs living in community with those in a general adult in-patient unit

BACKGROUND

Relationships are vital to recovery however, there is uncertainty whether users have different types of social networks in different mental health settings and how these networks may impact on users' wellbeing.

AIMS

To compare the social networks of people with long-term mental illness in the community with those of people in a general adult in-patient unit.

METHOD

A sample of general adult in-patients with enduring mental health problems, aged between 18 and 65, was compared with a similar sample attending a general adult psychiatric clinic. A cross-sectional survey collected demographic data and information about participants' social networks. Participants also completed the Short Warwick Edinburgh Mental Well-Being Scale to examine well-being and the Significant Others Scale to explore their social network support.

RESULTS

The study recruited 53 participants (25 living in the community and 28 current in-patients) with 339 named as important members of their social networks. Both groups recorded low numbers in their social networks though the community sample had a significantly greater number of social contacts (7.4 vs. 5.4), more monthly contacts with members of their network and significantly higher levels of social media use. The in-patient group reported greater levels of emotional and practical support from their network.

CONCLUSIONS

People with serious and enduring mental health problems living in the community had a significantly greater number of people in their social network than those who were in-patients while the in-patient group reported greater levels of emotional and practical support from their network. Recommendations for future work have been made.

Recovery beyond clinical improvement - Recovery outcomes measured for people with bipolar disorder between 1980 and 2020

BACKGROUND

Outcome measurement in bipolar disorder (BD) traditionally focused on clinical improvement without considering other domains. Improvement trajectories in clinical and social-functional domains are different and can simultaneously appear in one while not in other domains. Measuring personal recovery (PR) has become a priority internationally. This review explored the shift in research investigating operational recovery definitions and underpinning factors of recovery in BD over the past four decades.

METHODS

Studies defining recovery domains (other than clinical recovery) in BD were systematically reviewed; operational recovery definitions and factors assessed in association with recovery were thematically categorised and integrated in a narrative synthesis.

RESULTS

Thirty-three studies, comprising 3638 participants from 19 countries were included. Identified operational recovery definition themes included i) PR ii) social-functional (SFR), and iii) occupational-residential (ORR) recovery. Examined factors were grouped as demographic, clinical and psychosocial factors. Predominantly demographic factors were linked to ORR and clinical factors to SFR. Depressive symptomatology was the only clinical factor associated with PR. Research investigating psychosocial factors in PR is emerging and has showed that resilience and appraisals of mood seem to be associated with PR.

LIMITATIONS

Studies not available in English or examining functioning without defining recovery were excluded.

CONCLUSIONS

Earlier operational recovery definitions of ORR and SFR were often arbitrary and inconsistent, and predominantly focused on clinical and demographic underpinning factors. While research attempts to follow the significant policy shifts towards personalised care by measuring what matters to individuals and exploring broader underpinning psychosocial factors, it is still lagging behind.

Occupational Dysfunction as a Mediator between Recovery Process and Difficulties in Daily Life in Severe and Persistent Mental Illness: A Bayesian Structural Equation Modeling Approach

Background. This study is aimed at verifying a hypothetical model of the structural relationship between the recovery process and difficulties in daily life mediated by occupational dysfunction in severe and persistent mental illness (SPMI). Methods. Community-dwelling participants with SPMI were enrolled in this multicenter cross-sectional study. The Recovery Assessment Scale (RAS), the World Health Organization Disability Assessment Schedule second edition (WHODAS 2.0), and the Classification and Assessment of Occupational Dysfunction (CAOD) were used for assessment. Confirmatory factor analysis, multiple regression analysis, and Bayesian structural equation modelling (BSEM) were determined to analyze the hypothesized model. If the mediation model was significant, the path coefficient from difficulty in daily life to recovery and the multiplication of the path coefficients mediated by occupational dysfunction were considered as each the direct effect and the indirect effect. The goodness of fit in the model was determined by the posterior predictive $P$ value (PPP). Each path coefficient was validated with median and 95% confidence interval (CI). Results. The participants comprised 98 individuals with SPMI. The factor structures of RAS, WHODAS 2.0, and CAOD were confirmed by confirmatory factor analysis to be similar to those of their original studies. Multiple regression analysis showed that the independent variables of RAS were WHODAS 2.0 and CAOD, and that of CAOD was WHODAS 2.0. The goodness of fit of the model in the BSEM was satisfactory with a $\text{PPP}=0.27$ . The standardized path coefficients were, respectively, significant at -0.372 from “difficulty in daily life” to “recovery” as the direct effect and at -0.322 (95% CI: -0.477, -0.171) mediated by “occupational dysfunction” as the indirect effect. Conclusions. An approach for reducing not only difficulty in daily life but also occupational dysfunction may be an additional strategy of person-centered, recovery-oriented practice in SPMI.

Housing First for homeless people with severe mental illness: extended 4-year follow-up and analysis of recovery and housing stability from the randomized Un Chez Soi d'Abord trial

AIMS

Housing First (HF), a recovery-oriented approach, was proven effective in stabilising housing situations of homeless individuals with severe mental disorders, yet had limited effectiveness on recovery outcomes on a short-term basis compared to standard treatment. The objective was to assess the effects of the HF model among homeless people with high support needs for mental and physical health services on recovery, housing stability, quality of life, health care use, mental symptoms and addiction issues on 4 years of data from the Un Chez Soi d'Abord trial.

METHODS

A multicentre randomised controlled trial was conducted from August 2011 to April 2018 with intent-to-treat analysis in four French cities: Lille, Marseille, Paris and Toulouse. Participants were homeless or precariously-housed patients with a DSM-IV-TR diagnosis of bipolar disorder or schizophrenia. Two groups were compared: the HF group (n = 353) had immediate access to independent housing and support from the assertive community treatment team; the Treatment-As-Usual (TAU) group (n = 350) had access to existing support and services. Main outcomes were personal recovery (Recovery Assessment Scale (RAS) scale), housing stability, quality of life (S-QoL), global physical and mental status (Medical Outcomes Study 36-item Short Form Health Survey (SF-36)), inpatient days, mental symptoms (Modified Colorado Symptom Index (MCSI)) and addictions (Mini International Neuropsychiatric Interview (MINI) and Alcohol Use Disorders Identification Test (AUDIT)). Mixed models using longitudinal and cluster designs were performed and adjusted to first age on the street, gender and mental disorder diagnosis. Models were tested for time × group and site × time interactions.

RESULTS

The 703 participants [123 (18%) female] had a mean age of 39 years (95% CI 38.0-39.5 years). Both groups improved RAS index from baseline to 48 months, with no statistically significant changes found between the HF and TAU groups over time. HF patients exhibited better autonomy (adjusted β = 2.6, 95% CI 1.2-4.1) and sentimental life (2.3, 95% CI 0.5-4.1), higher housing stability (28.6, 95% CI 25.1-32.1), lower inpatient days (-3.14, 95% CI -5.2 to -1.1) and improved SF-36 mental composite score (-0.8, 95% CI -1.6 to -0.1) over the 4-year follow-up. HF participants experienced higher alcohol consumption between baseline and 48 months. No significant differences were observed for self-reported mental symptoms or substance dependence.

CONCLUSION

Data at 4 years were consistent with 2-year follow-up data: similar improvement in personal recovery outcomes but higher housing stability, autonomy and lower use of hospital services in the HF group compared to the TAU group, with the exception of an ongoing alcohol issue. These sustained benefits support HF as a valuable intervention for the homeless patients with severe mental illness.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01570712.

From darkness to light: Barriers and facilitators to mental health recovery in the South African context

BACKGROUND

South Africa is a low and middle income country facing many challenges in public mental health care and implementation of recovery.

AIMS

To contribute to what barriers and facilitators to recovery might be for service users in South Africa, from the perspective of service users, carers and service providers from three psychiatric hospitals in the Western Cape province.

METHOD

Interviews and focus groups were conducted with service users, carers and service providers. Interviews and focus groups were transcribed and analysed using atlas.ti software and reflexive thematic analysis, from the bottom up.

RESULTS

The barriers, environment, family, public mental health services, stigma and service users' attitude or behaviour generated, were found to be the most salient. The facilitators to recovery generated were support, family or friends, service providers, structure and empowerment. The need for support was identified as an underlying component to all these themes.

CONCLUSION

Barriers and facilitators to recovery seemed to have both intrapersonal and external sources that intersect at times. Recovery needs to be supported at an individual level, especially through an under-utilised resource such as peer support work, but in conjunction with the development of recovery-enabling environments in services and communities in South Africa.

Attachment as a framework to facilitate empowerment for people with severe mental illness

OBJECTIVES

Recovery and empowerment have evolved into key objectives in the treatment and care of people with severe mental illness (SMI), and interest has grown in the role of social relationships in recovery. This study is the first to explore whether attachment styles are related to levels of empowerment, and secondly, whether attachment anxiety and attachment avoidance are associated with lower empowerment levels, independently of quality and frequency of social contact.

DESIGN

We used a cross-sectional design.

METHODS

In a sample of 157 participants with SMI in outpatient care, associations between attachment (Revised Adult Attachment Scale), self-reported social functioning, and empowerment (Netherlands Empowerment List) were assessed.

RESULTS

Attachment anxiety and attachment avoidance were both associated with lower levels of empowerment. A stepwise multiple regression analysis showed that the prediction of empowerment was significantly improved by adding attachment anxiety and attachment avoidance to quality and frequency of social contact. Attachment anxiety, attachment avoidance, and quality of social contact were significant predictors; frequency of social contact was not.

CONCLUSIONS

Although our design does not allow causal conclusions, our results highlight the importance of interpersonal processes and behaviours as routes to improving empowerment for people with SMI. A promising approach might thus consist of securing attachment bonds with significant others so that the self and the other are perceived as reliable resources. Our findings also feature the importance of reciprocity and equality in social relationships. Taken together, our study emphasizes the value of social, contextualized interventions in recovery work for people with SMI.

PRACTITIONER POINTS

Working towards attachment safety in interpersonal relations may be important in recovery-oriented treatment and care for people with severe mental illness (SMI). Helping people with SMI to recognize and change how they tend to relate themselves to others may promote engagement and effectiveness of recovery-oriented treatment and care. Reciprocity and equality in social relationships as vital complements to the more one-sided nature of 'standing alongside' and offering support may be important requisites for empowerment.

The Power of Perception: Lived Experiences with Diagnostic Labeling in Mental Health Recovery without Ongoing Medication Use

The recovery movement in mental health emphasizes holistic and individualized treatment through many pathways to recovery, though the majority of mental health treatment and existing literature emphasize pharmacotherapy and medication adherence for major mental health conditions. The reimbursement system and research literature are oriented around formal diagnostic categories based in a biomedical perspective of mental health problems, but diagnostic labels also carry stigma and influence how clients perceive themselves and their mental health problems. To investigate the influence of labeling and perception in alternate pathways to recovery, this qualitative study explores the lived experience of diagnostic labeling and self-perception among persons in sustained recovery without ongoing medication use. The study used a grounded theory approach to analyze data from in-depth interviews with 19 participants. Participants had previously received diagnoses of schizophrenia, bipolar disorder, and/or major depression, met criteria for functional recovery, and were no longer taking psychotropic medications for 12 months. The participants identified positive perceptions-externalization of the problem and hope for an external "cure"-and negative perceptions-stigma and powerlessness-following a diagnostic label. Notably, the theme of powerlessness related to the initially positive themes as the diagnosis placed the problem outside their control and some participants experienced treatments as unhelpful. Participants succeeded in overcoming powerlessness by finding internalized solutions and redefining their mental health experience as transformative. Rather than pressing clients to accept their diagnosis or "illness," mental health providers can support multiple pathways to recovery by emphasizing empowerment and personal meaning-making in the recovery process.

Internalized stigmatization and subjective recovery in individuals with chronic mental illness

BACKGROUND

Individuals with mental illness, as they are stigmatized by society, are also stigmatized themselves, and this process is internalized. This may adversely affect the recovery process.

AIMS

This study was conducted to investigate the relationship between internalized stigmatization and subjective recovery in patients with schizophrenic.

METHOD

This research was performed for patients with schizophrenia at rehabilitation centers registered with the community mental health center. The survey was performed out with 94 patients in the recovery phase who met the inclusion criteria and who going to the center. Sociodemographic information form, internalized stigmatization scale and subjective recovery assessment scale were used in the collection of data.

RESULTS

In the study it was found that there is a relationship between internalized stigmatization and subjective recovery. Increased levels of internalized stigma patient outcome would decrease the level of recovery.

CONCLUSION

It is recommended that nurses perform intervention programs to reduce internalized stigmatization in patients with schizophrenia.

Impact of Jointly Using an e-Mental Health Resource (Self-Management And Recovery Technology) on Interactions Between Service Users Experiencing Severe Mental Illness and Community Mental Health Workers: Grounded Theory Study

BACKGROUND

e-Mental health resources are increasingly available for people who experience severe mental illness, including those who are users of community mental health services. However, the potential for service users (SUs) living with severe mental illness to use e-mental health resources together with their community mental health workers (MHWs) has received little attention.

OBJECTIVE

This study aims to identify how jointly using an interactive website called Self-Management And Recovery Technology (SMART) in a community mental health context influenced therapeutic processes and interactions between SUs and MHWs from their perspective.

METHODS

We conducted a qualitative study using a constructivist grounded theory methodology. Data were collected through individual semistructured interviews with 37 SUs and 15 MHWs who used the SMART website together for 2 to 6 months. Data analysis involved iterative phases of coding, constant comparison, memo writing, theoretical sampling, and consultation with stakeholders to support the study's credibility.

RESULTS

A substantive grounded theory, discovering ways to keep life on track, was developed, which portrays a shared discovery process arising from the SU-worker-SMART website interactions. The discovery process included choosing to use the website, revealing SUs' experiences, exploring these experiences, and gaining new perspectives on how SUs did and could keep their lives on track. SUs and MHWs perceived that their three-way interactions were enjoyable, beneficial, and recovery focused when using the website together. They experienced the shared discovery process as relationship building-their interactions when using the website together were more engaging and equal.

CONCLUSIONS

Jointly using an e-mental health resource elicited recovery-oriented interactions and processes between SUs and MHWs that strengthened their therapeutic relationship in real-world community mental health services. Further work to develop and integrate this novel use of e-mental health in community mental health practice is warranted.

Mediating effect of empowerment on the relationship between global function and personal recovery among community-dwelling patients with schizophrenia: a cross-sectional study

BACKGROUND

Functional degradation among community-dwelling patients with schizophrenia can negatively influence their recovery. Given the importance of patient empowerment during recovery, this study examined the mediating effect of empowerment on the relationship between global function and personal recovery among community-dwelling patients with schizophrenia.

METHODS

This cross-sectional study recruited community-dwelling patients with schizophrenia from northern and central Taiwan. Questionnaires with verified reliability and validity were provided and collected on site by trained nurses. Global function, empowerment, and personal recovery were measured using the Global Assessment of Functioning (developed by the American Psychiatric Association), Empowerment Scale, and Questionnaire on the Process of Recovery, respectively. The causal steps approach proposed by Baron and Kenny and the Sobel test were utilized to verify the mediation effect. The causal steps approach tested the four following pathways (regression coefficients): global function on empowerment (Path a), global function and empowerment as predictors of personal recovery (Path b), global function on personal recovery (Path c), and global function and empowerment on personal recovery (Path c').

RESULTS

A total of 373 participants completed the survey. After controlling for factors associated with recovery, Paths a (β = .24, p < .001), b (β = .68, p < .001), and c (β = .19, p < .001) were found to be significant; however, Path c' was not significant (β = .03, p = .452). Empowerment was determined to exert "full mediation" over the effects of global function on personal recovery, and the Sobel test indicating significant mediation (Z = 3.61, p < .001).

CONCLUSIONS

Empowerment fully mediates the association between global function and personal recovery. This study suggested that offering empowerment-oriented care services may be more effective than global function improvement in recovery among these patients.

Factors influencing the implementation of mental health recovery into services: a systematic mixed studies review

BACKGROUND

Countries around the world have committed in policy to transforming their mental health services towards a recovery orientation. How has mental health recovery been implemented into services for adults, and what factors influence the implementation of recovery-oriented services?

METHODS

This systematic mixed studies review followed a convergent qualitative synthesis design and used the best-fit framework synthesis method. Librarians ran searches in Ovid- MEDLINE, Ovid-EMBASE, Ovid-PsycInfo, EBSCO-CINAHL Plus with Full Text, ProQuest Dissertations and Theses, Cochrane Library, and Scopus. Two reviewers independently screened studies for inclusion or exclusion using DistillerSR. Qualitative, quantitative, and mixed methods peer-reviewed studies published since 1998 were included if they reported a new effort to transform adult mental health services towards a recovery orientation, and reported findings related to implementation experience, process, or factors. Data was extracted in NVivo12 to the 38 constructs of the Consolidated Framework for Implementation Research (CFIR). The synthesis included a within-case and a cross-case thematic analysis of data coded to each CFIR construct. Cases were types of recovery-oriented innovations.

RESULTS

Seventy studies met our inclusion criteria. These were grouped into seven types of recovery-oriented innovations (cases) for within-case and cross-case synthesis. Themes illustrating common implementation factors across innovations are presented by CFIR domain: Intervention Characteristics (flexibility, relationship building, lived experience); Inner Setting (traditional biomedical vs. recovery-oriented approach, the importance of organizational and policy commitment to recovery-transformation, staff turnover, lack of resources to support personal recovery goals, information gaps about new roles and procedures, interpersonal relationships), Characteristics of Individuals (variability in knowledge about recovery, characteristics of recovery-oriented service providers); Process (the importance of planning, early and continuous engagement with stakeholders). Very little data from included studies was extracted to the outer setting domain, and therefore, we present only some initial observations and note that further research on outer setting implementation factors is needed.

CONCLUSION

The CFIR required some adaptation for use as an implementation framework in this review. The common implementation factors presented are an important starting point for stakeholders to consider when implementing recovery-oriented services.

Validation of an 8-item Recovery Assessment Scale (RAS-8) for people with schizophrenia in China

Background

The 24-item Recovery Assessment Scale (RAS) is the most widely-used and well-validated tool for measuring recovery for people with mental illness. The current study aims to assess the reliability and validity of an 8-item short form of RAS (RAS-8) among a Chinese sample of people living with schizophrenia.

Methods

A sample of 400 people living with schizophrenia were recruited for scale validation. Internal consistency was tested by calculating Cronbach's α. Test–retest reliability was calculated using the intraclass correlation coefficient (ICC) for the total score and weighted kappa for each item. Factor structure was tested with confirmatory factor analysis, and concurrent validity was examined by investigating the correlation of the RAS-8 with patient symptoms, disability, depression, anxiety, patient functioning, quality of life and general health.

Results

The RAS-8 full scale and subscales showed good internal consistency with Cronbach’s alpha ranging from 0.87 to 0.92. ICC of 0.99 and weighted kappa ranged from 0.62 to 0.88, which generally indicates good test–retest reliability. The findings supported an a priori two-factor structure, χ²/df = 2.93, CFI = 0.98, TLI = 0.98, RMSEA = 0.07, SRMR = 0.035. Concurrent validity of the RAS-8 was further supported by its significant negative correlations with patient symptoms (r =  −0.24, p < 0.01), disability (r =  −0.30, p < 0.01), depression (r =  −0.16, p < 0.05), and anxiety (r =  −0.14, p < 0.05), and its significant positive relationships with patient functioning (r = 0.26, p < 0.01), quality of life (r = 0.39, p < 0.01) and general health (r = 0.34, p < 0.01).

Conclusions

This study confirmed the reliability and validity of an 8-item short-form RAS for people living with schizophrenia in Chinese communities. The validation of the RAS-8 allows for its use as an alternative for the full RAS as a rapid assessment tool in clinical and research settings. The findings are discussed for their implications for application and validation with other populations and in other countries.

Lived Experiences of a Sustained Mental Health Recovery Process Without Ongoing Medication Use

Serious mental health conditions have historically been considered lifelong conditions, with substantial literature supporting pharmaceutical approaches to remission. More recently, the recovery movement has emphasized lasting recovery, which can occur through a variety of pathways. With the traditional focus on medication, less is known about the recovery process of persons who achieve sustained recovery without ongoing medication use. This qualitative study used a grounded theory approach to explore the recovery process of 19 participants with diagnoses of schizophrenia, bipolar disorder, or major depression who were in recovery and not taking medications for at least twelve months. Participants identified internal recovery processes (cognitive changes, emotional processes, and spirituality/faith) leading to a perspective change about self and symptoms. Participants also identified external recovery processes including both support received and productive ways of giving back. The study findings highlight the importance of self-efficacy, emotion management, and social giving in mental health recovery.

Achieving better outcomes for schizophrenia patients in Hong Kong: Strategies for improving treatment adherence

Recent research on second-generation long-acting injectable antipsychotics (LAI SGAs) has proven its effectiveness in minimizing medication nonadherence problem and reducing relapses. Administered by medical professionals, making quick detection of nonadherence possible, long-acting injectable antipsychotics (LAIs) facilitate immediate intervention and recovery process, and thus are favored by psychiatrists. Despite a higher initial cost with LAIs, the subsequent schizophrenia-related health costs for hospitalizations and outpatients are greatly reduced. With reference to guidelines published by psychiatric associations around the globe, this article looks at scenarios in Hong Kong on the management of severe mentally ill patients with regard to the use of a host of psychosocial interventions as well as LAI SGAs as a preferable treatment. In particular, it examines the benefits of using LAI SGAs for Hong Kong patients who demonstrated high nonadherence treatment rates due to their social environment. It assesses the rationale behind the early usages of LAI SGAs, which help to provide better recovery outcomes for patients.

Effects of Mindfulness on Stimulating Hope and Recovery among People with Schizophrenia

Background: Hope has an essential role in the recovery journey for people with schizophrenia. Current studies showed that people with schizophrenia reported having low hope. There is growing evidence that mindfulness has favorable effects on mental health in populations with chronic illness, including people with schizophrenia. However, the studies evaluating effects of mindfulness on hope and recovery for people with schizophrenia are limited.Purpose: This study aimed to examine the effects of mindfulness on hope and recovery among people with schizophrenia.Methods: This quasi-experimental study was carried out on 54 patients with schizophrenia based on purposive sampling in a psychiatric hospital in Indonesia. The respondents were divided into two groups with 27 patients each in the intervention and the control group. The intervention group received 2-session mindfulness, while the control group received standard care. The data were collected using the demographic questionnaire, the Schizophrenia Hope Scale (SHS-9), and Recovery Assessment Scale (RAS), and analyzed using the Chi-Square and Mann-Whitney tests. Results: After mindfulness therapy, the intervention group showed a higher mean score of hope than the control group (14.30±2.50 and 9.04±2.15, respectively) as well as in the mean of recovery (86.78±4.00 and 73.56±6.04, respectively). There were significant differences in hope and recovery levels between the two groups with p-value <0.001.Conclusion: This study showed that mindfulness is an effective strategy to stimulate hope and recovery among people with schizophrenia. Nurses can apply mindfulness as one of the nursing interventions for helping the recovery process among this population. 

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.

Experiences of physiotherapy in mental health: an interpretative phenomenological analysis of barriers and facilitators to care

BACKGROUND

Service users with severe mental illness (SMI) are at increased risk of physical health co-morbidity such as musculoskeletal pain, neurological impairment, obesity and COPD; many of which require input from physiotherapists. Physiotherapists play a pivotal role in treatment of those with SMI but are reported to lack skills and confidence with this patient group. Furthermore, disparities in accessing healthcare are evidenced for those with SMI.

PURPOSE

This study explored experiences of physiotherapeutic care for those with co-morbid physical and mental health complaints to identify barriers and facilitators to care.

METHODS

A qualitative study using Interpretive Phenomenological Analysis was undertaken. Semi-structured interviews were completed with service users (n=8) with longstanding physiotherapeutic and psychiatric complaints. Focus groups were completed with physiotherapists working in mental health. Verbatim transcripts of interviews were analysed using Interpretive Phenomenological Analysis to obtain in depth insight into participant experiences. Study quality was enhanced through use of methodological and investigator triangulation, negative case analysis, reflexivity and secondary coding.

ANALYSIS

Data was analysed systematically following the structure: individual case analysis, emergence of themes, cross case analysis, validation of themes and ideas.

RESULTS

This analysis produced five master themes: Communication [1], holistic care [2], benefit of physiotherapy [3], healthcare politics and service interaction [4], patient activation [5]. Results identified current service provision did not always meet the complexities of service user needs.

CONCLUSION AND IMPLICATIONS

Improved physiotherapist awareness of mental health and how to communicate and treat this population was identified. The importance of better integration between services was also highlighted. A positive experience of physiotherapy is vital for patient activation and engagement with physiotherapy.

Peer support and skills training through an eating club for people with psychotic disorders: A feasibility study

OBJECTIVE

The HospitalitY (HY) intervention is a novel recovery oriented intervention for people with psychotic disorders in which peer support and home-based skill training are combined in an eating club. A feasibility study was conducted to inform a subsequent randomised trial.

METHODS

This study evaluated three eating clubs consisting of nine participants and three nurses. Semi-structured interviews and pre- and post-intervention measures (18 weeks) of personal recovery, quality of life and functioning were used to evaluate the intervention. Participants received individual skills training, guided by self-identified goals, while organising a dinner at their home. During each dinner, participants engaged in peer support, led by a nurse.

RESULTS

In personal interviews participants reported positive effects on social support, loneliness, and self-esteem. Nurses reported that participants became more independent during the intervention. Participants were satisfied with the HY-intervention (attendance rate = 93%). All were able to organise a dinner for their peers with practical support from a nurse. Pre- and post -intervention measures did not show important improvements.

LIMITATIONS

Outcome measures were not sensitive to change, likely due to a short intervention period (5 months) and a limited number of participants (N = 9). Using Goal Attainment Scaling to evaluate personal goals turned out to be unfeasible.

CONCLUSIONS

The HY-intervention is feasible for participants with psychotic disorders. This study refined intervention and research design for the upcoming multicentre randomised controlled trial. We expect that the Experience Sampling Method will be more sensitive to changes in recovery outcomes than regular pre-post intervention measures.

The resource group method in severe mental illness: study protocol for a randomized controlled trial and a qualitative multiple case study

Background

The resource group method provides a structure to facilitate patients' empowerment and recovery processes, and to systematically engage significant others in treatment and care. A patient chooses members of a resource group (RG) that will work together on fulfilling patients' recovery plan. By adopting shared decision-making processes and stimulating collaboration of different support systems, a broad and continuous support of patients' chosen goals and wishes is preserved and problem solving and communication skills of the RG members are addressed.

Objective

The objectives of this study are (1) to establish the effectiveness of the RG method in increasing empowerment in patients with severe mental illnesses (SMI) in the Netherlands; (2) to investigate the cost-effectiveness and cost utility of the RG method; and (3) to qualitatively explore its dynamics and processes.

Methods/design

This multisite randomized controlled trial will compare the effects of the RG-method integrated in Flexible Assertive Community Treatment (FACT) (90 patients) with those of standard FACT (90 patients). Baseline assessments and 9-month and 18-month follow-up assessments will be conducted in face-to-face home visits. The primary outcome measure, empowerment, will be assessed using the Netherlands Empowerment List (NEL). The secondary outcomes will be quality of life (MANSA); personal, community and clinical recovery (I.ROC); general, social and community functioning (WHODAS 2.0); general psychopathological signs and symptoms (BSI-18); and societal costs (TiC-P). An economic evaluation of the cost-effectiveness and cost utility of the RG method will also be conducted. A qualitative multiple case-study will be added to collect patients', RG members' and professionals' perspectives by in-depth interviews, observations and focus groups.

Discussion

This trial will be the first to study the effects of the RG method on empowerment in patients with SMI. By combining clinical-effectiveness data with an economic evaluation and in-depth qualitative information from primary stakeholders, it will provide a detailed overview of the RG method as a mean of improving care for patients with SMI.Trial registration The study has been registered in the Dutch Trial Register, identifier: NTR6737, September 2017.

Psychosocial and functional contributors to personal recovery in serious mental illness

Background: Although recovery-oriented services have been conceptualized to improve personal recovery, related research often focuses on measures of clinical recovery. Identifying the relationships between personal recovery, clinical recovery, and psychosocial variables will inform service components and outcome measurement in recovery-oriented services. Aims: This study sought to determine the connection between personal recovery and two sets of potential contributors: psychosocial variables (i.e., empowerment, resilience, and consumer involvement) and functional indicators of clinical recovery. Method: These relationships were examined by analyzing survey data collected from 266 consumers who are receiving public mental health services in the United States. Results: Empowerment, resilience and psychological involvement were associated with personal recovery. Clinical recovery did not uniquely contribute to personal recovery once psychosocial factors were accounted for. Interactions revealed that the relationship between psychological involvement and personal recovery was stronger for those who had been recently hospitalized, and for those with relatively greater resilience. Conclusions: Results indicate that personal recovery is an essential outcome measure for recovery-oriented services that cannot be replaced by clinical recovery outcome measurement. Additionally, empowerment, resilience, and consumer involvement are key components of recovery, which suggests that services and outcome measures should prioritize incorporation of these constructs.

Living with schizophrenia in rural communities in north-east Thailand

In the rural villages of Thailand, rich social support networks exist that bond the community members to help each other. This study explored the barriers and facilitators of living with schizophrenia in Thai villages. A descriptive qualitative study was conducted using semi-structured interviews with individuals with schizophrenia, family members, and significant others. Content analysis of transcripts involved examining the data, recording observations, data reduction, and coding themes. Four main themes emerged from the narratives: (i) keep doing day-to-day activities as a way of life; (ii) support sustains day-to-day living; (iii) controlling medication side effects maintains daily living; and (iv) managing self maintains daily living. Self-regulation and social support are keys to moving from dependence to a normative life goal in rural communities. The patterns of living in the rural communities provide a strong social network as people with schizophrenia learn to lead successful lives. Using supportive families and community members as resources is an alternative and effective way of providing supportive care.

Achieving recovery in patients with schizophrenia through psychosocial interventions: A retrospective study

AIM

Recovery, or functional remission, represents the ultimate treatment goal in schizophrenia. Despite its importance, a standardized definition of remission is still lacking, thus reported rates significantly vary across studies. Moreover, the effects of rehabilitative interventions on recovery have not been thoroughly investigated. This study aimed to evaluate recovery in a sample of patients with chronic schizophrenia engaged in rehabilitation programs and to explore contributing factors, with a focus on sociocognitive rehabilitative interventions.

METHODS

Data from 104 patients with schizophrenia treated either with a standard rehabilitation program, including cognitive remediation (n = 46), or the latter plus a specific sociocognitive intervention (n = 58), and assessed for psychopathology, cognition, social cognition, and Quality of Life Scale, were retrospectively analyzed for this study.

RESULTS

Recovery, evaluated with the Quality of Life Scale, was achieved by 56.76% of patients in our sample. While no effects were observed for clinical, cognitive, or sociocognitive variables, participation in the sociocognitive rehabilitative interventions was positively associated with recovery.

CONCLUSION

Our results indicate that high rates of recovery can be achieved in patients treated with psychosocial interventions and suggest that rehabilitative programs targeting social cognition may further facilitate the process of recovery. If confirmed, these results may have relevant implications for daily clinical practice and service provision, allowing clinicians to develop and optimize specific rehabilitation programs in order to promote recovery.

An overview of systematic reviews on the public health consequences of social isolation and loneliness

OBJECTIVES

Social isolation and loneliness have been associated with ill health and are common in the developed world. A clear understanding of their implications for morbidity and mortality is needed to gauge the extent of the associated public health challenge and the potential benefit of intervention.

STUDY DESIGN

A systematic review of systematic reviews (systematic overview) was undertaken to determine the wider consequences of social isolation and loneliness, identify any differences between the two, determine differences from findings of non-systematic reviews and to clarify the direction of causality.

METHODS

Eight databases were searched from 1950 to 2016 for English language reviews covering social isolation and loneliness but not solely social support. Suitability for inclusion was determined by two or more reviewers, the methodological quality of included systematic reviews assessed using the a measurement tool to assess systematic reviews (AMSTAR) checklist and the quality of evidence within these reviews using the grading of recommendations, assessment, development and evaluations (GRADE) approach. Non-systematic reviews were sought for a comparison of findings but not included in the primary narrative synthesis.

RESULTS

Forty systematic reviews of mainly observational studies were identified, largely from the developed world. Meta-analyses have identified a significant association between social isolation and loneliness with increased all-cause mortality and social isolation with cardiovascular disease. Narrative systematic reviews suggest associations with poorer mental health outcomes, with less strong evidence for behavioural and other physical health outcomes. No reviews were identified for wider socio-economic or developmental outcomes.

CONCLUSIONS

This systematic overview highlights that there is consistent evidence linking social isolation and loneliness to worse cardiovascular and mental health outcomes. The role of social isolation and loneliness in other conditions and their socio-economic consequences is less clear. More research is needed on associations with cancer, health behaviours, and the impact across the life course and wider socio-economic consequences. Policy makers and health and local government commissioners should consider social isolation and loneliness as important upstream factors impacting on morbidity and mortality due to their effects on cardiovascular and mental health. Prevention strategies should therefore be developed across the public and voluntary sectors, using an asset-based approach.

Social network, recovery attitudes and internal stigma among those with serious mental illness

BACKGROUND

Social network size and strength is an important determinant of overall health.

AIMS

This study describes the extent and strength of the social network among a sample of individuals with serious mental illness (SMI) and explores the relationship between an individual's social network and their experience of internal stigma and recovery attitudes.

METHODS

Over a 2-year period, consecutive new patients with SMI attending two community mental health clinics were recruited and interviewed using a comprehensive battery of assessments including assessment of internalized stigma, recovery attitudes and symptom severity.

RESULTS

Among the 271 patients interviewed, social network size was small across all diagnostic categories. In adjusted results, the number of friends and support from relatives and friends was significantly related to the personal confidence and hope recovery attitude ( p < .05). The number of relatives and friends and support from relatives was significantly related to internalized stigma ( p < .05). Frequency of contact with relatives or friends was not related to either recovery factors or internalized stigma.

CONCLUSION

There is a significant positive relationship between the size and perceived strength of an individual's social network and internalized stigma and some recovery attitudes. Clinical programs that address any of these factors could potentially improve outcomes for this population.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Psychological resilience in people experiencing schizophrenia and suicidal thoughts and behaviours

Background: Negative stressors can aggravate the impact of schizophrenia. However, some people find ways of combating such stressors. There is a dearth of research examining factors which enable individuals with schizophrenia to show psychological resilience.Aims: The goal of this study was to investigate resilience to negative stressors in people with disorders on the schizophrenia spectrum using a qualitative methodology.Methods: Data were collected from 23 participants who had experienced schizophrenia and suicidal thoughts and behaviours. Semi-structured interviews followed a topic guide. Participants were asked (i) what resilience meant to them, (ii) which stressors they had experienced over 12 months and (iii) how they had counteracted those stressors. Thematic analysis was conducted to identify re-occurring themes across interviews.Results: A continuum of psychological mechanisms described participants' views about the meaning of resilience which ranged from passive acceptance to resistance (e.g. withstanding pressure), and then to active strategies to counter stressors (e.g. confronting). These themes were also evident in narratives expressing personal resilience strategies but, additionally, included emotional coping techniques. External factors were highlighted that supported resilience including social support, reciprocity and religious coping.Conclusions: People with schizophrenia develop ways of being resilient to negative events which should inform therapeutic interventions.

Cortical Thinning in Network-Associated Regions in Cognitively Normal and Below-Normal Range Schizophrenia

This study assessed whether cortical thickness across the brain and regionally in terms of the default mode, salience, and central executive networks differentiates schizophrenia patients and healthy controls with normal range or below-normal range cognitive performance. Cognitive normality was defined using the MATRICS Consensus Cognitive Battery (MCCB) composite score (T = 50 ± 10) and structural magnetic resonance imaging was used to generate cortical thickness data. Whole brain analysis revealed that cognitively normal range controls (n = 39) had greater cortical thickness than both cognitively normal (n = 17) and below-normal range (n = 49) patients. Cognitively normal controls also demonstrated greater thickness than patients in regions associated with the default mode and salience, but not central executive networks. No differences on any thickness measure were found between cognitively normal range and below-normal range controls (n = 24) or between cognitively normal and below-normal range patients. In addition, structural covariance between network regions was high and similar across subgroups. Positive and negative symptom severity did not correlate with thickness values. Cortical thinning across the brain and regionally in relation to the default and salience networks may index shared aspects of the psychotic psychopathology that defines schizophrenia with no relation to cognitive impairment.

Recovery assessment scale: Examining the factor structure of the German version (RAS-G) in people with schizophrenia spectrum disorders

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.

Service user experiences of REFOCUS: a process evaluation of a pro-recovery complex intervention

PURPOSE

Policy is increasingly focused on implementing a recovery-orientation within mental health services, yet the subjective experience of individuals receiving a pro-recovery intervention is under-studied. The aim of this study was to explore the service user experience of receiving a complex, pro-recovery intervention (REFOCUS), which aimed to encourage the use of recovery-supporting tools and support recovery-promoting relationships.

METHODS

Interviews (n = 24) and two focus groups (n = 13) were conducted as part of a process evaluation and included a purposive sample of service users who received the complex, pro-recovery intervention within the REFOCUS randomised controlled trial (ISRCTN02507940). Thematic analysis was used to analyse the data.

RESULTS

Participants reported that the intervention supported the development of an open and collaborative relationship with staff, with new conversations around values, strengths and goals. This was experienced as hope-inspiring and empowering. However, others described how the recovery tools were used without context, meaning participants were unclear of their purpose and did not see their benefit. During the interviews, some individuals struggled to report any new tasks or conversations occurring during the intervention.

CONCLUSION

Recovery-supporting tools can support the development of a recovery-promoting relationship, which can contribute to positive outcomes for individuals. The tools should be used in a collaborative and flexible manner. Information exchanged around values, strengths and goals should be used in care-planning. As some service users struggled to report their experience of the intervention, alternative evaluation approaches need to be considered if the service user experience is to be fully captured.

Facilitators of recovery for step-up and step-down clients of a sub-acute residential mental health service

BACKGROUND

Sub-acute residential mental health services provide care for people who are not acutely unwell but require more support than generally available when living in the community. Little is known about how these services facilitate recovery and whether these facilitators differ for clients entering from the community (step-up) or from inpatient settings (step-down).

AIM

To identify features of a sub-acute residential service that have assisted step-up and step-down clients in their recovery.

METHOD

Semi-structured interviews were conducted with 16 step-up and 21 step-down clients. Interview transcripts were examined using an inductive, semantic content analysis approach.

RESULTS

Themes identified included the community context, personal support, the formal program offered and assistance in personal recovery processes, with the level of support for these themes differing for step-up and step-down clients.

CONCLUSIONS

Step-up and step-down clients have differing needs to be addressed in a sub-acute service. These services can better meet the needs of clients if they are aware of the setting the client has come from and tailor their services accordingly. Step-up clients prefer support in developing social skills and illness management techniques; step-down clients prefer a less structured environment with assistance in living skills and personal processes of recovery.

Integrating Evidence-Based Community-Care Services to Improve Schizophrenia Outcomes: A Preliminary Trial

This aim of this preliminary experimental study was to integrate effective evidence-based community-care services that are subjected to heavy caseloads, and to then examine the effects on individuals with schizophrenia. Using a cluster sampling method, four homecare nurses were randomly assigned to either the experimental group or the comparison group. The nurses in the experimental group applied the following six identified effective elements: (1) established an alliance with their patients; (2) assessed patient-care needs; (3) considered both medical and social-care practices; (4) addressed patients' self-management of medication and their daily tasks; (5) provided crisis intervention; and (6) coordinated resources. The patients comprised 85 individuals with schizophrenia. In the experimental group, psychiatric homecare nurses were randomly assigned to implement integrated, evidence-based community-care services during a six-month follow-up period. Patients in the comparison group continued to receive their customary community care. In the experimental group, patient satisfaction scores, medication attitudes, and general functioning levels were significantly higher than in the comparison group. These preliminary findings indicate a potentially effective model for community care in areas where intensive case management cannot be provided.

'No man is an island'. Testing the specific role of social isolation in formal thought disorder

Recent work has focused on the role of the environment in psychosis with emerging evidence that specific psychotic experiences are associated with specific types of adversity. One risk factor that has been often associated with psychosis is social isolation, with studies identifying isolation as an important feature of prodromal psychosis and others reporting that social networks of psychotic patients are smaller and less dense than those of healthy individuals. In the present study, we tested a prediction that social isolation would be specifically associated with formal thought disorder. 80 patients diagnosed with psychosis-spectrum disorder and 30 healthy participants were assessed for formal thought disorder with speech samples acquired during an interview that promoted personal disclosure and an interview targeting everyday topics. Social isolation was significantly associated with formal thought disorder in the neutral interview and in the salient interview, even when controlling for comorbid hallucinations, delusions and suspiciousness. Hallucinations, delusions and suspiciousness were not associated with social isolation when formal thought disorder was controlled for. Formal thought disorder is robustly and specifically associated with social isolation. Social cognitive mechanisms and processes are discussed which may explain this relationship as well as implications for clinical practice and future research.

How stigma impacts on people with psychosis: The mediating effect of self-esteem and hopelessness on subjective recovery and psychotic experiences

This study aimed to examine how stigma impacts on symptomatic and subjective recovery from psychosis, both concurrently and longitudinally. We also aimed to investigate whether self-esteem and hopelessness mediated the observed associations between stigma and outcomes. 80 service-users with psychosis completed symptom (Positive and Negative Syndrome Scale) and subjective recovery measures (Process of Recovery Questionnaire) at baseline and 6-months later, and also completed the King Stigma Scale, the Self-Esteem Rating Scale and the Beck Hopelessness Scale at baseline. In cross sectional regression and multiple mediation analyses of the baseline data, we found that stigma predicted both symptomatic and subjective recovery, and the effects of stigma on these outcomes were mediated by hopelessness and self-esteem. When the follow-up data were examined, stigma at baseline continued to predict recovery judgements and symptoms. However, self-esteem only mediated the effect of stigma on PANSS passive social withdrawal. Self-esteem and hopelessness should be considered in interventions to reduce the effects of stigma. Interventions that address the current and long-term effects of stigma may positively affect outcome for people being treated for psychosis.

Managing preconceived expectations: mental health service users experiences of going home from hospital: a grounded theory study

ACCESSIBLE SUMMARY

What is known on the subject? The time of discharge from a mental health hospital can be challenging for mental health service users, with high rates of readmission in the immediate months following discharge. Although some research exists that explores service users' perspectives of being discharged, little evidence exists that explores the processes influencing or used by service users' to adapt to the transition from in-patient acute mental health service. What this papers adds to existing knowledge? The findings of this grounded theory study demonstrates the strategies service users used to managed their own, as well as their social audiences, preconceived expectations arising from their new identity as 'psychiatric patients' following their discharge from hospital. While there is a move to develop recovery-orientated mental health services, key indicators of recovery-oriented practices were often absent from service users' experiences of service provision. What are the implications for practice? Nurses and other mental health professionals need to recognize their contribution to the architecture of stigma that transcends the physical structures of hospital or ward and are entrenched within attitudes, interactions and practices. The findings of this study can provide guidance to those working with service users and help them to understand the complexities of their experiences when using mental health services, which go far beyond the management of their symptoms.

INTRODUCTION

Following a period of hospitalization, the transition to home can result in increased vulnerability and a source of stress for mental health service users. Readmission rates have been suggested as one indicator of the success of the transition from hospital to community care. Despite knowledge of some of the factors that impact on service users following discharge, no coherent model or theoretical framework could be located in the literature, which explains or aides an in-depth understanding of the transition from hospital to community for service users.

AIM

The aim of this study was to develop a grounded theory that explored service users' experiences of going home from hospital.

METHOD

This qualitative study used grounded theory, and a total of 35 interviews were conducted with 31 service users.

RESULTS

The core category was 'Managing Preconceived Expectations', which had seven subcategories, describes how the participants were negatively perceived by themselves and others following their admission and discharge from hospital.

IMPLICATIONS FOR PRACTICE

This theory presents the strategies that the participants used to manage this new identity. This theory demonstrates that although there has been a move to adopt recovery-orientated services, key indicators of recovery were often absent for service users being admitted and subsequently discharged.