Recovery and its correlates among patients with bipolar disorder: A study from a tertiary care centre in North India

Abstract

Background and Aim:

The goal of treatment in mental illness has evolved from a symptom-based approach to a personal recovery–based approach. The aim of this study was to evaluate the predictors of personal recovery among patients with bipolar disorder.

Methodology:

A total of 185 patients with bipolar disorder, currently in remission, were evaluated on Recovery Assessment Scale (RAS), Internalized Stigma of Mental Illness Scale (ISMIS), Brief Religious coping scale (RCOPE), Duke University Religiosity Index (DUREL), Religiousness Measures Scale, Hamilton depression rating scale (HDRS), Young Mania rating scale (YMRS) and Global Assessment of Functioning (GAF) scale.

Results:

The mean age of the sample was 40.5 (standard deviation (SD), 11.26) years. Majority of the participants were male, married, working, Hindu by religion and belonged to extended/joint families of urban background. In the regression analysis, RAS scores were predicted significantly by discrimination experience, stereotype endorsement and alienation domains of ISMIS, level of functioning as assessed by GAF, residual depressive symptoms as assessed by HDRS and occupational status. The level of variance explained for total RAS score and various RAS domains ranged from 36.2% to 46.9%.

Conclusion:

This study suggests that personal recovery among patients with bipolar disorder is affected by stigma, level of functioning, residual depressive symptoms and employment status of patients with bipolar disorder.

Keywords

Personal recovery Recovery Assessment Scale bipolar disorder stigma

Introduction

The goal of treatment in severe mental illnesses has gradually evolved from a focus on symptom remission to a personal recovery–based approach. Personal recovery is understood as a process aimed at enabling persons with mental illness to regain control over their lives and give them meaning with an emphasis placed on holistic and ‘psychological recovery’ (Bellack, 2006; Bonney & Stickley, 2008; Davidson, Lawless, & Leary, 2005; Davidson, Sells, Sangster, & O’Connell, 2005; Diamond, 2006; Harrison, 1984; Jensen & Wadkins, 2007; Liberman & Kopelowicz, 2002; Ramon, Healy, & Renouf, 2007; Whitwell, 1999). Personal recovery is defined as

a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness. (Anthony, 1993)

Among patients with severe mental disorders, especially schizophrenia, various patient-related and treatment-related factors have been reported to influence the process of personal recovery. The patient-related factors include good relationships, financial security and satisfying work (Bonney & Stickley, 2008; Ramon et al., 2007), developing resilience to stress and adversity, and understanding the illness from cultural and spiritual perspectives (Jacob, Munro, & Taylor, 2015). The treatment-related factors which have been associated with recovery include satisfying relationships with clinicians, satisfaction with psychiatric medications, support that can help manage deficits in resources and quality of care received for medical conditions (Green et al., 2013).

Among the severe mental disorders, bipolar disorder (BD) is a chronic relapsing disorder which has significant negative impact on the functioning and quality of life (Rosa et al., 2008), and it is the fourth leading cause among mental illnesses for life years lost (Prince et al., 2007).

Although there is significant amount of literature on personal recovery of patients with schizophrenia, the data for personal recovery among patients with BD patients are limited. Most of the initial data are in the form of qualitative narrations from few patients which make it difficult to generalize the results (Kwok, 2014; Leitan, Michalak, Berk, Berk, & Murray, 2015; Licinio, 2005; Lobban, Taylor, Murray, & Jones, 2012; Todd, Jones, & Lobban, 2012; A. T. Young, Green, & Estroff, 2008). A study from the United Kingdom evaluated 12 patients with BD for personal recovery and identified that the key component of personal recovery was taking responsibility for managing one’s illness (Todd et al., 2012). Another qualitative study titled ‘Study of Transitions and Recovery Strategies (STARS)’ from United States which included patients with severe mental disorders including those with BD showed that collaborative, mutually trusting clinician–patient relationships lead to more endeavours from patients towards the recovery process (A. T. Young et al., 2008).

There are very few quantitative questionnaire-based studies, which have evaluated personal recovery among patients with BD. One study from the United Kingdom used Bipolar Recovery Questionnaire (BRQ) and reported that personal growth, well-being and lower self-reported depression were predictive of higher recovery scores on BRQ scores (Jones, Mulligan, Higginson, Dunn, & Morrison, 2013). A study from Australia evaluated 161 patients with severe mental disorder on Recovery Assessment Scale (RAS), of which 38 were suffering from BD and reported that patients with BD experience higher level of personal recovery when compared to those with schizophrenia and depression/ anxiety spectrum patients (Lloyd, King, & Moore, 2010). However, the small sample size of BD patients makes it difficult to draw conclusions.

From the available literature among patients with schizophrenia and other severe mental disorders, it is known that many factors like stigma, religious coping and spirituality can influence personal recovery (Aukst-Margetić & Jakovljević, 2008; Chan & Mak, 2014; Hasson-Ohayon et al., 2014; Jose et al., 2015; Mohr & Huguelet, 2004). However, these factors have not been evaluated among patients with BD. Overall, there is lack of data on personal recovery from developing countries. One study from China evaluated 75 patients with schizophrenia and 75 patients with BD, currently in remission for >6 months on Stages of Recovery Scale (SRS) and for functional recovery (in terms of employment and residential status). The SRS allows for assessment of four stages of recovery – overwhelmed by disability, struggling with disability, living with the disability and living beyond the disability (Cavelti, Kvrgic, Beck, Kossowsky, & Vauth, 2012). There was positive correlation between functional and personal recovery but the effect size was small. The predictors of better personal recovery were female gender, married status, belonging to higher socioeconomic status and giving less importance to social role. The same group of authors also reported that patients with BD have higher personal recovery scores as compared to those with schizophrenia (Tse, Davidson, Chung, Ng, & Yu, 2014). Among patients with BD, ‘respect, hope, and self-directed empowerment’, older age, binge drinking history, early first diagnosis and ‘meaningful role’ were all associated with being in a later stage of personal recovery, as assessed on SRS (Tse, Murray, et al., 2014) and Recovery elements assessment questionnaire (Siu et al., 2012).

There are no data on personal recovery among patients with BD, from India. Considering the fact that cultural factors and service-related factors influence personal recovery, it is important to study the concept of personal recovery across different countries and using standardized scales. In this background, this study aimed to evaluate the predictors of personal recovery among patients with BD. Additionally, an effort was made to study the association of personal recovery with residual psychopathology, level of functioning, stigma, religiosity, religious practices and religious coping. It was hypothesized that besides clinical variables, personal recovery would be influenced by stigma, religiosity, religious practices and religious coping.

Methodology

This study was carried out among the patients attending the outpatient services of Department of Psychiatry at Postgraduate Institute of Medical Education & Research, a tertiary care hospital in North India. The study was approved by the Institute Ethics Committee and all participants were recruited after obtaining written informed consent.

This study assessed religious practices, aetiological models held by patients, religiosity, stigma, psychopathology, level of functioning and psychological recovery. Data in terms of religious practices, aetiological models held by patients, religiosity and stigma have been published previously (Grover, Hazari, Aneja, Chakrabarti, & Avasthi, 2016a, 2016b). In this article, we focus on personal recovery and its correlates.

Participants were recruited by purposive sampling. To be included in the study, the participants were required to fulfil the diagnosis of BD as per the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV), aged between 18 and 65 years and currently in euthymic state, that is, score <7 on Young Mania rating scale (YMRS) and Hamilton depression rating scale (HDRS). Patients with comorbid intellectual disability were excluded. Clinical details were collected by one of the first three authors (S.G., N.H., J.A.) and the information on RAS, Brief Religious coping scale (RCOPE), Duke University Religiosity Index (DUREL), Religiousness Measures Scale and Internalized Stigma of Mental Illness Scale (ISMIS) was completed by patients themselves or they were assisted by one of the authors (S.S.).

Instruments

RAS

It is a 41-item scale which can be either self-administered or administered by a clinician. It can be completed in about 20 minutes (Corrigan & Phelan, 2004). Each item is rated on a 5-point scale, with higher scores indicating higher level of recovery. This scale has been used for evaluation of recovery among patients with severe mental disorders from various ethnic groups. It has been shown to have high internal consistency (alpha −.93) and test–retest reliability (Pearson correlation coefficient −.88). A factor analysis of RAS showed that out of 41 items of the scales, 24 items can be groups into 5 factors, namely, personal confidence, willingness to ask for help, goal and success orientation, reliance on others and not dominated by symptoms. Validation study done in India also showed a 5-factor model. However, in this study, all the 41 items loaded onto one or the other factor and these factors had lot of similarity with the previous factor analysis. According to similarity with the previous factor analysis, these factors were named as defeated the illness/overcome the illness, personal confidence and hope, seeking and relying on social support, awareness and control over the illness and goal and success orientation (Grover et al., 2016c).

RCOPE

It is a 14-item self-rated scale, with half of the items assessing positive religious coping and another half assessing negative religious coping. It has good internal consistency with median alpha values for the positive religious coping measures as .92 and .81 for negative religious measures (Pargament, Koenig, & Perez, 2000). A Hindi version of the scale was developed for one of the previous studies from our centre and for this study the Hindi version of the scale was used.

DUREL

It is a 5-item scale with the first and second item measuring organizational religiosity and non-organizational religiosity, respectively. The remaining three items measure intrinsic religiosity on a Likert scale. Cronbach’s alphas for the scale vary between .78 and .92, indicating high internal consistency (Koenig, Meador, & Parkerson, 1997). A Hindi version of the scale was developed for one of the previous studies from our centre and for this study the Hindi version of the scale was used.

Religiousness Measures Scale

It is a 17-item Likert scale which measures religious hope, involvement and influence. It has a monotheistic question related to belief in God (Sethi & Seligman, 1993).

ISMIS

It is a 29-item scale which assesses subjective self-stigma/internalized stigma experienced by a person with mental illness. Each item is rated on a 4-point scale (strongly disagree – 1, disagree – 2, agree – 3 and strongly agree – 4), with higher scores indicating higher level of internalized stigma. Various items of the scale are combined into five domains – alienation, stereotype endorsement, perceived discrimination, social withdrawal and stigma resistance. The items for stigma resistance have reversed scoring and are considered to be different from other domains. Different cut-offs have been proposed to estimate the stigma. A cut-off of 2.5 for total and subscales of ISMIS has been suggested as a cut-off to categorize the presence or absence of stigma by the authors of the scale (Ritsher, 2003; Ritsher & Phelan, 2004). A Hindi version of the scale which was validated at our centre was used in this study (Singh, Grover, & Mattoo, 2016).

HDRS

Depression was assessed using HDRS and a score of less than 7 was used to define remission (Hamilton, 1960).

YMRS

Manic symptoms were assessed using YMRS and a score of less than 7 was used to define remission (R. C. Young, Biggs, Ziegler, & Meyer, 1978).

Global Assessment of Functioning scale

It was used to assess the level of functioning of the patients (Jones, Thornicroft, Coffey, & Dunn, 1995).

Data were analysed as per the objectives of the study. Mean and standard deviation (SD) were calculated for the continuous variables. Frequency and percentages were calculated for discontinuous variables. Comparisons were done using t-test. Correlations were studied using Pearson’s correlation coefficient. Multiple regression analysis was used to study the predictors of recovery.

Results

The sociodemographic profile of the study sample is shown in Table 1. The mean age of the sample was 40.5 (SD, 11.26) years. Majority of the participants were male, married, working, Hindu by religion and belonged to extended/joint families of urban background.

Table 1.

Sociodemographic and clinical details of the study sample (N = 185).

Variable	Frequency (%)/mean (SD)
Age in years	40.55 (11.26) (range, 19–63)
Gender – male	124 (67)
Marital status – currently married	150 (81.1)
Education – less than 10th	97 (52.4)
Mean duration of formal education in years	10.7 (3.72) (range, 0–17)
Occupation – on paid employment	103 (55.7)
Religion^a – Hindu	114 (61.6)
Income of the patient – >Rs 7000	145 (72.4)
Family type – extended/joint	99 (53.5)
Background – urban	105 (56.8)
Age at onset of psychiatric illness	28.98 (10.09) (range, 10–58)
Total duration of illness (months)	134.7 (99.77) (range, 12–468)
Duration of remission (months)	15.11 (22.45) (range, 2–180)
Total number of lifetime episodes	7.56 (6.89) (range, 2–41)
Total number of lifetime hospitalizations	0.39 (0.76) (range, 0–4)
Hospitalizations to psychiatry inpatient in lifetime	50 (27)
Hospitalizations to psychiatry inpatient in last 6 months	15 (8.1)
Mean HDRS score	0.30 (0.74) (range, 0–5)
Mean YMRS score	0.64 (1.38) (range, 0–6)
Mean GAF score	80.8 (9.89) (range, 40–95)

SD: standard deviation; HDRS: Hamilton depression rating scale; YMRS: Young Mania rating scale; GAF: Global Assessment of Functioning.

Among non-Hindus, 63 were Sikhs, 5 were Muslims and 3 were Christians by religion.

The mean duration of illness was 134 (SD, 99.8; median, 108; range, 12–456) months and the mean duration of remission was 15.1 (SD, 22.5) months, with a median of 8 months. The mean number of lifetime episodes were 7.6 (SD, 6.9; range, −2 to 41) and median of 5. Patients had low level of residual psychopathology with mean of 0.3 and 0.64 HDRS and YMRS total scores, respectively, with a median of 0. The mean Global Assessment of Functioning (GAF) score was 80.8 (9.89), indicating high level of functioning.

Recovery-related measures on RAS, stigma, coping and religiosity

As shown in Table 2, the mean scores on RAS were highest for the ‘willingness to ask for help’ and ‘not dominated by symptoms’ domains. The scores obtained using the factor analysis of the scale in India (Grover, Hazari, Singla, et al., 2016) reflected nearly equal scores for all the factors.

Table 2.

Recovery measures, religiousness measures, coping and religiosity (N = 185).

Variable	Mean (SD)	Range
Recovery assessment scale
Personal confidence	3.86 (0.48)	2.33–5
Willingness to ask for help	3.89 (0.52)	7–15
Goal and success orientation	3.83 (0.47)	1.8–5
Reliance on others	3.86 (0.50)	2–5
Not dominated by symptoms	3.89 (0.56)	2.33–5
RAS total score (of 24 items loaded on 5 factors)	92.71 (11.03)	53–120
RAS (Factors of Indian validation)
Defeated the illness/overcome the illness	3.87 (0.49)	2.2–5
Personal confidence and hope	3.87 (0.49)	2.11–5
Seeking and relying on social support	3.87 (0.51)	2.2–5
Awareness and control over the illness	3.87 (0.48)	2.33–5
Goal and success orientation	3.82 (0.48)	1.83–5
RAS total score (of 41 items loaded on 5 factors)	158.41 (19.26)	91–205
ISMIS
Alienation	2.25 (0.43)	1–3.83
Stereotype endorsement	2.21 (0.43)	1–4
Discrimination experience	2.65 (0.52)	1.2–4
Social withdrawal	2.23 (0.50)	1–3.83
Stigma resistance (reverse scoring)	2.21 (0.51)	1–3.8
Total ISMIS score (including all the five components)	2.33 (0.41)	1.4–3.36
ISMIS total (excluding the stigma resistance component)	2.33 (0.43)	1.2–3.92
Total ISMIS raw score	67.45 (11.77)	40.7–97.3
DUREL
Organizational religiosity	4.77 (0.74)	3–6
Non organizational/private religiosity	4.41 (0.97)	1–6
Intrinsic religiosity	10.66 (1.75)	4–15
Religiousness measure scale
Involvement	3.83 (1.31)	1–6
Influence	4.22 (0.63)	1.86–5.57
Hope	4.51 (0.75)	1.83–6
Total religiosity score	12.56 (1.27)	8.64–15.95
Religious coping (RCOPE)
RCOPE – positive religious coping	9.60 (4.95)	0–21
RCOPE – negative religious coping	2.39 (3.70)	0–17

SD: standard deviation; RAS: Recovery Assessment Scale; ISMIS: Internalized Stigma of Mental Illness Scale; DUREL: Duke University Religiosity Index; RCOPE: Brief Religious Coping Scale.

On the ISMIS scale, the highest scores were obtained for the factor of ‘discrimination experience’ followed by alienation factor. On the individual domains of ISMIS (using a cut-off of >2.5), alienation was experienced by 28.6%, stereotype endorsement by 23.8%, discrimination experience by 38.9%, social withdrawal by 28.6% and stigma resistance (reverse scored) by 25.9%, respectively.

On the religiousness measures scale, highest scores were seen on the religious hope subscale. The mean scores on positive and negative religious coping were 9.6 (SD, 4.95) and 2.39 (SD, 3.70), respectively. On DUREL, the mean scores on organizational religiosity, non-organizational/private religiosity and intrinsic religiosity were 4.77, 4.41 and 10.66, respectively.

Factors associated with recovery

Sociodemographic and clinical correlates

There was no significant correlation between RAS scores and age, gender, education, marital status, family type and locality. Those who were on paid employment experienced high level of recovery in the domain of ‘willingness to ask for help’. Compared to those who had lower income, those who were earning more than Rs 7000 reported higher level of recovery in the domain of ‘goal orientation’ and ‘not dominated by symptoms’. As is evident from Table 3, in terms of psychopathology, the presence of residual depressive symptoms was associated with lower recovery in most of the domains. There was no association with YMRS, number of episodes, age of onset of illness, total duration of illness, duration of remission and number of hospitalizations.

Table 3.

Association of recovery with sociodemographic variables, clinical variables, residual psychopathology, religiosity and stigma.

	Factor structure as per Corrigan and Phelan (2004)						Factor structure as per Grover et al. (2016)
	Personal confidence	Willingness to ask for help	Goal orientation	Reliance on others	Not dominated by symptoms	RAS total of 24 items	Defeated the illness/overcome the illness	Personal confidence and hope	Seeking and relying on social support	Awareness and control over the illness	Goal and success orientation	Total score of 41 items
Occupation – employed		−2.079*
Income – >7000		−2.225*			−2.387*
HDRS	−0.326***	−0.353***	−0.256***	−0.306***	−0.385***	−0.325***	−0.231**	−0.251***	−0.269***	−0.241***	−0.227**	−0.341***
GAF	0.450***	0.445***	0.435***	0.480***	0.426***	0.484***	0.440***	0.497***	0.497***	0.450***	0.483***	0.497***
Stigma
Alienation	−0.528***	−0.461***	−0.415***	−0.453***	−0.472***	−0.515***	−0.537***	−0.506***	−0.467***	−0.502***	−0.449***	−0.519***
Stereotype endorsement	−0.525***	−0.418***	−0.488***	−0.469***	−0.525***	−0.534***	−0.560***	−0.500***	−0.456***	−0.497***	−0.519***	−0.530***
Discrimination experience	−0.591***	−0.479***	−0.441***	−0.489***	−0.548***	−0.566***	−0.592***	−0.556***	−0.553***	−0.561***	−0.483***	−0.575***
Social withdrawal	−0.526***	−0.440***	−0.357***	−0.437***	−0.475***	−0.496***	−0.519***	−0.510***	−0.462***	−0.480***	−0.411***	−0.505***
Stigma resistance (reversed coded)	−0.259***	−0.351***	−0.171***	−0.277***	−0.286***	−0.282***	−0.287***	−0.239***	−0.329***	−0.339***	−0.218***	−0.299***
ISMIS total	−0.587***	−0.517***	−0.447***	−0.511***	−0.552***	−0.573***	−0.559***	−0.536***	−0.461***	−0.493***	−0.477***	−0.582***
ISMIS total without stigma resistance	−0.593***	−0.491***	−0.462***	−0.504***	−0.551***	−0.576***	−0.602***	−0.566***	−0.524***	−0.557***	−0.506***	−0.581***
Religious coping
Positive coping	0.203**			0.169*		0.172*	0.165*	0.162*	0.158*	0.184*		0.168*
DUREL
Non organizational/ private religiosity			0.144*								0.149*

RAS: Recovery Assessment Scale; HDRS: Hamilton depression rating scale; GAF: Global Assessment of Functioning; ISMIS: Internalized Stigma of Mental Illness Scale; DUREL: Duke University Religiosity Index.

p < .05; **p < .01; ***p ⩽ .001.

All the domains of RAS (defined as per both the factor analysis) and the total score (of 24 and 41 items) correlated negatively with HDRS scores and positively correlated with functioning on GAF.

Association of recovery with stigma and religiosity

As shown in Table 3, there was significant negative correlation between all the domains of stigma assessed on ISMIS and recovery on RAS indicating greater stigma was associated lower recovery. However, reversed coded stigma resistance domain had negative correlation with recovery, indicating that higher stigma resistance was associated with better personal recovery.

There was significant positive correlation between positive religious coping (on RCOPE) and RAS domains of personal confidence, reliance on others and total RAS score as defined by Corrigan and Phelan (2004). When the domains of recovery were defined as per the factor structure as obtained in Indian patients, positive RCOPE correlated with total RAS score and all the domains scores except for the domain of ‘goal and success orientation’.

There was no significant correlation between negative religious coping and RAS domains. There was no significant correlation between religiousness measures (involvement, influence, hope) and RAS scores. On DUREL, positive correlation was seen between private religiosity and ‘goal orientation’ domain of RAS (Corrigan & Phelan, 2004) and between private religiosity and ‘goal and success orientation’ as per factor structure of data from India (Grover et al., 2016).

As shown in Table 4, the absence of stigma in all the domains was associated with significantly higher recovery.

Table 4.

Comparison of recovery of those with and without stigma.

Variable		Total RAS scoreMean (SD)	t
RAS total (24 items)
Alienation	Present (N = 53)Absent (N = 132)	83.75 (13.04)96.31 (7.60)	6.577***
Stereotype endorsement	Present (N = 44)Absent (N = 144)	82.98 (13.34)95.75 (8.13)	6.014***
Discrimination experience	Present (N = 72)Absent (N = 113)	87.10 (13.47)96.29 (7.17)	5.329***
Social withdrawal	Present (N = 53)Absent (N = 132)	83.58 (12.76)96.38 (7.67)	6.820***
Stigma resistance	Present (N = 48)Absent (N = 137)	86.54 (13.29)94.88 (9.24)	4.019***
Total ISMIS	Present (N = 55)Absent (N = 130)	84.24 (12.52)96.30 (8.02)	6.598***
RAS total (41 items)
Alienation	Present (N = 53)Absent (N = 132)	142.60 (22.88)164.76 (13.10)	6.627***
Stereotype endorsement	Present (N = 44)Absent (N = 144)	141.41 (23.21)163.72 (14.25)	6.032***
Discrimination experience	Present (N = 72)Absent (N = 113)	148.32 (23.48)164.84 (12.36)	5.504***
Social withdrawal	Present (N = 53)Absent (N = 132)	142.30 (22.29)164.88 (13.29)	6.897***
Stigma resistance	Present (N = 48)Absent (N = 137)	147.27 (22.83)162.31 (16.21)	4.209***
Total ISMIS	Present (N = 55)Absent (N = 130)	143.67 (21.73)164.65 (14.13)	6.593***

RAS: Recovery Assessment Scale; SD: standard deviation; ISMIS: Internalized Stigma of Mental Illness Scale.

***

p < .001.

Multiple regression analysis: predictors of recovery

All the variables which had significant correlation with total recovery scores and scores of various domains of RAS were entered into the multiple regression analysis. As is evident from Table 5, variables which had significant influence of total RAS scores and various domains scores included discrimination experience, stereotype endorsement and alienation as assessed by ISMIS, level of functioning as assessed by GAF and residual depressive symptoms as assessed using HDRS. The level of variance explained for total RAS score and various domain scores ranged from 36.2% to 46.9% as reflected by the adjusted R² values. Among the various component of stigma, discrimination experience had the maximum bearing on most components of RAS. Stereotype endorsement also had maximum influence on the domains of goal orientation as per Corrigan and Phelan (2004) and goal and success orientation as per Grover et al. (2016).

Table 5.

Multiple regression analysis showing predictors of recovery.

Variable	R	R ²	Adjusted R²	Significance (p)
RAS total 24 items
Discrimination experience	.566	.320	.316	<.001***
Discrimination experience, GAF	.668	.446	.440	<.001***
Discrimination experience, GAF, alienation	.679	.461	.452	<.001***
RAS total 41 items
Discrimination experience	.575	.331	.327	<.001***
Discrimination experience, GAF	.682	.465	.459	<.001***
Discrimination experience, GAF, Alienation	.691	.478	.469	<.001***
RAS – personal confidence
Discrimination experience	.591	.350	.346	<.001***
Discrimination experience, GAF	.669	.448	.442	<.001***
Discrimination experience, GAF, Alienation	.680	.462	.453	<.001***
RAS – willingness to ask for help
Discrimination experience	.479	.229	.225	<.001***
Discrimination experience, GAF	.585	.342	.335	<.001***
Discrimination experience, GAF, HDRS	.606	.367	.357	<.001***
Discrimination experience, GAF, HDRS, occupation	.625	.391	.378	<.001***
RAS – goal orientation
Stereotype endorsement	.488	.239	.234	<.001***
Stereotype endorsement, GAF	.594	.353	.346	<.001***
RAS – reliance on others
Discrimination experience	.489	.239	.235	<.001***
Discrimination experience, GAF	.613	.376	.369	<.001***
RAS – not dominated by symptoms
Discrimination experience	.548	.300	.296	<.001***
Discrimination experience, GAF	.624	.390	.383	<.001***
Discrimination experience, GAF, stereotype endorsement	.638	.407	.397	.004**
RAS (modified) – defeated the illness/overcome the illness
Discrimination experience	.592	.350	.346	<.001***
Discrimination experience, GAF	.665	.442	.436	<.001***
Discrimination experience, GAF, alienation	.678	.460	.451	<.001***
RAS (modified) – personal confidence and hope
Discrimination experience	.556	.309	.306	<.001***
Discrimination experience, GAF	.669	.447	.441	<.001***
Discrimination experience, GAF, alienation	.679	.461	.452	<.001***
RAS (modified) – seeking and relying on social support
Discrimination experience	.533	.284	.280	<.001***
Discrimination experience, GAF	.652	.425	.419	<.001***
Discrimination experience, GAF, HDRS	.668	.446	.437	<.001***
RAS (modified) – awareness and control over the illness
Discrimination experience	.561	.314	.311	<.001***
Discrimination experience, GAF	.646	.417	.411	<.001***
Discrimination experience, GAF, HDRS	.658	.433	.424	<.001***
RAS (modified) – goal and success orientation
Stereotype endorsement	.519	.269	.265	<.001***
Stereotype endorsement, GAF	.643	.414	.407	<.001***

RAS: Recovery Assessment Scale; GAF: Global Assessment of Functioning; HDRS: Hamilton depression rating scale.

***

p < .001.

Discussion

Personal recovery in mental illness is determined by many factors beyond the resolution of symptoms. Ultimately, functioning and quality of life are determined by personal recovery. Accordingly, the goal of mental health professionals encompasses improving recovery rather than merely targeting symptom remission. The determinants of recovery vary in different societal and cultural contexts based on different expectations in terms of functioning, stigma, aetiological models of illness and the use of religiosity as a form of coping. In India, religiosity and religious practices are integral part of life. Many patients with BD also experience psychopathology with religious content (Grover et al., 2016a). The research on personal recovery in BD is scarce with no data from developing countries including India. This study attempted to fill the void by evaluating personal recovery and its correlates in 185 patients diagnosed with BD, who were in clinical remission.

In this study, recovery was assessed using the RAS, which is a scale developed after the input of consumers to reflect their understanding of the concept of recovery. In the past, it has been validated in a multi-ethnic population. The scale was also evaluated for the factor structure in Indian setting. In this study, data were also analysed as per the factor structure of RAS (Grover et al., 2016c) in Indian setting.

The sociodemographic and clinical profile of the patients included in this study is similar to the profile of patients included in earlier studies from India which have evaluated BD patients in remission phase from this centre and many studies from other parts of the country (Chand, Mattoo, & Sharan, 2004; Grover, Ghosh, Sarkar, Chakrabarti, & Avasthi, 2014; Krishnadas, Ramanathan, Wong, Nayak, & Moore, 2014; Pradhan, Chakrabarti, Nehra, & Mankotia, 2008; Somaiya, Grover, Chakrabarti, & Avasthi, 2014).

Earlier studies, which have evaluated personal recovery among patients with BD quantitatively, have used different scales, which make the comparisons difficult. Only one study had evaluated recovery among patients with BD using RAS. In this study, the mean RAS score was 61.2 (SD, 14.7) for the BD cohort of 38 patients (Lloyd et al., 2010). When we compare the mean score of 24 items of RAS obtained in this study with this earlier study, it can be said that patients in our study experienced higher level of recovery. These differences could be due to sample size, selection criteria and low level of residual psychopathology in our study sample.

In terms of sociodemographic variables, there were very few correlates of recovery. Previous studies from other parts of the world also suggest that in general sociodemographic variables do not predict personal recovery among patients with BD (Jones et al., 2013; Lloyd et al., 2010; Todd et al., 2012; van der Voort et al., 2015; A. T. Young et al., 2008).

In this study, currently employed status was associated with higher recovery scores in the domain of ‘willingness to ask for help’ domain on RAS. Our study supports the association of being employed and higher level of recovery as seen in an earlier study (Lloyd et al., 2010). This association suggests that to improve the personal recovery of patients with BD, there is a need to improve the employment opportunities for patients with mental illnesses. In a country like India, where although there are few employment opportunities for differently abled persons, but those with mental illness have to compete with people with other disabilities. In view of the stigma attached to mental illnesses in our society, although competent to handle a particular job, those with mental illnesses are denied job opportunities. Hence, there is a need to impress upon the policy makers for separate employment opportunities for those with mental disorders.

Higher income was associated with higher scores in the domains of ‘willingness to ask for help’ and ‘not dominated by symptoms’ domains on RAS. These associations suggest that being employed and having higher income promote personal recovery. Furthermore, these appear to have a reciprocal relationship. Greater efforts at seeking help when needed and less perception of symptoms controlling one’s life enables the persons to take high-income jobs.

Among the clinical characteristics, the presence of residual depressive symptoms has been consistently shown to be associated with poor recovery (Henry et al., 2015; Samalin et al., 2014; van der Voort et al., 2015), and this study supports the same. These associations are understandable given the distress associated with the presence of residual depressive symptoms which affects social and occupational functioning. Hence, it is important to address the residual depressive symptoms in patients with BD to improve personal recovery.

Previous studies have evaluated recovery among patients with BD and have not evaluated the association of personal recovery with stigma. Findings of this study suggest that the presence of stigma is associated with poor personal recovery. In fact in this study, in the regression analysis, ‘discrimination experience’ and ‘stereotype endorsement’ had maximum influence on scores of various domains of recovery and total recovery scores. Accordingly, it can be said that there is an urgent need to address the stigma associated with mental illness by proper interventions at the individual level, at the level of the society and general public at large. In terms of policy, all efforts must be made to give equal opportunities to those with mental illnesses.

In the Indian subcontinent, religion is part and parcel of life and it influences aetiological models about the illnesses, pathways to care and health-seeking behaviour (Grover et al., 2016a). Many patients with mental illness seek help from the faith healers and religious places. In this study, higher use of positive religious coping was associated with better personal recovery; however, no association was seen between other aspects of religiosity and personal recovery. Accordingly, it can be said that clinicians should be sensitive to the religious beliefs and practices of the patients with BD and should encourage them to use positive religious coping mechanisms to promote personal recovery.

In this study, higher level of functioning, as assessed by GAF, was associated with higher level of personal recovery. Previous studies have also shown good correlation between functioning and personal recovery (Jones et al., 2013; Lloyd et al., 2010; Tse, Davidson, et al., 2014; van der Voort et al., 2015).

This study has certain limitations in that it was limited to patients in clinical remission attending outpatient services of a tertiary care hospital. Hence, the findings of this study cannot be generalized to those patients who do not achieve remission. Further the findings cannot be generalized to patients with BD living in community. In this study, we did not evaluate many psychosocial and clinical factors like social support, medication compliance, treatment adherence, insight, level of disability, level of cognitive dysfunction, knowledge about illness, disability, work performance and social supports, which could also influence personal recovery. Future studies on recovery should attempt to study the association of recovery and these dimensions to have a better understanding of all the variables influencing personal recovery.

In conclusion, findings of this study suggest that recovery in patients with BD correlates with level of functioning. This study suggests that the presence of residual depressive symptoms and higher level of internalized stigma have negative impact on personal recovery, whereas higher use of positive religious coping promotes personal recovery. Furthermore, being in a paid employment and having higher income are associated with better personal recovery. Accordingly, it can be said that making efforts to minimize the residual depressive symptoms and improving functioning can possibly promote personal recovery. Furthermore, understanding the religious belief system of patients and encouraging the use of positive religious coping when faced with stressful situations can possibly improve personal recovery among patients of BD in remission. Addressing stigma can possibly lead to better social integration and job opportunities and can possibly promote personal recovery. At the society level, creation of more job opportunities for patients with mental illness and addressing the stigma at the community level would possibly lead to better personal recovery among patients with BD.

Footnotes

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

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