The impact of affective symptoms on personal recovery of patients with severe mental illness

Abstract

Background:

Clinical recovery is often defined as remission of symptoms. Personal recovery is described as growing beyond the catastrophic effects of mental illness, sometimes despite ongoing symptoms.

Aims:

To examine the relationship between the severity of clinical symptom domains and personal recovery in patients with severe mental illness (SMI).

Methods:

Symptom severity and personal recovery of 105 outpatients with SMI at Mentrum, part of Arkin Institute for Mental Health in Amsterdam, the Netherlands, were assessed using the Brief Psychiatric Rating Scale–Expanded Version (BPRS-E) and the Mental Health Recovery Measure (MHRM). Correlation and regression analyses were used to investigate the associations.

Results:

The multiple regression analysis showed that only affective symptoms significantly predicted personal recovery, whereas neither positive nor negative symptom severity added to the explained variance in the model.

Conclusion:

The association between affective symptoms and personal recovery in patients with SMI implies that treatment of affective symptoms may advance personal recovery, and/or support of personal recovery may improve mood, whereas focussing on treatment of psychotic symptoms might not be the key to personal recovery. More research is needed to elucidate causal interrelations.

Keywords

Personal recovery empowerment clinical recovery severe mental illness (SMI)schizophrenia psychosis affective symptoms

Introduction

Severe mental illness (SMI) is a trans-diagnostic category of psychiatric disorders that have major and long-term impacts on social and community functioning. Common disorders in SMI patients are schizophrenia, severe bipolar disorder, chronic depression and personality disorders (Delespaul, 2013; Ruggeri, Leese, Thornicroft, Bisoffi, & Tansella, 2000).

Recovery of patients with SMI is an important focus of mental health care all across the world (Schrank & Slade, 2007). Scientists and patients have, independently of each other, formulated a definition of recovery (Bellack, 2006). These different forms of recovery are usually named clinical versus personal recovery.

Traditionally, the primary treatment goal of patients with SMI is clinical recovery, which includes at least remission of symptoms, for instance a score of mild or less on specific items of a symptom scale over a 6 month period, for example, the Positive and Negative Syndrome Scale (PANSS) or the Brief Psychiatric Rating Scale (BPRS) (Andreasen et al., 2005). Some studies have incorporated functional improvement in the definition of clinical recovery (Jaaskelainen et al., 2013; Liberman, Kopelowicz, Ventura, & Gutkind, 2002; Torgalsbøen, 2013).

Personal recovery is based on stories of patients with SMI showing that living a productive and satisfying life is possible despite ongoing symptoms (Slade, Amering, & Oades, 2008). Anthony (1993) described this as ‘the development of new meaning and purpose in one’s life, as one grows beyond the catastrophic effects of mental illness’. Based on narratives of individuals who have experienced mental illness, the following processes have been defined as being important in personal recovery: connectedness, hope, identity, meaning and empowerment. Together they form the acronym ‘CHIME’ (Deegan, 2002; Leamy, Bird, Le Boutillier, Williams, & Slade, 2011; Mead & Copeland, 2000).

The relationship between personal and clinical recovery has been a subject of debate (Slade et al., 2014). Some authors have suggested that clinical and personal recovery complement each other and should be equally acknowledged in clinical practice (Davidson, Lawless, & Leary, 2005). It has also been suggested that clinical recovery is sometimes needed for personal recovery but that this might not be the case for all patients (Slade, 2009).

So far, the association between personal and clinical recovery has been investigated primarily in patients with a schizophrenia spectrum disorder. These studies show substantial variation in direction and magnitude of the association between clinical and personal recovery (Giusti et al., 2015; Roe, Mashiach-Eizenberg, & Lysaker, 2011; Vass et al., 2015). In a recent meta-analysis, it was shown that core symptoms of schizophrenia, that is, delusions and hallucinations, only have a small to medium negative association with personal recovery, whereas affective symptoms have a stronger association with lower levels of personal recovery in patients with schizophrenia spectrum disorders (Van Eck, Burger, Vellinga, Schirmbeck, & De Haan, 2018). Studies in patients with affective disorders also suggest an important role for mood symptoms in personal recovery (Aloba et al., 2015; Brown, Rempfer, & Hamera, 2008; Shahar & Davidson, 2003).

In clinical practice, chronic care is mostly not organised by diagnosis but by type of care needed. That is why research in patients with SMI who are treated long term in a multidisciplinary team is more applicable than investigating only people with, for instance, schizophrenia.

It is important to know which symptom domains particularly influence personal recovery and vice versa, because this could inform professionals about their focus in treatment and recovery-oriented practices.

The aim of the current study is to examine the correlation between the severity of clinical symptom domains and personal recovery in patients with SMI. Besides that, the predictive value of the symptom domains on personal recovery is investigated, taking into account potential confounders, such as age, gender and diagnosis.

Based on findings in patients with schizophrenia, we expect to find a stronger association between affective symptoms and personal recovery than between psychotic symptoms and personal recovery. Also a larger predictive value of affective symptoms on personal recovery is expected.

Methods

Participants and procedure

Patients were recruited from five Flexible Assertive Community Treatment teams (F-ACT) of Mentrum, part of Arkin Institute for Mental Health, Amsterdam, the Netherlands. F-ACT is a Dutch version of Assertive Community Treatment (ACT), aimed exclusively at SMI patients (Nugter, Engelsbel, Bähler, Keet, & van Veldhuizen, 2016). F-ACT teams are multidisciplinary and offer two levels of care: individual case management and ACT when there is a need for shared caseload and assertive outreach. In short, the F of F-ACT stands for a team that is flexible to temporarily intensify treatment to ACT if this is needed.

Our study took place between September 2015 and September 2016. Patients were recruited by posters and flyers in the waiting room. Moreover, all mental health workers were requested to ask their patients if they would participate in this research project. All patients in the F-ACT teams meet the criteria of having a SMI (see the introduction for criteria). Patients were 18 years or older, able to understand the Dutch language and able to provide informed consent. Approval for the study was obtained from the Medical Ethics Review Committee of VU University Medical Centre, Amsterdam.

A trained researcher obtained informed consent and administered clinical interviews and questionnaires. In addition to self-reported information of the patient, a member of the F-ACT team (usually a psychiatric nurse) was asked to complete additional questions.

Measures

Brief Psychiatric Rating Scale–Expanded Version

To assess clinical recovery, defined as experienced and observed symptom severity, the Brief Psychiatric Rating Scale–Expanded Version (BPRS-E) was used (Lukoff, Nuechterlein, & Ventura, 1986). This is a 24-item symptom rating scale. Fourteen items are scored based on answers of the patient, whereas 10 items are scored based on observations of the interviewer. BPRS-E items are rated on a Likert-type scale ranging from 1, not present, to 7, extremely severe. The total score ranges from 24 to 168. Higher scores represent greater symptom severity. In the analysis, we used the subscales as proposed by Ruggeri et al., namely, positive symptoms (5 items), negative symptoms (7 items), depression/anxiety (affective, 6 items) and manic excitement/disorganization (8 items). The internal consistency of the four component scales (Cronbach’s alpha) ranged from .69 to .74 (Ruggeri et al., 2005).

Mental Health Recovery Measure

The Mental Health Recovery Measure (MHRM) was used to assess personal recovery (Young & Bullock, 2003). The concepts of CHIME are represented in the items of the MHRM (Shanks et al., 2013). The MHRM is a self-report questionnaire. Items are rated on a 5-point Likert-type scale ranging from 1, strongly disagree, to 5, strongly agree. Higher MHRM scores indicate higher self-reported levels of recovery. Based on factor analysis of the Dutch version of the MHRM, three subscales have been defined: self-empowerment (13 items), learning and new potentials (15 items) and spirituality (2 items). Self-empowerment contains, for instance, self-esteem, self-efficacy and optimism and control over the future. Being positive about possibilities to learn and opportunities for new potentials are part of the second subscale. Spirituality is about how faith and spirituality help people to recover. A mean total score for all completed items is calculated. The score then again ranges from 1 to 5. The Dutch version of the MHRM has a Cronbach’s alpha that ranges from .86 to .94 (Van Nieuwenhuizen, Wilrycx, Moradi, & Brouwers, 2014).

Data analysis

Data analysis was performed with SPSS version 23 (IBM Released, 2015). Spearman’s correlation coefficients were calculated between domains of clinical recovery assessed with the BPRS-E and personal recovery measured with the MHRM. Linear regression analyses were used to assess the additive predictive value of specific BPRS-E symptom domains on personal recovery. Age, gender, diagnosis, country of origin, housing status, neighbourhood, marital status, legal status and treatment status were assessed as potential confounders.

Results

Sample characteristics

Characteristics of the 105 participants are shown in Table 1. The average age of participants was 48.94 (SD = 10.12, range = 22–71) years. Slightly more men (54.3%) than women were included. Most patients were from Dutch origin (62.9%), were single (78.1%) and lived independently (85.7%). Most patients had a schizophrenia spectrum disorder (71%) and 14.3% of the patients received treatment on an involuntary basis.

Table 1.

Demographic characteristics of participants (n = 105).

Gender (n, %)
Male	57 (54.3)
Female	48 (45.7)
Age range (M, SD)	22–71 (48.94, 10.12)
Primary diagnosis (n, %)
Schizophrenia spectrum	71 (67.6)
Bipolar disorder or chronic depression	18 (17.1)
Personality disorder	9 (8.6)
Autism spectrum disorder	6 (5.7)
Addiction	1 (1.0)
Country of origin (n, %)
The Netherlands	66 (62.9)
Other Western	9 (8.6)
Non-Western	30 (28.6)
Housing status (n, %)
Independent living	90 (85.7)
Supported living	12 (11.4)
Sheltered home	2 (1.9)
Homeless	1 (1.0)
Marital status (n, %)
No relationship	82 (78.1)
In a relationship	23 (21.9)
Legal status (n, %)
Voluntary	90 (85.7)
Non-voluntary	15 (14.3)

We found that the current sample was comparable to all potentially eligible F-ACT patients of Mentrum (n = 2,513) regarding sociodemographic variables, gender, age, diagnosis, legal status and the Health of the Nation Outcome Scale (HoNOS) score, which is collected for Routine Outcome Monitoring (ROM) purposes. Unfortunately, due to missing data on country of origin, housing status and marital status in the potentially eligible Mentrum F-ACT patients, comparisons on these variables were not possible.

Clinical and personal recovery scores

Table 2 shows the means and standard deviations of the scores on the BPRS-E and MHRM.

Table 2.

Clinical and personal recovery scores of participants (n = 105).

Scale (score range)	M (SD)
BPRS-E
Total (24–168)	42.70 (11.34)
Positive (5–35)	9.40 (5.61)
Negative (7–49)	11.85 (3.61)
Affective (6–42)	13.06 (5.21)
Excitement (8–56)	11.48 (2.91)
MHRM (mean)
Total (1–5)	3.33 (0.46)
Self-empowerment	3.30 (0.57)
Learning and new potentials	3.39 (0.45)
Spirituality	3.03 (1.05)

BPRS-E: Brief Psychiatric Rating Scale–Expanded Version; MHRM: Mental Health Recovery Measure.

Association between symptom domains and personal recovery

Associations between symptom domains as measured with the BPRS-E and personal recovery as measured with the MHRM were assessed with non-parametric Spearman’s correlation coefficients (Table 3). Affective symptoms were significantly associated with total MHRM scores and the two subscales self-empowerment, and learning and new potentials. Furthermore, positive symptoms were significantly correlated with the MHRM subscales self-empowerment and spirituality. Negative symptoms showed only a significant correlation with MHRM learning and new potentials. Excitement symptoms did not have a significant correlation with personal recovery.

Table 3.

Correlations between BPRS-E and MHRM scores.

	MHRM mean total	MHRM self-empowerment	MHRM learning	MHRM spirituality
BPRS-E positive	–.098	–.207*	–.041	.230*
BPRS-E negative	–.158	–.073	–.275**	.035
BPRS-E affective	–.536**	–.647**	–.352**	–.088
BPRS-E excitement	–.109	–.177	–.095	–.123

BPRS-E: Brief Psychiatric Rating Scale–Expanded Version; MHRM: Mental Health Recovery Measure.

Correlation is significant at the .05 level.

Correlation is significant at the .01 level.

A linear regression analysis was performed to investigate the additive predictive values of severity of different symptom domains on personal recovery. BPRS-E subscales were consecutively entered to the regression model in the following order: affective symptoms, negative symptoms and finally positive symptoms. This analysis showed that 35.1% of the variance of overall personal recovery was explained by affective symptom severity. Negative symptom severity did not significantly add to the model, whereas positive symptoms showed a trend (p = .065) of significance by explaining an additional 2.1% of variance in personal recovery (see Table 4).

Table 4.

Multiple linear regression with affective, negative and positive symptoms (BPRS-E) as predictors of personal recovery (MHRM) in the total sample.

Predictor	β	R² change	F change	p
BPRS-E affective	–0.592	.351	55.686	.000**
BPRS-E negative	–0.118	.014	2.187	.142
BPRS-E positive	0.160	.021	3.469	.065

BPRS-E: Brief Psychiatric Rating Scale–Expanded Version; MHRM: Mental Health Recovery Measure.

Significant at the .001 level.

Subsequently, the possible confounders age, gender, diagnosis, country of origin, housing status, neighbourhood, marital status, legal status and treatment status were entered. Only diagnosis was found to have a significant predictive value, ΔF(1, 103) = 10.385, p = .002. When including interaction effects between BPRS symptom domains and diagnosis, analyses revealed a significant interaction effect with affective symptoms (p = .047), showing a stronger association between personal recovery and affective symptoms in patients with a non-psychotic disorder (see Supplemental Figure 1).

To account for this effect, we separately assessed the association between symptom domains and personal recovery in the sample of patients with a psychotic (schizophrenia spectrum) disorder (n = 71) and in the non-psychotic group, including patients with a primary diagnosis of a bipolar disorder, chronic depression, personality disorder, autism spectrum disorder or addiction (n = 34).

Analyses in the psychosis group showed that 20.7% of the variance of personal recovery was explained by affective symptom severity, ΔF(1, 69) = 17.987, p = .000. Negative symptoms showed a significant trend by explaining 3.9% of the variation in personal recovery, ΔF(1, 68) = 3.543, p = .064. Positive symptoms did not significantly contribute to personal recovery, ΔF(1, 67) = 0.245, p = .622.

In the non-psychotic group, analyses showed that 60.4% of the variance of personal recovery was explained by affective symptom severity, ΔF(1, 32) = 48.812, p = .000. Negative (ΔF(1, 31) = 0.118, p = .733) and positive symptoms (ΔF(1, 30) = 1.744, p = .197) did not significantly add to the model.

Discussion

This study was performed to evaluate the relationship between clinical and personal recovery in patients with SMI by investigating specific associations between the severity of different symptom domains and reported personal recovery. Previous research has mainly focussed on patients with schizophrenia spectrum disorders, but chronic care is mostly not organised by diagnosis, but by type of care needed. That is why research in patients with all SMIs is desirable.

A multiple regression analysis showed that only affective symptoms significantly predicted personal recovery, whereas neither positive, nor negative symptom severity added to the explained variance in the model. It is known that depressive symptoms have a high prevalence in patients with schizophrenia spectrum disorders, with estimates of 80% (Schennach et al., 2012). Earlier studies in patients with schizophrenia spectrum disorders, as well as with affective disorders, have found that affective symptoms correspond more closely to personal recovery than psychotic symptoms (Aloba et al., 2015; Brown et al., 2008; Shahar & Davidson, 2003; Van Eck et al., 2018). However, post hoc analyses of the current sample revealed that severity of affective symptoms was more strongly related to personal recovery in patients with a non-psychotic disorder than in patients with schizophrenia. We propose that the association is related to partly overlapping expressions in depressive mood and personal recovery. It is evident that a depressive mood is associated with a decreased sense of hope and optimism which are also important aspects of personal recovery (Brown et al., 2008; Landeen, Pawlick, Woodside, Kirkpatrick, & Byrne, 2000; Leamy et al., 2011). Earlier studies have also found a relationship between affective symptoms and constructs related to personal recovery, such as quality of life, self-esteem, hopelessness and stigma (Eack & Newhill, 2007; Law, Neil, Dunn, & Morrison, 2014; Priebe et al., 2011; Vass et al., 2015).

In contrast, positive and negative symptoms were not associated with overall personal recovery. This finding is in line with literature regarding patients with schizophrenia spectrum disorders, which also reported non-significant or small associations (Giusti et al., 2015; Kukla, Salyers, & Lysaker, 2013; Roe et al., 2011).

If we look into the subscales of the MHRM, there is a clear relationship between self-empowerment and affective symptoms. The questions of the MHRM that address empowerment mostly concern believing in and being positive about oneself. These notions are influenced by a depressive mood.

The main implication of our findings for clinical practice is that for SMI patients treated in F-ACT teams, not only attention to positive and negative symptoms but also affective symptoms is important. Treating these symptoms could support personal recovery and specifically empowerment and attention to personal recovery could result in remission of affective symptoms. Several recovery-oriented practices have been developed that target the key recovery processes: CHIME (Slade et al., 2014). For example, it has been shown that supporting self-esteem increases clinical recovery and coping skills (Borras et al., 2009; Lecomte et al., 1999). A qualitative research approach could explain more about the specific link between affective symptoms and personal recovery (Young & Ensing, 1999).

Limitations

Our results should be interpreted in the light of several limitations. We had no data on longitudinal course of symptom severity or personal recovery. This would have given valuable information concerning the process of recovering over time and might have revealed a causal direction in the correlations found (Jørgensen et al., 2015; Law, Shryane, Bentall, & Morrison, 2016; Macpherson et al., 2015; Snyder, Young, & Schactman, 2016; Vass et al., 2015). Another limitation concerns the operationalisation of the concept personal recovery. Personal recovery is often regarded as a subjective story about overcoming the catastrophic effects of a mental disease. By using a standardized questionnaire, this individual story is not assessed, although it is, in all its diversity, central to the concept of personal recovery. Finally, no international consensus exists regarding the processes that contribute to personal recovery and the best suitable instrument to measure it. Future research should both address international consensus about the theoretical framework of personal recovery, perhaps with CHIME as a basis, and the psychometric quality of assessment instruments.

Conclusion

The findings of present study suggest a link between affective symptoms and personal recovery in a representative sample of patients with SMI, whereas psychotic symptoms do not show this association. Self-empowerment was the subdomain of personal recovery that was most prominently associated with affective symptoms. Treatment of affective symptoms may advance personal recovery, and/or support of personal recovery may improve mood, whereas focussing on treatment of psychotic symptoms might not be the key to personal recovery. More research is needed to elucidate causal interrelations.

Supplemental Material

Supplementary_material – Supplemental material for The impact of affective symptoms on personal recovery of patients with severe mental illness

Supplemental material, Supplementary_material for The impact of affective symptoms on personal recovery of patients with severe mental illness by Robin Michael Van Eck, Thijs Jan Burger, Marij Schenkelaars, Astrid Vellinga, Mariken Beatrijs de Koning, Frederike Schirmbeck, Martijn Kikkert, Jack Dekker and Lieuwe de Haan in International Journal of Social Psychiatry

Footnotes

Author’s note

Marij Schenkelaars is now affiliated to Brijder Addiction Care, Parnassia Group, The Netherlands.

Funding

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

ORCID iD

Robin Michael Van Eck

Supplemental material

Supplemental material for this article is available online.

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