Psychiatry Research 228 (2015) 14–19
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Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Relationships over time of subjective and objective elements of recovery in persons with schizophreni Rikke Jørgensen a, Vibeke Zoffmann b, Povl Munk-Jørgensen c, Kelly D. Buck d, Signe O.W. Jensen a, Lars Hansson e, Paul H. Lysaker d,f,n a
Unit for Psychiatric Research, Aalborg University Hospital - Psychiatry, Denmark Research Unit Women's and Children's Health, the Juliane Marie Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark c Department M, Aarhus University Hospital, Risskov, Denmark d Roudebush Veteran Affairs Medical Center, Indianapolis, IN, USA e Department of Health Science, Lund University, Lund, Sweden f Indiana University School of Medicine, Indianapolis, IN, USA b
art ic l e i nf o
a b s t r a c t
Article history: Received 13 August 2014 Received in revised form 2 January 2015 Accepted 12 March 2015 Available online 20 March 2015
Recovery from schizophrenia involves both subjective elements such as self-appraised wellness and objective elements such as symptom remission. Less is known about how they interact. To explore this issue, this study examined the relationship over the course of 1 year of four assessments of symptoms with four assessments of self-reports of subjective aspects of recovery. Participants were 101 outpatients with schizophrenia. Symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS) while subjective recovery was assessed with the Recovery Assessment Scale (RAS). Separate Pearson's or Spearman's rank's correlation coefficients, calculated at all four measurement points, revealed the total symptom score was linked with lower levels of overall self-recovery at all four measurement points. The PANSS emotional discomfort subscale was linked with self-reported recovery at all four measurement points. RAS subscales linked to PANSS total symptoms at every time point were Personal confidence and hope, Goal and success orientation, and No domination by symptoms. Results are consistent with conceptualizations of recovery as a complex process and suggest that while there may be identifiably different domains, changes in subjective and objective domains may influence one another. Published by Elsevier Ireland Ltd.
Keywords: Recovery Schizophrenia Psychosis Symptoms Depression Outcome
1. Introduction It has been increasingly recognized that many individuals with schizophrenia move towards and attain wellness or recovery. While recovery has become the focus of international treatment imperatives, it is still an evolving concept that lacks a firm definition Liberman and Kopelowicz, 2005; Roe et al., 2007; Ng et al., 2008). Researchers have suggested that recovery might be parsed into different domains. Resnick et al. (2004) and Silverstein and Bellack (2008), have proposed that recovery may involve objective phenomena, including the absence or remission of symptoms and psychosocial deficits and subjective phenomena, which involve changes in how persons feel about themselves. While research suggests that individuals with schizophrenia value subjective and objective domains of recovery (Kuhnigk et al., 2012), research concerning the relationship of objective
n Corresponding author at: Roudebush Veteran Affairs Medical Center, 1481 West 10th Street, Indianapolis, IN 46202, USA. E-mail address: [email protected] (P.H. Lysaker).
http://dx.doi.org/10.1016/j.psychres.2015.03.013 0165-1781/Published by Elsevier Ireland Ltd.
and subjective domains of recovery has been equivocal. Liberman and Kopelowicz (2005) consider them as complementary, though as noted by Silverstein and Bellack (2008), this remains unproven. Resnick et al. (2004) initially investigated correlations of subjective recovery in individuals with schizophrenia and found that severity of symptoms was negatively correlated with recovery orientation defined as satisfaction with life, hope, knowledge and empowerment. A negative relationship between symptoms and self-perceived recovery was also observed by Corrigan et al. (2004). Roe et al. (2011) have found no direct correlation between symptom severity and selfreported recovery, while recently Norman et al. (2012) found both negative and positive symptoms to be negatively correlated with subjective recovery in first episode psychosis. More recently Kukla et al. (2014) have suggested that while the subjective reports of recovery is not related to symptoms, it may moderate the link between symptoms and social function. To date, one potential cause of these inconsistencies is the cross sectional nature of this work. Given the inconsistencies in findings we decided to use an exploratory approach to examine the relationship between
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self-perceived recovery and one element of objective recovery, namely symptom severity, and changes across four measurements over 12 months. In addition to exploring the longitudinal relationships between the subjective and objective aspects of recovery, we also investigated what kinds of self-experience of recovery are related to what kinds of symptoms over time to provide knowledge and insight into their dynamics, which might be useful when developing interventions to promote recovery. Understanding the relationship between subjective and objective aspects of recovery could have important implications for both understanding the complex processes involved in achieving wellness in schizophrenia as well as designing new treatments.
2. Methods 2.1. Participants Participants were 101 adults enrolled in a trial of Guided Self-Determination (Zoffmann and Kirkevold, 2011; Jørgensen et al., 2012, 2014) recruited from 6 different outpatient clinics in Denmark. Inclusion criteria included participation in intensive outpatient treatment and participants' hospital records meeting the criteria for schizophrenia ICD-10 F. 20.0-9 or schizoaffective disorder F. 25.0-9, age 18–7018–707018–70 years, ability to understand, speak, and write Danish, no intellectual handicap, and no evidence of dementia or organic brain disease. Forty seven were male (47%) and 54 female (53%). Their ages ranged from 20 to 69 years, (mean¼ 37.5, SD ¼12.6). The mean age at the time of their first psychiatric hospitalization was 25.5 years (SD ¼ 8.1) ranging from 14 to 50 years; the mean age at the time of diagnosis was 27.7 years (SD ¼ 8.4) ranging from 16 to 58 years; and the mean number of hospitalizations was 8.5 (SD ¼10.8) that ranged from 1 to 50. Ten participants had never been hospitalized before because of other treatment modalities offered instead of hospitalization. Ninety-three (92%) were diagnosed with an ICD-10 schizophrenia and eight (8%) with schizoaffective disorder. Seventynine (78%) participants were on stable doses of antipsychotic medication for at least 3 months before taking part in the study, and 22 (22%) had changed their antipsychotic medication within the last 3 months.
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control groups (Jørgensen et al., 2015). All participants completed a demographic data sheet, which included data about medication and course of illness, a selfrating questionnaire (RAS), and an symptom interview (PANSS) at baseline, and after 3, 6 and 12 months. Data were collected from February 2008 until July 2012. The first author collected the data. In every case the RAS was administered prior to the PANSS interview. 2.4. Statistical methods The data were analyzed using Stata 11 (StataCorp LP, College Station, TX). Initially, multiple imputation on missing RAS and PANSS measures was performed using group, time, sex, age, level of education, type of benefit, recruitment team, and switch in medicine as explanatory variables. Twenty imputations were estimated for each missing value. The distributions of all measures were inspected using Q–Q plots to determine whether they approximated normal distributions. Analyses were performed in five steps. First missing scores were imputed and groups with and without full data set were compared. Changes in all PANSS and RAS variables were assessed with a repeated measures analysis using mixed models. Second, the PANSS total and RAS scores were correlated with each other at baseline, 3, 6 and 12 months follow-up. Given the significant risk of spurious findings as a result of such large correlation matrix we began by correlating only the RAS and PANSS total scores. We planned then to only examine the relationships of the subscales with each other only for those time points in which the totals were significantly related to one another in our second step. Pearson's correlation coefficient was calculated between variables which approximated normal distributions, while the non-parametric equivalent Spearman's rank correlation was used when one of the variables was not normally distributed. In the fourth step, we planned to conduct stepwise multiple regressions in cases in which multiple PANSS symptom components predicted the RAS total score. Fifth, linear mixed effects models were estimated to evaluate if time, sex, age at baseline, age at diagnosis and number of admissions moderated the relationship between objective and subjective recovery. We defined the PANSS score as the outcome variable and included RAS, time, sex, age at baseline, age at diagnosis and number of admissions at baseline as fixed factors, while each individual patient was entered as a random effect. The analyses were carried out for three different samples; total sample, control group only, and intervention group only. In the analysis of the total sample we furthermore adjusted for the group variable and time-by-group interaction. Significance level was set at p o 0.05 and all tests were two-tailed.
2.2. Measures
3. Results 2.2.1. Recovery Assessment Scale (RAS) The Recovery Assessment Scale (RAS; Corrigan et al., 1999; 2004) is a selfreport instrument that assesses self-perception of recovery from severe mental illness. The scale consists of 41 items, which are rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). This study used the total scores and the five subscales: Personal confidence and hope (nine items), Willingness to ask for help (three items), Goal and success orientation (five items), Reliance on others (four items), and No domination by symptoms (three items). 2.2.2. The Positive and Negative Syndrome Scale (PANSS) The PANSS (Kay et al., 1987) is a semi-structured interview composed of 30 items measuring symptom severity of patients diagnosed with schizophrenia during the previous seven days. The symptoms are rated on a seven-point Likert scale, ranging from one (absent) to seven (extreme) on each item, with higher scores indicating higher levels of psychopathology. This study used the five PANSS factor analytically derived components: Positive, Negative, Cognitive, Excitement and Emotional discomfort (Bell et al., 1994) and the total score instead of the rational scoring system which contained three scales. 2.3. Procedures Following approval by the Danish Data Protection Agency and the Danish National Committee on Biomedical Research Ethics and then informed consent, 50 participants were randomly assigned to the intervention group and 51 to a control group. The control group was offered treatment as usual consisting of medication, cognitive behavioral therapy, cognitive milieu therapy, psychoeducation, and social skills training. The intervention group by contrast was offered 10 sessions of individual training with the Guided Self-Determination (GSD) method modified for people diagnosed with schizophrenia and treatment as usual. The GSD method is a shared decision-making and mutual problem-solving method and have been described elsewhere (Jørgensen et al., 2012; Jørgensen et al.,2015). Previous analyses revealed no group differences on the RAS between the intervention and control groups at any of the four time points, or on any of the PANSS scores at baseline, 3 months and 6 months. A significant group difference on PANSS and the subscales Negative, Cognitive, Emotional discomfort and Excitement were found at 12-month follow-up with the intervention having lower symptoms than the
3.1. Mean scores and change over time The overall drop-out rate for the sample was 8% with the following sample sizes for each time point: 101; 94; 94 and 93. Comparisons of PANSS and RAS scores for participants with and without full data set revealed no significant between group differences. Mean scores for the RAS and PANSS at all three time points are presented in Table 1. This table reveals considerable variability in symptom severity with the average subject experiencing moderate to moderately severe levels of symptoms. Repeated Measures using Mixed Effects are presented in Table 2. These analyses revealed that all scales, except the PANSS Excitement component and the RAS Reliance on others, improved significantly over the four assessment points. 3.2. Relationship between total scores for subjective personal recovery and objective clinical recovery at baseline, 3, 6, and 12 months Correlations between RAS and PANSS scores are reported in Table 3 and are graphically displayed in Fig. 1. These analyses revealed that higher levels of overall PANSS scores were significantly related to overall lower levels of self-reported recovery at all four time points. 3.3. Relationship between subscales for subjective personal recovery and objective clinical recovery at baseline, 3, 6, and 12 months. As revealed in Table 3, the PANSS Emotional Discomfort Component was the only PANSS component significantly related
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Table 1 Mean component scores on the Recovery Assessment Scale and the Positive and Negative Syndrome Scale at all four time points. Measure
Mean (t¼ 0)
S.D.(t ¼ 0)
Mean (t1¼ 1)
S.D. (t¼ 1)
Mean (t¼ 2)
S.D. (t¼ 2)
Mean (t¼ 3)
S.D. (t¼ 3)
RAS Total Personal confidence and hope Willingness to ask for help Goal and success orientation Reliance on others No domination by symptoms PANSS Total Negative Positive Cognitive Emotional discomfort Excitement
146.77 24.50 9.69 18.66 14.77 9.75 66.11 19.17 13.82 13.86 11.84 4.85
19.94 4.25 2.39 3.56 2.61 2.41 10.43 4.11 4.41 4.10 3.50 1.61
149.03 24.93 10.04 18.65 15.02 9.95 63.93 18.52 13.81 13.03 11.33 5.03
20.27 4.14 2.30 3.27 2.61 2.28 10.48 3.97 4.46 4.18 3.45 2.02
151.45 25.20 10.00 18.93 15.26 10.45 59.64 17.33 12.78 11.76 10.87 4.83
20.95 4.79 2.04 3.11 2.49 2.30 9.81 4.08 3.95 4.03 3.27 1.76
153.59 25.88 10.17 19.46 15.06 10.51 57.34 17.21 12.10 11.14 9.94 4.65
20.77 4.27 2.17 3.31 2.43 2.20 10.54 4.55 4.38 3.79 3.13 1.35
Table 2 Repeated measure analysis using mixed effects on the Recovery Assessment Scale and the Positive and Negative Syndrome Scale. Measure
Within group change
CI (95%)
p-Value
ICC
RAS Total Personal confidence and hope Willingness to ask for help Goal and success orientation Reliance on others No domination by symptoms PANSS Total Negative Positive Cognitive Emotional discomfort Excitement
0.56 0.11 0.03 0.07 0.02 0.07 0.75 0.17 0.16 0.23 0.16 0.02
0.34–0.79 0.05–0.17 0.00–0.06 0.03–0.11 0.01–0.06 0.04–0.09 0.90 0.60 0.23 0.11 0.22 0.10 0.29 0.17 0.21 0.11 0.05–0.00
0.0000 0.0001 0.0273 0.0006 0.2091 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0825
0.74 0.63 0.61 0.68 0.61 0.66 0.55 0.57 0.60 0.60 0.56 0.54
to the RAS total at all four time points. The Negative subscale was significantly related to the RAS total at three time points, the Positive subscale was significantly related to the RAS total at two, while Excitement was significantly related to the total at one time point and the Cognitive scale was not significantly related to the RAS total at any time point. Regarding the RAS scores, the Personal confidence and hope, Goal and success orientation and No domination by symptoms scales were related to the PANSS total at all four time points. Reliance on others was significantly related to the PANSS total at two time points. Willingness to ask for help was related to the PANSS total at two time points. In terms of the time points themselves, there was a higher frequency of significant correlations between PANSS and RAS subscales at baseline and 12 months (12 of 25 and 14 of 25, respectively). By contrast, nine of 25 correlations were significant at 3 months and only two of 25 correlations were significant at 6 months. 3.4. Stepwise multiple regression predicting the RAS total from PANSS components. Given that the RAS total was related to multiple symptoms at baseline, 3 and 12 months follow ups, we conducted three stepwise multiple regressions, one for each time point to determine whether the PANSS components each made a contribution in the prediction of overall self-reported subjective recovery. A significant equation was produced for prediction of the baseline RAS total (F(97,3)¼ 17.86; p o0.0001; total r2 ¼0.36) with emotional discomfort (partial r2 ¼0.18 p o0.0001), negative (partial r2 ¼0.11 p o0.0001) and excitement components (partial r2 ¼0.07 p o0.001) all making significant contributions: A significant equation was similarly produced for the 3-month follow-up (F(98,2) ¼ 11.50; p o0.0001; total r2 ¼0.19) with emotional discomfort (partial r2 ¼ 0.15; po 0.0001) and negative symptoms (partial r2 ¼ 0.04;
po 0.02) making significant contributions to the prediction of the RAS total at the 3-month follow-up. Finally the same pattern was observed for the 12-month follow-up. An overall significant predictor model was produced (F(98,2) ¼17.80; p o0.0001; total r2 ¼ 0.27) with emotional discomfort (partial r2 ¼0.18; p o0.0001) and negative symptoms (partial r2 ¼0.08; p o0.001) making significant contributions to the prediction of the RAS total at the 12month follow-up. 3.5. Demographic and clinical variables as moderating variables between subjective and objective recovery Linear mixed effects models examining the overall association between RAS and PANSS scores adjusting for time, sex, age at inclusion, age at diagnosis, and number of admissions are presented in Table 4. These analyses found no evidence that these variables moderated the relationship between the RAS and the PANSS. This was the case for the total sample as well as the control group and intervention group individually. Of note we used a datadriven stepwise approach instead of a priori hierarchical regression given that our exploration of the subscales was an exploratory step following hypothesized associations between the totals. 3.6. Exploratory analyses In an exploratory analysis we correlated the RAS subscales with each other in order to determine the extent to which these scales were independent of one another. This revealed that subscales were significantly related to one another at each time point. At baseline the correlations ranged from 0.35 (Reliance on others and Willingness to ask for help) to 0.68 (Goal orientation and Reliance on others). At the second time point they ranged from 0.37 (Hope and No domination by symptoms) to 0.70 (Willingness to ask for
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Table 3 Correlations between the Recovery Assessment Scale total and subscales and the Positive and Negative Syndrome Scale total and subscales at baseline, 3, 6 and 12 months. Baseline absolute scores (N ¼ 101)
RAS total
Personal confidence and hope
Willingness to ask for help
Goal and success orientation
Reliance on others
No domination by symptoms
PANSS Total Negative Positive Cognitive Emotional discomfort Excitementa
0.440nnn 0.322nn 0.195 0.061 0.423nnn 0.234n
0.393nnn 0.292nn 0.195 0.099 0.373nnn 0.090
0.134 0.074 0.026 0.126 0.374nnn 0.125
0.428nnn 0.343nnn 0.211n 0.209n 0.242n 0.213n
0.305nn 0.363nnn 0.079 0.093 0.138 0.067
0.406nnn 0.161 0.256nn 0.022 0.504nnn 0.286nn
3 months Absolute scores (N¼ 101) PANSS Total Negative Positive Cognitive Emotional discomfort Excitementa
RAS total
Personal confidence and hope 0.337nnn 0.148 0.271nn 0.004 0.380nnn 0.099
Willingness to ask for help 0.285nn 0.205n 0.141 0.016 0.330nnn 0.124
Goal and success orientation 0.313nn 0.192 0.218n 0.096 0.169 0.051
Reliance on others 0.296nn 0.274n 0.185 0.087 0.058 0.005
No domination by symptoms 0.331nnn 0.022 0.310nn 0.013 0.505nnn 0.220n
6 months absolute scores (N¼ 101) PANSS Total Negative Positive Cognitive Emotional discomfort Excitementa
RAS total
Personal confidence and hope 0.237n 0.172 0.071 0.093 0.191 0.138
Willingness to ask for help 0.059 0.021 0.020 0.075 0.030 0.155
Goal and success orientation 0.199n 0.174 0.076 0.026 0.106 0.136
Reliance on others 0.148 0.144 0.094 0.077 0.131 0.059
No domination by symptoms 0.327nnn 0.035 0.343nnn 0.013 0.465nnn 0.107
12 months Absolute scores (N¼ 101) PANSS Total Negative Positive Cognitive Emotional discomfort Excitementa
RAS total
Personal confidence and hope 0.437nnn 0.280nn 0.301nn 0.027 0.400nnn 0.092
Willingness to ask for help 0.339nnn 0.233n 0.239n 0.027 0.249n 0.163
Goal and success orientation 0.456nnn 0.365nnn 0.266nn 0.062 0.304nn 0.127
Reliance on others 0.345nnn 0.207n 0.229n 0.089 0.308nn 0.076
No domination by symptoms 0.410nnn 0.171 0.355nnn 0.076 0.440nnn 0.088
nnn
0.397 0.206n 0.298nn 0.009 0.385nnn 0.128
nn
0.261 0.147 0.162 0.024 0.242n 0.171
0.489nnn 0.328nnn 0.317nn 0.046 0.430nnn 0.127
a
Spearman correlation coefficient calculated due to non normally distributed data. po 0.05. nn p o0.01. nnn p o 0.001. n
3 months 100
80
80
PANSS
PANSS
Baseline 100
60 40
60 40
100
120
140
160
180
200
100
120
RAS
160
180
200
180
200
RAS
6 months
12 months
100
100
80
80
PANSS
PANSS
140
60 40
60 40
100
120
140
160
180
200
RAS
100
120
140
160
RAS
Fig. 1. Scatter-plots of total Recovery Assessment Scale and total Positive and Negative Syndrome Scale at baseline, 3, 6, and 12 months.
help and No domination by symptoms). At the third time point they ranged from 0.46 (Reliance on others and No domination by symptoms) to 0.74 (Goal orientation and Reliance on others). At
the final time point they ranged from 0.53 (Goal orientation and Reliance on others) to 0.70 (Willingness to ask for help and No domination by symptoms).
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Table 4 Regression analysis of Recovery Assessment Scale on Positive and Negative Syndrome Scale. PANSS Total
Total samplec Controls only Intervention only a b c
RAS total
RAS total
Coefa
95% CI
p-Value
Coefb
95% CI
p-Value
0.18 0.21 0.16
0.24; 0.12 0.29; 0.12 0.23; 0.08
o0.001 o0.001 o0.001
0,18 0,20 0,13
0.24; 0.12 0.29; 0.12 0.22; 0.05
o 0.001 o 0.001 0.001
Adjusted for time. Adjusted for time, sex, age at inclusion, age at diagnosis, and number of admissions. Total sample is further adjusted for group variable and time-by-group interaction.
4. Discussion Recovery has been increasingly emphasized as a desired clinical outcome. Debate has continued regarding the ways different forms of recovery are related to one another. To explore this issue this study examined the associations between five domains of selfreported subjective recovery and a clinical index of recovery captured by five domains of symptoms in a longitudinal design. As predicted, we found that objective and subjective reports of recovery were in part related. Specifically, overall self-report of subjective recovery was negatively associated with symptom severity at all four time points. When we looked at individual domains of symptoms and recovery, however, the picture was less consistent. We found that the symptom component related to distressing emotions, such as depression, anxiety and guilt, was the only symptom index linked consistently with overall self-reported recovery. By contrast, multiple forms of subjective recovery were consistently related to overall symptoms. Specifically, lesser abilities to hold onto confidence and hope, to keep focused on a personal goal, and feeling that the participant's life was not dominated by symptoms were related to higher symptom levels. Analyses further revealed that these relationships were all unaffected by sex, age at baseline, age at diagnosis, number of admissions, time group and time-by-group interaction. Given the wide array of correlations among those performed, there are many possible interpretations of the findings, which could direct future research. Most striking for us is the link of emotional discomfort with self-reported recovery. While we are not able to measure causality, we have several hypotheses. For one as in the case of global levels of symptoms and self-reported recovery, it is possible that these variables affect one another, for instance with greater levels of emotional distress persons may naturally lack confidence and hope, lose track of goals, withdraw from others and feel defeated. It is also possible that the profound sense of demoralization that comes with having no sense of hope or purpose in life leads to depression. Results of the stepwise regressions suggest further that the link of emotional discomfort with self-reported recovery cannot be accounted for by negative symptoms as each made unique contributions to the RAS total at three of the four time points. This is consistent with the findingS by Resnick et al. (2004) and Corrigan et al. (2004) as well as another study (Kuhnigk et al., 2012) which observed that patients ranked fewer depressive thoughts and emotion as the number-one treatment goal. It is also consistent with other work suggesting that emotional distress is a major contributor to poor quality of life (Cavelti et al. 2012; Fervaha et al., 2013; Saarni et al.; 2010). Of note, alternative hypotheses cannot be ruled out including that other factors may account for the observed relationships in this study including social and community relationships. Interestingly, outside of depressive symptoms, the relationship of symptom severity with recovery did not appear to be generally stable. Negative symptoms were linked to subjective recovery at three but not one time point while Positive symptoms were linked
to subjective recovery at one but not three time points. Further, at one time point there were almost no significant relationships between the individual subscale scores. This may suggest that relationships of the variables are periodically disturbed by other factors such that at some points personal sense of recovery is not impacted by persons' immediate clinical state (Kukla et al., 2014). It is also consistent with reflections that recovery is a nonlinear process involving progress and decline which may be unrelated to clinical status (Onken et al., 2007). This observed fluctuation might explain the lack of consistent findings in previous studies, which used a single time point (Resnick et al., 2004; Corrigan et al., 2004; Roe et al., 2011). There were some unexpected findings. One study reported that patients ranked improvement of cognitive abilities their third highest treatment goal (Kuhnigk et al., 2012) and yet no relationships were found between cognitive or disorganized symptoms and self-reported recovery. This may suggest that the extent to which persons think in a concrete or disorganized manner has relatively little to do with how they assess their own subjective sense of recovery. Similarly the Excitement component which involves hostility, impulse control and excitability, was virtually unrelated to self-recovery. This may suggest that issues with anger and arousal are also not implicated in how persons feel about their recovery. Both of these negative findings may work against stigmatizing view of schizophrenia, which place disorganization and aggression as the core aspects to be addressed in this condition. Additionally relationships amongst variables appeared notably weaker at one particular time point that is at 6 months. There is no clear explanation for this finding though we speculate it may point to other factors not assessed here which may affect either symptoms or self-reported recovery without affect the other. Recovery is a complex construct that has multiple factors and correlates. The two constructs of recovery presented here are not synonymous, and neither are their domains. The results point in the direction that they can be seen as complementary. As suggested by Resnick et al. (2004) and Mead and Copeland (2000), mental health services ought to integrate both the biomedical model of recovery and the consumer model of recovery rather than placing them in opposition, as they may be found to be mutually reinforcing. There are limitations to this study. While we used the overall relationships of the RAS and PANSS total as permission to examine relationships among the subscales, we nonetheless performed many correlations and the risk of spurious findings was significant. For instance, among the 100 correlations amongst the subscales there were 38 significant at the 0.05 level, within which one would expect five spurious correlations. Effect sizes were furthermore moderate and there was considerable shared variance amongst the RAS subscales. The PANSS and RAS subscales have furthermore not been validated in Danish. We also used only one symptom measure to operationalize objective measure and one to measure subjective recovery. Future research is needed with other objective measures of recovery including role functioning and hospitalization as well as other assessment of subjective recovery including
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personal experiences of sense of self which may not be captured by the RAS. The time intervals in this study were also uneven, though we have no reason to expect that the longer 6 months interval between the third and fourth assessment would create any kind of bias. We additionally estimated age of onset of illness by collecting age of first hospitalization and thus we may have underestimated the onset of illness among participants who did not initially seek hospitalization. Generalizability is also limited by the sample characteristics. It is unknown whether similar relationships apply, for instance, to individuals who are not in treatment or who are acutely ill and receiving inpatient care. As most participants were diagnosed with schizophrenia, we cannot say whether the purported relationships are specific to schizophrenia. Certainly the relationship between objective and subjective recovery is likely to be influenced by culture and thus broad international replication is needed. Given findings linking self-reported recovery and the capacity for recovery (Kukla et al., 2013) future work is needed examining potential moderators and mediators of the relationship of different forms of recovery, such as stigma, trauma history, metacognition and attachment style. Of note, our sample size did permit us to look at whether changes in the RAS and PANSS predicted future changes in those variables. Future work is needed though to explore not only these variables relate to one another concurrently but whether they predict one another in a cross lagged manner. With replication there may be important clinical implications. It may be that addressing both emotional distress and a person's lack of sense of recovery through any of a number of recovery oriented approaches (Lysaker et al., 2010) might have an overall synergistic effect on wellness over time. Contributors Authors R. Jørgensen, P. Munk-Jørgensen and V. Zoffmann designed the study. Author R. Jørgensen managed the literature searches. Authors R. Jørgensen and SOW. Jensen did the statistical analysis. Author R. Jørgensen and PH. Lysaker wrote the first draft of the manuscript. Authors P. Munk-Jørgensen, K.D. Buck, P.H. Lysaker, SOW Jensen, L. Hansson and V. Zoffmann commented on the first manuscript and contributed to the writing of the subsequent manuscript versions. All authors contributed in the finalization of the manuscript and have approved the final version. Conflict of interests The authors have no conflict of interests. Acknowledgments The study was funded by Aalborg Psychiatric Hospital, The Novo Nordisk Foundation, The Health Insurance Foundation, and TrygFonden, but they had no influence on planning the study or preparing the manuscript.
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References Bell, M.D., Lysaker, P.H., Beam-Goulet, J.L., Milstein, R.M., Lindenmayer, J.P., 1994. Five-component model of schizophrenia: assessing the factorial invariance of the Positive and Negative Syndrome Scale. Psychiatry Research 52, 295–303. Cavelti, M., Beck, E.-M., Kvrgic, S., Kossowsky, J., Vauth, R., 2012. The role of subjective illness beliefs and attitude toward recovery within the relationship of insight and depressive symptoms among people with schizophrenia spectrum disorders. Journal of Clinical Psychology 68, 462–476. Corrigan, P.W., Giffort, D., Rashid, F., Leary, M., Okek,e, I., 1999. Recovery as a psychological construct. Community Mental Health Journal 35 (3), 231–239. Corrigan, P.W., Salzer, M., Ralph, R.O., Sangster, Y., Keck, L., 2004. Examining the factor structure of the Recovery Assessment Scale. Schizophrenia Bulletin 30 (4), 1035–1041. Fervaha, G., Aqid, O., Takeuchi, H., Foussias, G., Remington, G., 2013. Clinical determinants of life satisfaction in chronic schizophrenia: data from the CATIE study. Schizophrenia Research 151, 203–208. Jørgensen, R., Hansson, L., Zoffmann, V., 2012. Changes in persistent delusions in schizophrenia using guided self-determination: a single case study. Issues in Mental Health Nursing 33, 293–300. Jørgensen, R., Licht, R.W., Lysaker, P.H., Munk-Jørgensen, P., Buck, K.D., Wallenstein, S.O., Hansson, L., Zoffmann, V., 2015. Effects on cognitive and clinical insight with the use of Guided Self‐Determination in outpatients with schizophrenia: a randomized open trial. European Psychiatry, electronic publication , http://dx. doi.org/10.1016/j.eurpsy.2014.12.007 16 January. Jørgensen, R., Munk-Jørgensen, P., Lysaker, P.H., Buck, K.D., Hansson, L., Zoffmann, V., 2014. Overcoming recruitment barriers revealed high readiness to participate and low dropout rate among people with schizophrenia in a randomized controlled trial testing the effect of a Guided Self‐Determination intervention. BMC Psychiatry 14, 28. Kay, S.R., Fiszbein, A., Opler, L.A., 1987. The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin 13, 261–276. Kuhnigk, O., Slawik, L., Meyer, J., Naber, D., Reimer, J., 2012. Valuation and attainment of treatment goals in schizophrenia, perspectives of patients, relatives, physicians, and payers. Journal of Psychiatric Practice 18 (5), 321–328. Kukla, M., Lysaker, P.H., Salyers, M., 2013. Do persons with schizophrenia who have better metacognitive capacity also have a stronger subjective experience of recovery? Psychiatry Research 209 (3), 381–385. Kukla, M., Lysaker, P.H., Roe, D., 2014. Strong subjective recovery as a protective factor against the effects positive symptoms on quality of life outcomes in schizophrenia. Comprehensive Psychiatry 55 (6), 1363–1368. Liberman, R.P., Kopelowicz, A., 2005. Recovery from schizophrenia: a concept in search of research. Psychiatric Services 56 (6), 735–742. Lysaker, P.H., Roe, D., Buck, K.D., 2010. Recovery and wellness amidst schizophrenia: definitions, evidence, and the implications for clinical practice. Journal of the American Psychiatric Nurses Association 16 (1), 36–42. Mead, S., Copeland, M.E., 2000. What recovery means to us: consumers' perspectives. Community Mental Health Journal 36, 315–328. Ng, R.M., Pearson, V., Lam, M., Law, C.W., Chiu, C.P., Chen, E.Y., 2008. What does recovery from schizophrenia mean? Perceptions of long-term patients. International Journal of Social Psychiatry 54, 118–130. Norman, R.M.G., Windell, D., Lynch, J., Manchanda, R., 2012. Correlates of subjective recovery in an early intervention program for psychoses. Early Intervention in Psychiatry 7, 278–284. Onken, S.J., Craig, C.M., Ridgway, P., Ralph, R.O., Cook, J.A., 2007. An analysis of the definitions and elements of recovery: a review of the literature. Psychiatric Rehabilitation Journal 31 (1), 9–22. Resnick, S.G., Rosenheck, R.A., Lehman, A.F., 2004. An exploratory analysis of correlates of recovery. Psychiatric Services 55 (5), 540–547. Roe, D., Rudnick, A., Gill, K.J., 2007. The concept of “being in recovery”. Psychiatric Rehabilitation Journal 30, 171–173. Roe, D., Mashiach-Eizenberg, M., Lysaker, P.H., 2011. The relation between objective and subjective domains of recovery among persons with schizophrenia-related disorders. Schizophrenia Research 131, 133–138. Saarni, S.I., Viertiö, S., Perälä, J., Koskinen, S., Lönnqvist, J., Suvisaari, J., 2010. Quality of life of people with schizophrenia, bipolar disorder and other psychotic disorders. British Journal of Psychiatry 197 (5), 386–394. Silverstein, S.M., Bellack, A., 2008. A scientific agenda for the concept of recovery as it applies to schizophrenia. Clinical Psychology Review 28, 1108–1124. Zoffmann, V., Kirkevold, M., 2011. Realizing empowerment in difficult diabetes care: a guided self-determination intervention. Qualitative Health Research 22 (1), 103–118.
Contents lists available at ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Relationships over time of subjective and objective elements of recovery in persons with schizophreni Rikke Jørgensen a, Vibeke Zoffmann b, Povl Munk-Jørgensen c, Kelly D. Buck d, Signe O.W. Jensen a, Lars Hansson e, Paul H. Lysaker d,f,n a
Unit for Psychiatric Research, Aalborg University Hospital - Psychiatry, Denmark Research Unit Women's and Children's Health, the Juliane Marie Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark c Department M, Aarhus University Hospital, Risskov, Denmark d Roudebush Veteran Affairs Medical Center, Indianapolis, IN, USA e Department of Health Science, Lund University, Lund, Sweden f Indiana University School of Medicine, Indianapolis, IN, USA b
art ic l e i nf o
a b s t r a c t
Article history: Received 13 August 2014 Received in revised form 2 January 2015 Accepted 12 March 2015 Available online 20 March 2015
Recovery from schizophrenia involves both subjective elements such as self-appraised wellness and objective elements such as symptom remission. Less is known about how they interact. To explore this issue, this study examined the relationship over the course of 1 year of four assessments of symptoms with four assessments of self-reports of subjective aspects of recovery. Participants were 101 outpatients with schizophrenia. Symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS) while subjective recovery was assessed with the Recovery Assessment Scale (RAS). Separate Pearson's or Spearman's rank's correlation coefficients, calculated at all four measurement points, revealed the total symptom score was linked with lower levels of overall self-recovery at all four measurement points. The PANSS emotional discomfort subscale was linked with self-reported recovery at all four measurement points. RAS subscales linked to PANSS total symptoms at every time point were Personal confidence and hope, Goal and success orientation, and No domination by symptoms. Results are consistent with conceptualizations of recovery as a complex process and suggest that while there may be identifiably different domains, changes in subjective and objective domains may influence one another. Published by Elsevier Ireland Ltd.
Keywords: Recovery Schizophrenia Psychosis Symptoms Depression Outcome
1. Introduction It has been increasingly recognized that many individuals with schizophrenia move towards and attain wellness or recovery. While recovery has become the focus of international treatment imperatives, it is still an evolving concept that lacks a firm definition Liberman and Kopelowicz, 2005; Roe et al., 2007; Ng et al., 2008). Researchers have suggested that recovery might be parsed into different domains. Resnick et al. (2004) and Silverstein and Bellack (2008), have proposed that recovery may involve objective phenomena, including the absence or remission of symptoms and psychosocial deficits and subjective phenomena, which involve changes in how persons feel about themselves. While research suggests that individuals with schizophrenia value subjective and objective domains of recovery (Kuhnigk et al., 2012), research concerning the relationship of objective
n Corresponding author at: Roudebush Veteran Affairs Medical Center, 1481 West 10th Street, Indianapolis, IN 46202, USA. E-mail address: [email protected] (P.H. Lysaker).
http://dx.doi.org/10.1016/j.psychres.2015.03.013 0165-1781/Published by Elsevier Ireland Ltd.
and subjective domains of recovery has been equivocal. Liberman and Kopelowicz (2005) consider them as complementary, though as noted by Silverstein and Bellack (2008), this remains unproven. Resnick et al. (2004) initially investigated correlations of subjective recovery in individuals with schizophrenia and found that severity of symptoms was negatively correlated with recovery orientation defined as satisfaction with life, hope, knowledge and empowerment. A negative relationship between symptoms and self-perceived recovery was also observed by Corrigan et al. (2004). Roe et al. (2011) have found no direct correlation between symptom severity and selfreported recovery, while recently Norman et al. (2012) found both negative and positive symptoms to be negatively correlated with subjective recovery in first episode psychosis. More recently Kukla et al. (2014) have suggested that while the subjective reports of recovery is not related to symptoms, it may moderate the link between symptoms and social function. To date, one potential cause of these inconsistencies is the cross sectional nature of this work. Given the inconsistencies in findings we decided to use an exploratory approach to examine the relationship between
R. Jørgensen et al. / Psychiatry Research 228 (2015) 14–19
self-perceived recovery and one element of objective recovery, namely symptom severity, and changes across four measurements over 12 months. In addition to exploring the longitudinal relationships between the subjective and objective aspects of recovery, we also investigated what kinds of self-experience of recovery are related to what kinds of symptoms over time to provide knowledge and insight into their dynamics, which might be useful when developing interventions to promote recovery. Understanding the relationship between subjective and objective aspects of recovery could have important implications for both understanding the complex processes involved in achieving wellness in schizophrenia as well as designing new treatments.
2. Methods 2.1. Participants Participants were 101 adults enrolled in a trial of Guided Self-Determination (Zoffmann and Kirkevold, 2011; Jørgensen et al., 2012, 2014) recruited from 6 different outpatient clinics in Denmark. Inclusion criteria included participation in intensive outpatient treatment and participants' hospital records meeting the criteria for schizophrenia ICD-10 F. 20.0-9 or schizoaffective disorder F. 25.0-9, age 18–7018–707018–70 years, ability to understand, speak, and write Danish, no intellectual handicap, and no evidence of dementia or organic brain disease. Forty seven were male (47%) and 54 female (53%). Their ages ranged from 20 to 69 years, (mean¼ 37.5, SD ¼12.6). The mean age at the time of their first psychiatric hospitalization was 25.5 years (SD ¼ 8.1) ranging from 14 to 50 years; the mean age at the time of diagnosis was 27.7 years (SD ¼ 8.4) ranging from 16 to 58 years; and the mean number of hospitalizations was 8.5 (SD ¼10.8) that ranged from 1 to 50. Ten participants had never been hospitalized before because of other treatment modalities offered instead of hospitalization. Ninety-three (92%) were diagnosed with an ICD-10 schizophrenia and eight (8%) with schizoaffective disorder. Seventynine (78%) participants were on stable doses of antipsychotic medication for at least 3 months before taking part in the study, and 22 (22%) had changed their antipsychotic medication within the last 3 months.
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control groups (Jørgensen et al., 2015). All participants completed a demographic data sheet, which included data about medication and course of illness, a selfrating questionnaire (RAS), and an symptom interview (PANSS) at baseline, and after 3, 6 and 12 months. Data were collected from February 2008 until July 2012. The first author collected the data. In every case the RAS was administered prior to the PANSS interview. 2.4. Statistical methods The data were analyzed using Stata 11 (StataCorp LP, College Station, TX). Initially, multiple imputation on missing RAS and PANSS measures was performed using group, time, sex, age, level of education, type of benefit, recruitment team, and switch in medicine as explanatory variables. Twenty imputations were estimated for each missing value. The distributions of all measures were inspected using Q–Q plots to determine whether they approximated normal distributions. Analyses were performed in five steps. First missing scores were imputed and groups with and without full data set were compared. Changes in all PANSS and RAS variables were assessed with a repeated measures analysis using mixed models. Second, the PANSS total and RAS scores were correlated with each other at baseline, 3, 6 and 12 months follow-up. Given the significant risk of spurious findings as a result of such large correlation matrix we began by correlating only the RAS and PANSS total scores. We planned then to only examine the relationships of the subscales with each other only for those time points in which the totals were significantly related to one another in our second step. Pearson's correlation coefficient was calculated between variables which approximated normal distributions, while the non-parametric equivalent Spearman's rank correlation was used when one of the variables was not normally distributed. In the fourth step, we planned to conduct stepwise multiple regressions in cases in which multiple PANSS symptom components predicted the RAS total score. Fifth, linear mixed effects models were estimated to evaluate if time, sex, age at baseline, age at diagnosis and number of admissions moderated the relationship between objective and subjective recovery. We defined the PANSS score as the outcome variable and included RAS, time, sex, age at baseline, age at diagnosis and number of admissions at baseline as fixed factors, while each individual patient was entered as a random effect. The analyses were carried out for three different samples; total sample, control group only, and intervention group only. In the analysis of the total sample we furthermore adjusted for the group variable and time-by-group interaction. Significance level was set at p o 0.05 and all tests were two-tailed.
2.2. Measures
3. Results 2.2.1. Recovery Assessment Scale (RAS) The Recovery Assessment Scale (RAS; Corrigan et al., 1999; 2004) is a selfreport instrument that assesses self-perception of recovery from severe mental illness. The scale consists of 41 items, which are rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). This study used the total scores and the five subscales: Personal confidence and hope (nine items), Willingness to ask for help (three items), Goal and success orientation (five items), Reliance on others (four items), and No domination by symptoms (three items). 2.2.2. The Positive and Negative Syndrome Scale (PANSS) The PANSS (Kay et al., 1987) is a semi-structured interview composed of 30 items measuring symptom severity of patients diagnosed with schizophrenia during the previous seven days. The symptoms are rated on a seven-point Likert scale, ranging from one (absent) to seven (extreme) on each item, with higher scores indicating higher levels of psychopathology. This study used the five PANSS factor analytically derived components: Positive, Negative, Cognitive, Excitement and Emotional discomfort (Bell et al., 1994) and the total score instead of the rational scoring system which contained three scales. 2.3. Procedures Following approval by the Danish Data Protection Agency and the Danish National Committee on Biomedical Research Ethics and then informed consent, 50 participants were randomly assigned to the intervention group and 51 to a control group. The control group was offered treatment as usual consisting of medication, cognitive behavioral therapy, cognitive milieu therapy, psychoeducation, and social skills training. The intervention group by contrast was offered 10 sessions of individual training with the Guided Self-Determination (GSD) method modified for people diagnosed with schizophrenia and treatment as usual. The GSD method is a shared decision-making and mutual problem-solving method and have been described elsewhere (Jørgensen et al., 2012; Jørgensen et al.,2015). Previous analyses revealed no group differences on the RAS between the intervention and control groups at any of the four time points, or on any of the PANSS scores at baseline, 3 months and 6 months. A significant group difference on PANSS and the subscales Negative, Cognitive, Emotional discomfort and Excitement were found at 12-month follow-up with the intervention having lower symptoms than the
3.1. Mean scores and change over time The overall drop-out rate for the sample was 8% with the following sample sizes for each time point: 101; 94; 94 and 93. Comparisons of PANSS and RAS scores for participants with and without full data set revealed no significant between group differences. Mean scores for the RAS and PANSS at all three time points are presented in Table 1. This table reveals considerable variability in symptom severity with the average subject experiencing moderate to moderately severe levels of symptoms. Repeated Measures using Mixed Effects are presented in Table 2. These analyses revealed that all scales, except the PANSS Excitement component and the RAS Reliance on others, improved significantly over the four assessment points. 3.2. Relationship between total scores for subjective personal recovery and objective clinical recovery at baseline, 3, 6, and 12 months Correlations between RAS and PANSS scores are reported in Table 3 and are graphically displayed in Fig. 1. These analyses revealed that higher levels of overall PANSS scores were significantly related to overall lower levels of self-reported recovery at all four time points. 3.3. Relationship between subscales for subjective personal recovery and objective clinical recovery at baseline, 3, 6, and 12 months. As revealed in Table 3, the PANSS Emotional Discomfort Component was the only PANSS component significantly related
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Table 1 Mean component scores on the Recovery Assessment Scale and the Positive and Negative Syndrome Scale at all four time points. Measure
Mean (t¼ 0)
S.D.(t ¼ 0)
Mean (t1¼ 1)
S.D. (t¼ 1)
Mean (t¼ 2)
S.D. (t¼ 2)
Mean (t¼ 3)
S.D. (t¼ 3)
RAS Total Personal confidence and hope Willingness to ask for help Goal and success orientation Reliance on others No domination by symptoms PANSS Total Negative Positive Cognitive Emotional discomfort Excitement
146.77 24.50 9.69 18.66 14.77 9.75 66.11 19.17 13.82 13.86 11.84 4.85
19.94 4.25 2.39 3.56 2.61 2.41 10.43 4.11 4.41 4.10 3.50 1.61
149.03 24.93 10.04 18.65 15.02 9.95 63.93 18.52 13.81 13.03 11.33 5.03
20.27 4.14 2.30 3.27 2.61 2.28 10.48 3.97 4.46 4.18 3.45 2.02
151.45 25.20 10.00 18.93 15.26 10.45 59.64 17.33 12.78 11.76 10.87 4.83
20.95 4.79 2.04 3.11 2.49 2.30 9.81 4.08 3.95 4.03 3.27 1.76
153.59 25.88 10.17 19.46 15.06 10.51 57.34 17.21 12.10 11.14 9.94 4.65
20.77 4.27 2.17 3.31 2.43 2.20 10.54 4.55 4.38 3.79 3.13 1.35
Table 2 Repeated measure analysis using mixed effects on the Recovery Assessment Scale and the Positive and Negative Syndrome Scale. Measure
Within group change
CI (95%)
p-Value
ICC
RAS Total Personal confidence and hope Willingness to ask for help Goal and success orientation Reliance on others No domination by symptoms PANSS Total Negative Positive Cognitive Emotional discomfort Excitement
0.56 0.11 0.03 0.07 0.02 0.07 0.75 0.17 0.16 0.23 0.16 0.02
0.34–0.79 0.05–0.17 0.00–0.06 0.03–0.11 0.01–0.06 0.04–0.09 0.90 0.60 0.23 0.11 0.22 0.10 0.29 0.17 0.21 0.11 0.05–0.00
0.0000 0.0001 0.0273 0.0006 0.2091 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0825
0.74 0.63 0.61 0.68 0.61 0.66 0.55 0.57 0.60 0.60 0.56 0.54
to the RAS total at all four time points. The Negative subscale was significantly related to the RAS total at three time points, the Positive subscale was significantly related to the RAS total at two, while Excitement was significantly related to the total at one time point and the Cognitive scale was not significantly related to the RAS total at any time point. Regarding the RAS scores, the Personal confidence and hope, Goal and success orientation and No domination by symptoms scales were related to the PANSS total at all four time points. Reliance on others was significantly related to the PANSS total at two time points. Willingness to ask for help was related to the PANSS total at two time points. In terms of the time points themselves, there was a higher frequency of significant correlations between PANSS and RAS subscales at baseline and 12 months (12 of 25 and 14 of 25, respectively). By contrast, nine of 25 correlations were significant at 3 months and only two of 25 correlations were significant at 6 months. 3.4. Stepwise multiple regression predicting the RAS total from PANSS components. Given that the RAS total was related to multiple symptoms at baseline, 3 and 12 months follow ups, we conducted three stepwise multiple regressions, one for each time point to determine whether the PANSS components each made a contribution in the prediction of overall self-reported subjective recovery. A significant equation was produced for prediction of the baseline RAS total (F(97,3)¼ 17.86; p o0.0001; total r2 ¼0.36) with emotional discomfort (partial r2 ¼0.18 p o0.0001), negative (partial r2 ¼0.11 p o0.0001) and excitement components (partial r2 ¼0.07 p o0.001) all making significant contributions: A significant equation was similarly produced for the 3-month follow-up (F(98,2) ¼ 11.50; p o0.0001; total r2 ¼0.19) with emotional discomfort (partial r2 ¼ 0.15; po 0.0001) and negative symptoms (partial r2 ¼ 0.04;
po 0.02) making significant contributions to the prediction of the RAS total at the 3-month follow-up. Finally the same pattern was observed for the 12-month follow-up. An overall significant predictor model was produced (F(98,2) ¼17.80; p o0.0001; total r2 ¼ 0.27) with emotional discomfort (partial r2 ¼0.18; p o0.0001) and negative symptoms (partial r2 ¼0.08; p o0.001) making significant contributions to the prediction of the RAS total at the 12month follow-up. 3.5. Demographic and clinical variables as moderating variables between subjective and objective recovery Linear mixed effects models examining the overall association between RAS and PANSS scores adjusting for time, sex, age at inclusion, age at diagnosis, and number of admissions are presented in Table 4. These analyses found no evidence that these variables moderated the relationship between the RAS and the PANSS. This was the case for the total sample as well as the control group and intervention group individually. Of note we used a datadriven stepwise approach instead of a priori hierarchical regression given that our exploration of the subscales was an exploratory step following hypothesized associations between the totals. 3.6. Exploratory analyses In an exploratory analysis we correlated the RAS subscales with each other in order to determine the extent to which these scales were independent of one another. This revealed that subscales were significantly related to one another at each time point. At baseline the correlations ranged from 0.35 (Reliance on others and Willingness to ask for help) to 0.68 (Goal orientation and Reliance on others). At the second time point they ranged from 0.37 (Hope and No domination by symptoms) to 0.70 (Willingness to ask for
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Table 3 Correlations between the Recovery Assessment Scale total and subscales and the Positive and Negative Syndrome Scale total and subscales at baseline, 3, 6 and 12 months. Baseline absolute scores (N ¼ 101)
RAS total
Personal confidence and hope
Willingness to ask for help
Goal and success orientation
Reliance on others
No domination by symptoms
PANSS Total Negative Positive Cognitive Emotional discomfort Excitementa
0.440nnn 0.322nn 0.195 0.061 0.423nnn 0.234n
0.393nnn 0.292nn 0.195 0.099 0.373nnn 0.090
0.134 0.074 0.026 0.126 0.374nnn 0.125
0.428nnn 0.343nnn 0.211n 0.209n 0.242n 0.213n
0.305nn 0.363nnn 0.079 0.093 0.138 0.067
0.406nnn 0.161 0.256nn 0.022 0.504nnn 0.286nn
3 months Absolute scores (N¼ 101) PANSS Total Negative Positive Cognitive Emotional discomfort Excitementa
RAS total
Personal confidence and hope 0.337nnn 0.148 0.271nn 0.004 0.380nnn 0.099
Willingness to ask for help 0.285nn 0.205n 0.141 0.016 0.330nnn 0.124
Goal and success orientation 0.313nn 0.192 0.218n 0.096 0.169 0.051
Reliance on others 0.296nn 0.274n 0.185 0.087 0.058 0.005
No domination by symptoms 0.331nnn 0.022 0.310nn 0.013 0.505nnn 0.220n
6 months absolute scores (N¼ 101) PANSS Total Negative Positive Cognitive Emotional discomfort Excitementa
RAS total
Personal confidence and hope 0.237n 0.172 0.071 0.093 0.191 0.138
Willingness to ask for help 0.059 0.021 0.020 0.075 0.030 0.155
Goal and success orientation 0.199n 0.174 0.076 0.026 0.106 0.136
Reliance on others 0.148 0.144 0.094 0.077 0.131 0.059
No domination by symptoms 0.327nnn 0.035 0.343nnn 0.013 0.465nnn 0.107
12 months Absolute scores (N¼ 101) PANSS Total Negative Positive Cognitive Emotional discomfort Excitementa
RAS total
Personal confidence and hope 0.437nnn 0.280nn 0.301nn 0.027 0.400nnn 0.092
Willingness to ask for help 0.339nnn 0.233n 0.239n 0.027 0.249n 0.163
Goal and success orientation 0.456nnn 0.365nnn 0.266nn 0.062 0.304nn 0.127
Reliance on others 0.345nnn 0.207n 0.229n 0.089 0.308nn 0.076
No domination by symptoms 0.410nnn 0.171 0.355nnn 0.076 0.440nnn 0.088
nnn
0.397 0.206n 0.298nn 0.009 0.385nnn 0.128
nn
0.261 0.147 0.162 0.024 0.242n 0.171
0.489nnn 0.328nnn 0.317nn 0.046 0.430nnn 0.127
a
Spearman correlation coefficient calculated due to non normally distributed data. po 0.05. nn p o0.01. nnn p o 0.001. n
3 months 100
80
80
PANSS
PANSS
Baseline 100
60 40
60 40
100
120
140
160
180
200
100
120
RAS
160
180
200
180
200
RAS
6 months
12 months
100
100
80
80
PANSS
PANSS
140
60 40
60 40
100
120
140
160
180
200
RAS
100
120
140
160
RAS
Fig. 1. Scatter-plots of total Recovery Assessment Scale and total Positive and Negative Syndrome Scale at baseline, 3, 6, and 12 months.
help and No domination by symptoms). At the third time point they ranged from 0.46 (Reliance on others and No domination by symptoms) to 0.74 (Goal orientation and Reliance on others). At
the final time point they ranged from 0.53 (Goal orientation and Reliance on others) to 0.70 (Willingness to ask for help and No domination by symptoms).
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R. Jørgensen et al. / Psychiatry Research 228 (2015) 14–19
Table 4 Regression analysis of Recovery Assessment Scale on Positive and Negative Syndrome Scale. PANSS Total
Total samplec Controls only Intervention only a b c
RAS total
RAS total
Coefa
95% CI
p-Value
Coefb
95% CI
p-Value
0.18 0.21 0.16
0.24; 0.12 0.29; 0.12 0.23; 0.08
o0.001 o0.001 o0.001
0,18 0,20 0,13
0.24; 0.12 0.29; 0.12 0.22; 0.05
o 0.001 o 0.001 0.001
Adjusted for time. Adjusted for time, sex, age at inclusion, age at diagnosis, and number of admissions. Total sample is further adjusted for group variable and time-by-group interaction.
4. Discussion Recovery has been increasingly emphasized as a desired clinical outcome. Debate has continued regarding the ways different forms of recovery are related to one another. To explore this issue this study examined the associations between five domains of selfreported subjective recovery and a clinical index of recovery captured by five domains of symptoms in a longitudinal design. As predicted, we found that objective and subjective reports of recovery were in part related. Specifically, overall self-report of subjective recovery was negatively associated with symptom severity at all four time points. When we looked at individual domains of symptoms and recovery, however, the picture was less consistent. We found that the symptom component related to distressing emotions, such as depression, anxiety and guilt, was the only symptom index linked consistently with overall self-reported recovery. By contrast, multiple forms of subjective recovery were consistently related to overall symptoms. Specifically, lesser abilities to hold onto confidence and hope, to keep focused on a personal goal, and feeling that the participant's life was not dominated by symptoms were related to higher symptom levels. Analyses further revealed that these relationships were all unaffected by sex, age at baseline, age at diagnosis, number of admissions, time group and time-by-group interaction. Given the wide array of correlations among those performed, there are many possible interpretations of the findings, which could direct future research. Most striking for us is the link of emotional discomfort with self-reported recovery. While we are not able to measure causality, we have several hypotheses. For one as in the case of global levels of symptoms and self-reported recovery, it is possible that these variables affect one another, for instance with greater levels of emotional distress persons may naturally lack confidence and hope, lose track of goals, withdraw from others and feel defeated. It is also possible that the profound sense of demoralization that comes with having no sense of hope or purpose in life leads to depression. Results of the stepwise regressions suggest further that the link of emotional discomfort with self-reported recovery cannot be accounted for by negative symptoms as each made unique contributions to the RAS total at three of the four time points. This is consistent with the findingS by Resnick et al. (2004) and Corrigan et al. (2004) as well as another study (Kuhnigk et al., 2012) which observed that patients ranked fewer depressive thoughts and emotion as the number-one treatment goal. It is also consistent with other work suggesting that emotional distress is a major contributor to poor quality of life (Cavelti et al. 2012; Fervaha et al., 2013; Saarni et al.; 2010). Of note, alternative hypotheses cannot be ruled out including that other factors may account for the observed relationships in this study including social and community relationships. Interestingly, outside of depressive symptoms, the relationship of symptom severity with recovery did not appear to be generally stable. Negative symptoms were linked to subjective recovery at three but not one time point while Positive symptoms were linked
to subjective recovery at one but not three time points. Further, at one time point there were almost no significant relationships between the individual subscale scores. This may suggest that relationships of the variables are periodically disturbed by other factors such that at some points personal sense of recovery is not impacted by persons' immediate clinical state (Kukla et al., 2014). It is also consistent with reflections that recovery is a nonlinear process involving progress and decline which may be unrelated to clinical status (Onken et al., 2007). This observed fluctuation might explain the lack of consistent findings in previous studies, which used a single time point (Resnick et al., 2004; Corrigan et al., 2004; Roe et al., 2011). There were some unexpected findings. One study reported that patients ranked improvement of cognitive abilities their third highest treatment goal (Kuhnigk et al., 2012) and yet no relationships were found between cognitive or disorganized symptoms and self-reported recovery. This may suggest that the extent to which persons think in a concrete or disorganized manner has relatively little to do with how they assess their own subjective sense of recovery. Similarly the Excitement component which involves hostility, impulse control and excitability, was virtually unrelated to self-recovery. This may suggest that issues with anger and arousal are also not implicated in how persons feel about their recovery. Both of these negative findings may work against stigmatizing view of schizophrenia, which place disorganization and aggression as the core aspects to be addressed in this condition. Additionally relationships amongst variables appeared notably weaker at one particular time point that is at 6 months. There is no clear explanation for this finding though we speculate it may point to other factors not assessed here which may affect either symptoms or self-reported recovery without affect the other. Recovery is a complex construct that has multiple factors and correlates. The two constructs of recovery presented here are not synonymous, and neither are their domains. The results point in the direction that they can be seen as complementary. As suggested by Resnick et al. (2004) and Mead and Copeland (2000), mental health services ought to integrate both the biomedical model of recovery and the consumer model of recovery rather than placing them in opposition, as they may be found to be mutually reinforcing. There are limitations to this study. While we used the overall relationships of the RAS and PANSS total as permission to examine relationships among the subscales, we nonetheless performed many correlations and the risk of spurious findings was significant. For instance, among the 100 correlations amongst the subscales there were 38 significant at the 0.05 level, within which one would expect five spurious correlations. Effect sizes were furthermore moderate and there was considerable shared variance amongst the RAS subscales. The PANSS and RAS subscales have furthermore not been validated in Danish. We also used only one symptom measure to operationalize objective measure and one to measure subjective recovery. Future research is needed with other objective measures of recovery including role functioning and hospitalization as well as other assessment of subjective recovery including
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personal experiences of sense of self which may not be captured by the RAS. The time intervals in this study were also uneven, though we have no reason to expect that the longer 6 months interval between the third and fourth assessment would create any kind of bias. We additionally estimated age of onset of illness by collecting age of first hospitalization and thus we may have underestimated the onset of illness among participants who did not initially seek hospitalization. Generalizability is also limited by the sample characteristics. It is unknown whether similar relationships apply, for instance, to individuals who are not in treatment or who are acutely ill and receiving inpatient care. As most participants were diagnosed with schizophrenia, we cannot say whether the purported relationships are specific to schizophrenia. Certainly the relationship between objective and subjective recovery is likely to be influenced by culture and thus broad international replication is needed. Given findings linking self-reported recovery and the capacity for recovery (Kukla et al., 2013) future work is needed examining potential moderators and mediators of the relationship of different forms of recovery, such as stigma, trauma history, metacognition and attachment style. Of note, our sample size did permit us to look at whether changes in the RAS and PANSS predicted future changes in those variables. Future work is needed though to explore not only these variables relate to one another concurrently but whether they predict one another in a cross lagged manner. With replication there may be important clinical implications. It may be that addressing both emotional distress and a person's lack of sense of recovery through any of a number of recovery oriented approaches (Lysaker et al., 2010) might have an overall synergistic effect on wellness over time. Contributors Authors R. Jørgensen, P. Munk-Jørgensen and V. Zoffmann designed the study. Author R. Jørgensen managed the literature searches. Authors R. Jørgensen and SOW. Jensen did the statistical analysis. Author R. Jørgensen and PH. Lysaker wrote the first draft of the manuscript. Authors P. Munk-Jørgensen, K.D. Buck, P.H. Lysaker, SOW Jensen, L. Hansson and V. Zoffmann commented on the first manuscript and contributed to the writing of the subsequent manuscript versions. All authors contributed in the finalization of the manuscript and have approved the final version. Conflict of interests The authors have no conflict of interests. Acknowledgments The study was funded by Aalborg Psychiatric Hospital, The Novo Nordisk Foundation, The Health Insurance Foundation, and TrygFonden, but they had no influence on planning the study or preparing the manuscript.
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