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 Table of Contents  
AWARD PAPER: BB SETHI POSTER AWARD PAPER
Year : 2016  |  Volume : 32  |  Issue : 2  |  Page : 92-103

Recovery among patients with severe mental illness: Factor analysis of recovery assessment scale in Indian setting


Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication25-Apr-2016

Correspondence Address:
Dr. Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9962.181088

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  Abstract 

Aim: This study aimed to evaluate recovery among patients with severe mental disorders by using Recovery Assessment Scale (RAS). Additionally this study evaluated the, factor structure of RAS in the Indian setting, and assessed the correlates of recovery in severe mental illness. Methodology: Two hundred and eighty-five patients with severe mental illness (bipolar disorder-185 [BD], schizophrenia-100) currently in remission were recruited for the study. Clinical rating scales - Young Mania Rating Scale, Hamilton Depression Rating Scale, and Positive and Negative Syndrome Scale for Schizophrenia were used for assessing remission and residual symptoms. RAS was administered for recovery assessment. Results: Majority of the patients were married males belonging to urban background with no significant difference in sociodemographic profile of schizophrenia and BD groups. On factor analysis of RAS, all 41 items had loaded on one of the factors (compared to 24 items on the old factor structure). Five-factor were obtained with two factors - personal confidence and hope, goal and success orientation being similar to the old factor structure and three new factors being identified as awareness and control over the illness, seeking and relying on social support and, defeated/overcome the illness. Overall recovery measures were higher in BD group, and higher levels of residual depressive symptoms were associated with significantly lower level of recovery in BD. In the schizophrenia group, level of positive symptoms correlated negatively with goal and success orientation (as per the current analysis) and higher level of negative symptoms correlated positively with the domain of “reliance on others” as per the old factor structure. Conclusion: RAS follows a five-factor structure in Indian context, which is different than that reported in the previous study. There are few sociodemographic and clinical correlates of recovery.

Keywords: Bipolar disorder, recovery, Recovery Assessment Scale, schizophrenia, severe mental illness


How to cite this article:
Grover S, Hazari N, Singla N, Chakrabarti S, Aneja J, Sharma S, Avasthi A. Recovery among patients with severe mental illness: Factor analysis of recovery assessment scale in Indian setting. Indian J Soc Psychiatry 2016;32:92-103

How to cite this URL:
Grover S, Hazari N, Singla N, Chakrabarti S, Aneja J, Sharma S, Avasthi A. Recovery among patients with severe mental illness: Factor analysis of recovery assessment scale in Indian setting. Indian J Soc Psychiatry [serial online] 2016 [cited 2019 Aug 24];32:92-103. Available from: http://www.indjsp.org/text.asp?2016/32/2/92/181088


  Introduction Top


Historically, poor outcome has often been considered as an integral part of the concept of schizophrenia. However, over the years, research has shown that all patients with schizophrenia do not have deteriorating course.[1],[2],[3],[4] A meta-analysis of 320 studies conducted across different countries showed that about 40% of patients with schizophrenia are considered to be improved after an average follow-up duration of 5–6 years.[3] Besides symptom remission, many other outcomes have been discussed in the literature such as level of occupational functioning, level of social functioning, level of disability, and quality of life. However, evaluation of all these outcomes does not take the patient's perspective into account. In recent times, patient led groups from the West have proposed the concept of recovery which takes patient's perspective into account while evaluating the outcome.

Recovery is a socially constructed concept which has gained increasing prominence in the delivery of mental health services to people with severe mental illness over the past 30 years. Historically, the concept of recovery has moved away from a dominant medical model, where mental health professionals promoted “clinical recovery,” which emphasizes reductionist illness deficit paradigms, and narrowly defined recovery as the absence of symptoms. Now, emphasis is placed upon a holistic and personal recovery.[5],[6],[7],[8],[9],[10],[11],[12] This concept has emerged from narrative discourses of recovery provided by people who have lived a satisfactory life despite having a mental illness, like schizophrenia. This is also now known as “personal recovery.”[13] Accordingly, personal/psychological recovery from mental illness involves much more than recovery from the illness itself. People with mental illness may have to recover from the stigma; they have incorporated into their very being, from the iatrogenic effects of treatment settings, from lack of recent opportunities for self-determination, from the negative side effects of unemployment, and from crushed dreams. Hence, recovery is often understood as a complex, time-consuming process.[14]

Qualitative studies based on individuals' narrative accounts highlight a number of common themes which are important in the process of recovery, which include hope; acceptance; redefining self; a sense of identity and movement beyond the illness, living outside of illness; self-esteem; empowerment; social support systems; spirituality; establishment of meaning and purpose in life, including a positive personal and social identity; and overcoming social stigma.[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27]

While the qualitative studies add to the growing evidence, generalization from these studies is limited given small sample sizes. This, therefore, calls into question the external validity of such studies. Accordingly, there is a need to study the concept of recovery by using quantitative studies. It is expected that understanding the concept of recovery and its correlates in larger population can help in generalization of the findings, improving the mental health care, and organizing the services with an aim to promote recovery.

Keeping the need for having quantitative studies involving large numbers of patients, researchers have designed many instruments to assess personal recovery. A recent review of literature revealed that there are at least 22 instruments to assess personal psychological recovery and 11 instruments have been designed to assess recovery orientation of the psychiatric services. The most commonly used and psychometrically tested instruments for assessment of personal recovery include Recovery Assessment Scale (RAS),[28] Illness Management and Recovery Scales,[29] stages of recovery instrument,[30] and recovery process inventory.[31] The RAS was designed to assess various aspects of recovery from the perspective of the consumer, with a particular emphasis on hope and self-determination. The original instrument comprises 41 items. Each item is rated on a 5-point Likert scale, and it can be either self-administered or be administered by a clinician interview.[28],[32] It has been evaluated in adult patients from various ethnic and racial backgrounds, including Asian. However, data have not been analyzed to evaluate as to whether any significant differences exist across different ethnic and racial groups.

Exploratory and confirmatory factor analysis of RAS yielded five-factor models, which included 24 out of the 41 items. These factors were named as personal confidence and hope, willingness to ask for help, goal and success orientation, reliance on others, and no domination of symptoms. The alpha values for these factors varied from 0.74 to 0.87.[25]

Data on personal recovery of patients with severe mental disorders from India are almost nonexistent. One small sample study, involving fifty patients with a diagnosis of schizophrenia reported that each stage of recovery in schizophrenia had significant correlation with the level of functioning. This indicates that there is significant relationship between psychopathological symptoms and the person's ability to pursue the path of recovery.[33] Another study from Chennai studied the consumer perspective of recovery. It involved 100 patients who were asked open-ended questions regarding what they personally considered as indicators of recovery. From the interviews, a total of 31 indicators were generated. The most common theme that was equated with recovery included the absence of symptoms (88% of the respondents) and not having any more relapses (73%). Other common themes included getting back to their regular lives in terms of functioning (70%), being able to handle the associated responsibilities (62%), and not having to take medicines anymore (65%). More women (80%) than men responded this way. About 35% of participants mentioned getting married and having children as indicators of recovery.[34] However, there is a need to evaluate the concept of recovery among patients with severe mental disorders in the Indian context and expand the literature. Accordingly, this study aimed to evaluate recovery among patients with severe mental disorders by using RAS. In addition, the study aimed to analyze the factor structure of RAS in the Indian setting, compare the process of personal recovery among patients with schizophrenia and bipolar disorder (BD) and to evaluate the correlates of recovery.


  Methodology Top


This study was carried out in the psychiatry outpatient setting of a Tertiary Care Hospital. The sample was drawn from two studies done at the same institute. Both the studies were approved by the Ethics Committee of the Institute, and all the patients were recruited after obtaining written informed consent. To be included in the study, the patients were required to fulfil the diagnosis of schizophrenia or BD as per the International Classification of Diseases-10 (ICD-10) criteria, aged between 18 and 65 years and have an illness of at least 1 year. In addition, patients with schizophrenia were required to fulfil the remission criteria,[35] and patients with BD were required to be currently in euthymic state (Young Mania Rating Scale [YMRS] and Hamilton Depression Rating Scale [HDRS] scores of <7).[36],[37] Patients with comorbid intellectual disability, organic brain disease, and chronic physical illnesses were excluded.

Instruments

International Classification of Diseases and Health Related Conditions, 10th Revision (WHO, 1992)

ICD-10 criteria were used to establish the psychiatric diagnosis. This diagnostic system is in widespread use internationally and provides clinical psychiatric diagnosis.[38]

Positive and Negative Syndrome Scale for Schizophrenia

The Positive and Negative Syndrome Scale has 30 items divided into three subscales - positive, negative, and general psychopathology. Each item is rated on a 7-point scale on the basis of a formal semi-structured clinical interview and other informational sources, pertaining to the previous week. Alpha coefficient analyses have indicated high interrater reliability and homogeneity among items, with coefficients ranging from 0.73 to 0.83 (P < 0.001) for each of the subscales.[39] Remission criteria have been proposed by Andreasen in 2006[35] based on the Positive and Negative Syndrome Scale for Schizophrenia (PANSS) with scores of ≤ 3 on items P1, P2, P3, N1, N4, N6, G5, and G9.

Young Mania Rating Scale

It is an 11-item clinician-administered scale designed for assessment of the severity of manic symptoms. Information for assigning scores is gained from the patient's subjective reported symptoms over the previous 48 h and from clinical observation during the interview. Four items are rated from 0 to 8 and the remaining seven items are rated from 0 to 4. Total score shows high interrater correlation of 0.93, and individual item scores have a correlation of 0.66–0.92.[36]

Hamilton Depression Rating Scale

It is a 17-item clinician administered scale for assessment of the severity of depressive symptoms. Eight items are rated from 0 to 4 and nine items are rated from 0 to 2. It has been widely used in clinical and research settings and has high interrater reliability.[37]

Recovery Assessment Scale

It is a 41-item scale with each item rated on a 5-point scale. It can be self-administered or be administered by an individual interview. The interview usually takes 20 min, and the interviewer is required to be able to reliably read and score the items.[25] It has been evaluated in patients with severe mental disorders. Its psychometric properties have been evaluated twice, once in a small sample of 35 participants and then in the as Consumer Operated Service Program Multi-site Research Initiative, which involved 1750 patients from various ethnic and racial background. It has been shown to have high internal consistency (alpha − 0.93) and test-retest reliability (Pearson correlation coefficient − 0.88).[25] RAS total score has been shown to correlate positively with Rosenberg Self-esteem Scale (0.55),[40] Self-orientation Domain of Empowerment Scale (0.71),[41] Short Version of the Social Support Questionnaire (0.48)[42] and subjective component of the quality of life interview (0.62).[43] In terms of psychopathology, RAS total score has been shown to correlate negatively with expanded version of the Brief Psychiatric Rating Scale (−0.44);[44] however, this correlation coefficient did not meet the Bonferroni criterion for significance.[25]

For this study patients with clinical diagnosis of schizophrenia and BD, attending the outpatient services were approached. They were explained about the nature of the study. Consenting patients who agreed to participate and provided informed consent were assessed on the selection criteria. Those meeting the inclusion and exclusion criteria were recruited by purposive sampling. The sociodemographic and the clinical profile sheets were completed from the information provided by the patient, his/her caregiver, and the medical records. Then the patients with schizophrenia were assessed on PANSS, and those with BD were evaluated on HDRS and YMRS. After this, the patients were evaluated on RAS by a clinician.

Data were analyzed by using Statistical Package for the Social Sciences Windows version 14 (SPSS version 14, Chicago, SPSS Inc.). Categorical variables are described by using frequency/percentage. Descriptive analysis was carried out using mean and standard deviation with range for continuous variables. Exploratory factor analysis with varimax rotation was used to study the factor structure of the scale. Associations were studied by using Pearson's correlation coefficient and Spearman rank correlations. Comparisons were done by using t-test, Chi-square test, and Fisher exact test. Significance was set at two-tailed values at 0.05.


  Results Top


The study included 285 patients, of which 100 were diagnosed with schizophrenia and 185 were diagnosed with BD. The sociodemographic and clinical profile of the study sample is shown in [Table 1].
Table 1: Sociodemographic profile of the study sample

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The mean age of the sample was 39.34 (standard deviation [SD] 11.68) years and two-third of the patients were male. Majority of the patients were married, Hindus and from urban background. Slightly more than half of the patients had <10 years of formal education and the mean duration of formal education for the study sample was 10.76 (SD 3.93) years.

When compared with each other, there was no significant difference between schizophrenia and BD group except for the variables of age and marital status, with patients with schizophrenia significantly older than those with BD and higher proportion of BD patients being married.

The mean duration of illness was 130.64 (SD 97) months; mean duration of remission at the time of assessment was 16.99 (SD 26.47) months. Total numbers of lifetime episodes or relapses were 6.11 (SD 6.14) months. When those with schizophrenia and BD were compared, patients with BD had significantly higher number of lifetime episodes/relapses and had a higher number of follow-ups in the last 3 months. The mean HDRS and YMRS scores were 0.30 (SD 0.74) and 0.64 (SD 1.38) for the BD group.

In the schizophrenia group, more than two-third (70%) of the patients were diagnosed with paranoid schizophrenia. The most common subtype in the nonparanoid group was undifferentiated schizophrenia (25%). The mean total PANSS score was 32.7 (SD 3.5; range 28–41). The mean positive symptom subscale score was 7.5 (SD 0.9; range 7–12), and the mean score was 8.7 (SD 1.6; range 7–13) and 16.6 (SD 2.1; range 14–22) for negative and general psychopathology subscales, respectively. In the BD group, mean HDRS score was 0.30 (SD 0.74) and mean YMRS score was 0.64 (1.38).

Factor analysis of Recovery Assessment Scale

Exploratory factor analysis was done. Initially, Kaiser–Meyer–Olkin measure (KMO) of sampling adequacy was determined for the sample to know whether the data could be subjected to factor analysis. The KMO value for the study sample was 0.909, and the Bartlett's test of Sphericity value was 11,024 (df = 820; P < 0.001) suggesting that the data was adequate to carry out factor analysis. Initial factor analysis of the data yielded seven factors with Eigen value of 1 or more and they together explained 72.45% variance of the data. Only variables with loadings of 0.4 or greater were considered to have significant loading. A scree plot was also generated simultaneously to determine the optimal number of factors. On inspection of the factors, it was evident that two factors had only 1 item having loading of 0.4 or more.

It is usually recommended in the literature that only factors with 3 or more variables must be considered. Accordingly, further multiple factor analyses were run to determine the optimal factor structure. Finally, a 5-factor model was accepted. Together, these five-factor explained 66.37% of variance [Table 2] and the five-factors included all the items of the scale.
Table 2: Exploratory factor analysis of Recovery Assessment Scale

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We compared the factor structure of the current factor analysis with that described in earlier factor analysis.[25] In contrast, to the earlier factor analysis, in the current study, the factor structure included all 41 items. In the, previous study only 24 items had significant loading. As shown in [Table 3], in the current analysis, Factor-1 included 10 items and of which 3 items were same as Factor-5 of earlier factor analysis. We labeled this factor as “defeated the illness/overcome the illness,” based on the themes of various items. The Factor-2 of the current analysis included 9-item with 4-item similar to Factor-1 of the previous analysis. Hence, we retained the same name, i.e., ”personal confidence and hope” for this factor. The Factor-3 in the current study also included 10-item, of which 2 items were similar to that of Factor-4 in previous factor analysis in which this factor had only 4 items. However, considering the content of various items, this factor was named as “seeking and relying on social support.” Factor-4 in the current analysis included 6 items, 2 of which were similar to Factor-1 of the previous analysis. Based on the description of various items, this factor was named as “awareness and control over the illness.” Factor-5 in the current analysis included 6 items, of which 4 were similar to the Factor-3 of the previous analysis which had 5 items. Accordingly, we retained the same name, i.e., goal and success orientation for this factor.
Table 3: Comparison of factor structure of current study and previous study by Corrigan et al. (2004)

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Comparison of recovery between schizophrenia and bipolar disorder groups

As shown in [Table 4], patients with schizophrenia and BD were compared for recovery as per the factor structure of Corrigan and Phelan [25] and that obtained in the current study. Before making the comparisons, the mean raw scores obtained for each factor were divided by number of items included in those factors to get weighted mean score. This was done to make the factors comparable. As shown in [Table 5], patients of BD experienced higher level of recovery compared to schizophrenia on three out of five domains as per Corrigan and Phelan [25] and current factor analysis.
Table 4: Correlates of recovery

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Table 5: Recovery among patients with severe mental disorder

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As shown in [Table 5], as per the factor structure of Corrigan and Phelan [25] and current study too, patients with BD had almost equal scores on various domains.

However, in the schizophrenia group, as per the factor structure of Corrigan and Phelan,[25] the mean scores for the domain of “willingness to ask for help” was highest and this was closely followed by the mean score for the domain of “reliance on others,” “goals and success,” “no domination of symptoms” and least for the domain of “personal confidence and hope.” As per the current factor analysis, mean scores were highest for the domain of “seeking and relying on social support,” followed by the domain of “defeated the illness/overcome the illness,” “goal and success orientation,” “personal confidence and hope,” and least for the domain of “awareness and control over the illness.”

Factors associated with recovery

When the relationship of various aspects of recovery was evaluated with sociodemographic and clinical factors, very few correlates emerged. In the whole group, those who belonged to the joint/extended family reported significantly higher recovery in the domain of “awareness and control over the illness” (3.76 [SD 0.58] vs. 3.63 [SD 0.52]; t-test value 2.02; P = 0.044). In the BD group, those who were on paid jobs reported higher level of recovery in the domain of “willingness to ask for help” (3.96 [SD 0.46] vs. 3.80 [SD 0.52]; t-test value 2.08; P = 0.039). In the schizophrenia subgroup, level of education correlated with three out of five domains as per Corrigan and Phelan and two out of five domains in the current study. These correlations were positive, indicating that those who were more educated experienced higher level of recovery. None of the other sociodemographic variables had significant association with various domains in the whole study group, BD subgroup, and schizophrenia subgroup. In terms of clinical variables, higher number of visits to the hospital in 3 months period prior to assessment was associated with higher level of recovery in some of the domains or recovery. These correlations are shown in [Table 4]. There was a negative correlation between age of onset and the domain of “personal confidence and hope” in the schizophrenia sub-group. In the schizophrenia subgroup, higher numbers of relapses were associated with lower scores in the domains of “personal confidence and hope” and “goal and success orientation” as per the Corrigan and Phelan factor structure. In terms of factor structure of the current analysis, higher numbers of relapses were associated with lower scores in the domains of “goal and success orientation.” In the BD group, higher levels of residual depressive symptoms were associated with significantly lower level of recovery in all the domains of recovery. In the schizophrenia, level of positive symptoms correlated negatively with the do the domain of willingness to ask for help (as per Corrigan and Phelan 2004) and goal and success orientation (as per the current analysis). Higher level of negative symptoms correlated positively with the domain of “reliance on others.”


  Discussion Top


This study evaluated the concept of recovery among patients with severe mental disorder. This study included patients of schizophrenia and BDs who were clinically in remission.

The sociodemographic profile of the patients included in this study broadly resembles the profile of patients included in some of the earlier studies from India, which have evaluated patients with schizophrenia and BD in remission phase.[45],[46],[47],[48],[49],[50],[51] The clinical profile of the patients of either disorder included in the present study is also comparable with previous studies from this center and many studies from other parts of the country.[45],[46],[47],[48],[49],[50],[51]

Findings of the present study suggest that various items of RAS can be grouped into 5-factor structure. The 5-factor structure obtained in the present study is similar to some extent to that reported in an earlier factor analysis.[25] However, when one compares the factor structure of the present study with that of the earlier factor structure, certain important differences are noted. First, in the present factor analysis, all the 41 items of the RAS, loaded into various factors. This is in contrast to the previous analysis in which only 24 items loaded onto various factors. This difference in the factor structure possibly reflects certain socio-cultural differences in the study populations included in the present study and the earlier study. The earlier study included multi-ethnic population, with very few of Asian origin and did not report on the ethnic differences. It is quite possible that inclusion of multi-ethnic population actually influenced the factor structure. Accordingly, the factor structure was different and possibly did not include many items evaluating seeking support from other and available social support. In a country like India, where family structure is relatively better preserved, resultantly many people seek and rely on available social support. This was reflective in the factor structure of RAS, in which these items loaded together. Hence, it can be concluded that concept of recovery can have a different meaning for different persons from different ethnic backgrounds.[52]

In terms of recovery, in the present study, patients with BD had almost equal scores on various domains/factors. In contrast, in the schizophrenia group, as per the factor structure of Corrigan and Phelan,[25] the mean scores for the domain of 'willingness to ask for help' was highest and as per the current factor analysis, mean scores were highest for the domain of “seeking and relying on social support.” These findings suggest that overall experience of recovery is slightly different in patients with BD and schizophrenia and for patients with schizophrenia available social support is an important determinant of personal recovery. Accordingly, wherever possible, treating clinicians should make efforts to improve the available social support and for patients who do not seek support, the clinicians should encourage them to seek support from others.[27]

In terms of comparison of schizophrenia and BD groups, it was evident that those with BD have higher scores on some of the domains of RAS and this suggests that patients with BD achieve higher level of personal recovery compared to those with schizophrenia. Besides the other possible causes for the difference between the two groups, these differences could be due to the nature of the disorders.

In terms of correlates, the present study shows that sociodemographic variables do not have much influence on the personal recovery. This is similar to most of the previous studies which have not come up with consistent correlates.[35],[53],[54],[55] There is some evidence to suggest that better personal recovery is seen in those with higher education level.[35] Findings of the present study also support the same.

Among the clinical variables, age of onset has been shown to have inconsistent association with personal recovery in some of the studies. Some studies have shown negative correlation of early onset with later subjective sense of recovery,[56] whereas other studies suggest that age at onset moderates the relationship between symptoms and self-report of being in recovery.[56] In the present study, a negative correlation was seen between age of onset and one of the domains of recovery, i.e., personal confidence and hope. This suggests that higher age of onset is associated with lower personal confidence and hope. This could be possibly due to higher sense of loss when the illness starts at a higher age. In the present study, an important clinical- and service-related correlate was “number of contact with the treating agency in the 3 months prior to assessment,” with those having higher number of contacts in previous 3 months, achieving a higher level of personal recovery. This suggests that frequent clinical contact is very important in promoting personal recovery. Data from available studies also suggest that individuals who accessed and engaged in ongoing mental health services tended to recover from schizophrenia better than those with less accessibility and engagement.[57] The positive association of personal recovery with number of visits could be due to various factors. First, frequent touch with the clinicians possibly gives patients a sense of perceived social support as to someone is available when they need it. In addition, it may give a feeling of being understood by someone. Second, the therapeutic contact, possibly often validates the personal feeling of being well and out of the clutches of the illness. Third, the therapeutic contact possibly helps in dealing with day to day difficulties arising in dealing with various issues in patient's life in terms of education, job, family and marital issues, coping difficulties, side effects of medications. Resultant redressal of the same makes the person feel that they are in control of their life and, as a result, same is reflected in the form of higher perceived personal recovery. Hence, it can be said that clinicians managing patients with severe illnesses, should respect the needs of the patients and should follow an agreed upon schedule for follow-up visits.[58]

In terms of relapse, there were no significant correlations between number of relapses and level of recovery among patients of BD. However, for schizophrenia group, there was significant negative correlation between number of relapses and recovery factors. Two of the factors (i.e., personal confidence and hope and goal and success orientation) of Corrigan and Phelan [25] correlated negatively with total number of relapses, suggesting that prevention of relapse can help in promoting recovery. The factor structure of current study also showed a negative correlation between total number of relapses and goal and success orientation. The negative associations are understandable, considering the fact that any relapse is a devastating experience and is an important setback in the patient's life. Hence, all efforts must be made to ensure that there is no relapse of symptoms in patient's life.

In general, findings among patients of schizophrenia suggest that recovery in the sense of reduction or elimination of symptoms is not synonymous with self-assessment as being in a state of recovery.[54],[56],[59],[60] In the present study too, there were very few correlations between the level of residual psychopathology and personal recovery. Presence of residual positive symptoms is also associated with poorer recovery in the domains of “willingness to ask help” and “goal and success orientation.” These suggest that those with residual positive symptoms possibly avoid meeting people and seeking support and are not able to plan their future. Hence, all efforts must be made to reduce the psychopathology to the minimum possible level.

In the BD group, presence of residual depressive symptoms was consistently associated with poor recovery. Previous studies also support the same,[61],[62],[63] and these associations are understandable considering the distress associated with the presence of residual depressive symptoms.

The present study has certain limitations. The present study was limited to patients who were in clinical remission and were attending outpatient services of a Tertiary Care Hospital. Accordingly, the findings of the present study cannot be generalized to those patients who do not achieve remission or are not experiencing remission. Further, the findings cannot be generalized to those living in community. In the present study, we did not evaluate many psychosocial and clinical factors such as social support, medication compliance, insight, coping, level of disability, level of cognitive dysfunction, knowledge about illness, quality of life, and spirituality. Future studies must attempt to overcome these limitations.


  Conclusion Top


To conclude, the present study shows that various items of RAS follow a five-factor model and the 5-factor structure is different than that reported in the previous study.[25] This suggests that possibly there are certain sociocultural differences in the perception of recovery among patients with severe mental disorders. The present study also suggests that patients with BD experience more personal recovery than those suffering from schizophrenia. These differences could possibly be due to the difference in the nature of the illnesses in terms of age of onset, type of symptoms, level of interepisodic residual symptoms, interepisodic quality of life, functioning, etc.

In terms of correlates, recovery is affected by few sociodemographic variables. In terms of clinical variables, higher level of psychopathology, especially residual depressive symptoms among patients with BD is associated with poor personal recovery.

In general, higher number of follow-ups in the preceding 3 months is associated with better recovery. This suggests that being in touch with the clinicians possibly helps in achieving personal recovery. Accordingly, the clinicians should space the number of visits of the patients in such a way that patients who want to attend the services more frequently should be allowed to do so, and they should be attended adequately. In patients with schizophrenia, higher numbers of relapses had negative association with different aspects of recovery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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1 Recovery and its correlates among patients with bipolar disorder: A study from a tertiary care centre in North India
Sandeep Grover,Nandita Hazari,Jitender Aneja,Subho Chakrabarti,Sunil Sharma,Ajit Avasthi
International Journal of Social Psychiatry. 2016; 62(8): 726
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