Personal Recovery Among People at Risk for Developing Serious Mental Health Problems: A Qualitative Systematic Review.

OBJECTIVE: Personal recovery refers to a person's pursuit of a full, meaningful life despite the potentially debilitating impact of a mental illness. An evidence base describing personal recovery among people at risk for developing a mental illness is lacking, limiting the potential for mental health services to support personal recovery. To address this gap, the authors synthesized the extant research describing personal recovery among people at risk for developing a mental illness. METHODS: A systematic search of several literature databases (MEDLINE, Embase, APA PsycInfo, Web of Science Core Collection, and Cochrane Library) was conducted to retrieve qualitative and case studies and first-person accounts. The Joanna Briggs Institute guidelines for systematic reviews were followed. Included studies reported on participants at variable risk for developing a schizophrenia spectrum, bipolar, major depressive, or borderline personality disorder. Articles were retrieved through a librarian-assisted search and through use of additional strategies (e.g., expert consultation). Abstracts were screened by the research team, and themes were developed by using thematic synthesis. RESULTS: The 36 included articles were synthesized, and six themes were generated: difficulties and challenges; establishing an understanding of, and finding ways to cope with, one's mental health challenges; reestablishing a sense of agency and personhood; receiving support from people and services, as well as restoring relationships; reestablishing hope, meaning, and purpose; and overcoming stigma and destigmatizing mental illness in others. CONCLUSIONS: These findings provide a conceptual foundation that can guide future research on personal recovery and clinical interventions that foster it among people at risk for mental illness.

Through COVID-19 and beyond: developing a multidisciplinary telehealth family intervention in first episode psychosis.

The COVID-19 pandemic presents unique challenges to high quality, safe Early Intervention in Psychosis (EIP) service provision. Due to the necessity to ensure EIP continues despite this, we developed a multidisciplinary, blended, telehealth intervention, incorporating psychoeducation and peer support, for family members of first episode psychosis service users: PERCEPTION. This perspective article aims to: describe PERCEPTION; offer reflections on our experience of delivering it; make recommendations for future research; and synthesise key learning to assist the integration of similar interventions in other EIP services. We provide a descriptive account of PERCEPTION's development and implementation, with reflections from the clinicians involved, on supporting families using this approach. We experienced telehealth as patient-focused, safe, and efficient and believe the intervention's blended nature augmented families' engagement. The approach adopted can assist service providers to attain balance between protecting public health and offering a meaningful, therapeutic intervention to support families in the current epoch.

20-Year Prospective, Sequential Follow-Up Study of Heterogeneity in Associations of Duration of Untreated Psychosis With Symptoms, Functioning, and Quality of Life Following First-Episode Psychosis.

OBJECTIVE: Determining the extent to which relationships between duration of untreated psychosis (DUP) and outcome endure longitudinally across the lifetime course of psychotic illness requires prospective, systematic studies of epidemiologically representative incidence cohorts across decades. Transience, persistence, or heterogeneity in associations between DUP and distinct outcome domains are yet to be investigated over such time frames. METHODS: Prospective, sequential follow-up studies of an epidemiologically representative first-episode psychosis incidence cohort in Ireland were conducted at 6 months and 4, 8, 12, and 20 years (N=171). Linear mixed-model analyses were applied to determine whether prospective associations of DUP with symptoms, functioning, and quality of life were consistent or varied across psychotic illness trajectory over a 20-year period. Evaluations included time, DUP quartile, and DUP quartile-by-time interaction effects. RESULTS: Prospective, sequential follow-ups showed positive and negative symptoms, function, and quality of life to exhibit distinct trajectories of improvement in relation to shorter DUP. Despite heterogeneity in course and relationship to premorbid features, associations between shorter DUP and greater improvement were still evident 20 years after the first psychotic episode. Across the long-term course of psychotic illness, trajectories of association between shorter DUP and better outcome differed between domains of psychopathology, functionality, and quality of life. Nevertheless, such associations with shorter DUP were sustained for at least 20 years. CONCLUSIONS: These profiles indicate that while associations between DUP and long-term outcome can vary according to the domain of outcome, they are sustained across decades in a manner that could not be fully accounted for in terms of premorbid features or lead-time bias.

Keyworker mediated enhancement of physical health in patients with first episode psychosis: A feasibility/acceptability study.

AIM: Early intervention for people experiencing first episode psychosis is a priority, and keyworkers are vital to such services. However, keyworkers' roles in addressing first episode psychosis patients' physical health are under researched. This study addresses this knowledge gap by evaluating a keyworker-mediated intervention promoting physical health among first episode psychosis patients. METHODS: The study was informed by the Medical Research Council's Framework for Complex Interventions to Improve Health. First episode psychosis participants were recruited from three Irish mental health services. The intervention was evaluated in terms of its feasibility/acceptability. RESULTS: Feasibility outcomes were mixed (recruitment rate = 24/68 [35.3%]; retention rate = 18/24 [75%]). The baseline sample was predominantly male (M:F ratio = 13:6; Med age = 25 y; IQR = 23-42 y). Common health issues among participants included overweightness/obesity (n = 11) and substance use (smoking/alcohol consumption [n = 19]). Participants' initial health priorities included exercising more (n = 10), improving diet (n = 6), weight loss (n = 7) and using various health/healthcare services. The intervention's acceptability was evidenced by the appreciation participants had for physical health keyworkers' support, as well as the healthy lifestyle, which the intervention promoted. Acceptability was somewhat compromised by a low-recruitment rate, variable linkages between keyworkers and general practitioners (GPs) and COVID-19 restrictions. CONCLUSIONS: Physical health-oriented keyworker interventions for first episode psychosis patients show promise and further evaluation of such initiatives is warranted. Future interventions should be mindful of participant recruitment challenges, strategies to enhance relationships between keyworkers and GPs, and if necessary, they should mitigate COVID-19 restrictions' impacts on care.

A qualitative study exploring personal recovery meaning and the potential influence of clinical recovery status on this meaning 20 years after a first-episode psychosis.

PURPOSE: Long-term data on recovery conceptualisation in psychotic illness are needed to support mental health services to organise themselves according to recovery-oriented frameworks. To our knowledge, no previous research has investigated how first-episode psychosis (FEP) service users (sampled across psychotic illness type) perceive recovery beyond 5 years after diagnosis. We aimed to explore personal recovery meaning with individuals 20 years after their FEP and examine the potential influence of clinical recovery status on how they defined recovery (i.e. personal recovery). METHODS: Twenty participants were purposefully sampled from an epidemiologically representative FEP incidence cohort. At 20-year follow-up, semi-structured interviews were conducted with 10 cohort members who met full 'functional recovery criteria' (Clinically Recovered Group) and 10 who did not (Not Clinically Recovered Group). A thematic analysis was performed to develop shared themes and group-specific sub-themes to capture agreement and divergence between groups. RESULTS: Five shared themes were produced: pursuing balance in conflict, generating meaning in life, experiencing a dynamic personal relationship with time, redressing inequality while managing added challenges/vulnerability, and directing life from resilience to flourishing. The five group-specific sub-themes developed illuminate differences in the meaning ascribed to personal recovery by each group. CONCLUSION: Findings emphasise the role of time in how personal recovery is conceptualised by service users and identify ways clinical recovery may influence personal recovery meaning in FEP at mid-later life. Mental health services failing to consider temporal changes in meaning-making and discounting clinical recovery risk ignoring key factors affecting personal recovery.

Meaning in Life in Long-Term Recovery in First-Episode Psychosis: An Interpretative Phenomenological Analysis.

Background: Meaning in Life (MIL) is a central aspect of service user defined personal recovery in mental health. It is unclear whether current knowledge regarding MIL is applicable to the lives of those who have experienced psychosis. As it was not possible to locate any study examining service user perspectives on MIL in first-episode psychosis (FEP), conducting in-depth qualitative research in this area offers an opportunity to develop a conceptualisation of MIL that may be transferable to the broad psychosis spectrum. Aim: The aim of the study was to explore how people find, develop, and maintain MIL approximately 21 years after their FEP diagnosis. Materials and Methods: The study aim was addressed using Interpretative Phenomenological Analysis (IPA). Participants were members of an epidemiologically complete FEP incidence cohort in Ireland. Purposive maximum variation sampling enabled the recruitment of a sample balanced across remission status, age at time of FEP onset, and gender. Semi-structured interviews were conducted circa 21 years post FEP with 16 participants. Data analysis was guided by IPA procedures. Results: Participants experienced MIL as awareness of connectedness to context - the interrelated conditions they existed in (their relationships with the self, others, systems, the environment, and time). Awareness of connectedness to context occurred in five main ways: Being myself - de-othering and authenticity (Enacting identity); Becoming significant where the self is witnessed (Belonging in life); Generating meaning within and beyond systems (Independence); Shaping and being shaped by life (Agency and patiency); and Integrating different perspectives of time (Reconciling temporality). Conclusions: Findings offer the first in-depth understanding of how people diagnosed with a FEP experience MIL in mid-later life recovery. Current tripartite MIL theories do not fully represent the array of MIL perspectives articulated by our participants. MIL concepts developed are potential areas for intervention for mental health services seeking to implement the recovery approach. Findings can be used to foster optimism among service users and their supporters for MIL attainment in psychosis and offer guidance for education, clinical practice, policy, and future research.

The iHOPE-20 study: mortality in first episode psychosis-a 20-year follow-up of the Dublin first episode cohort.

PURPOSE: Increased mortality rates have been found in those with a diagnosis of psychosis; studies suggest a shortened life expectancy of up to 20 years less than that of the general population. This study aimed to investigate the mortality of a first episode psychosis cohort at 20-year follow-up, compare it to that of the general Irish population, and explore whether the mortality gap has changed over time. METHODS: 171 individuals diagnosed with a first episode psychosis identified between 1995 and 1999 in a community mental health service were traced. Mortality was established by matching death certificates to deceased cohort members (using name, age at date of death, and address at date of death). Date of first presentation to service was used as date of entry point and date of death or end of follow-up as the end point. RESULTS: Of the 171 cases there were 20 deaths during follow-up. Nine deaths were attributed to natural causes; 7 to unnatural causes; and 4 were unknown. Comparing standardised mortality rates at 20-year follow-up to those at 12 year showed a reduction in rates over time. CONCLUSION: Findings suggest that the mortality gap in people with schizophrenia and other psychoses remains high, especially in young males.

The iHOPE-20 study: Relationships between and prospective predictors of remission, clinical recovery, personal recovery and resilience 20 years on from a first episode psychosis.

OBJECTIVE: Knowledge of outcome in psychotic illness is limited by the paucity of very long-term epidemiologically representative studies of incidence first episode psychosis (FEP) cohorts that measure and compare outcomes reflecting modern clinical practice, mental health policy and research agendas. Our study aimed to address this gap. METHOD: iHOPE-20 is a prospective 20-year follow-up study of a FEP incidence cohort (N = 171) conducted between 2014 and 2017 in Ireland. Data from previous studies and medical records were used to recruit cohort members. We assessed remission, clinical recovery, personal recovery and resilience at 20 years; explored the relationships between these outcomes and examined the predictive value of baseline characteristics in determining them. RESULTS: At follow-up, 20 out of 171 cohort members (11.70%) were deceased. We assessed 80 out of 151 alive cohort members (53% recruitment rate); 65% were in remission; 35.2% were in Full Functional Recovery and 53.7% confirmed they were fully recovered according to their personal definition of recovery. A complex array of relationships between outcomes was found. Outcomes were better for people who had a short duration of untreated psychosis, displayed higher premorbid social adjustment (between the ages of 5-11) and at baseline, were older, not living alone, in full-time employment, given a non-affective diagnosis, and had lower Global Assessment of Functioning scores. CONCLUSION: Among participants, full remission of psychotic symptoms and personally defined recovery was not just possible but likely in the very long term. However, attaining positive functional outcomes and building resilience in FEP remain key challenges for mental health services.

Friendship and money: A qualitative study of service users' experiences of participating in a supported socialisation programme.

BACKGROUND: Social opportunities can be limited in the lives of people with enduring mental illness (EMI) due to psychiatric stigma, restricted home environments and employment barriers. Supported socialisation programmes have the potential to redress the impact of social isolation. AIM: To explore the experiences of service users with EMI taking part in a supported socialisation programme, using written diary entries. METHODS: This article reports on the qualitative component of a randomised controlled trial of supported socialisation for people with EMI (published previously in this journal). Trial participation involved (1) being matched with a volunteer partner and engaging in social/leisure activities while receiving a stipend of €20 or (2) receiving this stipend only and engaging in self-driven socialisation. Participants completed written diaries documenting their perspectives on their experiences of supported socialisation. Data were analysed using Thematic Analysis. RESULTS: Experiences of participation were characterised by involvement 'normalising' life, fostering a sense of connectedness, improving physical health, and facilitating engagement with culture. Taking part helped participants integrate socialising into their identity, enhanced their perceived capacity to be social, and cemented/expanded social networks. Participants also experienced significant obstacles to socialisation. CONCLUSION: Supported socialisation can increase confidence, social competence and self-agency; buffer against psychiatric stigma; build social capital; and afford opportunities to enhance social integration, inclusion and belonging.

'Recovery' in the Real World: Service User Experiences of Mental Health Service Use and Recommendations for Change 20 Years on from a First Episode Psychosis.

Little is known about how recovery oriented policy and legislative changes influence service users' perceptions of mental health care over time. Although the recovery approach is endorsed in many countries, qualitative research examining its impact on service use experiences has been lacking. This study aimed to explore this impact as well as experiences of service utilisation and suggestions for change with people diagnosed with a First Episode Psychosis between 1995 and 1999. Participants had used services during the 10 year period prior to, and 10 years post, policy and legislative shifts to the recovery approach. Semi-structured interviews were conducted with 10 participants who met criteria for 'full functional recovery' and 10 who did not. Data were analysed using Thematic Networks Analysis to develop Basic, Organising, and Global Themes. Over time, recovered participants perceived an improvement in service quality through the 'humanising' of treatment and non-recovered participants experienced their responsibility in recovery being recognised, but felt abandoned to the recovery approach. Findings suggest the importance of viewing service users as demonstrating personhood and having societal value; examining the personal meaning of psychotic experiences; and matching expectations with what services can feasibly provide. The implementation and the principal tenets of the recovery approach warrant further investigation.

Feasibility of a psychosis information intervention to improve mental health literacy for professional groups in contact with young people.

The aim of this study was to assess the feasibility of a psychosis information intervention for professionals in contact with young people in Ireland. A quasi-experimental pre- and post-intervention design was used. One thousand and thirty-two professionals received an information intervention designed to improve mental health literacy (MHL) and confidence in providing help to people with psychosis. Seven hundred and fifty-five participants completed the Psychosis Information and Confidence Questionnaire pre- and post-intervention. The information intervention significantly improved participants': (1) knowledge of psychosis; (2) ability to recognize signs and symptoms of psychosis; (3) awareness of how to access services; and (4) confidence in providing help to people experiencing psychosis. Findings provide promising support for the intervention's feasibility and acceptability. The intervention enhanced MHL regarding psychosis among professionals in contact with young people. Further research assessing if such improvements translate to the facilitation of appropriate help seeking, the enhanced early detection of psychosis and a reduction of the duration of untreated psychosis is required.

The relationship between mental health literacy regarding schizophrenia and psychiatric stigma in the Republic of Ireland.

BACKGROUND: There is an unclear relationship between mental health literacy (MHL) and psychiatric stigma. MHL is associated with both positive and negative attitudes to mental illness. To our knowledge, no published peer reviewed study has examined this relationship in the Republic of Ireland. AIMS: This study was conducted to assess MHL regarding schizophrenia and the degree of psychiatric stigma displayed by the general public in the Republic of Ireland. METHOD: A face-to-face in-home omnibus survey was conducted with a representative sample of residents of the Republic of Ireland. Participants (N = 1001) were presented with a vignette depicting schizophrenia and were asked questions to determine their ability to recognise the condition and to ascertain their attitudes towards schizophrenia and mental illness. RESULTS: Among the participants, 34.1% correctly identified schizophrenia. Higher age, higher socioeconomic status, and an urban geographic location predicted identification. Those who did not correctly identify schizophrenia were significantly more optimistic about recovery and perceived people with schizophrenia as less dangerous. However, only the relationship with perceived dangerousness was considered robust. CONCLUSIONS: Participants with higher MHL displayed more negative attitudes to mental illness. Findings have implications internationally for MHL and anti-stigma campaigns.

Improving social functioning and reducing social isolation and loneliness among people with enduring mental illness: Report of a randomised controlled trial of supported socialisation.

BACKGROUND: This randomised controlled trial examined if for people with enduring mental illness, being supported to socialise leads to improved social functioning, increased self-esteem and extended social networks; a reduction in social isolation, social, emotional and family loneliness and a reduction in illness symptoms, namely depression. METHODS: A prospective randomised controlled trial was undertaken from November 2007 to September 2011. Service users with a diagnosis of enduring mental illness (>18 years) were invited to participate. Participants were randomly allocated to intervention or control group conditions in a 1:1 ratio. Intervention group participants were matched with a volunteer partner, asked to engage in social/leisure activities for 2 hours weekly over a 9-month period, and received a €20 stipend monthly. Control group participants received a €20 monthly stipend and were asked to engage in a weekly social/leisure activity. Social functioning, the primary outcome, was measured using the Social Functioning Scale (SFS) at three time points (baseline, midpoint and endpoint). FINDINGS: In all, 107 people completed this study. There were no significant differences between control and intervention groups at the commencement of the intervention on demographic characteristics or the main outcome measures of interest. Overall social functioning positively changed throughout the three time points from a mean of 99·7 (standard deviation (SD) = 15.1) at baseline, to a mean of 106.0 (SD = 27.0) at the endpoint for the control group, and from a mean of 100·4 (SD = 15.0) at Time 1 for the intervention group, to a mean of 104.1 (SD = 23.4) at the endpoint for the intervention group. CONCLUSIONS: The intervention showed no statistical differences between the control and intervention groups on primary or secondary outcome measures. The stipend and the stipend plus volunteer partner led to an increase in recreational social functioning; a decrease in levels of social loneliness, in depression and in the proportion living within a vulnerable social network.