Subjective experiences of illness recovery in individuals treated for first-episode psychosis.

PURPOSE: Individuals with psychotic disorders identify several parallel dimensions of recovery as being important, including illness related, personal and social domains. Learning how patients deal with the experience of psychosis and recovery early in the course of illness may provide insights for improvement of early intervention services. The primary aim of the present research is to explore experiences related to recovery for individuals receiving services following a first episode of psychosis (FEP) in a specialized early intervention (SEI) program and to examine key turning points that shape such recovery. METHODS: Semi-structured interviews were carried out with 30 individuals in early recovery following an FEP. Interpretative phenomenological analysis (IPA) was used to examine the subjectively identified important processes and turning points in relation to the illness domain of recovery. RESULTS: Participants described several early recovery processes including symptom recovery; reconciling the meaning of the illness experience; regaining control over the experience; and negotiation and acceptance of treatment. Of particular relevance were the various turning points associated with the recovery processes that were described. CONCLUSIONS: Differences in illness acceptance trajectories and the turning points within such trajectories have important implications for understanding psychological adjustment to the experience of psychosis, its diagnosis and treatment. These findings underline the importance of assisting individuals with the construction of meaning following the initial illness experience.

Attitudes and physical distance to an individual with schizophrenia: the moderating effect of self-transcendent values.

BACKGROUND: There is evidence that personal value priorities may influence prejudicial behaviors. In particular, it has been hypothesized that those who place a high priority on values such as equality, benevolence and social justice may be less likely to express any prejudicial personal attitudes in behavior. In the present study, we tested this hypothesis in the context of physical distance with reference to a person with schizophrenia. Self-transcendent value priorities and attitudes toward a young woman described as having schizophrenia were assessed in 95 university students. They were then led to anticipate meeting the person and the distance they sat from the expected location of the ill person was assessed. RESULTS: Women sat closer to the anticipated seat of the person with schizophrenia. In addition, there was a significant interaction between priority placed on self-transcendent values and attitude toward the person in predicting seating distance. There was a significant relationship between favorability of attitudes and sitting closer for those who were low in self-transcendent values, but attitudes did not predict physical proximity for those with high self-transcendent values. CONCLUSION: The impact of attitudes toward an individual with schizophrenia and subtle aspects of behavior such as physical proximity appear to be moderated by self-transcendent personal values. The role of implicit in comparison to explicit attitudes in explaining these results is worthy for further investigation.

The role of perceived norms in the stigmatization of mental illness.

BACKGROUND: Past research on stigmatization of the mentally ill has emphasized the importance of beliefs about mental illness in determining preferred social distance to those with such illnesses. In the current paper we examine the importance of perceived social norms in improving the prediction of social distance preferences. METHODS: Two hundred university students completed scales measuring their beliefs about either depression or schizophrenia; their perception of relevant social norms and their preferred level of social distance to someone with schizophrenia or depression. Measures of social desirability bias were also completed. RESULTS: The proportion of variance in preferred social distance was approximately doubled when perceived norms were added to beliefs about illness in a regression equation. Perceived norms were the most important predictor of social distance to an individual with either illness. A general preference for social distance towards a control, non-ill person was also an independent predictor of behavioral intentions toward someone with either schizophrenia or depression. CONCLUSIONS: Perceived social norms are an important contributor to an individual's social distance to those with mental illness. Messages designed to influence perceived social norms may help reduce stigmatization of the mentally ill.

Does treatment delay predict occupational functioning in first-episode psychosis?

Although duration of untreated psychosis (DUP) predicts treatment outcome as assessed by symptoms in first-episode psychosis, there is much less evidence concerning its relation to social functioning. We present the results of a prospective study of 163 first-episode psychosis patients examining occupational activity at three years, after initiation of treatment. Both shorter DUP and higher social support were significantly associated with more full time occupational activity at follow-up. The findings suggest the importance of reducing treatment delay and increasing social support in order to improve occupational outcomes for those with first-episode psychosis.

The prognostic significance of early remission of positive symptoms in first treated psychosis.

We examine the relationship between achieving remission of positive symptoms within 3 months in first episode psychosis and outcomes 5 years later. Time to remission of positive symptoms, other early characteristics and 5 year outcomes were assessed in a prospective study of 132 patients being treated for the first time for a psychotic disorder. Just under 60% of patients showed remission of positive symptoms within 3 months. In comparison to later remitters, they showed lower levels of positive symptoms, greater likelihood of competitive employment and less likelihood of collecting a disability pension at 5 years. Earlier remission of positive symptoms may have prognostic significance for longer term outcomes.

The significance of possible selves in patients of an early intervention programme for psychotic disorders.

AIMS: To assess the possible importance of patients' perceptions of possible future selves in determining self-esteem and mood. METHODS: One hundred and two patients of an early intervention programme for psychotic disorders completed measures of perceived positive and negative current and possible future selves, as well as indices of self-esteem and mood. RESULTS: Measures of current and possible selves generally showed bivariate correlations with self-esteem, depression and anger/hostility. Perceived negative possible self was the most important independent predictor of self-esteem, depression and anger/hostility. CONCLUSIONS: Perceptions of possible negative future selves may be a particularly important determinant of self-esteem and negative mood states. Addressing fears about possible future self is likely to be an important aspect of recovery from psychotic disorders.

A qualitative analysis of influences on recovery following a first episode of psychosis.

BACKGROUND: Understanding perceived influences on recovery following a first episode of psychosis could help improve services. MATERIAL: Thematic analysis was used to examine important influences on early recovery identified by 30 individuals receiving services in an early intervention programme. DISCUSSION: Social support, medication, meaningful activities and lifestyle modification were identified as helpful, and stigma, substance abuse and medication side effects as harmful. Perceptions of benefits of social support and the negative effects of stigma were particularly prominent. CONCLUSIONS: Results suggest the importance of assistance with engagement in valued activities and relationships, and provision of messages of worth and hope for recovery.

Correlates of subjective recovery in an early intervention program for psychoses.

AIM: To examine the relative importance of symptoms and components of social support in predicting subjective recovery from psychosis. METHODS: Eighty-four clients of a first-episode program for psychotic disorders completed measures of subjective recovery (the Recovery Assessment Scale and the Modified Engulfment Scale) and measures of social support related to appraisal support, tangible support, general sense of belongingness and perceived relational evaluation (PRE). Measures of positive and negative symptoms of psychosis were completed by an independent assessor. RESULTS: Although symptoms, particularly negative symptoms, were correlated with several indices of recovery, PRE generally emerged as the most consistent and important predictor. CONCLUSIONS: PRE appears to be a particularly important aspect of social support in predicting subjective recovery. Prospective studies of the importance of PRE are warranted.

The personal meaning of recovery among individuals treated for a first episode of psychosis.

OBJECTIVE: There is little understanding of service users' conceptions of recovery in the early phase of psychotic disorders. An enhanced understanding of personal notions of recovery may help with the development and evaluation of interventions that address the concerns of service users. This study examined personal definitions of recovery among individuals recently treated in a specialized early-intervention service in Canada. METHODS: Semistructured interviews were carried out with 30 individuals three to five years after initial treatment of a first episode of psychosis. Interpretative phenomenological analysis was used to examine participants' personal meanings of recovery. A typology of recovery definitions was constructed. RESULTS: A majority of individuals considered themselves to be recovered. Responses indicated that recovery is a multidimensional experience and is often a personalized and achievable goal at this early stage in treatment. Individuals described recovery as improvement in one or more of three domains: illness recovery, psychological and personal recovery, and social and functional recovery. There was variation in the extent to which individuals perceived that recovery involved alleviation of symptoms and elimination of underlying vulnerability to illness. CONCLUSIONS: There were several components of the personal meanings of recovery from a first episode of psychosis and variations in the emphasis that individuals placed on each component. An overall positive outlook may be a function of younger age, shorter duration of illness, and receipt of client-centered comprehensive and phase-specific treatment. Improved understanding of personal notions of recovery can guide clinical practices to address service users' recovery goals.

Examining differences in the stigma of depression and schizophrenia.

BACKGROUND: Although there is evidence of greater stigmatization of schizophrenia in comparison to depression, there has been little investigation of the reasons for this difference. AIMS: To examine the role of beliefs about depression and schizophrenia in mediating the difference in preferred social distance towards individuals with these two disorders. METHODS: In Study I, 200 undergraduates completed questionnaires concerning beliefs about depression or schizophrenia and willingness to interact with an individual who has one of the two disorders. In Study II, 103 members of a community service club completed similar measures. RESULTS: For both samples, beliefs about likely appropriateness of social behaviour showed evidence of mediating differences in preferred level of social distance. In addition, differences in perceived danger may have been a mediator for the undergraduate sample and perceived prognosis for the service club respondents. CONCLUSIONS: Beliefs about social appropriateness, danger and prognosis, which have implications for likely costs and benefits of interaction, are more likely to mediate differences in social distance towards the disorders than beliefs concerning causation or continuity with normal experience.

Perceived relational evaluation as a predictor of self-esteem and mood in people with a psychotic disorder.

OBJECTIVE: There is evidence that social support predicts self-esteem and related moods for people with psychotic disorders. However, there has been little investigation of relative importance of specific components of social support. Evidence from social psychology suggests that perceived relational evaluation (PRE) or the extent to which people see others as valuing them, is a particularly important determinant of self-esteem and mood. Our study compared the importance of PRE and other types of social support, in predicting self-esteem and depressive mood, anxiety, and anger-hostility in a sample of patients in an early intervention program for psychotic disorders. METHOD: One hundred and two patients of the Prevention and Early Intervention Program for Psychoses in London, Ontario, completed measures of PRE, appraisal, tangible and general emotional social support, self-esteem, and mood. In addition, ratings of positive and negative symptoms were completed for all participants. RESULTS: In general, perceived relational value was the most important predictor of self-esteem and mood. These relations were not a result of confounding with positive or negative symptoms. CONCLUSIONS: PRE appears to be a particularly important aspect of social support in predicting self-esteem and mood states. Possible implications of these findings and future research directions are discussed.

Social support and functional outcomes in an early intervention program.

OBJECTIVE: To examine social support at initiation of treatment of psychosis and after one year of treatment as predictors of functioning at five year follow-up. METHODS: Early social support was assessed for 132 patients. Follow-up assessments included number of weeks of full-time occupation, number of weeks on a disability pension and global assessment of functioning. RESULTS: One year ratings of social support better predicted occupational activity at follow-up than initial social support. Social support predicted functional outcomes independently of other early characteristics. CONCLUSIONS: Findings support the importance of interventions to improve the level of support of individuals with psychotic disorders.

Parsing the relationship of stigma and insight to psychological well-being in psychotic disorders.

BACKGROUND: It has been postulated that the effects of the stigma of mental illness on the psychological well-being of patients is mediated through internalization of the stigma. On the other hand, there is reason to suppose that simple awareness of public stigma could also have an impact to the extent that an individual is aware of being ill. AIM: To investigate whether internalization of the stigma of having a psychotic disorder and an interaction between perceived public stigma and awareness of being ill make independent contributions to the prediction of psychological well-being in patients with psychotic disorder. METHOD: 102 patients in an early intervention program for psychoses were assessed for awareness of public stigma, internalization of stigmatizing beliefs, insight and various aspects of psychological well-being including self-esteem, depression, anxiety, anger/hostility and engulfment. RESULTS: Internalization of stigma was associated with lower levels of psychological well-being. In addition, perception of public stigma also contributed to lower well-being for those individuals with greater awareness of being ill. CONCLUSIONS: While internalization of stigma is an important contribution to psychological well-being in patients with psychosis, awareness of public stigma, even if this is not internalized, also is associated with lower self-esteem, and greater anxiety, anger/hostility, and engulfment in patients with better insight.

Symptom and functional outcomes for a 5 year early intervention program for psychoses.

There continues to be controversy concerning the long term benefits of specialized early intervention programs (SEI) for psychotic disorders. Recent reports of five year outcomes for SEI programs indicate that benefits of early intervention programs at two year follow-up have disappeared at five years. The Prevention and Early Intervention Program for Psychoses (PEPP) in London, Ontario offers continuity of care for five years, with a lower intensity level of specialized intervention after the initial two years. In this paper we examine whether the outcomes observed at two years were maintained at five year follow-up. In addition, it was possible to compare PEPP outcomes with those of the OPUS project at two and five years. Results indicate that improvement of symptoms between entry into PEPP and two year follow-up were maintained at five years. In addition, there was further improvement in global functioning between two and five year follow-up. Comparison of PEPP outcomes at two and five year follow-up to those of OPUS suggest that longer term continuity of care within SEI is associated with continuing benefits at least with respect to level of positive symptoms and functioning.

Predicting behavioural intentions to those with mental illness: the role of attitude specificity and norms.

BACKGROUND: Social psychological research suggests that prediction of behavioural intentions towards those with mental illness could be increased by assessing attitudes towards specific actions or behaviours and by including a measure of perceived normative expectations by others concerning such behaviours. AIMS: To investigate whether attitudes towards specific behaviours and perceived normative expectations improve prediction of behavioural intentions towards a person with mental illness. METHODS: Two studies were carried out; one with university undergraduates and one with community service club members. Each included assessments of attitudes towards a person described as having a mental illness; attitudes towards specific behaviours reflecting social distance; perceived descriptive and injunctive norms with reference to those behaviours; and behavioural intentions. RESULTS: Attitude towards the specific behaviour frequently showed a higher correlation with behavioural intentions than did attitude towards the person. Inclusion of perceived norms also improved prediction of behavioural intention. CONCLUSIONS: The prediction of behavioural intentions towards those with mental illness may be improved by increasing the specificity of the attitude measures to the behavioural intentions being predicted and including measures of perceived norms. Furthermore, the effectiveness of efforts to reduce the stigma of mental illness may be increased by addressing their impact on perceived norms.

Are personal values of importance in the stigmatization of people with mental illness?

OBJECTIVES: To investigate the relation of responses to the Schwartz Value Scale to preferred social distance to a person with either schizophrenia or depression. The influence of personal value priorities on discrimination has been investigated in several contexts, but seldom with reference to social distance towards those with mental illness. METHOD: University students (n = 200) completed the Schwartz Value Scale, as well as a measure of beliefs about mental illness and preferred social distance with reference to a vignette describing a person with either schizophrenia or depression. RESULTS: Consistent with past findings, respondents indicated a preference for greater social distance for schizophrenia than depression, and beliefs about likelihood of socially inappropriate behaviour and danger were correlated with social distance. Self-transcendence value orientation was a significant independent predictor of preference for less social distance. These findings were not influenced by a social desirability bias. CONCLUSIONS: Value orientation makes a significant contribution to the prediction of social distance towards those with mental illness. Evaluation of value-based interventions to reduce such discrimination appears warranted.

A multisite Canadian study of outcome of first-episode psychosis treated in publicly funded early intervention services.

OBJECTIVE: The aim of this study was to determine 1-year symptomatic outcome and its predictors in patients with FEP treated at 3 different publicly funded sites. METHOD: We evaluated FEP patients (n = 172) treated in specialized programs in 2 medium-sized centres and 1 large urban centre with an identical protocol for demographic variables, diagnosis, and duration of untreated psychosis (DUP) at entry, and positive, negative, and general psychopathology symptoms at entry, 6 months, and 1 year. We used a mixed model analysis of variance, with time and centre and interaction between time and centre as fixed effects and sex and DUP as covariates, to analyze data. RESULTS: A significant effect of time and time x centre interaction on positive, negative, and general symptom outcome was shown after controlling for ethnicity, education, and diagnosis. Patients showed significantly better outcome on all dimensions of symptoms in the 2 medium-sized centres, compared with the 1 large urban centre. Sex had a significant effect on negative and general symptoms, while DUP had no effect on any outcome measure. CONCLUSIONS: Similarly enriched EI services may produce different outcomes, even within a relatively homogeneous mental health system.

Status of first-episode psychosis patients presenting for routine care in a defined catchment area.

OBJECTIVE: To examine the clinical and behavioural status of all first-episode psychosis (FEP) patients admitted to hospital within a defined catchment area. METHOD: We used a structured format to review clinical records of all first admissions to hospitals from a catchment area (population 390 000) with diagnosis of a first episode of nonaffective psychosis over a 3-year period. RESULTS: Patients were somewhat older than usually reported for FEP (mean age 31.3 years). They were mostly male (63.7%), single (80.8%), unemployed (87.4%), with a primary diagnosis of schizophrenia spectrum psychoses (85%), and had spent a mean of 31 days in an open inpatient unit and 2.93 days in an intensive care psychiatric unit during their first admission. Most (60.3%) were admitted involuntarily; 34.2% had a history of legal involvement; 18.8% had attempted suicide prior to admission; 31.5% had demonstrated violence toward people, property, or animals; 14.4% had suffered injuries; and 15.9% had shown aggressive behaviour during the hospital admission. CONCLUSIONS: These results identify some of the potential needs of FEP patients, toward whom early intervention services should be directed.

Impact of a specialized early intervention service for psychotic disorders on patient characteristics, service use, and hospital costs in a defined catchment area.

OBJECTIVE: To evaluate the impact of a new early intervention service for first-episode psychosis on patient characteristics, service use, and hospital costs. METHOD: We examined clinical records of all first admissions to hospitals of patients diagnosed with first-episode psychoses (nonaffective) over a 3-year period before and after the introduction of an early intervention service, the Prevention and Early Intervention Program for Psychosis (PEPP), in a defined catchment area. We examined demographic, clinical, and service use indices covering a 2-year period subsequent to the index admission for each patient. RESULTS: Patients in the post-PEPP phase were significantly younger (P < 0.01), were more often male (P < 0.05), and were less likely to be admitted to hospital with an involuntary status (P < 0.05) or with injuries (P < 0.05) at the time of their first hospital admission. Over the 2 years following the initial admission, post-PEPP patients had significantly fewer admissions to a regular psychiatric service (P < 0.001) and made significantly fewer visits to the hospital emergency department (P < 0.01). There was a significant mean reduction in costs per case of regular hospital bed use ($1028.49, SD 528.02, compared with $792.28, SD 528.02; P < 0.01) and emergency visits ($519.18, SD 353.79, compared with $353.79, SD 345.0; P < 0.01). Time series analyses followed by Chow tests failed to confirm that these cost changes could be attributed specifically to the introduction of an early intervention service. CONCLUSION: Introduction of a specialized early intervention program may be beneficial to patients and to the health care system. To evaluate the cost-benefit ratio of early intervention services, longer term and more detailed data may be required.