Personal Recovery Mediates Symptom Impact on Quality of Life in Schizophrenia: Implications for Mental Health Services

Introduction and Purpose:

In the traditional treatment of schizophrenia spectrum diagnoses, there has been a pronounced focus on symptom reduction, often leading to a deficit-focused approach. This singular emphasis can be frustrating for both service users and mental health providers, overlooking hollistic well-being and recovery. Service users in recovery-oriented care have shown significant improvement in key indicators of quality of life (QoL) and illness remission. Recognizing the significant disturbance to QoL that individuals with schizophrenia often experience, this study aims to examine personal recovery as a mechanism through which different symptom types affect various domains of QoL. Understanding these relationships further could catalyze the implementation of client-centered care alongside traditional treatment modalities.

Methods:

Adults with early-stage schizophrenia (N = 102) participated in an 18-month randomized trial of Cognitive Enhancement Therapy (CET) in which an active treatment control condition was implemented. Participants were primarily non-white (57%) and transition aged (24.76). Assessments included quality of life (QoL), stage of recovery (SoR), and symptomatology prior to treatment, at mid treatment, and treatment completion. Composites were created from a battery of field-standard measures assessing positive symptoms, negative symptoms, affective symptoms, neurocognition, and social cognition. QoL domains included physical health, psychological health, social relationships, and environment. Mixed-effects models were used to examine the effects of each symptom or cognition composite on the four QoL subdomains over the 18-month period. Next, mediator analyses using mixed-effects models were conducted to examine the mediating effects of movement through SoR on changes in QoL during treatment. All models included treatment assignment with time interaction as covariates. The size and significance of mediation effects were estimated using the MacKinnon asymptotic z′ test of indirect effects.

Results:

Almost all symptom types were significant predictors of the four domains of QoL with medium-large effect sizes (d=.47-1.08), though positive symptoms did not significantly predict psychological QoL. Social and non-social cognition only significantly predicted Environment QoL (d=.48, p<.05; d=.43, p<.05; respectively). The effects of negative and affective symptoms on all QoL domains were consistently lowered or eclipsed when SoR was introduced to the models, significantly mediating (z′=2.07-3.86, all p<.01). A similar pattern was observed between positive symptoms and physical and environment QoL domains (z′=2.98, p<.001; z′=2.13, p<.05; respectively). Apart from cognition domains, SoR significantly mediated all relationships between symptoms and QoL, despite some nonsignificant direct effects. Cognition’s effect on all QoL domains was significantly mediated by SoR, most clear in Environment QoL (z′=1.95, p<.05). SoR did not significantly mediate any social cognition trends. All treatment assignment by time effects were nonsignificant.

Discussion:

The inclusion of SoR within these models showed the substantial impact that recovery orientation can have on QoL as a mitigator of the impacts of increased symptom acuity. Social workers can play a pivotal role in advocating for the integration of recovery-oriented principles into mental health services. By championing a paradigm shift towards recovery, social workers can contribute to creating a mental health system that is more compassionate, empowering, and conducive to the long-term well-being of individuals living with schizophrenia.