Progress of recovery and its associated factors in recent-onset psychosis : a mixed-methods study

Abstract

Background: Recovery from psychosis is a major concern to patients, families and health care providers. Symptomatic recovery, functional recovery and subjective recovery are the three common types of recovery in mental illness. Subjective recovery is a relatively recent view of recovery that is conceptualized as an individualistic process towards self-defined goals through the endeavours of the individual and assistance from important others. Studies showed that recovery levels are different in countries with different developmental levels, being influenced by several individual, cultural and contextual factors. However, evidence from low-income, particularly African countries is scant. This makes the topic among the principal issues to be studied in the region to have a more conclusive understanding of subjective recovery; which is essential for the development of recovery-oriented mental health services. Objective: This study was conducted in order to: a) investigate the levels and progress of subjective recovery from recent-onset psychosis; b) examine its predictive factors and; c) explore the conceptualizations of recovery and describe perceived challenges and opportunities affecting recovery. Method: To address these objectives a sequential explanatory mixed-methods study design was employed (quantitative followed by qualitative approaches). For the quantitative part, a nine-month longitudinal study approach was employed with three time-point measurements (baseline, third-month and ninth-month). Predictor variables for subjective recovery from recent-onset psychosis were identified by hierarchical multiple linear regression tests. Following the quantitative survey, qualitative data were collected, transcribed and thematically analysed. Finally, the findings from the two approaches are integrated and discussed together. Results: From three referral hospitals in North-western Ethiopia 263 service users with recent-onset psychosis participated at baseline, while 190 completed the nine-month follow-up. High mean subjective recovery scores were recorded throughout the study (Questionnaire about the Process of Recovery (QPR) score ranging from 44.17 to 44.65). Quality of life, internalized stigma, disability, hopelessness, satisfaction with social support, and central obesity were the significant predictors of subjective recovery across the three time-points. Nineteen participants were involved in qualitative in-depth interviews. Their conceptualizations of recovery were summarized in four main themes; "domination over the disturbance of psychosis", "complete medical treatment course and stay normal", "stay active in life with optimal functioning", and "reconcile with the new reality and rebuild hope and life". Participants' perceived challenges affecting their recovery were categorized into four main themes; "altered health, psychiatric treatment and side effects of antipsychotics", "collective understanding and social process to psychosis management", "opportunities and challenges of working" and "faith, hope and determinations". Discussion: Consistently high mean subjective recovery scores and the related variables in the quantitative approach were found to be complemented and explained by the qualitative findings. Getting a meaningful improvement in psychotic symptoms within a short treatment period and having optimistic view towards the treatment for the illness could be among reasons that contributed to the high perceived recovery level. Close interdependence within the family and utilization of care from both spiritual and modern treatment modalities could also make substantial contributions. Factors that predicted subjective recovery in the quantitative approach were also explained by the interview findings of altered physical and mental health, antipsychotic side effects, strong familial interdependence, strong faith and reliance on spirituality, impaired functioning, challenges in working environment and related economic constraints. Implications and conclusions: In low-income countries like Ethiopia, a low percentage of individuals with SMIs initiate psychiatric treatment and the majority of them visit spiritual healing sites, most by discontinuing their psychiatric treatment. Stakeholders should work on the mental health literacy of the community by informing that mental illness is treatable and illnesses like psychosis often require long term follow-up treatment. Devising mechanisms to integrate the two sectors (spiritual healing sites and Western treatment modalities) is suggested. Participants were found to believe that they would only need a limited period of treatment and once finished they would be cured. This misunderstanding needs appropriate interventions. Future research should include participants from different settings, adopt and develop different interventions to suit the local context.