Background
The management of schizophrenia has traditionally focused on the assessment of symptomatology and neurocognitive functioning [
1]. However, there is increasing interest in developing more comprehensive models focusing on functional recovery [
2‐
9]. Unlike clinical remission, which is well defined and can be measured, the concept of recovery encompasses multiple aspects of the patient’s life, making it difficult to settle on a definition and to develop reliable assessment criteria. Liberman and colleagues [
10] proposed operational criteria for recovery from schizophrenia that included symptom remission, improved vocational functioning, independent living, and improved peer relationships. In contrast, Anthony [
11] described functional recovery as a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles, even with limitations caused by illness. On the other hand, some clinicians have warned that functional recovery can only be accepted when symptoms are mild and stable enough to not interfere with normal functioning in social activities and relationships [
6,
12]. Regardless of the perspective of the various stakeholders, it is widely accepted that functional recovery is influenced by the severity of symptoms as well as by disease-related aspects such as neurocognitive performance [
7,
13‐
15]. Additionally, social and family circumstances, opportunities, and lifetime events contribute to extending the list of environmental factors that may influence functional recovery beyond clinical manifestations of schizophrenia [
7,
15,
16].
Patients with schizophrenia now have access to a wide variety of pharmacological agents and psychosocial therapies which may eventually meet the particular needs of each patient profile and, therefore, increase the chances of positive therapeutic outcomes [
17]. The lack of standardized tools for the assessment of functional recovery prevents from drawing strong conclusions regarding the contribution of these interventions to functional recovery in patients with schizophrenia. Nevertheless, results of clinical studies – including randomized controlled trials – on various interventions for schizophrenia suggest that the achievement of functional recovery is possible in many cases [
18‐
21].
Due to the heterogeneity of published information and the limited empirical evidence on functional recovery, this concept is not commonly considered an assessment criterion and/or a therapeutic goal in most clinical practice guidelines [
1]. In a non-standardized way, most clinicians are familiar with the concept of functional recovery and consider it useful in their day-to-day practice [
22]. Nevertheless, it is not clear whether clinicians have a common construct of functional recovery and to what extent these ideas meet the empirical evidence published in the literature. We present herein the results of a Delphi consensus process aimed to identify commonly accepted concepts regarding the definition and assessment of functional recovery, as well as the perceived impact of psychosocial and pharmacological interventions on its attainment.
Discussion
Following a two-round Delphi dynamics approach, we found high homogeneity in the opinion of clinicians regarding functional recovery in patients with schizophrenia. Psychiatrists from different areas in Spain achieved consensus in 85% of the concepts addressed regarding various aspects of functional recovery.
Functional recovery is a complex, multidimensional concept to be considered not only by clinicians but also researchers, patients and caregivers, as well mental health policy makers. Although the perspective of the various stakeholders involved in the definition of functional recovery may converge on many aspects, the lack of a common terminology and the pursuit of different goals has led to a wide repertoire of definitions, none of which stands out clearly over the rest [
2,
6,
7,
16,
26]. The result of our consensus regarding the concept of functional recovery mirrored this scenario, resulting in a lack of consensus regarding a well-established concept of functional recovery. Nevertheless, the general agreement on specific factors influencing the concept of functional recovery suggests that despite the lack of a standardized definition of recovery, most clinicians share a common archetype of what functional recovery actually is.
The feasibility of achieving functional recovery in patients with schizophrenia has been under discussion since the emergence of interest in this concept [
2,
6,
22,
27]. Most experts in our panel (87%) agreed that functional recovery is a realistic goal in the management of patients with schizophrenia. This is in line with the results of recent research on schizophrenia, which showed that psychological well-being and mental health recovery can improve in individuals with first-episode psychosis [
28]. The lack of a clear definition and assessment tools prevents from drawing strong conclusions regarding the feasibility of a therapeutic model based on the concept of recovery. However, empirical evidence on various therapeutic interventions suggests that many patients with schizophrenia can achieve goals related to functional recovery such as independent living and competitive employment and education in routine community settings [
18‐
21,
29]. In line with the common perception regarding the definition of functional recovery, M. Farkas proposed four key values commonly reflected in the recovery literature which should be considered in all recovery-oriented services: person orientation, person involvement, self-determination/choice, and growth potential [
30].
The lack of a standardized definition is probably a bottleneck for the development of validated tools for the assessment of functional recovery. Other difficulties that may compromise an appropriate assessment of functional recovery include the limitations of some informants to make accurate judgments [
31], the limited capacity of some patients for self-assessment [
32], and the heterogeneity in their clinical course, which may lead to inconsistencies between the outcome of functioning scales and milestone achievement in some patients (e.g., in some patients, functioning scales may not capture milestone achievements in social, vocational, and residential domains of patients with schizophrenia) [
33]. Regarding the source of information for the assessment of functional recovery, there was strong agreement on the suitability of gathering information from three primary sources: patients, their relatives (and/or caregivers), and clinicians. Indeed, some authors have warned of the risk of bias associated with motivation-related negative symptoms (e.g. emotional withdrawal, passive-apathetic social withdrawal) [
34]. Furthermore, patient-reported assessments of quality of life and everyday abilities have shown poor correlation with information about lifetime achievements in many patients with schizophrenia [
35]. All these limitations are consistent with the lack of consensus on the concept that the patient is the most reliable source of information for functional assessment.
Due to the absence of a single tool for the assessment of functional recovery, clinicians and researchers use different strategies to evaluate it. In an attempt to broaden functional assessment towards a comprehensive model of functional recovery, researchers have combined commonly used scales such as the Global Assessment Functioning (GAF) scale and Global Assessment Scale (GAS) with the Social Functioning Rating Score – which includes both social skills and social roles – and other objective indicators of lifetime achievements [
36‐
38]. The experts exhibited heterogeneous knowledge of the functional assessment tools currently available for identifying areas subject to improvement, and planning the management of patients with schizophrenia. Beyond the scales used, it was suggested that functional recovery is somehow assessed in routine practice, albeit without any standardized procedure. In this regard, treatments based on a recovery model should be consistent with evidence-based treatments [
2].
Functional recovery, may be influenced by multiple factors. According to the experts, these factors are a combination of environmental factors, stressful life events, substance abuse, socioeconomic conditions, and family dynamics. Other environmental factors such as the type of origin (i.e. migrant/local) and residence (i.e. urban/rural) were not considered to influence functional recovery significantly. Some authors have observed that patients living in rural areas tend to show better functional outcomes, probably due to greater family and social support as well as simpler vocational roles [
39]. However, in our consensus, the experts’ opinion might be strongly influenced by the area where they work. Thus, while some centers provide mental health care to patients from both rural and urban areas, most of them serve one or the other type, whereby the influence of this factor may be unnoticed. Finally, there was 96% agreement that, despite the different perspectives of clinicians and patients (i.e. clinicians tend to focus on the clinical aspects of recovery, whereas patients and their relatives attach importance to the activities of daily living and life project), the attitude of the various stakeholders has an influence on functional recovery.
In line with the results of clinical studies, which suggest that both negative symptoms and cognitive deficits may be primary predictors of impaired social and vocational performance [
34,
40,
41], the experts in the panel agreed that both negative and cognitive symptoms cause a significant impact on functional recovery. Also, in agreement with recent recommendations to treat negative symptoms [
42], the experts agreed that functional recovery should not be addressed only through symptoms but also considering the cognitive, emotional, and relationship difficulties.
Stigma is another factor with potential influence on functional recovery, and it is generally accepted that it has a major impact on self-esteem and hampers recovery in people with mental illnesses [
7,
43]. The experts agreed that the negative image associated with psychiatry compared to other medical specialties increases stigma in patients with schizophrenia and that self-stigma (or internalized stigma) has a greater impact on functional recovery than social stigma. Although the mechanisms of stigma are not clear, social (or public) stigma and self-stigma might work in different ways. In an interview-based study conducted on patients with major depression or schizophrenia, social stigma showed a trend towards underestimating the importance of informal caregivers (e.g. family and friends). Conversely, self-stigma had a negative impact on the perceived importance of seeking help provided by a general practitioner or a psychiatrist [
44].
The relevance of psychosocial interventions agreed in this consensus are consistent with the positive results of these interventions reported in randomized clinical trials conducted according to the gold standards of clinical design [
45‐
47]. Although the items regarding the type of therapy with highest effectivity were written in an exclusive way, the experts achieved consensus in the highest effectivity of social skills training, family therapy, cognitive rehabilitation, social cognitive training, and occupational programs. This result indicates that, irrespective of the median score achieved in each therapy, none of them stood out from the rest. Of note, recovery-based interventions are not widespread in clinical practice and some authors have stressed the need to develop more interventions going beyond symptom reduction [
48]. Although the inclusion of cognitive rehabilitation in psychosocial interventions was considered useful, cognitive disorders were not agreed to be the primary target of these interventions. The apparent inconsistency regarding the role of cognitive functioning in psychosocial interventions can be explained by the recent evolution of the concept of cognition. Thus, while the construct of cognitive impairment has been traditionally built solely on basic neurocognition, it is now accepted that social cognition differs from basic neurocognition and that it could be the link between neurocognition and functional recovery in psychosocial programming [
5,
49].
The positive impact of long-acting antipsychotics on adherence and the closer relationship between patients and the healthcare team associated with the dosing of these agents have been considered helpful for achieving functional recovery [
38]. Some authors have questioned the suitability of maintaining long-lasting treatment with antipsychotics [
50]. However, the impact of long-lasting antipsychotic treatments on functional recovery is unclear, and other authors have highlighted important limitations of studies investigating early discontinuation of antipsychotic therapy [
51].
Although it is not clear whether medication alone can impact directly on functional performance, there is long-time evidence on the synergistic effect of pharmacological and psychosocial treatments, particularly pharmacological treatments with a significant impact on positive symptoms [
7,
52‐
54]. Besides attenuating the symptomatology associated with schizophrenia, pharmacological treatments – particularly atypical antipsychotic agents – cause morphological changes in patients’ brains which could be associated with an improvement in neurochemical functioning [
55,
56]. Despite the proven usefulness of some antipsychotic agents in achieving functional recovery [
57,
58], the experts identified potential drawbacks of pharmacological treatment for achieving functional recovery: extrapyramidal symptoms, sedation, the worsening of negative symptoms, and cognitive impairment. Of note, most of the adverse events limiting functional recovery are more frequently associated with first-generation than second-generation antipsychotics [
59‐
61]. Combination antipsychotic therapy was also considered to result in poorer functional recovery than monotherapy.
The scope of the results presented herein must be weighed considering some limitations of our work. First, the selection of experts was neither systematic nor randomized. Alternatively, we recruited specialists in the management of schizophrenia from various Spanish regions. Thus, although all experts must account at least 10 years of clinical practice, a selection bias cannot be ruled out. Second, some items expressing mutually incompatible ideas yielded inconsistent results. Items affected by this phenomenon were discussed and eventually not considered for drawing the final conclusions. Finally, the resulting recommendations were not drawn following a consensus process, but as an interpretation of the agreements and disagreements resulting from the Delphi process. Nevertheless, due to the expected heterogeneity on the concept, we deemed it more appropriate to address the conclusions by weighing the scope of each result carefully and addressing the inconsistencies that might arise from the responses of the panel of experts.
Acknowledgements
Medical writing assistance was provided by Dr. Gerard Carot-Sans, PhD, and Medical Writers 5.0 on behalf of Janssen. The authors gratefully acknowledge the time and effort of the panel members: Adolfo Benito, Ainara Arnaiz, Ana Catalán, Ana González-Pinto, Ana Landa, Celso Iglesias, Clemente García-Rizo, Consuelo Llinares, David Fraguas, Demetrio Mármol, Eduard Parellada, Fernando Montiano, Francisco Salido, Ignacio García, Ignacio Zarranz, Jesús Mesones, Jesús Morillas, José A. Alcalá, Jose L. Montero, José M. Montes, José M. Olivares, José R. Gutiérrez, Juan A. Martínez, Juan J. Fernández, Luis Docasar, Luis Gutiérrez, Luis San, M. Ángeles Escudero, Manuel Serrano, M. Luisa Terradillos, Mariano Villar, Marina Díaz, Mario Páramo, Marta Alonso, Mercedes Hellín, Migdyrai Martín, Miguel Lliteras, Miquel Bioque, Nieves Prieto, Pedro Sopelana, Pilar Saiz, Rosa Gutiérrez, Rosa Molina, Rubén T. López, Samuel Leopoldo, Santiago Ovejero, Selman Franco, Sergio Sánchez, Tomás Castelló, Vicente Tordera M. José Escartín, José M. Mongil, Julián Rodríguez.