East Asian Arch Psychiatry 2014;24:139-147

ORIGINAL ARTICLE 

杨剑云、吴日岚、潘佳雁

Dr Kim-Wan Young, PhD, RSW, Department of Social Work, Hong Kong Baptist University, Hong Kong SAR, China.
Prof. Petrus Ng, PhD, PsyD, RSW, Department of Social Work, Hong Kong Baptist University, Hong Kong SAR, China.
Dr Jiayan Pan, PhD, RSW, Department of Social Work, Hong Kong Baptist University, Hong Kong SAR, China.

Address for correspondence: Dr Kim-Wan Young, Department of Social Work, Hong Kong Baptist University, Kowloon Tong, Hong Kong SAR, China.
Tel: (852) 3411 7772; Fax (852) 3411 7145; Email: danielyoung@hkbu.edu.hk

Submitted: 14 May 2014; Accepted: 3 September 2014

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Introduction

Many people hold a pessimistic view towards the progressive deteriorating course of consumers with severe mental illness, leading to increased impairment in functioning of these individuals.¹ On the contrary, research has shown that many consumers with severe mental illness can achieve recovery.^1,2 Recovery has been adopted as an important element of mental health policy in many western countries.³ Also, recovery is found relevant to Chinese consumers with severe mental illness and plays a significant role in the rehabilitation outcomes of these individuals.⁴

Since the initial conceptualisation of recovery proposed by Anthony,⁵ a variety of definitions have been proposed and there is no single definition of recovery.⁶ In general, the literature has defined and focused on recovery as an outcome or a process. Those researchers regarding recovery as a process define recovery as a way of living a satisfying, hopeful, and contributing life, even within the limitations of a mental illness.⁷ Those defining recovery as an outcome tend to focus on symptom reduction and improvement in functioning.⁶ In fact, recovery is a complex process and may involve different dimensions of recovery, including clinical recovery, functional recovery, existential recovery, physical recovery, and social recovery.⁸ Functional recovery, which reflects improved social and vocational functioning, has been identified by many researchers and mental health professionals as an important treatment outcome for consumers with severe mental illness.

Functional Recovery

The conceptual framework of functional recovery is greatly influenced by that of clinical recovery and symptom remission, which needs to be mentioned first. A criteria- based definition of symptom remission in schizophrenia has been proposed by Andreasen et al⁹ who define symptomatic remission as a state no greater than mild severity in core psychotic symptoms, as measured by standardised measuring tools (e.g. Brief Psychiatric Rating Scale¹⁰ [BPRS]), that are well maintained for a minimum duration of 6 months. Nowadays, Andreasen et al’s definition of symptom remission is widely regarded as clinical recovery.⁹

Similar to symptom remission, functional remission is proposed as a tenable concept and is regarded as functional recovery for consumers with severe mental illness.¹¹ Recently, a definition of functional recovery has been proposed by Harvey and Bellack¹¹ according to which functional recovery is a state of no or only minimal disability in core functioning areas leading to greater individual autonomy, including productive activities, self- maintenance activities, and social relationships that are well maintained over a 6-month period.

However, unlike clinical recovery, there is no common consensus with regard to the measurement of functional recovery.^12,13 Nevertheless, long-term longitudinal follow- up studies have shown that consumers with severe mental illness can achieve functional recovery after their discharge from mental hospitals. For example, Harding et al¹⁴ reported a study of 269 consumers with psychosis who were followed up for a mean of 32 years; about half of the subjects achieved functional recovery at follow-up. The World Health Organization (WHO) International Study of Schizophrenia followed 1633 people with schizophrenia in 14 countries for 15 to 25 years, and reported that about half of the research subjects achieved functional recovery.¹⁵ Also, in a review of 85 long-term follow-up studies published between 1919 and 1994, nearly half of the research subjects with severe mental illness were found to achieve functional recovery.² Similarly, in another review of 10 long-term follow-up studies published between 1974 and 2001, about half of the research subjects with severe mental illness were found to achieve functional recovery.¹

Although the long-term longitudinal follow-up studies described above found that about half of the consumers with severe mental illness can achieve functional recovery after getting discharged from the mental hospital for ≥ 15 years, little is known about the functional recovery rate in the short-term follow-up period after their discharge from mental hospitals. Those few studies done in this area indicated that the rate of functional recovery within the short-term follow-up period for consumers with severe mental illness ranged from 10.2% to as high as 35% (Table 1^16-26). Also, functional recovery was found to yield a better quality of life.²³

Moreover, researchers have tried to identify those factors that predict functional recovery. Research results showed that better cognitive functioning,^20,25 better premorbid adjustment,²⁵ better social functioning at baseline,¹⁸ and having a job at baseline²² were found to be significant predictors of functional recovery. On the other hand, some studies identified the following factors related to functional recovery: age,²² gender,¹⁶ shorter duration of illness,²⁰ and symptom remission at earlier stage²³; however, these findings were not supported in other studies.²⁵

The research studies on functional recovery described above have some limitations. Firstly, all except one of the above studies on the functional recovery of consumers with severe mental illness were carried out in western countries. However, functional recovery is not only affected by the severity of an individual’s symptoms and functioning level, but also by the social and cultural environment.¹⁸ Thus, it is important to study the functional recovery rate and identify factors predicting functional recovery in a local context, especially in non-western societies. Secondly, the above studies involve research subjects with different characteristics and severity of illness. Whether or not these subjects were recently discharged from mental hospitals remains unclear. Thus, it is important to investigate the functional recovery for those who are recently discharged from a mental hospital, which is the focus of this study. Finally, the identification of factors predicting functional recovery remains inconclusive, and, thus, more research work needs to be done in this area.

In Hong Kong, local studies on the functional recovery of consumers who get discharged from mental hospitals are lacking and, therefore, it needs further investigation. This research study attempted to explore the prevalence of functional recovery among consumers discharged from a mental hospital and receiving community- based psychosocial treatment from a non-governmental organisation (NGO), and identify factors predicting functional recovery for these individuals in the Hong Kong context.

Methods

Research Design and Data Collection

A prospective, naturalistic, longitudinal follow-up research design was adopted in this study. A cohort of Chinese consumers with severe mental illness who were receiving community-based rehabilitation services from an NGO in Hong Kong between 2006 and 2008 was followed up for 12 months. Convenience sampling was used to recruit participants.²⁷ The inclusion criteria for this study were: (a) meeting the DSM-IV-TR criteria for the diagnoses of any kind of mental disorders²⁸; (b) a history of discharge from a psychiatric hospital within the previous 2 years and currently living in the community; and (c) aged between 15 and 70 years. The community-based rehabilitation service provided by the NGO mainly included outreach case management and vocational rehabilitation services. This study was approved by the Review Board of the Executive Committee of the concerned NGO, and data collection began in 2006 and was completed in 2009. All data analyses were performed by using SPSS Windows version 21.0 (Armonk, NY [US]).

At baseline, a total of 120 consumers with severe mental illness were recruited and had given their written consent to participate in this study after the experimental procedures were fully explained to them. These participants were followed up for 12 months. Data were collected at baseline, after a period of 6 months, and after 12 months. Standardised measuring scales were used to assess their social functioning, psychiatric symptoms, self-efficacy, and quality of life. Also, basic demographic and medical data were obtained from participants and staff of the NGO upon the participants’ consent.

Among these 120 participants, 87 were successfully interviewed at baseline, after 6 months and after 12 months, while 33 subjects were lost to follow-up and their data were not available. The reasons for defaulting follow-up included death, admission to a halfway house or residential care homes for the elderly, hospital readmission, or refusal to be interviewed.

Measuring Instruments

St. Louis Inventory of Community Living Skills

The Chinese version of St. Louis Inventory of Community Living Skills²⁹ (SLICLS) was used in this study to measure the functional recovery of participants. In this study, the approach to functional recovery proposed by Harvey and Bellack¹¹ was adopted, and the criteria for functional recovery were defined as having no or only minimal disability in all functioning areas as measured by the SLICLS over a 6-month observational period. Thus, functional recovery required that all SLICLS items had to be scored ≥ 5 on a scale ranging from 1 (few or no skills) to 7 (self-sufficient and very adequate skills) during a 6-month observational period. The validity and reliability of the Chinese version of the SLICLS has been tested and found to be satisfactory.²⁹ In this study, the SLICLS was used by social workers of the NGO who were the case managers of the participants.

Brief Psychiatric Rating Scale

Brief Psychiatric Rating Scale¹⁰ was used in this study to assess the remission of symptoms in participants. In this study, the definition of symptom remission proposed by Andreasen et al⁹ was adopted, and the criteria for symptom remission were defined as having no symptoms, or at most, mild psychiatric symptoms as measured by the BPRS over a 6-month observational period. Symptom remission required that all the BPRS item scores be 3 (mild) or less on a scale ranging from 1 (not present) to 7 (severe) during a 6-month observational period. In this study, the BPRS was used by psychiatric nurses of the NGO who were familiar with the participants.

General Self-Efficacy Scale

The Chinese version of General Self-Efficacy Scale (SES)³⁰ was used to measure the self-efficacy of the participants. The scale has been translated into various languages, and its Chinese version has been tested with satisfactory validity and reliability.³⁰ Each item was rated by the participants on a 4-point scale, with higher scores indicating a higher level of self-efficacy.

World Health Organization Quality of Life Instrument

The Chinese version of WHO Quality of Life brief version (WHOQOL-BREF), which has been reported as demonstrating adequate validity and reliability,³¹ was used to measure the quality of life of the participants. This 28-item Chinese version of the WHOQOL-BREF assesses an individual’s perception of his or her overall quality of life as well as 4 quality-of-life domains (physical, psychological, social relationships, and environmental). The response set for each item ranged from 1 to 5, with 5 indicating a better overall quality of life.

Results

Characteristics of the Research Sample at Baseline

As data were only available for 87 participants, the analysis below was based mainly on this cohort of participants. Their baseline characteristics are shown in Table 2. Over half of the subjects was female, with a mean (± standard deviation [SD]) age of 39.3 (± 12.7) years (range, 18-72 years). About half of them (48%, n = 42) were single, about one- third were married, while the rest were separated, divorced, or widowed. Approximately 60% of them had completed secondary school, 22% had completed primary school, and 12% college or university. At baseline, only about 10% achieved open employment, i.e. working at a full-time or part-time paid job, and a small proportion was attending some kind of vocational training programme (6.9%, n = 6). The most common diagnosis was schizophrenia (57%), followed by mood disorder (37%) and some other psychosis or personality disorder (6%). All of them had been admitted to a mental hospital at least once, and more than two- thirds (69%, n = 60) had been admitted more than once. Most of them suffered from a mental illness for a long time, ranging from 1 to 47 years, with the mean of 9.1 ± 9.5 years. Besides, participants had a mean baseline BPRS score of 33.78 ± 7.39 and 43% (n = 37) of them currently manifested at least 1 psychiatric symptom rated as moderate or above. Also, participants had a mean SLICLS score of 82.87 ± 12.29 and 80% (n = 70) of them manifested at least 1 significant problem in their social functioning which needed a moderate or higher level of assistance. Participants had a mean of 4.68 ± 10.72 significant problem areas in their social functioning as assessed by SLICLS. More than half of the participants had a significant problem in leisure activities, meal preparation, and clothing maintenance. Most of them did not manifest any significant problem in their self-care skills.

Outcome Assessment at Baseline, after 6 Months, and after 12 Months

As shown in Table 3, after receiving community-based rehabilitation services for 12 months, this cohort of participants achieved improvement in their overall quality of life assessed by the WHOQOL-BREF (one-way analysis of variance [ANOVA] repeated measure, F = 11.77, p < 0.001), improvement in all 4 quality-of-life domains as assessed by the WHOQOL-BREF (physical domain: F = 13.19, p < 0.001; psychological domain: F = 15.40, p < 0.001; social relationships domain: F = 3.4, p < 0.05; and environmental domain: F = 7.86, p < 0.01), reduction in psychiatric symptoms as assessed by the BPRS (F = 52.17, p < 0.001), improvement in social functioning as assessed by the SLICLS (F = 64.27, p < 0.001), and improvement in self-efficacy as measured by the SES (F = 6.10, p < 0.001). In addition, a significantly higher proportion of participants was working at a full-time or part-time job at the 12-month follow-up (39%) than that at baseline (10%).

Functional Recovery during the Follow-up Period

As SLICLS and BPRS data at 6 months before baseline were not available, the rate of functional recovery or symptom remission at baseline could not be calculated. At 6-month follow-up, few participants (5%) achieved functional recovery, while nearly half (48%) achieved symptom remission. At 12-month follow-up, 23% of the participants achieved functional recovery, while 79% achieved symptom remission (Table 3).

Functional Recovery Yielded a Better Quality of Life

The characteristics of subjects who achieved functional recovery (functionally recovered group) were compared with those who did not (non-recovered group) [Table 2].

At 12-month follow-up, the functionally recovered group had better outcomes than the non-recovered group in 2 quality-of-life domains (psychological: one-way ANOVA test, F = 9.84, p < 0.01; environmental: F = 7.12, p < 0.01). Also, self-efficacy in the functionally recovered group did not significantly differ from that in the non-recovered group.

Factors Relating to Functional Recovery

The functionally recovered group and the non-recovered group did not show any significant differences in the baseline demographic and medical background area including sex, age, marital status, education, diagnosis, duration of illness, open employment (i.e. having a full-time or part-time paid job), current level of psychiatric symptoms, quality of life, and self-efficacy. The 2 groups differed only in terms of their baseline social functioning level, with the functionally recovered group having better social function than the non- recovered group (one-way ANOVA test, F = 10.41, p = 0.002).

Functional recovery was found to be associated with the following variables: lower BPRS score at 12 months (one-way ANOVA test, F = 9.05, p = 0.003), higher SLICLS score at 6 months (F = 14.76, p < 0.001) and at 12 months (F = 20.90, p < 0.001), having open employment at 6 months (Pearson Chi-square [χ²] = 6.76, p = 0.01) and at 12 months (χ² = 4.94, p = 0.03), as well as higher quality-of-life scores in psychological and environmental domains at 12 months. More details are shown in Table 2.

Factors Predicting Recovery and Remissions

In order to identify the variables predicting functional recovery, multivariate logistic regression analysis was conducted with functional recovery included as a dependent variable, while the related variables were placed into the multivariate logistic regression models. Stepwise model reduction was conducted by dropping non-significant variables from the model.

According to Table 4, results indicated that functional recovery was significantly predicted by functioning level at 12 months (odds ratio [OR] = 1.15; 95% confidence interval [CI], 1.06-1.26; p = 0.001), psychiatric symptoms at 12 months (OR = 0.50; 95% CI, 0.30-0.82; p = 0.01), and having open employment at 12 months (OR = 4.47; 95% CI, 1.08-18.51; p = 0.04). In particular, having open employment at 12 months was found to be the strongest predictor of functional remission. These 3 predicting factors altogether accounted for 54.4% variance of functional recovery.

Discussion

This prospective longitudinal follow-up research study found that 23% of the consumers discharged from mental hospital and receiving community-based psychosocial services from an NGO in Hong Kong achieved functional recovery within 1 year. This result is comparable with that reported in previous studies which indicate that the short-term functional recovery rate ranges from 10.2% to 35%.^{16,18,20,22,23,25,26} As shown in the present study, the fact that < 25% of research subjects achieved functional recovery while > 75% achieved clinical recovery (i.e. symptom remission) within 1 year indicates that it is far more difficult to facilitate functional recovery than clinical recovery for consumers discharged from a mental hospital. This research finding is consistent with that from previous studies.^{18,20,22,25,26} Thus, it is important to develop more effective interventions to improve the functional recovery rate for consumers discharged from mental hospitals.

The difference in the reported rate of functional recovery between the present study and other previous studies (Table 1^16-26) is due to a number of reasons, which warrant more discussion. Firstly, the difference in severity of illness of research subjects may yield different functional recovery rates among studies. For example, subjects with lower severity of illness were included in the study done by Lambert et al,²² which may explain their high recovery rate. The research subjects in the present study were characterised by recent discharge from a mental hospital, unemployment, manifesting a mean of 4.68 significant problems in their social functioning, and currently manifesting at least 1 psychiatric symptom. These research subjects had higher severity of illness than those in the study by Lambert et al²²; thus, it is not surprising that the present study reported a lower functional recovery rate. Secondly, different socioeconomic conditions may yield different functional recovery rates for consumers. For example, research subjects in Bali¹⁸ achieved high employment rate because most of them were farmers or household industry workers and were allowed to work according to decreased level of disability, which may lead to their higher functional recovery rate. On the other hand, research subjects in Spain²⁵ were not expected to resume their vocational roles after receiving a disability social benefit, which may contribute to their lower functional recovery rate. In Hong Kong, low unemployment rate and relatively low level of welfare benefits have been consistently observed in recent years. Under such socioeconomic situations, consumers were motivated to seek open employment. In the present study, at 1-year follow-up, the employment rate was 39% for all participants and 60% for functionally recovered patients, which was relatively high compared with that reported in European countries.²² It may explain the higher functional recovery rate in the present study than that reported in Spain.²⁵ Finally, different local rehabilitation services are provided in different societies, which may affect the functional recovery rate for consumers. For example, research subjects included in 3 previous studies received more intensive and comprehensive rehabilitation services such as Assertive Community Treatment,²³ early psychosis prevention and intervention,¹⁶ as well as case management, day hospital and family psycho-education services.²⁰ This may explain the higher functional recovery rate reported in these studies.^16,20,23 In the present study, research subjects received outreach case management and vocational training, which seemed to be effective in facilitating functional recovery in the Hong Kong context. In sum, in the present study, the provision of outreach case management and vocational rehabilitation as well as local socioeconomic conditions in facilitating consumers to achieve open employment may contribute to the relatively high functional recovery rate within 1 year of follow-up period in the Chinese culture and Hong Kong context.

On the other hand, the present study has identified the following 3 factors predicting functional recovery: better social functioning, open employment, and fewer psychiatric symptoms. These factors altogether accounted for half of the variance in functional recovery. These research findings are supported by previous studies.^18,22,26 These findings also have important implications for community-based rehabilitation services. In fact, the 3 factors identified as predicting factors for functional recovery, i.e. better social functioning, open employment, and fewer psychiatric symptoms, are all modifiable. Thus, it is important for community-based rehabilitation services to help consumers to reduce psychiatric symptoms, improve social functioning, and achieve open employment. Effective interventions have been developed and are available for reducing psychiatric symptoms, improving social functioning, and enhancing open employment, including drug therapy, case management, social skill training, family psycho-education, and supported employment.^32,33 Having said that, interventions effective in facilitating functional recovery vary from one country to another due to the differences in local rehabilitation services. The community-based rehabilitation service involved in this present study emphasised providing outreach case management as well as vocational training, which seemed to be effective in facilitating functional recovery in the local context. Vocational training was provided in the form of supported employment as well as assistance in seeking open employment. The outreach case management service, which provided regular home visits, regular needs assessment, skills training, and family psycho-education could help consumers to stabilise the mental state and achieve open employment.

Several methodological limitations of this longitudinal study require attention. Firstly, this study involved a community-based psychosocial programme which emphasised on providing case management as well as vocational training in the local context, and so the present research findings on functional recovery might not be generalised to other settings involving different severity of illness of participants, different contents of treatment programmes, as well as different socioeconomic circumstances. Secondly, in this study, functional recovery was measured by SLICLS which was rated by the social workers of the community-based psychosocial treatment programme who also delivered case management services to participants. Thus, the reported improvement in SLICLS for participants should be interpreted with caution. Nevertheless, the functional recovery rate reported in this study was found comparable to that reported in previous studies.^{16,18,20,22,23,25,26} Thirdly, this prospective longitudinal follow-up study lacked a control group for comparison which might also limit generalisation of the research results. The improvement in functioning, psychiatric symptoms, and quality of life of participants might be due to other interventions such as rehabilitation services delivered by the mental hospital as well as change in psychiatric medications. In future, it would be better to conduct a large-scale randomised controlled study with blinded assessment to validate the effectiveness of community- based psychosocial treatment programme on facilitating functional recovery. Finally, the participants were followed up only for 1 year in this longitudinal study. It would be better to conduct a naturalistic longitudinal study with a longer follow-up period so as to identify various functional recovery rates for consumers according to different follow- up periods after their discharge from mental hospitals.

Conclusions

As shown in this study, about 25% of participants achieved functional recovery while about 75% achieved symptom remission within 1 year, which indicates that it is far more difficult to achieve functional recovery than clinical recovery for consumers discharged from mental hospitals. Thus, it is important to develop more therapeutic interventions to improve the functional recovery rate for these individuals. Helping consumers to improve social skills, achieve open employment, and reduce psychiatric symptoms are identified as significant factors predicting functional recovery, and thus, it is recommended to incorporate these elements in the local community-based rehabilitation services in order to facilitate functional recovery for consumers discharged from mental hospitals in the local context.

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