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Recovery From Schizophrenia in Community-Based Psychosocial

Rehabilitation Settings Rates and Predictors

Article  in  Research on Social Work Practice · June 2015

DOI: 10.1177/1049731515588597

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Original Article
Research on Social Work Practice
1-14
Recovery From Schizophrenia in ª The Author(s) 2015
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Community-Based Psychosocial DOI: 10.1177/1049731515588597
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Rehabilitation Settings: Rates
and Predictors

Caroline Lim1, Concepción Barrio1, Mercedes Hernandez1,

Armando Barragán1, and John S. Brekke1

Abstract
Objective: We assessed the rate of recovery from schizophrenia in community-based psychosocial rehabilitation and
whether psychosocial attributes predicted the achievement of recovery beyond demographic and clinical characteristics.
Methods: We used data from 246 individuals with schizophrenia spectrum disorder collected at baseline and at 6 and
12 months after admission to psychosocial rehabilitation. Results: The proportion of participants who showed recovery during
either 6-month period and the full 1-year period was 19.86% and 7.53%, respectively. Although predictors of recovery for the
1-year period could not be reliably estimated due to its low rate, higher levels of intrinsic motivation and more positive family
relationships at baseline predicted recovery for either 6-month period after controlling for initial functioning capacity.
Conclusions: One in five individuals with schizophrenia who engage in intensive community-based psychosocial rehabilitation
can achieve periods of recovery during treatment. Psychosocial attributes at the start of treatment are important contributors to
subsequent recovery.

Keywords
schizophrenia, recovery, predictors, psychosocial rehabilitation

Schizophrenia, which affects approximately 24 million Literature Review

people worldwide, is considered a serious mental illness
(National Institute of Mental Health, 2009; World Health
Organization, 2013). The onset of the disorder typically
occurs during the critical developmental period of late ado-
lescence and emerging adulthood, and significant social and
occupational impairment are often the corollary of florid
psychotic symptoms (American Psychiatric Association,
2000). The longitudinal course interspersed with acute exacer-
bation and the extent and persistence of psychosocial impair-
ment between episodes distinguish schizophrenia from
other mental disorders, making it one of the most disabling
psychiatric disorders (Harrow, Grossman, Jobe, & Herbener,
2005; McGlashan, 1988). Psychosocial dysfunction as a
concomitant of symptom onset places affected individuals
at risk of socioeconomic disadvantages (Susser, Lin, &
Conover, 1991; Susser, Moore, & Link, 1993). Research
to determine factors that promote recovery and the propor-
tion of individuals with schizophrenia who have the poten-
tial for recovery is necessary and beneficial to facilitate the
development of interventions or enhancement of existing
treatments to generate more favorable outcomes in individ-
uals with schizophrenia.
Recovery From Schizophrenia
Accumulating evidence from several longitudinal studies of
schizophrenia, documenting a more heterogeneous and promis-
ing long-term course, has challenged the conventional notion
that schizophrenia is a mental disorder characterized by a uni-
formly poor outcome (Hegarty, Baldessarini, Tohen, Waternaux,
& Oepen, 1994; Jääskeläinen et al., 2012; McGlashan, 1988).
Accordingly, favorable findings from these long-term outcome
studies have prompted research on recovery from schizophre-
nia (Bellack, 2006). An outgrowth of this research activity
included developing an operational definition of recovery that
can be organized into two broad groups: outcome-oriented
1
School of Social Work, University of Southern California, Los Angeles, CA,
USA
Corresponding Author:
Concepción Barrio, School of Social Work, University of Southern California,
Montgomery Ross Fisher Building, 669 W. 34th Street, Los Angeles, CA 90089,
USA.
Email: cbarrio@usc.edu

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2 Research on Social Work Practice
research and process-oriented research (Jääskeläinen et al.,
2012; Lieberman et al., 2008; Silverstein & Bellack, 2008).
Outcome-oriented definitions emphasize recovery as marked
by abatement of psychotic symptoms and restoration of func-
tioning to premorbid levels (e.g., Liberman, Kopelowicz,
Ventura, & Gutkind, 2002). Process-oriented definitions
describe ways of coping and managing mental health despite
the challenges and limitations caused by the disorder (Anthony,
1993; Resnick, Fontana, Lehman, & Rosenheck, 2005; Resnick,
Rosenheck, & Lehman, 2004). Another notable difference
between outcome-oriented and process-oriented definitions of
recovery is that the former were developed for the purpose of
facilitating comparative evaluations of treatments. Process-
oriented definitions, however, were geared toward advocating
for changes in the mental health system from a paternalistic to
a recovery-oriented model of care (Bellack, 2006). However, the
mental health community has not been able to reach a consensus
on how best to define the concept of recovery as it applies to
schizophrenia (Bellack, 2006; Lieberman et al., 2008; Onken,
Craig, Ridway, Ralph, & Cook, 2007; Silverstein & Bellack,
2008). Indeed, various definitions of recovery have been pro-
posed (Færden, Nesvåg, & Marder, 2008). Regardless of how
recovery is operationalized, the research agenda for schizophre-
nia should include the identification of malleable factors related
to recovery (Liberman, 2002; Silverstein & Bellack, 2008). To
this end, many outcome studies on schizophrenia have applied
an outcome-oriented definition of recovery in investigating its
rate and predictors.
Predictors of Recovery
Researchers have applied variants of outcome-oriented defini-
tions of recovery to determine predictors of recovery from schi-
zophrenia. Findings from studies focusing on biological or
clinical variables have indicated that recovery is predicted by
female gender, younger age (Lambert et al., 2008; Verma, Sub-
ramaniam, Abdin, Poon, & Chong, 2012), shorter duration of
untreated psychosis (Petersen et al., 2008), better premorbid
adjustment (Bertelsen et al., 2009; Petersen et al., 2008),
absence of deficit syndrome (Petersen et al., 2008; Strauss,
Harrow, Grossman, & Rosen, 2010; Verma et al., 2012),
absence of Schneiderian first-rank symptoms (Rosen, Grossman,
Harrow, Bonner-Jackson, & Faull, 2011), milder psychopathol-
ogy at presentation (Bertelsen et al., 2009), better cognitive func-
tion (Kopelowicz, Liberman, Ventura, Zarate, & Mintz, 2005),
higher level of medication adherence (Petersen et al., 2008), bet-
ter response to antipsychotic medication during the early course
of treatment (Lambert et al., 2008; Verma et al., 2012), and
absence of substance use (Petersen et al., 2008).
Conceptual Framework
The stress–diathesis model forms the basis for understanding
the course of schizophrenia and has guided the management
of schizophrenia (Rosenthal, 1970). The model considers the
confluence of predisposing traits, clinical characteristics, and
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environmental factors in understanding outcomes in schizo-
phrenia. The model posits that stress is a precipitating factor
that triggers the first psychotic break among individuals with
preexisting vulnerability and an important prognostic factor
that can impinge on the course of schizophrenia by exacerbat-
ing symptoms (Rosenthal, 1970). Notwithstanding the impor-
tance of stress, the model suggests that favorable environmental
factors such as strong social support and rich personal capital,
in the context of reduced biological vulnerability, can provide
a buffer against the deleterious effects of stress to prompt a more
favorable prognosis (Mueser & McGurk, 2004). Therefore, in
our efforts to achieve a deeper understanding of recovery from
schizophrenia, it is necessary to investigate the contribution of
psychosocial factors, particularly in the context of psychosocial
rehabilitation in which social work practitioners are charged
with planning for the provision and delivery of therapies that tar-
get intrapersonal resources and the environment.
Gaps in Research on Recovery
There are several noteworthy gaps in past research that the cur-
rent study sought to address. Most notably, empirical studies
have tended to examine the influence of nonmalleable factors
(e.g., gender) or factors that are mostly targets of pharma-
cotherapy (e.g., severity of psychopathology), thus causing a
gap in knowledge about the effects of psychosocial factors on
recovery from schizophrenia. Due to this emphasis on identify-
ing demographic and clinical predictors, it is unclear whether
there are other unidentified malleable predictors of recovery
that are capable of being influenced using psychosocial inter-
ventions and informal support systems of family and friends.
This gap in knowledge could hamper the development of a col-
laborative relationship among mental health clinicians, allied
health professionals, and caregivers to facilitate better out-
comes for individuals with schizophrenia. Indeed, one of the
contentious issues raised by the consumer movement is that
mental health professionals have often failed to include consu-
mers and family members as partners in the treatment process
(Bellack, 2006).
Second, although the influence of psychosocial correlates
has been evaluated qualitatively, few empirical studies have
quantitatively assessed the impact of these factors on recovery.
Findings from qualitative studies of individuals considered to
be in recovery from severe mental illnesses that included schi-
zophrenia have suggested the importance of personal attributes
and social factors in facilitating recovery. Hope of recovery
(Ridgway, 2001), self-determination (Mancini, 2007; Ochocka,
Nelson, & Janzen, 2005), spirituality and religion (Barham &
Hayward, 1998), presence of meaningful activities (Dunn,
Wewiorski, & Rogers, 2008; Mancini, Hardiman, & Lawson,
2005), elimination of stigma (Jacobson & Greenley, 2001;
Ridgway, 2001), peer support (Mancini, 2007; Schön, Denhov,
& Topor, 2009), resilience (Torgalsbøen & Rund, 2010), strong
clinician–client relationship (Green et al., 2008), and social
support (Cohen, 2005; Davidson, 2003; Jacobson & Greenley,
2001; Mancini et al., 2005; Schön et al., 2009) are among the
Lim et al.
important facilitative psychosocial factors of recovery identi-
fied in qualitative studies.
Third, several psychosocial factors that have been investi-
gated for their association with more favorable outcomes
marked by circumscribed deterioration in function or less
severe symptomatology have not been empirically tested for
their predictive relationships with recovery, a more demanding
treatment outcome that requires concurrent resolution of psy-
chotic symptoms and restoration of functioning. For example,
previous research has demonstrated that better functional
outcomes in schizophrenia are predicted by higher levels
of intrinsic motivation (Gard, Fisher, Garrett, Genevsky, &
Vinogradov, 2009; Nakagami, Hoe, & Brekke, 2010; Nakagami,
Xie, Hoe, & Brekke, 2008; Saperstein, Fiszdon, & Bell, 2011)
and self-esteem (Brekke & Long, 2000; Roe, 2003). Despite the
association of intrinsic motivation and self-esteem with better
functional outcomes, previous research has not investigated
whether these factors that are malleable to psychosocial inter-
ventions are related to recovery from schizophrenia.
Finally, there is a dearth of research on recovery in
community-based psychosocial settings. Previous research has
been limited to clinical specialty programs that deliver varying
intensity of psychosocial rehabilitation interventions. At pres-
ent, it is not clear how many individuals with schizophrenia
who are engaged in community-based psychosocial rehabilita-
tion have the potential to achieve periods of recovery. Asses-
sing recovery in such a setting is necessary because between
a quarter and a third of individuals with schizophrenia and
other severe mental illnesses participate in psychosocial
rehabilitation programs (Hatfield, Gearon, & Coursey, 1996;
Lehman & Steinwachs, 1998). Assessing how readily recovery
can be achieved in community-based psychosocial rehabilita-
tion programs and understanding the specific promoters of
recovery would be beneficial for social work practitioners in
psychosocial settings.
Study Aims and Hypotheses
The intent of this study was to fill the research gap by assessing
recovery from schizophrenia in community-based psychosocial
settings. Specifically, the aims of this study were twofold (a) to
assess the percentage of individuals with schizophrenia spec-
trum disorder who show periods of recovery, for either any
6-month period or the full 1-year period, during the first year
of intensive psychosocial rehabilitation for their current admis-
sion and (b) to investigate the effects of baseline intrapersonal
attributes (intrinsic motivation and self-esteem) and social fac-
tors (family network relations and social support), hereafter
referred to as psychosocial predictors, on subsequent recovery,
after controlling for the influence of demographic and clinical
characteristics (gender, educational attainment, length of ill-
ness, substance use, medication use, severity of symptomatol-
ogy, and role and social functioning). This study included
mostly non-first-episode participants (subsequently described)
who may have received treatment—pharmacotherapy, psycho-
social rehabilitation, or a combination—before their current
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3
admission. Therefore, the examination of recovery during the
first year of intensive psychosocial rehabilitation pertained to
the period of current treatment and does not imply a first-
episode sample.
The demographic and clinical variables selected were based
on findings from prior studies reporting a predictive relation-
ship with recovery (e.g., Lambert et al., 2008; Rosenthal,
1970). Informed by the stress–diathesis conceptual framework,
we examined the predictive strength of personal attributes
defined by intrinsic motivation and self-esteem and social fac-
tors defined by social support and family relationships on
recovery. Severity of symptomatology and functioning at base-
line were included as covariates to minimize spurious associa-
tions between psychosocial variables and recovery (Johnson,
2005). Several salient variables such as duration of untreated
psychosis and treatment characteristics could not be included
in the model due to insufficient or unavailable data. We
hypothesized that recovery would be predicted by more favor-
able psychosocial attributes, namely, higher levels of intrinsic
motivation, higher levels of self-esteem, more intact family
network relations, and higher levels of social support, after
adjusting for salient demographic and clinical characteristics.
Method
Sample Selection
Data came from two longitudinal studies conducted in Los
Angeles, CA, designed to identify factors related to individual
responsiveness to psychosocial rehabilitation services in the
community. Participants (N ¼ 328) were recruited between
1996 and 2005 at admission to one of six community psycho-
social rehabilitation programs operating in the Los Angeles
public mental health sector. These programs had been serving
individuals with severe mental illness for more than 50 years
through the provision of mental health services (e.g., mental
health treatment; vocational, social, and independent living ser-
vices; substance abuse treatment; and 24-hr crisis response)
aimed at facilitating maximum community adjustment and
integration and were selected for study involvement because
data have demonstrated that they yielded improvement in func-
tional outcomes among participants. Both studies applied sim-
ilar inclusion criteria: (a) age 18–55 years, (b) received a chart
diagnosis of psychotic disorder, (c) absence of alcohol or drug
dependence during the previous 6 months, and (d) absence
of neurological illness. Participants completed a battery of
research assessments at admission and every 6 months there-
after during a period of up to 2 years. For the purpose of this
study, analyses were conducted using data collected at baseline
and 6 and 12 months after admission. The analytic sample fea-
tured 246 individuals with schizophrenia spectrum disorder:
168 from the first longitudinal study and 78 from the second
study. Participants who were not diagnosed with a schizophre-
nia spectrum disorder (n ¼ 62) or had missing diagnosis
(n ¼ 20) were excluded from the analyses. Participants from
both longitudinal studies were comparable in demographic and
4 Research on Social Work Practice
clinical characteristics except that participants in the latter
longitudinal study presented with more severe symptomatol-
ogy and most had racial minority backgrounds. Both studies
were reviewed and approved by the affiliated university’s insti-
tutional review board and the Los Angeles County Department
of Mental Health’s Research Committee.
Measurements
Demographic and psychiatric history form. Demographic and psy-
chiatric history data used for this study were participants’ age,
gender, race, highest level of education completed, age at onset
of psychiatric illness, and length of illness. These data were
collected as part of the baseline assessment. Educational attain-
ment was determined by asking participants to indicate whether
they had completed high school or an equivalent credential
(e.g., general equivalency diploma). This variable was dichot-
omized, with participants who did not have at least a high
school credential forming the reference group. Age at onset
was determined by asking participants how old they were when
they first saw a mental health professional. Length of illness
was calculated by subtracting the age at onset from the age at
study entry and represented the period following the first onset
of unspecified psychiatric symptoms that were sufficiently dis-
tressing to prompt participants to seek mental health treatment.
Diagnosis was determined using clinical records, a checklist of
symptoms according to the Diagnostic and Statistical Manual
fourth edition criteria (American Psychiatric Association, 1994),
and collateral reports from the admitting clinician and on-site
psychiatrists.
Community adjustment form. This instrument (Test et al., 1991)
was used to assess substance use, medication use, and level of
intrinsic motivation.
Alcohol and substance use. Alcohol and substance use were
determined by assessing the frequency of alcohol, marijuana,
and street drug consumption during the previous 6 months
based on participants’ self-report. The variable was dichoto-
mized as 0 (no alcohol or substance use during the previous
6 months) and 1 (use of alcohol or substances during the pre-
vious 6 months).
Medication use. Medication use was defined as days of use of
any antipsychotic medications during the previous 180 days.
Given the bimodal distribution, with predominant response
categories of full use (180 days) and nonuse (0 days), the
variable was dichotomized as low use and regular use. In
accordance with the criterion proposed by Kane, Leucht,
Carpenter, and Docherty (2003), participants who reported not
being on any antipsychotic medication for more than 50% of
the time during the previous 6 months were coded as low use.
Intrinsic motivation. Intrinsic motivation refers to the desire to
engage in certain behaviors due to curiosity, interest, enjoy-
ment, and satisfaction derived from participation (Deci &
Ryan, 1985; Ryan & Deci, 2000). It was measured by 4 of the
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6 items from the intrapsychic deficit subscale of the Quality of
Life Scale (Heinrichs, Hanlon, & Carpenter, 1984): sense of
purpose, motivation, curiosity, and anhedonia. Sense of pur-
pose was defined as the extent to which participants expressed
realistic and integrated goals for their life, motivation measured
the extent to which participants were able to initiate and sustain
goal-directed activities, curiosity reflected the degree to which
participants were interested in their surroundings and ques-
tioned things they did not understand, and anhedonia measured
the extent to which participants were able to experience
pleasure and satisfaction. Each item was rated on a 7-point
Likert-type scale, with lower scores reflecting higher levels
of deficit.
Whereas previous studies have operationalized intrinsic
motivation using only 3 items (Nakagami et al., 2008), the item
measuring anhedonia was added to better represent the con-
struct’s definition, which considers the ability to experience
participatory satisfaction an important characteristic. To deter-
mine whether the 4 items measured one underlying concept,
principal component factor analyses with varimax and promax
rotations were performed. Regardless of the rotational method
applied, one factor was extracted, which accounted for 56.3%
of the variance of the 4 items. Moreover, all items loaded
highly on this factor (loadings of .5 or above). The Cronbach’s
a for these items was .73, demonstrating adequate internal
consistency among the items. Additionally, results from confir-
matory factor analysis using maximum likelihood with miss-
ingness assumed to be at random revealed that the items
loaded strongly and statistically significant at p < .001 on the
latent factor of intrinsic motivation, yielding a model fit of
w2(2, 244) ¼ 2.56, p ¼ .28, root mean square error of approx-
imation ¼ .034, and confirmatory factor index ¼ .998, thus
indicating an excellent fit and providing preliminary evidence
that the 4 items measured the same concept. Accordingly, rat-
ings assigned to the 4 items were aggregated and averaged to
generate a mean score, ranging from 1 to 7, to indicate each
participant’s level of intrinsic motivation.
Index of self-esteem. This 25-item index (Hudson, 1982) was
used to evaluate participants’ level of self-esteem. The items
measure participants’ subjective evaluation of themselves and
others’ perceptions of them. Responses to the items ranged
from 1 (rarely or none of the time) to 5 (most or all of the time).
Reverse coding was performed on 12 items as specified by
Hudson (1982). Responses to all items were summed to derive
an aggregate score for the scale, with higher scores indicating
greater severity of self-esteem problems. Cronbach’s a for this
scale was .90.
Role Functioning Scale (RFS). The RFS (Goodman, Sewell,
Cooley, & Leavitt, 1993) was used to cross-sectionally evalu-
ate the quantity and quality of each participant’s work produc-
tivity, independent living and self-care skills, immediate social
network relationships, and family network relationships. Each
item was rated on a 7-point Likert-type scale ranging from 1
(severely limited) to 7 (no evidence of deficit). The a coefficient
Lim et al.
for the 4 items was .50, indicating that the items were not
closely related and hence should be analyzed separately to
determine their predictive relationship with recovery. For the
purpose of this study, work productivity, social network rela-
tionships, and family network relationships were examined.
Work productivity is a measure of role functioning. In essence,
the variable measures the ability to function in school, indepen-
dent employment, or at home. Immediate social network is an
evaluation of social functioning, essentially the ability to
develop and maintain close relationships with friends. Family
network relationships indicate the extent to which individuals
are able to maintain positive relationships with family members
as characterized by consistent contacts and reciprocity.
Social support. An adapted version of the self-rated Medical
Outcome Study Social Support Survey (Sherbourne & Stewart,
1991) was used to assess perceived social support. The 18-item
survey assesses level of social support in the dimensions of
emotional and informational support, tangible support, affec-
tionate support, and positive social interaction. Items in each
domain were rated from 1 (none of the time) to 5 (all of the
time). The ratings were aggregated and divided by the number
of items completed to achieve an index of each participant’s
level of social support ranging from 1 to 5. Cronbach’s a for
the scale was .95.
Brief Psychiatric Rating Scale (BPRS). The 24-item BPRS (Lukoff,
Nuechterlein, & Ventura, 1986) was administered once every 6
months to assess the presence and severity of psychiatric symp-
toms during the prior 2 weeks. Every item was rated on a
Likert-type scale ranging from 1 (not present) to 7 (extremely
severe) on the basis of each participant’s self-report and beha-
vior during interview.
Strauss and Carpenter Outcome Scale (S-CS). The 3-item S-CS
(Strauss & Carpenter, 1972) was used to evaluate outcomes
of schizophrenia during the previous 6 months in terms of dura-
tion of hospitalization for psychiatric treatment, frequency of
social contacts, and engagement in useful employment, includ-
ing work as a homemaker or student. Each item was rated
on a 5-point Likert-type scale. Higher scores indicated better
outcomes.
Operational Definition of Recovery
We followed the precedent of Harrow, Grossman, Jobe, and
Herbener (2005), Strauss, Harrow, Grossman, and Rosen
(2010), and Ventura et al. (2011) in operationalizing recovery
to enable comparison. Recovery was defined as simultaneously
fulfilling the following set of criteria for a specified duration:
(a) be in symptomatic remission per the operational definition
proposed by the Remission in Schizophrenia Working Group
(Andreasen et al., 2005), (b) demonstrate adequate work func-
tioning defined by a score of 2 or higher on the S-CS item mea-
suring useful employment, (c) demonstrate adequate social
functioning defined by a score of 2 or higher on the S-CS item
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5
measuring social contacts, and (d) receive no psychiatric hospi-
talization defined by a score of 4 on the S-CS item measuring
duration of hospitalization for psychiatric treatment. Two lev-
els of recovery were examined: meeting the aforementioned
criteria for either 6-month period (less demanding criteria) or
the full 1-year period (more stringent criteria) during the first
year of follow-up.
The Remission in Schizophrenia Working Group proposed
that symptomatic remission is achieved if the symptomatology
unique to schizophrenia, namely, delusions, hallucinations, dis-
organized speech, grossly disorganized or catatonic behavior,
and negative symptoms, are of minimal intensity for at least
6 months (Andreasen et al., 2005). To this end, selected BPRS
items that correspond to key features of schizophrenia were
used to determine whether participants achieved symptomatic
remission: grandiosity, suspiciousness, unusual thought con-
tent, hallucinatory behavior, conceptual disorganization, man-
nerisms or posturing, blunted affect, emotional withdrawal,
and motor retardation. Participants who received BPRS ratings
of mild or less ( 3) for these items and were not hospitalized
during the previous 6 months were classified as in remission.
Given the constraints of administering a structured BPRS
assessment schedule every 2 weeks during a 6-month period,
the length of psychiatric hospitalization was used as an indirect
indicator of the stability of symptom severity to be consistent
with extant studies’ methodology (Eberhard, Levander, &
Lindström, 2009; Novick, Haron, Suarez, Vieta, & Naber, 2009;
Strauss et al., 2010).
Statistical Analysis Plan
Descriptive statistics and rate of recovery for the sample were
derived using univariate analyses. Due to the study’s modest
sample size, which precluded the inclusion of all proposed
baseline explanatory variables in the multivariate model for
prediction of recovery, the selection of variables was guided
by the purposeful method proposed by Hosmer, Lemeshow,
and Sturdivant (2013b). First, Pearson chi-square tests for cate-
gorical explanatory variables or two-sample t-tests for contin-
uous explanatory variables were performed to investigate the
predictive relationship between the investigated baseline vari-
ables and recovery during the first year of follow-up (see
Figure 1). For categorical factors with few observations, Fish-
er’s exact test was performed instead of the regular chi-square
test. Explanatory variables that were statistically significantly
associated with recovery at p < .10 in the bivariate analyses
were candidates for entry in the multivariate model. Second,
a direct binary logistic regression analysis was performed to
identify statistically significant psychosocial predictors of
recovery after adjusting for baseline demographic and clinical
characteristics. Explanatory variables that were not statistically
significant in the multivariable model were removed. Third,
explanatory variables that were not statistically significant at
the bivariate level were added to the multivariate model sepa-
rately to identify variables that were statistically significantly
related to recovery in the presence of other variables. Variables
6 Research on Social Work Practice

Table 1. Demographic and Clinical Descriptors of Sample at Baseline

Symptomatic
Remission
(N ¼ 246).
(n = 52)
Variable M (SD) n (%)

Demographic characteristics
21
Age 37.93 (9.35)
Male 161 (66.80)
14 6
Ethnicity
11 African American 101 (42.80)
Adequate Social Adequate Work European American 84 (35.59)
Functioning 20 11 Functioning Latino 30 (12.71)
6
(n = 51) (n = 34) Asian 10 (4.24)
Other ethnicities 11 (4.66)
Marital statusa
Married or living together 4 (1.65)
Figure 1. Rate of recovery for the 1-year period (n ¼ 146). Single 176 (72.43)
Divorced or separated 63 (25.93)
that were not statistically significant were removed, resulting in Completed high school 153 (65.38)
Clinical characteristics
the final model. The purposeful selection method has been Length of illness (years) 14.43 (10.14)
shown to be superior to stepwise selection in retaining sta- Medication use
tistically significant explanatory variables and confounders Low use 57 (23.65)
(Bursac, Gauss, Williams, & Hosmer, 2008). Regular use 184 (76.35)
Diagnostic statistics were calculated to determine whether Alcohol and substance use 43 (17.70)
the final multivariate model satisfied the assumptions of logis- Severity of symptomatologyb 40.31 (11.34)
tic regression. Area under the receiver–operating characteristic Role functioningc 2.00 (1.60)
Social functioningc 3.06 (1.66)
curve was estimated for the final model as a measure of the
a
short listed predictors’ ability to discriminate between partici- Total does not sum to full sample or 100% due to missing data.
b
pants who did or did not show periods of recovery. Lowess Measured with the Brief Psychiatric Rating Scale. Higher scores indicate more
severe symptomatology.
smooth and fractional polynomials methods were used to check c
Measured with the Role Functioning Scale. Higher scores indicate higher levels
the assumption that the logit of the outcome variable (recovery of impairment.
outcome) was a linear combination of the explanatory variables
(Hosmer, Lemeshow, & Sturdivant, 2013a). To test for model
quarters (76.35%) of participants were on antipsychotic medi-
specification errors, a link test was performed. To check for
cation more than 50% of the time during the previous 6 months
multicollinearity, tolerance levels and variance inflation factors
before enrollment in psychosocial rehabilitation. Moreover,
were generated. Tolerance values less than .10 and variance
a majority (82.30%) did not use any substances during the
inflation factor values greater than 10 suggest the presence of
6 months preceding admission. Notwithstanding the high rate
redundant predictors. Preselected two-tailed directional tests
of medication use, the lower baseline RFS scores indicate that
and statistical significance were determined at a ¼ .05. Analy-
the sample featured participants who presented with marked
ses were performed with STATA 13.0 using data from partici-
functional deficits (M ¼ 2.00, SD ¼ 1.60) and impaired social
pants who completed all three assessments during the 1-year
function (M ¼ 3.06, SD ¼ 1.66).
study period and had complete information for all variables
included in the analytic model.
Attrition Rate
Results Outcome data with respect to recovery status during the 1-year
study period were obtained for 59.35% (n ¼ 146) of the 246
Sample Characteristics participants. The rate of attrition in the sample was 22.36%
Table 1 displays the demographic and clinical profile of the (n ¼ 55) at 6 months and 32.93% (n ¼ 81) by 12 months.
sample (N ¼ 246). Of note, the study had a racially diverse Approximately one fifth (n ¼ 52, 21.13%) of the sample missed
sample with majorities of participants between the age of 30 at least one follow-up assessment and 17.07% (n ¼ 42) missed
and 50 (66.67%), men (66.80%), singles (72.43%), and high both 6- and 12-month assessments. Six participants (2.44%)
school graduates or an equivalent credential (65.38%). Regard- had incomplete outcome data, which precluded the assessment
ing the sample’s clinical characteristics, the average and med- of their recovery status.
ian length of illness was 14.43 years (SD ¼ 10.14) and 12.50 Table 2 reveals that participants who missed at least one
years, respectively, suggesting that most participants were not follow-up assessment did not differ from participants who
experiencing their first episode. On average, the participants completed all follow-up assessments in terms of most baseline
presented with very mild psychiatric symptoms as assessed demographic and clinical characteristics. However, partici-
by the BPRS (M ¼ 40.31, SD ¼ 11.02). More than three pants who missed at least one follow-up assessment had

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Lim et al. 7

Table 2. Baseline Characteristics of Participants Who Completed All or Missed at Least One Follow-Up Assessment.

Variable Completers (n ¼ 152) Noncompleters (n ¼ 94) Test Statistic p

Demographic characteristics
Agea 38.24 (0.78) 37.43 (0.92) t(241) ¼ 0.14 .52
Male 100 (66.67) 61 (67.03) w2(1, 241) ¼ 0.00 .95
Ethnicityb .59
African American 63 (41.45) 38 (45.24)
European American 57 (37.50) 27 (32.14)
Latino 21 (13.82) 9 (10.71)
Asian 6 (3.95) 4 (4.76)
Other ethnicities 5 (3.29) 6 (7.14)
Marital statusb .91
Married or living together 3 (1.97) 1 (1.10)
Single 111 (73.03) 65 (71.43)
Divorced or separated 38 (25.00) 25 (27.47)
Completed high school 104 (70.27) 49 (56.98) w2(1, 234) ¼ 4.25 .04
Clinical characteristics
Length of illness (years)a 14.27 (0.85) 14.73 (1.11) t(224) ¼ 0.14 .74
Medication use .63
Low use 37 (24.67) 20 (21.98) w2(1, 241) ¼ 0.23
Regular use 113 (75.33) 71 (78.02) w2(1, 243) ¼ 0.43
Alcohol and substance use 25 (16.45) 18 (19.78) t(236) ¼ 1.91 .51
Severity of symptomatologya,c 39.22 (0.91) 42.10 (1.22) w2(1, 242) ¼ 1.96 .06
Role functioninga,d 2.15 (0.14) 1.74 (0.13) w2(1, 242) ¼ 0.90 .05
Social functioninga,d 3.13 (0.13) 2.93 (0.17) .37
Note. Values represent n (%) unless otherwise noted.
a
Values represent M (SD).
b
Fisher’s exact test was used to determine if groups differed at statistically significant levels.
c
Measured with the Brief Psychiatric Rating Scale. Higher scores indicate more severe symptomatology.
d
Measured with the Role Functioning Scale. Higher scores indicate higher levels of impairment.

statistically significantly lower educational attainment (56.98%
vs. 70.27% completed high school, respectively), w2(1, 234) ¼
4.25, p < .05, and higher levels of functional impairment at
study entry (RFS work productivity score of 1.74 vs. 2.15,
respectively), w2(1, 242) ¼ 1.96, p ¼ .05. Moreover, there were
marginally statistically significant differences in the overall
severity of symptomatology (BPRS score of 42.10 vs. 39.22,
respectively), t(236) ¼ 1.91, p ¼ .06. These findings indicate
that participants with possibly lower premorbid role function-
ing and who were more ill at study entry were more likely to
miss a follow-up assessment.
Rate of Recovery
Figure 1 shows the proportion of participants who achieved the
outcomes germane to fulfilling the recovery criteria for 1-year
period. Applying the more stringent recovery criteria, which
required participants to be in symptomatic remission and con-
currently demonstrate adequate work and social functioning for
1 year, yielded a rate of 7.53% (n ¼ 11). When considering the
entire 1-year follow-up period, 35.62% (n ¼ 52) of the sample
sustained symptomatic remission, 34.93% (n ¼ 51) had ade-
quate social functioning, and 23.29% (n ¼ 34) had adequate
work functioning. More than one sixth (n ¼ 25, 17.12%) of par-
ticipants simultaneously maintained symptomatic remission
and adequate social functioning, however, a considerable
smaller proportion of participants were able to concurrently
maintain symptomatic remission and adequate work functioning
(n ¼ 17, 11.64%) or adequate work and social functioning (n ¼
17, 11.64%). Achieving an adequate level of work functioning
was an impediment to meeting the recovery criteria for the major-
ity of participants. More than half (n ¼ 77, 52.74%) did not parti-
cipate in any useful work during the 1-year follow-up period.
When the less demanding recovery criteria were considered,
which required the fulfillment of the aforementioned outcome
criteria for either 6-month period rather than for the full 1-year
period during the first year of follow-up, the rate of recovery
nearly tripled (n ¼ 29, 19.86%). In addition to the participants
who met criteria for recovery for 1-year period, another 12.33%
(n ¼ 18) of participants met criteria for recovery during either
6-month period. Eight (5.48%) participants showed recovery
during the first half of the 1-year follow-up period, but subse-
quently lost their recovery status because they did not maintain
an adequate level of work or social functioning or both.
Regarding the 10 (6.85%) participants who achieved recovery
during the second half of the follow-up period, inadequate
symptomatic remission or work functioning delayed their
achievement of recovery during the first 6 months.
Group Differences in Baseline Investigated Factors
The low rate of participants who met recovery criteria for the
1-year period relative to the number of participants who did not
experience recovery limited the number of predictors that could

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8 Research on Social Work Practice

Table 3. Results of Bivariate Analyses Relating Baseline Demographic, Clinical, and Psychosocial Variables to Recovery.a

Variable Not in Recovery (n ¼ 117) In Recoveryb (n ¼ 29) Test Statistic P

Demographic characteristics
Male 77 (66.96) 19 (65.52) w2(1, 144) ¼ 0.02 .88
Completed high school 76 (67.26) 23 (79.31) w2(1, 142) ¼ 1.59 .21
Clinical characteristics
Length of illness (years)c 15.05 (10.33) 12.03 (10.07) t(137) ¼ 1.40 .16
Medication used .64
Low use 30 (26.09) 6 (20.69)
Higher use 85 (73.91) 23 (79.31)
Alcohol and substance use 16 (13.68) 6 (20.69) w2(1, 146) ¼ 0.89 .35
Severity of symptomatologyc,e 40.15 (11.01) 35.41 (10.68) t(141) ¼ 2.08 .04
Role functioningc,f 1.86 (1.49) 3.45 (2.26) t(144) ¼ 4.59 <.01
Social functioningc,f 2.84 (1.51) 4.31 (1.66) t(144) ¼ 4.28 <.01
Psychosocial characteristics
Intrinsic motivationc,g 3.82 (1.23) 4.95 (0.99) t(144) ¼ 4.62 <.01
Self-esteemc,g 65.75 (19.40) 63.40 (19.50) t(144) ¼ 0.59 .56
Family network relationshipsc 3.68 (1.96) 4.75 (1.58) t(144) ¼ 2.70 <.01
Social supportc,h 3.24 (1.06) 3.38 (0.97) t(144) ¼ 0.65 .52
Note. Values represent n (%) unless otherwise noted.
a
n ¼ 146.
b
Recovery for either 6-month period during the 1st year of follow-up.
c
Values represent M (SD).
d
Fisher’s exact test was used to determine if groups differed at statistically significant levels.
e
Measured with the Brief Psychiatric Rating Scale. Higher scores indicate more severe symptomatology.
f
Measured with the Role Functioning Scale. Higher scores indicate higher levels of impairment.
g
Higher scores indicate higher levels of intrinsic motivation.
h
Higher scores indicate higher levels of social support.

be estimated precisely in a multivariable logistic regression Predictors of Recovery

model (Argresti, 2007). Therefore, analyses of bivariate and
The bivariate analyses identified the following baseline variables
multivariate relationships were performed with recovery for
as candidates for the multivariable logistic regression model:
either 6-month period as the outcome variable, which was more
severity of symptomatology, role functioning, social functioning,
prevalent in this sample. Additional analyses revealed that par-
intrinsic motivation, and family network relationships. Severity
ticipants who showed recovery for the 1-year period and parti-
of symptomatology did not retain its statistical significance in the
cipants who showed recovery for either 6-month period did not
fitted multivariable model at p < .05 (results not shown) and was
differ at statistically significant levels with regard to all inves-
removed. When the explanatory variables that were not statisti-
tigated baseline characteristics.
cally significant at the bivariate level were entered individually
Table 3 displays the results of the bivariate analyses com-
into the multivariate model, the coefficient for substance use was
paring participants who showed recovery for 6 months and par-
on the border of statistical significance (p ¼ .08) and the remain-
ticipants who were not in recovery during the 1-year follow-up
ing variables remained statistically nonsignificant.
period, on the investigated baseline characteristics. Compared
The results of the final fitted model of recovery on intrinsic
to participants who were not in recovery during the 1-year
motivation and family network relationships after adjusting for
follow-up period, participants who showed 6-month periods
role and social functioning are shown in Table 4. For every unit
of recovery presented with statistically significantly less severe
increase in role functioning, the odds of achieving recovery
symptomatology (40.15 vs. 35.41, respectively) t(141) ¼ 2.08,
increased by 1.34, and for every unit increase in social func-
p < .05, less functional impairment (1.86 vs. 3.45, respec-
tioning, the odds of achieving recovery increased by 1.40. After
tively), t(144) ¼ 4.59, p < .01, better social functioning
controlling for baseline functioning, intrinsic motivation and
(2.84 vs. 4.31, respectively), t(144) ¼ 4.28, p < .01, higher
family network relationships at baseline reliably predicted
levels of intrinsic motivation (3.82 vs. 4.95, respectively),
the achievement of recovery for either 6-month period during
t(144) ¼ 4.62, p < .01, and more intact family network rela-
the follow-up period. For every unit increase in intrinsic moti-
tionships (3.68 vs. 4.75, respectively), t(144) ¼ 2.70, p < .01.
vation, the odds of recovery was estimated to increase by 1.68
Moreover, participants who showed periods of recovery
(95% confidence interval [CI] ¼ [1.01, 2.79]) for a given level
appeared more likely to have completed high school (67.26%
of role and social functioning. Likewise, for every unit increase
vs. 79.31%, respectively), w2(1, 142) ¼ 1.59, p ¼ .21, and
in family network relationships, the odds of recovery were esti-
tended to have shorter lengths of illness (15.05 vs. 12.03,
mated to increase by 1.33 (95% CI ¼ [1.01, 1.74]) after control-
respectively), t(137) ¼ 1.40, p ¼ .16, although the differences
ling for role and social functioning.
were not statistically significant.

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Lim et al.
Table 4. Results of Fitting the Final Multivariable Model.a
Baseline Characteristics Coeff. SE OR 95% CI
Intrinsic motivation 0.52 0.26 1.68 [1.01, 2.79]
Family network relationships 0.28 0.14 1.32 [1.01, 1.74]
Role functioning 0.29 0.13 1.34 [1.03, 1.74]
Social functioning 0.33 0.15 1.40 [1.05, 1.86]
Note. CI ¼ confidence interval; Coeff. ¼ estimated unstandardized coefficient;
OR ¼ odds ratio; SE ¼ standard error.
a
n ¼ 146.
As a set, the predictors reliably distinguished between parti-
cipants’ recovery outcomes during the first year of follow-up,
w2(1, 146) ¼ 37.94, p < 0.01. The set of predictors had a sensi-
tivity value of 34.48%, a specificity value of 94.87%, a positive
predictive value of 62.50%, and a negative predictive value of
85.38%, for an overall classification rate of 82.88%. The model
yielded a receiver–operating characteristic curve of .86, indi-
cating excellent discrimination of outcomes (Hosmer et al.,
2013a). These results indicate that the model fit the data by
adequately reflecting the observed outcome in the sample.
Lowess smooth and fractional polynomial tests found no statis-
tical evidence of nonlinearity in the logit for the three continu-
ous explanatory variables in the model. The link test was not
significant (p ¼ .13), confirming that the multivariate model
was properly specified, thereby indicating that the model
included meaningful predictors and excluded any irrelevant
variables. Both measures of tolerance and variance inflation
factors confirmed the absence of multicollinearity in the esti-
mated model. Taken together, these findings demonstrate that
the assumptions of multivariate logistic regression were not
violated.
Discussion
In the present study, the proportion of participants who showed
periods of recovery for either 6-month period or the full 1-year
period was 19.86% and 7.53%, respectively. The hypotheses
that higher levels of positive psychosocial attributes at baseline
would increase the likelihood of recovery during the follow-up
period were partially supported. Although predictors of recov-
ery that lasted for 1 year could not be reliably estimated due to
its low rate in this sample, recovery that lasted for either 6-
month period during the follow-up period was predicted by
higher levels of intrinsic motivation and more positive family
relationships at baseline after controlling for initial role and
social functioning. Collectively, these findings indicate that
in this sample of individuals with schizophrenia spectrum dis-
order who were engaged in community-based psychosocial
rehabilitation, about 20% achieved periods of recovery that
lasted for 6 months. Furthermore, our findings suggest that psy-
chosocial attributes at the start of treatment are important con-
tributors to subsequent recovery.
Our finding regarding the lower occurrence of recovery that
lasted for 1 year during the first year of follow-up after enroll-
ment in psychosocial rehabilitation (7.53%) is consistent with
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9
extant findings. Longitudinal studies that have applied the
same set of criteria to examine the rate of recovery in individ-
p
uals with schizophrenia during the early stages of treatment
.047 have noted rates between 1% and 18% (Harrow et al., 2005;
.044 Strauss et al., 2010; Ventura et al., 2011). Comparing the rate
.030 of recovery that lasted for 1 year across studies suggests that
.023 individuals with less severe forms of schizophrenia (i.e., schi-
zophreniform disorder and absence of negative symptoms)
tended to have better prognoses. Nonetheless, the lower rates
of recovery that lasted for 1 year in the present study and the
aforementioned studies suggest that achievement of uninter-
rupted remission for 1 year is demanding during the early
stages of treatment. As noted previously, achieving an adequate
level of work functioning was an impediment to meeting the
more stringent recovery criteria. Harrow et al. (2005) and
Strauss et al. (2010) found that rate of recovery tended to
increase over time, suggesting that recovery might be a more
distal outcome for the majority of individuals with schizophre-
nia, given that functional restoration is a more laborious task.
Nonetheless, the finding that more than 1 in 20 participants
in this sample achieved recovery that lasted for 1 year chal-
lenges the long held view that schizophrenia is characterized
by a uniformly poor outcome. In this study, most participants
had experienced a more persistent course of schizophrenia and
the rate of recovery for 1-year period in this study is not lower
than the rates found in first-episode samples, suggesting that
schizophrenia is not necessarily characterized by a deteriorat-
ing course.
Our finding regarding the higher rate of recovery for either
6-month period compared with recovery for the 1-year period is
consistent with the findings by Ventura et al. (2011) who docu-
mented a rate of 10% when they applied the less stringent
recovery criteria to their sample of individuals with first-
episode schizophrenia. The marginal discrepancy in the rate
of recovery for the 6 month-period between the present study
and the study by Ventura et al. (2011) may be attributed to
differences in research and therapeutic methodology. First,
Ventura et al. (2011) conducted symptom assessments biweekly,
whereas we completed the assessments once every 6 months
and confined the assessment period to the previous 2 weeks.
Due to our less rigorous assessment schedule, the rate of recov-
ery may be inflated in the present study. Second, participants in
Ventura et al.’s study were not enrolled in specific psychoso-
cial interventions, which may have hindered the restoration
of adequate functioning in the sample. Indeed, Ventura et al.
(2011) noted that achieving adequate role functioning was an
impediment to meeting the recovery criteria in their first-
episode sample.
There has been little research relating psychosocial attributes
to recovery in schizophrenia, with the exception of several stud-
ies (Albert et al., 2011; Bertelsen et al., 2009; Harrow, Hans-
ford, & Astrachan-Fletcher, 2009). A central finding from
this study indicates that for a given level of functioning at base-
line, recovery for either 6-month period during the first year of
follow-up was predicted by higher levels of intrinsic motivation
and more positive family network relationships at enrollment in
10
psychosocial rehabilitation. Because individuals who are intrin-
sically motivated are driven by curiosity, interest, derived
enjoyment, and satisfaction, it is possible that higher levels of
intrinsic motivation prompt recovery in individuals with schizo-
phrenia through better engagement in both pharmacotherapy
and psychosocial rehabilitation interventions (Medalia &
Brekke, 2010), thereby increasing the likelihood of sympto-
matic remission and functional restoration, respectively. Con-
cerning the influence of family relationships on recovery, the
evidence that emerged from this study suggests that having bet-
ter family network relationships at enrollment in psychosocial
rehabilitation is statistically significantly predictive of both
symptomatic remission and adequate functioning sufficient to
generate periods of recovery, thus expanding previous research
on the association between familial relations and clinical or
functional outcomes in schizophrenia (Cechnicki, Bielańska,
Hanuszkiewicz, & Daren, 2013; Guada, Hoe, Floyd, Barnour,
& Brekke, 2012). More positive familial relationships may be
indicative of low levels of expressed emotion in the family.
Maintaining more positive ties with family members may also
afford participants more opportunities to establish meaningful
connections and increase the likelihood of finding work and
age-appropriate roles through referrals from individuals in
affiliated social networks.
In addition to intrinsic motivation and family relationships,
we found that higher levels of social and role functioning at
baseline were statistically significant predictors of recovery
at follow-up. Although this finding suggests that participants
who had less functional impairment at admission to psychoso-
cial rehabilitation were more likely to achieve periods of recov-
ery, it also underscores the importance of intervening more
intensively during the early phase of psychosocial rehabilita-
tion with individuals who present with marked psychosocial
impairments to enhance their chances of recovery.
Contrary to expectations, social support and self-esteem did
not predict recovery, although the data revealed a trend toward
recovery with respect to these factors. It is possible that social
support influences certain domains of functional outcomes but
does not directly influence the remission of psychotic symp-
toms. When outcomes germane to the recovery criteria mea-
sured at the 6-month follow-up were individually regressed
on level of baseline social support, social support was only sig-
nificantly associated with social functioning, suggesting that it
may not be a predictor of symptomatic remission or improved
role functioning. Concerning self-esteem, it is possible that
recovery engenders higher levels of self-esteem but not vice
versa. Indeed, previous studies have found support for the
cross-sectional association between better functional outcomes
and improvement in self-esteem (Davis, Kurzban, & Brekke,
2012).
It is noteworthy that most of the investigated clinical vari-
ables—length of illness, medication use, and substance use—
did not predict recovery in this sample, although converse
effects were documented in studies of first-episode samples
(Albert et al., 2011; Bertelsen et al., 2009; Petersen et al., 2008;
Verma et al., 2012). There are several possible explanations
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Research on Social Work Practice
for our statistically nonsignificant findings. First, the data had
limited variation in values of medication use and substance
use because the majority of participants reported high medi-
cation use and no substance use at baseline. The relative
homogeneity in these explanatory variables could have lim-
ited the detection of significant effects on recovery. Second,
length of illness is conceptually distinct from the duration of
untreated psychosis. The former considers periods of active
psychosis and remission. In contrast, the latter is a measure
of the length of active illness. It is possible that longer peri-
ods of active psychosis, rather than the aggregated length of
illness, impinge on the likelihood of recovery. Third, these
discrepancies may suggest that beyond the first psychotic
episode, psychosocial attributes may play a more significant
role in recovery relative to clinical factors, however, this is a
hypothesis that has yet to be empirically tested.
Limitations
Several limitations to this research must be acknowledged.
First, intrinsic motivation and family network relationships
predicted shorter periods of recovery that lasted at least
6 months but less than 1 year. It is unclear whether these
psychosocial attributes would effect longer periods of recov-
ery. Second, intrinsic motivation and negative symptoms share
conceptual similarities. We sought to determine their empirical
independence by conducting principal component factor anal-
ysis with varimax rotation on 4 items from the Quality of Life
Scale that measured intrinsic motivation and 3 items from the
BPRS that measured negative symptoms. The 7 items were
empirically summarized by two factors that accounted for
62.5% of the variance. The first factor included the 4 items
measuring intrinsic motivation, with each item loading highly
on the factor (loadings above .4). The second factor included
the 3 BPRS items measuring negative symptoms, which loaded
highly on the factor (loadings above .7). Similar results were
derived when we applied the oblique rotational method. These
findings suggest that intrinsic motivation and negative symp-
toms are empirically independent of each other, consistent with
the findings from previous studies (Nakagami et al., 2008;
Saperstein et al., 2011). If the items used to measure intrinsic
motivation were in fact measuring negative symptoms, our
study findings suggest that negative symptoms typified by
motivation are crucial targets of pharmacotherapy to increase
the odds of recovery. Third, the study was not sufficiently pow-
ered to detect the effects of other investigated explanatory vari-
ables on recovery in the multivariate model. Peduzzi, Concato,
Kemper, Holford, and Feinstein (1996) proposed that there
should be 10 outcomes of each type for every predictor in the
multivariate model. Because 29 participants in this sample
showed periods of recovery, the multivariate logistic regression
model should not include more than three explanatory vari-
ables. Because an insufficiently powered study is more prone
to committing a Type II error, findings regarding the statisti-
cally nonsignificant effects of the investigated demographic
and clinical characteristics should be interpreted conservatively.
Lim et al.
Fourth, as previously noted, the use of a less rigorous symptom
assessment schedule may have resulted in the misclassification
of outcomes such that participants were more likely to be mis-
classified as meeting the recovery criteria, and hence the rate of
recovery may be inflated in the present study. This methodolo-
gical limitation is not unique to the present study and has been
widely reported in other studies (Bobes, Ciudad, Álvarex, &
San, 2009; Novick et al., 2009; Petersen et al., 2008; Robinson,
Woerner, & McMeniman, 2004; Schennach et al., 2012). We
attempted to minimize the rate of misclassification by using
the length of psychiatric hospitalization during the previous
6 months as an indicator of the stability of symptomatic remis-
sion, which represents a methodological improvement over
previous studies that tended to assume stability of symptoms
in the absence of a rigorous assessment schedule. It is neverthe-
less an inadequate indicator, given that contextual factors may
influence participants’ odds of receiving psychiatric hospitali-
zation. Selective attrition of participants with possibly lower
premorbid role functioning and who were more ill at study
entry could have also inflated the rate of recovery. Fifth, the
presence of selection bias may have influenced the magnitude
of the observed association between the investigated explana-
tory variables and recovery. Because the sample featured par-
ticipants with a more persistent course of schizophrenia and
who experienced higher levels of functional disability at study
entry, predictors found to be associated with recovery in the
present study may not be generalized to all individuals with
schizophrenia, particularly individuals with first-episode psy-
chosis and individuals not engaged in psychosocial rehabilita-
tion. Sixth, the multivariate model yielded a pseudo R2 of
26.06%, which attests to the presence of uninvestigated predic-
tors, for example, treatment factors, service characteristics, and
neurocognition. Notwithstanding these limitations, this study
offers evidence suggesting the potential of psychosocial attri-
butes in effecting recovery from schizophrenia and lays the
foundation for further research on the contribution of nonclini-
cal factors.
Conclusion
In the context of psychosocial rehabilitation, individuals with
schizophrenia have highly heterogeneous trajectories. Although
the majority of participants in psychosocial rehabilitation may
not show recovery during the early course of treatment, a sub-
group of individuals with more positive family relationships,
higher levels of intrinsic motivation, and less social and func-
tional impairment have an increased probability of achieving
early recovery. Findings from this study have important clini-
cal implications, the most central being that intrinsic motiva-
tion and family network relationships are important targets of
psychosocial interventions to promote recovery from schizo-
phrenia. Choi and Medalia (2010) found that intrinsic motiva-
tion in individuals with schizophrenia was enhanced with
psychosocial interventions that were contextualized and perso-
nalized and that promoted independent decision making, sug-
gesting that intrinsic motivation is both malleable and shaped
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11
by the social environment. Therefore, the delivery of mental
health interventions that emphasize consumer choice over deci-
sions about their treatment could encourage recovery in indi-
viduals with schizophrenia. Given the empirical support for
the effectiveness of family psychoeducation in reducing the
odds of relapse (Kreyenbuhl, Buchanan, Dickerson, & Dixon,
2010), social work clinicians are encouraged to offer psychoe-
ducation intervention to family members as a means to foster
or enhance positive relationships. Additionally, incorporating
supportive family members as partners in the treatment pro-
cess could facilitate better outcomes for individuals with
schizophrenia.
Regarding future research implications, we offer several
recommendations. First, longitudinal studies with more fre-
quent follow-up intervals are needed to reduce the misclassifi-
cation of recovery outcomes. Research has generally used two-
wave designs to identify predictors of recovery. This limitation
is noteworthy because such designs preclude the identification
of changes in recovery status over time. Therefore, more multi-
wave studies are needed to classify the varied trajectories of
schizophrenia and identify the predictors of these outcomes.
Considering that the investigated clinical factors found to exert
significant influence on recovery in first-episode samples did
not predict recovery in our sample, studies should include both
first-episode and multiple-episode participants to determine
whether recovery after a first episode of psychosis is predicted
by the same factors that predict recovery after multiple epi-
sodes. Because schizophrenia is a complex disorder whose pro-
gression is influenced by varied factors that have not been
satisfactorily investigated, future studies need to be sufficiently
powered to determine the contributory effects of a larger set of
explanatory variables. Related to the measure of intrinsic moti-
vation, further validation of the expanded definition is needed.
We also need studies with racially and ethnically diverse sam-
ples to examine the contribution of sociocultural and contextual
factors to recovery from schizophrenia (Brekke & Barrio,
1997; Lopez, Barrio, Kopelowicz, & Vega, 2012).
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: Data for
this study came from research supported by grants MH53282 and
MH01628 awarded to John S. Brekke by the National Institute of
Mental Health.
References
Albert, N., Bertelsen, M., Thorup, A., Petersen, L., Jeppesen, P., Le
Quack, P., . . . Nordentoft, M. (2011). Predictors of recovery from
psychosis: Analyses of clinical and social factors associated with
recovery among patients with first-episode psychosis after 5 years.
Schizophrenia Research, 125, 257–266. doi:10.1016/j.schres.
2010.10.013
12
American Psychiatric Association. (1994). DSM-IV: Diagnostic and
statistical manual of mental disorders. Washington, DC: American
Psychiatric Publishing.
American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed.). Washington, DC: American
Psychiatric Publishing.
Andreasen, N. C., Carpenter, W. T., Kane, J. M., Lasser, R. A., Marder,
S. R., & Weinberger, D. R. (2005). Remission in Schizophrenia:
Proposed criteria and rationale for consensus. American Journal of
Psychiatry, 162, 441–449. doi:10.1176/appi.ajp.162.3.441
Anthony, W. A. (1993). Recovery from mental illness: The guiding
vision of the mental health service system in the 1990s. Psychoso-
cial Rehabilitation Journal, 16, 11–23. doi:10.1037/h0095655
Argresti, A. (2007). Building and applying logistic regression models.
In D. J. Balding, N. A. C. Cressie, G. M. Fitzmaurice, H. Golstein,
I. M. Johnstone, G. Molenberghs, . . . S. Weisberg (Eds.), An intro-
duction to categorical data analysis (p. 138). Hoboken, NJ:
John Wiley.
Barham, P., & Hayward, R. (1998). In sickness and in health: Dilem-
mas of the person with severe mental illness. Psychiatry, 61,
163–170. doi:10.1521/00332747.1998.11024826
Bellack, A. S. (2006). Scientific and consumer models of recovery in
schizophrenia. Schizophrenia Bulletin, 32, 432–442. doi:10.1093/
schbul/sbj044
Bertelsen, M., Jeppesen, P., Petersen, L., Thorup, A., Øhlenschlæger,
J., Quach, P. L., . . . Nordentoft, M. (2009). Course of illness in a
sample of 265 patients with first-episode psychosis—Five-year
follow-up of the Danish OPUS trial. Schizophrenia Research,
107, 173–178. doi:10.1016/j.schres.2008.09.018
Bobes, J., Ciudad, A., Álvarex, E., & San, L. (2009). Recovery from
schizophrenia: Results from a 1-year follow-up observation study
of patients in symptomatic remission. Schizophrenia Research,
115, 58–66. doi:10.1016/j.schres.2009.07.003
Brekke, J. S., & Barrio, C. (1997). Cross-ethnic symptom differences
in schizophrenia: The influence of culture and minority status.
Schizophrenia Bulletin, 23, 305–316. doi:10.1093/schbul/23.2.305
Brekke, J. S., & Long, J. D. (2000). Community-based psychosocial
rehabilitation and prospective change in functional, clinical, and
subjective experience variables in schizophrenia. Schizophrenia
Bulletin, 26, 667–680. doi:10.1093/oxfordjournals.schbul.a033485
Bursac, Z., Gauss, H. C., Williams, D. K., & Hosmer, D. W. (2008). Pur-
poseful selection of variables in logistic regression. Source Code for
Biological and Medicine, 16, 3–17. doi:10.1186/1751-0473-3-17
Cechnicki, A., Bielańska, A., Hanuszkiewicz, I., & Daren, A. (2013).
The predictive validity of expressed emotions (EE) in schizophre-
nia: A 20-year prospective study. Journal of Psychiatric Research,
47, 208–214. doi:10.1016/j.jpsychires.2012.10.004
Choi, J., & Medalia, A. (2010). Intrinsic motivation and learning in
a schizophrenia spectrum sample. Schizophrenia Research, 118,
12–19. doi:10.1016/j.schres.2009.08.001
Cohen, O. (2005). How do we recover? An analysis of psychiatric
survivor oral histories. Journal of Humanistic Psychology, 45,
333–354. doi:10.1177/0022167805277107
Davidson, L. (2003). Living outside mental illness: Qualitative studies
of recovery in schizophrenia. New York: New York University
Press.
Downloaded from rsw.sagepub.com at UNIV OF SOUTHERN CALIFORNIA on September 25, 2015
Research on Social Work Practice
Davis, L., Kurzban, S., & Brekke, J. (2012). Self-esteem as a mediator
of the relationships between role functioning and symptoms of
individuals with severe mental illness: A prospective analysis of
modified labeling theory. Schizophrenia Research, 137, 185–189.
doi:10.1016/j.schres.2012.02.003
Deci, E. L., & Ryan, R. M. (1985). Intrinsic motivation and self-
determination in human behavior. New York, NY: Plenum.
Dunn, E. C., Wewiorski, N., & Rogers, E. S. (2008). The meaning and
importance of employment to people in recovery from serious
mental illness: Results of a qualitative study. Psychiatric Rehabi-
litation Journal, 32, 59–62. doi:10.2975/32.1.2008.59.62
Eberhard, J., Levander, S., & Lindström, E. (2009). Remission in schi-
zophrenia: Analysis in a naturalistic setting. Comprehensive Psy-
chiatry, 50, 200–208. doi:10.1016/j.comppsych.2008.08.010
Færden, A., Nesvåg, R., & Marder, S. R. (2008). Definitions of the
term ‘recovered’ in schizophrenia and other disorders. Psycho-
pathology, 41, 271–278. doi:10.1159/000141921
Gard, D. E., Fisher, M., Garrett, C., Genevsky, A., & Vinogradov, S.
(2009). Motivation and its relationship to neurocognition, social
cognition, and functional outcome in schizophrenia. Schizophrenia
Research, 115, 74–81. doi:10.1016/j.schres.2009.08.015
Goodman, S. H., Sewell, D. R., Cooley, E. L., & Leavitt, N.
(1993). Assessing levels of adaptive functioning: The Role
Functioning Scale. Community Mental Health Journal, 29,
119–131. doi:10.1007/BF00756338
Green, C. A., Polen, M. R., Janoff, S. L., Castleton, D. K., Wisdom, J.
P., Vuckovic, N., . . . Oken, S. L. (2008). Understanding how
clinician-patient relationships and relational continuity of care
affect recovery from serious mental illness: STARS study results.
Psychiatric Rehabilitation Journal, 32, 9–22. doi:10.2975/
32.1.2008.9.22
Guada, J., Hoe, M., Floyd, R., Barbour, J., & Brekke, J. S. (2012).
How family factors impact psychosocial functioning for African
American consumers with schizophrenia. Community Mental
Health Journal, 48, 45–55. doi:10.1007/s10597-010-9365-6
Harrow, M., Grossman, L. S., Jobe, T. H., & Herbener, E. S. (2005).
Do patients with schizophrenia ever show periods of recovery?
A 15-year multi-follow-up study. Schizophrenia Bulletin, 31,
723–734. doi:10.1093/schbul/sbi026
Harrow, M., Hansford, B. G., & Astrachan-Fletcher, E. B. (2009).
Locus of control: Relation to schizophrenia, to recovery, and to
depression and psychosis: A 15-year longitudinal study. Psy-
chiatry Research, 168, 186–192. doi:10.1016/j.psychres.2008.
06.002
Hatfield, A. B., Gearon, J. S., & Coursey, R. D. (1996). Family mem-
bers’ ratings of the use and value of mental health services: Results
of a national NAMI survey. Psychiatric Services, 47, 825–831.
doi:10.1176/ps.47.8.825
Hegarty, J. D., Baldessarini, R. J., Tohen, M., Waternaux, C., &
Oepen, G. (1994). One hundred years of schizophrenia: A meta-
analysis of the outcome literature. American Journal of Psychiatry,
151, 1409–1416. doi:10.1176/ajp.151.10.1409
Heinrichs, D. W., Hanlon, T. E., & Carpenter, W. T., Jr. (1984). The
quality of life scale: An instrument for rating the schizophrenic def-
icit syndrome. Schizophrenia Bulletin, 10, 388–398. doi:10.1093/
schbul/10.3.388
Lim et al.
Hosmer, D. W., Lemeshow, S., & Sturdivant, R. X. (2013a). Assessing
the fit of the model. In D. J. Balding, N. A. C. Cressie, & G. M.
Fitzmaurice (Eds.), Applied logistic regression (3rd ed.,
pp. 153–227). Hoboken, NJ: John Wiley.
Hosmer, D. W., Lemeshow, S., & Sturdivant, R. X. (2013b). Model
building strategies and methods for logistic regression. In D. J.
Balding, N. A. C. Cressie, & G. M. Fitzmaurice (Eds.), Applied
logistic regression (3rd ed., pp. 89–153). Hoboken, NJ: John
Wiley.
Hudson, W. (1982). The clinical measurement package: A field
manual. Chicago, IL: Dorsey Press.
Jääskeläinen, E., Juola, P., Hirvonen, N., McGrath, J. J., Saha, S.,
Isohanni, M., . . . Miettunen, J. (2012). A systematic review and
meta-analysis of recovery in schizophrenia. Schizophrenia Bulle-
tin, 39, 1296–1306. doi:10.1093/schbul/sbs130
Jacobson, N., & Greenley, D. (2001). What is recovery? A conceptual
model and explication. Psychiatric Services, 52, 482–485.
doi:10.1176/appi.ps.52.4.482
Johnson, D. (2005). Two-wave panel analysis: Comparing statistical
methods for studying the effects of transitions. Journal of
Marriage and Family, 67, 1061–1075. doi:10.1111/j.1741-3737.
2005.00194.x
Kane, J. M., Leucht, S., Carpenter, D., & Docherty, J. P. (2003).
Expert consensus guideline series. Optimizing pharmacologic
treatment of psychotic disorders. Introduction: Methods, commen-
tary, and summary. Journal of Clinical Psychiatry, 64, 5–19.
Kopelowicz, A., Liberman, R. P., Ventura, J., Zarate, R., & Mintz, J.
(2005). Neurocognitive correlates of recovery from schizophre-
nia. Psychological Medicine, 35, 1165–1173. doi:10.1017/
S0033291705004575
Kreyenbuhl, J., Buchanan, R. W., Dickerson, F. B., & Dixon, L. B.
(2010). The schizophrenia patient outcomes research team
(PORT): Updated treatment recommendations 2009. Schizophre-
nia Bulletin, 36, 94–103. doi:10.1093/schbul/sbp130
Lambert, M., Naber, D., Schacht, A., Wagner, T., Hundermer, H.-P.,
Karow, A., . . . Schimmelmann, B. G. (2008). Rates and predictors
of remission and recovery during 3 years in 392 never-treated
patients with schizophrenia. Acta Psychiatrica Scandinavica,
118, 220–229. doi:10.1111/j.1600-0447.2008.01213.x
Lehman, A. F., & Steinwachs, D. M. (1998). Patterns of usual
care for schizophrenia: Initial results from the schizophrenia
patient outcomes research team (PORT) client survey. Schizo-
phrenia Bulletin, 24, 11–20. doi:10.1093/oxfordjournals.schbul.
a033303
Lieberman, J. A., Drake, R. E., Sederer, L. I., Belger, A., Keefe, R.,
Perkins, D., & Stroup, S. (2008). Science and recovery in schizo-
phrenia. Psychiatric Services, 59, 487–496. doi:10.1176/appi.
ps.59.5.487
Liberman, R. P. (2002). Future directions for research studies and
clinical work on recovery from schizophrenia: Questions with
some answers. International Review of Psychiatry, 14, 337–342.
doi:10.1080/0954026021000016987
Liberman, R. P., Kopelowicz, A., Ventura, J., & Gutkind, D. (2002).
Operational criteria and factors related to recovery from schizophre-
nia. International Review of Psychiatry, 14, 256–272. doi:10.1080/
0954026021000016905
Downloaded from rsw.sagepub.com at UNIV OF SOUTHERN CALIFORNIA on September 25, 2015
13
Lopez, S. R., Barrio, C., Kopelowicz, A., & Vega, W. A. (2012). From
documenting to eliminating disparities in mental health care
for Latinos. American Psychologist, 67, 511–523. doi:10.1036/
a0029737
Lukoff, D., Nuechterlein, K. H., & Ventura, J. (1986). Manual for the
expanded Brief Psychiatric Rating Scale. Schizophrenia Bulletin,
12, 594–602.
Mancini, M. A. (2007). The role of self-efficacy in recovery from
serious psychiatric disabilities: A qualitative study with fifteen
psychiatric survivors. Qualitative Social Work, 6, 49–74.
doi:10.1177/1473325007074166
Mancini, M. A., Hardiman, E. R., & Lawson, H. A. (2005). Making
sense of it all: Consumer providers’ theories about factors facilitat-
ing and impeding recovery from psychiatric disabilities. Psychia-
tric Rehabilitation Journal, 29, 48–55. doi:10.2975/29.2005.48.55
McGlashan, T. H. (1988). A selective review of recent North Ameri-
can long-term follow-up studies of schizophrenia. Schizophrenia
Bulletin, 14, 515–542. doi:10.1093/schbul/14.4.515
Medalia, A., & Brekke, J. (2010). In search of a theoretical structure
for understanding motivation in schizophrenia. Schizophrenia
Bulletin, 36, 912–918. doi:10.1093/schbul/sbq073
Mueser, K. T., & McGurk, S. R. (2004). Schizophrenia. Lancet, 363,
2063–2072. doi:10.1016/S0140-6736(04)16458-1
Nakagami, E., Hoe, M., & Brekke, J. S. (2010). The prospective rela-
tionships among intrinsic motivation, neurocognition, and psycho-
social functioning in schizophrenia. Schizophrenia Bulletin, 36,
935–948. doi:10.1093/schbul/sbq043
Nakagami, E., Xie, B., Hoe, M., & Brekke, J. S. (2008). Intrinsic moti-
vation, neurocognition and psychosocial functioning in schizo-
phrenia: Testing mediator and moderator effects. Schizophrenia
Research, 105, 95–104. doi:10.1016/j.schres.2008.06.015
National Institute of Mental Health. (2009). Schizophrenia (NIH
Publication No. 09-3517). Retrieved from http://www.nimh.
nih.gov/health/publications/schizophrenia/nimh-schizophrenia-
booklet.pdf
Novick, D., Haron, J. M., Suarez, D., Vieta, E., & Naber, D. (2009).
Recovery in the outpatient setting: 36-month results from the schi-
zophrenia outpatient health outcomes (SOHO) study. Schizophre-
nia Research, 108, 223–230. doi:10.1016/j.schres.2008.11.007
Ochocka, J., Nelson, G., & Janzen, R. (2005). Moving forward:
Negotiating self and external circumstances in recovery. Psychia-
tric Rehabilitation Journal, 28, 315–322. doi:10.2975/28.2005.
315.322
Onken, S. J., Craig, C. M., Ridway, P., Ralph, R. O., & Cook, J. A.
(2007). An analysis of the definitions and elements of recovery:
A review of the literature. Psychiatric Rehabilitation Journal,
31, 9–22. doi:10.2975/31.1.2007.9.22
Peduzzi, P., Concato, J., Kemper, E., Holford, T. R., & Feinstein, A. R.
(1996). A simulation study of the number of events per variable in
logistic regression analysis. Journal of Clinical Epidemiology, 49,
1373–1379. doi:10.1016/S0895-4356(96)00236-3
Petersen, L., Thorup, A., Øqhlenschlæfer, J., Christensen, T. Ø.,
Jeppesen, P., Krarup, G., . . . Nordentoft, M. (2008). Predictors of
remission and recovery in a first-episode schizophrenia spectrum
disorder sample: 2-year follow-up of the OPUS trial. Canadian
Journal of Psychiatry, 53, 660–670.
14
Resnick, S. G., Fontana, A., Lehman, A. F., & Rosenheck, R. A.
(2005). An empirical conceptualization of the recovery orientation.
Schizophrenia Research, 75, 119–128. doi:10.1016/j.schres.2004.
05.009
Resnick, S. G., Rosenheck, R. A., & Lehman, A. F. (2004). An
exploratory analysis of correlates of recovery. Psychiatric Services,
55, 540–547. doi:10.1176/appi.ps.55.5.540
Ridgway, P. (2001). Restorying psychiatric disability: Learning from
first person narrative accounts of recovery. Psychiatric Rehabilita-
tion Journal, 24, 335–343. doi:10.1037/h0095071
Robinson, D. C., Woerner, M. G., & McMeniman, M. (2004). Symp-
tomatic and functional recovery from a first episode of schizophre-
nia. American Journal of Psychiatry, 161, 473–479. doi:10.1176/
appi.ajp.161.3.473
Roe, D. (2003). A prospective study on the relationship between self-
esteem and functioning during the first year after being hospita-
lized for psychosis. Journal of Nervous and Mental Disease,
191, 45–49. doi:10.1097/00005053-200301000-00008
Rosen, C., Grossman, L. S., Harrow, M., Bonner-Jackson, A., & Faull,
R. (2011). Diagnostic and prognostic significance of schneiderian
first-rank symptoms: A 20-year longitudinal study of schizophrenia
and bipolar disorder. Comprehensive Psychiatry, 52, 126–131.
doi:10.1016/j.comppsych.2010.06.005
Rosenthal, D. (1970). Genetic studies of schizophrenia. In N.
Garmezy, R. L. Solomon, L. V. Jones, & H. W. Stevenson (Eds.),
Genetic theory and abnormal behavior (pp. 92–200). New York,
NY: McGraw-Hill.
Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the
facilitation of intrinsic motivation, social development, and well-
being. American Psychologist, 55, 68–78. doi:10.1037/0003-
066X.55.1.68
Saperstein, A. M., Fiszdon, J. M., & Bell, M. D. (2011). Intrinsic moti-
vation as a predictor of work outcome after vocational rehabilita-
tion in schizophrenia. Journal of Nervous and Mental Disease,
199, 672–677. doi:10.1097/NMD.0b013e318229d0eb
Schennach, R., Riedel, M., Obermeier, M., Jäger, M., Schmauss, M.,
Laux, G., . . . Möller, H.-J. (2012). Remission and recovery and
their predictors in schizophrenia spectrum disorder: Results from
a 1-year follow-up naturalistic trial. Psychiatric Quarterly, 83,
187–207. doi:10.1007/s11126-011-9193-z
Schön, U.-K., Denhov, A., & Topor, A. (2009). Social relationships as
a decisive factor in recovering from severe mental illness.
Downloaded from rsw.sagepub.com at UNIV OF SOUTHERN CALIFORNIA on September 25, 2015
View publication stats
Research on Social Work Practice
International Journal of Social Psychiatry, 55, 336–347.
doi:10.1177/0020764008093686
Sherbourne, C. D., & Stewart, A. L. (1991). The MOS social support
survey. Social Science and Medicine, 32, 705–714. doi:10.1016/
0277-9536(91)90150-B
Silverstein, S. M., & Bellack, A. S. (2008). A scientific agenda for the
concept of recovery as it applies to schizophrenia. Clinical
Psychology Review, 28, 1108–1124. doi:10.1016/j.cpr.2008.03.004
Strauss, G. P., Harrow, M., Grossman, L. S., & Rosen, C. (2010). Peri-
ods of recovery in deficit syndrome schizophrenia: A 20-year
multi-follow-up longitudinal study. Schizophrenia Bulletin, 36,
788–799. doi:10.1093/schbull/sbn167
Strauss, J. S., & Carpenter, W. T. (1972). The prediction of out-
come in schizophrenia: I. Characteristics of outcome. Archive
of General Psychiatry, 27, 739–746. doi:10.1001/archpsyc.1972.
01750300011002
Susser, E. S., Lin, S. P., & Conover, S. A. (1991). Risk factors for
homelessness among patients admitted to a state mental hospital.
American Journal of Psychiatry, 148, 1659–1664. doi:10.1176/
ajp.148.12.1659
Susser, E. S., Moore, R., & Link, B. (1993). Risk factors for homeless-
ness. Epidemiologic Reviews, 15, 546–556.
Test, M. A., Knoedler, W. H., Allness, D. J., Burke, S. S., Brown, R.
L., & Wallisch, L. S. (1991). Long-term community care through
an assertive continuous treatment team. In C. A. Tamming &
S. C. Schulz (Eds.), Advances in neuropsychiatry and psychophar-
macology: Vol. 1, Schizophrenia research (pp. 239–246). New
York, NY: Raven Press.
Torgalsbøen, A.-K., & Rund, B. R. (2010). Maintenance of recovery
from schizophrenia at 20-year follow-up: What happened? Psychiatry,
72, 70–82. doi:10.1521/psyc.2010.73.1.70
Ventura, J., Subotnik, K. L., Guzik, L. H., Hellemann, G. S., Gitlin, M.
J., Wood, R. C., & Nuechteriein, K. H. (2011). Remission and
recovery during the first outpatient year of the early course of schi-
zophrenia. Schizophrenia Research, 132, 18–23. doi:10.1016/
j.schres.2011.06.025
Verma, S., Subramaniam, M., Abdin, E., Poon, L. Y., & Chong, S. A.
(2012). Symptomatic and functional remission in patients with
first-episode psychosis. Acta Psychiatrica Scandinavica, 126,
282–289. doi:10.1111/j.1600-0447.2012.01883.x
World Health Organization. (2013). Schizophrenia. Retrieved from
http://www.who.int/mental_health/management/schizophrenia/en/