This study examines the recovery process and associated factors in a sample of people with schizophrenia in Brazil. To our knowledge, this is the first quantitative study on the level of recovery and its associated factors in a Brazilian sample, since most of the previous studies in the country focused on qualitative data from the narratives and reports of people with mental disorders.
The result of the mean score for RAS scale in the present sample (average score = 3.9) replicates findings from international studies. A literature review that included 28 international studies that used the instrument, found the mean score to range between 3.14 and 4.12 [33]. It is important to note that this review included studies from several countries, including non-English-speaking countries (such as Portugal, Spain, Sweden, Sweden, China and Japan).
According to the results of the analysis of variance (ANOVA), which compared the means of RAS domains, lower scores were found in the domain “no domination by symptoms” and the highest ones in the domains of “reliance on others” and “goal and success orientation”. The higher score in the domain of trust in others might be related to the sociocultural aspect of this specific population in Brazil, which values the importance of long lasting affective and even financial support (especcially from relatives) for life and, consequently, as support for processes recovery, as pointed out by a previous qualitative studies from Brazil [28-30].
The variables included in the regression model explain only 20% of the variance in the RAS score in the present sample. In addition, only sociodemographic and clinical variables, and measures of symptoms and functioning were introduced into the model as independent variables. On the other hand, factors that have been shown in the literature as more associated with the recovery process, such as hope, empowerment, well-being and quality of life, for example, were not included in this study [50,51]. This might explain the low percentage found in this study.
Positive Symptoms (as measured by PANSS) and global symptom and functioning assessment (as measured by CGI) did not demonstrate a significant association with personal recovery. Together with the lower score for the domain “not dominated by symptoms”, compared to other RAS domains, this result is in convergence with international studies. For example, recent metanalysis have pointed that positive, negative and general symptoms usually have small and negative correlation with recovery measures [50,52]. In this sense, this finding suggests that the recovery process takes place beyond symptoms, and that, even with their presence and manifestation, people are able to have meaningful ,productive lives, as stated in the most cited defnitions of personal recovery [6].
The lack of significant association, in this study by the ILSS, between the clinical parameter of functional independence and recovery processes, could be related to the fact that performance and independence in some activities of daily living might not be consideredin the participants' perception, as important for their recovery processes. Furthermore, almost none of the participants lived alone and therefore, might not need to carry out certain activities in their daily routine at home, for example. In this sense, it could also be associated with the above mentioned Brazilian and Latin-American sociocultural aspect of long lasting affective and financial reliance on family, which has been pointed out in previous studies [21-24,29, 33].
The significant association found between SAOF and RAS scores reinforces the importance of subjective assessment of the occupational dimension for the recovery process. This association is also in agreement with international studies, which point to the importance of the occupational dimension and performance of work activities such as, the function and role of the person with experience as a peer worker in health services. Accordingly, the perception and satisfaction that the person has of his/her own performance, as assessed by SAOF, in the area of personal causality, personal interests and sense of self-fulfillment, seem to be related to their recovery process (positive identity, purpose and meaning in life and empowerment) [50,54-56, 57].
It was also possible to identify a significant and negative association between personal recovery and depressive symptoms (as measure by Calgary scale). This finding converges with previous studies, which pointed out that affective symptoms are often the only symptoms showing a moderate and negative correlation with recovery [50,52,58]. This might also be explained by the fact that the presence of depressive symptoms as measured by this scale, especially hopelessness and self depreciation, points to a state opposite to recovery, in which hope and positive identity appear as core processes [57].
Some limitations should be mentioned. First, the study included a non-probability sample. Consequently, further quantitative Brazilian and Latin-American research on this topic is required, using a larger and probabilistic sample. Another limitation is the cross-sectional design, which does not allow causal inferences between the variables.
Despite these limitations, this study is the first to explore the factors associated with the recovery level for people with schizophrenia in Brazil, using quantitative data. It replicates, data from the international literature and highlights specificcultural aspects. As such, the study reinforces the idea of recovery as a universal process, and the need for better guidance of health practices and services aimed at promoting strategies to support people's recovery process.