36 Chapter 2 outcome measures in clinical practice, which mainly focus on symptom remission and functioning (25), should be extended to include personal recovery. Our findings highlight the relative importance of affective symptoms for personal recovery. This is in line with studies of patients with affective disorders (77-79). A key component of depression is that everything is perceived as pointless and hope is lost. The question is whether treatment of affective symptoms will promote personal recovery, or that promoting personal recovery, in general, will relieve feelings of depression. On the other hand, this meta-analysis shows that positive symptoms were only slightly related to personal recovery. This may imply that an emphasis on reducing positive symptoms, might not result in improved personal recovery. Although few studies were found that investigated the relationship between general functioning and personal recovery, the results show a small correlation between these 2 outcomes (r = .21). This is remarkable because one would expect that better functioning, for instance having a house, work and relationships would increase the perceived level of recovery. A possible explanation is that the GAF is scored by the professional and personal recovery by the patient. Possibly, the GAF does not reflect important aspects of functioning from the perspective of patients. Also, symptom and functioning ratings are both part of the GAF and it is known from the literature that GAF ratings are highly correlated with ratings of symptoms in schizophrenia (80). A higher correlation (r = .36) between personal recovery and social functioning, measured by the social functioning scale (SFS) has been found (81). Several empirically validated personal recovery-oriented practices have already been developed, eg peer support workers, wellness recovery action planning, recovery colleges, and mental health trialogues, but implementation in mental health systems remains limited (82). To make recovery-oriented practices a success, professional and organizational commitment toward supporting subjective outcome measures such as personal recovery is needed. The relative emphasis of the evidence-based medicine paradigm on objective (clinical) outcomes (83), possibly together with an implicit idea that individuals with mental health problems do not qualify as equal partners in the evaluation of treatment, might have been the reason that earlier findings of a small relationship between objective and subjective domains of outcome have not resulted in implementation of effective practices on a larger scale (82). Implications for future research Clinical, as well as personal recovery, change over time. Because most of the selected studies did not investigate these concepts longitudinally, the current meta-analyses focused on cross-sectional associations. Longitudinal research gives additional
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