37 Clinical and personal recovery, a meta-analysis information about the process of personal recovery and whether or not this relates to the reduction of symptoms and if so, which symptoms in particular. It would also be possible to investigate how clinical recovery changes according to stages of recovery (12, 84). Few studies have been performed to investigate changes in personal recovery and symptom severity over time. Some studies showed no correlation between the changes of personal recovery scales and symptom-focused scales (43, 85) and others showed that there is some degree of alignment between clinical and personal outcomes (22, 42, 62, 68). Similar to what was found in the current cross-sectional meta-analysis, affective symptoms were more strongly associated with personal recovery over time than psychotic symptoms (62, 68). More studies are needed to understand the longitudinal interaction between clinical and personal recovery. Because some studies did not report the stage of the disorder of the subjects included and only 2 studies were found that explicitly investigated patients with early psychosis, it was not possible to integrate stage of disorder in the metaregression analyses. Because age showed a tendency to correlate with the effect size, it is imaginable that the stage of the disorder would also play a role. In future research, it would be helpful to investigate the relationship between clinical and personal recovery in homogeneous groups of early and chronic patients to evaluate the potential difference between these groups of patients. The few studies that investigated the relationship between personal recovery and functioning used the GAF. This general measure might not be the best fit to assess functional outcome (see Implications for clinical practice). For future research, agreement about the instrument best suitable to measure functional recovery is needed (86). Cognitive deficits are an important aspect of schizophrenia (87). Although a consensus measure for cognitive deficits in schizophrenia is available (88), the 3 studies we found on the relationship between cognition and personal recovery used heterogeneous measures. In future research on personal recovery and cognition, consistent application of the consensus measure is needed (89-91). Furthermore, international agreement concerning a measure to evaluate personal recovery is necessary. This starts with the definition of personal recovery and which aspects are most important to measure. We would suggest using the CHIMEframework of Leamy et al. as a basis of this definition (13, 14). According to existing evidence, the RAS seems to be a good choice as a personal recovery scale for regular use, because it was developed with patient involvement, maps relatively well on the CHIME-framework, appears to be sensitive to change over time, is easy to administer and shows good internal consistency (α = .70–.93), test-retest reliability, and interrater reliability (16, 17, 19, 92-94). 2
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