58 Chapter 3 also affective symptoms is important. Treating these symptoms could support personal recovery and specifically empowerment and attention to personal recovery could result in remission of affective symptoms. Several recovery-oriented practices have been developed that target the key recovery processes: connectedness, hope, identity, meaning and empowerment (CHIME) (14). For example, it has been shown that supporting self-esteem increases clinical recovery and coping skills (37, 38). A qualitative research approach could explain more about the specific link between affective symptoms and personal recovery (39). Limitations Our results should be interpreted in the light of several limitations. We had no data on longitudinal course of symptom severity or personal recovery. This would have given valuable information concerning the process of recovering over time and might have revealed a causal direction in the correlations found (19, 40-43). Another limitation concerns the operationalisation of the concept personal recovery. Personal recovery is often regarded as a subjective story about overcoming the catastrophic effects of a mental disease. By using a standardized questionnaire this individual story is not assessed, although it is, in all its diversity, central to the concept of personal recovery. Finally, no international consensus exists regarding the processes that contribute to personal recovery and the best suitable instrument to measure it. Future research should both address international consensus about the theoretical framework of personal recovery, perhaps with CHIME as a basis, and the psychometric quality of assessment instruments. Conclusion The findings of the present study suggest a link between affective symptoms and personal recovery in a representative sample of patients with SMI, whereas psychotic symptoms do not show this association. Self-empowerment was the subdomain of personal recovery that was most prominently associated with affective symptoms. Treatment of affective symptoms may advance personal recovery, and/or support of personal recovery may improve mood, whereas focusing on treatment of psychotic symptoms might not be the key to personal recovery. More research is needed to elucidate causal interrelations. Ethical approval The Medical Ethics Review Committee of VU University Medical Centre, Amsterdam, (FWA00017598) confirmed that approval of this study was not necessary according to Dutch law, because there was no medical intervention involved and no possible harm to participants (reference number: 2015.350). Funding No external funding or financial resources have been used for this project.
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