75 Change in symptom severity and personal recovery (17). Qualitative research could gain more insight into the patterns of change and individual factors that influence the relationship between clinical and personal outcome. O’Keeffe et al. showed that themes of personal recovery meaning can be different between service users with or without clinical recovery (41). Absence of symptoms is important for some, but not for all (42). Implications Awareness that not only reduction of symptoms helps patients with their personal recovery, but that other factors also contribute, is important. Keeping in mind the five core elements of personal recovery, presented in CHIME (connectedness, hope, identity, meaning and empowerment) (1), determinants found in other research, can be of interest for clinicians trying to promote the personal recovery of their patients. Examples are: self-esteem, stigma, social interaction, pro-active coping (16, 43-46). Because personal recovery processes are very different and show heterogeneity in their association with symptomatology, a personalized treatment approach is of great importance (36). Depression/anxiety symptoms show more impact on personal recovery than positive, negative or excitement symptoms in the combined SMI group. It is imaginable that treatment of mood and anxiety symptoms will influence the personal recovery process. Strengths and limitations To our knowledge, this is one of the first studies investigating the longitudinal relationship between change in symptom severity and change in personal recovery and one that is performed in a population of SMI patients, not only patients with a schizophrenia spectrum disorder. Investigating these variables over time is important because personal recovery is usually defined as a process, not a state. Also new is the fact that we examined different domains of symptoms. A limitation is the relatively small group of participants and the drop-out at followup. Therefore, generalizability is only allowed after independent replication. Conclusion Change of symptom severity only explains part of the change in the subjective experience of recovery. This means that besides treating symptoms, also other potential determinants of personal recovery should be addressed in treatment of SMI, e.g. gaining more self-esteem, improving the social environment and pro-active coping. Clinically, mainly depression/anxiety symptoms affect personal recovery in SMI patients, so attention and treatment targeting this symptom domain is important. 4
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