Quels outils thérapeutiques en faveur du rétablissement dans la schizophrénie ?

Abstract

Recovery is a multidimensional construct that encompasses both subjective (e.g. well-being, satisfaction with life, self-esteem) and objective outcomes (e.g. independent living, interpersonal and intimate relationships, work). Recovery can be defined either from a clinical perspective (i.e. clinical and functional remission) or from a consumer-focused one, as a self-broadening process aimed at living a meaningful life beyond mental illness. Recovery-oriented practices imply to create pro-recovery environment seeking to enhance hope, control, strengths, goal striving and self-management. Their implementation in mental health services has shown effectiveness in improving personal recovery. Psychiatric rehabilitation brings together a wide range of recovery-oriented interventions. A comprehensive clinical, functional and cognitive assessment is performed to establish the individual's strengths and weaknesses, autonomy, and occupational level. Therapeutic tools are selected based on the participant's personal life goals as part of an individualized psychiatric rehabilitation action plan. The action plan can include strengths-based case management, psychoeducation, improvements in physical and mental health, peer-support interventions, joint crisis plans, cognitive remediation (CR), cognitive behavior therapy (CBT), social skills training (SST), self-stigma reduction, making empowered decisions about disclosure, family support, recovery-oriented interventions from preconception to post-partum care and supported housing and supported employment. Psychiatric rehabilitation interventions improve patient's outcomes after one year of follow-up (i.e. symptom reduction, improvements in insight, treatment adherence and cognitive and psychosocial function). The access to psychiatric rehabilitation interventions remains however limited (1/3 of the participants with SSD included in the FondaMental Advanced Centers of Expertise for SSD) and should be further developed. Supported housing and supported employment improve the access to stable housing and sustained competitive employment. They have been associated to improved patient's outcomes and have shown to be cost-effective. Recovery-oriented interventions from preconception to post-partum care (reproductive health counseling, strength-based case management by a trained midwife, shared action plan, self-stigma reduction, cognitive remediation, gender-sensitive CBT and SST) could reduce the risk of psychiatric, obstetrical and neonatal complications. They could reduce the risks of parent-infant separation and custody loss and could prevent the development of psychosis in family high-risk children. These interventions should be further developed and evaluated. Recovery-oriented practices and psychiatric rehabilitation support recovery in people with SSD. The access to a comprehensive standardized evaluation and to a personalized recovery-oriented care including psychosocial treatment remains limited. Their implementation in mental health services figures among the priorities under the French decree on the territory national mental health plan for recovery-focused care.