Mental disorders are one of the leading causes in the non-fatal burden of diseases worldwide that can affect people of all ages (1). Approximately 450 million individuals globally are believed to be afflicted by these severe illnesses (2).  The Global Burden of Diseases research in 2022 indicates that Disability-adjusted life years (DALYs) for mental illnesses rose from 80.8 million in 1990 to 125.30 million in 2019. The ratio of DALY for mental disorders to all disorders has risen from 1.3% to 9.4% between 1990 and 2019, showing that they are still one of ten leading causes of disease burden globally, with no evidence of a reduction since 1990 (3). Data from different countries show that five of the most severe health problems are related to mental disorders (2). One out of every four adults is estimated to be affected by a mental disorder, with 5% of people in society suffering from a severe mental disorder such as schizophrenia or bipolar disorder (4).
In the Eastern Mediterranean region, mental disorders cause 4.7% of the DALYs, and almost all countries in this region had higher DALY rates of mental disorders compared to the global average (1). In Iran, mental problems rank as the second most prevalent ailment behind accidental accidents.  National surveys in Iran indicate that mental illnesses account for around 16% of the overall disease burden. A study of mental disorders prevalence in Iran showed that 23.6% of Iranian population between the ages of 15 and 64 met the criteria of at least one DSM-IV mental disorder in the past 12 months. The 12-month prevalence of bipolar disorder, major depression, and any type of primary psychotic disorder were 12.7%, 1%, and 0.5%, respectively (7). Furthermore, mental diseases exert considerable societal and economic strains, including elevated healthcare expenditures, diminished output, and notable social difficulties.  These effects highlight the essential need for efficient recovery-oriented therapies to mitigate individual distress and wider society expenses (8). While recovery from mental disorders is often considered to be a complex and time-consuming process, a person with severe mental illness could still recover, even if the disease is "untreated". Recovery-oriented service should include the belief that recovery is possible for people with mental illness (9). Considering the patients with schizophrenia spectrum or major mood disorders experience many limitations and disabilities throughout the disease course, efforts should be made to improve the patients' living conditions despite the presence of episodic symptoms. In other words, instead of focusing on eliminating the symptoms, we could focus on improving quality of life dimensions.
Since the patient is the best source for monitoring the changes during the disease course, self-report psychological well-being scales are crucial for a recovery-oriented evaluation (10). First, we need recovery criteria and measurement tools for its evaluation. In recent years, the studies on the development and implementation of recovery-oriented programs increased (10-12), and the necessity of evaluating recovery using standard self-report tools has been emphasized (13, 14).  For the past two decades, researchers have endeavored to create a precise measurement instrument for mental health recovery.  In order to evaluate the recovery of patients with severe mental illnesses, numerous instruments have been developed and reviewed in a systematic manner (15-17). Although there is no gold standard measurement tool, Recovery Assessment Scale (RAS) was the most commonly used scale in recovery-based studies (12, 18-20). For example, McNaught et al in Australia in 2006 (24), Chiba et al in Japan 2009 (25), Jorge-Monteiro and colleagues in Portugal 2016 (26), and Cavelti et al in German-speaking patients 2017 (27), have translated and psychometrically evaluated RAS in patients from various nations and cultural backgrounds (21-23). Validity and reliability of this scale was reported to be reasonably acceptable, with Cronbach's alpha coefficient higher than 0.7 in all these studies. Implementing recovery-oriented care in low-resource settings like Iran presents several challenges, including underfunded mental health services, cultural perceptions of mental illness, and systemic barriers within the healthcare infrastructure (28). Addressing these obstacles is essential for the successful adoption of recovery-oriented practices.
Among further modifications, Recovery Assessment Scale - Domains and Stages (RAS-DS) is a well-developed, evaluated, systemically reviewed and widely used scale that was revised and developed during a collaborative process with the patients, which has showed good reliability and validity in some studies (20, 29). Due to its comprehensive evaluation of recovery across multiple domains and stages, its collaborative development that included patient input, and its demonstrated applicability across diverse cultural contexts, the RAS-DS was chosen over other recovery scales (28). Consequently, it is particularly well-suited for adaptation to the Iranian setting. Comparatively, other instruments may not encompass the full spectrum of recovery experiences or may lack validation in varied cultural environments, thereby limiting their applicability in Iran. Considering the lack of self-report psychometric questionnaires in Persian language, which can measure the recovery of patients with severe mental disorders comprehensively in a short time, this study was designed to translate and evaluate the validity and reliability of RAS-DS in the patients with schizophrenia and major mood disorder in Iran.

  

Discussion

We prepared the Persian translation version of self-report questionnaire RAS-DS. We evaluated the validity and reliability to assess recovery for the patients with schizophrenia spectrum disorders, and major mood disorders. Based on our findings, the translated Persian version of RAS-DS questionnaire has appropriate face and content validity, and the test-retest reliability of the questionnaire was at an acceptable level, as in all domains, the scores of the first and second evaluations showed internal consistency. The second evaluation's better scores, especially in the third and fourth categories, however, emphasize the need of a methodical study of condition modifications or other variables impacting these outcomes; for instance, they could point to a familiarization or learning effect. Future research should look at this and accept it as a shortcoming. The higher score of the third and fourth domains of questionnaire and total score in the second evaluation (retest) could be attributed to the long interval between the first and second evaluations resulting in condition changes since the first evaluation in hospitalization. The management of disease symptoms in the second evaluation could also be another reason. In our study, all domains of RAS-DS significantly correlated with each other and total questionnaire score. The alpha coefficient above 0.7 in our study indicates the internal consistency of the translated questionnaire. It also demonstrates that the domains of the questionnaire are not independent from one another, as the alpha coefficient and variance of a specific domain would not be substantially enhanced by the removal of a specific question in any field.  In other words, all inquiries are pertinent to the assessment's objective and its outcome. Various tools were used in different studies to measure the correlation with RAS-DS. In our study, we used WHOQoL-BREF, DASS-21, and BPRS for this purpose. We found significant correlations for all domains of RAS-DS with different domains of the quality of life (WHOQoL-BREF), and with the severity of depression, anxiety, and stress scales (DASS-21). However, RAS-DS total score was not correlated with the severity of psychopathology based on the BPRS. This suggested that a patient's perception of recovery might not be influenced by the severity of the disorder, indicating the need for additional research to explore this relationship. In contrast, the absence of correlation with the BPRS emphasizes the significance of distinguishing subjective recovery, as assessed by self-report instruments such as the RAS-DS, from clinical symptomatology.  This discovery may indicate that self-report instruments offer complementary insights and should not be exclusively utilized for a comprehensive recovery assessment. Hancock et al. evaluated the feasibility, acceptability and measurement features of RAS-DS in youth mental healthiness services in 2020. Then, both clients and clinicians provided feedback on its usefulness. Fifty-eight client-physician couples participated, and analyzes showed that RAS-DS items corresponded well with the expectations. This study shows that the RAS-DS has acceptable measurement properties for youth and clinicians (38). Hancock et al. also demonstrated exceptional internal validity for the RAS-DS in a separate study. The point correlation was positive for all cases and ranged from 0.42 to 0.70. The reliability indexes of patients and items were 0.93 and 0.98, respectively, and the Cronbach's alpha coefficient was 0.96 (20). In our study, Cronbach's alpha coefficient for RAS-DS was calculated 0.960 for entire questionnaire, and 0.835, 0.944, 0.881, and 0.815 for its four domains, respectively, indicating the translated questionnaire has a high internal consistency. Scanlan et al. in 2018 investigated the convergence validity and sensitivity to change overtime in RAS-DS test and Camberwell Assessment of Need - Short Appraisal Scale (CANSAS). Their results showed a moderate and significant correlation between RAS-DS total and domain scores and CANSAS scores. The results of this study show that RAS-DS was sensitive to identify changes in long term. On the other hand, the relative correlation between CANSAS and RAS-DS shows that self-report recovery measurement should be considered important in providing recovery-based services (39).
Our results are consistent with these studies, indicating that RAS-DS is not only culturally adaptable to the Iranian population but also reliable. However, future research should take into account the unique sociocultural factors that influence recovery perceptions in non-Western contexts. Recovery from a disease or disability does not always imply the elimination of all symptoms and the full restoration of complete function. (40). The concept of recovery therefore is creating a fulfilling life and well-being feeling despite concurrent limitations (41). People who experience severe psychiatric symptoms episodically may recover (42); however, recovery from mental disorders is often complex and time-consuming (43). It is clear that to improve the recovery and recovery-oriented interventions assessment, there is a need for valid and reliable tools to measure meaningful and practical outcomes for patients and healthcare providers. Over the past two decades, researchers have been trying to create a precise measurement instrument for assessing mental health recovery (20). These evaluations should be capable of directing the intervention and identifying the patient's improvement or any domain that has the potential for recovery.  Additionally, it should establish the context for initiating discussions between patients and employees and propose potential avenues for collaboration (44). By addressing the gaps in recovery-oriented assessment tools available in Iran, our study contributes to filling a critical void in the mental health care framework. Since there was no such possibility in Iran, this study was done to develop and use Persian version of RAS-DS in evaluating patients' recovery, and performing appropriate interventions for them. Considering acceptable reliability and validity, as well as the internal consistency of Persian translation for the RAS-DS in this study, it is suggested that colleagues in future studies use this tool to investigate and improve the situation of Iranian patients with schizophrenia spectrum disorders and major mood disorders. Future study options might include longitudinal studies to assess recovery trajectories, adaption for different Persian-speaking groups, and integration with other objective performance metrics. Conducting similar studies allows for assessing recovery for the patients with severe mental disorders. The results of such analyses can be used to improve patients' health care and inform healthcare decision-makers about their current situation, as well as the possibility of comparing the outcomes with the studies of other countries.

 

Limitation

Since this study was conducted in a single specialized psychiatric hospital, subjects might not necessarily reflect all patients, as they tend to have more severe symptoms compared with the general population of patients. This restricted the generalizability of our findings to a more extensive Iranian population with severe mood disorders and schizophrenia spectrum disorder.  In order to improve representativeness, future research should incorporate a more diverse sample that encompasses a variety of psychiatric settings and community-based care facilities. On the other hand, as the study coincided with COVID-19 pandemic, our ability to conduct clinical examinations and administer other questionnaires was constrained. Consequently, we relied on above-mentioned questionnaires that could be considered a limitation of our study. In addition, the translation process may have introduced subtle biases that necessitate further investigation in subsequent studies, as a result of the challenges encountered, such as assuring cultural and linguistic equivalence. We therefore suggest correlation assessment of this tool with the clinical and objective performance tools, for instance Mini-Mental State Examination (MMSE) and Positive and Negative Syndrome Scale (PANSS) in the future studies. Besides, during the process of psychometric tools evaluation in a new language, it is possible to discover the factor structure of that tool in the same study or test it in other studies. Owing to the insufficient sample size for conducting both exploratory and confirmatory analyses, we restricted our investigation to exploratory analysis, which may be seen as a drawback of our work.  Future research should analyze the confirmatory factor analysis of the instrument. Moreover, the sample size for follow-up evaluation (n=20) was relatively small, which could affect the robustness of test-retest reliability results. Future research should aim for larger follow-up cohorts to validate the consistency of findings over time. We should consider that the ability of researchers to evaluate the various aspects of one instrument´s validity is limited and like most other validity evaluations cannot be done adequately in one study. We therefore suggest examining the validity of this tool from different perspectives, such as differential validity, in the upcoming assessments.

 

Conclusion

Based on this study, the Persian translation of RAS-DS questionnaire has good reliability and validity, as well as acceptable internal consistency (Cronbach's alpha= 0.960). All domains of the Persian version of RAS-DS had a positive and significant correlation with each other and the total score of the questionnaire. This version of RAS-DS demonstrated a positive and substantial association with several areas of quality of life (WHOQoL-BREF), as well as a negative and significant correlation with the severity of depression, anxiety, and stress scales (DASS-21). However, except for the fourth domain (Connecting and belongings), the scores of other RAS-DS domains, and the total score were not correlated with the severity of psychopathology according to the BPRS. Researchers could therefore investigate recovery process of Iranian patients with schizophrenia spectrum disorders and major mood disorders using this translated version of the tool.

 

Declarations

Acknowledgements

Not applicable.

 

Ethical Considerations

The proposal of the study was reviewed by the ethics committee of Iran University of Medical University and was approved with the review board license number: IR.IUMS.FMD.REC.1399.206.

 

Authors' Contributions

Conceptualizing he study, analaysing the data: Kaveh Alavi.
Managing the overall research process: Kaveh Alavi, Amir Hossein Jalali Nadoushan.
Data collection: Fatemeh Banihashemian, Maryam Rafieian Koopaiee, Tara Rezvankhah, Kaveh Alavi.
Drafting the manuscript or revising it critically for important intellectual content: Fatemeh Banihashemian, Amir Hossein Jalali Nadoushan, Mahdi Safdarian, Maryam Rafieian Koopaiee, Tara Rezvankhah, Kaveh Alavi
Providing data or critical feedback on manuscript: Fatemeh Banihashemian, Amir Hossein Jalali Nadoushan, Mahdi Safdarian, Maryam Rafieian Koopaiee, Tara Rezvankhah, Kaveh Alavi.
All authors had full access to all the data in the study and had final responsibility for the decision to submit for publication.

 

Conflicts of Interest

The authors declare that there are no conflicts of interest.

 

Fund or Financial Support

This research received no specific grant from any funding agency in the public, commercial, or not for profit sector.

 

Using Artificial Intelligence Tools (AI Tools)

The authors were not utilized AI Tools.

 

Informed consent

The participants entered the project after signing informed consent form. All the patients and one of their caregivers were given sufficient information about the research process and its goals.