Hope theory

What is hope? In the medical literature, the term ‘hope’ is frequently cited as a fundamental element for a successful treatment.Reference Bellack^1, Reference Van Allen, Steele, Nelson, Peugh, Egan and Clements² Hope has many definitions including a positive perspective of the future; the expectation of achieving an objective; an effective coping strategy; an inner power that enables one to overcome obstacles (for a review see Snyder et al Reference Snyder, Irving, Anderson, Snyder and Forsyth³). As originally theorised by Snyder et al,Reference Snyder, Irving, Anderson, Snyder and Forsyth³ the ‘hope theory’ refers to an individual's positive perspective that make them invest energy and planning toward goal attainment. Hope is often confused with optimism; optimism or ‘hype’ is related to the individual's general expectancy for good rather than bad outcomes in their life. The hope theory intends to assess one's capacity to select appropriate routes and overcome barriers to goals rather than just one's confidence in a positive outcome. This can best be exemplified by the following analogy – an optimistic person would expect no rain and therefore leave home without an umbrella, whereas the hopeful person would expect no rain but take an umbrella to cope with any unexpected rain. How can one evidence the importance of hope? One could examine data from diseases where it is possible to have biological measures of outcomes – an example would be diabetes mellitus. Van Allen et al Reference Van Allen, Steele, Nelson, Peugh, Egan and Clements² prospectively examined the associations between patients’ hope and optimism with health outcomes in a sample of young people with type 1 diabetes mellitus; they found that hope improved glycaemic control whereas optimism did not help – and they are developing interventions to improve patients’ and families’ hope. In psychiatry, only the early intervention programmes for psychosis have incorporated hope as a treatment target and has been presented as an important example in the field.

Psychiatrists’ attitudes to schizophrenia

Although hope is a key element for recovery,Reference Bellack¹ how many psychiatrists have a truly positive perspective of outcomes in schizophrenia? Schizophrenia has traditionally been viewed as a neurodegenerative chronic condition with a very pessimistic outlook. The tautological approach in which the diagnosis of schizophrenia is questioned when there is complete return to premorbid functioning still prevails. Perhaps it is not surprising that psychiatrists display higher scores of negative stereotypes of schizophrenia and perceived prejudice than the general population.Reference Schulze⁴

So why is it that clinicians still have a negative perspective of schizophrenia? According to Cohen & Cohen,Reference Cohen and Cohen⁵ psychiatrists suffer from ‘the clinician's illusion’ – since the patient population who seek specialised treatment are chronic, more severe and have more comorbidities, which per se presents the worst outcome of the disease, however, this group is not representative of the range of schizophrenia. Clearly, sustaining a positive perspective about treatment effectiveness in this scenario is very challenging; given this negative bias it is difficult for clinicians to remain hopeful and focus energy and planning towards the best treatment strategies available for each patient.

Translation of current knowledge into clinical care

What opportunities for change have arisen recently? There have been significant advances in our understanding of schizophrenia; there is a wealth of clinical and neurobiological data demonstrating that schizophrenia is a neurodevelopmental disorder with heterogeneous phenotypes and a markedly diverse range of outcomes.Reference Schulze⁴ Similarly, recent large cohort studies have shown that the evolution of the disease is more favourable than previously thought.Reference Schulze⁴

What are the best treatment strategies for people with schizophrenia? Although, the hype of neurobiological research has not yet provided a reliable set of predictors of the disease trajectory, there is robust evidence showing that antipsychotic medications and psychosocial interventions are fundamental elements in improving outcomes in schizophrenia.Reference Tandon, Nasrallah and Keshavan⁶ In order to discuss the implication for clinical attitudes, we focus on three aspects of the treatment of schizophrenia that are recommended in the majority of the guidelines, including those of the American Psychiatric Association and the UK National Institute for Health and Care Excellence (NICE), namely: (a) patients whose recovery is limited by poor adherence should be offered a trial of LAI; (b) patients who respond poorly to first- and second-line antipsychotics (treatment resistant) should be encouraged to have a trial of clozapine, and (c) patients with persistent symptoms and/or poor social interactions should be offered adjunct psychosocial treatments

Surprisingly, despite the clear advantages offered by LAIs, clozapine and psychosocial interventions, their use remains limited.Reference Patel, Haddad, Chaudhry, McLoughlin, Husain and David^7–Reference Dweck and Leggett¹⁰ Although non-adherence reaches about 50% in the first year of treatment in first-episode psychosis and partial adherence rates range from one- to two-thirds, LAIs are widely underused in many settings around the world.Reference Patel, Haddad, Chaudhry, McLoughlin, Husain and David⁷ Rates of treatment resistance are also very high (~30%) and surveys show low rates of clozapine prescription ranging from 2 to 3% in North America to 15.9% in China and some European countries.Reference Gören, Meterko, Williams, Young, Baker and Chou⁸ Likewise, uptake of psychosocial treatments remains very low even though at least eight different evidence-based psychosocial interventions such as cognitive–behavioural therapy, family-based services and skills training are recommended by experts and people with the disorder.Reference Dixon, Dickerson, Bellack, Bennett, Dickinson and Goldberg⁹

Why are clinicians not able to implement these evidence-based strategies that offer ‘realistic hope’ to people with schizophrenia? Modern care delivery processes involve an alliance between clinicians, the person with schizophrenia and their family and carers; this is a move away from paternalistic relationships towards more effective strategies, involving shared decision-making.Reference Bellack¹ Doctors have a key role in providing information and support in discussing LAIs, clozapine and psychosocial interventions to empower patients and caregivers in their decision-making. However, there can be logistical issues with the (un)availability of both pharmacological and psychosocial interventions, which it is argued, may be more to do with service resources than with hope, nevertheless, addressing resourcing issues also requires a positive attitude and hope for a positive outcome.

The current negative perspective towards the prognosis of schizophrenia is one example of poor translation of current knowledge to clinical care. Without a positive attitude it is difficult for clinicians to maintain ‘hope’; creating a self-fulfilling prophecy, in which a false assessment of the situation evokes a behaviour that makes the original false conception come true. In other words, a biased view of the likely outcome in schizophrenia makes the doctors less hopeful towards the patients’ prognosis and thus has an impact on their prescribing – precluding patients from access to the best treatment options. Inevitably, the lack of the most appropriate treatment has an impact on patients, resulting in poorer functioning and hindering the recovery process. These poor outcomes validate the original hopeless bias, perpetuating the reign of error! In practice, psychiatrists end up citing this course as proof that they were right to be hopeless about the poor prognosis of schizophrenia from the very beginning.