According to the World Health Organization (2005), mental health is a “state of wellbeing in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.” This definition has its foundation in positive mental health (PMH), a construct first proposed by Jahoda (1958), who described PMH as individuals' attitudes toward themselves and the environment and their ability to adapt to situations.

Mental health and mental illness are traditionally conceptualized as being on opposite ends of the same continuum. However, evidence indicates that they represent two distinct, yet interrelated, dimensions. Therefore, the absence of the disorder does not guarantee the presence of health, and vice versa (Keyes, 2013). Based on this belief, people with mental disorders can experience at the same time positive emotions, form close relationships, have a purposeful life and function well by relating to PMH. This means that a patient suffering from a mental disorder will require not only a clinical assessment of the disease process, but also special care from a positive perspective. The positive aspect of mental health is currently considered in mental health care systems (e.g., Forsman et al., 2015; Wahlbeck, 2015).

In this respect, the PMH construct has been studied for years based on Lluch-Canut's Multifactor PMH model (1999), made up of six interrelated factors: F1-Personal Satisfaction (F1), F2-Prosocial Attitude (F2), F3-Self-Control (F3), F4-Autonomy (F4), F5-Problem-Solving and Self-Actualization (F5), and F6-Interpersonal Relationship Skills (F6). To evaluate this multifactorial model, the author created the Positive Mental Health Questionnaire (PMHQ), which is described in detail in the Methods section. Lluch-Canut's PMHQ (1999) has been used in various studies and settings: in patients with schizophrenia (Miguel, 2014); in chronic patients (Lluch-Canut et al., 2013; Puig-Llobet et al., 2020); in carers of patients with schizophrenia (Albacar, 2014), and in university students (Roldán-Merino et al., 2017; Sequeira et al., 2020). The questionnaire has also been translated into Portuguese (Sequeira et al., 2014) and Turkish (Teke and Baysan Arabaci, 2018). Although there is increasingly more research on PMH, it has been little researched in people with psychotic disorder (Miguel, 2014; Jeyagurunathan et al., 2017; Na and Lim, 2020), and only one study (Miguel, 2014) uses the PMHQ. It is therefore important to assess PMH and its factors in people with mental illness, as it will help health professionals in better understanding these individuals' specific needs and also in implementing both health promotion and prevention activities to improve their mental health.

Following this line of research, we set out to study PMH supplemented with other positive constructs, such as recovery, subjective wellbeing (SWB), insight and functioning, and in this way characterize the relationship between them. We briefly describe below some highlights in the scientific literature on the use of these constructs.

Recovery research focusing on people with mental disorders is still relatively recent. However, in the last few years, the concept of recovery has experienced significant momentum both at clinical and policy level, being incorporated into health policies in various countries (e.g., Burgess et al., 2011). The Substance Abuse Mental Health Services Administration (2005) defined mental health recovery as “a journey of healing and transformation, enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential” (p. 1), this being one of the most widely used and accepted definitions.

SWB can be defined as a normally positive state of mind that involves the whole life experience. One of the models proposed to explain how SWB works is the Homeostatic Theory and stems from the idea that SWB, under normal conditions, is managed by a psychological, homeostatic system in such a way that people are usually satisfied with their life and this does not tend to change substantially over time (Cummins, 2010).

In recent decades, the term “insight” has aroused great interest in the field of mental health due to the relationship it has been shown to have with numerous variables, which have an important impact on mental disorders. Insight refers to the degree of awareness that the individual has of their disease. It is considered a multidimensional construct that affects different areas with different intensity and may be present in some areas, but not in others (David, 1990).

Functioning is the individual's ability to effectively carry out the activities of daily living (World Health Organization, 2001). By definition, psychotic disorders involve suffering and impaired functioning (American Psychiatric Association, 2013).

Evidence exists of a link between recovery, SWB, insight and functioning and mental disorders (Cannavò et al., 2016; Chan et al., 2018; Widschwendter et al., 2018; Yu et al., 2020). However, no previous studies have been known to address the innovative PMH construct and its correlation with this set of positive measures. It is important to manage as many positive measures as possible in order to develop multi-component intervention programs. This is the reason why we have conducted this study. Its objectives are to evaluate the level of PMH and its relationship with sociodemographic and clinical determinants as well as to explore the relationship between PMH and the positive constructs of recovery, SWB, insight and functioning in patients with psychotic disorder being treated in mental healthcare facilities in Catalonia (Spain).

Although this is a descriptive and exploratory study, the main hypothesis that has guided the analysis of the data collected is defined as follows. Specifically, the level of PMH in people with psychotic disorder is thought to correlate positively with recovery, SWB and functioning, and negatively with insight.

The participants in our study presented lower levels of PMH than sample populations without mental disorders who had responded to the PMHQ (Lluch-Canut et al., 2013; Albacar, 2014; Roldán-Merino et al., 2017; Puig-Llobet et al., 2020; Sequeira et al., 2020). However, results were similar to findings in a study on patients with schizophrenia (Miguel, 2014). These results are a cause for concern and reinforce the importance of developing services and interventions aimed at improving PMH in patients with psychotic disorder.

The level of recovery was similar to that of a sample of patients with severe mental disorder (Drapalski et al., 2016). In contrast, it was lower than in a sample of patients included in an early intervention program (EIP) in psychosis (Bhullar et al., 2018). These results demonstrate the effectiveness of EIP programs in terms of recovery.

The PWI-A score for SWB was low (M = 60.20) compared to the normative range within Western populations, which is between 70 and 80 points (International Wellbeing Group, 2013). One study conducted in Israel on patients with severe mental disorder obtained similar results (Werner, 2012). Cummins et al. (2014) argued that SWB may decrease in response to adverse events, but these deviations are generally temporary thanks to the action of a homeostatic mechanism. However, when normal feelings of wellbeing disappear, they are replaced by depression (Cummins, 2010). The most plausible hypothesis put forward is that psychotic disorder and the life experience that accompanies severe mental illness may affect this population's SWB.

No studies were found in the literature in which OLS had been administered to patients with psychotic disorder. The data we obtained were consistent with the study by Fervaha et al. (2016), which showed that patients with schizophrenia were less happy in general than healthy controls.

The level of insight in the sample was generally low (Birchwood et al., 1994), although 45.3% of the patients presented adequate insight. This finding is consistent with a literature review in which it was estimated that between 50 and 80% of patients with schizophrenia partially, or totally, lacked awareness of their mental illness (Raffard et al., 2008).

The mean GAF score was similar to that of other studies in European populations (Gaite et al., 2005) and in the Spanish population (Al-Halabí et al., 2016). Scientific evidence has shown that diagnosis and an EIP could significantly improve therapeutic results and enhance the effectiveness of established treatments (Arango, 2015).

When analyzing PMH and sociodemographic and clinical variables, some aspects of interest were found that are relevant for discussion. Single patients presented a lower level of global PMH than married, separated or widowed subjects. These data are similar to findings in other studies conducted on patients with mental disorders (Vaingankar et al., 2013; Sambasivam et al., 2016), which used other instruments to measure PMH. In contrast, patients in active employment reported higher global PMH, in line with other research (Sambasivam et al., 2016; Na and Lim, 2020), although the PMHQ was not used.

As in other studies in which the PMHQ was used, with regard to factor F2, women reported having greater prosocial behavior (Lluch-Canut et al., 2013; Albacar, 2014). These results also coincided with other studies conducted on patients with mental disorders (Vaingankar et al., 2013; Sambasivam et al., 2016; Jeyagurunathan et al., 2017). Single patients reported lower prosocial behavior compared to those who were married, separated, divorced or widowed. The data we obtained were consistent with the study by Sambasivam et al. (2016) conducted on patients with mental disorders, although the PMHQ was not used. In contrast, in the study carried out by Miguel (2014), single patients presented greater prosocial behavior. Similarly, patients in active employment reported greater prosocial behavior, whereas patients with some type of disability had the lowest scores. These results are in line with other studies that show lower levels of PMH among the unemployed or people who have unstable jobs (Sambasivam et al., 2016), although the PMHQ was not used.

It was found that patients with the highest score in factor F4 were those who lived alone and those who were separated, divorced or widowed. In contrast, single patients showed more autonomy. These results are consistent with the study by Sambasivam et al. (2016), where single people reported lower levels of autonomy, although the PMHQ was not used.

With regard to factor F5, higher values were observed among patients who were married or active workers. In contrast, single and disabled patients showed a lower capacity for problem-solving and self-actualization. These data are similar to other studies (Vaingankar et al., 2013; Sambasivam et al., 2016) that used other instruments to measure PMH.

Finally, women obtained higher scores in interpersonal relationship skills than men with regard to the F6 factor, coinciding with other studies (Lluch-Canut et al., 2013). However, married patients were found to have greater interpersonal relationship skills. These data are similar to other studies (Sambasivam et al., 2016), although the PMHQ was not used. Patients in active employment reported greater interpersonal relationship skills, coinciding with similar results in other studies (Vaingankar et al., 2013; Sambasivam et al., 2016) in which the PMHQ was not used.

Based on the literature, few research studies have related the level of PMH measured with the PMHQ and the clinical variables used in this study among patients with psychotic disorder. Patients with a family history of mental illness, those prescribed three or more antipsychotics, those being treated with anxiolytics, and also those who had attempted suicide reported lower levels of PMH. Similar data were obtained in the study carried out by Lluch-Canut et al. (2013), which used the PMHQ to show that polymedicated patients presented lower overall PMH levels. These results can be explained by the prevalence of comorbidity of anxiety and depressive disorders in schizophrenia, which is significantly higher than in the general population (Buckley et al., 2009; Kiran and Chaudhury, 2016). Epidemiological studies have shown that polypharmacy is extremely common in schizophrenia, although evidence of its benefits remains scant (Ballon and Stroup, 2013).

When analyzing specific PMH factors and clinical variables, results in the F1 factor showed that patients prescribed three or more antipsychotics, those being treated with antidepressants, and those who had attempted suicide reported lower personal satisfaction, although no studies with similar results were found. In factors F3, F4 and F5, it was observed that patients prescribed three or more antipsychotics, those being treated with antidepressants, and those who had attempted suicide reported less self-control, autonomy and capacity for problem-solving and self-actualization. Similar data were obtained in Lluch-Canut et al. (2013), showing that polymedicated patients presented lower levels in these three factors. Moreover, it was found in factor F3 that patients with a family history of mental illness showed less capacity for self-control. Regarding factor F5, it was observed that patients with fewer years of evolution of the psychotic disorder reported a lower capacity for problem-solving and self-actualization. Finally, regarding factor F6, patients prescribed three or more antipsychotics and those being treated with anxiolytics or antidepressants reported lower interpersonal relationship skills.

Regarding the relationship between PMH and recovery, it was observed that both the global levels of PMH and the PMHQ factors correlated positively with the MARS. One study on patients with mental disorders had similar results, although different instruments were used (Iasiello et al., 2019). The results have indicated that PMH can be an important resource for patients to recover from a mental disorder and stay mentally healthy. Similarly, based on the analysis of the relationship between PMH and SWB, it would appear that global PMH levels and PMHQ factors correlated positively with the PWI-A and the OLS. Several studies can be found with similar results, although different instruments were used (Seow et al., 2016; Vaingankar et al., 2016). Based on these results, it can be asserted that mental health is directly related to SWB.

As for the relationship between PMH and insight, it was observed that both global levels of PMH and PMHQ factors correlated negatively with the overall level and dimensions of insight. However, no studies exist linking these two constructs. Similarly, a relationship was found between terms related to PMH (wellbeing, quality of life, etc.) and insight in patients with psychotic disorder, associating high levels of insight with poorer quality of life and wellbeing (Lien et al., 2018; Davis et al., 2020).

Finally, a positive correlation was obtained between PMH and functioning. Accordingly, several studies on patients with mental disorders have shown a similar association (Seow et al., 2016; Vaingankar et al., 2016), although other measurement instruments were used.

The present study reveals that PMH is significantly positively associated with recovery, SWB, functioning, age and being separated, divorced or widowed. In contrast, insight and having a family history of mental disorder showed a significant and negative association with global PMH. However, according to the literature consulted, no studies are available that have analyzed this set of variables that may favor the level of PMH in patients with psychotic disorder.

Various interventions to improve PMH exist in a variety of modalities, including individual, group and online formats, but targeting the general population (Bolier et al., 2013; Teixeira et al., 2019; Eisenstadt et al., 2021). However, no evidence-based intervention research on PMH in the psychotic disorder population has been found. However, there are possible interventions that could provide substantial benefits to PMH in this population, such as cognitive remediation (Vita et al., 2021), progressive muscle relaxation (Melo-Dias et al., 2019) or social cognition training (d'Arma et al., 2021).

This study contributes to increasing the scant existing knowledge of PMH in patients with psychotic disorder. It also helps us to identify the variables, and the relationships between them, which have the greatest impact on mental health. Accordingly, they can be considered when designing interventions, strategies and programs for this type of population. Specific interventions should be made to improve PMH since levels are lower in patients with psychotic disorder than in the general population.

The original contributions presented in the study are included in the article/supplementary files, further inquiries can be directed to the corresponding author.

The studies involving human participants were reviewed and approved by the Clinical Research Ethics Committee at the Healthcare Institute (Reference Number: S041-1094), the Benito Menni Mental Healthcare Complex (Reference Number: PR-2015-19), the Mar Health Park (Reference Number: 2015/6303/I), and by the Research Committee at the Sant Joan de Déu Health Park. The patients/participants provided their written informed consent to participate in this study.

MB-B, MG-C, and ML-C conceptualized the study. MB-B, MG-C, DJ-C, and ML-C contributed to the preparation of the final draft and study protocols. MB-B collected data, conducted initial data analysis, and wrote the first draft. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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