Evgenia Gkintoni, Ignatia Farmakopoulou, Maria Theodoratou, Maria Panagioti
Background/Objectives: Recovery from schizophrenia-spectrum disorders is increasingly recognized as achievable, yet no synthesis has simultaneously examined long-term outcome rates, intervention effectiveness, cognitive predictors, social determinants, personal-recovery trajectories, and mediating mechanisms within a unified framework. This systematic review aimed to address these six domains and to propose an integrative theoretical model of functional recovery, applying meta-analysis where the evidence permitted and structured narrative synthesis elsewhere. Methods: Seven databases (PubMed/MEDLINE, PsycINFO, Embase, Cochrane CENTRAL, Web of Science, Scopus, CINAHL) were searched through December 2025 following PRISMA 2020 and MOOSE guidance. We extracted eligible records (longitudinal designs, ≥6 months, adults with schizophrenia-spectrum disorders reporting functional outcomes) into two structured databases, then consolidated and de-duplicated them, yielding 467 unique papers. After topical screening and a duplicate audit, we retained 368 studies (1980-2025) and grouped them into six thematic clusters. A pre-specified rule pooled only clusters with at least five independent primary studies. Proportions were pooled with the Freeman-Tukey transformation and associations with Fisher's z under DerSimonian-Laird random-effects models; certainty was appraised with GRADE. Results: Three pools met the threshold. Long-term functional recovery was 35.4% (95% CI 22.6-49.4; k = 11) and symptomatic remission 39.6% (95% CI 29.3-50.5; k = 7), both with very high heterogeneity (I2 = 92-98%) and low certainty. The pooled association between psychological mediators and functional outcome was weak and imprecise (r = 0.23; 95% CI -0.09-0.51; k = 7; very low certainty), reflecting facilitators (positive mental health, social support, self-efficacy, hope) and barriers (internalized stigma, substance-use comorbidity, longer duration of untreated psychosis, persistent negative symptoms) acting in opposite directions. The questions concerning specific interventions, cognitive prediction, rehabilitation, and personal recovery were synthesized narratively: structured psychosocial and combined interventions and integrated rehabilitation were associated with small-to-medium functional gains; cognition, particularly social cognition and motivation, predicted later functioning; and personal recovery followed a course partly independent of clinical status. Conclusions: Recovery and remission are attainable for a substantial minority but remain heterogeneous and modestly certain. The proposed Multi-Pathway Dynamic Recovery Model organizes the evidence into five testable principles-an ordered recovery hierarchy, social-cognitive mediation of the cognition-function link, an early-phase intervention window, social-ecological embedding, and self-reinforcing feedback loops, offered as a hypothesis-generating framework rather than a validated structure. Services should prioritize comprehensive early intervention, target social cognition and stigma, and address structural determinants to optimize long-term recovery.