Social Psychiatry and Psychiatric Epidemiology

, Volume 53, Issue 2, pp 171–182 | Cite as

Untreated illness and recovery in clients of an early psychosis intervention program: a 10-year prospective cohort study

  • Gina Bhullar
  • Ross M. G. Norman
  • Neil Klar
  • Kelly K. AndersonEmail author
Original Paper



To investigate whether duration of untreated psychosis (DUP) and duration of untreated illness (DUI) are associated with measures of both subjective and objective recovery 10 years after a first episode of psychosis.


A cohort of 65 clients from an early psychosis intervention program completed a battery of outcome measures 10 years following initial treatment for first-episode psychosis (FEP). The outcomes of interest were self-perceived recovery scores (Maryland Assessment of Recovery in People with Serious Mental Illness Scale) and occupational activity, defined as engagement in work and/or school on a full/part-time basis. Multiple linear and logistic regression analyses were used to estimate the associations between DUP and DUI with each measure of recovery, adjusting for potential confounding factors.


We did not find a statistically significant association between DUP and either occupational activity (OR = 1.26, 95% CI 0.81–1.95) or self-perceived recovery score (β = − 0.73, 95% CI − 2.42 to 0.97). However, we found a significant negative association between DUI and self-perceived recovery score (β = − 0.52, 95% CI − 0.87 to − 0.16).


Our findings suggest that DUI may have a stronger influence than DUP on recovery from FEP at 10-year follow-up. This suggests the potential value in targeted interventions for people with a long DUI to increase the likelihood of achieving recovery after the first episode of psychosis.


First-episode psychosis Duration of untreated psychosis Duration of untreated illness Recovery Early intervention Prospective 


Compliance with ethical standards

Ethical standard

All participants provided informed consent prior to their inclusion in this study, and ethics approval was granted by the Health Sciences Research Ethics Board at The University of Western Ontario. Therefore, this study “has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its amendments.” Furthermore, no details have been published that may disclose the identity of the participants in this study.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    de Koning MB, Bloemen OJN, van Amelsvoort TAMJ., Becker H, Nieman DH, van der Gaag M, Linszen DH (2009) Early intervention in patients at ultra high risk of psychosis: benefits and risks. Acta Psychiatr Scand 119(6):426–442. CrossRefPubMedGoogle Scholar
  2. 2.
    Lam MM, Pearson V, Ng RM, Chiu CP, Law CW, Chen EY (2010) What does recovery from psychosis mean? Perceptions of young first-episode patients. Int J Soc Psychiatry 57(6):580–587. CrossRefPubMedGoogle Scholar
  3. 3.
    Marshall M, Rathbone J (2011) Early intervention for psychosis. Schizophr Bull 37(6):1111–1114. CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Austin SF, Mors O, Secher RG, Hjorthøj CR, Albert N, Bertelsen M, Thorup A (2013) Predictors of recovery in first episode psychosis: the OPUS cohort at 10 year follow-up. Schizophr Res 150:163–168. CrossRefPubMedGoogle Scholar
  5. 5.
    Verma S, Subramaniam M, Abdin E, Poon LY, Chong SA (2012) Symptomatic and functional remission in patients with first-episode psychosis. Acta Psychiatr Scand 126(4):282–289. CrossRefPubMedGoogle Scholar
  6. 6.
    de Wet A, Swartz L, Chiliza B (2015) Hearing their voices: the lived experience of recovery from first-episode psychosis in Schizophrenia in South Africa. Int J Soc Psychiatry 61:27–32. CrossRefPubMedGoogle Scholar
  7. 7.
    Eisenstadt P, Monteiro VB, Diniz MJ, Chaves AC (2012) Experience of recovery from a first-episode psychosis. Early Interven Psychiatry 6(4):476–480. CrossRefGoogle Scholar
  8. 8.
    Windell D, Norman RMG (2012) A qualitative analysis of influences on recovery following a first episode of psychosis. Int J Soc Psychiatry 59(5):493–500. CrossRefPubMedGoogle Scholar
  9. 9.
    Thompson KN, McGorry PD, Harrigan SM (2003) Recovery style and outcome in first-episode psychosis. Schizophr Res 62:31–36. CrossRefPubMedGoogle Scholar
  10. 10.
    Drake RE, Noel VA, Deegan PE (2015) Measuring recovery as an outcome. Die Psychiatrie 12:174–149Google Scholar
  11. 11.
    Evensen J, Røssberg JI, Barder H, Haahr U, Hegelstad WTV, Joa I, McGlashan T (2012) Apathy in first episode psychosis patients: a ten year longitudinal follow-up study. Schizophr Res 136:19–24. CrossRefPubMedGoogle Scholar
  12. 12.
    Hill M, Crumlish N, Clarke M, Whitty P, Owens E, Renwick L, O’Callaghan E (2012) Prospective relationship of duration of untreated psychosis to psychopathology and functional outcome over 12 years. Schizophr Res 141(2):215–221. CrossRefPubMedGoogle Scholar
  13. 13.
    Chang WC, Tang JYM, Hui CLM, Lam MML, Wong GHY, Chan SKW, Chan K (2012) Duration of untreated psychosis: relationship with baseline characteristics and three-year outcome in first-episode psychosis. Psychiatry Res 198(3):360–365. CrossRefPubMedGoogle Scholar
  14. 14.
    Singh SP, Fisher HL (2005) Early intervention in psychosis: obstacles and opportunities. Adv Psychiatr Treat 11:71–78. CrossRefGoogle Scholar
  15. 15.
    Norman RMG, Malla AK (2001) Duration of untreated psychosis: a critical examination of the concept and its importance. Psychol Med 31(3):381–400. CrossRefPubMedGoogle Scholar
  16. 16.
    Norman RMG, Malla AK, Manchanda R, Harricharan R, Takhar J, Northcott S (2005) Social support and three-year symptom and admission outcomes for first episode psychosis. Schizophr Res 80(2):227–234. CrossRefPubMedGoogle Scholar
  17. 17.
    Marshall M, Lewis S, Lockwood A, Drake R, Jones P, Croudace T (2005) Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review. Arch Gen Psychiatry 62(9):975–983. CrossRefPubMedGoogle Scholar
  18. 18.
    Perkins DO, Gu H, Boteva K, Lieberman JA (2005) Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia: a critical review & meta-analysis. Am J Psychiatry 162(10):1785–1804. CrossRefPubMedGoogle Scholar
  19. 19.
    Penttilä M, Jääskeläinen E, Hirvonen N, Isohanni M, Miettunen J (2014) Duration of untreated psychosis as predictor of long-term outcome in schizophrenia: systematic review and meta-analysis. Br J Psychiatry 205(2):88–94. CrossRefPubMedGoogle Scholar
  20. 20.
    Kinoshita H, Nakane Y, Nakane H, Ishizaki Y, Honda S, Ohta Y, Ozawa H (2005) Nagasaki schizophrenia study: influence of the duration of untreated psychosis on long-term outcome. Acta Medica Nagasakiensia 50:17–22. Google Scholar
  21. 21.
    Röpcke B, Eggers C (2005) Early-onset schizophrenia. Eur Child Adolesc Psychiatry 14(6):341–350. CrossRefPubMedGoogle Scholar
  22. 22.
    White C, Stirling J, Hopkins R, Morris J, Montague L, Tantam D, Lewis S (2009) Predictors of 10-year outcome of first-episode psychosis. Psychol Med 39(9):1447–1456. CrossRefPubMedGoogle Scholar
  23. 23.
    Ichinose H, Nakane Y, Nakane H, Kinoshita H, Ohta Y, Honda S, Ozawa H (2010) Nagasaki schizophrenia study: relationship between ultralong-term outcome (after 28 years) and duration of untreated psychosis. Acta Medica Nagasakiensia 54(3):59–66. Google Scholar
  24. 24.
    Shrivastava A, Shah N, Johnston M, Stitt L, Thakar M, Chinnasamy G (2010) Effects of duration of untreated psychosis on long-term outcome of people hospitalized with first episode schizophrenia. Indian J Psychiatry 52(2):164–167. CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Tang JYM, Chang WC, Hui CLM, Wong GHY, Chan SKW, Lee EHM, Pang EPF (2014) Prospective relationship between duration of untreated psychosis and 13-year clinical outcome: a first-episode psychosis study. Schizophr Res 153:1–8. CrossRefPubMedGoogle Scholar
  26. 26.
    Austin SF, Mors O, Budtz-Jørgensen E, Secher RG, Hjorthøj CR, Bertelsen M, Nordentoft M (2015) Long-term trajectories of positive and negative symptoms in first episode psychosis: a 10 year follow-up study in the OPUS cohort. Schizophr Res 168:84–91. CrossRefPubMedGoogle Scholar
  27. 27.
    Jaracz K, Górna K, Kiejda J, Grabowska-Fudala B, Jaracz J, Suwalska A, Rybakowski JK (2015) Psychosocial functioning in relation to symptomatic remission: a longitudinal study of first episode schizophrenia. Eur Psychiatry 30(8):907–913. CrossRefPubMedGoogle Scholar
  28. 28.
    Rund BR, Barder HE, Evensen J, Haahr U, Hegelstad WTV, Joa I, Opjordsmoen S (2015) Neurocognition and duration of psychosis: a 10-year follow-up of first-episode patients. Schizophr Bull 42:87–95. PubMedPubMedCentralGoogle Scholar
  29. 29.
    Friis S, Melle I, Johannessen JO, Røssberg JI, Barder HE, Evensen JH, Larsen TK (2015) Early predictors of ten-year course in first-episode psychosis. Psychiatric Ser 67(4):438–443. CrossRefGoogle Scholar
  30. 30.
    Crumlish N, Whitty P, Clarke M, Browne S, Kamali M, Gervin M, O’Callaghan E (2009) Beyond the critical period: longitudinal study of 8-year outcome in first-episode non-affective psychosis. Br J Psychiatry 194:18–24. CrossRefPubMedGoogle Scholar
  31. 31.
    Dell’Osso B, Glick ID, Baldwin DS, Altamura AC (2013) Can long-term outcomes be improved by shortening the duration of untreated illness in psychiatric disorders? A conceptual framework. Psychopathology 46:14–21CrossRefPubMedGoogle Scholar
  32. 32.
    Harris MG, Henry LP, Harrigan SM, Purcell R, Schwartz OS, Farrelly SE, McGorry PD (2005) The relationship between duration of untreated psychosis and outcome: an eight-year prospective study. Schizophr Res 79:85–93. CrossRefPubMedGoogle Scholar
  33. 33.
    Keshavan MS, Haas G, Miewald J, Montrose DM, Reddy R, Schooler NR, Sweeney JA (2003) Prolonged untreated illness duration from prodromal onset predicts outcome in first episode psychoses. Schizophr Bull 29(4):757–769CrossRefPubMedGoogle Scholar
  34. 34.
    Norman RMG, Manchanda R, Windell D, Harricharan R, Northcott S, Hassall L (2012) The role of treatment delay in predicting 5-year outcomes in an early intervention program. Psychol Med 42(2):223–233. CrossRefPubMedGoogle Scholar
  35. 35.
    Albert N, Bertelsen M, Thorup A, Petersen L, Jeppesen P, Le Quack P, Nordentoft M (2011) Predictors of recovery from psychosis: analyses of clinical and social factors associated with recovery among patients with first-episode psychosis after 5 years. Schizophr Res 125(2):257–266. CrossRefPubMedGoogle Scholar
  36. 36.
    Chang WC, Tang JY, Hui CL, Lam MM, Chan SK, Wong GH, Chen EY (2012) Prediction of remission and recovery in young people presenting with first-episode psychosis in Hong Kong: a 3-year follow-up study. Aust N Z J Psychiatry 46(2):100–108. CrossRefPubMedGoogle Scholar
  37. 37.
    Faber G, Smid HG, Van Gool AR, Wunderink L, Wiersma D, van den Bosch RJ (2011) Neurocognition and recovery in first episode psychosis. Psychiatry Res 188:1–6. CrossRefPubMedGoogle Scholar
  38. 38.
    Gumley AI, Schwannauer M, Macbeth A, Fisher R, Clark S, Rattrie L, Birchwood M (2014) Insight, duration of untreated psychosis and attachment in first-episode psychosis: prospective study of psychiatric recovery over 12-month follow-up. Br J Psychiatry 205:60–67. CrossRefPubMedGoogle Scholar
  39. 39.
    Major BS, Hinton MF, Flint A, Chalmers-Brown A, McLoughlin K, Johnson S (2010) Evidence of the effectiveness of a specialist vocational intervention following first episode psychosis: a naturalistic prospective cohort study. Soc Psychiatry Psychiatric Epidemiol 45:1–8. CrossRefGoogle Scholar
  40. 40.
    Wunderink L, Sytema S, Nienhuis FJ, Wiersma D (2009) Clinical recovery in first-episode psychosis. Schizophr Bull 35(2):362–369. CrossRefPubMedGoogle Scholar
  41. 41.
    Jørgensen R, Zoffmann V, Munk-Jørgensen P, Buck KD, Jensen SO, Hansson L, Lysaker PH (2015) Relationships over time of subjective and objective elements of recovery in persons with schizophrenia. Psychiatry Res 228:14–19. CrossRefPubMedGoogle Scholar
  42. 42.
    Kukla M, Lysaker PH, Roe D (2014) Strong subjective recovery as a protective factor against the effects of positive symptoms on quality of life outcomes in schizophrenia. Compr Psychiatry 55(6):1363–1368. CrossRefPubMedGoogle Scholar
  43. 43.
    Lloyd C, King R, Moore L (2010) Subjective and objective indicators of recovery in severe mental illness: a cross-sectional study. Int J Soc Psychiatry 56(3):220–229. CrossRefPubMedGoogle Scholar
  44. 44.
    Morland T (2007) The Predictive Factors of Subjective Recovery in First-Episode Psychosis. Doctoral dissertation, University of LondonGoogle Scholar
  45. 45.
    Norman RMG, Windell D, Lynch J, Manchanda R (2013) Correlates of subjective recovery in an early intervention program for psychoses. Early Interven Psychiatry 7(3):278–284. CrossRefGoogle Scholar
  46. 46.
    Resnick SG, Rosenheck RA, Lehman AF (2004) An exploratory analysis of correlates of recovery. Psychiatric Ser 55(5):540–547. CrossRefGoogle Scholar
  47. 47.
    Roe D, Mashiach-Eizenberg M, Lysaker PH (2011) The relation between objective and subjective domains of recovery among persons with schizophrenia-related disorders. Schizophr Res 131:133–138. CrossRefPubMedGoogle Scholar
  48. 48.
    Addington J, Young J, Addington D (2003) Social outcome in early psychosis. Psychol Med 33(6):1119–1124. CrossRefPubMedGoogle Scholar
  49. 49.
    Gee B, Hodgekins J, Fowler D, Marshall M, Everard L, Lester H, Freemantle N (2016) The course of negative symptom in first episode psychosis and the relationship with social recovery. Schizophr Res 174:165–171. CrossRefPubMedGoogle Scholar
  50. 50.
    Kam SM, Singh SP, Upthegrove R (2015) What needs to follow early intervention? Predictors of relapse and functional recovery following first-episode psychosis. Early Interven Psychiatry 9(4):279–283. CrossRefGoogle Scholar
  51. 51.
    Windell D, Norman RMG, Malla AK (2012) The personal meaning of recovery among individuals treated for a first episode of psychosis. Psychiatric Services 63(6):548–553. CrossRefPubMedGoogle Scholar
  52. 52.
    Connell M, Schweitzer R, King R (2015) Recovery from first-episode psychosis: a dialogical perspective. Bull Menninger Clin 79:70–90CrossRefPubMedGoogle Scholar
  53. 53.
    Law H, Shryane N, Bentall RP, Morrison AP (2016) Longitudinal predictors of subjective recovery in psychosis. Br J Psychiatry 209:48–53. CrossRefPubMedGoogle Scholar
  54. 54.
    Morrison AP, Shryane N, Beck R, Heffernan S, Law H, McCusker M, Bentall RP (2013) Psychosocial and neuropsychiatric predictors of subjective recovery from psychosis. Psychiatry Res 208(3):203–209. CrossRefPubMedGoogle Scholar
  55. 55.
    Bellack AS, Drapalski A (2012) Issues and developments on the consumer recovery construct. World Psychiatry 11(3):156–160. CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Ahmed AO, Birgenheir D, Buckley PF, Mabe PA (2013) A psychometric study of recovery among certified peer specialists. Psychiatry Res 209(3):721–731. CrossRefPubMedGoogle Scholar
  57. 57.
    Malla AK, Norman RMG, McLean T, Scholten D, Townsend L (2003) A Canadian programme for early intervention in non-affective psychotic disorders. Aust N Z J Psychiatry 37(4):407–413. CrossRefPubMedGoogle Scholar
  58. 58.
    Norman RMG, Manchanda R (2016) Prevention and early intervention program for psychoses (PEPP). Healthcare Quarterly (Toronto, Ont.), 18, pp 37–41Google Scholar
  59. 59.
    Norman RMG, Malla AK, Verdi MB, Hassall LD, Fazekas C (2004) Understanding delay in treatment for first-episode psychosis. Psychol Med 34(2):255–266. CrossRefPubMedGoogle Scholar
  60. 60.
    Drapalski AL, Medoff D, Dixon L, Bellack A (2016) The reliability and validity of the Maryland Assessment of Recovery in Serious Mental Illness Scale. Psychiatry Res 239:259–264. CrossRefPubMedGoogle Scholar
  61. 61.
    World Health Organization (1992) Life chart schedule. World Health Organization, GenevaGoogle Scholar
  62. 62.
    Andreasen NC (1984) Scale for the assessment of positive symptoms (SAPS). Department of Psychiatry, College of Medicine, University of Iowa, Iowa CityGoogle Scholar
  63. 63.
    Andreasen NC (1983) Scale for the assessment of negative symptoms (SANS). Department of Psychiatry, College of Medicine, University of Iowa, Iowa CityGoogle Scholar
  64. 64.
    Cohen S, Mermelstein R, Kamarck T, Hoberman H (1985) Measuring the Functional Components of Social Support. In: Sarason IG, Sarason BR (eds) Social support: theory, research and application, Springer, Netherlands, pp 73–94CrossRefGoogle Scholar
  65. 65.
    Skinner HA (1982) The drug abuse screening test. Addict Behav 7(4):363–371. CrossRefPubMedGoogle Scholar
  66. 66.
    Vittinghoff E, Glidden DV, Shiboski SC, McCulloch CE (2011) Regression methods in biostatistics: linear, logistic, survival, and repeated measures models. Springer Science & Business MediaGoogle Scholar
  67. 67.
    Bouhlila DS, Sellaouti F (2013) Multiple imputation using chained equations for missing data in TIMSS: a case study. Large-Scale Assess Edu 1:1–33. CrossRefGoogle Scholar
  68. 68.
    Bodner TE (2008) What improves with increased missing data imputations? Structural equation modeling. Multidis J 15:651–675. Google Scholar
  69. 69.
    Von Hippel PT (2009) How to impute squares, interactions, and other transformed variables. Sociol Methodol 39:265–291. CrossRefGoogle Scholar
  70. 70.
    StataCorp (2015) Stata statistical software: release 14. StataCorp LP, College StationGoogle Scholar
  71. 71.
    Ng RKM, Pearson V, Lam M, Law CW, Chiu CPY, Chen EYH (2008) What does recovery from schizophrenia mean? Perceptions of long-term patients. Int J Soc Psychiatry 54(3):118–130. CrossRefPubMedGoogle Scholar
  72. 72.
    Davidson L, O’Connell MJ, Tondora J, Staeheli M, Evans AC (2005) Recovery in serious mental illness: paradigm shift or shibboleth. In: Davidson L, Harding CM, Spaniol L (eds) Recovery from severe mental illnesses: research evidence and implications for practice. Centre for Psychiatric Rehabilitation of Boston University, BostonGoogle Scholar
  73. 73.
    Harvey PD, Bellack AS (2009) Toward a terminology for functional recovery in schizophrenia: is functional remission a viable concept? Schizophr Bull 35(2):300–306. CrossRefPubMedPubMedCentralGoogle Scholar
  74. 74.
    Liberman RP, Kopelowicz A (2005) Recovery from schizophrenia: a concept in search of research. Psychiatric Ser 56(6):735–742. CrossRefGoogle Scholar
  75. 75.
    Silverstein SM, Bellack AS (2008) A scientific agenda for the concept of recovery as it applies to schizophrenia. Clin Psychol Rev 28(7):1108–1124. CrossRefPubMedGoogle Scholar
  76. 76.
    Lysaker PH, Taylor A, Miller A, Beattie N, Strasburger A, Davis LW (2006) The scale to assess narrative development: associations with other measures of self and readiness for recovery in schizophrenia spectrum disorders. J Nerv Mental Dis 194(3):223–225. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2017

Authors and Affiliations

  • Gina Bhullar
    • 1
    • 2
  • Ross M. G. Norman
    • 1
    • 2
    • 3
  • Neil Klar
    • 1
  • Kelly K. Anderson
    • 1
    • 2
    • 3
    Email author
  1. 1.Department of Epidemiology and Biostatistics, Schulich School of Medicine and DentistryThe University of Western OntarioLondonCanada
  2. 2.Department of Psychiatry, Schulich School of Medicine and DentistryThe University of Western OntarioLondonCanada
  3. 3.Prevention and Early Intervention Program for Psychoses (PEPP)London Health Sciences CentreLondonCanada

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