Springer Nature is making Coronavirus research free. View research | View latest news | Sign up for updates

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



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.

This is a preview of subscription content, log in to check access.

Fig. 1


  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.

  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.

  3. 3.

    Marshall M, Rathbone J (2011) Early intervention for psychosis. Schizophr Bull 37(6):1111–1114.

  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.

  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.

  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.

  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.

  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.

  9. 9.

    Thompson KN, McGorry PD, Harrigan SM (2003) Recovery style and outcome in first-episode psychosis. Schizophr Res 62:31–36.

  10. 10.

    Drake RE, Noel VA, Deegan PE (2015) Measuring recovery as an outcome. Die Psychiatrie 12:174–149

  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.

  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.

  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.

  14. 14.

    Singh SP, Fisher HL (2005) Early intervention in psychosis: obstacles and opportunities. Adv Psychiatr Treat 11:71–78.

  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.

  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.

  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.

  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.

  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.

  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.

  21. 21.

    Röpcke B, Eggers C (2005) Early-onset schizophrenia. Eur Child Adolesc Psychiatry 14(6):341–350.

  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.

  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.

  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.

  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.

  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.

  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.

  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.

  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.

  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.

  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 46:14–21

  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.

  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):757–769

  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.

  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.

  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.

  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.

  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.

  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.

  40. 40.

    Wunderink L, Sytema S, Nienhuis FJ, Wiersma D (2009) Clinical recovery in first-episode psychosis. Schizophr Bull 35(2):362–369.

  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.

  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.

  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.

  44. 44.

    Morland T (2007) The Predictive Factors of Subjective Recovery in First-Episode Psychosis. Doctoral dissertation, University of London

  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.

  46. 46.

    Resnick SG, Rosenheck RA, Lehman AF (2004) An exploratory analysis of correlates of recovery. Psychiatric Ser 55(5):540–547.

  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.

  48. 48.

    Addington J, Young J, Addington D (2003) Social outcome in early psychosis. Psychol Med 33(6):1119–1124.

  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.

  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.

  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.

  52. 52.

    Connell M, Schweitzer R, King R (2015) Recovery from first-episode psychosis: a dialogical perspective. Bull Menninger Clin 79:70–90

  53. 53.

    Law H, Shryane N, Bentall RP, Morrison AP (2016) Longitudinal predictors of subjective recovery in psychosis. Br J Psychiatry 209:48–53.

  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.

  55. 55.

    Bellack AS, Drapalski A (2012) Issues and developments on the consumer recovery construct. World Psychiatry 11(3):156–160.

  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.

  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.

  58. 58.

    Norman RMG, Manchanda R (2016) Prevention and early intervention program for psychoses (PEPP). Healthcare Quarterly (Toronto, Ont.), 18, pp 37–41

  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.

  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.

  61. 61.

    World Health Organization (1992) Life chart schedule. World Health Organization, Geneva

  62. 62.

    Andreasen NC (1984) Scale for the assessment of positive symptoms (SAPS). Department of Psychiatry, College of Medicine, University of Iowa, Iowa City

  63. 63.

    Andreasen NC (1983) Scale for the assessment of negative symptoms (SANS). Department of Psychiatry, College of Medicine, University of Iowa, Iowa City

  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 73–94

  65. 65.

    Skinner HA (1982) The drug abuse screening test. Addict Behav 7(4):363–371.

  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 Media

  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.

  68. 68.

    Bodner TE (2008) What improves with increased missing data imputations? Structural equation modeling. Multidis J 15:651–675.

  69. 69.

    Von Hippel PT (2009) How to impute squares, interactions, and other transformed variables. Sociol Methodol 39:265–291.

  70. 70.

    StataCorp (2015) Stata statistical software: release 14. StataCorp LP, College Station

  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.

  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, Boston

  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.

  74. 74.

    Liberman RP, Kopelowicz A (2005) Recovery from schizophrenia: a concept in search of research. Psychiatric Ser 56(6):735–742.

  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.

  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.

Download references

Author information

Correspondence to Kelly K. Anderson.

Ethics declarations

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.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Bhullar, G., Norman, R.M.G., Klar, N. et al. Untreated illness and recovery in clients of an early psychosis intervention program: a 10-year prospective cohort study. Soc Psychiatry Psychiatr Epidemiol 53, 171–182 (2018).

Download citation


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