Predictors of recovery from psychosis
Analyses of clinical and social factors associated with recovery among
patients with first-episode psychosis after 5 years
Nikolai Alberta,c, Mette Bertelsena, Anne Thorupa, Lone Petersena, Pia Jeppesena,
Phoung Le Quackb, Gertrud Krarupb, Per Jørgensenb, Merete Nordentofta,⁎
aPsychiatric Center Copenhagen, Copenhagen University, Faculty of Health Sciences, Copenhagen, Denmark
bCenter for Psychiatric Research, Psychiatric University Hospital Risskov, Aarhus, Denmark
cDivision of Psychiatry, Haukeland University Hospital, Sandviken, Bergen, Norway
a r t i c l ei n f oa b s t r a c t
Received 16 June 2010
Accepted 9 October 2010
Available online 5 November 2010
Introduction: This paper aims to investigate the predictors of good outcome after first-episode
non-affective psychosis and the clinical and social trajectories of those that recover.
Methods: A cohort of 255 patients with first-episode non-affective psychosis was interviewed
5 years after first diagnosis and treatment. Recovery was defined as working or studying,
having a GAF-function score of 60 or above, having remission of negative and psychotic
symptoms, and not living in a supported housing facility or being hospitalized during the last
2 years before the five-year follow-up interview.
Results: A total of 40 (15.7%) were found to be recovered, and 76 (29.8%) had a job or were
studying after 5 years. Of those working, as many as 20 still had psychotic symptoms. Also
notable is that out of the 40 recovered, less than half were recovered after 2 years. Recovery
after 5 years was predicted by female sex (OR 2.4, 95% CI 1.0–5.8), higher age (OR 0.91, 95% CI
0.83–0.99), pre-morbid social adaptation (OR 0.72, 95% CI 0.56–0.93), growing up with both
parents (OR 2.6, 95% CI 1.0–6.8) and low level of negative symptoms (OR 0.51, 95% CI 0.33 to
0.77) at baseline.
Discussion: Our findings suggest that a stable social life with normal social functioning has a
predictive value for good outcome.These measures mightbe influenced bynegative symptoms,
but in the multivariate analysis with negative symptoms included they have an independent
effect. Also our findings suggest that, after first-episode psychosis, some patients can still
experience psychotic symptoms, but have a job and a fairly stable life.
© 2010 Elsevier B.V. All rights reserved.
Recovery in schizophrenia and schizophrenia-like psy-
chosis has increasingly come into focus. There is no overall
agreement on the definition of recovery, but there is con-
sensus that at least clinical and functional outcome such as
remission of symptoms and ability to work or study should
be included. In general, long-term follow-up studies with
multiple follow-up points focusing on the course of illness are
scarce. Studies on outcome suggest that one-third to one-
quarter of patients have the potential of reaching remission
(Bertelsen et al., 2008).
With regard to risk factors for schizophrenia, the litera-
ture suggests that early onset appears to predict the severity
of the long-term course of illness (Harrison et al., 2001;
Rabinowitz et al., 2006). The literature also indicates that
prolonged duration of untreated psychosis (DUP) predicts a
worse functional and clinical outcome (Jeppesen et al., 2008;
Schizophrenia Research 125 (2011) 257–266
⁎ Corresponding author. Psychiatric Center Copenhagen, Bispebjerg Bakke
23, 2400 Copenhagen NV, Denmark. Tel.: +45 20607552; fax: +45 35313953.
E-mail address: firstname.lastname@example.org (M. Nordentoft).
0920-9964/$ – see front matter © 2010 Elsevier B.V. All rights reserved.
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Marshall et al., 2005; Perkins, 2006). Similarly, among first-
episode psychosis patients, diagnosis of schizophrenia, male
sex, high age, high level of negative symptoms, poor pre-
morbid social function and substance abuse are associated
with poorer outcome (Arseneault et al., 2002; Brill et al.,
2009; Harrison et al., 2001; Harrow et al., 2005; Hofer et al.,
2006; Lambert et al., 2005; van et al., 2002). Early trajectory
also seems to predict long-term outcome (Eaton et al., 1995;
Harrison et al., 2001). This finding has given rise to the critical
phase theory, which hypothesizes that the first 2 years of
illness are critical for the long-term outcome.
The OPUS trial (for details see (Bertelsen et al., 2008;
Petersen et al., 2005)) is one of very few long-term pro-
spective follow-up studies of first-episode psychotic patients
(Bromet et al., 2005; Eaton et al., 1995; Harrison et al., 2001;
Harrow et al., 2005; Wiersma et al., 1998) with multiple
follow-up points. It offers an important contribution to the
literature, since the sample has been assessed after 1, 2 and
5 years, and the results at the ten-year follow-up will be
completed in 2011.
This study aims to investigate:
1. The proportion of first-episode psychosis patient who
meet criteria for recovery 5 years after the first contact
with mental health services.
2. The predictors for recovery
3. The clinical and social trajectories of those who recover
fully and those who are able to hold a normal job or study
full time, even though they are not fully recovered.
2.1. Study design
A total of 547 patients with a disorder within the schizo-
phrenia spectrum were included in the Danish OPUS trial,
which is a randomized clinical trial comparing 2 years of
intensive early-intervention programme with standard treat-
ment. The intensive early-intervention programme consisted
of enriched ACT (Assertive Community Treatment), psycho-
educational family treatment (McFarlane et al., 1995) and
social skills training (Liberman et al., 1998). The caseload was
1:10. Standard treatment consisted of the standard routines
offered by the mental health services in the Danish cities
Copenhagen and Aarhus, with a caseload of 1:30. Adminis-
tration of antipsychotic medication was based on the same
principles in both groups.
At the time of inclusion, all patients were between 18 and
45 years of age and were diagnosed within the schizophrenia
spectrum (ICD 10 codes in the F2 category) after a compre-
hensive interview, including Schedule for Clinical Assessment
in Neuropsychiatry, with independent researchers. None of
at baseline before entering the trial, and again after 1, 2 and
5 years (Fig. 1). Centralised randomisation with concealed
allocation sequence was carried out. The main results of the
RCT are described at follow-up after 2 years (Petersen et al.,
2005) and after 5 years (Bertelsen et al., 2008).
The focus of the present study is the prognosis for
patients with a first-episode psychosis. Of the 547 included
in the OPUS study, we excluded 79 first diagnosed with
schizotypal personality disorder. Due to attrition in the
follow-up period, the final sample that we were able to
analyse consisted of 255 patients out of 468 eligible
patients. The reasons for drop-out are: death=15, refused
to participate=35, moved far away=15, could not be
traced=74, only partly participating=74.
Information on the following topics was collected through
interviews carried out by independent research assistants:
• Main diagnosis and substance abuse based on the Schedule
for Clinical Assessment in Neuropsychiatry (SCAN 2.1)
(Wing et al., 1990).
• Symptoms based on Scale for Assessment of Positive
Symptoms and Scale for Assessment of Negative symptoms
(SAPS and SANS). The scale is a six-point scale with the
categories: none, questionable, mild, moderate,marked and
severe. The higher the scores, the more severe the symp-
toms. The scales are summed up in three dimensions: psy-
chotic, negative and disorganized. To investigate the
differences, we split the psychotics dimension into global
ratings of hallucination and delusion and use them as
separate predictors in the regression analysis (Andreasen
et al., 1990; Arndt et al., 1995).
• Socio-demographic factors; those collected were: occupa-
tion, education, relationship, children, upbringing with or
Schizotypal disorder 79
Psychosis in the schizophrenia spectrum
Declining to participate
Cannot be found
Attending five -year follow-up
Fig. 1. Flow-chart.
N. Albert et al. / Schizophrenia Research 125 (2011) 257–266
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