Risk factors that have so far been independently associated with longer DUP contributed to the most unfavorable configuration: the population of younger, male, unemployed patients in supported living who use cannabis showed prolonged DUP. Hence, this subpopulation shares most risk factors previously associated with longer DUP, such as unemployment (Limbu et al., 2025; Morgan et al., 2006; Qiu et al., 2019; Reichert & Jacobs, 2018), lower SES (Fordham et al., 2023; Peralta et al., 2005), and male sex (Apeldoorn et al., 2014; Skrobinska et al., 2024). Overall, this aligns with prior work conducted in a cohort of patients with psychosis from the United States, where the more disadvantaged classes in terms of social position and first-contact experienced a longer DUP (van der Ven et al., 2022). However, direct comparisons are challenging because they investigated time to first contact and time to specialized care separately, and the United States has a vastly different health care system. Furthermore, the class with predominantly White individuals in the study in the United States mainly diverged from the other identified classes and experienced the shortest time from onset to first contact (van der Ven et al., 2022). This echoes our results, as White ethnicity was most prevalent in class 3 in both samples and class 1 in GROUP, showing shorter DUP.

Our results underline the importance of interpreting social and substance use-related risks within their broader context. Prolonged DUP was only observed in the presence of specific configurations of multiple risk factors (class 2), whereas other configurations were not associated with longer DUP. For example, class 1 in GROUP – with the shortest DUP – was characterized by female sex, White ethnicity, and the absence of cannabis use, but showed relatively high rates of unemployment. This specific configuration may create intersections that buffer the negative effect of unemployment through other financial and social resources, such as higher levels of social contacts (Reininghaus et al., 2008). Contrary to previous results suggesting that living with family members is associated with shorter DUP compared to living alone (Compton et al., 2011), in our study, living with parents was part of risk configurations (class 2), whereas the class with shorter DUP (class 3) lived alone more frequently. Similarly, the association of recent cannabis use and DUP differed in accordance with risk configurations: while cannabis use was associated with prolonged DUP in class 2, and the absence of cannabis use was linked to shorter DUP in class 1 in GROUP, class 3 in GROUP still exhibited higher levels of cannabis use and a shorter DUP, potentially buffered by higher SES. In addition, the association between attained education and DUP remains equivocal. Although prior work in the Brazilian EU-GEI subsample (Shuhama et al., 2021) and other studies (Skrobinska et al., 2024; Souaiby et al., 2019; Takizawa et al., 2021) reported an association between lower levels of educational attainment and longer DUP, prior work in GROUP did not (Apeldoorn et al., 2014). Notably, lower educational attainment in our study was most prevalent in classes with younger age, who may not yet have completed college.

Prolonged DUP has been associated with higher symptom severity and a lower chance of remission in psychotic disorders (Howes et al., 2021). Thus, the question remains whether risk configurations of male sex, unemployment, cannabis use, and supported living may not only predict longer DUP, but may also directly index risk for poorer overall prognosis. Identified classes with cumulated adverse social and behavioral factors may cause treatment delays and simultaneously prevent a more favorable course and long-term outcome in psychosis. For example, lower levels of educational attainment and substance use have been previously reported to be associated with nonadherence and treatment dropout (Leclerc, Noto, Bressan, & Brietzke, 2015), and cannabis use with relapse (Hasan et al., 2020). Therefore, treatment outcomes might be shaped by the same upstream social and substance use-related factors that impact DUP, creating a dual pathway that increases health disparities. More generally, the complex interplay of how adverse social experiences may co-occur, impact, and intersect with each other over time to impact DUP remains to be established. Ignoring or neglecting the effects of social determinants on DUP and the interaction with treatment outcomes might inadvertently augment social and ethnic inequalities in health.

There is an indication that a difference in median DUP of 4–5 weeks (between class 2 and class 3) might be clinically relevant: It has been previously reported that patients with a DUP of 4 weeks compared to 1 week may have up to 20% more severe symptoms (Howes et al., 2021). Thus, subpopulations might need alternative, more targeted pathways to, and lower thresholds for accessing care, as shorter DUP accelerates functional recovery and seems critical for maximizing the effects of early intervention (Hazan et al., 2025). Some populations, for example, ethnic minority groups, may be less likely to receive early intervention for psychosis (Schlief et al., 2023), and the coordinated specialized care actually received may be less effective, as has been shown for patients with lower SES (Bennett & Rosenheck, 2021). Early intervention for psychotic disorders may be improved if delivered to these populations more effectively. Addressing the underlying social and behavioral factors might not only improve treatment delays, but also illness trajectories down the line. Future studies should integrate a broader range of social determinants and exposures, for example, childhood adversity (Kirkbride et al., 2024), and associated neighborhood characteristics (Oluwoye et al., 2024), to evaluate if any marginalized groups with at-risk configurations exist and identify potential targets for intervention. Programs that aim to reduce DUP should evaluate differential effects, which were previously highlighted as a research gap (Murden, Allan, Hodgekins, & Oduola, 2024), to move toward more equitable interventions in public mental health (Reininghaus et al., 2024).