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Duration of untreated psychosis (DUP): mean 61 weeks, median 12, among people who reached care

Among people who reached a service with a first episode of psychosis, the mean duration of untreated psychosis (DUP, the time from first signs of psychosis to treatment) is 2.6 to 6.4 times the median in the studies we compared: 61.4 weeks against 12.0 across 3,339 people from 16 studies (Boonstra 2012). A few very long waits pull the mean up. The wait is longer with gradual onset of the illness (in England a median of 32 weeks against 3 with acute onset), but onset is dated from recall, and gradual onset is harder to date. The wait does not differ by sex (in schizophrenia), pooled estimates (estimates combining several studies) show no difference by ethnic group, and on age the studies disagree: three found a longer wait when the illness began earlier, one (Denmark, ages 15–25 only) when it began later, and the samples differ. In one US study of 34 non-academic community clinics (RAISE-ETP, 404 people aged 15–40), a long wait was the norm: a median of 74 weeks.

PublishedResearch summaryPublished England (London, Nottingham); Hong Kong; Japan; India; US; Denmark; Norway; Mexico; multi-country summaries

What we conclude

Among people who reached care for a first episode of psychosis, the mean time to treatment was 2.6 to 6.4 times the median in the four studies in the table, Hong Kong and Japan (see the section on onset), where both are reported for the same people, so the mean describes a few long waits more than a typical one. Gradual onset went with longer waits in England, Japan and Hong Kong, and chronic onset (a category used in that study) in a US sample; sex (in schizophrenia) and ethnic group showed no difference in pooled estimates; on age, three studies found a longer wait with earlier onset and one (Denmark, ages 15–25 only) with later onset, in different samples; and models that included demographics, functioning before the illness and symptom severity explained 18–26% of the variation. This does not show that gradual onset causes the delay: onset is dated from recall, and gradual onset is harder to date.

What we will not claim

Only people who reached a service are counted; people who never reached one are not in the data at all. The start of the illness is dated from what the person and their family recall, and gradual onset is harder to date than acute onset, so part of the link between gradual onset and a long wait may come from how the wait is measured; it is an association, not a cause. The often-cited median of 14 weeks from a 2024 summary of 206 studies (Salazar de Pablo 2024) is a median of study medians, not the point that half of all people waited longer than. In one US study of 34 non-academic community clinics (RAISE-ETP, 404 people aged 15–40) and in the Danish OPUS study a long wait is not a tail but the norm: medians of 74 and 52 weeks. The data are old and uneven: the 16 studies in Boonstra 2012 were published in 1992–2009, and in Salazar de Pablo 2024 the mean was 70.0 weeks in studies from Africa and 38.6 in studies from Europe (medians 22.5 and 12.0).

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Weeks from first signs of psychosis to treatment: mean and median, among people who reached a service

Study (where)PeopleMeanMedianMean ÷ median
Boonstra 2012, individual data from 16 studies published 1992–2009 (https://pubmed.ncbi.nlm.nih.gov/23025994/)3,33961.412.05.1
AESOP, England (London and Nottingham) (https://pubmed.ncbi.nlm.nih.gov/17077436/)4955896.4
India (https://pubmed.ncbi.nlm.nih.gov/22303040/)11990.230.13.0
RAISE-ETP, US, 34 non-academic community clinics in 21 states, ages 15–40 (https://pubmed.ncbi.nlm.nih.gov/25588418/)404193.5742.6

Weeks. Only people who reached a service are counted. Onset is dated in retrospect, from what the person and their family recall. The mean-to-median ratio is our own division of the published figures.

What the mean hides

In the pooled data on 3,339 individual people from 16 studies (published 1992–2009), the mean was 61.4 weeks and the median 12.0 (Boonstra 2012): half of these people, all of whom reached a service, began treatment within 12 weeks, while the mean is about five times higher. The same gap appears in single studies: in London and Nottingham (AESOP) the median was 9 weeks and the mean 58 (Morgan 2006); in India 30.1 and 90.2 weeks (Thirthalli 2011). Large 2008 notes that a few patients with very long waits pull the mean up. A single average therefore says more about those few than about a typical wait. All these figures cover only people who reached a service.

Gradual onset goes with the longest waits

In England (AESOP) the median was 32 weeks with gradual onset and 3 weeks with acute onset (Morgan 2006). In Japan, among 150 people with schizophrenia, it was 18.0 months against 2.0; across the whole sample the mean was 20.3 months and the median 6.0, about 3.4 times apart (Nishii 2010). In Hong Kong, among 360 people aged 26–55, the mean was 515 days and the median 93, about 5.5 times apart, and the wait was longer with gradual onset (Hui 2015). In the US, among 180 people admitted to hospital, mostly low-income African Americans, the median was 11.2 weeks with acute onset, 16.9 with subacute and 71.9 with chronic onset (categories used in that study, from fastest to slowest); acute and subacute onset did not differ statistically (Broussard 2013). A caveat: onset is dated from what the person and their family recall, and a gradual onset is harder to date than an acute one, so part of the link may come from the measurement itself. It is an association, not a cause.

Known predictors explain little

In schizophrenia, across 27 studies with 4,721 people, the wait did not differ by sex; the mean was 64 weeks (Cascio 2012). Pooled estimates found no difference by ethnic group (Anderson 2014; Schoer 2019, 17 studies); when groups are split out, differences appear in UK studies. On age the studies disagree. In three, the wait was longer when the illness began earlier: in Norway (Takizawa 2021), in Hong Kong (Hui 2015) and in the US RAISE-ETP study (Addington 2015). In one, a Danish register of 1,266 people aged 15–25 only, it was longer when the illness began later (Hastrup 2018). The samples differ, so these results cannot simply be added up. Models that included demographics, functioning before the illness and symptom severity explained 18–26% of the variation in the wait in Norway (Takizawa 2021) and in Mexico and the US (Fresan 2020), so most of the variation is left unexplained. These studies, too, count only people who reached care.

Where a long wait is the norm

In some samples a long wait is not a tail but the typical case. In one US study of 34 non-academic community clinics in 21 states (RAISE-ETP, 404 people aged 15–40), the median was 74 weeks and the mean 193.5; 68% had waited more than six months (Addington 2015). In the Danish OPUS study of 552 people with a first episode of psychotic or schizotypal disorder (a related condition counted in some psychosis services; 82 of them schizotypal), the median was 52 weeks; the abstract does not make clear whether it was counted for all 552 or only for the 470 with psychosis (Nordentoft 2008). Both figures again count only people who reached these services.

Where the 14 weeks comes from

A summary of published studies gives a mean of 42.6 weeks (283 studies, 41,320 people) and a median of 14 weeks (206 studies, 37,215 people) (Salazar de Pablo 2024). The 14 weeks is a median of study medians: half of the studies reported a median above it. It is not the point that half of all people waited longer than, and the mean and the median come from different sets of studies, so we did not divide one by the other. Counted person by person, in pooled data on 3,339 people, the median was 12 weeks (Boonstra 2012). The same summary shows how uneven the data are: the mean was 70.0 weeks in studies from Africa and 38.6 in studies from Europe, with medians of 22.5 and 12.0. All these studies count only people who reached a service.

Family involvement: the studies disagree

Family involvement in seeking help points in different directions. In England (AESOP) the median was 5 weeks when the family was involved and 12 when it was not (Morgan 2006). In Hong Kong, among people aged 26–55, family involvement was not linked to the length of the wait (Hui 2015). Two studies are not enough to say which holds where, or why.

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