Early intervention in psychosis in low‐ and middle‐income countries: a WPA initiative

Abstract

Specialist early intervention in psychosis (EIP) services have been considered the “most positive development in mental health services since the beginning of community care”1. The development and implementation of specialist EIP services in high-income countries was predicated on the “critical period hypothesis” , which argued that poor outcomes in psychosis accumulated in the first 2-5 years since onset of the disorder2, and that longer duration of untreated psychosis (DUP) was associated with poorer outcomes3. Early intervention incorporates three different paradigms: assertive and high-quality evidence-based care by specialist teams in first-episode psychosis; early detection of untreated cases in the community (i.e., shortening of DUP); and interventions for young people at clinical high risk (CHR) – also known as ultra high risk (UHR) – for developing a psychotic disorder4, 5. The most consistent evidence is from trials of specialist EIP care versus treatment as usual, which shows better short-to-medium clinical and functional outcomes for those receiving EIP care6, as well as cost-effectiveness of EIP7, while the evidence of specific effective CHR/UHR interventions to prevent the emergence of psychosis remains unclear8, 9. Almost 80% of all patients with first-episode psychosis live in low- and middle-income countries (LMICs), where mental health services are scarce and most people do not get any form of mental health care10. Mental health treatment gap – the difference between those needing mental health care and those receiving it – is extraordinarily high in LMICs11. In the absence of adequate care, many people with psychotic disorders in LMICs end up restrained, neglected or simply abandoned. Despite the burden of untreated or inadequately treated psychotic disorders, the resource scarcity in LMICs – inadequate funding, lack of basic services and shortage of trained professionals – means that it is not feasible to set up specialized EIP services when even basic care for mental disorders is lacking. However, while “Western” models of care cannot be just translocated to LMICs, it should be possible to incorporate the principles and “therapeutic ingredients” of early intervention into routine mental health settings in LMICs, at all levels of care – primary (community), secondary and specialist tertiary (where these exist)12, 13. To meet this challenge, the WPA has set up an Expert International Advisory Panel to develop a set of priorities, guidelines and recommendations for early intervention in LMIC settings. An initial meeting was held in May 2019 in Coventry, UK. At this meeting, a small group of experts agreed on the needs and priorities that could guide the development of early intervention strategies in LMICs within the existing constraints of scarce resources. The group is planning a larger meeting in early 2020, where formal guidelines and recommendations will be agreed upon and adopted as part of the WPA initiative.

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