The WPA Expert International Advisory Panel for Early Intervention in Psychosis in Low‐ and Middle‐Income Countries: an update on recent relevant activities

In 2019, the WPA set up an Expert International Advisory Panel for Early Intervention in Psychosis (EIP) in Low‐ and Middle‐Income Countries (LMICs), as part of a presidential initiative ¹ linked to the WPA Action Plan 2020‐2023 ² , ³ , ⁴ . Here we present an update on recent activities related to that initiative.

The WPA has promoted several symposia and keynote/plenary lectures at international conferences on EIP models in LMICs, their clinical effectiveness, cultural contextualization, and implementation challenges. These conferences included the 21st World Congress of Psychiatry (virtual, October 2021); the WPA/UK National Institute for Health and Care Research (NIHR) Webinar on EIP in LMICs (December 2021); the WPA Thematic Conference “Public Health and Associated Opportunities” (Lahore, Pakistan, March 2022); the 22nd World Congress of Psychiatry (Bangkok, August 2022); and the WPA Thematic Conference “Early Intervention across the Lifespan” (Athens, June 2022).

Some recent examples (illustrative, not an exhaustive list) of EIP programmes in LMICs include the Schizophrenia Research Foundation (SCARF)’s dedicated EIP service in Chennai, India ⁵ , developed in collaboration with the Prevention and Early Intervention Program for Psychosis in Montreal ⁶ ; the University of Chile High‐risk Intervention Program for Ultra‐High‐Risk Youth ⁷ ; and a pilot EIP service in Malawi ⁸ .

Understanding that inadequate mental health workforce, fragmented health care systems and scarcity of research and implementation capacity are significant barriers to introducing such programmes in LMICs, the Warwick‐India‐Canada (WIC) network was formed with a shared strategic vision to reduce the burden of psychotic disorders in resource‐poor settings ⁹ . This network brought together knowledge and expertise of four internationally recognized institutions: the University of Warwick, UK; the McGill University, Canada; the All India Institute of Medical Sciences (AIIMS), New Delhi, India; and the SCARF, Chennai, India. The largest cohort of first‐episode psychosis cases in LMIC settings was recruited and followed through the WIC programme at SCARF and AIIMS. A comprehensive package of biopsychosocial care, ready to use in any LMIC setting, has been developed.

The integration of faith/traditional/indigenous healing with mental health services in LMICs appears a promising way for community detection of untreated psychosis, but there are significant challenges in such collaborations. Trusting relationships are difficult to build, ongoing training and supervision beyond the project timelines are hard to deliver, and sustainability is more easily promised than achieved. The COllaborative Shared care to IMprove Psychosis Outcome (COSIMPO) trial ¹⁰ assessed the effectiveness of a collaborative shared care (CSC) for psychosis delivered by traditional healers and primary health care providers, compared to enhanced care‐as‐usual, in Ghana and Nigeria. Participants randomized to the CSC model had significantly lower symptom scores at 6‐month follow‐up. CSC led to greater reductions in overall care costs. Such models offer the prospect of scaling up across LMICs. A new programme of such collaborations is under way in Nigeria and Bangladesh.

Digital technology can play a vital role in overcoming resource and infrastructure limitations in LMICs ¹¹ . The WIC early psychosis study ⁹ co‐designed the Saksham app for people with schizophrenia and their caregivers. The app is ready for public roll out in India. Telepsychiatry offers another innovative approach to reaching individuals in rural regions who may otherwise not have access to treatment. Several models of telepsychiatry have been launched in India: the SCARF STEP tele‐psychiatry model ¹² ; the psychiatristonweb application ¹³ ; the Ganiyari model; and the National Institute of Mental Health and Neurosciences (NIMHANS) hub‐and‐spoke model ¹⁴ . Emerging evidence suggests that these models improve medication and appointment adherence, and lead to reductions in relapses and fewer hospitalizations.

Our Panel will submit a detailed action plan with recommendations to the forthcoming WPA General Assembly, which will include the following principles:

• Early intervention should be the target of a WPA Scientific Section, to advance the field, facilitate sharing of expert contributions on the rapidly changing landscape of EIP in LMICs, and provide education and support for clinicians.

• In LMICs, EIP services should not focus only on first episodes, but rather provide good clinical care for early and established untreated or inadequately treated psychosis.

• Shared care models such as COSIMPO offer promise for scaling up EIP programmes in LMICs by drawing on local resources.

• Early intervention models in LMICs need to be co‐designed with those with lived experience either as patients or carers.

• A public health approach is needed to increase mental health literacy and reduce stigma, in order to facilitate early access to care.

• There is a need for capacity building programmes at the clinical, research and implementation level.

• There is a need for regional and national meetings with stakeholder input to develop a network of collaboration that facilitates development and implementation of EIP.

• Telepsychiatry and leveraging digital approaches can help increase reach of services to individuals in rural areas and provide a more cost‐effective approach.