Making early intervention for psychosis feasible in India: Lessons from two decades of SCARF’s first episode psychosis program

Abstract

Early intervention in psychosis (EIP) has long been recognized as the critical determinant of long-term outcomes, yet in India, it remains largely absent from routine psychiatric care. This viewpoint reflects on two decades of experience at Schizophrenia Research Foundations (SCARF’s) First Episode Psychosis (FEP) program in Chennai, offering grounded insights into how early intervention can be adapted to low-resource contexts without reliance on complex infrastructure. Drawing from lessons shaped in real time: through embedded services, hybrid follow-up models, and family-centered approaches, it argues that meaningful care can begin not only at the earliest signs of illness, but also at the point individuals first seek help. The paper challenges the assumption that specialist-heavy models are the only path to success, proposing instead a simple, responsive, and scalable model rooted in contextual realities. In doing so, it calls for a shift in how early psychosis is understood, engaged, and supported across India.

THE UNMET NEED FOR EARLY INTERVENTION IN INDIA

The need for early intervention in psychosis (EIP) is paramount in countries like India, where delayed treatment is widespread due to stigma, lack of mental health infrastructure, and cultural beliefs. Despite evidence for better prognosis with early treatment, functional EIP services are largely absent, especially for First Episode Psychosis (FEP).

India’s mental health system still faces severe shortfalls: the treatment gap for serious mental illness remains 83%,[1] with only 0.75 psychiatrists per 100,000 people—far below the global average of 3.96.[2] Given these limitations, early detection remains aspirational, and timely, sustained engagement at the point of care becomes a more feasible and impactful goal. Even at this stage, well-timed intervention can reduce long-term disability.

Although Western models of EIP are difficult to replicate in resource-constrained settings, India needs grounded, scalable alternatives that work within existing systems and leverage family support. The Schizophrenia Research Foundation (SCARF) in Chennai has run a structured FEP program for two decades, offering insights into how such care can be delivered in real-world Indian settings.

FIRST EPISODE PSYCHOSIS: UNDERSTANDING THE “CRITICAL PERIOD” AND DEFINITIONAL NUANCES

FEP refers to the initial emergence of psychotic symptoms, a period that is often distressing and poorly understood. Definitions vary widely: some rely on the first-time diagnosis, others emphasize symptom duration, severity, or disruption to functioning. These definitional nuances significantly affect service response, treatment timing, and long-term outcomes.[3]

The concept also aligns with the “critical period hypothesis”[4]—the notion that there is a narrow window after symptom onset during which timely intervention can substantially change the course of illness. Early engagement helps reduce biological and psychosocial damage, and supports long-term quality of life.

INDIAN INSIGHTS ON EARLY INTERVENTION IN PSYCHOSIS: AN EMERGING EVIDENCE BASE

Recent Indian research affirms that EI is not only feasible but effective. Studies from Delhi, Chennai, and other parts of India[5,6,7] show that culturally adapted protocols are well accepted by families and can significantly improve outcomes.

While most Indian services do treat FEP, we argue that structured care offers distinct advantages.[6,7,8,9,10] Our two-decade experience shows consistent follow-up, family involvement, and deliberate early-phase interventions are associated with better outcomes. While most of our cohort had schizophrenia-spectrum disorders, over 80% remained in sustained remission at 2 years after a single treated episode—even in cases where antipsychotics were gradually reduced under supervision.[8,9,10] These findings challenge deterministic views that FEP inevitably progresses to chronic illness and support the need for structured, replicable care pathways.

SCHIZOPHRENIA RESEARCH FOUNDATION’S PIONEERING FIRST EPISODE PSYCHOSIS PROGRAM: A CONTEXTUALIZED, EVOLVING MODEL

SCARF established its FEP program in 2003 in collaboration with McGill University’s Prevention and Early Intervention Program for Psychosis (PEPP) Canada,[7,8,9,10] becoming one of the country’s earliest dedicated services for individuals experiencing psychosis for the first time.

Though urban and clinic-based, the program was designed to be contextually Indian and adaptable to diverse settings,[7,8,9,10] including rural and semi-urban areas. By embedding services within the general outpatient department, it ensures low-barrier access and continuity of care without requiring parallel infrastructure.

The program follows a phased 24-month model—acute, recovery, and maintenance—delivered through a hybrid of in-person and mobile-based follow-ups. Everyone is anchored by an assigned psychiatric social worker or a psychologist, with families engaged as equal partners in care. Simple, low-cost monitoring tools and structured psychoeducation further sustain engagement, prevent relapse, and support functional recovery.

Over two decades, the model has been refined to remain practical and culturally relevant. During the COVID-19 pandemic, for example, it quickly pivoted to telephonic follow-ups and WhatsApp-based prescription renewals, maintaining engagement despite disruptions. Forged by real-world application rather than rigid protocols, it is now highly scalable and profoundly relevant for other low-resource settings nationwide.

CORE COMPONENTS OF SCHIZOPHRENIA RESEARCH FOUNDATION’S EARLY INTERVENTION PROGRAM

1. Delivering Focused Care Through Embedded Services: FEP services were integrated into SCARF’s out-patient department, improving reach, while keeping costs low. Each mental health professional manages 80–100 individuals at a time, with support tailored to their current needs.[9,10,11]

2. The First Encounter Shapes Everything: Perhaps the most critical moment is the first clinical encounter. Individuals and families often arrive with a mix of anxiety, confusion, and hope that treatment will help, having chosen to seek care despite sometimes holding on to alternate belief systems,[12,13] as is common in our cultural context. We have learned that taking time to clarify, listen, and reassure, without overwhelming—sets the foundation for ongoing engagement.[14] Even small steps like giving a follow-up phone number and explaining medication, side effects, and so on can make individuals and families feel more grounded in those first fragile days.

3. Early Investment, Enduring Impact: The first few months after the onset of psychosis offer a powerful window for recovery. Many individuals return to school, work, or caregiving roles during this time, especially when care is timely, steady, and systematically delivered. FEP often responds remarkably well to early treatment, and this initial phase sets the tone for long-term outcomes.[9,10,11]

   Recovery, however, is not just about medication.[8] What truly shapes progress is consistent engagement, through a flexible mode of follow-up vital to sustaining engagement,[14] collaborative planning, and early recognition of warning signs. Brief, structured interventions, delivered reliably over the first 3–6 months, have proven both effective and feasible in our setting.[5,6,7]

   Though the initial effort may seem intensive, it ultimately reduces the load on families, clinicians, and systems. For scaling, a simple but focused early-phase approach yields outsized benefits.

4. Strengthening Family Involvement Through One Consistent Point of Contact: Early identification of one primary caregiver has been one of the most effective and easily replicable strategies in our work. In the context of FEP, families often approach care with concern, openness, and genuine hope that treatment will help.[15] This simple step streamlines communication, strengthens trust,[16] and prevents fragmentation of care. In settings where clinical time is limited, a consistent point of contact lightens the follow-up load and reinforces continuity. With basic psychoeducation, caregivers become reliable allies—tracking progress, supporting adherence, and alerting the team to early relapse signs.

5. Tailored Local Training: Uniform national training modules rarely work across India’s diverse settings. SCARF provides brief, hands-on training tailored to the local context, ensuring it is practical and relevant. Training is offered to mental health staff, while structured psychoeducation and skills sessions are provided to patients and caregivers, so they are better equipped to support recovery. Core themes are adapted to the cultural and community realities of those we serve, making the program both effective and sustainable.

6. Ensuring Engagement Through a Hybrid Model of Care: A reliable and responsive communication system is central to early intervention. Our longitudinal study on engagement showed that sustained involvement is not solely resource-dependent but emerges from dynamic interactions between patients, caregivers, and providers, underscoring the need for adaptable service models.

   In our program,[14] we use a a hybrid model blending in-person visits with mobile-based follow-ups through regular phone calls or WhatsApp voice/video checkins. From the outset, everyone is introduced to a dedicated team—usually a psychiatrist and an assigned psychologist or social worker—and provided with a specific mobile number and call timings. Patients and families may reach out for queries or concerns, and once the prescribed review period is over (a date given in advance), they may contact us again either by phone or in person. In the initial days, even medication dosages can be adjusted over the phone, reducing the need for frequent hospital visits, while ensuring safe adjustment, preventing side effects, and building trust and comfort. Prescriptions, when required, are issued telephonically. If there has been no in-person or online contact for 30 days, the team proactively initiates follow-up.

   This straightforward, structured system strengthens therapeutic relationships, enables early identification of emerging concerns, and sustains engagement during the fragile initial phase. Over time, the hybrid approach has proved critical to reducing dropouts, enhancing adherence, and supporting meaningful recovery.

7. Rethinking Maintenance: Supervised Antipsychotic Discontinuation: Despite standard guidelines recommending at least two years of continued antipsychotic treatment after remission, our experience shows that in many cases—particularly when the duration of untreated psychosis has been less than two years—careful dose reduction or even stopping the medication can be safe and effective, provided the person remains closely connected with the care team. Often, this process begins at the request of the patient or family, especially when they have returned to work, school, or caregiving roles. Planning the taper collaboratively has strengthened trust, improved engagement, reduced side effects, and helped maintain recovery without raising relapse risk.[8] For others, especially those with a longer duration of untreated psychosis, more severe symptoms, or repeated relapses, continued treatment is often necessary. Importantly, any decision about reducing or discontinuing medication is individualized, closely supervised by the treating team, and always made collaboratively with the patient and family to balance recovery goals with relapse risk.

CONCLUSION

The SCARF FEP program conclusively demonstrates that EIP is not only possible but uniquely well-suited for low-resource settings like India, especially when core elements are embedded rather than imported wholesale. Two decades of practice reveal adaptable, effective principles: early, simple, regular engagement; care integrated within existing systems; and meaningful family investment.

In a national context grappling with treatment delays and uneven service distribution, SCARF’s FEP model serves as proof of concept. The key to scaling EIP in India lies not in awaiting ideal conditions or large budgets, but in intentionally building on what already exists. This is achieved by embracing robust local evidence from routine follow-up with simple indicators, changing the conversation around psychosis through schools, media, and local leaders, and using simple, accessible tools usable by families and non-specialist staff. In doing so, we demonstrate impact, secure support, and foster earlier help-seeking without overwhelming the system.

While our model has limitations—being urban, relatively resourced, and situated within an NGO with a longstanding mental health mandate—it is grounded in the Indian clinical and cultural context, extending its relevance beyond its immediate setting. Our experience has supported similar programs in India and low-resource settings like Ghana through structured training and capacity-building.

As EIP gains policy traction in India, the conversation must shift to achieving national scale. We offer these reflections not as prescriptions, but as hard-won knowledge from a program that has endured, adapted, and consistently made a measurable difference.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.