Develop context-specific guidelines

Comprehensive and culturally sensitive guidelines tailored to the respective health care system are essential to standardise and optimise psychosis care. They should consider local beliefs about mental illness, address stigma, use culturally appropriate communication and involve traditional or community leaders to build trust and engagement. This includes:

1. (a) developing appropriate tools for identifying early signs of psychosis in schools, communities and primary care settings; ^{Reference Theodoridou, Schultze-Lutter and Ambarini10}

2. (b) integrating evidence-based pharmacological (e.g. long-acting injectable antipsychotics) and psychosocial interventions, adapted for low-resource settings, especially in rural areas – while acknowledging potential barriers such as medication availability, affordability and supply chain limitations in LMICs; ^{Reference Calabrese and Al Khalili1,Reference Theodoridou, Schultze-Lutter and Ambarini10}

3. (c) designing strategies to involve families in timely symptom detection and adequate care; ^{Reference Calabrese and Al Khalili1,Reference Jorm, Minas, Langlands and Kelly11}

4. (d) involving patients and carers in service development. ^{Reference Calabrese and Al Khalili1,Reference van der Ven, Yang, Mascayano, Weinreich, Chen and Tang3,Reference Keynejad, Spagnolo and Thornicroft6}

Expand access to care

Improving access to mental health services and reducing DUR and DUP requires innovative approaches, such as:

1. (a) training non-specialist health workers, such as nurses and community health workers, through task-sharing models like the World Health Organization’s Mental Health Gap Action Programme (mhGAP) or collaborative care approaches can improve early detection and basic management of psychosis in LMICs; and establishing connections between primary care providers, traditional healers and mental health specialists to ensure coordinated care – for instance, several studies have demonstrated that structured collaboration between primary care workers and traditional or faith healers significantly improves symptom outcomes and reduces harmful practices, while remaining cost-effective; ^{Reference Keynejad, Spagnolo and Thornicroft6}

2. (b) integrating mental health care into primary healthcare systems to reach underserved areas, particularly rural communities; ^{Reference van der Ven, Yang, Mascayano, Weinreich, Chen and Tang3,Reference Keynejad, Spagnolo and Thornicroft6,Reference Jorm, Minas, Langlands and Kelly11}

3. (c) utilising telepsychiatry and mobile health tools can support remote screening, diagnosis and follow-up, although their use may be constrained in areas with limited internet access, inadequate digital infrastructure or low smartphone availability. ^{Reference Theodoridou, Schultze-Lutter and Ambarini10}

Address stigma and mental health literacy

Stigma and low mental health literacy are a major barrier to early detection and treatment. ^{Reference van der Ven, Yang, Mascayano, Weinreich, Chen and Tang3} Public awareness campaigns can play a transformative role by:

1. (a) educating communities about the early signs of psychosis and the benefits of timely treatment; ^{Reference Calabrese and Al Khalili1,Reference van der Ven, Yang, Mascayano, Weinreich, Chen and Tang3,Reference Keynejad, Spagnolo and Thornicroft6}

2. (b) educating communities about psychosis with a focus on psychosocial risk factors to combat stigma; ^{Reference Calabrese and Al Khalili1,Reference van der Ven, Yang, Mascayano, Weinreich, Chen and Tang3,Reference Keynejad, Spagnolo and Thornicroft6}

3. (c) engaging community leaders, religious figures and media to amplify positive mental health messages; ^{Reference van der Ven, Yang, Mascayano, Weinreich, Chen and Tang3,Reference Keynejad, Spagnolo and Thornicroft6}

4. (d) collaborating with people with lived experience of psychosis to educate about psychosis and reduce stigma ^{Reference van der Ven, Yang, Mascayano, Weinreich, Chen and Tang3,Reference Keynejad, Spagnolo and Thornicroft6} – for example, targeted outreach linked to the Grupo de Atenção às Psicoses Iniciais [Early Psychosis Group] (GAPi) initiative in Brazil helped reduce DUP and improve help-seeking by raising awareness of early signs and available services. ^{Reference Cavalcante and Noto12}

Foster community engagement

Communities are an untapped resource in LMICs. Peer support programmes, where individuals with lived experience of psychosis offer mentorship and advocacy, can empower others and reduce stigma. ^{Reference van der Ven, Yang, Mascayano, Weinreich, Chen and Tang3,Reference Keynejad, Spagnolo and Thornicroft6}

Build a skilled workforce

A trained and well-supported workforce, including specialists committed to long-term engagement, is essential for delivering professional and humanitarian care to psychiatric patients. ^{Reference Keynejad, Spagnolo and Thornicroft6,Reference O’Connell, O’Connor, McGrath, Vagge, Mockler and Jennings9} This sustained commitment forms the backbone of effective EIP. Thus, LMICs should:

1. (a) invest in training healthcare providers, educators, and community workers to recognise and manage early signs of psychosis; ^{Reference Calabrese and Al Khalili1,Reference Keynejad, Spagnolo and Thornicroft6,Reference O’Connell, O’Connor, McGrath, Vagge, Mockler and Jennings9}

2. (b) provide supervision and support for non-specialist workers to maintain high-quality care; ^{Reference Calabrese and Al Khalili1,Reference Keynejad, Spagnolo and Thornicroft6,Reference O’Connell, O’Connor, McGrath, Vagge, Mockler and Jennings9}

3. (c) collaborate with educational institutions and non-governmental organisations to help strengthen training and support workforce sustainability. ^{Reference Keynejad, Spagnolo and Thornicroft6,Reference O’Connell, O’Connor, McGrath, Vagge, Mockler and Jennings9}

Conduct cost-effectiveness studies

Cost-effectiveness studies are crucial for demonstrating the value of EIP programmes and securing investments in particular in countries with limited resources. ^{Reference Keynejad, Spagnolo and Thornicroft6} These should assess metrics such as symptom reduction, functional recovery, hospitalisation rates, relapse prevention and caregiver burden, and compare service costs against standard care. Taking account of regional particularities, economic studies of EIP programmes in LMICs should:

1. (a) compare the economic impact of EIP to standard care;

2. (b) assess the cost-effectiveness of different service models and intervention components.