In mental health, the routes of access to care are diverse and varied. Patients with FEP access care through a number of agencies, including social services and the criminal justice systems (Singh and Grange 2006). There have been some attempts at developing and evaluating early detection strategies for FEP with mixed results. The first comprehensive trial was the Scandinavian TIPS study which ran over 4 years in four health sectors in Norway and Denmark (Friis et al. 2005; Johannessen et al. 2005; Melle et al. 2005). Both the intervention and control area had similar specialised EISs. In addition, in the intervention arm, GPs and other health professionals were trained face-to-face, schools visited for providing information on psychosis to students, teachers and counsellors, and general public educated about psychosis and help-seeking through information leaflets and a media campaign. TIPS also conducted a historical comparison with DUP data prior to the development of early detection services. Despite a short median DUP in the control area, the TIPS trial found significant further reduction in DUP in the intervention arm. Patients from early detection sectors presented with less severe psychotic symptoms and milder functional deficits prior to treatment initiation. Early detected cases had significantly less suicidal ideation and suicidal attempts at baseline. TIPS is the first large and comprehensive study to show that a community’s median DUP can be significantly reduced with clinical advantages both at intake and at follow-up.

Lloyd-Evans et al. (2011) conducted a systematic review of 11 studies which used eight early detection initiatives. They found that general practitioner education campaigns and dedicated EISs do not reduce DUP or increase the number of patients seeking help for psychotic disorders. Multi-focus initiatives such as a mixture of public education campaigns combined with ease of access to care had better, but still mixed results. The authors concluded that the most promising evidence was for identifying hidden cases in the community via intensive public awareness campaigns.

Facilitating recovery in first-episode psychosis: There is now considerable evidence from EISs around the world that effective and assertive intervention in first-episode psychosis improves short- and medium-term outcomes. Besides several naturalistic studies, there have been 12 trials comparing specialised EISs with standard care from Denmark, Spain, Australia, UK, Holland, USA and China. Of these, the OPUS study from Denmark (Nordentoft et al. 2006; Bertelsen et al. 2007, 2008) is the largest (sample size 547), and also the one of two with a 5-year follow-up, the other being the LEO trial (Craig et al. 2004). In the OPUS study, participants received integrated care consisting of high-fidelity assertive community treatment supplemented by behavioural family therapy and social skills training. Standard care consisted of care at a community mental health centre. At 2 years, participants receiving specialist EIS care had better clinical outcomes, including better symptom control and functioning and reduced hospitalisation. After 2 years of specialist input, all patients in the trial received standard care and were followed up for further 3 years. At the five-year follow-up, there were no differences between the two groups on clinical outcomes although the EIS-treated group were more likely to be living independently. Similarly, the LEO trial in the UK showed that specialised EIS was better than a generic community team in improving short-term outcomes in FEP (Craig et al. 2004).

Specialised teams also appear to be cost-effective. McCrone and Knapp (2007) conducted Markov modelling to compare costs between specialist and generic team care for FEP and found that specialist teams incurred lower costs, primarily due to lower hospitalisation and readmission rates. Similar cost savings have been demonstrated from Danish, Swedish and Italian studies (Valmaggia et al. 2009).

Overall, trials confirm that FEP patients treated under specialist EIS teams have better outcomes than standard care. However, the effect of specialist care lasts only as long as the early intervention approach is maintained. Like the OPUS 5-year results, findings from longer follow-up of LEO sample also showed loss of early intervention gains when patients were discharged back to standard care (Gafoor et al. 2010). It appears therefore that once the EI “grip is relaxed”, clinical gains are lost; interventions are therefore effective only as long as actively implemented. This suggests that the heterogeneous trajectories of early psychosis require differentiation, with EI provision being tailor-made for longer periods for those with poorer early outcomes. EIS is a complex intervention with several interacting components, and we are yet to determine the active “therapeutic ingredients” within EIS and how these are exerting their effect (Singh 2010).

Many patients with emerging psychosis in India receive little or no treatment, with major barriers to access and availability of care and the economic impediments especially for the remote and rural population groups. It is hard to justify setting up prodromal services in such a context, given the limited evidence for such interventions and the clinical, resource and policy imperative of prioritising care for those already ill over those who may become ill in the future. Detection of all, not just first-episode, untreated cases in the community is, however, a public mental health priority. Treating these cases effectively in the first episode and preventing relapse must be another key priority demanding urgent action. In countries such as India, schizophrenia is the sixth leading cause of years lost due to disability (DALYs), higher than iron deficiency anaemia, and only slightly less than cataract. The goal of an integrated approach to meeting the challenge of untreated psychosis should combine a public awareness programme particularly dealing with stigma and lack of awareness of treatment options, training primary care workers and general practitioners identifying cases and using the emerging power of the Internet and the voluntary sector in India.

Farooq et al. (2009a, b), Farooq (2013) have argued for a public health approach to psychosis similar to those being applied for infectious and non-communicable diseases. This would require public education campaigns with particular focus on traditional healers and care provision through a network of primary care workers and social welfare organisations. Such an approach is being used by non-profit organisation such as Schizophrenia Research Foundation (SCARF) in Chennai, which is providing early intervention programmes with emerging evidence of success (Rangaswamy et al. 2012). Telepsychiatry is another promising innovation which can allow clinician access to remote areas overcoming the obstacles of time and travel and using mobile connectedness of rural India to considerable advantage (Thara et al. 2008; Thara 2012; Malhotra et al. 2013; Thara and Sujit 2013). Widespread adoption of these innovative models will depend upon policy makers prioritising mental health care and integrating mental health provision into general health care delivery especially in rural and remote areas. In the West, user voice was eventually heard after a sustained campaign by carers, voluntary organisations and concerned clinicians. The emerging economic power of India should not leave behind among the most vulnerable of its citizens, the untreated psychotic patients languishing in the community.