Interventions to support recovery of people with psychosis in low-income and middle-income countries: a systematic review.

Abstract

This systematic review synthesises the evidence on effectiveness and cost-effectiveness of interventions to support the recovery of people with psychosis in low-income and middle-income countries (LMICs). Prioritised recovery-oriented outcomes were defined as social inclusion, personal recovery, reduction in stigma and discrimination, and protection from human rights violations. Outcomes were mapped to the socioecological model of disability, demonstrating how interventions can have direct and indirect effects at the individual, family, service, and community level simultaneously. Study participants were assumed to have been treated with antipsychotic medication where needed. We included 310 studies (published 2001-24) involving 34 435 participants across 37 countries and five additional meta-analyses. Most studies were from upper middle-income settings and evaluated individual-level mental health and functioning rather than recovery-oriented outcomes. Comprehensive and contextualised measures for recovery-oriented outcomes were absent and few studies reported economic evidence. More than half the studies were judged to have high risk of bias. We found some evidence that collaborative care models, family interventions, and multicomponent, comprehensive psychosocial interventions have potential to impact meaningfully on valued outcomes. However, these interventions have not been sufficiently developed and tested, especially in lower-middle-income and low-income settings and with non-specialist deliverers. Models of care in the community involving social rehabilitation (eg, Clubhouse model), psychiatric outreach, and task-sharing demonstrate effects on the individual and family level, but require optimisation to support recovery. We recommend development of comprehensive measures of recovery adaptable for cross-cultural use, adoption of the socioecological model to frame outcome assessment and mechanistic understanding of intervention effects, continued efforts to ethically and effectively implement task-sharing, and the involvement of people with lived experience in the co-production of optimised interventions. Achieving these priorities will require sustained investment to strengthen capacity for rigorous psychosis research across LMICs.