Discussion
long-term psychosis, psychosis
This study addresses the treatment gap for individuals with SMI, in India and Pakistan, by utilising the existing resources within the healthcare system as well as mobilising the resources of patients, their families and communities. It aims to test a low-cost, resource-orientated approach to improve the quality of community-based care for people with psychosis in two cities in India and Pakistan. The intervention to be tested is evidence based and is generic, such that it can be used by a range of staff in different clinical settings without the need to set up new services or employ specifically trained staff. The inclusion criteria for the trial is broad to reflect the individuals commonly seen in community-based services. This will allow us to assess a range of patient-level (e.g. financial and clinical status) characteristics which might influence intervention effectiveness. The active control condition will help control for the additional time during the consultation and for the addition of a tablet computer, which may be novel within these LMIC settings.Despite the strengths of the study, there are a number of limitations to consider.Karachi and Chennai are both cosmopolitan urban sites within Pakistan and India where there are a variety of local languages spoken by the residents. Being larger cities with greater resources, many patients will travel to the cities from neighbouring villages to seek mental health services and medical help. Our study excludes patients who do not speak the most common local language which reduces the population we can recruit, however, if the intervention proves effective it can easily be further translated for future use more broadly.To ensure the trial runs as per the protocol, researchers play a big role in facilitating the process of appointments, including providing frequent reminders and rescheduling of missed appointments to ensure we are able to test the intervention as it is proposed for the first 6 months of the trial. We overcome this limitation to a great extent by observing if/how patients and clinicians manage their own appointments and sessions for the period between the 6- and 12-month follow-up to understand how the intervention would work without added assistance.India and Pakistan have a large proportion of the population which resides within rural settings, which limits the generalisability of our findings. However, if the intervention is found to be effective in improving the quality of life for individuals with long-term psychosis in these urban settings, there is potential for the approach to be adopted within rural settings and other LMICs, where a treatment gap exists for individuals with SMI. The flexibility of the approach, such that it can be delivered by a range of professionals, with only minimal training, will facilitate uptake and wider implementation across different clinical settings, ultimately improving the quality of life for millions of individuals with long-term psychosis worldwide.