Medication Adherence and Service Engagement in First-Episode Psychosis: Insights from a Retrospective Cohort Study in India

Medication Adherence and Service Engagement in First-Episode Psychosis: Insights from a Retrospective Cohort Study in India | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 3 February 2026 V1 Latest version Share on Medication Adherence and Service Engagement in First-Episode Psychosis: Insights from a Retrospective Cohort Study in India Authors : Aditi Sunil Modak [email protected] , Ajay Aditya Aadhi Mani 0009-0000-1681-1500 , and Shilpa Waikar Authors Info & Affiliations https://doi.org/10.22541/au.177012729.92688196/v1 167 views 92 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background: First-episode psychosis (FEP) is a critical period where treatment engagement influences long-term outcomes. While early intervention models are informed by high-income country data, evidence from low- and middle-income countries (LMICs) such as India remains limited. Objectives: To assess sociodemographic and clinical predictors of medication adherence and follow-up among adolescents and young adults with FEP in India. Methods: A retrospective cohort study of 150 patients aged ≤24 years with FEP was conducted at the Institute of Psychiatry and Human Behaviour, Goa (2019-2023). Sociodemographic and clinical variables were extracted from records. Patients were categorized as 6-month completers (n=82), 12-month completers (n=30), and those lost to follow-up (n=38). Descriptive statistics, chi-square, and analysis of variance were applied. Results: Mean age was 20.9 years; 59.3% were male. Attrition was 25.3% at 6 months and 80% at 12 months. Female gender (p<0.001), rural residence (p<0.001), lower education (p=0.004), and lower socioeconomic status (p<0.001) predicted dropout. Substance use (23.3%), poor insight (38.7%), and prior faith healer contact (29.3%) were also linked to disengagement. Risperidone (52.7%) and olanzapine (34.7%) were the most prescribed. Side effects, chiefly extrapyramidal symptoms and sedation, commonly led to discontinuation. Antipsychotic polypharmacy occurred in 27.3%, and 8% received electroconvulsive therapy. Conclusions: Sociodemographic vulnerabilities, substance use, poor insight, and cultural beliefs predicted early disengagement. Culturally sensitive, youth-focused interventions addressing structural barriers, dual diagnosis, and medication tolerability are essential for improving early psychosis outcomes in LMICs. INTRODUCTION First-episode psychosis (FEP) refers to the initial presentation to psychiatric services with psychotic symptoms, provided there has been no prior antipsychotic treatment or that current treatment was initiated ≤30 days before referral to specialized services (1)(2) . The onset of psychosis during adolescence or early adulthood can be a critical period that influences long-term outcomes. Several factors-such as age, gender, education level, socio-economic status, and duration of untreated psychosis (DUP)-have been identified as key determinants of prognosis in FEP (3) . Adolescents (10–19 years) and young adults (15–24 years) are especially vulnerable, with early detection and intervention shown to reduce symptom severity, enhance functioning, and lower hospitalization rates (4) . Antipsychotic medications form the cornerstone of FEP management, with studies reporting up to 80% symptom reduction (5) . However, non-adherence remains a major challenge, with rates ranging from 26% to 53% within the 1 st year (6) . Extensive research has examined FEP trajectories and outcomes; most data originate from high-income countries(HICs) (7)(8) . This limits the generalizability of findings to low- and middle-income countries (LMICs), including India, where differences in healthcare infrastructure, cultural beliefs, and socioeconomic conditions may significantly influence access to treatment and continuity of care. Moreover, pathways to care in LMICs are often shaped by culturally mediated illness attributionssuch as supernatural explanations for psychosisand reliance on faith-based or traditional healing systems, which may impact engagement with formal psychiatric services (9) . Identifying demographic, clinical, and cultural variables associated with follow-up adherence and treatment dropout in these settings is essential for informing context-specific early intervention strategies and improving long-term outcomes. This study aims to examine the sociodemographic and clinical characteristics of adolescents and young adults presenting with FEP at a tertiary care psychiatric centre in India. It further investigates the treatment regimens employed, evaluates follow-up adherence over 6 and 12 months, and analyzes factors associated with continued engagement versus loss to follow-up. While Indian studies on FEP have contributed significantly to understanding diagnostic patternsDUP, and clinical insight at presentation, relatively few have systematically investigated longitudinal adherence, follow-up engagement, or service retention beyond the acute treatment phase,particularly in adolescent and young adult populations. Most available literature is limited by modest sample sizes, hospital-based samples, and cross-sectional or short-term follow-up designs, limiting insights into real-world continuity of care. To address this gap, we conducted a retrospective cohort study at a tertiary psychiatric institute to assess sociodemographic and clinical correlates of follow-up and treatment patterns over 1 year, thereby contributing to the understanding of long-term service utilization and early intervention outcomes in an Indian context. MATERIALS AND METHODS This is a retrospective cohort study carried out at the Institute of Psychiatry and Human Behaviour (IPHB), Goa, a tertiary mental health facility. All adolescent and young adult patients up to 24 years of age, diagnosed with FEP and registered as new cases between January 2019 and September 30, 2023, were considered for the study. A universal sampling method was used, whereby all eligible case records within the defined period were included for analysis. Brief Description of Study Setting IPHB is a tertiary care government-run psychiatry facility in the state of Goa. It caters to the entire state and the adjoining regions of Maharashtra and Karnataka. Detailed individual case records are maintained for each patient in the Medical Records Department (MRD). These include documentation of each outpatient visit, inpatient admission, investigations, diagnosis, treatment provided, and clinical progress. Patients are registered with a nominal one-time fee, after which all services,including consultations, investigations, and treatment,are provided free of cost. Medications are dispensed for 7 - 60 days based on clinical status and follow-up requirements. In the context of FEP, the diagnosis is typically made during the first point of contact,in the outpatientsetting. Diagnostic evaluation follows structured clinical assessment, and management includes pharmacological and psychosocial interventions. Follow-up adherence is encouraged through scheduled appointments, medication dispensation policies, and family psychoeducation. Procedure All case records of adolescent and young adult patients diagnosed with FEP and registered as new cases at IPHB between January 2019 and September 2023 were retrieved from the MRD. Data were extracted on demographic details, clinical diagnosis, duration of illness, comorbidities, treatment regimens, and follow-up status. A total of 150 case records fulfilling the inclusion criteria were included in the analysis. The study population was stratified into three groups based on follow-up status: 1. Patients who followed up for at least 6 months (n = 82) 2. Patients who followed up for at least 12 months (n = 30) 3. Patients who did not follow up after initial evaluation (n = 38) Sociodemographic and clinical characteristics were compared across these three groups to identify factors associated with treatment continuity and loss to follow-up. All data were de-identified before analysis. The study was approved by the Institutional Ethics Committee on 09/01/2025 (Ref: GMC IEC/2024/350). Follow-up Categorization and Defining Dropouts Patients were categorized based on the duration and continuity of their engagement with clinical services over the follow-up period. Six-month completers were defined as individuals who had at least one follow-up visit within 180 days of their initial presentation and did not have any continuous gap in care exceeding 90 days during this period. Twelve-month completers were those who remained in active follow-up for a minimum of 365 days from baseline, with no lapse in clinical contact lasting 90 days or more. Patients who failed to return for follow-up within 90 days of their last documented visit were operationally defined as dropouts. The 90-day threshold was chosen to reflect the typical medication supply duration provided at the study site (ranging from 7 to 60 days), ensuring that patients missing follow-up beyond this window were reasonably considered disengaged from care. Help-Seeking History and Faith Healer Contact As part of the initial assessment protocol for new cases of FEP at our department, a comprehensive treatment history is obtained and documented in the case record. This includes detailed information on prior help-seeking behaviour, encompassing both biomedical and non-biomedical avenues. Specifically, patients and caregivers are asked about any prior consultations with traditional or faith healerssuch as priests, spiritual leaders, astrologers, or other non-allopathic practitionersas part of the structured clinical interview. This information is routinely recorded in the past treatment history section of the intake notes and was retrospectively extracted for this study. InsightAssessment As part of the initial diagnostic work-up for all new FEP cases, we routinely evaluateinsight during mental status examination. Insight was rated clinically by the treating psychiatrist based on a six-point staging system adapted from David’s model of insight, which classifies the patient’s awareness of illness and need for treatment as follows: 1. Complete denial of illness 2. Slight awareness but denial of need for help 3. Awareness of illness but attributing the cause to external factors 4. Awareness of internal cause but denial of treatment need 5. Intellectual insight (acknowledgement without emotional acceptance) 6. True emotional insight (full acceptance of illness and treatment need) For analytic purposes, scores were collapsed into two groups: Poor Insight (Stages 1-3) and Good Insight (Stages 4-6) to evaluate their relationship with follow-up adherence. Statistical Analysis Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 29.0. A two-tailed P <0.05 was considered statistically significant. Descriptive statistics were used to summarize sociodemographic and clinical variables. Quantitative variables were presented as mean ± standard deviation, and categorical variables were expressed as frequencies and percentages. The normality of continuous variables was assessed using the Kolmogorov-Smirnov test. For comparison of means across the three study groups (6-month follow-up, 12-month follow-up, and those lost to follow-up), one-way analysis of variance was used for continuous variables, and Chi-square tests were used for categorical variables. Binary logistic regression wasusedto identify predictors of dropout at 12 months. However, due to a small sample size and quasi-complete separation of data points, model estimates were unstable and uninterpretable. Therefore, descriptive and bivariate analyses (e.g., Chi-square tests) were prioritized for identifying significant associations. Sociodemographic Details The study cohort comprised 150 patients diagnosed with FEP;39 (26%) patients were from the adolescent age group, and 111 (74%) patients were from the young adults age group,with a male predominance (59.33%) and a mean age of 20.99±3.00 years. The majority of patients were unmarried (94%) and living with family (93.33%). Most participants resided in urban or semi-urban settings (62%) and were unemployed (61.33%). Socioeconomic status was predominantly lower (56%), and 63.33% had completed high school or higher education. Additional sociodemographic characteristics are summarized in Table 1. Sociodemographic Variables Entire cohort ( n =150), n (%) Followed up for 6 months ( n =82), n (%) Followed up for 12 months ( n =30), n (%) Did not follow up ( n =38), n (%) Test statistics ( P ) Age means age (years) range of age (years) 20.99±3.00 21.40±3.00 21.53±3.37 20.86±2.69 F =1.122 (0.328) Gender Male 89 (59.33) 55(67.07) 21(70) 13 (34.21) χ ²=13.39 (<0.001) Female 61 (40.67) 27 (32.93) 9 (30) 25 (65.79) Marital status Married 14(9.33) 4 (4.88) 7 (23.33) 3 (7.89) χ ²=8.965 (0.011) Unmarried 136 (90.67) 78 (95.12) 23 (76.67) 35(92.11) Address Urban/semiurban 94(62.67) 58 (70.73) 19 (63.33) 17 (44.74) χ ²=7.51 (0.234) Rural 56(37.33) 24 (29.27) 11 (36.67) 21 (55.26) Education No education 12 (8) 3 (3.66) 2 (6.67) 7 (18.42) χ ²=14.91 (0.004) Primary/middle school 46 (30.67) 19 (23.17) 13 (43.33) 14 (36.84) High school and above 92 (61.33) 60 (73.17) 15 (50) 17 (44.74) Socioeconomic status Lower socioeconomic status 84 (56) 45 (54.88) 12 (40) 25 (65.79) χ ²=21.618 (<0.001) Middle 62 (41.33) 35 (42.68) 11 (36.67) 13 (34.21) High socioeconomic status 9 (6) 2 (2.44) 7 (23.33) 0 Living arrangement Living with family 140 (93.33) 76 (92.68) 29 (96.67) 35 (92.11) χ ²=0.684 (0.711) Living alone/institutional 10 (6.67) 6 (7.32) 1 (3.33) 3 (7.89) Religion Hindu 111 (74) 60 (73.17) 19 (63.33) 32 (84.21) χ²=15.44 (0.004) Catholics 22 (14.67) 15 (18.29) 2 (6.67) 5 (13.16) Muslim 17(11.33) 7 (8.54) 9 (30) 1 (2.63) Others 0 0 0 0 Domicile In Goa 109 (72.67) 59 (71.95) 21 (70) 29 (76.32) χ²=1.065 (0.90) Outside Goa 38 (25.33) 22 (26.83) 8 (26.67) 8 (21.05) Foreigner 3 (2) 1 (1.22) 1 (3.33) 1 (2.63) Employment status Employed 58 (38.67) 34 (41.46) 11 (36.67) 13 (34.21) χ ²=0.639 (0.726) Unemployed 92 (61.33) 48 (58.54) 19 (63.33) 25 (65.79) Clinical Profile The most common diagnostic category at presentation was unspecified non-organic psychosis (51.33%), followed by acute and transient psychotic disorder (ATPD) (27.33%) and schizophrenia (21.33%). The average duration of illness at presentation was 6.48± 6.06 weeks. A positive family history of psychiatric illness was noted in one-third of the participants, and 14% had a family history of substance use disorders. One-fourth of the cohort had comorbid substance use, while 8.67% had a documented medical comorbidity. A minority (17.33%) required admission at the time of initial presentation.Table 2 presents detailed clinical characteristics and diagnostic distribution. Clinical Profile Variables Entire cohort ( n =150), n (%) Followed up for 6 months ( n =82), n (%) Followed up for 12 months ( n =30), n (%) Did not follow up ( n =38), n (%) Test statistics ( P ) Diagnosis Schizophrenia 32 (21.33) 19 (23.17) 8 (26.67) 5 (13.16) χ ²=8.583(0.072) ATPD 41 (27.33) 19 (23.17) 5 (16.67) 17 (44.74) Unspecified non organic psychosis 77 (51.33) 44 (53.66) 17 (56.67) 16 (42.11) Insight Poor insight 58(38.67) 23 (28.05) 13 (43.33) 22 (57.89) χ ²=10.10(0.006) Good insight 92 (61.33) 59 (71.95) 17 (56.67) 16(42.11) Mean total duration of illness (weeks) 6.48±6.06 7.03±5.82 8.70±6.54 5.18±5.91 Family history of psychiatric illness Yes 45 (30) 25 (30.49) 4 (13.33) 16 (42.11) χ ²=6.629(0.036) No 105 (70) 57 (69.51) 26 (86.67) 22 (57.89) Family history of substance use Yes 41 (27.33) 14 (17.07) 9 (30) 18(47.37) χ² =12.13(0.0023) No 109 (72.67) 68 (82.93) 21 (70) 20 (52.63) Comorbid substance use Yes 35 (23.33) 9 (10.98) 6 (20) 20 (52.63) χ ²=25.42(<0.001) No 115 (76.67) 73 (89.02) 24 (80) 18 (47.37) Medical comorbidity Yes 13 (8.67) 8 (9.76) 3 (10) 2 (5.26) χ²=0.7460.689 No 137 (91.33) 74 (90.24) 27 (90) 36 (94.74) Admissions required Yes 27 (18) 15 (18.29) 5 (16.67) 7 (18.42) χ²=0.0450.978 No 123 (82) 67 (81.71) 25 (83.33) 31 (81.58) ATPD: Acute and transient psychotic disorder Help-Seeking Pathways and Faith Healer Contact Help-seeking pathways and faith healer contact Variables Visited faith healer ( n= 44), n (%) Did not visit faith healer ( n =106), n (%) P Gender Male 23 (52.3) 66 (62.3) χ ²=0.91 (0.22) Female 21 (47.7) 40 (37.7) Residence Rural 28 (63.6) 28 (26.4) χ ²=16.86 (<0.001) Urban/semiurban 16 (36.4) 78 (73.6) Education level No education 6 (13.64) 6 (5.66) χ ²=7.16 (0.027) Primary/middle school 18 (40.91) 28 (26.42) High school and above 20 (45.45) 72 (67.92) Insight at presentation Poor insight 30 (68.2) 28 (26.4) χ ²=21.14 (<0.001) Good insight 14 (31.8) 78 (73.6) 12-month follow-up Completed 12 months 5 (11.4) 25 (23.6) χ ²=4.70 (0.03) Did not complete 12 months 39 (88.6) 81 (76.4) Of the total cohort, 29.33% (n=44) reported visiting a faith healer before presenting at IPHB. Faith healer contact was significantly associated with rural residence ( p < 0.001), lower educational attainment ( p = 0.027), and poor insight at presentation ( p < 0.001). No significant association was observed with gender ( p = 0.22, not statistically significant after correction). A non-significant trend was noted toward lower 12-month follow-up among those with prior faith healer contact ( p = 0.09).Table 3 presents detailed characteristics of patientshelp-seeking pathways and faith healer contact before visiting our OPD for management. TREATMENT REGIMENS OF PATIENTS First-line antipsychotic n =150, n (%) Risperidone 79 (52.7) Olanzapine 52 (34.7) Aripiprazole 11 (7.3) Amisulpride 5 (3.3) Clozapine 1 (0.7) Trifluoperazine 1 (0.7) Haloperidol 1 (0.7) Out of the 150 case records reviewed for patients diagnosed with FEP, the majority were initiated on combination pharmacotherapy. Most patients (58.7%, n=88) were prescribed two psychotropic medications, and 35.3% (n=53) were receiving three or more, while only 6% (n=9) were on one drug. The most common first-line antipsychotic was risperidone (52.7%), followed by olanzapine (34.7%) and aripiprazole (7.3%). Other agents included amisulpride (n=5), clozapine, trifluoperazine, and haloperidol (n=1 each).Table 4 presents the initial antipsychotic agents prescribed at first presentation. Medication category n =198, n (%) Sedatives 90 (45.46) Anticholinergics (Trihexyphenidyl) 39 (19.70) Mood stabilizers 16 (8.08) SSRIs 12 (6.06) Augmenting antipsychotic 41 (20.71) SSRIs: Selective serotonin reuptake inhibitors All patients received at least one antipsychotic, often in combination with sedatives or adjunctive agents. Sedative agents, including benzodiazepines and Z-drugs, were co-prescribed in 60% of cases. Anticholinergic medications (trihexyphenidyl) were used in 26% of patients. Mood stabilisers and selective serotonin reuptake inhibitors were prescribed in 10.7% and 8% of the cohort, respectively. In addition,27.3% of patients required augmentation with a second antipsychotic agent.Table 5 summarizes the concomitant psychotropic medications prescribed in addition to first-line antipsychotics. Drug Patients with side effects, n (%) Discontinued due to side effects, n (%) Continued despite side effects, n (%) Risperidone ( n =84) 19 (22.61) 18 (21.42) 1 (1.19) Olanzapine ( n =67) 10 (14.92) 8 (11.94) 2 (2.98) Aripiprazole ( n =25) 3 (12) 3 (100) 0 (0) Amisulpride ( n =8) 4 (50) 1 (12.5) 3 (37.5) Clozapine ( n =3) 3 (100) 1 (33.33) 2 (66.67) Key side effects included: Risperidone – amenorrhea ( n =6), EPS ( n =13), Olanzapine – weight gain ( n =6), EPS ( n =4); Aripiprazole – EPS ( n =3); Amisulpride – EPS ( n =4), Clozapine – hypersalivation ( n =2), sedation ( n =1), weight gain ( n =2). EPS: Extrapyramidal symptoms Clozapine was initiated in three patients, all of whom had inadequate response to prior antipsychotic trials. All three required subsequent treatment augmentation. Antipsychotic polypharmacy was implemented in 41 patients (27.3%), whereas 12 patients (8%) received electroconvulsive therapy during the course of treatment.Table 6 outlines the frequency of side effects and discontinuation rates across individual antipsychotic medications, along with the key adverse effects observed. DISCUSSION This retrospective cohort study examined clinical, demographic, and pharmacological variables associated with follow-up adherence and treatment patterns among adolescents and young adults with FEP in India. The findings not only mirror established global patterns but also highlight critical LMIC-specific challenges such as follow-up attrition, medication tolerability, and systemic barriers to sustained care. This discussion contextualises our results with existing literature from both HICs and LMICs, offering insights for tailoring early intervention models. Sociodemographic Predictors of Follow-Up and Service Engagement The 25.3% attrition rate at follow-up is consistent with prior Indian studies reporting significant disengagement in early psychosis care (10) . Key sociodemographic predictors of poor follow-up in our cohort included female gender, lower educational attainment, rural residence, and low socioeconomic statusvariables, repeatedly associated with reduced service engagement across settings (6)(7)(11) . Female patients in our sample were disproportionately represented among those lost to follow-up. This aligns with findings by Raghavan et al., suggesting that caregiving roles, cultural expectations, and mental health stigma may hinder continuity of care for women in India (10) . Structural gender-based barrierssuch as lower autonomy and restricted mobilitymay further impede treatment access, particularly in rural areas. Rural residence was another significant predictor of attrition, underscoring systemic inequities in mental health infrastructure. Inadequate specialist services, travel costs, and limited awareness contribute to geographic disparities in FEP care, particularly in LMICs (4) . These trends mirror global evidence from Peralta et al, (3) , who found that social disadvantage and poor functional baseline status predicted poorer outcomes in both HIC and LMIC contexts. Substance Use, Dual Diagnosis, and Disengagement Comorbid substance use emerged as a strong predictor of follow-up attrition in our cohort. This is consistent with prior Indian and international studies demonstrating that substance use,both personal and within families,complicates engagement and retention in FEP care (10)(7)(6) . Dual diagnosis cases often present with lower insight, increased behavioural disinhibition, and greater risk of treatment discontinuation. Such patterns emphasize the need for integrated dual-diagnosis services in early intervention models. In settings where addiction psychiatry resources are limited, substance-using patients may cycle through acute care without long-term stabilizationa scenario particularly problematic in LMICs with under-resourced mental health systems. Medication Prescribing Patterns and Antipsychotic Tolerability Risperidone and olanzapine were the most commonly prescribed agents, consistent with early-phase treatment protocols. However, extrapyramidal symptoms, menstrual irregularities, and sedation were frequent, with 26% requiring anticholinergic medication. Notably, nearly all patients who developed significant side effects subsequently discontinued their medications-a trend echoed in studies by (4)(10)(5) , which reported side effect burden as a key driver of nonadherence. The low use of clozapine,restricted to three patients,reflects known systemic challenges in LMICs, such as the lack of monitoring infrastructure, clinician hesitancy, and logistical barriers to initiating treatment despite guideline-based indications (4) .Clozapine underutilization is a global issue, but is particularly pronounced in resource-constrained settings. In our study, approximately 60% of patients were prescribed sedatives, benzodiazepines or Z-drugs-raising concerns regarding masking of core psychopathology, long-term dependence, and possible disengagement from care. This pattern may reflect the urgent need for sedation in acute psychosis, but long-term reliance remains problematic and should be more systematically monitored (4)(11) . Adherence Challenges and Psychosocial Factors Medication nonadherence in our cohort was most commonly attributed to side effects, poor insight, and stigma,consistent with findings from both LMICs and HICs (6)(7)(12) . Studies from Tanzania and Chinareinforce that in both chronic and early-phase psychosis, insight and culturally mediated beliefs significantly impact treatment decisions. (6)(12) The importance of psychoeducation and therapeutic alliance has been highlighted across multiple studies (7)(3) , yet remains underdeveloped in many LMIC care pathways. Our findings stress the need for early rapport-building, culturally informed communication, and family engagement to counteract stigma and promote sustained adherence. Cultural and Belief-Based Service Use: Role of Faith Healer Contact In our cohort, 29.3% of patients (n = 44) reported seeking help from faith healers before presenting at our institute. Compared to those who did not, patients with prior faith healer contact were significantly more likely to reside in rural areas, have lower educational attainment, and present with poor insight. Importantly, only 11.4% of those who visited faith healers completed 12-month follow-up, compared to 23.6% among those who did not—a statistically significant association (P = 0.03). This suggests that prior reliance on faith healing may be linked to reduced engagement with long-term psychiatric care. These findings are aligned with those of Singh et al. (2015), who reported that many Indian and South Asian patients commonly attribute psychotic symptoms to supernatural causes and seek help from traditional or religious healers (9) . While these alternative help-seeking pathways may not always delay initiation of psychiatric care, they can influence patients’ insight, expectations from treatment, and adherence to follow-up. In our study, contact with faith healers appeared to cluster with several factors previously associated with poorer service retention. Culturally informed engagement strategies,including outreach to community-based healers and religious leaders,could help bridge the gap between traditional belief systems and biomedical psychiatry. As emphasized by Singh et al. and Leclerc et al., acknowledging and respectfully integrating patients’ explanatory models can improve the acceptability of mental health interventions and potentially support better continuity of care in early psychosis (9)(7) . Comparisons with International Cohorts and Implications for low-and middle-income country Systems While many findings in our cohort mirror those from HICs,such as high side-effectdriven nonadherence (5) , risk associated with substance use (11) , and the predictive value of education or functional baseline (3) the LMIC context amplifies structural barriers such as rurality, workforce shortages, and infrastructure limitations. Clark et al. noted similar challenges in real-world service delivery, even in better-resourced contexts, suggesting that implementation gaps may transcend national income status and reflect broader issues of continuity, monitoring, and patient-centred care (11) . Future Directions and Recommendations This study underscores the urgent need for youth-friendly early intervention services in India that address not only clinical symptomatology but also sociocultural, geographic, and systemic barriers. Interventions should: • Integrate psychoeducation and shared decision-making to improve adherence. • Include substance use screening and dual-diagnosis care pathways. • Strengthen follow-up mechanisms, especially in rural and underserved regions • Engage with parallel systems of care (faith-based or traditional) to improve cultural acceptability. Prospective longitudinal studies with standardized assessments of insight, side effect burden, and social support are needed to develop predictive models for adherence and long-term outcomes. In addition, further exploration of sedative and anticholinergic prescribing practices, as well as access to clozapine, is warranted to optimize pharmacological safety in LMIC FEP populations. Strengths and Limitations This study offers several notable strengths. First, it is among the few Indian investigations to examine longitudinal service engagement and medication adherence in adolescents and young adults with FEP, extending beyond the acute treatment phase. By employing universal sampling over 4 years at a tertiary psychiatric center, the study captures real-world patterns of care and enhances generalizability within similar LMICsettings. The inclusion of culturally salient variables,such as prior faith healer contact,adds contextual depth to understanding pathways to care and their influence on insight and follow-up. The stratified analysis by 6-month and 12-month follow-up status allows for nuanced exploration of treatment retention and disengagement across time. Additionally, detailed extraction of antipsychotic prescribing patterns and side-effect-related discontinuation enhances the clinical relevance of the findings. However, the study also has important limitations. As a retrospective chart review, it is subject to the inherent constraints of record-based research, including variability in clinical documentation and potential underreporting of key variables such as insight, adverse effects, and help-seeking history. The small number of patients completing 12-month follow-up limited statistical power and precluded robust multivariable regression analyses. Insight ratings were derived from clinician judgment using a semi-structured framework rather than standardized instruments, which may affect inter-rater reliability. Furthermore, treatment outcomes such as symptom remission or functional recovery could not be evaluated due to a lack of standardized follow-up assessments. CONCLUSION This study offers important insights into the demographic, clinical, and cultural factors associated with service engagement and medication use in adolescents and young adults with FEP in an Indian tertiary care setting. Poor insight, rural residence, lower education, and prior contact with faith healers were significantly associated with reduced 12-month follow-up, highlighting areas where targeted interventions may improve continuity of care. Comorbid substance use and treatment-emergent side effects also played a role in early disengagement. Prescribing patterns were largely consistent with recommended practices for early psychosis, with risperidone and olanzapine being the most commonly used agents. While sedative co-prescription was frequent, it may reflect the clinical need for managing acute agitation or distress in early stages of illness. Nonetheless, judicious use and close monitoring remain important to avoid long-term dependence and to preserve diagnostic clarity. These findings underscore the value of culturally responsive and system-aware early intervention approaches that address both clinical and contextual determinants of adherence. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Declaration of generative AI and AI-assisted technologies in the manuscript preparation process During the preparation of this work, the authors used an AI-assisted language tool (ChatGPT, OpenAI) solely to improve readability and clarity. The authors reviewed and edited the manuscript in full and take complete responsibility for its content. REFERENCES 1. Breitborde NJK, Srihari VH, Woods SW. Review of the operational definition for first-episode psychosis. Early Interv Psychiatry. 2009;3(4):259–65. 2. Sajatovic M, Meltzer HY. Clozapine-induced myoclonus and generalized seizures. Biol Psychiatry. 1996;39(5):367–70. 3. Peralta V, García De Jalón E, Moreno-Izco L, Peralta D, Janda L, Sánchez-Torres AM, et al. Long-Term Outcomes of First-Admission Psychosis: A Naturalistic 21-Year Follow-Up Study of Symptomatic, Functional and Personal Recovery and Their Baseline Predictors. Schizophr Bull. 2022;48(3):631–42. 4. 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Information & Authors Information Version history V1 Version 1 03 February 2026 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords adolescents early intervention faith healer first-episode psychosis medication adherence Authors Affiliations Aditi Sunil Modak [email protected] Institute of Psychiatry and Human Behaviour View all articles by this author Ajay Aditya Aadhi Mani 0009-0000-1681-1500 Institute of Psychiatry and Human Behaviour View all articles by this author Shilpa Waikar Institute of Psychiatry and Human Behaviour View all articles by this author Metrics & Citations Metrics Article Usage 167 views 92 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Aditi Sunil Modak, Ajay Aditya Aadhi Mani, Shilpa Waikar. Medication Adherence and Service Engagement in First-Episode Psychosis: Insights from a Retrospective Cohort Study in India. Authorea . 03 February 2026. 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