To qualitatively understand experiences of those impacted by early psychosis, current care practices for early psychosis in Ghana, barriers and facilitators to accessing in-person early psychosis care in hospitals and clinics, and opportunities for digital mental health to address early psychosis, we conducted focus groups with patients with early psychosis, their caregivers, and mental health care providers at Accra Psychiatric Hospital (APH). This facility is Ghana’s national psychiatric referral hospital. It provides services to 28,000 outpatients per year and serves up to 300 inpatients at a time, making it the largest psychiatric hospital in Ghana. Patients and their families often travel long distances within Ghana and the surrounding region to receive psychiatric services at APH. Ghana’s mental health care system is situated within a multitiered public sector health care system comprised of community, district, regional, and national-level health facilities. Mental health care professionals are situated within each level, predominantly master’s-level trained practitioners. Typical pharmacological treatments include injectable and oral first-generation antipsychotics. Psychotherapeutic modalities such as supportive counseling are provided, which sometimes includes manualized cognitive behavioral therapy. Ghana’s National Health Insurance Scheme includes coverage for mental health services; however, implementation does not always consistently cover these services, leading to out-of-pocket expenses.

We identified patient and caregiver participants for potential participation in focus group discussions through purposive sampling, contacting families participating in a pilot program at APH for early psychosis. This pilot program aimed to provide coordinated multispecialty and assertive community outreach services to individuals experiencing early psychosis. Early psychosis was characterized as the onset of psychotic symptoms within the previous 5 years, with no continuous pharmacological treatment of more than 3 consecutive months. To assess interest in study participation among patients with early psychosis and caregivers enrolled in the early psychosis pilot program, trained research staff (psychiatric residents training and practicing at APH) reached out to the caregivers of patients identified with early psychosis via telephone. All patients and caregivers enrolled in the pilot program at APH were contacted. Participation by patients and caregivers was independent, with no requirement that both be involved. We held 1 focus group for patients with early psychosis and 1 for caregivers. Focus groups were conducted at APH and lasted about 1 hour.

Mental health care providers were eligible for participation in focus group discussions if they were actively providing mental health care to individuals experiencing early psychosis at APH. We recruited providers by inviting all APH mental health clinicians providing early psychosis care (eg, clinical psychologists, psychiatrists, and psychiatric residents) to a seminar on opportunities for digital mental health to support early psychosis care. Providers interested in contributing provided contact information and were scheduled into 1 of 2 focus group discussions based on clinical schedule and workload. To accommodate interest and optimize inclusion of provider experiences, we held two 1-hour focus groups at APH for early psychosis clinicians. Focus group sessions were audio-recorded, translated (from a mix of English and Twi into English), and transcribed.

Data on demographic characteristics were collected for each participant using REDCap (Research Electronic Data Capture; Vanderbilt University) electronic questionnaires on tablets by trained data assessors. Qualitative researchers (DAA and AL) used a structured interview guide that was informed by the theoretical framework of acceptability [31] to inquire about the topics of interest (experiences of those impacted by early psychosis, current care practices for early psychosis in Ghana, barriers and facilitators to facility-based early psychosis care, and opportunities for digital mental health interventions). Focus group discussions were conducted in a private room away from clinical activity on the APH campus. Discussions were carried out in English with translation into Twi by translators (AFO and CAD) fluent in both languages. Accra-based researchers cofacilitated the discussions and reviewed the data to mitigate power imbalances and ensure culturally sensitive interpretations.

We conducted a thematic analysis of the focus group transcripts using a mixed inductive and deductive approach. Thematic analysis involves identifying, organizing, and interpreting patterns of meaning within qualitative data [32]. This flexible method follows a structured process, including data familiarization, coding, theme development, review, and refinement. We followed a mixed deductive (ie, predefined codes) and inductive (ie, codes emerging from data) approach to facilitate identification of themes emerging from participants’ narratives while also attending to topics of interest informed by our interview guide and relevant literature [33].

Verbal consent was obtained from all individuals before participation, as this study was deemed sufficiently low risk to allow verbal consent. Study participants were compensated with 140 Ghanaian Cedis (~US $10)—an amount comparable to covering their transportation costs and time to and from the study setting. This amount did not represent undue influence in this economic and cultural context. Ethical approval for the study was granted by the University of Washington Institutional Review Board (STUDY00020314) and the Ethics Review Committee of APH (APH-ERC 00020/24). Participants were provided with a copy of the informed consent form, as desired, which made clear their right to withdraw from the study at any time. Privacy and confidentiality were protected for all study participants. Before study enrollment, team members clarified that participation was voluntary and unrelated to clinical services.

Overall, 31 participants engaged in focus group discussions to inform the development of a digital support tool for individuals impacted by early psychosis in Ghana. Seven patients with early psychosis, 6 of their caregivers, and 18 clinicians participated. Among patients with early psychosis, the median age was 28 (IQR 21‐41) years (Table 1). Clinicians were slightly older, with a median age of 30 (IQR 29‐34) years. Caregivers had a median age of 58 (IQR 54‐68) years. A third of patients with early psychosis and their caregivers were female (patients: n=2, 29% and caregivers: n=2, 33%), while our sample of clinicians had an equal distribution of men and women.

The most common role among clinician participants was Psychiatric Resident (n=9, 50%)—many of the clinicians providing direct care to patients with psychosis are Psychiatric Residents completing their training at APH. The second most common role was Medical Officer or Clinical Psychology trainee (n=7, 39%), indicating that our sample of clinicians represented relatively early-career professionals, which is well-aligned with the demographics of practicing clinicians within APH and the Ghana National Mental Health System.

Only 1 early psychosis patient was married (n=1, 14%), while caregivers were predominantly married (n=5, 83%), and nearly half of clinicians were married (n=8, 44%). The majority of patients with early psychosis had completed secondary or tertiary education (n=6, 86%), a lower proportion of caregivers had achieved more than primary education (n=4, 67%), and all clinicians had achieved university education or higher (n=18, 100%). Only 1 early psychosis patient was regularly employed (n=1, 14%), while most caregivers (n=5, 83%) were employed. Patients with early psychosis and their caregivers lived on average 1 hour away from APH. Demographic characteristics of these study participants are similar to those in a survey of 256 patients with early psychosis and their caregivers conducted by our team at APH, demonstrating that this sample is representative of this population visiting APH [36].

During focus group discussions, participants described the current status of care practices for early psychosis in Ghana, including actions taken to address early psychosis, sources of early psychosis support and information, and how caregivers are involved in early psychosis care. Additional representative quotations regarding current care practices are provided in Table 2.

Focus group discussions with patients with early psychosis, caregivers, and clinicians illuminated several barriers that prevented families from seeking or achieving formal health care system–based early psychosis care. These discussions also highlighted motivating factors that facilitated facility-based care.

We explored opportunities for enhancing early psychosis care by leveraging technology. Among patients with early psychosis, caregivers, and clinicians, we asked about their use of technology to support their typical daily activities, their use of technology to support psychoeducation or mental health, and their perceptions and feelings about the potential use of technology to support mental health. Common uses of technology in the daily lives of patients with early psychosis and caregivers included internet access for searching information, communicating with friends and family, and using social media. Extended and additional quotations about current care practices for early psychosis in Ghana are provided in Table 3.

In this qualitative study among patients with early psychosis, their caregivers, and their mental health care providers in Ghana, several themes emerged, exemplifying opportunities to enhance early psychosis care with digital mental health interventions (eg, smartphone-based apps, text-messaging interventions, telehealth interactions, and so on). Early psychosis care in the West African region is often delayed due to care-seeking from spiritual and traditional healing approaches and impeded or discontinued by practical barriers (eg, financial, logistical, real, or perceived health care system capacity limitations), as identified in other studies in Africa [37]. Substantial engagement by caregivers in early psychosis care is common in Ghana, which often vitally facilitates treatment yet imposes caregiver burnout and mental distress, as reported in other settings [38].

Youth experiencing their first episode of early psychosis in LMIC settings of West Africa represent a particularly vulnerable population. However, early intervention with effective treatment has the potential to improve their symptom trajectory, functioning dramatically, and ultimately integration in society [10,39]. Digital interventions to support early psychosis treatment are expanding globally, with demonstrated feasibility, acceptability, and preliminary efficacy to improve treatment outcomes [40], yet they do not currently exist in West Africa. Existing tools have strengths in leveraging evidence-based psychotherapies for early psychosis symptom management and treatment adherence promotion; however, they are not appropriate for West African contexts due to high literacy requirements and cultural irrelevance. Our study is one of the first to characterize patient, caregiver, and clinician perspectives about the use of digital interventions to address early psychosis in the African region. Focus on early intervention in psychosis programs in LMICs is generally low [41]. Our qualitative findings identify potential integration points, content, attributes, and unique strengths of digital modalities that could be leveraged to support patients with early psychosis and their caregivers in Ghana. Specifically, a tool that incorporates psychoeducation about early psychosis symptoms, effective treatment options, principles of evidence-based psychotherapies for self-management, and caregiver resources, integrated into in-person early psychosis care, could improve support for families in this context.

In qualitative discussions, patients with early psychosis, caregivers, and clinicians illuminated persistent gaps in current early psychosis care in Ghana that could be alleviated with digital mental health interventions. Delays in seeking treatment were common, often shaped by a misunderstanding of symptoms and a lack of awareness of available mental health services. Overwhelmingly, participants described a dearth of information and resources within the community about mental health. Longer duration of untreated psychosis in LMICs compared to higher-income countries is well-documented [14,42]. Digital mental health awareness campaigns and media about the signs of early psychosis and available mental health services could be offered via frequented platforms such as WhatsApp (WhatsApp Inc), YouTube (YouTube LLC), and social media sites to normalize experiences and encourage earlier treatment engagement.

Participants discussed that psychoeducation at the point of first contact was especially important in improving their understanding of mental health conditions and justifying the importance of timely and consistent treatment. A digital platform offering early psychosis psychoeducation could reinforce information shared during clinical visits and provide patients and families with an accessible resource between appointments. Digital psychoeducation integrated into early psychosis care has been shown to enhance quality of care and support patient engagement and functional recovery in high-income settings [43]. Both patients and caregivers described challenges navigating and sustaining engagement with psychiatric services. Digital tools could be used in these settings to support mental health referral or appointment tracking, care navigation, treatment adherence support, and shared decision-making among families impacted by early psychosis, which could strengthen continuity of care. Digital care navigation is increasingly implemented globally to facilitate mental health care system engagement and retention [44].

The extensive role that caregivers play in facilitating early psychosis treatment in this setting suggests that digital interventions for early psychosis will be most effective if they integrate caregiver-specific content alongside patient-focused modules. In-person mental health services have strengths such as the ability to distribute medications, conduct necessary labs and symptom screenings, enable real-time clinical observation and risk assessment, and provide structure and social connection. Digital interventions integrated into routine care could leverage the strengths of in-person care while improving consistency and completeness of psychoeducation and therapeutic messages about early psychosis. Cultural values of family cohesion and community shared responsibility are assets in West Africa [45-47], contributing to high potential for early psychosis remission and functional recovery if caregivers are provided ample psychoeducation and resources in this setting. Caregivers in Ghana described significant emotional and financial stress, similar to other settings [38,45], underscoring the potential benefit of providing caregiver-specific content (eg, coping strategies, resources, and self-care approaches) via digital interventions to support the well-being of caregivers and their loved ones.

Our findings were specifically evaluated in the context of early psychosis, yet they likely have applicability to other mental health disorders. The first episode or early stage of psychosis is a crucial time for intervention with high potential to improve symptom trajectory. Thus, our findings about the potential for digital tools to fill current gaps in early intervention in Ghana are particularly salient for early psychosis. However, we note that findings about intervention content (psychoeducation, care navigation and tracking, and caregiver resources) and barriers to mental health care that could be overcome by digital tools likely apply to other mental health conditions (eg, depression, anxiety, bipolar disorder, and so on) in West Africa.

Participants described barriers to care-seeking and continuity within the mental health care system, including stigma around mental illness, spiritual or supernatural beliefs about symptoms, limited knowledge of psychosis and available care, financial and logistical challenges such as cost, distance, and long wait times, and lack of insight or reluctance to seek treatment. These findings are consistent with prior research in West Africa about barriers to mental health care [15,48,49]. Motivators for seeking or continuing care included positive experiences and trust in mental health care providers, success stories from community members, family support, and increased awareness of psychosis and treatment options.

Digital mental health interventions could supplement facility-based care, offering opportunities to overcome barriers while amplifying care facilitators. A commonly cited factor delaying facility-based early psychosis care was the attribution of psychosis symptoms to spiritual causes [15,48]. Digital interventions hold promise for counteracting misinformation about early psychosis in Ghana by integrating spiritual explanations for psychosis with messages that promote evidence-based etiologic understanding [21]. Further, participants expressed hesitancy to seek care at APH due to stigma historically associated with the institution as a former “lunatic asylum” under colonial rule [49]. Participants emphasized the importance of normalizing and destigmatizing mental health conditions in Ghana, which could be facilitated via digital content relevant to the cultural context. A recent meta-analysis demonstrated stigma-reduction effects of online interventions among people with mental health conditions [50]. Content delivered privately via digital modalities may reduce shame and foster acceptance. The on-demand and location-agnostic nature of digital interventions may circumvent common practical barriers to care, including transportation costs, long wait times, and extensive travel distances. Accessing psychoeducational materials in the privacy of one’s home may encourage repeated engagement and deeper reflection, supporting the development of insight among patients with early psychosis.

Leveraging existing facilitators within the formal health care system–based care, digital interventions are an optimal modality to extend patient-provider communication and amplify trust-building. Expansion of telehealth in psychiatry accelerated during the COVID-19 pandemic to address barriers to in-person care, exemplifying the potential for digital approaches to improve patient-provider alliance [51]. Digital interventions could also include success stories as motivating examples, amplifying one of the approaches that clinicians voiced as effective in engaging and retaining families in treatment. Additionally, providing caregiver-focused content in a digital intervention could harness the integral influence of caregivers in facilitating early psychosis care, potentially expanding that influence and providing caregiver-specific well-being support.

Focus groups with patients with early psychosis, caregivers, and clinicians concluded with discussions about their experiences with technology and perceptions of using technology to support early psychosis care. Our findings highlight the widespread use of phones for information seeking and communication—both to support typical daily tasks and specific mental health–related objectives. The ubiquity of mobile phone availability and the acceptability of digital mental health interventions for early psychosis were echoed in our team’s survey results among more than 250 individuals affected by early psychosis in Ghana [36]. A digital early psychosis intervention could be embedded within this familiar hardware to improve uptake and usability. Participants also described seeking relaxation and stress reduction via digital content types (eg, radio sermons and television shows with moral messages). Digital tools could provide evidence-based psychoeducation and psychological skills tutorials relevant to early psychosis using culturally acceptable narrative storytelling formats [52]. Clinicians emphasized the importance of introducing a digital intervention via trustworthy, respected, and nonpartisan community leaders to optimize trust and uptake. Participants further emphasized that a digital intervention should be accessible offline in settings with low internet bandwidth and should use simple interfaces and limited written language to optimize equity.

This qualitative study enrolled a small sample of patients with early psychosis, caregivers, and clinicians at APH. As such, participants were enrolled based on their care attendance at a single hospital in Accra, Ghana. Our findings may not be generalizable to patients not seeking facility-based care or those attending care in other facilities in the region. However, we intentionally situated our study at APH, the largest and most prominent psychiatric hospital in Ghana. Eligibility for patients with psychosis was based on receiving an initial psychosis diagnosis within the prior 5 years without continuous treatment exceeding 3 months. This definition aligned with that used by APH’s early psychosis pilot program and reflects the long duration of untreated psychosis commonly observed in Ghana. This definition may be overly inclusive, such that it includes individuals who would not be considered “early psychosis” in other settings; however, our priority was alignment with the care context at APH. Since qualitative research was conducted via group discussions, our study may have been subject to social desirability bias, whereby participants tailored their responses to align with perceived expectations or desired responses, particularly given the sensitive and stigmatized nature of the topic. To counteract this potential bias, trained qualitative researchers opened each focus group by reinforcing the voluntary nature of study participation and the researchers’ genuine interest in understanding participants’ authentic experiences and perceptions.

Our qualitative study among those affected by early psychosis in Ghana highlights the potential for culturally grounded digital interventions to address acute gaps in early psychosis care in West Africa. By leveraging familiar technologies to disseminate psychoeducation, challenge stigmatizing beliefs, and support care continuity, digital tools may offer an acceptable and accessible complement to facility-based mental health services. Our findings suggest relevant content, design features, and contextual strengths that could be harnessed to develop a digital early psychosis intervention to support patients and their caregivers. Practical specifications such as offline-accessible, low-bandwidth, and low-literacy features are particularly relevant for digital mental health interventions in West African settings. As Ghana and other West African countries expand mental health service coverage, digital approaches represent a promising avenue to strengthen support for families affected by early psychosis. Overall, individuals affected by early psychosis in Ghana are open to digital interventions to enhance early psychosis treatment in West Africa. Future research should build on these findings to co-develop culturally relevant and evidence-based digital interventions for early psychosis in the region.