Psychosis is a debilitating health condition that often occurs in the early 20s and disrupts various aspects of life with long-term health consequences. The aetiology of psychosis is complex and multifaceted; although the biological and genetic causes of psychosis are inevitable, social, economic and cultural factors play a role in both causing and influencing the outcomes of the disease.^1,2 In the mental health research debate, persistent health consequences of psychosis include relapse, treatment resistance, cognitive impairment, reduced social and occupational functioning, poor quality of life and stigma and discrimination.^3,4 Individuals living with psychosis have a wide range of needs defined as ‘a requirement of an individual to achieve, maintain, or restore an acceptable level of social independence’.^5,6,7 Exploring the type and extent of patients’ needs is a crucial component of patient-centred care, as it provides the basis for developing appropriate interventions, ensuring holistic support or treatment and improving overall long-term well-being.^5,8

According to the social causation theory, income poverty increases the risk of developing mental disorders such as anxiety and depression.⁹ Conversely, the social drift theory posits that mental illness contributes to poverty, as affected individuals often experience reduced productivity and income, thereby deepening their economic disadvantage.⁹ Young people with first episode of psychosis (FEP) often face significant challenges, including being unskilled, unemployed and socially isolated. Although a few may have skills and employment, psychosis frequently leads to job loss.¹⁰ The effects of psychosis disrupt various aspects of life, creating a wide range of needs. The needs include medical and psychiatric care and social needs.¹¹ To meet these needs and re-establish themselves, support may be required from family, friends and mental health services.¹²

For the youth in South Africa who are often unemployed or unskilled because of the nature of their young age,¹³ experiencing psychosis (for the first time) further compounds needs and future aspirations at a critical juncture when the transition from education to employment needs to take place for one to become a productive member of society. In South Africa (SA), 53.4% of youth aged 18–35 years living in rural areas are unemployed because of limited work opportunities.¹⁴ Although there is no estimate in (rural) South Africa, the unemployment among patients with FEP is 65% in the United States, even in a country with a traditionally high employment rate.¹⁵ Addressing poverty-related challenges requires financial support, with cash transfer interventions being one such approach. These interventions effectively encourage service utilisation and reduce structural barriers created by poverty, thereby supporting better health outcomes, including mental health. Cash grants are typically offered in two forms: conditional cash transfers (CCTs) and unconditional cash transfers (UCTs).^16,17

Given complex and wide-ranging needs in a region with a high scarcity of community-based mental health services, support may be required from various sources, including family, friends and local non-mental health organisations (i.e. social services).^11,12 Early interventions during the first signs/stages of FEP can be critical in reducing the morbidity associated with the illness and assisting with lowering rehospitalisation rates, improving symptom management and enhancing functioning and quality of life for those affected by psychosis.¹⁸ Minimising relapse is crucial as each episode is associated with cognitive changes and an increased risk of complications. To date, several studies have assessed the needs of individuals with severe mental illness (SMI) in the Western Cape and KwaZulu-Natal, South Africa, using the Camberwell Assessment of Needs. Still, neither study quantified the needs of FEP individuals.^8,19 This study aims to determine young patients’ needs following the FEP and inform clinical practice by underscoring the importance of holistic care to enhance patient engagement and reduce the risk of relapse.

This study assessed the level of need among 60 young adults following FEP. Firstly, our research report reveals a substantial unmet need because of difficulties in accessing government benefits to which individuals are entitled, coupled with limited information and communication regarding their medical conditions. Secondly, although access to mental health services remains a challenge in SA, most participants reported having their needs either fully or partially met in terms of managing psychotic symptoms. Lastly, a significant portion of youth expressed dissatisfaction with the type of support they received.

Most participants rated the lack of government benefits as a severe unmet need, expressing dissatisfaction with the assistance provided by family and relatives, with only one acknowledging receiving support from local services. This aligns with our expectations as all study participants are unemployed and rely on government benefits. A few studies conducted in Chile and Canada have reported similar findings despite differences in population profiles and national income levels,^30,31 possibly as psychosis often disrupts plans and goals, mainly when onset occurs at a young age, impacting skills development. In this study, about half of the participants reported receiving the social relief of distress (SRD) grant of R350 per month, even though all participants were unemployed and therefore qualified for this support. This discrepancy highlights potential barriers to accessing social protection, such as administrative challenges, a lack of awareness or systemic inefficiencies. The government needs to strengthen and streamline the mechanisms for assessing eligibility and distributing grants in a timely and efficient manner to ensure that individuals with disabling mental health conditions receive the financial support to which they are entitled.

Also, most participants reported a need for information about their condition and available treatments. This indicates a communication gap between patients and their healthcare professionals, consistent with findings from studies conducted in Spain and the United Kingdom.^32,33 Despite differences in population characteristics and the availability of mental health resources, similar gaps in communication and patient education were observed. This suggests that providing clear, accessible information remains a fundamental requirement of mental healthcare across diverse contexts.

Nearly half of the study sample had been hospitalised during this baseline assessment, with management efforts focused more on their acute challenges, leaving other need domains unaddressed in the initial stages of treatment. Improving communication in healthcare is crucial for ensuring that patients fully understand their conditions, treatment options and potential outcomes. Effective communication can lead to better-informed decisions, increased adherence to treatment and improved patient outcomes. It is essential to create a collaborative and supportive healthcare environment where patients feel empowered and informed about their health and treatment options. Healthcare workers require training on the importance of delivering comprehensive care, particularly in mental health, with an emphasis on using psychoeducation to inform and empower patients about their conditions. In addition, improving the quality of care should focus on strategies implemented within the existing human resource capacity, without reliance on external interventions, by optimising the use of available resources effectively.

Although mental health services in South Africa face significant challenges related to access because of resource constraints and pervasive stigma,³⁴ it was surprising to find in this study that the majority of participants indicated having met or partially met needs in the domain of psychotic symptoms. This outcome is likely because all participants were recruited from an ongoing study project, ensuring that they had some level of engagement with mental health services. This engagement may have facilitated better access to necessary treatments and support. Also, all participants reported receiving antipsychotic medication for treatment, this being similar to the previous literature.³⁰ Both studies included participants with FEP, and this may be because of their early stages of the disease, the need of being associated with significant changes in their health conditions.

In this study, none of the participants reported receiving assistance from local services or referring to community health services for psychotic symptoms. Resource constraints in community mental health services and stigma and discrimination associated with mental health patients may contribute to the patient’s failure to seek help from local services for psychotic symptoms, especially at the early stages of the illness.³⁵ Also, the structure of the healthcare system may influence the limited support from local services. During the initial months of treatment, patients are typically monitored within hospital settings until their condition is deemed stable by the attending psychiatrist. Transition to community care is initiated through a referral made by the treating hospital psychiatrist. However, the lack of data on care pathways introduces uncertainty, as some participants may have been referred from primary healthcare services. In practice, individuals with FEP are often directed to higher-level facilities for comprehensive diagnosis and evaluation. This underscores the need for policymakers and mental health authorities to re-evaluate existing support structures, particularly at the primary healthcare level, to strengthen accessibility and ensure that mental health services are comprehensive, inclusive and responsive to the needs of all community members.

Our assessment found that none of the participants expressed a need for transport because of limitations in how the tool addresses transportation needs. The CAN tool primarily evaluates access to public transportation. Still, it does not explicitly consider financial barriers, such as participants’ ability to afford fares, which could prevent consistent access even if public transport is technically available. This narrow scope may overlook significant barriers, particularly for those with mental health conditions who need reliable, affordable transportation to access essential services. Further assessment, which includes questions about affordability and transportation reliability, could provide a more comprehensive view of participants’ needs, enabling mental health professionals to deliver better-targeted support.

Climate change has negatively affected physical and mental health directly and indirectly,³⁶ the prolonged drought because of climate change results in food and water insecurity.³⁷ Although a small proportion of participants indicated unmet needs in the food domain assessed by CAN-R, many fell under severe food insecurity after the HFIAS assessment, similar to a recent systematic review among mental health patients.³⁸ These patients are subjected to considerable life challenges, especially in cognitive functioning and employment, which increase the risk of financial difficulties and, therefore, access to food.³⁹ Studies have shown that a lack of food is associated with poor medication adherence in HIV patients. A few studies performed to assess the reasons for poor medication adherence in mental health patients report an association with a lack of food.⁴⁰

In addition, individuals who experience water scarcity may focus on meeting their immediate needs, affecting medication adherence.⁴¹ Medication adherence has also been reported to be the critical determinant for single-episode psychosis among patients with mental health problems.⁴² Early intervention services that include the provision of or access to food after FEP will help affected persons to meet their basic needs and adhere to their treatment.

In this study, we anticipate identifying a higher number of reported needs from participants because of the early stage of their psychosis. Our expectation aligns with our findings, indicating that the number of unmet needs in this sample is higher than in studies that examined needs in the severe mental health population,^4,19 possibly because of the early stage of their illness. The additional needs may be associated with the initial stage of the disease, often accompanied by worries and fear of management. These data underscore the importance of early intervention and comprehensive support for those newly diagnosed with psychosis.

Lastly, most participants expressed dissatisfaction with the support they received, facing substantial unmet needs in accessing government benefits. All were unemployed, and the pressures of meeting essential survival needs often took priority, limiting their ability to continue with necessary care. Despite the availability of disability grants in SA, no participants received these benefits, highlighting the need for enhanced social security measures. Although cash transfer programmes have proven to be effective in addressing basic needs, there is limited evidence of their feasibility and acceptability for individuals with FEP. Therefore, a feasibility study is needed to evaluate whether UCTs can effectively support health needs and continuity of care for individuals with FEP.

A serious unmet need in the benefits domain indicates the need for financial assistance to help young FEP patients engage in care in the early stage of the disease to prevent its progression into the chronic stage. Poor coordination between hospital and community mental health services exacerbates the lack of support at the local level. There is a need to strengthen mental health support services at the community level to improve detection and treatment adherence through collaboration with specialised hospitals.