Background Early Intervention for Psychosis Services (EIPS) enhance outcomes for individuals experiencing their first episode of psychosis (FEP). However, in low-resource settings, there is limited knowledge about i) the pathways patients take to access EIPS, ii) the proportion and factors associated with acceptance of referral to EIPS, and iii) if different pathways to EIPS services affect clinical outcomes. Uganda’s first EIPS, the Specialised Treatment Early in Psychosis Service at Makerere University Hospital (STEP_MaKH), presents a unique opportunity to explore these important questions.

Aims We aimed to examine the pathways to EIPS, the factors associated with referral to specialised psychosis care and the impact of initial treatment-seeking behaviour on long-term symptom remission and quality of life.

Methods We conducted a multiple-method study. Pathways to care were assessed retrospectively using the WHO Encounter Form among adults with FEP eligible for referral to STEP_MaKH. Among those who completed referral and enrolled in STEP_MaKH. Symptom severity and quality of life were followed prospectively for 12 months. Modified Poisson regression identified predictors of referral completion. Kaplan–Meier methods and Cox proportional hazards models examined time to symptom remission and time to achieving a good quality of life.

Results Of the 187 adults with first-episode psychosis eligible for referral to STEP_MaKH, Native/religious healers (n = 86) were the predominant first point of contact. Only 56 (29.9%) accepted referral to STEP_MaKH. Participants referred from Mulago National Referral Hospital more likely to enrol than those referred from Butabika (RR = 4.7; 95% CI: 2.90–7.87). Longer delays from first treatment contact were associated with reduced likelihood of reaching STEP_MaKH (RR = 0.99 per month; p = 0.041). After enrolment, symptoms improved rapidly with 60% achieving PANSS remission by Month 1, and fewer than 10% remained non-remitted by Months 2–3. In adjusted Cox models, participants initially seen by mental health workers achieved remission more quickly than those initially seen by non-medical personnel (HR = 1.48; 95% CI: 1.05–2.10). Older age was associated with slower remission (HR = 0.94; p = 0.023). Quality of life improved over the follow-up period, with earlier attainment of good quality of life among those initially managed by mental health workers.

Conclusions Pathways to care for FEP in Uganda are complex and culturally mediated, with substantial attrition before specialised early psychosis care is reached. Referral completion is strongly shaped by referral site and by delays in the care pathway. Once in specialised care, clinical outcomes improve rapidly, and initial contact with mental health workers is associated with faster symptom remission and earlier gains in quality of life. Strengthening referral systems, reducing pathway delays, and developing collaborative detection-and-referral links with community and frontline providers are key priorities for optimising early psychosis outcomes in low-resource settings.

The authors have declared no competing interest.

Research reported in this publication was supported by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health under Award Number D43NS118560.

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Ethical approval was obtained from the School of Medicine Research and Ethics Committee of Makerere University College of Health Sciences (Mak-SOMREC-2024-869). Institutional approval was also obtained from Butabika National Referral Mental Hospital. All participants provided informed consent.

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All data produced in the present study are available upon reasonable request to the authors.