Response

In their thoughtful feature, Baum and colleagues highlight important ethical challenges arising from the increasing use of advanced diagnostic technologies for rare and potentially reversible causes of psychosis. ^{Reference Baum, Blackman, Al-Diwani, Handel, Endres and Binks1} Their discussion focuses on diagnostic justice, moral responsibility and the unintended consequences of work-up. ^{Reference Baum, Blackman, Al-Diwani, Handel, Endres and Binks1} While these concerns are highly relevant, the ethical realities in low- and middle-income countries, such as India, differ fundamentally.

Baum and colleagues describe how ‘geographic serendipity’ may influence access to advanced investigations for rare causes of psychosis. ^{Reference Baum, Blackman, Al-Diwani, Handel, Endres and Binks1} In India, this disparity is amplified by structural inequities. India faces a significant human resource deficit in mental healthcare, with approximately 0.75 psychiatrists per 100 000 population (concentrated heavily in metropolitan tertiary centres). Over 75% of advanced diagnostic facilities (e.g. 1.5 Tesla/3 Tesla magnetic resonance imaging, specialised auto-antibody testing laboratories) are centralised in urban private or academic institutes, whereas roughly 65% of the population resides in rural or semi-urban districts. A patient presenting to a rural service faces formidable logistical and financial barriers before reaching tertiary care. In these settings, diagnostic justice depends not on whether technology exists but on whether referral pathways allow equitable access.

The consequences of these disparities become particularly important when an underlying medical disorder may initially present with psychotic symptoms. Our experience with autoimmune psychosis, anti-N-methyl-D-aspartate receptor encephalitis and COVID-19-related psychosis suggests that potentially reversible conditions may first present to psychiatric services with few obvious neurological signs. ^{Reference Palakkuzhiyil, Uvais, Moideen and Shihabudheen2–Reference Uvais and Moideen4} In such situations, delayed access to appropriate investigations may prolong diagnostic uncertainty and postpone potentially effective treatment. The ethical challenge is therefore not merely the recognition of rare disorders but ensuring equitable access to the pathways required to diagnose them.

Another crucial issue is financial toxicity. ^{Reference Pisu and Martin5} In India, out-of-pocket expenditure (OOPE) accounts for ∼47.1% of total health expenditure. ^{Reference Kamath, Maliyekkal, Elstin Anbu Raj, Varshini, Brand and Sirur6} Comprehensive neurodiagnostic work-ups – involving neuroimaging, antibody panels, lumbar puncture and prolonged hospitalisation – frequently lead to debt, asset sales and long-term economic instability. Such consequences are rarely incorporated into conventional bioethical analyses but are highly relevant in everyday clinical practice. The principle of non-maleficence requires clinicians to consider not only the physical risks associated with investigations but also their potential financial consequences. ^{Reference Varkey7} In resource-constrained settings, responsible diagnostic practice requires balancing the risk of missing a treatable disorder against the risk of exposing families to potentially catastrophic expenditure.

Baum and colleagues also raise questions regarding epistemic responsibility. ^{Reference Baum, Blackman, Al-Diwani, Handel, Endres and Binks1} In overburdened systems, psychiatrists cannot possess specialist expertise in every rare condition but must maintain diagnostic openness when clinical course, treatment response or neurological features deviate from expectations. However, epistemic responsibility cannot rest solely on clinicians. A psychiatrist recognising red flags without access to referral pathways or laboratory support faces a structural systems failure rather than an individual epistemic error. Healthcare systems share this diagnostic responsibility.

Furthermore, decision-making in India occurs within a familial framework. Families finance investigations, provide caregiving and negotiate choices collectively. Stigma surrounding psychiatric illness may lead families to seek a neurological explanation, while invasive procedures like lumbar puncture elicit apprehension. Ethical decision-making must therefore incorporate relational autonomy – balancing legitimate family involvement with patient dignity and agency. ^{Reference Uvais8}

The challenge for India is not simply to replicate diagnostic pathways developed in resource-rich settings. Rather, the goal should be to develop approaches that are scientifically robust, clinically practical and ethically sustainable. To operationalise epistemic responsibility and resource stewardship in resource-constrained settings, we propose a structured, three-tier diagnostic pathway tailored to the Indian context (Fig. 1). ^{Reference Uvais, Imam and Ahmad9}

Fig. 1

Three-tier operational triage model for the evaluation of secondary psychosis in India. LMICs, low- and middle-income countries; EEG, electroencephalogram; CSF, cerebrospinal fluid; NMDAR, N-methyl-D-aspartate receptor.

Fig. 1 Long description

A diagram outlining a three-tier operational triage model for evaluating secondary psychosis in low- and middle-income countries. The diagram is divided into three main tiers: Tier 1, Tier 2, and Tier 3. Tier 1, labeled ‘Careful Bedside Assessment,’ involves identifying clinical red flags suggestive of neurological or medical disorders. These red flags include atypical symptom profiles, catatonia, autonomic instability, seizures, altered consciousness, prominent cognitive impairment, and unusual treatment responses. Tier 2, labeled ‘Selective Use of Accessible Investigations,’ involves the use of accessible investigations such as EEG and structural neuroimaging. This tier aims to identify patients requiring further evaluation. Tier 3, labeled ‘Referral for Specialised Investigations,’ involves specialized investigations such as CSF studies, auto-antibody testing, and tumor screening when clinically indicated. The purpose of the framework is to reserve resource-intensive tests for patients with higher pre-test probability, maintain diagnostic vigilance, promote distributive justice, and minimize unnecessary financial burdens on families.

At the primary and secondary care level, Tier 1 focuses on comprehensive bedside triage and red-flag screening. Conducted at primary care centres, district out-patient clinics or private facilities run by medical officers, general practitioners or psychiatrists, this step involves minimal OOPE – routine bedside evaluations and basic metabolic blood work typically cost ₹300–1000 (∼£2.30–7.80) and are often subsidised in public facilities. Clinicians at this stage can rely on validated clinical tools, including the Graus criteria for autoimmune encephalitis, the Bush–Francis Catatonia Rating Scale and the Confusion Assessment Method for delirium or Glasgow Coma Scale (GCS) for altered consciousness. To prevent diagnostic oversight during routine care, mandatory Tier 1 re-screening is triggered if a patient exhibits treatment resistance, severe extrapyramidal side effects at sub-therapeutic antipsychotic doses within 2–4 weeks, subtle dyskinesias or rapid cognitive decline. Crucially, high-risk presentations – such as new-onset status epilepticus, rapidly deteriorating GCS, severe autonomic instability or acute focal neurological deficits – warrant immediate escalation directly to specialised tertiary care (Tier 3), bypassing intermediate delays.

For patients requiring further objective evaluation, Tier 2 provides targeted basic neurodiagnostics accessible at district-level general hospitals. Direct OOPE at this level remains relatively modest, with a digital electroencephalogram (EEG) ranging from ₹1000–2700 (∼£7.80–21) and a structural brain MRI (1.5 Tesla/3 Tesla) costing ₹4500–8000 (∼£35–63.10). An EEG is specifically indicated for acute or subacute psychosis with fluctuating sensorium, unexplained confusion, catatonia refractory to benzodiazepines, or suspected non-convulsive status epilepticus, where findings such as extreme delta brush guide urgent escalation. ^{Reference Uvais, Imam and Ahmad9} Meanwhile, brain MRI is reserved for cases with Tier 1 red flags, EEG abnormalities or atypical presentations, focusing on identifying T2/fluid-attenuated inversion recovery hyperintensities in mesial temporal structures, demyelinating lesions or space-occupying masses.

Finally, Tier 3 encompasses specialised investigations concentrated in urban academic institutes and referral hubs. Because these advanced modalities carry substantial OOPE – including lumbar puncture and cerebrospinal fluid work-ups (₹3000–10 000/∼£23.60–78.90), commercial neuronal auto-antibody panels (₹19 000–35 000/∼£149.90–276.10), and fluorodeoxyglucose positron emission tomography or systemic tumour screening (₹10 000–35 000/∼£78.90–276.10) – they pose a profound risk of financial toxicity. Tier 3 testing must therefore be reserved for patients with a high pre-test probability flagged through Tier 1 and Tier 2 evaluations.

Importantly, the purpose of this framework is not to ration care. Rather, it seeks to reconcile competing ethical obligations. By reserving resource-intensive investigations for patients with a higher pre-test probability of secondary psychosis, clinicians can maintain diagnostic vigilance while promoting distributive justice and minimising unnecessary financial burdens on families. In this sense, the framework functions not merely as a diagnostic pathway but as a mechanism for ethical resource stewardship.