Help-seeking behavior of patients with mental health problems visiting a tertiary care center in north India.

BACKGROUND: Patients with mental health problems in the nonwestern world seek help from a variety of sources, such as the family physicians, psychiatrists, psychologists, traditional faith-healers, or alternative medicine practitioners. Understanding the help-seeking behavior is important from the public health perspective.
MATERIALS AND METHODS: Two hundred new patients visiting a psychiatric outpatient service at a tertiary care hospital were interviewed on a semi-structured questionnaire for various services contacted by them for their mental health problems.
RESULTS: Psychiatrists were the first choice in 45% of the cases followed by nonpsychiatric physicians and religious faith healers. Important reasons to seek help from different sources included easy accessibility, belief in the system, or particular healer and good reputation. Mean duration of treatment varied from 2.35 months with the alternative system practitioners to 16.63 months with the psychiatrists. The mean expenditure per visit to a service was highest for the nonpsychiatric physician and lowest for alternative system practitioners.
CONCLUSION: Patients with mental health problems seek help from psychiatrists, nonpsychiatric physicians, faith healers, alternative system practitioners, and traditional faith healers for multiple reasons. It is important to sensitize various nonpsychiatric physicians with early identification and optimum management of mental disorders.

INTRODUCTION

An understanding of the way people seek care for mental disorders is important to know for planning mental health services, provision of appropriate training to the health care providers, and mental health reforms.[1] Reasons for choosing a particular service help in understanding how the population perceive mental illnesses and respond to them. This knowledge can be helpful in developing community awareness programs so as to remove myths and misconceptions about mental illnesses and sensitize the people with the availability of various sources of help available in the community.

Epidemiological studies across different nations show that only about one third of people with a mental disorder consult the mental health services, others seeking help from different sectors, such as the family physicians, general practitioners, or other physicians, depending on the type of health system of the country.[2] Even in the high-income countries, such as USA, Canada, Italy, and Netherlands, a substantial number of patients with mental health problems don’t seek treatment from the mental health sector, and rather seek help in the general medical sector, which includes general physicians or general practitioners, and are referred to the psychiatrists later, if required.[3-6]

In India, the mental health resources are very low compared with high-income countries. According to a recent estimate, the country has just 0.25 psychiatric beds per 10,000 population, 0.2 psychiatrists, 0.03 clinical psychologists, 0.05 psychiatric nurses, and 0.03 social workers per 100,000 of the population.[7] The facilities for psychiatric treatment are generally available in general hospital psychiatric units, mental hospitals, and office-based practice. Besides these, the patients, depending on the availability and accessibility, may consult a nonpsychiatric physician, general practitioner, lay counselor, local religious leaders, or traditional faith healer.[8-12]

The present study was conducted to investigate various health care facilities used by a group of patients with mental health problems and reasons for using the services.

MATERIALS AND METHODS

Study setting

The study was conducted in psychiatric outpatient setting at the All India Institute of Medical Sciences, New Delhi. The institute is a tertiary care premier medical institution of the country. Its catchment area includes the city of Delhi, neighboring states of Haryana, Uttar Pradesh, Rajasthan, as well as many distant states, such as Bihar, Orissa, Uttrakhand, Jammu and Kashmir, Madhya Pradesh, Jharkhand, and West Bengal. Patients attending the clinical services are mostly accompanied by their family members.

Sample selection

The sample consisted of new patients registering at the psychiatric outpatient clinic during July–August 2009. Every fifth new patient registering at the outpatient clinic was screened for the study. The patient and the accompanying family member, if any, were explained the purpose of the study and a written informed consent was taken. In cases of minor patients or patients with psychotic disorders, information as well as the consent was also gathered from the accompanying relative, who acted as an additional informant. A semistructured questionnaire was used to elicit the information.[10] The questionnaire included sociodemographic details of the patient and details of illness and various treatment facilities contacted by the patient. The patients were interviewed prior to seeing their doctor and information about the diagnosis was obtained from their medical notes.

Assessment

Patients were assessed on the semistructured questionnaire.[10] Information collected included demographic details, duration of illness, presenting symptoms and their duration, diagnosis according to ICD-10, various types of healers consulted before coming to the center, reasons for coming to our center, duration of treatment, expenditure per visit for each of them, and reasons for choosing a specific service. The expenditure included consultation fee, and expenses incurred on travel, investigations, and medications. The study was approved by the institute's ethics committee.

Analysis

The data were tabulated and analyzed using the Statistical Package for Social Sciences (SPSS) version 15 (SPSS Inc., Chicago, IL, USA). Chi-square test, Student's t test, Mann–Whitney U test, and Kruskal–Wallis Analysis of variance (ANOVA) were applied where appropriate.

RESULTS

Sample characteristics

The sample consisted of 200 patients, 125 males and 75 females. The mean age of the sample was 31.49±11.83 years with a range of 3–70 years. Fifty-two percent of the patients belonged to the age group 18–35 years and about one fourth in the age group 36–50 years. Sixty-two percent of the patients were married. The patients belonged to diverse education background with 18% being illiterate and about one third having received university education. Most patients were gainfully employed, which included homemakers (31%), students (21%), unskilled/semiskilled workers, skilled workers, and professionals/semiprofessionals (about 14% each). Only 6% of the sample was unemployed.

Diagnosis and disease characteristics

Common diagnoses included neurotic, stress-related and somatoform disorders (42.5%), mood disorders (17.5%), schizophrenia and related disorders (11%), organic brain disorders (11%), and mental retardation (5%). In 10 (5%) cases, the diagnosis was deferred and 16 (8%) patients did not receive any psychiatric diagnosis. The duration of psychiatric illness ranged from 2 days to 25 years (median 1 year). No significant difference was observed in the duration of illness between males and females. First contact with a psychiatrist was made as early as just with 1 day of illness, but could be delayed to the extent of 19 years (median 6 months).

Services used by the patients

The mean number of treatment facilities consulted was 2.11±1.12. Psychiatrists were the most common service providers chosen as the first contact, which included direct visit to our outpatient service (25%) or a psychiatrist outside (20.5%). Forty-four percent patients had consulted a nonpsychiatric physician in the first instance, whereas 8% went to traditional faith healer and 2.5% consulted an alternative medicine practitioner. Fifty-one percent of the patients sought help from a traditional faith healer at some time during the course of their illness, whereas more than 80% consulted a nonpsychiatric physician at some time. Forty-one percent had visited a psychiatrist outside the institute before coming to our setting, and 7% had been to an alternative medicine practitioner during the course of illness. Interestingly, 86% of the patients had consulted a psychiatrist by their second consultation, although some of them might have changed their health provider later [Table 1].

Table 1

The distribution of patients according to their previous contacts of choice

Duration of treatment with different service providers varied from 1 day to 120 months. The mean duration of treatment was longest with psychiatrists (16.62±22.60 months), followed by nonpsychiatric physicians (6.00±13.99 months), traditional/religious healers (4.27±17.91 months), and alternative medicine practitioners (2.35±3.16 months). Patients paid 1–120 visits to their service providers, although the mean number varied from 3.89±7.92 with traditional/religious healers to 13.72±18.61 with psychiatrists. The mean expenditure made per visit was minimum with the psychologist (Indian rupees 400) and maximum with nonpsychiatric doctors (Indian rupees 822.12±155.06) [Table 2].

Table 2

Details of treatment taken from different services

Reasons for choosing different services

Easy accessibility of the service, good reputation, enough time given for consultation, belief in the system of healing and recommendation by someone were the common reasons for choosing a service [Table 3]. About 9% of the patients who had consulted a nonpsychiatric physician thought that their illness was nonpsychiatric in nature. Most of those who went to a psychiatrist said that a specialist should be consulted for any illness. Reasons given for visiting our center included recommendation by someone (68.5%), lack of satisfactory response from previous treatment (87.33%), previous contact with the hospital (39.5%), low cost of treatment (54%), side effects with previous medication (16.66% ), and for second opinion (15.33%) [Table 4].

Table 3

Reasons for visiting various treatment facilities as the first contact (N=150)

Table 4

Reasons given by patients for visiting the place of study (N=200)

DISCUSSION

The main finding of the study was that the psychiatrists were the most common first contact service provider, sought by a group of patients with mental health problems, followed by nonpsychiatric physicians, including the primary care doctors. Treatment with a psychiatrist was not as expensive as with nonpsychiatric physicians. Nearly one third of the patients consulted a traditional faith healer or an alternative medicine practitioner at some point of course of their illness. Similarly, more than 80% of the patients also consulted a nonpsychiatric physician at some time for their mental health problem.

In one of earlier studies on mental health facilities used by the patients visiting a psychiatric hospital in North India, a psychiatrist was the first doctor consulted by 58% of the patients, and nearly one third of them had come directly to the psychiatric hospital.[10] Somewhat similar findings were observed in another Indian study conducted in the late 1970s from South India in a psychiatric hospital setting.[11] However, a recent study from a psychiatric hospital in the state of Madhya Pradesh (Central India)[13] found faith healers as the first contact of help in 68% of the total sample. Most of the patients in these studies suffered from psychotic disorders of different types. In the first two studies, having been conducted in the cities of Delhi and Bangalore, majority of the patients were from urban background, whereas in the third study, nearly 70% of the sample was from a rural background. Another reason for a high percentage of patients going to faith healers as the first contact in the study could be that number of psychiatrists in the state of Madhya Pradesh is much lower compared with the places of other studies. In the current study, schizophrenia and related disorders formed just 11% of the sample. Some of the patients from organic brain disorders and mood disorders might also have suffered from illnesses of psychotic nature, which constituted about 28% of the sample. But this also included substantial number of patients with depressive illness of mild to moderate severity. Disorders of neurotic spectrum were the most represented in our sample. The findings show that patients with common mental disorders, such as anxiety disorders, somatoform disorders, and mild to moderate depressive illness, form a substantial proportion of the clientele of psychiatrists in general hospital settings.

Community-based studies from the high income countries, such as USA, Canada, and Netherlands, have shown that only about 22–32% of patients with mental disorders consult the mental health professionals. A substantial number of the patients, 66–78% in Canada and Netherlands and 36% in USA consult the general medical sector for their mental health problems.[2] The figures vary across different countries depending on the health delivery systems of the country. For example, in the UK, all patients first need to go to their general practitioner,[114] whereas in the East European countries, about one third access the psychiatrist directly.[5] In Japan, nearly 40% of patients reach psychiatrists directly, and others reach the psychiatrist indirectly after being referred by some other specialists in the general hospitals or private practitioners.[15] One study from Australia reported that patients with mental health problems often need to make an average of three professional consultations prior to first contact with public mental health services. Family physicians occupy a pivotal role in the help-seeking pathway with 53% of patients consulting a general practitioner. The median time taken to reach specialist mental health services was 6 months, with significantly shorter time for patients with psychotic disorders.[6] In the current study, some patients had reached the tertiary care center as early as after 2 days of illness, although the median duration was 1 year for the center and 6 months for reaching a psychiatrist.

Common reasons for choosing a service were easy accessibility of the service, good reputation, enough time given for consultation, belief in the system of healing, and recommendation by someone. Nonpsychiatric physicians, who were often the family physicians, were often consulted for their reputation as well as giving sufficient time for consultation. Surprisingly, the treatment cost per visit was also highest for them as compared to the other facilities, including the psychiatrist, probably because of physical investigations. Many times, patients tend to go to the faith healers due to stigma associated with the mental illness.[16] In our study, expenses incurred by the patients on visits to the traditional faith healers and alternative medical practitioners were substantial, about two third of that incurred on visits to psychiatrist and about half of that incurred on visit to a nonpsychiatric physician. Thus the services of the traditional faith healers as well as the alternative medical practitioners are not cheap. Patients often have to spend a lot on various rituals, although consultations may be free.

It appears that the satisfaction levels of treatment with the psychiatrist were reasonable as once a patient reached a psychiatrist, treatment was often continued, as the duration of treatment as well as the number of visits with the psychiatrist was maximum as compared to other services. This was probably because the psychiatrist was often the last service provider chosen by the patients and they tended to continue treatment there. In the study, only one patient had been to a psychologist and that too only a single visit. The finding is surprising but is also an indication of low availability of other mental health professionals in the community.

It has been suggested that for integration of mental health in primary care, an educational approach is more likely to succeed.[5] One of the main objectives of the National Mental Health Program of India is the integration of mental health care in general medical care and it includes sensitization programs in mental health care for the doctors and paramedical personnel.[17] Since, the patients with mental health problems frequently visit the nonpsychiatric physicians, including primary care doctors, general practitioners, and general physicians, it is important to sensitize them with early identification and proper management of various mental health problems in their patients.[18] This will help reducing the delays in treatment, avoid unnecessary investigations, and reduce the associated disability as well as the cost of treatment. In the present study also, treatment cost per visit was found highest with the nonpsychiatric physicians.[19]

It is difficult to generalize the findings of the study as it was hospital based and includes the viewpoint of the patients who seek treatment from hospital-based settings. A large number of psychiatric patients even in the western countries never seek treatment,[2021] and thus the findings are biased towards a group that already has a relatively good health-seeking behavior. However, the site of the study gets patients coming from a number of states of the country, covering almost half of the country and in a way can be seen representative of wide areas of the country. Another important limitation of the study was the possibility of information bias and retrospective falsification as the information elicited was based on a long period of recall about the onset, duration of illness, and reasons for choosing different treatment facilities.

To conclude, we would say that the patients with mental health problems in India seek treatment from a wide range of services, including psychiatrists, nonpsychiatric physicians, traditional faith healers, and alternative medicine practitioners. Treatment with nonpsychiatric physicians is costlier than that with the others. In recent years, patients with even common mental disorders are seeking treatment with the psychiatrists. It is important to sensitize various nonpsychiatric physicians with early identification and optimum management of mental disorders so that they are able to manage the patients appropriately and also seek timely referral to psychiatrists. Similarly, there is a need of community awareness programs on mental health so as to prevent delays in treatment.