Pathways to care among patients with severe mental disorders attending a tertiary health-care facility in Puducherry, South India.

INTRODUCTION: Pathways to care can be defined as the pathway adopted by the patient to reach the appropriate health facility. In India, health workforce related to mental health care is inadequate. Persons with mental disorders approach different types of care providers. This study describes the number, sequence of care providers visited, and time gap between providers among individuals newly diagnosed with severe mental disorders.
MATERIALS AND METHODS: We conducted a facility-based descriptive study in the psychiatric outpatient department of a tertiary care center in South India between April and September 2017. All patients with any of the following diagnosis; acute psychosis, depression, bipolar disorder, or schizophrenia were included in the study. Information on number and sequence of care providers visited and the reasons for preference of providers were assessed using a validated World Health Organization questionnaire. Patients seeking care was summarized as numbers.
RESULTS: Of the total 150 participants, 86 (57%) were females and the mean (standard deviation) age was 35 (11.5) years. The first point of contact were traditional healers in 52 (34.7%) participants, general hospitals in 23 (15.3%), and psychiatric services in the remaining 75 (50%). The patients with schizophrenia and bipolar disorder had greater delays in accessing psychiatric care when compared to other disorders. Median (interquartile range) number of care providers visited till the diagnosis made was 2 (1-3). The availability and recommendation by close relatives were the major reasons for the preference of traditional healers.
CONCLUSIONS: One-third of patients visited traditional healers as the first point of contact and about half visited the psychiatric facilities directly. Copyright:

INTRODUCTION

Mental health is fundamental to health. Worldwide, community-based epidemiological studies have estimated that the lifetime prevalence of mental disorders in adults is 12.2%–48.6%, and 12-month prevalence is 8.4%–29.1%.[1] As per the World Health Report 2001,[2] the prevalence of mental illnesses is 10% and is projected to increase to 15% by the year 2020. Depression is among the largest single cause of disability worldwide, affecting mainly women.[3] It also contributes to 11% of disability-adjusted life years globally. Untreated mental, neurological, and substance use disorders account for 14% of the total global burden of disease. Estimates from India show that the prevalence of common mental disorders is 6%–7%, and the prevalence of severe mental disorders is 1%–2%.[4] The report also highlighted that the delay in treatment was found to be in 50% and 90% of cases with severe and common mental disorders, respectively.

In a developing country like India, the major problem with mental health care is the treatment gap defined as percentage with mental disorders requiring treatment but do not receive it. Reasons for this gap include scarcity of resources, unequal distribution, inefficient use, non-medical explanations, and lack of awareness, accessibility, and availability of health-care services.[5] The treatment gap and the delay in the diagnosis of mental disorders have their impact on treatment outcomes. Longer the duration of untreated illness (DUI), poorer are the treatment outcomes in mental disorders.[678]

“Pathways to care” can be defined as the pathways adopted by the patient to reach the appropriate treatment center.[9] It is important to understand where individuals with mental health problems seek care. Among patients with mental disorders, seeking help from formal psychiatric services is uncommon. Majority of the participants or their caregivers prefer to go to informal practitioners and traditional healers who are close to the community. Other reasons for this preference include extreme poverty, stigma, and belief in the role of supernatural powers in mental health disorders.[10] Understanding the pathways to care and the decision process associated with it will be helpful in identifying the right first level health-care providers in providing training in mental health care for the early identification of symptoms and referral.[11] There are a few studies from North India on this aspect.[121314] These studies reported that faith healers are the most popular portal of care (39%–69%). The regional disparities in availing resources, services, and opportunities are markedly well established in India.[15] South Indian states have much higher health care use rates and accessibility to primary care facilities than North Indian states. Similarly, there is evidence for cultural differences prevailing in the use of modern medical services.[16] Therefore, in this study, we aimed to assess the pathways of care and delay in seeking care for those individuals newly diagnosed with severe mental disorders (acute psychosis, depression, bipolar disorder (BD), and schizophrenia) at a tertiary teaching care hospital in Puducherry in the southern part of India.

MATERIALS AND METHODS

A hospital-based descriptive study was conducted in the psychiatric outpatient department of a tertiary care teaching institute in Puducherry, South India. Adults aged 18 years or above with a diagnosis of any of the following: schizophrenia, bipolar disorder (BD), acute psychosis, and depression were included. All diagnoses were made by qualified psychiatrists using the ICD 10 criteria. We included all eligible outpatients registered during April 2017–September 2017. Since this was an exploratory study in our setting, we did not attempt sample size calculation but decided to include 150 patients.

Data were collected by face-to-face interviews with the caretaker in the outpatient clinic. We used World Health Organization (WHO) encounter form[17] to collect the information on a number of care providers accessed, provider of first contact, reasons for preference of providers, and duration between care providers. We also collected the details on age, gender, occupation, educational status, marital status, residence (urban/rural), diagnosis, presence of any other chronic illness (diabetes, hypertension, and chronic obstructive pulmonary disease), alcohol use, and tobacco use.

Relevant information was elicited from the key informant who was the relative accompanying the patient on the day of consultation. When the key informant was not able to provide the required information, we contacted any other available relative by calling them up. The study protocol was reviewed and approved by the Institutional Ethics Committee (ref.no. JIP/IEC/2017/0195). Written informed consent was obtained from the patient and from the care giver at the time of recruitment.

Data were single entered in EpiData Entry Client version 4.0 (EpiData Association, Odense, Denmark) and analyzed in SPSS software version 20 (IBM PASW Statistics, Country office Bengaluru, India). Continuous variables such as age and family income were summarized as mean and standard deviation (SD) or median and inter-quartile range (IQR). Pathways to care were described using a flow diagram with corresponding number of patients seeking care at different providers.

RESULTS

A total of 150 participants were included. Of them, 86 (57%) were females and mean (SD) age was 35 (11.5) years. More than three-fourths (77%) of the patients were from rural areas, and 22% did not have any formal education. Tobacco use in the past 1 month and alcohol use in the past 1 year were reported by 15% and 10% of the participants, respectively. The sociodemographic characteristics are described in Table 1.

Table 1

Sociodemographic and behavioral characteristics of psychiatric outpatients attending a tertiary health care facility in Puducherry, South India, 2017 (n=150)

Variable	n (%)
Age (years)
<25	31 (20.7)
26-45	95 (63.3)
>46	24 (16.0)
Gender
Male	64 (42.7)
Female	86 (57.3)
Residence
Rural	116 (77.3)
Urban	34 (22.7)
Occupation
Unemployed	35 (23.3)
Homemaker	64 (42.7)
Employed	51 (34.0)
Education
No formal education	26 (22.0)
1-8th class	31 (16.0)
9-12th class	61 (40.7)
Graduate and above	32 (21.3)
Marital status
Single	49 (32.7)
Married	100 (66.7)
Divorced/separated/widowed	1 (0.7)
Socioeconomic class*
Class 1 (INR 6254 and above)	6 (4)
Class 2 (INR 3127-6253)	39 (26)
Class 3 (INR 1876-3126)	32 (21.3)
Class 4 (INR 938-1875)	41 (27.3)
Class 5 (INR 938 and below)	32 (21.3)
Alcohol use	15 (10)
Tobacco use	22 (14.7)

*Modified BG Prasad’s classification September 2017

Pathways undertaken by patients are described in Figure 1. Fifty-two (34.7%) participants chose traditional healer as the first point of care, and 75 (50%) participants directly sought care from psychiatrists either at government or private health facilities. Remaining 23 (15.3%) participants visited general hospital as their first point of contact. Out of 150 participants, 104 reached second point of care, 43 sought a third-care provider, and nine accessed a fourth-care provider. In diagnostic groups, 55% of acute psychosis, 41% of BD, and 30% of schizophrenia patients visited traditional healers as the first point of care, whereas 72% of patients with depression chose psychiatric facilities as the first point of contact. Reasons reported for choosing traditional healers were “availability at a close distance” and “recommended by close relatives.” Financial reasons (poor affordability at private facilities) was the major reason cited for preferring public psychiatric facilities.

Figure 1

Pathways undertaken to seek psychiatric care among psychiatric outpatients attending a tertiary health-care facility in Puducherry, South India, 2017 (n = 150)

The median (IQR) duration between the onset of symptoms and reaching the first point of care was 30 (0–180) days. Between first and second point of care (n = 104), the median duration was 180 (60–720) days. Median duration between the points of care is depicted in Figure 2. The time gap between the various points of contact for different mental illnesses is described in Table 2. Delay in seeking appropriate psychiatric care was found to be more in patients with schizophrenia and BD when compared to other disorders. Maximum time gap of 360 (150–978) days was found between the 2nd and 3rd contact in patients with schizophrenia.

Figure 2

Time gap between the providers in days among psychiatric outpatients attending a tertiary health-care facility in Puducherry, South India, 2017 (n = 150)

Table 2

Median (interquartile range) time gap between the onset of symptoms and contact with care providers among psychiatric outpatients attending a tertiary health care facility in Puducherry, South India, 2017 (n=150)

Diagnosis	n	Median (IQR) time gap between point of cares (days)
		Symptoms to 1st PC	1st PC to 2nd PC	2nd PC to 3rd PC	3rd PC to 4th PC
Depression	46	29.1 (0-120)	60 (30-180)	0 (0-90)	0 (0-0)
Acute psychosis	38	30 (0-337.5)	75 (30-232.5)	45 (45-150)	0 (0-25.5)
Schizophrenia	30	60 (0-210)	360 (150-978)	105 (9-240)	0 (0-60)
BD	29	60 (0-330)	150 (60-840)	30 (18-105)	0 (0-27)
Other mood disorders‡	7	15 (0-30)	90 (13-270)	2 (0-89)	0 (0-0)

‡Anxiety disorder and stress-related disorder. PC – Point of care; BD – Bipolar affective disorder; IQR – Interquartile range

Time duration between the onset of symptoms and diagnosis is described in Figure 3. In 75 patients whose first contact was psychiatrists were diagnosed in a median (IQR) time of 60 (0–330) days. In 58 participants who were diagnosed at the second point of contact, the median (IQR) duration for the diagnosis was 285 (112.5–697) days. Median (IQR) number of providers till the diagnosis was 2 (1–3). Median (IQR) DUI in months (time from symptoms to diagnosis) was the highest for schizophrenia (20 [9-38]) followed by BD (10 [3-23]). Patients with acute psychosis had a median DUI of 6.5 months, whereas those with depression had a median DUI of 2 months.

Figure 3

Time gap between the onset of symptoms and diagnosis in days among psychiatric outpatients attending a tertiary health-care facility in Puducherry, South India, 2017 (n = 150)

DISCUSSION

Our study among patients in a tertiary care center showed that about one-third (34.7%) went to traditional healers as the first point of contact, and about half of the participants directly contacted the psychiatrists. There were substantial delays between each point of contact and this was higher for patients with schizophrenia and BD.

Similar findings regarding traditional healers as the first point of contact for mental illness were reported in studies from India. Studies from Gwalior, central part of India and Jaipur reported that 69% and 40%, respectively, had first contacted traditional healers.[1218] This is also true for illness related to mental health in children as a study from Ranchi, Jharkhand reported a high preference for traditional healers (61%).[14] However, in contrast, a study from New Delhi, India, reported that only 8% of patients visited traditional healers as the first point of contact.[19] There is a large proportion of people, especially in rural areas who may want to avail care but did not seek care as they do not know where to avail care. Studies reveal that 45% of patients with psychiatric illnesses have sought about 1–15 sessions with traditional healers in South India, and nearly, about 69% of patients consult faith healers in North India before approaching to psychiatric care.[122021] The major reason for the difference might be the cultural or regional background affecting the level and kind of utilization of existing health-care services. The more tradition-bound North Indian population are more likely to seek care from non-allopathic or traditional healers compared to South Indians. Culturally accepted conventional practices like temple healing is quite acceptable in some parts of India, yet they may not be considered acceptable in other places.[22] The study also highlights regional differences in help-seeking patterns among patients with mental illness. More such studies from different parts of the country may assist in developing need-based solutions to bridge the treatment gap in psychiatry.[23] As traditional healers are present in higher numbers, especially in rural areas in India and live closer to the population, they form the first level of care. Hence, these traditional healers if trained by public health programs can act as bridge workers who can identify the people with mental health problems and refer them to appropriate care.[2425]

We also assessed the reasons for the preference for traditional healers as the first contact of choice. The predominant reasons were the trust or belief in the traditional healers, easy access, and recommendations by the close relatives or family members. Relatives or family members play a vital role in preference toward particular service provider. Easy accessibility, trustworthiness, belief in supernatural causation of mental disorders, and recommendation of relatives or friends were the common reasons reported in other studies.[1214132627282930] The reasons for the preference of psychiatry hospital included recommendation by other physicians or providers including traditional healers, lack of response to other systems of medicine, and availability of low-cost treatment.[30]

Besides traditional healers, strengthening the primary care workers in the diagnosis and management of mental health problems will reduce the time delays. Opportunistic screening for mental health illness during the outpatient visits by trained physicians in primary health-care settings or task shifting of screening by community health workers may help in overcoming the shortage of specialists to some extent. These approaches have been already proven useful in the management of other noncommunicable diseases.[313233343536]

In the current study, most of the patients reached first point of care within 1 month of onset of symptoms and half of them approached psychiatric service directly, a finding similar to previous study from a private psychiatric hospital in North India.[37] This reflects a positive aspect of the care-seeking behavior of patients in this study setting. In our study, participants (n = 104) spent a median (IQR) of 180 (60–720) days to reach the second point of care. Out of this, around half (56.7%) of them contacted psychiatric services, similar to other studies findings from India,[1219] which reported longer than 6-month duration to reach psychiatric services if they had not approached psychiatric service as their first point of care. The delay in reaching psychiatric service among patients who sought care from other providers clearly suggests the lack of awareness on appropriate referral practices among these care providers.

Our study has following strengths. We used “WHO Encounter Form” developed for a multi-country study by the WHO and has been used by majority of the previous studies which enabled the comparison of findings across studies. We comprehensively studied the pathways to care, including the number and sequence of providers, reason for preference for a particular provider, and the duration. Furthermore, inclusion of newly diagnosed patients in the study would have limited the biases related to recall limitation on the number of providers and duration.

The pathway may not be generalizable to all individuals with mental health illness in a community since the study gives no account of the people who did not reach tertiary health care. Although reasons for the preference for a particular healer or provider was assessed quantitatively, qualitative methods could have provided richer information on the context of decision making and the players involved. Since this was an exploratory study, we did not calculate sample size. Larger sample size could have provided a precise estimate at each level of care.

CONCLUSIONS

To conclude, one-third of patients sought traditional healers as the first point of contact, and about half visited the psychiatric facilities directly. Innovative and sustained efforts are required to engage traditional healers and primary care workers in the identification of patients with mental health problems and referral to formal psychiatric services.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.