G Model
AJP-729; No. of Pages 4 Asian Journal of Psychiatry xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Pathways to tertiary care adopted by individuals with psychiatric illness Ananya Prabhu a, G. Vishnu Vardhan b,*, Lakshmi V Pandit a a b
Kempegowda Institute of Medical Sciences, K R Road, Basavangudi, Bangalore 560004, India Raja Rajeshwari Medical College and Hospital, Kambi pura, Mysore Road, Bangalore, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 May 2015 Received in revised form 7 May 2015 Accepted 20 June 2015 Available online xxx
Awareness of mental illness as a cause of morbidity is increasing the world over. Of the top ten causes of disability, five are psychiatric illnesses. Availability and accessibility of psychiatrists as well as treatment facilities is meagre, making pathways to psychiatric care tortuous hence delayed, affecting outcomes negatively. With an attempt to study the pathways to psychiatric care, a cross sectional study was undertaken, on 63 consecutive first contact patients in tertiary care centre in Bangalore, India. Socio demographic details, time taken to reach professional help, and reasons for delay were noted. Pathways to care were recorded using ‘WHO pathways to care’ proforma. One third of the study population were aged between 31 and 45 years, mostly Hindus. Two thirds of them had received about 10 years of formal education, hailed from urban areas and lived in nuclear families. Majority sought help from trained medical professionals, with almost 40% seeking psychiatric help initially itself. While the choice of consultation was influenced by people in the immediate environment, that of first contact was based on the physician or treating facility. Almost 57% had more than two referrals before reaching the tertiary care centre. Though the urban educated population are well aware of the nature of psychiatric illnesses, need for medical intervention and its availability, there was a delay in seeking help from a tertiary psychiatric centre. There is thus a need to educate medical professionals about timely referral to these centres, as early and appropriate interventions result in a favourable outcome. ß 2015 Elsevier B.V. All rights reserved.
Keywords: Pathways to care First contact Choice of treatment Tertiary psychiatric care
1. Introduction ‘Awareness’ of mental illness as a significant cause of morbidity is increasing worldwide, caused by the steady decline of morbidity due to nutritional disorders, communicable diseases and other forms of physical illness, especially in countries undergoing epidemiological transitions (shift in epidemiological attention from communicable diseases, malnutrition and problems associated with pregnancy and childbirth, to chronic non communicable diseases) (Fahad et al., 2006). A significant disease burden is attributable to mental illness globally. Out of the top ten leading causes of disability throughout the world, five are psychiatric illnesses (Banerjee, 1997), and six
* Corresponding author. Tel.: +91 9845211970. E-mail addresses: [email protected] (A. Prabhu), [email protected] (G. Vishnu Vardhan), [email protected] (L.V. Pandit).
neuropsychiatric conditions have figured in the top 20 (Trivedi and Sethi, 1979). According to WHO, mental illnesses account for 11.5% of the global burden of disease—a figure that is projected to increase to 15% by 2020. Majority of those with mental illnesses live in the developing world (Pradhan et al., 2001) approximately half of them are living in the Asia Pacific regions (Syed et al., 2012). It is estimated that, at any point in time, in India, 2–5% of the population is suffering from serious mental illnesses, and 10% from minor mental illnesses (National Institute of Health and Family Welfare (NIHFW), 2005). Prevalence rates of psychiatric disorders in India range from 9.5 to 370/1000 population (Jilani et al., 2009; Lahariya et al., 2010). The number of psychiatric beds in the country is only about 0.2/one lakh population and there are two psychiatrists per ten lakh population (Roger and Cortes, 1993), mostly concentrated in the metropolitan and the urban areas (Sharma et al., 2007). Professional psychiatric help thus being non available, it is only understandable that the path leading to it is long, punctuated by
http://dx.doi.org/10.1016/j.ajp.2015.06.005 1876-2018/ß 2015 Elsevier B.V. All rights reserved.
Please cite this article in press as: Prabhu, A., et al., Pathways to tertiary care adopted by individuals with psychiatric illness. Asian J. Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.06.005
G Model
AJP-729; No. of Pages 4 A. Prabhu et al. / Asian Journal of Psychiatry xxx (2015) xxx–xxx
2
penury, stigma, and superstitions associated with mental illness, coupled with an unwillingness or inability of families to care for their mentally ill relatives (Jain et al., 2012). In addition, only a minority of individuals attribute their illness to psychological causes, prompting them to seek help from faith healers, with a few seeking the help of general practitioners before approaching a psychiatrist. The first line of treatment for the mentally ill constitutes the most important stage of psychiatric care. It thus becomes important to understand pathways to care so as to be able to ensure that those individuals with mental illnesses have direct access to professional help. The current study is thus undertaken with an aim to trace the pathway taken by the mentally ill to reach professional care, and elicit the factors responsible for their choice of help seeking.
Table 1 Depicting the socio-demographic details of the patients. Socio-demographic details
Numbers (N = 63)
Percentage (%)
Age 30 years
27 36
42.8 57.2
Gender Male Female
34 29
54 46
Marital status Unmarried/widowed Married
21 42
33.3 66.7
Education Educated Uneducated
38 25
60.3 39.7
Occupation Unemployed/student Employed
36 27
57.1 42.9
Residence Rural Urban
16 47
25.4 74.6
Family type Joint Nuclear
18 45
28.6 71.4
Income 10,000
41 22
65.1 34.9
2. Material and methods As the aim of the study was to trace the pathways taken by the mentally ill to reach professional psychiatric help and to delineate the factors influencing the same, a cross sectional study was designed and consecutive patients presenting to the department of psychiatry in a tertiary care hospital, located in the city of Bangalore, India, during a period of three months (June to August 2013) were recruited. After obtaining clearance and approval from the institutional ethics committee, 68 patients and their relatives, aged above 18 years were included in this study. A written consent was obtained from both the patients and their relatives. All patients were diagnosed using ICD-10(DCR) (World Health Organization, 1993) and only patients presenting to us for the first time were included. A total of 68 patients fulfilled the inclusion criteria, of whom three were unable to complete the study and two of them were residents of a destitute home with no relatives, hence the results are based on the data of 63 patients. The time taken to reach professional help was noted, being defined as the time between onset of illness as described by the informant and the current consultation. Details of the chosen pathways and reasons for the same were collected as reported by the informant as well as the patient where relevant. Socio demographic details were obtained by a proforma developed for the study, while pathways to care were recorded using the ‘WHO pathway to care proforma’ developed by Gater et al. (1991). To avoid bias, all the interviews (lasting for about one hour each) were conducted by a single well trained psychiatrist, who had the previous experience of working with the study instruments. 3. Results 3.1. Sociodemographic details 36.5% of the study population were aged between 31 and 45 years, with 54% of them being males. Majority of them were Hindus (95%), with 60% having had 10 years or more of formal education. They hailed from urban areas (75%) and lived mostly in nuclear families (70%) 40% were unemployed while 36% had a monthly income of between five and ten thousand per month (Table 1). 3.2. Tracing the pathway Half the study population had an onset of illness more than five years ago. A small percentage of the patient population approached a native healer as first contact of care (6.3%) while a large majority of them sought trained medical help for initial consultation (90%), with 39% of these patients having approached a psychiatrist initially (Table 2). It was found that on an average it took the patients 69.3 months to reach tertiary psychiatric care (Table 3).
The choice for the first consultation was influenced by either a relative or a friend in 73% of the patients, while only 11.1% of the patients made the choice themselves (Table 4). Majority of them (59%) made their choice based on care related issues such as faith in the consulting physician, previous experience with the treating facility, and the preference for a multi speciality hospital. Some made their choice based on their personal likes for the hospital/ clinic (28.5%), while others (21%) based their decision on environmental factors such as location, affordability, referral practices of their local doctors and the opinion of those around them. 27% of them had a single referral before reaching trained professional help, while 35% had two and 22% had three referrals. Table 2 Depicting the first contact of care. Help sought from
N = 63
Native healer Medical practitioner (GP) Gen. Hospital Psychiatrist Ayurveda/homeopathy Others
4 21 14 22 1 1
Total
63
Percentage (%) 6.3 33.3 22.2 35 1.6 1.6 100
Please cite this article in press as: Prabhu, A., et al., Pathways to tertiary care adopted by individuals with psychiatric illness. Asian J. Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.06.005
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AJP-729; No. of Pages 4 A. Prabhu et al. / Asian Journal of Psychiatry xxx (2015) xxx–xxx Table 3 Indicating the time taken by the psychiatrically ill to reach the tertiary care centre. Time period from the onset of illness
Number of patients (N = 63)
Percentage (%)
Less than 1 month 1 month to 1 year 1 year to 5 years More than 5 years Total
16 9 17 21 63
25.4 14.3 26.9 33.3 100
The average time spent by a psychiatrically ill patient is 69.36 months before reaching a tertiary care centre.
Table 4 Depicting who influenced the choice of first contact of care. Choice influenced by
N = 63
Relative/friend Patients own choice Others
46 7 10
Total
63
Percentage (%) 73 11.1 15.9 100
4. Discussion The pathway that patients adopt to reach the appropriate treatment centre is termed as the ‘‘Pathway of Care’’. These pathways indicate psychosocial and cultural factors that influence help seeking behaviour (Roger and Cortes, 1993) and studying them aids in understanding how health services are utilized. It is important to understand them in the context of psychiatric illnesses, so as to be able to make the pathway to professional help more direct, thereby reducing the duration of untreated illness, a significant parameter in deciding the prognosis. Though the study was carried out on 68 patients, the results are derived from the 63 patients and their care givers, who could complete the study, A small sample thus preventing generalization of the findings. They were mostly aged between 31 and 45 years, the most productive part of their lives, which probably influenced them being brought for psychiatric care. Hailing largely from urban areas, they were educated up to secondary level or beyond. Both these factors have been found to positively influence the pathways to care. In various studies, a higher level of education, living in an urban setting and attributing mental illness to a rational cause were found to be significantly associated with approaching specialist care as the first option (Banerjee, 1997; Fahad et al., 2006; Pradhan et al., 2001). Greater superstitions about mental illness, rural residence, and lower educational attainment influenced approaching religious healers (Sharma et al., 2007). Male respondents were more likely to receive psychiatric care at first contact than the females (Banerjee, 1997; Fahad et al., 2006; Pradhan et al., 2001). In the current population, however, both genders were equally represented, probably as a very large part of the population were from the urban areas (75%). Approach to health care systems varies across different countries, being totally governed by the health delivery systems of that country. 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 mental health professionals, while the rest consult the general medical sector (Alegria et al., 2000). In the United Kingdom, all patients first need to go to their general practitioner (Bhugra et al., 2003; Gater et al., 1991), whereas in the East European countries, about one third access the psychiatrist directly (Gater et al., 2005). 40% of Japanese patients reach psychiatrists directly, while the others are referred by private practitioners or by other specialists in general hospitals (Fujisawa et al., 2008). An Australian study
3
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, and the median time to reach specialist help was six months, with a shorter time for patients with psychotic disorders (Steel et al., 2006); 53% of patients initially consult a general practitioner (Steel et al., 2006). Similar studies carried out in the developing countries like Nigeria, revealed that, the prayer house (34.5%), followed by a psychiatric hospital (32%), private clinic (15.9%), or a traditional healer (13.6%), were the treatment options employed in that order by mentally ill patients (Aniebue and Oseloka, 2009). Indian studies have found varied pathways to care. Sharma et al. (2007) reported a higher preference for spiritualists (38.2%) than psychiatrists (29.4%) in his study of treatment seeking behaviour of mentally ill in a rural area in Beri, India. To determine the changes over the last three decades in help seeking behaviour, a comparison was made of recent studies (Jilani et al., 2009; Lahariya et al., 2010) and the ones that were carried out three decades earlier at Lucknow (Trivedi and Sethi, 1979), regarding help seeking behaviour and pathways to care. It was found that despite the progress made by the country, faith healers are the first care providers for a majority of psychiatric patients, and they tend to seek help from both streams, or revert back at times to the faith healer. Direct access to psychiatric services is not a prominent pathway (Jilani et al., 2009; Trivedi and Sethi, 1979). Allopathic practitioners (51%), religious healers (26.9%) and mental health professionals (22.1%) were consulted in that order of frequency by 104 patients attending the outpatient clinic in a tertiary care hospital in Mysore, South India (Syed et al., 2012). Faith healers were found to be the most important portal of entry in a study done in a multi-speciality hospital in Jaipur on 60 patients attending the psychiatry department (Jain et al., 2012). In contrast to most other studies, a significantly larger number of patients in the current study (90%) sought the help of a medical professional for the first contact, predominantly at a general hospital, from a general practitioner or a psychiatrist. It is interesting to note that 39% of these patients first saw a psychiatrist, with only 6.3% seeking the help of faith healers. This indicates a high degree of awareness of the occurrence of psychiatric illnesses, a medical model for their occurrence, as also awareness about the availability of medical facilities for their care. The sample population being mostly urban and educated could explain this finding. Most other Indian studies, though hospital based, had a sample population that belonged mostly to the rural areas, with a larger number being illiterate in some of them. The choice of first consultation is generally based on factors specific to that population, though there are some common themes. Confidence of cure at the place of treatment (46.3%), ignorance of the existence of a mental health service (14.6%) and the belief that the mental condition was not amenable to orthodox treatment (8.1%), were the main reasons for the first treatment options in a Nigerian study (Aniebue and Oseloka, 2009). Treatment costs (49%) and confidentiality concerns (35.6%) have been reported as being barriers to obtaining specialist care (Syed et al., 2012). In the current study, 59% made the choice guided by care issues such as the treating doctor, consultation fee and the fact that the centre of care was a multi speciality hospital. It appears that trust in the treating physician is an important factor in their choice, which would be based on the past experience that they or others known to them must have had. This lays a great deal of responsibility on the physician to deliver his best in terms of quality of care, as well as be sensitive to refer the patient to the psychiatrist at the earliest. In the current study it was found that factors like affordability and availability of wholesome care under one roof, as in a general hospital influences treatment choice. 28% made the choice based
Please cite this article in press as: Prabhu, A., et al., Pathways to tertiary care adopted by individuals with psychiatric illness. Asian J. Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.06.005
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AJP-729; No. of Pages 4 A. Prabhu et al. / Asian Journal of Psychiatry xxx (2015) xxx–xxx
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on their personal likes of the facility, indicating the need for the patient to have a subjective ‘‘feel good’’ of the quality of care delivered to him (Chadda et al., 2000). About twenty one percent of the patients were influenced by environmental issues such as the location of the hospital and the popular opinion of individuals around them. Accessibility to health care is thus extremely important, as it influences choice of help seeking. The community at large being aware of available health care services guides the ‘‘help seeking behaviour’’ of the patients and their families. Approaching an agency as the first contact of care was influenced by individuals in the immediate environment of the patient. In almost 90% of the cases these influencers were closely associated with the patient, being a relative/friend in majority of the cases (73%). This appears to be the trend in most research done. In a study done in 1998 it was observed that 55.2% of the patients were guided in their choice of care by their spouse or relatives, while only 25% of them took their own initiative (Boey, 1998). The scenario in India too appears to be the same as the most common reason for the eventual visit to a neuropsychiatric hospital was advice by friends/relatives (44.8%) (Chadda et al., 2000; Sharma et al., 2007). This demonstrates that social networks play an extremely important role in decision making regarding care approach. Health education regarding recognising and understanding the nature of mental illnesses, and the availability of care, should thus target all members of the community. The pathway to psychiatric care has thus been found to be indirect at times with patients approaching faith healers and alternative systems of medicine, and more direct at times, with patients approaching medical help and even psychiatric help. Increasing awareness about the nature of psychiatric illnesses and the availability of psychiatric care must be the aim of public health education, in order to make the pathway to care more direct. The primary care physicians, as also those practicing alternative systems of medicine, must also be made aware of the need to identify patients with psychiatric illnesses so as to establish an effective and efficient referral system, reduce number of referrals, thereby preventing a delay in delivering appropriate care which will go a long way in improving the prognosis. References Alegria, M., Bijl, R.V., Lin, E., Walters, E.E., Kessler, R.C., 2000. Income differences in persons seeking outpatient treatment for mental disorders: a comparison of the
United States with Ontario and the Netherlands. Arch. Gen. Psychiatry 57, 383–391. Aniebue, P.C., Oseloka, K.C., 2009. Health seeking behaviour of mentally ill patients in Enugu, Nigeria. SAJP 15 (March (1)), 56–59. Banerjee, G., 1997. Help seeking behaviour and belief systems. Indian J. Soc. Psychiatry 13, 61–64. Bhugra, D., Thompson, N., Piracha, S., Kapoor, J., Oommen, G., Wing, J.C., 2003. Mental health of ethnic minority elders in West London: pathways into secondary care. Indian J. Psychiatry 45, 27–30. Boey, K.W., 1998. Help seeking pattern of psychiatric out patients in urban China. Int. J. Psychiatry Nurs. Res. 4, 433–443. Chadda, R.K., Aggarwal, V., Chandra, M., 2000. Help seeking behaviour of the psychiatric patients before seeking care at a mental hospital. Intern. J. Soc. Psychol. 47, 71–78. Fahad, A., Fahad, S., Hiba, R., Kamila, H., 2006. Relation of gender education and health seeking behaviour of the general population regarding psychiatric illness. J. Pak. Med. Assoc. 56 (9), 421–422. Fujisawa, D., Hashimoto, N., Masamune-Koizumi, Y., Otsuka, K., Tateno, M., Okugawa, G., et al., 2008. Pathway to psychiatric care in Japan: a multicenter observational study. Int. J. Ment. Health Syst. 2, 14. Gater, R.E., Almeida e Sousa, B., arrientos, G., Chandrashekar, C.R., Goldberg, D., al Kathiri, A.H., et al., 1991. The pathways to psychiatric care: a cross-cultural study. Psychol. Med. 21 (Aug (3)), 761–774 (WHO Encounter Form). Gater, R., Jordanova, V., Maric, N., Alikaj, V., Bajs, M., Cavic, T., et al., 2005. Pathways to psychiatric care in Eastern Europe. Br. J. Psychiatry 186, 529–535. Jain, N., Gautam, S., Jain, S., Gupta, I.D., VBatra, L., Sharma, R., Singh, H., 2012. Pathway to psychiatric care in a tertiary mental health facility in Jaipur, India. Asian J. Psychiatry 5 (Dec (4)), 303–308. Jilani, A.Q., Trivedi, J.K., Dalal, P.K., Dhyani, M., 2009. Pathway of care in first episode of non affective psychosis. Department of Psychiatry, CSMMU, Lucknow, India (Thesis submitted). Lahariya, C., Singhal, S., Gupta, S., Mishra, M., 2010. Pathway of care among psychiatric patients attending a mental health institution in Central India. IJP 52, 333–338. National Institute of Health and Family Welfare, 2005. National Mental Health Program. NIHFW, New Delhi Accessible form hhttp://www.nihfw.org/ndcnihfw/html/Programmes/National mental health.htmi (last accessed on 20/ 12/2014). Pradhan, S.C., Singh, M.M., Singh, R.A., et al., 2001. First care givers of mentally ill patients: a multicentre study. Indian J. Med. Sci. 55 (4), 203–208. Roger, L.H., Cortes, D.E., 1993. Help seeking pathways: a unifying concept in mental health care. AJP 150, 554–561. Sharma, P., Vorha, A.K., Khurana, H., 2007. Treatment seeking behaviour of mentally ill patients in a rural area. A cross sectional study. Indian J. Community Med. 32, 220–229. Steel, Z., McDonald, R., Silove, D., Bauman, A., Sandford, P., Herron, J., et al., 2006. Pathways to the first contact with specialist mental health care. ANZ J. Psychiatry 40, 347–354. Faizan, S., Raveesh, B.N., Ravindra, L.S., Sharath, K., 2012. US Psychiatry Congress Poster Session Abstract (In press). Trivedi, J.K., Sethi, B.B., 1979. A psychiatric study of traditional healers in Lucknow city. IJP 21, 133–137. World Health Organization, 1993. The ICD-10 Classification of Mental and Behavioural Disorders. Diagnostic Criteria for Research. World Health Organization, Geneva.
Please cite this article in press as: Prabhu, A., et al., Pathways to tertiary care adopted by individuals with psychiatric illness. Asian J. Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.06.005
AJP-729; No. of Pages 4 Asian Journal of Psychiatry xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Pathways to tertiary care adopted by individuals with psychiatric illness Ananya Prabhu a, G. Vishnu Vardhan b,*, Lakshmi V Pandit a a b
Kempegowda Institute of Medical Sciences, K R Road, Basavangudi, Bangalore 560004, India Raja Rajeshwari Medical College and Hospital, Kambi pura, Mysore Road, Bangalore, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 May 2015 Received in revised form 7 May 2015 Accepted 20 June 2015 Available online xxx
Awareness of mental illness as a cause of morbidity is increasing the world over. Of the top ten causes of disability, five are psychiatric illnesses. Availability and accessibility of psychiatrists as well as treatment facilities is meagre, making pathways to psychiatric care tortuous hence delayed, affecting outcomes negatively. With an attempt to study the pathways to psychiatric care, a cross sectional study was undertaken, on 63 consecutive first contact patients in tertiary care centre in Bangalore, India. Socio demographic details, time taken to reach professional help, and reasons for delay were noted. Pathways to care were recorded using ‘WHO pathways to care’ proforma. One third of the study population were aged between 31 and 45 years, mostly Hindus. Two thirds of them had received about 10 years of formal education, hailed from urban areas and lived in nuclear families. Majority sought help from trained medical professionals, with almost 40% seeking psychiatric help initially itself. While the choice of consultation was influenced by people in the immediate environment, that of first contact was based on the physician or treating facility. Almost 57% had more than two referrals before reaching the tertiary care centre. Though the urban educated population are well aware of the nature of psychiatric illnesses, need for medical intervention and its availability, there was a delay in seeking help from a tertiary psychiatric centre. There is thus a need to educate medical professionals about timely referral to these centres, as early and appropriate interventions result in a favourable outcome. ß 2015 Elsevier B.V. All rights reserved.
Keywords: Pathways to care First contact Choice of treatment Tertiary psychiatric care
1. Introduction ‘Awareness’ of mental illness as a significant cause of morbidity is increasing worldwide, caused by the steady decline of morbidity due to nutritional disorders, communicable diseases and other forms of physical illness, especially in countries undergoing epidemiological transitions (shift in epidemiological attention from communicable diseases, malnutrition and problems associated with pregnancy and childbirth, to chronic non communicable diseases) (Fahad et al., 2006). A significant disease burden is attributable to mental illness globally. Out of the top ten leading causes of disability throughout the world, five are psychiatric illnesses (Banerjee, 1997), and six
* Corresponding author. Tel.: +91 9845211970. E-mail addresses: [email protected] (A. Prabhu), [email protected] (G. Vishnu Vardhan), [email protected] (L.V. Pandit).
neuropsychiatric conditions have figured in the top 20 (Trivedi and Sethi, 1979). According to WHO, mental illnesses account for 11.5% of the global burden of disease—a figure that is projected to increase to 15% by 2020. Majority of those with mental illnesses live in the developing world (Pradhan et al., 2001) approximately half of them are living in the Asia Pacific regions (Syed et al., 2012). It is estimated that, at any point in time, in India, 2–5% of the population is suffering from serious mental illnesses, and 10% from minor mental illnesses (National Institute of Health and Family Welfare (NIHFW), 2005). Prevalence rates of psychiatric disorders in India range from 9.5 to 370/1000 population (Jilani et al., 2009; Lahariya et al., 2010). The number of psychiatric beds in the country is only about 0.2/one lakh population and there are two psychiatrists per ten lakh population (Roger and Cortes, 1993), mostly concentrated in the metropolitan and the urban areas (Sharma et al., 2007). Professional psychiatric help thus being non available, it is only understandable that the path leading to it is long, punctuated by
http://dx.doi.org/10.1016/j.ajp.2015.06.005 1876-2018/ß 2015 Elsevier B.V. All rights reserved.
Please cite this article in press as: Prabhu, A., et al., Pathways to tertiary care adopted by individuals with psychiatric illness. Asian J. Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.06.005
G Model
AJP-729; No. of Pages 4 A. Prabhu et al. / Asian Journal of Psychiatry xxx (2015) xxx–xxx
2
penury, stigma, and superstitions associated with mental illness, coupled with an unwillingness or inability of families to care for their mentally ill relatives (Jain et al., 2012). In addition, only a minority of individuals attribute their illness to psychological causes, prompting them to seek help from faith healers, with a few seeking the help of general practitioners before approaching a psychiatrist. The first line of treatment for the mentally ill constitutes the most important stage of psychiatric care. It thus becomes important to understand pathways to care so as to be able to ensure that those individuals with mental illnesses have direct access to professional help. The current study is thus undertaken with an aim to trace the pathway taken by the mentally ill to reach professional care, and elicit the factors responsible for their choice of help seeking.
Table 1 Depicting the socio-demographic details of the patients. Socio-demographic details
Numbers (N = 63)
Percentage (%)
Age 30 years
27 36
42.8 57.2
Gender Male Female
34 29
54 46
Marital status Unmarried/widowed Married
21 42
33.3 66.7
Education Educated Uneducated
38 25
60.3 39.7
Occupation Unemployed/student Employed
36 27
57.1 42.9
Residence Rural Urban
16 47
25.4 74.6
Family type Joint Nuclear
18 45
28.6 71.4
Income 10,000
41 22
65.1 34.9
2. Material and methods As the aim of the study was to trace the pathways taken by the mentally ill to reach professional psychiatric help and to delineate the factors influencing the same, a cross sectional study was designed and consecutive patients presenting to the department of psychiatry in a tertiary care hospital, located in the city of Bangalore, India, during a period of three months (June to August 2013) were recruited. After obtaining clearance and approval from the institutional ethics committee, 68 patients and their relatives, aged above 18 years were included in this study. A written consent was obtained from both the patients and their relatives. All patients were diagnosed using ICD-10(DCR) (World Health Organization, 1993) and only patients presenting to us for the first time were included. A total of 68 patients fulfilled the inclusion criteria, of whom three were unable to complete the study and two of them were residents of a destitute home with no relatives, hence the results are based on the data of 63 patients. The time taken to reach professional help was noted, being defined as the time between onset of illness as described by the informant and the current consultation. Details of the chosen pathways and reasons for the same were collected as reported by the informant as well as the patient where relevant. Socio demographic details were obtained by a proforma developed for the study, while pathways to care were recorded using the ‘WHO pathway to care proforma’ developed by Gater et al. (1991). To avoid bias, all the interviews (lasting for about one hour each) were conducted by a single well trained psychiatrist, who had the previous experience of working with the study instruments. 3. Results 3.1. Sociodemographic details 36.5% of the study population were aged between 31 and 45 years, with 54% of them being males. Majority of them were Hindus (95%), with 60% having had 10 years or more of formal education. They hailed from urban areas (75%) and lived mostly in nuclear families (70%) 40% were unemployed while 36% had a monthly income of between five and ten thousand per month (Table 1). 3.2. Tracing the pathway Half the study population had an onset of illness more than five years ago. A small percentage of the patient population approached a native healer as first contact of care (6.3%) while a large majority of them sought trained medical help for initial consultation (90%), with 39% of these patients having approached a psychiatrist initially (Table 2). It was found that on an average it took the patients 69.3 months to reach tertiary psychiatric care (Table 3).
The choice for the first consultation was influenced by either a relative or a friend in 73% of the patients, while only 11.1% of the patients made the choice themselves (Table 4). Majority of them (59%) made their choice based on care related issues such as faith in the consulting physician, previous experience with the treating facility, and the preference for a multi speciality hospital. Some made their choice based on their personal likes for the hospital/ clinic (28.5%), while others (21%) based their decision on environmental factors such as location, affordability, referral practices of their local doctors and the opinion of those around them. 27% of them had a single referral before reaching trained professional help, while 35% had two and 22% had three referrals. Table 2 Depicting the first contact of care. Help sought from
N = 63
Native healer Medical practitioner (GP) Gen. Hospital Psychiatrist Ayurveda/homeopathy Others
4 21 14 22 1 1
Total
63
Percentage (%) 6.3 33.3 22.2 35 1.6 1.6 100
Please cite this article in press as: Prabhu, A., et al., Pathways to tertiary care adopted by individuals with psychiatric illness. Asian J. Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.06.005
G Model
AJP-729; No. of Pages 4 A. Prabhu et al. / Asian Journal of Psychiatry xxx (2015) xxx–xxx Table 3 Indicating the time taken by the psychiatrically ill to reach the tertiary care centre. Time period from the onset of illness
Number of patients (N = 63)
Percentage (%)
Less than 1 month 1 month to 1 year 1 year to 5 years More than 5 years Total
16 9 17 21 63
25.4 14.3 26.9 33.3 100
The average time spent by a psychiatrically ill patient is 69.36 months before reaching a tertiary care centre.
Table 4 Depicting who influenced the choice of first contact of care. Choice influenced by
N = 63
Relative/friend Patients own choice Others
46 7 10
Total
63
Percentage (%) 73 11.1 15.9 100
4. Discussion The pathway that patients adopt to reach the appropriate treatment centre is termed as the ‘‘Pathway of Care’’. These pathways indicate psychosocial and cultural factors that influence help seeking behaviour (Roger and Cortes, 1993) and studying them aids in understanding how health services are utilized. It is important to understand them in the context of psychiatric illnesses, so as to be able to make the pathway to professional help more direct, thereby reducing the duration of untreated illness, a significant parameter in deciding the prognosis. Though the study was carried out on 68 patients, the results are derived from the 63 patients and their care givers, who could complete the study, A small sample thus preventing generalization of the findings. They were mostly aged between 31 and 45 years, the most productive part of their lives, which probably influenced them being brought for psychiatric care. Hailing largely from urban areas, they were educated up to secondary level or beyond. Both these factors have been found to positively influence the pathways to care. In various studies, a higher level of education, living in an urban setting and attributing mental illness to a rational cause were found to be significantly associated with approaching specialist care as the first option (Banerjee, 1997; Fahad et al., 2006; Pradhan et al., 2001). Greater superstitions about mental illness, rural residence, and lower educational attainment influenced approaching religious healers (Sharma et al., 2007). Male respondents were more likely to receive psychiatric care at first contact than the females (Banerjee, 1997; Fahad et al., 2006; Pradhan et al., 2001). In the current population, however, both genders were equally represented, probably as a very large part of the population were from the urban areas (75%). Approach to health care systems varies across different countries, being totally governed by the health delivery systems of that country. 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 mental health professionals, while the rest consult the general medical sector (Alegria et al., 2000). In the United Kingdom, all patients first need to go to their general practitioner (Bhugra et al., 2003; Gater et al., 1991), whereas in the East European countries, about one third access the psychiatrist directly (Gater et al., 2005). 40% of Japanese patients reach psychiatrists directly, while the others are referred by private practitioners or by other specialists in general hospitals (Fujisawa et al., 2008). An Australian study
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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, and the median time to reach specialist help was six months, with a shorter time for patients with psychotic disorders (Steel et al., 2006); 53% of patients initially consult a general practitioner (Steel et al., 2006). Similar studies carried out in the developing countries like Nigeria, revealed that, the prayer house (34.5%), followed by a psychiatric hospital (32%), private clinic (15.9%), or a traditional healer (13.6%), were the treatment options employed in that order by mentally ill patients (Aniebue and Oseloka, 2009). Indian studies have found varied pathways to care. Sharma et al. (2007) reported a higher preference for spiritualists (38.2%) than psychiatrists (29.4%) in his study of treatment seeking behaviour of mentally ill in a rural area in Beri, India. To determine the changes over the last three decades in help seeking behaviour, a comparison was made of recent studies (Jilani et al., 2009; Lahariya et al., 2010) and the ones that were carried out three decades earlier at Lucknow (Trivedi and Sethi, 1979), regarding help seeking behaviour and pathways to care. It was found that despite the progress made by the country, faith healers are the first care providers for a majority of psychiatric patients, and they tend to seek help from both streams, or revert back at times to the faith healer. Direct access to psychiatric services is not a prominent pathway (Jilani et al., 2009; Trivedi and Sethi, 1979). Allopathic practitioners (51%), religious healers (26.9%) and mental health professionals (22.1%) were consulted in that order of frequency by 104 patients attending the outpatient clinic in a tertiary care hospital in Mysore, South India (Syed et al., 2012). Faith healers were found to be the most important portal of entry in a study done in a multi-speciality hospital in Jaipur on 60 patients attending the psychiatry department (Jain et al., 2012). In contrast to most other studies, a significantly larger number of patients in the current study (90%) sought the help of a medical professional for the first contact, predominantly at a general hospital, from a general practitioner or a psychiatrist. It is interesting to note that 39% of these patients first saw a psychiatrist, with only 6.3% seeking the help of faith healers. This indicates a high degree of awareness of the occurrence of psychiatric illnesses, a medical model for their occurrence, as also awareness about the availability of medical facilities for their care. The sample population being mostly urban and educated could explain this finding. Most other Indian studies, though hospital based, had a sample population that belonged mostly to the rural areas, with a larger number being illiterate in some of them. The choice of first consultation is generally based on factors specific to that population, though there are some common themes. Confidence of cure at the place of treatment (46.3%), ignorance of the existence of a mental health service (14.6%) and the belief that the mental condition was not amenable to orthodox treatment (8.1%), were the main reasons for the first treatment options in a Nigerian study (Aniebue and Oseloka, 2009). Treatment costs (49%) and confidentiality concerns (35.6%) have been reported as being barriers to obtaining specialist care (Syed et al., 2012). In the current study, 59% made the choice guided by care issues such as the treating doctor, consultation fee and the fact that the centre of care was a multi speciality hospital. It appears that trust in the treating physician is an important factor in their choice, which would be based on the past experience that they or others known to them must have had. This lays a great deal of responsibility on the physician to deliver his best in terms of quality of care, as well as be sensitive to refer the patient to the psychiatrist at the earliest. In the current study it was found that factors like affordability and availability of wholesome care under one roof, as in a general hospital influences treatment choice. 28% made the choice based
Please cite this article in press as: Prabhu, A., et al., Pathways to tertiary care adopted by individuals with psychiatric illness. Asian J. Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.06.005
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on their personal likes of the facility, indicating the need for the patient to have a subjective ‘‘feel good’’ of the quality of care delivered to him (Chadda et al., 2000). About twenty one percent of the patients were influenced by environmental issues such as the location of the hospital and the popular opinion of individuals around them. Accessibility to health care is thus extremely important, as it influences choice of help seeking. The community at large being aware of available health care services guides the ‘‘help seeking behaviour’’ of the patients and their families. Approaching an agency as the first contact of care was influenced by individuals in the immediate environment of the patient. In almost 90% of the cases these influencers were closely associated with the patient, being a relative/friend in majority of the cases (73%). This appears to be the trend in most research done. In a study done in 1998 it was observed that 55.2% of the patients were guided in their choice of care by their spouse or relatives, while only 25% of them took their own initiative (Boey, 1998). The scenario in India too appears to be the same as the most common reason for the eventual visit to a neuropsychiatric hospital was advice by friends/relatives (44.8%) (Chadda et al., 2000; Sharma et al., 2007). This demonstrates that social networks play an extremely important role in decision making regarding care approach. Health education regarding recognising and understanding the nature of mental illnesses, and the availability of care, should thus target all members of the community. The pathway to psychiatric care has thus been found to be indirect at times with patients approaching faith healers and alternative systems of medicine, and more direct at times, with patients approaching medical help and even psychiatric help. Increasing awareness about the nature of psychiatric illnesses and the availability of psychiatric care must be the aim of public health education, in order to make the pathway to care more direct. The primary care physicians, as also those practicing alternative systems of medicine, must also be made aware of the need to identify patients with psychiatric illnesses so as to establish an effective and efficient referral system, reduce number of referrals, thereby preventing a delay in delivering appropriate care which will go a long way in improving the prognosis. References Alegria, M., Bijl, R.V., Lin, E., Walters, E.E., Kessler, R.C., 2000. Income differences in persons seeking outpatient treatment for mental disorders: a comparison of the
United States with Ontario and the Netherlands. Arch. Gen. Psychiatry 57, 383–391. Aniebue, P.C., Oseloka, K.C., 2009. Health seeking behaviour of mentally ill patients in Enugu, Nigeria. SAJP 15 (March (1)), 56–59. Banerjee, G., 1997. Help seeking behaviour and belief systems. Indian J. Soc. Psychiatry 13, 61–64. Bhugra, D., Thompson, N., Piracha, S., Kapoor, J., Oommen, G., Wing, J.C., 2003. Mental health of ethnic minority elders in West London: pathways into secondary care. Indian J. Psychiatry 45, 27–30. Boey, K.W., 1998. Help seeking pattern of psychiatric out patients in urban China. Int. J. Psychiatry Nurs. Res. 4, 433–443. Chadda, R.K., Aggarwal, V., Chandra, M., 2000. Help seeking behaviour of the psychiatric patients before seeking care at a mental hospital. Intern. J. Soc. Psychol. 47, 71–78. Fahad, A., Fahad, S., Hiba, R., Kamila, H., 2006. Relation of gender education and health seeking behaviour of the general population regarding psychiatric illness. J. Pak. Med. Assoc. 56 (9), 421–422. Fujisawa, D., Hashimoto, N., Masamune-Koizumi, Y., Otsuka, K., Tateno, M., Okugawa, G., et al., 2008. Pathway to psychiatric care in Japan: a multicenter observational study. Int. J. Ment. Health Syst. 2, 14. Gater, R.E., Almeida e Sousa, B., arrientos, G., Chandrashekar, C.R., Goldberg, D., al Kathiri, A.H., et al., 1991. The pathways to psychiatric care: a cross-cultural study. Psychol. Med. 21 (Aug (3)), 761–774 (WHO Encounter Form). Gater, R., Jordanova, V., Maric, N., Alikaj, V., Bajs, M., Cavic, T., et al., 2005. Pathways to psychiatric care in Eastern Europe. Br. J. Psychiatry 186, 529–535. Jain, N., Gautam, S., Jain, S., Gupta, I.D., VBatra, L., Sharma, R., Singh, H., 2012. Pathway to psychiatric care in a tertiary mental health facility in Jaipur, India. Asian J. Psychiatry 5 (Dec (4)), 303–308. Jilani, A.Q., Trivedi, J.K., Dalal, P.K., Dhyani, M., 2009. Pathway of care in first episode of non affective psychosis. Department of Psychiatry, CSMMU, Lucknow, India (Thesis submitted). Lahariya, C., Singhal, S., Gupta, S., Mishra, M., 2010. Pathway of care among psychiatric patients attending a mental health institution in Central India. IJP 52, 333–338. National Institute of Health and Family Welfare, 2005. National Mental Health Program. NIHFW, New Delhi Accessible form hhttp://www.nihfw.org/ndcnihfw/html/Programmes/National mental health.htmi (last accessed on 20/ 12/2014). Pradhan, S.C., Singh, M.M., Singh, R.A., et al., 2001. First care givers of mentally ill patients: a multicentre study. Indian J. Med. Sci. 55 (4), 203–208. Roger, L.H., Cortes, D.E., 1993. Help seeking pathways: a unifying concept in mental health care. AJP 150, 554–561. Sharma, P., Vorha, A.K., Khurana, H., 2007. Treatment seeking behaviour of mentally ill patients in a rural area. A cross sectional study. Indian J. Community Med. 32, 220–229. Steel, Z., McDonald, R., Silove, D., Bauman, A., Sandford, P., Herron, J., et al., 2006. Pathways to the first contact with specialist mental health care. ANZ J. Psychiatry 40, 347–354. Faizan, S., Raveesh, B.N., Ravindra, L.S., Sharath, K., 2012. US Psychiatry Congress Poster Session Abstract (In press). Trivedi, J.K., Sethi, B.B., 1979. A psychiatric study of traditional healers in Lucknow city. IJP 21, 133–137. World Health Organization, 1993. The ICD-10 Classification of Mental and Behavioural Disorders. Diagnostic Criteria for Research. World Health Organization, Geneva.
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