Where are patients who have co-occurring mental and physical diseases located?

Abstract

Background:

Patients with a psychiatric illness have a higher prevalence of physical diseases and thus a higher morbidity and mortality.

Aim:

The main aim was to investigate where patients with co-occurring physical diseases and mental disorders (psychotic spectrum or mood) in the health and social service system are identified most frequently before admission into psychiatry. The second aim was to compare the differences in the treatment routes taken by the patients before entry into psychiatric services in all the participating countries (Denmark, Germany, Japan, Nigeria and Switzerland).

Methodology:

On admission to a psychiatric service, patients diagnosed with schizophrenia, schizotypal or delusional disorders (International Classification of Diseases-10 (ICD-10) group F2) or mood (affective) disorders (ICD-10 group F3) and a co-morbid physical condition (cardiovascular disease, diabetes mellitus and overweight) were asked with which institutions or persons they had been in contact with in the previous 6 months.

Results:

Patients from Denmark, Germany and Switzerland with mental disorders had almost the same contact pattern. Their primary contact was to public or private psychiatry, with a contact percentage of 46%–91%; in addition, general practice was a common contact, with a margin of 41%–93%. Similar tendencies are seen in Japan despite the small sample size. With regard to general practice, this is also the case with Nigerian patients. However, religious guidance or healing was rarely sought by patients in Europe and Japan, while in Nigeria about 80% of patients with mental disorders had contacted this type of service.

Conclusion:

Promoting prophylactic work between psychiatry and the general practice sector may be beneficial in diminishing physical conditions such as cardiovascular disease, diabetes mellitus and overweight in patients with mental disorders in European countries and Japan. In Nigeria (a low-to-middle-income country), religious guides or healers, along with general practitioners, are the most frequently contacted, and they therefore seem to be the most obvious partner to collaborate with.

Keywords

Pathway to care collaboration physical disease psychiatric illness

Introduction

Patients with ongoing psychiatric disorders are known to have a higher somatic morbidity (Smith, Langan, McLean, Guthrie, & Mercer, 2013; Truyers et al., 2011) and mortality (Harris & Barraclough, 1998; Saha, Chant, & McGrath, 2007), than the background population.

A number of reasons have been suggested to explain this observation. Some patients with schizophrenia (up to 45% in some cases) have negative symptoms that prevent them from having contact with the health system compared with the general population. Negative symptoms are associated with social withdrawal and a higher incidence of cognitive dysfunction, which might make it difficult for patients to contact health centres (Bowie & Harvey, 2005; Malla et al., 2004; Malla et al., 2002; Pogue-Geile & Harrow, 1985). Another important factor for less contact with the health system may, perhaps, be related to the stigma the patients fear from family, friends and mental health staff (Harangozo et al., 2013; Pescosolido et al., 2010; Schomerus et al., 2012).

In general, patients with schizophrenia have an unhealthier lifestyle (Brown, Birtwistle, Roe, & Thompson, 1999; Dipasquale et al., 2013), for example, using substances three to four times more frequently than the background population (Mazzoncini et al., 2010). This is also true for patients with unipolar depression (Berk, Sarris, Coulson, & Jacka, 2013). One review showed that people with schizophrenia have a higher prevalence of several physical diseases such as cardiovascular disease (CVD), overweight (OW) and diabetes mellitus (DM) than the general population (Leucht, Burkard, Henderson, Maj, & Sartorius, 2007). Patients’ health behaviour must be taken into consideration when trying to identify the reason for these findings (Kilian, Becker, Krüger, Schmid, & Frasch, 2006).

A recent review, covering depression, shows a topographical map of causal network between, for example, genetic factors, social isolation, omega-3 fatty acid deficiency and increased inflammatory cytokines, connecting major depressive disorders with coronary heart disease (Stapelberg, Neumann, Shum, McConnell, & Hamilton-Craig, 2011). Coronary heart disease in patients with depression has been the subject of intense investigation. In one study, the authors found a higher correlation with acute myocardial infarction in patients with depression than in the background population (Janszky, Ahlbom, Hallqvist, & Ahnve, 2007). In a 40-year follow-up study, the Iowa study showed that there was an increased mortality in patients with major mental disorders, including schizophrenia, depression and mania, caused not only by suicide, which was an important contributor to mortality in the study (Castagnini, Foldager, & Bertelsen, 2013), but also by somatic diseases such as infections (Simpson & Tsuang, 1996).

In a previous paper, we reported an increased prevalence rate ratio of CVD, OW and DM in patients with schizophrenia, schizotypal and delusional disorders (International Classification of Diseases-10 (ICD-10) group F2), or mood (affective) disorders (ICD-10 group F3; Larsen et al., 2013). In brief, over a period of 1 year, we included patients with mental disorders (ICD-10 group F2) or mood (affective) disorders (ICD-10 group F3) presenting to hospital psychiatric services in the participating centres for the first time. Details of physical illnesses and pathways taken to access the services were assessed. We identified the health and social services where the patients with mental disorders co-occurring with physical diseases most frequently presented within the 6 months prior to contact with hospital psychiatric treatment.

Previous studies have reported different pathways to psychiatric care in both developed and developing countries. Most of these studies show that patients with mental disorders often first contact general practice and/or mental health professionals.

This is the tendency in Europe and other Western countries. In low- and middle-income countries such as Nigeria and Malaysia, most patients with mental disorders are found to have initial contacts with religious guides and/or healers (Abiodun, 1995; Razali & Najib, 2000). However, one South African study found that general practice was used as the first contact in 38% of first-episode psychiatric illness (Temmingh & Oosthuizen, 2008). Overall, general practitioners, psychiatrists in private practice, mental health professionals, hospitals, family members, close friends and native healers have often been reported to be frequent points of contact (Burnett et al., 1999; Fridgen et al., 2013; Fuchs & Steinert, 2004; Gater & Goldberg, 1991; Gater et al., 1991; Lincoln, Harrigan, & McGorry, 1998; Platz et al., 2006; Steel et al., 2006; Stowkowy, Colijn, & Addington, 2013).

Previous studies are without any information about the physical health status of those patients. It is not clear to what extent, if at all, those patients also had co-morbid physical illnesses. It is also not clear if patients with co-occurring physical illnesses and mental disorders take the same trajectory to psychiatric services as patients who have only mental disorders. Given that physical illnesses complicating mental disorders lead to increased morbidity and mortality, locating the initial contacts of such patients has preventive and treatment implications.

If patients who have mental disorders and somatic diseases are known to have regular and frequent initial contacts with particular sectors or sections of the health service system, it would be mutually beneficial for psychiatric services to collaborate with such institutions. This way, prompt interventions and referrals can be instituted.

Here, we report on the health and social service systems where patients with co-occurring physical illnesses and mental disorders most often contact before admission to psychiatric services in centres in Africa, Asia and Europe.

Aims of the study

The aims of the study were to investigate where in the health and social service systems patients with schizophrenia, schizotypal and delusional disorders (ICD-10 group F2) or mood (affective) disorders (ICD-10 group F3) and a co-morbid physical condition are likely to be located, before admission into psychiatry. The physical conditions examined were CVD, DM and/or OW. We also aimed to compare differences in routes taken by patients in the participating five countries (Nigeria, Japan, Denmark, Germany and Switzerland).

Methods

The study was performed over a period of 1 year in five countries: Nigeria, Japan, Denmark, Germany and Switzerland. We recruited participants from inpatient wards, outpatient clinics in psychiatric hospitals, psychiatry departments in general hospitals and community centres.

All patients admitted to a treatment centre over the 1-year period were invited to participate. Patients admitted more than once during the inclusion period were only counted at their first admission. Detailed physical and mental state examinations were conducted, and all diagnoses and coding were based on the ICD-10 research criteria (WHO, 1992). World Health Organization (1992) The ICD-10 Classification of Mental and Behavioural Disorders: Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization. Diagnoses were given by the responsible treating psychiatric specialist based on all the available information about health status at discharge or after 3 months if not yet discharged. The investigation period for each patient ended at discharge or, at the latest, 3 months after admission. The patients were treated following routines of the department and according to procedures of general good clinical practice. Schizophrenia, schizotypal or delusional disorders (ICD-10 group F2), or mood (affective) disorders (ICD-10 group F3) were included. Diagnoses of physical illness, for example, CVD and DM, were coded according to the ICD-10 criteria for ‘heart failure’, ‘ischemic heart disease’ and ‘angina pectoris’ (either current or historic). OW was defined as having a body mass index ≥ 25. The patients were interviewed about which health and/or social service institutions and/or persons they had been in contact with during the 6 months before intake in the psychiatric services of the participating centres.

The options were social care (sheltered housing, drop-in centres or other social institutions, other parts of the social system, social worker/support teacher), psychiatry (private practice psychiatrist or psychiatric department), somatic specialist (or somatic department), general practice and religious guidance and healing. Further details of the study have been reported previously (Frasch et al., 2012; Larsen et al., 2013).

Statistical analyses

The prevalence rates for patients diagnosed with schizophrenia, schizotypal and delusional disorders (ICD-10 group F2) or mood (affective) disorders (ICD-10 group F3) co-occurring with a physical illness to contact one of the above-listed health and social services were calculated with 95% confidence intervals (CIs).

Using health and social services as the outcome variable, and country as the explanatory variable, we carried out a logistic regression, stratifying the participants by age and sex. We used Denmark as the reference because it had the highest number of included probands, and calculated the odds ratios (ORs) for all the participating centres. All tests were two tailed, with a p-value < 0.05 indicating significance. We used STATA version 12 for the data analysis (StataCorp, College Station, TX, USA).

Results

Schizophrenia, schizotypal or delusional disorders (ICD-10 group F2) with CVD, DM and/or OW

Of this group, 65% were diagnosed with a schizophrenic illness and the rest had other forms of nonaffective psychosis (Table 1). Of the participating patients with F2 disorders, 32.5% reported that they had been in contact with one institution, 34.0% with two institutions and 29.9% with three or more institutions.

Table 1.

Schizophrenia, schizotypal and delusional disorders (International Classification of Diseases-10 group F2) with cardiovascular disease (CVD), diabetes mellitus (DM) and/or overweight (OW). Contact to services within the 6 months previous of the present admission.

Denmark	Presence of CVD, DM and/or OW	Total no. of patients with an F2 diagnosis	%	95% CI
Social care (s1)	43	59	72.9	61.5–84.2
Psychiatry (s2)	51	64	79.7	69.8–89.5
Somatic specialists (s3)	15	52	28.9	16.5–41.2
General practitioners (s4)	35	52	67.3	54.6–80.1
Religious and healing (s5)	2	48	4.2	0.0–09.8
Germany
Social care (s1)	26	56	46.4	33.4–59.5
Psychiatry (s2)	52	57	91.2	83.9–98.6
Somatic specialists (s3)	19	50	38.0	24.6–51.5
General practitioners (s4)	24	55	43.6	30.5–56.7
Religious and healing (s5)	1	50	2.0	0.0–5.9
Switzerland
Social care (s1)	2	19	10.5	0.0–24.3
Psychiatry (s2)	14	19	73.7	53.9–93.5
Somatic specialists (s3)	4	19	21.1	2.7–39.4
General practitioners (s4)	8	19	42.1	19.9–64.3
Religious and healing (s5)	0	19	0.0	–
Nigeria
Social care (s1)	1	51	2.0	0.0–5.8
Psychiatry (s2)	3	51	5.9	0.0–12.3
Somatic specialists (s3)	14	51	27.5	15.2–39.7
General practitioners (s4)	24	51	47.1	33.4–60.8
Religious and healing (s5)	38	50	76.0	64.2–87.8
Japan
Social care (s1)	0	3	0	–
Psychiatry (s2)	2	3	66.7	13.3–100
Somatic specialists (s3)	1	3	33.3	0.0–86.7
General practitioners (s4)	2	3	66.7	13.3–100
Religious and healing (s5)	1	3	33.3	0.0–86.7

The results showed that patients from the European countries most often used psychiatry and general practice, and almost none sought religious guidance or healing. The opposite was seen in Nigeria, where almost all of patients sought religious guidance and healing and only a few contacted psychiatry. The number of patients with schizophrenia from Japan was too small to determine a significant profile, with only three patients meeting the criteria.

Mood (affective) disorders (ICD-10 group F3) with CVD, DM and/or OW

Out of every 10 patients in the mood disorders group, 7 (73%) were diagnosed with depression, and the rest suffered from other affective disorders (Table 2). Of the participating patients with F3 disorders, 32.3% reported that they had been in contact with one institution, 37.7% with two institutions and 25.6% with three or more institutions.

Table 2.

Mood (affective) disorders (International Classification of Diseases-10 group F3) with cardiovascular disease (CVD), diabetes mellitus (DM) and/or overweight (OW). Contact to services within 6 months previous to present admission.

Denmark	Presence of CVD, DM and/or OW	Total no. of patients with an F2 diagnosis	%	95% CI
Social care (s1)	28	71	39.4	28.1–50.8
Psychiatry (s2)	33	72	45.8	34.3–57.3
Somatic specialists (s3)	25	70	35.7	24.5–46.9
General practitioners (s4)	62	67	92.5	86.2–98.8
Religious and healing (s5)	4	63	6.4	0.3–12.4
Germany
Social care (s1)	15	68	22.1	12.2–31.9
Psychiatry (s2)	53	69	76.8	66.9–86.8
Somatic specialists (s3)	35	65	53.9	41.7–66.0
General practitioners (s4)	50	68	73.5	63.0–84.0
Religious and healing (s5)	3	60	5.0	0.0–10.5
Switzerland
Social care (s1)	3	29	10.3	0.0–21.4
Psychiatry (s2)	15	29	51.7	33.5–69.9
Somatic specialists (s3)	7	29	24.1	8.6–39.7
General practitioners (s4)	12	29	41.4	23.5–59.3
Religious and healing (s5)	0	29	0.0	–
Nigeria
Social care (s1)	0	31	0	–
Psychiatry (s2)	4	31	12.9	1.1–24.7
Somatic specialists (s3)	7	31	22.6	7.9–37.3
General practitioners (s4)	13	31	41.9	24.6–59.3
Religious and healing (s5)	25	31	80.7	66.7–94.6
Japan
Social care (s1)	1	19	5.3	0.0–15.3
Psychiatry (s2)	18	19	94.7	84.7–100
Somatic specialists (s3)	8	19	42.1	19.9–64.3
General practitioners (s4)	5	19	26.3	6.5–46.1
Religious and healing (s5)	0	19	0.0	–

The patients with a mood disorder had the same contact pattern as patients diagnosed with schizophrenia. Looking at the patients from Japan showed that 18 of 19 patients had been in contact with psychiatry and none had sought religious guidance or healing.

Transcultural pattern

We compared the five countries by calculating ORs stratified for age and sex. We used Denmark as the reference (Tables 3 and 4).

Table 3.

Schizophrenia, schizotypal and delusional disorders (International Classification of Diseases-10 group F2), with cardiovascular disease, diabetes mellitus and/or overweight. Contact to services within 6 months previous to present admission. Logistic regression stratified by age and sex. Denmark is used as the reference country.

F2	Country, OR (95% CI)
Contact with	Germany	Switzerland	Nigeria	Japan
Social care (s1)	0.30 (0.14–0.67)	0.04 (0.01–0.19)	0.01 (0.00–0.05)	NA*
Psychiatry (s2)	2.88 (0.94–8.81)	0.68 (0.20–2.27)	0.01 (0.00–0.05)	0.38 (0.03–4.77)
Somatic specialists (s3)	1.49 (0.65–3.44)	0.69 (0.20–2.46)	0.98 (0.41–2.33)	1.39 (0.11–16.90)
General practitioners (s4)	0.38 (0.17–0.84)	0.39 (0.13–1.16)	0.46 (0.20–1.04)	0.10 (0.08–12.09)
Religious and healing (s5)	0.53 (0.05–6.10)	NA*	72.66 (15.04–351.05)	8.35 (0.50–140.17)

OR: odds ratio; CI: confidence interval; NA*: not applicable.

Cells highlighted in green indicate statistically significant results.

Table 4.

Mood (affective) disorders (International Classification of Diseases-10 group F3), with cardiovascular disease, diabetes mellitus and/or overweight. Contact to services within 6 months previous to present admission. Logistic regression, stratified by age and gender. Denmark is used as reference-country.

F3	Country, OR (95% CI)
Contact with:	Germany	Switzerland	Nigeria	Japan
Social care (s1)	0.41 (0.19–0.88)	0.17 (0.05–0.63)	NA*	0.09 (0.01–0.71)
Psychiatry (s2)	3.80 (1.82–7.93)	1.30 (0.54–3.12)	0.14 (0.04–0.45)	24.27 (3.03–194.52)
Somatic specialists (s3)	2.23 (1.10–4.52)	0.55 (0.20–1.49)	0.65 (0.24–1.79)	1.20 (0.42–3.43)
General practitioners (s4)	0.21 (0.07–0.62)	0.05 (0.02–0.17)	0.07 (0.02–0.23)	0.02 (0.01–0.10)
Religious and healing (s5)	0.76 (0.16–3.66)	NA*	49.92 (12.74–195.60)	NA*

OR: odds ratio; CI: confidence interval; NA*: not applicable.

Cells highlighted in green indicate statistically significant results.

Schizophrenia, schizotypal or delusional disorders (ICD-10 group F2) with CVD, DM and/or OW

Using Denmark as the reference country, comparison of the four other countries showed that for patients diagnosed with an F2 disorder, Nigerian patients were 73 times more likely to seek religious guidance or healing (OR 72.66, 95% CI 15.04–351.05).

General practice was contacted fewer by patients in Germany than in Denmark (OR 0.38, 95% CI 0.17–0.84). This was also the case in Switzerland (OR 0.39, 95% CI 0.13–1.16) and Nigeria (OR 0.46, 95% CI 0.20–1.04); however, the ORs are not significantly different from Denmark.

In Switzerland (OR 0.04, 95% CI 0.01–0.19), Nigeria (OR 0.01, 95% CI 0.00–0.05) and Germany (OR 0.30, 0.14–0.67), the patients contacted social care less often than the patients in Denmark.

Only the Nigerian patients contacted public or private psychiatry significantly less than Danish patients (OR 0.01, 95% CI 0.00–0.05).

Mood (affective) disorders (ICD-10 group F3) with CVD, DM and/or OW

Patients in Germany (OR = 0.21, 95% CI: 0.07–0.62), Switzerland (OR = 0.05, 95% CI: 0.02–0.17), Nigeria (OR = 0.07, 95% CI: 0.02–0.23) and Japan (OR = 0.02, 95% CI: 0.01–0.10) were found to contact general practice significantly less often than Danish patients. The same result was obtained for social care where each country had a significant lower OR (Germany: OR = 0.41, 95% CI: 0.19–0.88; Switzerland: OR = 0.17, 95% CI: 0.05–0.63; Japan: OR = 0.09, 95% CI: 0.01–0.71).

Nigerian patients were found to seek religious guidance and healing more often than the other four included countries. Public or private psychiatry was contacted more often by German (OR = 3.80, 95% CI: 1.82–7.93) and Japanese patients (OR = 24.27, 95% CI: 3.03–194.52) than Danish patients. German patients sought somatic specialists significantly more often than Danish ones (2.23, 95% CI: 1.10–4.52).

Discussion

We investigated which patients contacted which institutions/persons before admission to a psychiatric department. The patients were diagnosed with schizophrenia, schizotypal or delusional disorders (ICD-10 group F2), or mood (affective) disorders (ICD-10 group F3), and with CVD and/or DM and/or OW.

Our results showed that patients with mental disorders from Denmark, Germany and Switzerland had almost the same contact pattern. Patients primarily (46%–91%) contacted psychiatry (public and/or private); however, including Nigerians, general practice was a common first contact (41–93%). Religious guidance and/or healing were rarely sought by patients in Europe and Japan, but about 80% of patients with mental disorders in Nigeria had sought this type of service.

To the best of our knowledge, our study is the first to identify the first point of contact of patients with mental disorders who had a physical disease before admission into psychiatry (public and/or private). By investigating who these patients contact before admission, psychiatric departments could be encouraged to improve collaboration with those institutions/persons in order to identify these patients and offer them earlier treatment for their physical illness/condition (i.e. CVD, DM and/or OW).

It is of importance to recognise that physical diseases and thus higher morbidity are a common problem in patients with mental disorders (Smith et al., 2013; Truyers et al., 2011).

Our results show that general practice is one of the most important first points of contact, but social care and somatic specialists in, for example, Germany and Denmark are contacted with a similar frequency (38%–73% for patients diagnosed with an F2 disorder and 22%–54% for patients diagnosed with an F3 disorder). This could be explained by social care and somatic specialists being a group of services and thereby covering more than just one type of service. The contact rate for general practice is therefore a stronger indication of patients seeking help than social care or somatic specialists.

The same limitation is seen for psychiatry. During data collection, patients were only asked if they had been in contact with psychiatry. There was no indication on whether the psychiatry service was a private practice or a hospital. This is a limitation as knowing this would have given us a more precise result. However as, for example, in Denmark, there are very few private practice psychiatrists, a high level of contact to psychiatry is with a public psychiatric department. In Nigeria, psychiatrists in private practice are too scanty to make any meaningful contribution to psychiatric services.

The high proportion of patients registered as having had contact with psychiatry means that the patient is known to the psychiatric organisation in question (except for those where ‘psychiatry’ means private practice). Furthermore, this means that psychiatric departments, besides looking for collaborators in the effort to identify physical illnesses at an early stage, should also give high priority to an awareness of physical illness in its own daily clinical work.

It seems that when comparing patients from ICD-10 group F3 with ICD-10 group F2, patients in Denmark and Germany diagnosed with an F3 disorder have a higher correlation with contacting a general practice, whereas psychiatry in Denmark and Germany has the opposite relationship. One possible reason could be because F2 disorders are more severe illnesses requiring long-term contact with psychiatric departments (Insel, 2010).

With regard to patients from Nigeria versus patients from Denmark, Germany, Switzerland and Japan, it was common to seek religious guidance and healing.

The high contact rate of religious guidance and healing by Nigerian patients and a low contact rate to psychiatry must be seen on a background of the number of psychiatrists in Nigeria (one psychiatrist to 1.2 million inhabitants). It has been reported that in Nigeria the majority of general practitioners are without postgraduate training (Odejide & Morakinyo, 2003). However, it is likely that the situation has since changed, with an increased number of family physicians educated by the West African College of Physicians and the National Postgraduate Medical College of Nigeria. Of particular note is the recent introduction of the postgraduate medical diploma in family medicine awarded by the National Postgraduate Medical College of Nigeria. This has provided opportunities for Nigerian private general practitioners, who are not able to undergo a long and rigorous postgraduate residency training programme in family medicine, to acquire further knowledge. We speculate that a number of general practitioners in Nigeria may have taken advantage of this programme.

Other important factors, such as lack of knowledge of mental health services, stigma and transportation issues, could also be reasons why African patients with mental disorders do not regularly and frequently contact the healthcare system (Jack-Ide & Uys, 2013; Temilola, Adegoke, Olaolu, Adegboyega, & Olaide, 2013). Alternative approaches to finding help for mental illness are common, even in developed countries (e.g. the use of herbal products). Mental illnesses are still often viewed as illnesses of psyche (or spirit), and a spiritual approach to correct the problem is a cultural phenomenon in many societies. In such societies, patients may prefer the services of a faith healer owing to cultural and faith-related reasons even when psychiatric services are accessible (Chadda, Agarwal, Singh, & Raheja, 2001). Religious/faith healers can have a significant influence over patients and may constitute an important group to collaborate with in some countries. The ORs for the patient groups diagnosed with F2 or F3 disorders were 72.67 and 49.93, respectively, when comparing the contact rate of Danish patients with that of Nigerian patients. In other words, it is evident that religious guidance and healing services are far much more important in Nigeria than in Europe and Japan.

Contact with religious guidance and healing has been reported in other studies (Burns, Jhazbhay, Kidd, & Emsley, 2011; Chong, Mythily, Lum, Chan, & McGorry, 2005). The observation that Nigerian patients more often seek religious guidance and healing might motivate the Nigerian healthcare system to consider a workable collaboration with the religious guidance and healing sector. This way, it would be possible to provide patients with mental disorders who have a physical illness with an earlier, evidence-based treatment. What is evident from these results is that psychiatry is the most common point of contact, and not general practice. This was also found in other studies (Agyapong, 2012; Fridgen et al., 2013; Platz et al., 2006). A further consequence of this could be a practical integration between psychiatry and somatic specialities, for example, one of the centres participating in this study has employed a general practitioner and a general nurse in psychiatric care (B. Mogensen, personal communication). However, Agyapong (2012) found that almost 70% of patients stabilised on medication would prefer a private psychiatrist instead of a general practitioner owing to the lesser psychiatric expertise of the latter. In general, there is, in developing countries, a need to improve awareness among psychiatrists, as well general practitioners, about the high cardiometabolic morbidity seen in patients with mental illness. Disjointed healthcare systems in such countries will pose significant challenges to attempts for coordinated care.

It should further be made clear that this study deals exclusively with patients having overcome the nosocomial threshold to secondary hospital-based psychiatric healthcare. Many of them may have had a primary contact to general practice, possibly owing to physical complaints. In such cases, the physical illnesses are already identified. The vast majority of patients with mental disorders are treated exclusively in general practice. This group of patients is consequently not included in the present study. The questions about pathways and filters to psychiatric care are thoroughly discussed by Goldberg and Goodyear (2005).

Strength and limitations

Ethical boundaries prevented us from monitoring eligible patients who declined our invitation to participate in the study. The patients who participated in the study may not necessarily be representative of patients who have contact with psychiatric departments. However, it should be noted that no participating centres reported any meaningful face-value differences between the patients who participated and those who did not. For further information, see Larsen et al. (2013). We compressed our study population to either F2 or F3 combined with a physical diagnosis. This resulted in a small Japanese cohort, and conclusions about Japanese patients should be drawn with caution.

Remembering which care centres have been contacted during the past 6 months could be difficult for some patients and thus result in recall bias. Therefore, we did not make any attempts to register the sequence of contact. This would even be more important considering that both psychosis and mood disorders are associated with cognitive deficits. However, information was collected from all available sources, including family members, such that the chances of missing any service contact were reduced to a minimum.

We do not know whether the reliance on nonmedical practitioners delays the recognition and proper management of common co-morbid medical conditions in psychiatric patients. The fact that ‘healers’, with no medical training, are often ‘consulted’ in Nigeria is not necessarily good for the patients. The heterogeneity in our study population must also be taken into account. We included both in- and outpatients who may, perhaps, have different contact patterns.

The strengths of this study included the uniform and reliable method of data collection in all participating centres. We used self-reported physical illness and also carried out physical examinations with, where applicable, ancillary laboratory investigations to confirm somatic diseases. The use of the WHO ICD-10 research diagnostic criteria made comparisons across centres possible.

Conclusion

In Nigeria, most patients with schizophrenia, schizotypal and delusional disorders (ICD-10 group F2), or mood (affective) disorders (ICD-10 group F3) combined with a physical illness frequently seek religious guidance and/or healing before admission to psychiatric services.

The tendency in Denmark, Germany, Switzerland and Japan is that both general practice and psychiatry are the two most important points of contact and it could therefore be of value for the psychiatrist to collaborate with general practitioners. As ‘psychiatry’ also includes public psychiatry, this section of healthcare may benefit from an increased focus on our physical health of patients. Finally, it should be taken into consideration that our results may reflect the respective structures of the health services rather than patient characteristics in the different countries.

Footnotes

Declaration of conflicting interest

Karel Frasch has received travel payments/speaker honoraria from AstraZeneca (presentation of results from this study), Janssen, Bristol-Myers Squibb, Pfizer, Lilly and Lundbeck. Furthermore, he holds shares in the pharmaceutical company Stada. Bent A. Jacobsen is a member of the advisory board in Tillotts Pharma, approved by the Danish Health and Medicines Authority. J. Cordes was a member of an advisory board of Roche, accepted travel or hospitality not related to a speaking engagement from Servier, and support for symposia from Inomed, Localite, Magventure, Roche, Mag & More, NeuroConn, Syneika, FBI Medizintechnik, Spitzer Arzneimittel and Diamedic. Povl Munk-Jørgensen, Kristian L. Toftegaard, Lea Nørgreen Gustafsson, Kenji J. Tsuchiya, Graziella G. Bickel, Thomas Becker, Wulf Rössler, Jens Ivar Larsen, Richard Uwakwe, Christoph Lauber, Ulla A. Andersen, Birthe Mogensen and Reinhold Kilian have no conflicts of interest to report.

Funding

Eli Lilly supported the first planning meeting held in Aalborg, Denmark.

References

Abiodun

O. A.

(1995). Pathways to mental health care in Nigeria. Psychiatric Services, 46, 823–826.

Agyapong

V. I.

(2012). Continuing care for mentally stable psychiatric patients in primary care: Patients’ preferences and views. International Journal of Family Medicine, 2012, Article 575381. doi:10.1155/2012/575381

Berk

Sarris

Coulson

C. E.

Jacka

F. N.

(2013). Lifestyle management of unipolar depression. Acta Psychiatrica Scandinavica, 127(Suppl. 443), 38–54.

Bowie

C. R.

Harvey

P. D.

(2005). Cognition in schizophrenia: Impairments, determinants, and functional importance. The Psychiatric Clinics of North America, 28, 613–633, 626.

Brown

Birtwistle

Roe

Thompson

(1999). The unhealthy lifestyle of people with schizophrenia. Psychological Medicine, 29, 697–701.

Burnett

Mallett

Bhugra

Hutchinson

Der

Leff

(1999). The first contact of patients with schizophrenia with psychiatric services: Social factors and pathways to care in a multi-ethnic population. Psychological Medicine, 29, 475–483.

Burns

J. K.

Jhazbhay

Kidd

Emsley

R. A.

(2011). Causal attributions, pathway to care and clinical features of first-episode psychosis: A South African perspective. The International Journal of Social Psychiatry, 57, 538–545.

Castagnini

Foldager

Bertelsen

(2013). Excess mortality of acute and transient psychotic disorders: Comparison with bipolar affective disorder and schizophrenia. Acta Psychiatrica Scandinavica, 128, 370–375.

Chadda

R. K.

Agarwal

Singh

M. C.

Raheja

(2001). Help seeking behaviour of psychiatric patients before seeking care at a mental hospital. The International Journal of Social Psychiatry, 47(4), 71–78.

10.

Chong

S. A.

Mythily

Lum

Chan

Y. H.

McGorry

(2005). Determinants of duration of untreated psychosis and the pathway to care in Singapore. The International Journal of Social Psychiatry, 51, 55–62.

11.

Dipasquale

Pariante

C. M.

Dazzan

Aguglia

McGuire

Mondelli

(2013). The dietary pattern of patients with schizophrenia: A systematic review. Journal of Psychiatric Research, 47, 197–207.

12.

Frasch

Larsen

J. I.

Cordes

Jacobsen

Wallenstein Jensen

S. O.

Lauber

… Becker

(2012). Physical illness in psychiatric inpatients: Comparison of patients with and without substance use disorders. The International Journal of Social Psychiatry, 59, 757–764.

13.

Fridgen

G. J.

Aston

Gschwandtner

Pflueger

Zimmermann

Studerus

… Riecher-Rossler

(2013). Help-seeking and pathways to care in the early stages of psychosis. Social Psychiatry and Psychiatric Epidemiology, 48, 1033–1043.

14.

Fuchs

Steinert

(2004). Patients with a first episode of schizophrenia spectrum psychosis and their pathways to psychiatric hospital care in South Germany. Social Psychiatry and Psychiatric Epidemiology, 39, 375–380.

15.

Gater

de Almeida

Sousa

Barrientos

Caraveo

Chandrashekar

C. R.

Dhadphale

… Sartorius

(1991). The pathways to psychiatric care: A cross-cultural study. Psychological Medicine, 21, 761–774.

16.

Gater

Goldberg

(1991). Pathways to psychiatric care in South Manchester. The British Journal of Psychiatry, 159, 90–96.

17.

Goldberg

Goodyear

(2005). The Origins and Course of Common Mental Disorders. London and New York: Routledge.

18.

Harangozo

Reneses

Brohan

Sebes

Csukly

Lopez-Ibor

… Thornicroft

(2013). Stigma and discrimination against people with schizophrenia related to medical services. The International Journal of Social Psychiatry, 60, 359–366.

19.

Harris

E. C.

Barraclough

(1998). Excess mortality of mental disorder. The British Journal of Psychiatry, 173, 11–53.

20.

Insel

T. R.

(2010). Rethinking schizophrenia. Nature, 468, 187–193.

21.

Jack-Ide

I. O.

Uys

(2013). Barriers to mental health services utilization in the Niger Delta region of Nigeria: Service users’ perspectives. The Pan African Medical Journal, 14, Article 159. doi:10.11604/pamj.2013.14.159.1970

22.

Janszky

Ahlbom

Hallqvist

Ahnve

(2007). Hospitalization for depression is associated with an increased risk for myocardial infarction not explained by lifestyle, lipids, coagulation, and inflammation: The SHEEP Study. Biological Psychiatry, 62, 25–32.

23.

Kilian

Becker

Krüger

Schmid

Frasch

(2006). Health behaviour in psychiatric in-patients compared with a German general population sample. Acta Psychiatrica Scandinavica, 114, 242–248.

24.

Larsen

J. I.

Andersen

U. A.

Becker

Bickel

G. G.

Bork

Cordes

… Munk-Jorgensen

(2013). Cultural diversity in physical diseases among patients with mental illnesses. The Australian and New Zealand Journal of Psychiatry, 47, 250–259.

25.

Leucht

Burkard

Henderson

Maj

Sartorius

(2007). Physical illness and schizophrenia: A review of the literature. Acta Psychiatrica Scandinavica, 116, 317–333.

26.

Lincoln

Harrigan

McGorry

P. D.

(1998). Understanding the topography of the early psychosis pathways. An opportunity to reduce delays in treatment. The British Journal of Psychiatry, 172(Suppl. 33), 21–25.

27.

Malla

A. K.

Norman

R. M.

Takhar

Manchanda

Townsend

Scholten

Haricharan

(2004). Can patients at risk for persistent negative symptoms be identified during their first episode of psychosis? The Journal of Nervous and Mental Disease, 192, 455–463.

28.

Malla

A. K.

Takhar

J. J.

Norman

R. M.

Manchanda

Cortese

Haricharan

… Ahmed

(2002). Negative symptoms in first episode non-affective psychosis. Acta Psychiatrica Scandinavica, 105, 431–439.

29.

Mazzoncini

Donoghue

Hart

Morgan

Doody

G. A.

Dazzan

… Fearon

(2010). Illicit substance use and its correlates in first episode psychosis. Acta Psychiatrica Scandinavica, 121, 351–358.

30.

Odejide

Morakinyo

(2003). Mental health and primary care in Nigeria. World Psychiatry, 2, 164–165.

31.

Pescosolido

B. A.

Martin

J. K.

Long

J. S.

Medina

T. R.

Phelan

J. C.

Link

B. G.

(2010). ‘A disease like any other’? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence. The American Journal of Psychiatry, 167, 1321–1330.

32.

Platz

Umbricht

D. S.

Cattapan-Ludewig

Dvorsky

Arbach

Brenner

H. D.

Simon

A. E.

(2006). Help-seeking pathways in early psychosis. Social Psychiatry and Psychiatric Epidemiology, 41, 967–974.

33.

Pogue-Geile

M. F.

Harrow

(1985). Negative symptoms in schizophrenia: Their longitudinal course and prognostic importance. Schizophrenia Bulletin, 11, 427–439.

34.

Razali

S. M.

Najib

M. A.

(2000). Help-seeking pathways among Malay psychiatric patients. The International Journal of Social Psychiatry, 46, 281–289.

35.

Saha

Chant

McGrath

(2007). A systematic review of mortality in schizophrenia: Is the differential mortality gap worsening over time? Archives of General Psychiatry, 64, 1123–1131.

36.

Schomerus

Schwahn

Holzinger

Corrigan

P. W.

Grabe

H. J.

Carta

M. G.

Angermeyer

M. C.

(2012). Evolution of public attitudes about mental illness: A systematic review and meta-analysis. Acta Psychiatrica Scandinavica, 125, 440–452.

37.

Simpson

J. C.

Tsuang

M. T.

(1996). Mortality among patients with schizophrenia. Schizophrenia Bulletin, 22, 485–499.

38.

Smith

D. J.

Langan

McLean

Guthrie

Mercer

S. W.

(2013). Schizophrenia is associated with excess multiple physical-health comorbidities but low levels of recorded cardiovascular disease in primary care: Cross-sectional study. BMJ Open, 3(4), e002808. doi:10.1136/bmjopen-2013–002808

39.

Stapelberg

N. J.

Neumann

D. L.

Shum

D. H.

McConnell

Hamilton-Craig

(2011). A topographical map of the causal network of mechanisms underlying the relationship between major depressive disorder and coronary heart disease. The Australian and New Zealand Journal of Psychiatry, 45, 351–369.

40.

Steel

McDonald

Silove

Bauman

Sandford

Herron

Minas

I. H.

(2006). Pathways to the first contact with specialist mental health care. The Australian and New Zealand Journal of Psychiatry, 40, 347–354.

41.

Stowkowy

Colijn

M. A.

Addington

(2013). Pathways to care for those at clinical high risk of developing psychosis. Early Intervention in Psychiatry, 7, 80–83.

42.

Temilola

M. J.

Adegoke

A. O.

Olaolu

A. T.

Adegboyega

Olaide

A. K.

(2013). Self-stigma, quality of life and schizophrenia: An outpatient clinic survey in Nigeria. The International Journal of Social Psychiatry, 60, 377–386. doi:10.1177/0020764013491738

43.

Temmingh

H. S.

Oosthuizen

P. P.

(2008). Pathways to care and treatment delays in first and multi episode psychosis. Findings from a developing country. Social Psychiatry and Psychiatric Epidemiology, 43, 727–735.

44.

Truyers

Buntinx

De Lepeleire

De Hert

Van Winkel

Aertgeerts

… Lesaffre

(2011). Incident somatic comorbidity after psychosis: Results from a retrospective cohort study based on Flemish general practice data. BMC Family Practice, 12, Article 132. doi:10.1186/1471–2296–12–132

45.

World Health Organization (1992) The ICD-10 Classification of Mental and Behavioural Disorders: Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization.