Abstract
Background:
Research indicates that help seeking for mental health is low and often delayed. Understanding pathways to care is crucial to facilitate mental health referrals and reduce the time to consultation.
Methods:
In the present study, 63 individuals were assessed on illness severity, attitudes towards help-seeking and pathways-to-care.
Results:
Multiple pathways for therapy were noted, a delayed-pathway, two-step referral pathway and a direct-pathway. Most prominent pathway was the delayed-pathway. The direct-pathway had least treatment delay, contributed by timely recognition of symptoms by the patient. As first point of contact, patients preferred psychiatrists and popularly sought information about treatment via media.
Conclusions:
There are multiple pathways to consultations, often leading to treatment delay in care received. Timely recognition of symptoms was associated a direct pathway and the least delay. These findings have implications for strengthening routes to mental health specialists at early stages and increasing awareness about treatment available.
Keywords
Introduction
Mental and behavioural disorders account for about 12% of the global burden of diseases (WHO, 2001). In India, Mental and behavioural disorders account for a significant proportion of burden of diseases in India. A recent study found that nearly 197.3 million people in India had a mental disorder, of which depression and anxiety were most common (Sagar et al., 2020). The past few decades have witnessed large gains in treatment options and dissemination of information regarding mental health. Despite this, more than 70% people with mental disorder do not receive treatment (Henderson et al., 2013; National Mental Health Survey [NMHS] Collaborators, 2016).
Barriers to help-seeking include, depression, suicidal thoughts (Mohr et al., 2010), self-stigma and poor functioning (Ociskova et al., 2015; West et al., 2015). People tend to deny, dissociate (Ociskova et al., 2015), suppress, look for other somatic basis, delay consulting a psychiatrist, choose to adjust to the disorder, contributing to treatment delay (Latalova et al., 2013; Ociskova et al., 2013, 2015). Barriers to participation in psychotherapy include beliefs concerning misfit of therapy and ineffectiveness of treatment (Gulliver et al., 2010; Mohr et al., 2010; Rickwood et al., 2007; Verhaak, 1995).
Facilitating factors include past treatment experiences, higher education, illness chronicity, influence of partners and general practitioners (Gulliver et al., 2010); provision of accurate treatment information, good interpersonal skills of the mental health professional (Prins et al., 2008).
Pathways-to-care (PTC) indicate numerous routes taken prior to reaching appropriate mental health professionals. In India, PTC has been explored in across the country, in various cities (Chadda et al., 2001; Faizan et al., 2012; Jain et al., 2012; Lahariya et al., 2010; Mishra et al., 2011). Few studies have focussed on tertiary psychiatry settings (Faizan et al., 2012; Hossien et al., 2017; Mishra et al., 2011; Pradhan et al., 2013). There is a need for prioritising patient’s perspective to enhance help-seeking behaviours (Gulliver et al., 2010; Prins et al., 2008; Verhaak, 1995).
The primary aims of the study were to understand help-seeking processes, barriers and facilitators to help-seeking and the implications these have for mental health practice and referrals for treatment from the patient’s perspective (Faizan et al., 2012; Mishra et al., 2011).
Method
Design and participants
A cross sectional, design was adopted, with questionnaires and an interview with the participants. The sample consisted of 63 treatment seeking adults (Mean = 28.43, SD = 8.35), with psychiatric diagnosis as per ICD 10 criteria (WHO, 1992) able to read and write English, were recruited from outpatient mental health services of a tertiary centre in Southern India. Patients with primary diagnosis of current substance dependence (except nicotine dependence), neurological/neurosurgical conditions and those who have received three or more structured psychotherapy sessions, were excluded.
The study was reviewed and approved by the Institute Ethics Committee (NIMH/DO/IEC; BEH.Sc.DIV; 2016-17). Informed consent was obtained from all participants. All assessments were carried out individually, in English.
Measures
Modified Mini Screen or MMS (New York State Office of Alcoholism and Substance Abuse Services, 2005) is a 22 item self-report, structured screening questionnaire (based on DSM-IV and ICD-10) for psychiatric-disorders. The MMS was used in addition to the file diagnosis made during the clients’ evaluation by the treating mental health professional.
The Clinical Global Impression Scale-severity or CGI (Guy, 1976), clinician-rated scale was used to assess global severity of illness.
Attitudes toward Seeking Professional Psychological Help Scale or ATSPPHS (Fischer & Farina, 1995), a 10-item self-report, assesses attitudes toward seeking professional psychological help. Higher scores representative of positive attitudes.
In addition, an interview which contained both open ended and close ended questions, was used to gather information on sources of information about treatment, PTC and barriers to help-seeking. Medical records were used to corroborate information.
Statistical analysis
Data was analysed using Statistical Package for Social Sciences (IBM-SPSS) Version 20.0. The time taken to reach consultation/seeking help, with reference to demographic variables was assessed using Mann–Whitney U test. Nature of referral process was noted using a checklist developed for the purpose of the study. Barriers to help-seeking were noted using content analysis. PTC flowchart was drawn for all participants to arrive at a cumulative diagram.
Results
The sample was in their late 20’s (M = 28.43 years, SD ± 8.35 years) with 66.7% males and 33.3% females. Most participants were employed (39.7%), followed by unemployed (22.2%), students (28.6%) and homemakers (9.5%). About three-fourth of sample resided with families (74.6%), followed by flat-mate accommodation (17.5%) and few lived alone (8%). About two-third were single (61.9%), and one-third were engaged/married. All participants largely coming from middle socio-economic-status (98.4%).
Common mental disorders, was the most frequent presentation, comprising of anxiety (61.9%), mood disorders (22.2%), psychosis (3.2%), substance use (3.2%) and personality disorders (3.2%). About half had one or more comorbidities, a quarter reported presence of suicidal thoughts in the preceding month of meeting the professional. Nearly half (44.4%) had moderate severity on CGI. Subjectively experienced distress was 63.57% with considerable variance (SD = 26.79). Course of illness was chronic (Mean = 69.6 months, SD = 69.13, Range = 1 month–312 months).
Attitudes toward seeking professional psychological help was negatively correlated with time taken to consultation (ρ = .314, p < .05). On the Mann–Whitney test, time taken to consultation was greater for unmarried (Median = 12) than for married participants (Median = 0.05), U = 244.50, p = .028. Positive attitudes towards seeking professional psychological help was reported and participants found seeking help was (54.29%) beneficial. There was a gap of approximately one and a half years (17.47 months) prior to contacting a trained professional, ranging from seeking immediate help to delay of 19 years (Table 1).
Help-seeking beliefs and delay in time to consultation.
Note. ATSPPH = attitudes toward seeking professional psychological help scale.
Primary nodal point in help-seeking was the psychiatrist and source of information sought for available mental health services was largely media (Table 2). Most patients believed that their mental health concerns did not warrant meeting a professional and thus delayed time to seek consultation (Table 3). Common pathways were elicited based on frequencies. Figure 1 depicts multiple pathways as well as ‘recursive paths’ (Gater et al., 1991) that is, coming back to same professional for follow ups, which eventually delays referral to Tertiary Health Care (THC). Participants tallied in ‘blue’ boxes were the final sample in the present study (Figure 1). Many individuals had parallel consultations with different doctors or multiple consultations with same professional before reaching THC.
Referral processes.
Barriers in help-seeking actions.
Pathways to care.
Discussion
The present study attempted to explore pathways and attitudes to seeking professional mental health care. The sample comprised of young adults, who were either working or students, single and hailed from an urban background. A majority had anxiety disorders and this trend is similar to that reported by conducted in the same setting (Jain & Sudhir, 2010; Rukmini et al., 2014; Sudhir et al., 2012). Large proportion of the sample being educated and middle and upper middle SES could be because of the methodology in the present study and the setting of hospital being in urban locality. Sample was also representative in terms of severe and common mental disorders, and similar to study in north India (Mishra et al., 2011). Another study also noted anxiety and depression to be most common mental illnesses (Prins et al., 2008).
Gender distribution of the sample is also consistent with studies conducted in similar clinical settings (Lakshmi et al., 2016; Rukmini et al., 2014; Sudhir et al., 2012). Preponderance of males over females was also noted studies from other Indian studies (Lahariya et al., 2010; Mishra et al., 2011). It can be understood on the basis of the existing patriarchy in Indian context. It is also likely that occupational and role demands are some of the reasons why more men than women seek treatment (Lahariya et al., 2010). Further, most males are noted to be economically sound and often sole breadwinners in the family which aids in better access to care for the gender in the community. This is despite CMDs being prevalence in females in the community (Trivedi et al., 2013).
The time taken to consultation reported in the present study was a little more than a year, with significant variation. Further, married participants had a shorter time taken to consultation as compared to unmarried participants. This was similar to a study where demographic variables including marital status had significance for outcomes like treatment compliance for patients with bipolar affective disorder (Sajatovic et al., 2011). This was observed over and above patients’ having good relations with treating professional.
Large delay in time to consultation was reported by another study in the same setting, although the sample had greater illness severity than that of the present study (Anand et al., 2011). Similar patterns of delay in time to consultation are also reported by other Indian studies (Chadda et al., 2001; Hossien et al., 2017); no age or gender differences in delay in time to consultation were noted in these studies.
One reason for delayed help-seeking is, that individuals with chronic mental health conditions reach tertiary centres after exhausting other options for consultation. Delay in time until the final psychiatric consultation is noted to be multiple points of contact with sometimes a delay of 50 weeks in multi-point pathway to 12 weeks in direct psychiatrist pathway (Gater et al., 1991).
Barriers to help-seeking
Most common barrier to seeking professional mental health care was ‘therapy-need mismatch’ (Table 3), lower symptom severity and attempts to practice self-care. Some examples are, ‘I did not feel it was serious enough’, ‘I was able to manage it’, ‘I did not feel the need to go to a doctor for this’, ‘I thought I could manage by myself’. Similar beliefs have been reported in literature (Lahariya et al., 2010). Consistent with literature (Lahariya et al., 2010), poor understanding about illness, lack of information about availability of professional health care was another reason cited. Stigma was not reported as a barrier, and could be explained by the sample comprising of mostly educated employed males from urban backgrounds.
How was help sought and why?
In our study, patients first contacted a psychiatrist, a finding noted in previous studies (Chadda et al., 2001; Mishra et al., 2011; Pradhan et al., 2013); followed by allopathic practitioners (31.7%), and clinical psychologists (10.9%). This can be attributed to the demographic characteristics of the sample being educated, from middle socio-economic background, with easier access to mental health facility and primarily having common mental disorders.
Similar findings are reported by studies from Northern India, with first contact being a psychiatrist (57.7%), followed by faith healers (29.5%), physicians (11.5%) and finally alternate medicine (1.3%; Chadda et al., 2001). These findings were replicated in a follow up study carried out a decade later, in which 86% visited psychiatrist at second point of contact, if not first (Mishra et al., 2011).
Other studies have noted preference for physicians/allopathic practitioners (Faizan et al., 2012; Gater et al., 1991), faith healers (Jain et al., 2012; Lahariya et al., 2010; Pradhan et al., 2013). Faith healers were also noted to be junctions (Jain et al., 2012). Faith healers were not popular point of contact in present sample, perhaps due to demographic characteristics. Demographic factors have been noted to be statistically significant factors in choice of specialist (Faizan et al., 2012; Jain et al., 2012).
Patients with psychotic illnesses reported visiting faith healers more than patients with CMDs (Pradhan et al., 2013), primary reasons being ease of access, belief in supernatural, poor mental health literacy and recommendation by known person (Pradhan et al., 2013). A study conducted in Gwalior, Central India, noted preference for faith healers (68.5%) over psychiatrist (9.2%) at first consultation. The sample comprised of largely participants from rural background, with lower educational levels, with severe mental disorders (Lahariya et al., 2010).
Other reasons for preferring mental health professionals were availability (approachability) and low cost of treatment (Chadda et al., 2001). Cost of treatment has been noted by multiple centres as facilitating factor for psychiatrist-point of contact (Chadda et al., 2001; Mishra et al., 2011). This could also be attributed to the subsidised cost at the centre at which facility is availed. India being developing country, cost is relevant in decision making, it can be explored further in future studies. Importance of confidentiality has also been pointed out in choosing a specialist (Faizan et al., 2012).
Thus, there is continued need to enhance mental health awareness (Mishra et al., 2011), informing other health professionals about mental illness to fasten referral process (Mishra et al., 2011), especially about CMDs and the nature of therapeutic services (Prins et al., 2008).
Source of information
In the present study, most common source of information for mental disorders was media (Table 2). Whereas, information/recommendations for ‘who-to-consult’ for treatment was sought from relatives, friends, colleagues and acquaintances. This suggests that social network does not stop with the family, implicating different settings for psycho-education regarding mental health services. In the background of social inter-connectedness in Indian culture, seeking doctor recommendations from relatives is noted to be common (Chadda et al., 2001; Lahariya et al., 2010; Mishra et al., 2011). Previously treated persons often function as referring agents, although self-referral was not unaccounted for (Faizan et al., 2012; Lahariya et al., 2010).
Media was also most common source of information on ‘what is therapy/counselling’, followed by pre-existing knowledge about counselling or information gained from a doctor during past referral to therapy, has implications for seeking contacting appropriate mental health professional. While 80% of sample reached psychotherapy services through doctor’s referral, 20% were self-referred or pro-actively sought referral from doctor (Table 2), implying growing awareness about psychotherapy.
Further, while referring patients for psychotherapy, the treating doctor provided information about therapy 42.2% of times, while a little more than half was referred without any briefing about psychotherapy or reasons for referral. This is likely to have implications for the patient’s follow up with the referral.
Pathways to care
Several studies have used the WHO Encounter Form from the WHO pathways to care project (Gater et al., 1991; Jain et al., 2012), or ‘pathways to care’ section of Short Explanatory Model Interview (Hossien et al., 2017; Lloyd et al., 1998). In the present study, PTC was explored using semi-structured interview with open-ended questions (Chadda et al., 2001). It provides the researcher greater flexibility to explore complex, interlinked pathways adopted before reaching THC, in background of barriers and facilitators at each step.
Globally, common pathways fall under three categories, physician, specialist and, traditional healer (Jain et al., 2012). In the present study, pathways were identified based on time delay and number of consultations sought before reaching THC (Figure 1).
Delayed pathway
The most common pathway was the delayed pathway, wherein symptoms were recognised by patient/family members, consultation was sought at PHC, followed by consultations with same specialist and/or, multiple consultations with other specialists parallely. This contributed to delay in appropriate referral. After dissatisfaction with past experiences at PHCs, local clinics, more than half sought treatment at tertiary centres. Dissatisfaction was mostly related to poor treatment response or misdiagnosis, consistent with ‘the non-cohesive pathway’ (Hossien et al., 2017), ‘fragmented pathways’ (Hinton et al., 2004).
Two-step referral pathway
In the two-step referral pathway symptoms were recognised by patient/family members and consultation was sought at the nearest doctor, before referral to THC. Most individuals preferred psychiatrist over physician, perhaps due to symptom recognition and availability, access to psychiatry services. This is similar to ‘neuropsychiatrist (NP) pathway’ but psychiatrists were more preferred than ‘the general practitioner (GP) pathway’ (Hossien et al., 2017). Past knowledge about therapy was low.
Direct pathway
In the third pathway, a direct pathway, symptoms were recognised by the patient and consultation was sought at the out-patient services at a THC. While this pathway was least commonly observed, it had least treatment delay especially in light of chronicity of CMDs (Hinton et al., 2004; Hossien et al., 2017). Some studies report use of direct consultations with mental health care providers (Gater et al., 1991) or direct self-referral to psychiatrist (Chadda et al., 2001; Mishra et al., 2011).
Symptoms were clearly identified, recognised, and deemed needing professional help by the patient only in the direct pathway, and underscores the need to enhance mental health awareness.
Similar previous reports on PTC (Faizan et al., 2012; Jain et al., 2012), in the present study too, pathways can be observed on the basis of practitioner preferred (Figure 1); (1) ‘psychiatrist pathway’, (2) ‘physician pathway’, (3) ‘multiple-practitioner pathway’, (4) ‘direct clinical psychologist pathway’ (DCPP) in decreasing order. All pathways had delay in referral to individual therapy, except when help was sought from a clinical psychologist directly (DCPP). In a previous study carried out in a setting similar to that of the present study, physician pathway was noted to be predominant (Gater et al., 1991).
Previously, a study has reported 43.6% direct pathway, 32.1% with one point before THC, 23.1% with two points before THC and 1.3% with three points before THC consultation (Chadda et al., 2001). Almost all (96%) chose visiting psychiatrist upon recommendation of significant other, while many chose visiting psychiatrist because of lack of response from previous treatments/low-cost in psychiatry/seeking second opinion/need for hospitalisations. Majority were noted to have severe mental conditions in the sample. Similar trends were noted in terms of sources of information being relatives/ significant, after media. However, the present study had primarily common mental disorders. Thus, both media and social-support system are of precedence in increasing awareness about mental health services.
Five main pathways namely, faith healer, non-psychiatrist allopath care provider, non-THC psychiatrist, direct entry to THC and alternative medicine care provider, in descending order have been reported in literature with patients visiting nearly four practitioners before meeting mental health consultant and nearly six practitioners before reaching their THC setting (Jain et al., 2012).
In previous literature, a greater preponderance of severe mental disorders is commonly noted at centres collecting samples from psychiatry facility (Chadda et al., 2001; Jain et al., 2012; Lahariya et al., 2010). The sample in the present study had more common mental disorders and could be attributed to the fact that participants were recruited when they came for follow up or had already been referred or had sought psychological intervention, but had not yet initiated it.
The need for understanding patient’s route to clinic is important as a longer duration of untreated illness may negatively impact the course and prognosis of illness (Jain et al., 2012). Pathways to care have special relevance in developing countries like India, where access to care is challenging (Trivedi & Jilani, 2011). This can be worse for females who may face greater cultural barriers to seeking professional care, than males (Trivedi et al., 2013). CMDs are known to present to clinics later than severe mental illnesses (Gater et al., 1991; Jain et al., 2012), implicating need for specific focus on CMDs. Identifying pathways to mental health care is particularly important in CMD as psychological therapies are often the first line of treatment.
The present study has implications for health professionals who are likely to identify mental health concerns during the course for evaluation. Especially in a community setting, where physicians/health professionals are commonly contacted, liaison routes need to be reinforced for management of mental health concerns. Further, in the mental health hospital setting, patients are more likely to be screened/evaluated by a psychiatrist than clinical psychologist and consequently only be offered pharmacotherapy. There is a greater need to educate the patients about treatment options available and encourage multi-modal treatment. Presence of a mental health team (which includes a psychiatrist, clinical psychologist, and a psychiatry social worker), at the screening/OPD setting is also likely to aid the process and improve awareness, without burdening psychiatry residents/consultants with the responsibility of increasing mental-health awareness. Moving on, while majority received a referral for therapy in the OPD setting by a doctor, less than half were given any information about therapy. Receiving information about what therapy entails, at the point of referral by health professional is likely to improve adherence to appropriate therapy/counselling service. A multi-modal treatment approach can lead to better treatment outcomes. Providing information about available mental-health services and how they help, would also give an opportunity to address existing barriers/misperceptions about help-seeking.
Strengths, limitations and future directions
The present sample was representative of a treatment-seeking population. At the same time, the findings are applicable to largely educated individuals belonging to middle socio-economic background. Further, given the Indian context, females might have unique help-seeking behaviours which were not specifically tapped in the present study. The possibility of retrospective recall bias and hesitation to report all non-medical carers before reaching current THC, cannot be ruled out. Gaps in ability to correctly identify symptoms of mental illness is also to be considered and could be assessed using case vignettes (Fathima et al., 2018). Reports of simultaneous consultations may further enhance PTC diagram.
Conclusions
Our findings indicate that there are multiple pathways to consultations, often leading to treatment delay in care received. Timely recognition of symptoms was associated a direct pathway and the least delay. These findings have implications for strengthening routes to mental health specialists at early stages and increasing awareness about treatment available.
Footnotes
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.