Year : 2018 | Volume
: 23 | Issue : 1 | Page : 33--37
A study of treatment-seeking behavior in psychiatric patients at a tertiary care hospital in Delhi
Dinesh Kataria1, RC Jiloha2, MS Bhatia3, Sneha Sharma1,
1 Department of Psychiatry and Deaddiction Centre, Lady Hardinge Medical College, New Delhi, India
2 Department of Psychiatry and Rehabilitation Sciences, Hamdard Institute of Medical Sciences and Research, New Delhi, India
3 Department of Psychiatry, Guru Tegh Bahadur Hospital, New Delhi, India
Room No 15, Department of Psychiatry and Deaddiction Centre, Lady Hardinge Medical College, New Delhi - 110 001
Background and Aims: Patients with mental disorders often do not seek professional help for a multitude of reasons. These issues need to be highlighted and addressed. This cross-sectional study aims to collect and to analyze treatment-seeking behavior in psychiatric patients. Subjects and Methods: Five hundred patients presenting to psychiatry Outpatient Department of a tertiary hospital in Delhi, were recruited after obtaining written informed consent. Patients were diagnosed based on the International Classification of Disease-10 criteria, and sociodemographic details were collected. Treatment-seeking behavior schedule was applied. Results: Patients between 18 and 35 years of age constituted around 60% of the total treatment-seeking patients and only 2% were above the age of 65 years. More than 60% of the sample belonged to an urban, middle socioeconomic background from nuclear families. Depression and anxiety disorders were the most common psychiatric morbidities followed by psychotic disorders and substance use disorders. Up to half of the sample had sought treatment before coming for consultation. Of these 55% visited nonpsychiatric doctors, 30% of psychiatrists and others consulted faith healers, alternate medicine, and psychologists before visiting our facility. Easy accessibility, faith, and good reputation were the reasons for going to a doctor while belief in the supernatural causation of mental illness was the major reason for seeing a faith healer. Mostly, a family member had given information about our facility. Previous ineffective treatment and cost concerns regarding medications were the predominant reasons to visit after prior visits elsewhere. Conclusion: Factors determining treatment-seeking behavior can help address problems and delay in early identification and optimal management of mental disorders.
|How to cite this article:|
Kataria D, Jiloha R C, Bhatia M S, Sharma S. A study of treatment-seeking behavior in psychiatric patients at a tertiary care hospital in Delhi.J Mental Health Hum Behav 2018;23:33-37
|How to cite this URL:|
Kataria D, Jiloha R C, Bhatia M S, Sharma S. A study of treatment-seeking behavior in psychiatric patients at a tertiary care hospital in Delhi. J Mental Health Hum Behav [serial online] 2018 [cited 2020 Feb 20 ];23:33-37
Available from: http://www.jmhhb.org/text.asp?2018/23/1/33/244915
According to the existing literature,,, the high prevalence of mental health problems is not matched by a commensurate level of service use and associated help-seeking behavior. This remarkable mismatch between the prevalence of mental disorders and treatment seeking, especially from mental health professionals is a source of rising concern considering the availability of effective treatments for many mental health problems.
Various studies across the globe have shown that only about a third of the population with any mental illness approaches the mental health services, whereas rest take help from other physicians and general practitioners. This, in turn, is largely a factor of the healthcare system structure of the said country. Studies have shown that even in the high-income countries, such as Italy, USA, and Canada, a great number of mentally ill patients approach the general physicians or general practitioners, rather than mental health providers for initial care., A review of 37 studies on service utilization revealed high rates of treatment gap for various mental illnesses across different countries. Alcohol use disorders had the highest treatment gap at 78.1% while the lowest was for schizophrenia and other nonaffective psychosis at 32.2%. It is likely that the gaps are an underestimate owing to the poor availability of community-based data from low- and middle-income countries.
India too seems to follow the charts when it comes to treatment seeking in patients with mental illnesses. A study done by Mishra et al. in 2011 reflect an average lag of 6 months duration from onset of symptoms of mental illness to seeking treatment for the same. Recently completed National Mental Health Survey, 2016 found that in India, the treatment gap for mental disorders ranged between 70% and 92% for different disorders. Going along the same trajectory, the World Health Organization World Mental Health Survey Initiative, in India, revealed that 95% of people with any mental disorder did not receive treatment, pointing to a huge existing treatment gap. The treatment rates varied from as low as 1.66% for specific phobia to nearly 5%–6% for depressive episode, generalized anxiety, and substance use disorders to a maximum of 11.55% for panic disorder.
Despite the high burden of mental illnesses on individual and families, a typical mentally ill person not on treatment cites a number of reasons for not seeking help which range from perceived lack of efficacy of treatment, believing that the problem will eventually go away by itself, and the feeling that he/she wants to handle the problem himself/herself, without outside help. Inadequate treatment seeking could also be attributed to poor resource availability and infrastructure paucity. Other factors like false attribution of their illness to physical factors or supernatural causes may also have a role to play. Availability and accessibility to faith-healers, general practitioners, and psychiatrists also determine the frequency of the consultation sought.,
Despite the national level initiatives for the advancement of mental health, poor treatment-seeking for mental health problems and its determinant factors is an oft-neglected issue in India. In this aspect, statistics from a tertiary care center in the capital of the country might offer compelling insights into the problem.
Subjects and Methods
The study was conducted in psychiatric outpatient setting at Lady Hardinge Medical College, New Delhi, a tertiary care premier medical institution of the country. Its catchment area includes the city of Delhi, neighboring states of Haryana, Uttar Pradesh, Rajasthan, as well as many distant states, such as Bihar, Orissa, Uttrakhand, Jammu and Kashmir, Madhya Pradesh, Jharkhand, and West Bengal. Patients attending the clinical services are mostly accompanied by their family members.
The current study was a cross-sectional study spanning over a period of 3 years from 2012 to 2015. Five hundred new patients (age >18 years) having an International Classification of Disease 10 (ICD-10) psychiatric diagnosis, were taken by purposive sampling. Those with a psychiatric illness secondary to established medical/surgical conditions were excluded as the main focus of the study was on primary psychiatric diagnosis. Written informed consent was taken and the sociodemographic details were collected using a semi-structured pro forma. Modified Kuppuswamy Socioeconomic Status Scale was applied to assess the socioeconomic status of the patients.
Treatment-seeking behaviour schedule was used to assess the help-seeking behavior of patients presenting to mental health facility. It enquires about the different treatment facilities used, the reason for choosing that particular health facility and the response to treatment. It specifically asks for reasons to visit the mental health facility. The schedule has a list of probable reasons to choose from, though it offers the option to record any other reason also, which may not be specified in the list.
The data generated was analyzed using IBM SPSS Statistics, Version 20. Chi-square test, Student's t-test, Mann–Whitney U-test, and Kruskal–Wallis analysis of variance were applied where appropriate.
Ethical clearance was taken from the Institutional Ethical Committee.
The sample consisted of 500 patients with 53% males and 47% females. Majority of the sample was <35 years of age (~62%) with only a small percentage (~8%) above 55 years of age. The sample was predominantly representative of Hindus (74%) followed by Muslims (24%) with minority representing other religions (2%). Among the Hindu population, majority was of general caste followed by the nearly equal proportion of OBC and SC/ST combined. No caste subdivision was considered for other religions. Sixty-seven of the studied population was married and 27% unmarried. Rests were grouped as either widow/widower or separated/divorced. Most (60%) reported to be residing in nuclear family with only 33% in joint families whereas 70% of patients reported to be residing in urban areas in contrast to only 14% in rural areas. In accordance with the Kuppuswamy Socioeconomic Status Scale, majority were found to be of middle socioeconomic status.
Diagnosis and disease characteristics
Diagnoses were initially made as per the ICD-10 classification, but for the study and statistical analysis, diagnoses were grouped as mentioned. Fifty percent of patients were found to suffering from depression and other anxiety disorders (which includes generalized anxiety disorders, panic disorder, phobias, and anxiety not otherwise specified). Substance-related disorders (15%) and psychotic disorders (11%) were the next most common among the study population.
Chi-square test was used to determine the relationship between demographic variables and psychiatric diagnosis. Almost all psychiatric disorders were more common in <35 years of age (62.4%), and the difference was statistically significant. Depression and anxiety disorders were more common among females, whereas substance-related disorders were more common among males with differences being statistically significant. All disorders were more common in nuclear and urban families compared to joint and rural families, respectively, and both the differences were statistically significant. All the disorders were also significantly more common in the upper middle followed by lower middle socioeconomic status compared to higher and lower socioeconomic status. Differences based on religion, caste, and marital status were not found to be significant.
Services used by the patients
Approximately equal proportion of respondents reported to have and have not sought treatment prior to visiting our hospital. Many respondents reported to have visited more than one treatment provider (53.6%) before visiting our facility. Among those who did visit, majority reported to have visited nonpsychiatric doctors (55.6%) followed by psychiatrists (30.6). Faith healers were found to be the third most common preference. Majority of people sought treatment for <6 months (70.53) prior to this hospital and spent <Rs. 500 per visit (75.7). During this period, most of them visited more than 2 times to the treatment provider (59.7%). Around 90% of patients when visited our hospital were spending <Rs. 500 per visit even though >50% of the patients were traveling for >10 km to reach the hospital.
Fifty-eight percent of patients had presented to the hospital within 1 year of onset of symptoms and 48% did so within 6 months itself. A significant proportion (30%) presented after >2 years of illness onset. The time frame of presentation had significant variation based on diagnosis.
Reasons for choosing different services
Easy accessibility of the service, good reputation, faith in the system, enough time given for consultation, belief in the system of healing, and recommendation by someone were the common reasons for choosing a service.
Reasons given for visiting our center included being referred by someone predominantly some family member, ineffective treatment at other places, previous contact with our health facility (for someone else or some other reason), and cost concerns.
Patient's choice to choose a treatment provider before this hospital was significantly determined by the diagnosis (P < 0.05) though the determination of exact pattern could not be done based on current information. Similarly, the length of treatment and expenditure before this hospital varied significantly with the diagnosis.
Headache, ghabrahat, and low mood were found to be the major reasons for visit to the doctor and together these three formed nearly 40% of the total presentations. Among the remaining nearly 30% presented with nonpsychiatric complaints. Similar were the results for presentations over the last 1 year. These reasons for visit to the doctor were found to vary with the diagnosis and this variation was found to be statistically significant.
Untreated mental illness is a cause of major concern worldwide. Various estimates suggest that 30% of the world's population suffers from some mental illness, yet over two-thirds may not receive any treatment at all.,, The data from developed nations like the USA indicates that mental illness may affect up to 31% of the population/year, and out of this 61% are not treated., The untreated mental illness rate for some other developed nations are almost similar.,, The figure may be well above 90% in China. A study done by Patel et al. in 2003 showed a median prevalence of common mental disorders in developing countries at 20%–30%. The data from the NMHS, 2016 give the lifetime prevalence of mental illness in India at 13.7%. It estimates that around 150 million Indians require active intervention for their mental illness. Untreated mental illness has been directly related to poor health outcomes, which inturn may incur huge economic and social losses.,, It thus becomes important to understand barriers impeding people from seeking help for mental health problems to implement targeted interventions to improve the well-being of those affected with mental illness.
Sociodemographic differences in help-seeking behavior have been extensively studied in the literature, with gender being consistently reported as a significant factor. Research has established that females of all age groups are more likely to seek mental health services and engage in professional help-seeking.,, In our study, there was nearly equal number of patients of both genders (males -53%, females -47%). This finding is in contrast to majority of the studies which have shown lower rates of help-seeking in the males compared to the females explained by their primary role of protector and security provider for the family. However, these gender-based roles and definitions are constantly blurring in the modern society, and Delhi is at the very center of this urban transition. The relatively urban population of Delhi has been exposed to more and more campaigns of mental health and there is a priming of the population with regard to the signs and symptoms of common mental disorders. Moreover, there is increased emphasis on equal rights for both genders.
Evidence for the association between age and help-seeking, however, is conflicting, with most studies showing positive associations between increasing age and help-seeking intentions,,, although a few reported negatives, or no association. Among the study population of the present study, the majority of the people were <35 years of age (~62%) with only a small sample (~8%) representing age group above 55 years. Young people are more likely to seek help when they recognize that they have a mental health problem and have the knowledge, skills, and encouragement to seek help. Lack of recognition of mental health problems among young people and their parents is a major “filter” to help-seeking.
Differences based on religion, caste, and marital status were not found to be significant in our study. Although having a larger catchment area, the tertiary care center located in Delhi was frequented more by urban population (70%) with only 14% of the sample coming from the rural background. This could be because the rural population is catered to by the primary and secondary healthcare centers, and mostly only difficult cases reach a tertiary care center. Approximately half of the respondents reported to have sought treatment before visiting our hospital, either other biomedical or traditional care. This can be attributed to the easy availability and accessibility to number of private/public health facilities for those residing in Delhi and the long pathway of care/geographical barriers for those outside Delhi.
About 60% of these reported to have visited more than one treatment provider before visiting the tertiary facility which again reflects the long pathway of care. Nonpsychiatric doctors were the preferred treatment providers followed by psychiatrists. These findings go in accordance to various community-based studies conducted in high-income countries. A substantial number of the patients, 66%–78% in Canada and the Netherlands and 36% in the USA consult the general medical sector for their mental health problems. This could be due to the healthcare delivery systems in the country as well as the easy availability, more faith, reduced stigma in consulting a general practitioner or family physician.
Similar studies carried out in tertiary centers in India reported psychiatrists as the preferred treatment providers for the majority of the sample closely followed by nonpsychiatric doctors.,, This difference could be due to the fact that almost 50% of the current sample was falling in the neurotic spectrum and another 8% in substance use disorder. Since most of these illnesses present with physical sign and symptoms such as palpitations, headache, difficulty breathing, decreased energy levels in the body and multiple somatic concerns among others; a nonpsychiatric doctor is preferentially approached. This emphasises the need to create awareness in nonpsychiatric doctors for early referral and diagnosis which in turn will lead to improved care, reduced costs and better prognosis. It will also consolidate the faith of patients and their relatives in the healthcare system of the country.
Faith healers were found to be the third most common preference., This finding might not be representative of the Indian population as the majority of the patients in the sample were from urban background, who have better access and awareness about the disease model of psychiatric illnesses. Majority of people visiting faith healers reported to be doing so as they find them easily accessible. They also reported faith in the system along with their belief in the supernatural causation of behavioral changes as causes leading them to a faith-healer.
In this study, patient's choice to choose a treatment provider before this hospital was significantly determined by the diagnosis (P < 0.05) though determination of exact pattern could not be done based on the current information. Similarly, the length of treatment and expenditure before this hospital varies significantly with the diagnosis. Although the alternative system of medicines were not found to be very famous among the study population and despite few people having faith in system, people using them reported more effective treatment, more satisfactory consultations and lesser treatment side effects as the most common reasons to visit.
Majority of people sought treatment for <6 months before this hospital and spent <Rs. 500 per visit. During this period, most of them visited more than 2 times to the treatment providers. Nearly majority reported to being referred by someone, predominantly by a family member. Nearly equal proportion of people reported ineffective treatment at other places, the previous contact with our health facility (for someone else or some other reason) and cost concerns as reasons to visit our center. The availability of free medications from the hospital could be one of the major reasons for maintaining follow-up of the patients.
Although our study did show some interesting results, it had some shortcomings as well. A large sampled community-based study would have been more appropriate to actually know treatment-seeking behavior of psychiatric patients. A hospital-based sample has biased the results more toward medical-based care. Of course, with so much diversity in cultural beliefs and treatment-seeking attitudes in our country, this area can further benefit from finer research.
In the end, we conclude that patients with mental disorders often do not seek professional help for a multitude of factors. Reasons may vary on a vast spectrum ranging from difficulty in discussing mental health problems, lack of trust in mental health professionals, overestimation of one's coping abilities, the self-perceived presence of mental illness, self-rating of mental health, stigma, and embarrassment. Along with demographic and social background, these reasons constitute a set of factors that predispose, enable, or impede the use of mental health services. These issues need to be highlighted and addressed to achieve better treatment outcome for these patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
|1||Torres AR, Prince MJ, Bebbington PE, Bhugra D, Brugha TS, Farrell M, et al. Obsessive-compulsive disorder: Prevalence, comorbidity, impact, and help-seeking in the British national psychiatric morbidity survey of 2000. Am J Psychiatry 2006;163:1978-85.|
|2||Meltzer H, Bebbington P, Brugha T, Farrell M, Jenkins R, Lewis G, et al. The reluctance to seek treatment for neurotic disorders. Int Rev Psychiatry 2003;15:123-8.|
|3||Oliver MI, Pearson N, Coe N, Gunnell D. Help-seeking behaviour in men and women with common mental health problems: Cross-sectional study. Br J Psychiatry 2005;186:297-301.|
|4||Investing in mental health. Geneva: World Health Organization; 2003.|
|5||MacKian S. A review of health seeking behaviour: Problems and prospects. Health Systems Development University of Manchester, Manchester, UK 2003.|
|6||Andrews G, Issakidis C, Carter G. Shortfall in mental health service utilisation. Br J Psychiatry 2001;179:417-25.|
|7||Steel Z, McDonald R, Silove D, Bauman A, Sandford P, Herron J, et al. Pathways to the first contact with specialist mental health care. Aust N Z J Psychiatry 2006;40:347-54.|
|8||Kohn R, Saxena S, Levav I, Saraceno B. The treatment gap in mental health care. Bull World Health Organ 2004;82:858-66.|
|9||Mishra N, Nagpal SS, Chadda RK, Sood M. Help-seeking behavior of patients with mental health problems visiting a tertiary care center in North India. Indian J Psychiatry 2011;53:234-8.|
|10||Murthy RS. National mental health survey of India 2015-2016. Indian J Psychiatry 2017;59:21-6.|
|11||Sagar R, Pattanayak RD, Chandrasekaran R, Chaudhury PK, Deswal BS, Lenin Singh RK, et al. Twelve-month prevalence and treatment gap for common mental disorders: Findings from a large-scale epidemiological survey in India. Indian J Psychiatry 2017;59:46-55.|
|12||Gulliver A, Griffiths KM, Christensen H. Perceived barriers and facilitators to mental health help-seeking in young people: A systematic review. BMC Psychiatry 2010;10:113.|
|13||Saraceno B, van Ommeren M, Batniji R, Cohen A, Gureje O, Mahoney J, et al. Barriers to improvement of mental health services in low-income and middle-income countries. Lancet 2007;370:1164-74.|
|14||Choudhry FR, Mani V, Ming LC, Khan TM. Beliefs and perception about mental health issues: A meta-synthesis. Neuropsychiatr Dis Treat 2016;12:2807-18.|
|15||Weiss MG, Sharma SD, Gaur RK, Sharma JS, Desai A, Doongaji DR. Traditional concepts of mental disorder among Indian psychiatric patients: Preliminary report of work in progress. Soc Sci Med 1986;23:379-86.|
|16||Chandrashekar H, Prashanth NR, Naveenkumar C, Kasthuri P. Innovations in psychiatry: Ambulatory services for the mentally ill. Indian J Psychiatry 2009;51:169-70.|
|17||ICD-10 Classifications of Mental and Behavioural Disorder: Clinical Descriptions and Disgnostic Guidelines. Geneva: World Health Organisation; 1992.|
|18||Bairwa M, Rajput M, Sachdeva S. Modified Kuppuswamy's Socioeconomic Scale: Social researcher should include updated income criteria, 2012. Indian J Community Med 2013;38:185-6.|
|19||Chadda RK, Agarwal V, Singh MC, Raheja D. Help seeking behaviour of psychiatric patients before seeking care at a mental hospital. Int J Soc Psychiatry 2001;47:71-8.|
|20||BM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp; 2012.|
|21||World Health Organization. The WHO World Health Report 2001: Mental Health: New Understanding, New Hope. Geneva, Switzerland: World Health Organization; 2001.|
|22||Thornicroft G. Most people with mental illness are not treated. Lancet 2007;370:807-8.|
|23||Kessler RC, Demler O, Frank RG, Olfson M, Pincus HA, Walters EE, et al. Prevalence and treatment of mental disorders, 1990 to 2003. N Engl J Med 2005;352:2515-23.|
|24||Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings. US Patent 1,870,942; 2013. p. 1-63. Available from: http://www.google.com/patents/US1870942.|
|25||Andrews G, Henderson S, Hall W. Prevalence, comorbidity, disability and service Utilisation. Overview of the Australian National Mental Health Survey. Br J Psychiatry 2001;178:145-53.|
|26||Alonso J, Codony M, Kovess V, Angermeyer MC, Katz SJ, Haro JM, et al. Population level of unmet need for mental healthcare in Europe. Br J Psychiatry 2007;190:299-306.|
|27||Qian J. Mental health care in China: Providing services for under-treated patients. J Ment Health Policy Econ 2012;15:179-86.|
|28||Patel V, Kleinman A. Poverty and common mental disorders in developing countries. Bull World Health Organ 2003;81:609-15.|
|29||Boonstra N, Klaassen R, Sytema S, Marshall M, De Haan L, Wunderink L, et al. Duration of untreated psychosis and negative symptoms – A systematic review and meta-analysis of individual patient data. Schizophr Res 2012;142:12-9.|
|30||Dell'Osso B, Glick ID, Baldwin DS, Altamura AC. Can long-term outcomes be improved by shortening the duration of untreated illness in psychiatric disorders? A conceptual framework. Psychopathology 2013;46:14-21.|
|31||Beverley B, Richard C. Mental health literacy in Canada: Phase one report mental health literacy project. Can Alliance Ment Illn Ment Health 2007.|
|32||Rüsch N, Müller M, Ajdacic-Gross V, Rodgers S, Corrigan PW, Rössler W. Shame, perceived knowledge and satisfaction associated with mental health as predictors of attitude patterns towards help-seeking. Epidemiol Psychiatr Sci 2014;23:177-87.|
|33||Yeap R, Low WY. Mental health knowledge, attitude and help-seeking tendency: A Malaysian context. Singapore Med J 2009;50:1169-76.|
|34||Tieu Y, Konnert CA. Mental health help-seeking attitudes, utilization, and intentions among older Chinese immigrants in Canada. Aging Ment Health 2014;18:140-7.|
|35||Roh S, Burnette CE, Lee KH, Lee YS, Martin JI, Lawler MJ. Predicting help-seeking attitudes toward mental health services among American Indian older adults: Is Andersen's behavioral model a good fit? J Appl Gerontol 2017;36:94-115.|
|36||Eisenberg D, Golberstein E, Gollust SE. Help-seeking and access to mental health care in a university student population. Med Care 2007;45:594-601.|
|37||Alegría M, Bijl RV, Lin E, Walters EE, Kessler RC. Income differences in persons seeking outpatient treatment for mental disorders: A comparison of the united states with Ontario and the Netherlands. Arch Gen Psychiatry 2000;57:383-91.|
|38||Janakiramaiah N, Badrinath B, Channabasavanna SM, Kaliaperumal VG. Dealing with deviant behaviour. Indian J Psychiatry 1979;21:206-10.|