Anindita, Sandhya Ghai, Nitasha Sharma
Abstract : Introduction: Mental health care within primary health care presupposes adequate information how psychiatric patients are being handled by the family and community. Proper handling of these patients affect the outcome of illness. A variety of psycho social, cultural and religious factor reflects the beliefs and the attitude of family and community to the sick individual. The way a patient adopts to reach the appropriate treatment centre is termed as the pathways of care. Studying the pathway of care helps us to analyze the use of health care services, identify the cause of delay in attending the accurate and adequate care and to find out the possible remedies or alternatives. Objective: To identify the pathways of care before attending Psychiatry care services of PGIMER, Chandigarh. Methods: Research approach was quantitative & design was exploratory research design. The study was conducted in Psychiatric Outpatient Department and Psychiatric Ward during the month of July – August 2016 on 200 patients. Purposive sampling technique was used. Socio –demographic proforma and modified WHO encounter form was used for identifying pathways of care by interviewing the patients. Results: The result of the study had shown that for the patients first carers were private general practitioner (16 %), general practitioner in government hospital (3.5%), private psychiatrist (30.5%), government psychiatrist (18 %), 25.5 % came to PGIMER directly and only 1.5 % went to faith healer. Conclusion: It was seen that total 74% people came to psychiatry consultation and very few went to faith healer in their first help. Hence it can be concluded with that people were conscious, educated and aware about psychiatry illness. Sick individual was identified and unnecessary delaying was avoided to get care proper treatment.
Pathways of care, Psychiatric patients
Dr. Sandhya Ghai
National Institute of Nursing Education (NINE), PGIMER, Chandigarh
Mental illnesses are commonly connected with a high level of disability and burden of disease than many other physical illnesses. The World Health Organization noted that one in every four people is suffered by any mental disorder at any stage of life. Six neuropsychiatry conditions, like depression, alcohol abuse, schizophrenia, bipolar affective disorder, Alzheimer’s disease, dementia and migraine have figured in the top 20 causes of disability in the world.1 There is 1.5 crore people suffering from various mental disorders in India. Severe cases have higher representation at general hospital as well as specialized clinic. Epilepsy and hysteria were seen significantly high in rural area.2
Limited proportion of patients with psychiatric problem attends the health care facilities in severe condition. Treatment from unqualified medical practitioners and religious healers is very common and that is one of the general causes of delaying the proper treatment. Other contributing factors are major stigma, old cultural myth and supernatural explanation of psychiatric disorders specially in developing countries.3
The way a patient adopts to reach the appropriate treatment centre is termed as the pathways of care. Studying the pathway of care helps us to analyze the use of health care services, identify the cause of delay in attending the accurate and adequate care and to find out the possible remedies or alternatives. The purpose of early diagnosis and prompt treatment is to reduce the period of suffering in which a client’s life becomes disrupted and return them in community as a productive personnel as early as possible.
To identify the pathways of care before attending psychiatry care services of PGIMER, Chandigarh.
Material and Method
Research approach was quantitative & design was exploratory research design. Purposive sampling technique was used. This study was conducted in Psychiatry outpatient department and Psychiatry ward during the month of July – August 2016 on 200 patients. Among 200 patients 180 patients were taking their treatment from outpatient department and 20 patients had chosen from admitted patients of psychiatry ward. Socio demographic proforma to assess socio demographic profile of subjects and modified WHO encounter form to assess the pathway of psychiatry care from community to tertiary mental health services were used for both outpatients and inpatients.
WHO encounter form helped to identify when patient or family members initiate for first help to take treatment and how many referral patient had got; to whom patient had been referred and how long he/she got treatment from one agency; who accompanied patients for treatment and what were the symptoms or complications which were responsible for changing treatment agency; how much patients or family members were conscious or educated about psychiatric symptoms, intervention or drug compliance as it identified patient went to faith healer, alternative therapist or any psychiatric consultation. The form had been modified according to Indian scenario because treatment agencies were different from developed country and it was validated by experts in the field of Nursing and Psychiatry.
Inclusion criteria were patients who were willing to participate in the study, were cooperative and gave inform consent and patients who understood Hindi and English. Exclusion criteria were patient with chronic medical illness and primary memory disorder and patients without relatives were excluded from the study. Written permission was taken from HOD, Department of psychiatry, PGIMER, Chandigarh. Ethical clearance for the study had taken from the Institute Ethics Committee of PGIMER, Chandigarh. Written inform consent was taken from the subjects and caregivers who were willing to take part after explaining about the research study and reassure them about confidentiality. There was no interference in check-up of the subjects due to data collection in outpatient department and in the care of hospitalized subjects.
Data was collected by interview method from the patients along with their primary care giver. Subjects were interviewed in separated room as per interview schedule and approximately 20- 25 mins was taken for interviewing each candidate. Data was analyzed by Descriptive statistics (Mean, Range and Standard deviation), SPSS analysis and coral software.
The socio-demographic profile of 200 patients who were attending psychiatry care services from PGIMER, Chandigarh is summarized in the table number 1 below. The mean age ± SD of 200 patients was 41.40±14.410 years (Range 18-77 years). 37.5 % of the patients were in the age group of 31-45 years. 52.5 % patients were female and majority (65%) patients were married. 24.5 % patients have completed their secondary education and 41% patients were unskilled worker. Nearby 70.5% patients were Hindu among 200 patients. 55.5% patients belong from nuclear family and 51.5 % patients were from rural background. Per capita per month income of 42% patients was up to Rs 3000. The mean of per capita per month income ± SD of 200 patients was Rs. 6448.10
Table 1: Socio demographic profile of the patients attending psychiatric care service
|Widowed/ Divorced/ Separated||17(8.5)|
|Post high school diploma||8(4.0)|
|Post graduate/ Masters||19(9.5)|
|Semi skilled worker||12(6.0)|
|Type of family|
|Locality of subject|
|Percapita per month income (Rs.)**|
|Up to 3000||84(42.0)|
* Age (years) Mean ± SD (41.40±14.410) Range (18-77)
** Percapita of Income (Rs.) Mean ± SD (6448.10 ±7506.16)
±7506.16 (Range Rs. 300-50000). Range (300-50000)
Clinical Profile of the Subjects
Table 2 depicts that 78.5 % patients were psychotic, 20 % were non psychotic and 1.5% patients were suffering organic illness. 42.5% patients came to PGIMER, Chandigarh by him/herself, 32% patients brought by family or relatives, 22.5% patients referred by medical personal and only 3% patients referred from other department of PGIMER, Chandigarh for psychiatry consultation.
Pathways of Psychiatric Care
Table 3 depicts 61(30.5%) patients went to private psychiatrist directly at first time that is more than one fourth of total subjects. Total 74% patients went to psychiatrist as their first helping agency, it may be government psychiatrist, may be private psychiatrist or psychiatrist in PGIMER, Chandigarh. 22.5% patients came to general practitioners for their first help which include private general practitioners, government general practitioners and practitioners in other department of PGIMER, Chandigarh. Out of 200 patients 51(25.5%)
Table 2: Clinical profile of the patients attending psychiatric care service
|Source of referral|
|Other department of PGI||6(3.0)|
in first help, 68(34.5%) in first referral, 42(21%) in second referral, 29(14.5%) in third referral, 13(6.5%) in fourth referral, 9(4.5%) in fifth referral, 1(.5%) in sixth referral and 1(.5%) in eighth referral came to PGIMER, Chandigarh psychiatry OPD. 6(3.0%) patients was referred for psychiatry consultation from other department of PGIMER, Chandigarh. Very few patients (1.5%) went to faith healer and 4(2%) went to alternative therapist in their first help. One patient had the longest pathway of eighth referral and that patient had 9 choices of treatment in pathway of care.
Table 3: Frequency of psychiatric patients in various referral of their pathway
|Variables||First help||First Referral||Second Referral||Third Referral||Fourth Referral||Fifth Referral||Sixth Referral||Seventh Referral||Eighth Referral|
|Other dept. of PGI||6(3.0)||2(1.0)||0||1(.5)||0||0||0||0||0|
|PGI Psychiatry OPD||51(25.5)||68(34.5)||42(21.0)||29(14.5)||13(6.5)||9(4.5)||1(.5)||0||1(.5)|
|Patient cont. treatment from PGIMER||0||43(21.5)||106(53.0)||147(73.5)||176(88)||189(94.5)||198(99.0)||199(99.5)||199(99.5)|
Figure 1: Diagram of pathways of all subjects
Figure 1 shows pathway of total 200 patients how they changed their choice of treatment and entered tertiary psychiatric care service from community settings. In first help among 200 patients 36 patients went to government psychiatrist, 6 patients went to other department of PGIMER, Chandigarh, 61 patients went to private psychiatrist, 51 patients went to PGIMER psychiatry OPD, 7 patients went to government general practitioner, 32 patients went to private general practitioner, 3 patients went to native healer and other 4 patients went to alternative therapist. Various color code had used for every referral to make it easy to understand. To make it more clear 8 small pathway had been drawn.
Figure 2 depicts that out of 200 patients 51 patients directly came to psychiatry OPD of PGIMER, Chandigarh from their community setting. Out of them 43 patients were continuing their treatment from psychiatry OPD of PGIMER and 8 cases were drop out to private psychiatrist, government psychiatrist, private general practitioner, alternative therapist and native healer but finally came to PGIMER, Chandigarh psychiatry OPD after many referral. Figure 3 depicts the pathway of 3 patients who had come to native healer in their first help. In first referral 2 patients had gone to private psychiatrist and 1 patient went to private general practitioner. In 2nd referral 3 patients came to psychiatry OPD of PGIMER, Chandigarh. Figure 4 depicts that from community 6 patients came to other department of PGIMER, Chandigarh in their first help and after that they had referred for psychiatry consultation in OPD of PGIMER, Chandigarh.
Figure 5 depicts that among 200 patients 7 patients selected government general practitioner as their first helping agency and referred to PGIMER, Chandigarh. Figure 6 depicts the pathway of 4 patients who went to alternative therapist at their first contact of help. Figure 7 depicts that from community settings, 32 patients went to private general practitioners in their first help. After that they went to private psychiatrist, private general practitioners, government psychiatrist, government general practitioners, and only 2 patients went to native healer in their pathway of referral. Finally after so many referrals they came to PGIMER psychiatry OPD.
Figure 8 depicts that in first help more than one fourth patients (61) went to private psychiatrist and out of them 28 patients came to PGIMER psychiatry OPD in their first referral. That diagram of pathway showed one patient had the longest pathway of eighth referral and that patient had 9 choices of treatment in pathway of care. Figure 9 depicts that from community settings 36 patients came to government psychiatrist in their first help. Out of 36 patients 20 came to psychiatry OPD of PGIMER, Chandigarh in their first referral and rest of them went to various another referrals.
Mental health services are restricted in many areas of the world, particularly in developing countries. Even at places where they are available also, major portion of patient finds psychiatric treatment as the last option after having so many opinions from different types of non-psychiatric care provider. The various mode in which patients are being handled earlier to psychiatric intervention put forth decisive control on the course and outcome of illness. Lack of mental health awareness, lack of education, social stigma, poverty, supernatural belief is the common contributory factors of delaying proper mental health treatment. For that reason a lot of crucial time has been lost, which can help in better prognosis with early recognition and prompt right care.
Psycho-social problem in rural area is strongly coupled with social determinants such as gender, poverty and affects the entire population including farmers.4 Treatment gap is very high in that field. The way a patient adopts to reach the appropriate treatment centre is termed as the pathways of care. Studying the pathway of care helps us to analyze the use of health care services, identify the cause of delay in attending the accurate and adequate care and to find out the possible remedies or alternatives. The purpose of early diagnosis and prompt treatment is to reduce the period of suffering in which a client’s life becomes disrupted and return them in community as a productive personnel as early as possible. Hence, it is important to implement a community based mental health programs which address both the demand and barriers which helps in low levels of contact coverage.
of total patients and total 74% of patients went to psychiatrist, it may be government psychiatrist, private, PGIMER psychiatry OPD. Findings of the study depicted presence of much understanding and awareness towards mental health care in community.
Adeosun et al6 assessed the pathways to first contact with the mental health care along with cost among schizophrenic patients at Federal Neuro-Psychiatric Hospital of Lagos, Nigeria in 2008. Result was that majority (69%) of patients consulted traditional or spiritual healers in their first contact within the process of Lahariya et al1 proposed that due to seeking care for their illness. 17.4% of illiteracy most of the patient had first contact with faith healer and only 9.2 % of patient had met with psychiatrist at their first help. But in the present study most patients had completed their secondary level of education and their first contact was private psychiatrist. Only 1.5 % patient went to native or religious faith healer as first helping agency. So data of present study indicates that as subjects were from an educated group improved educational level helps to get right care promptly and prevent unnecessary delay of treatment. Reduced believes of supernatural cause among literate people helps to prevent treatment access from native/ religious faith healers.
Faizen et al5 had done a study on pathways of psychiatric care in southern region of India and result of the study was seen that allopathic practitioners worked as first careers for 51 % of mentally ill persons, and only 22.1 % of patients consulted with mental health professional in their first help. Present study depicted that general practitioner were the first helper for 19.5 % patients first contacted with psychiatrists and 13.8% patients consulted with non psychiatric physician or general practitioners. There was significantly greater delay in initiating physician contact approximately 17 weeks. Reasons for choosing non orthodox healers were super natural belief, influence of relatives and neighbours, stigma associated with illness and lack of adequate fund. But present study represented that circumstance had changed through the time. Very few patients (1.5%) used religious healer as first helping agency. Because of more awareness among public through mass media reduce stigma related to mental illness in society and people gives importance on mental health and able to identify mental sickness and also visit accessible treatment facility as early as possible.
Those patients who went to psychiatrist in their first help and continued their treatment from there only choose a good pathway. The patients who referred from general practitioners to psychiatrist also had good pathways of referral. But the patients who went to faith healer or any alternative therapist in their first help or anyone who discontinued treatment from psychiatrist and went for them had chosen the worst pathway of referral. In present study, it had shown very few patients choose faith healer or alternative therapist as their first help and once people came to psychiatrist, very few discontinued treatment from them and went to other agency. If patients came to general practitioners as first helping agency they were easily referred to psychiatrist. Reasons of choosing good pathways were education, awareness about mental health, good support from family or surroundings and for choosing bad pathway contributory factors were false super natural beliefs, myth, not getting adequate support system, stigmatized society.
We can conclude with that now people were concern about illness because 74% of total patients had gone to psychiatrist in their first visit. So, chances of delaying in the treatment were less. There is more awareness among public, reduce stigma related to mental illness in society and people can identify mental sickness and as early as possible they also visit accessible mental health facility. It is recommended to identify predictors of long or short pathways, causes to change any health care agency, distance of each agency from community setting, duration of treatment from any agency and treatment outcome. The study helped to identify the barriers faced by patients to access early and effective treatment. The nurses working in community and other health care professional can help the patients to overcome such barrier through informational and educational activities. Focus on those results should be given at the time of mental health programme to create more awareness among public, increased psycho education, importance on caring mental health and early diagnosis of mental illness.
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