Pathway of psychiatric care

In search of the best possible options for appropriate, evidence-based and effective management of psychiatric disorders, constant research activity, nationally and internationally, is being undertaken to underpin both biological and social factors relevant to early treatment, cost effectiveness and the best possible prognosis. Though psychiatric services are limited in many parts of the world, especially in developing countries like India, even at places where they are available and among those who could have easier access to avail benefits early from psychiatric services, significant proportion of patients find psychiatric services as the last resort after having consultations from many different types of non-psychiatric care providers, including faith healers. In this, lot of crucial time is lost, which could have relevance to better prognosis, as early recognition and management are of utmost importance in psychiatry.[1] This has increased the importance of not only the availability of mental health services in the community for easier access but also the various social and cultural factors which determine the help seeking behavior and pathway of psychiatric care, which is defined as the sequence of contacts with individuals and organizations, initiated by the distressed person's efforts and those of his significant others to seek appropriate help.[2]

Research related to help seeking behavior and attitude toward mental illnesses and services which primarily determine the pathway of care has been carried out mainly in developed nations. There is, however, deficiency of information from the developing countries.[3]

EFFECTIVENESS AND DETERMINANT OF PATHWAY OF CARE

As the basic purpose of the pathway of care is to provide early engagement with psychiatric services to minimize the effective cost of treatment and maximize better prognosis, this could be of great help in mental health services. Increasing emphasis is being placed on the implementation of care pathways in all types of healthcare settings, including psychiatry, in the developed countries.[4,5] Though currently the effectiveness of pathway of care and impact of care pathways on the delivery of mental healthcare is still rudimentary, in practice this could be of great help and effective for the developing nations where there is an urgent need to cater for psychiatric patients with limited psychiatric services. This needs explorations of many overt and covert factors acting as hindrance in the pathway of care and appropriate solutions. These factors play an important role at various steps. Factors causing delay in the initiation of appropriate treatment at the first instance vary from region to region depending upon the sociocultural profile, education, attitude of family/society toward mental illness, perceptions, myths, beliefs, stigma attached with psychiatric disorder, availability/accessibility of psychiatric services and referral patterns, and previous experience of receiving psychiatric help. These determinants also differ in their strength of impact deciding the pathway of care in different geographic regions of world. For example, in the developed nations, the major concern is of stigma, while in the developing nations it is the problem of age old cultural myths and supernatural explanations of psychiatric disorders. There is also a significant role of care providers in deciding the pathways to psychiatric care, the first care provider being the most important for giving direction to the pathway of care to seek further help.[6]

NEED OF PATHWAY OF CARE IN DEVELOPING NATIONS

It is estimated that one in four families has at least one member currently suffering from a mental or behavioral disorder. This results in substantial burden on family members, compromised quality of life, and the negative impact of stigma and discrimination.[7] Also, approximately half of the estimated 450 million people affected by mental illness globally live in Asia-Pacific regions;[8] but due to multiple factors playing as barriers in the pathway of care, many are left untreated, many are partially treated and only a small fraction gets access to appropriate place of treatment. Also, the cultural norms of the society of developing nations, where joint family system is still prevailing, especially in rural areas, increased cohesion between family members, community tolerance and simple ways of life lead to easier accommodation of the patients with mental illness, well without seeking any medical help for years.[9,10]

There is wide disparity in the type and numbers of the mental health workforce throughout the world. In comparison to the developed nations, psychiatric resources are limited. The median number of psychiatrists varies from 0.06 per 100,000 population in low-income countries to 9 per 100,000 in high-income countries and the mental health services are available in the range of 1/50 to 1/1000 of what is available in well developed countries.[10]

In the situation of larger prevalence of mental illness, half of which is confined to Asia-Pacific regions (majority are developing nations) with limited psychiatric services, studies underpinning determinant of pathway of care need to be undertaken so that mental health services could be planned according to the prevalent cultural norms and other factors more specific to the developing nations and important steps could be taken in the community, for example, increasing the mental health literacy

CURRENT SCENARIO: INDIAN PERSPECTIVE

The author views awareness about psychiatric disorder as one of the most important factors that could modify cultural myths regarding psychiatric disorders, consequently reaching to a favorable help seeking behavior.[11] To determine the changes over the last three decades in help seeking behavior, when a comparison was made of recent studies[11,12] and the one that was carried out three decades back at Lucknow by the author[13] regarding help seeking behavior and pathway of care, the author finds that even though India, like many other such developing nations across the globe, has made considerable progress with regard to mental healthcare facility, faith healers are the first care providers for majority of the psychiatric patients with poor referral patterns, and during pathways, there are instances where care seekers might revert back to faith healers or may simultaneously be seeking help from modern as well as traditional methods of therapy. Direct access to psychiatric services after the onset of illness is not a prominent pathway.[11,13] One of the most important factors responsible for faith healing is self-explanatory and magico-religious model of causation of psychiatric disorders. Thus, in the past three decades, despite significant advancement made and availability of psychiatric services in the form of community psychiatry (e.g. private sector's psychiatrist, district mental health programs), minimal change has taken place in the myths and beliefs related to the causation of psychiatric disorders, a major determinant of pathway of care.[14,15]

There is a need for further research to delineate psychiatric pathways of care and their determinant in the developing countries. Definitely, this information is most likely to assist service providers and policy makers to purposefully plan for culturally appropriate and accessible psychiatric services providing easy, cost-effective and favorable pathway of care for psychiatric patients as per the community needs. Also, there is a need to increase the awareness about psychiatric disorders and services for better help seeking behavior and favorable pathway of care.