Pathway to psychiatric care and cultural myth

Sir,

I read, with interest, the recent article “Pathway of Psychiatric Care” by Trivedi & Jilani.[1] Dr. Trivedi is a well-known scholar in the mental health field and has made valuable contributions to Indian Psychiatry. But unfortunately in this sketchy guest editorial, their comments on “Indian Perspective” appear to me as quite inadequate and incorrect. I would like to point out some of the discrepancies noted in their article.

1. It is true that “awareness about psychiatric disorder” is a strong determinant in reducing cultural myths about psychiatric disorders to enhance help seeking behaviour. Two important issues lack clarity in their view as whose awareness and whether alternative options (for care) are available to the cultural groups and communities. Psychiatric care pathway is a way forward for proper care provision, both for national administration and for the stakeholders. So awareness of authority is equally needed to implement PPC. I am not aware of any initiatives, either from the Central Government or from any of the State Governments in India, of any community-based initiative for mental health advocacy among the population (especially in the remote rural areas) to fight against cultural myth about mental illness. So it is not correct, in my view, to place the onus entirely on the community for their continued adherence to cultural myth. Secondly, in my long experience in mental health I have seen that, in addition to alternative treatment (traditional or folk), millions of people tend to use urban psychiatric clinics for treatment. So, it is primarily the availability of modern treatment and not the cultural myth that acts as the main determinant of whether people would avail it or not. I understand from many colleagues in urban set-ups having the experience of meeting thousands of rural people who, in spite of their cultural myth or having such treatment, sought modern treatments in the clinics. So in my opinion, it is the systemic failure, on the part of governments, to provide psychiatric care in the community, which compelled the patients to seek help from traditional healers. It is not their fault or negative contribution to the pathway of care, which in reality, is non-existent in India. This is a hard reality as Kapur[2] has pointed out “Most of the mentally ill are cared for by indigenous healers.”

2. The authors’ views on traditional healers or their care provision appear to be a little disrespectful. If one considers the Indian health system, mainly in rural India (partly in urban India also) the first line of contact for any illness constitutes local health care providers, a large proportion of whom is comprised of traditional healers. It is not people's cultural myth but forced choice, as there is no alternative layer of care available in the vicinity. If one has the correct emic view of help seeking, then one should not negatively implicate their simultaneous treatment approach from the traditional health system. It is one of the main aspects of cultural psychiatry (cultural relativism) to respect people's explanatory model of illness and help seeking (until it poses no serious health threat).

3. The authors mentioned about “direct access to psychiatric services” and “referral pattern” without mentioning how vacant and meaningless these academic and logistic terms are, in mental health care scenario in India. The concept of PPC is contingent on the referral system. The concept originated in the Western world where health services maintain strict boundaries among three service layers, namely primary, secondary, and tertiary, along with having a definite (geographically bounded and obligatory) catchment area from where the referrals originate. In this well-systematized market economic health care approach, the pathway of care ought to function, because the client has to follow the pathway otherwise he will not get the service. But in the Indian context, this “pathway of care” is a mere academic topic, not a practical approach because there is no referral system or a defined catchment area. Anybody can go to any facility anywhere, no definite pathways operate from rural to urban or from primary to secondary or tertiary care, there is no health card or national health number. In the pluralistic health care system, the functioning of pathway is a myth rather than a reality. Because of the failure of referral system, non-mandatory referral route and improper functioning of primary or secondary care, the tertiary level hospitals in India are crowded with millions from rural areas. If one examines the hospital attendance at any urban tertiary centre not just in psychiatry but in other medical faculties as well, several questions are to be considered, i.e., who are the main attendees? Who referred them? Do they belong to any identified catchment area for this hospital? Answers to all these questions are immaterial and impractical because there is no “pathway of care”.

4. What is the meaning of “direct accesses” in the context of pathway of care? Multiple factors influence the help-seeking behavior of patients with mental disorders. Two crucial factors are: patient's or family's knowledge and recognition of mental disorder, and accessibility and availability of a helping agency in the community. Unfortunately the community psychiatry program, which the authors mentioned as a mark of advancement in psychiatric services in India does not address any of these issues. The essential components of the District Health Programme under the aegis of National Mental Health Programme of Government of India (started in 1982) included the following[3]: (a) training of health functionaries; (b) continuous and uninterrupted provision of essential drugs; (c) a simple recording and reporting system; (d) continuous support and supervision by technical experts, and (e) community participation and establishment of district units. There is no mention about mental health advocacy to mitigate cultural myth or superstition about mental illness. Contrary to the false expectation of the authors, there was no agenda in the community mental health program to “change the myths and beliefs related to the causation of psychiatric disorder.” So community mental health programme is in that sense not a protocol to activate PPC in the Indian context. Yes, definitely it has expanded the scope of obtaining treatment for mental illness (biomedical care) outside the orbit of tertiary urban care. It does not offer or guarantee any referral system or direct mental health care for millions of Indian rural people, who are still surviving on their traditional care and social support system.

5. The authors indirectly blamed faith healing, etc. as if it is standing in the way of pathway of care. They also mentioned that, inspite of some “advancement of psychiatric services” no change is observed in cultural myth and thus help seeking behaviour of people, which they believe is the “major determinant of pathway of care”. This view is not only a very simplistic generalization but contains a major error in observation and is not evidenced based. Contrary to authors’ assertions, Campion and Bhugra[4] studied traditional methods of treatment by religious healers, who are consulted by 45% of mental patients before seeking treatment in a psychiatric clinic in southern India and commented that the medical literature seldom mentions traditional healers despite their importance as the first line of treatment in developing countries. A study from Kuala Lumpur[5] showed that the most common first contact for first-episode psychosis was with traditional healers and authors expressed the potential benefit in management from collaboration with traditional healers. A study[6] from South India reported that traditional community healing resources, including temple healing, are widely used in managing mental illness in India and they suggested that “existing traditional resources may have a role in providing community mental health care.”

6. Pathway to Care (PC): It has to be recalled that in Western countries, especially in the UK, when the shift took place from hospital-based care to community care of mental health patients, the clinical logistics and protocol of “pathway to care” evolved with a prime focus on GPs as the first focal point on the care pathway system.[7] WHO defined pathway to care as “the route whereby people with mental disorders gain access to providers of mental health services. These pathways influence the organization of services.”[8] In countries with market economy, the PC is usually the primary care system (where GP acts as the gatekeeper), referral from secondary and tertiary care and referral from other sources like school, police, judiciary, or social services. In developing countries, the picture is entirely different. The usual PC comprises of village health workers, NGOs, primary care hospitals, traditional healers, and even direct access to private or public mental health services. WHO stated that these PC may hinder access to mental health services and provided seven reasons for that, which are quite pertinent to the Indian context, as follows: (1) low awareness of available services; (2) a lack of well-organized primary mental health care; (3) inadequate links between services; (4) a lack of knowledge among rural populations about the causes of and treatments for mental disorders, resulting in the underutilization of mental health services; (5) inadequate mental health training of general practitioners and traditional healers, contributing to low rates of detection, treatment and referral of mental disorders in traditional and primary care settings; (6) failure of mental health services to actively identify cases in the community, users being required to find and access available pathways; and (7) difficulty in accessing specialist services, partly associated with the need for professional referral to specialist program. WHO thus recommended: “Service planners should organize services so as to overcome these barriers, improve access and thus reduce the duration and severity of disability caused by mental disorders.” So basically the onus lies with the government to proactively develop a suitable service design for effective PC to enable direct access to mental health services. The main focus here is that the service must be available and there should be an organized primary care with established and binding referral link. Unfortunately these provisions are neither in existence nor functional in India. So it is not the cultural myth that stood in the way to effective PC in India, as the authors stressed in their discourse.

7. Medical pluralism and PPC: PPC varies greatly among different communities, regions and countries.[9] GP's role in effective PPC is crucially important. Studies of PPC in first episode psychosis from UK and Australia have shown a very high rate (around 50 - 60%) of GP contact.[10] On the other hand, studies from the developing world show that GPs play a less prominent role with involvement of varieties of health professionals including traditional healers and criminal justice system.[11] These pathways are called “Adverse pathways” and are characterized by the absence of GP involvement, increased criminal justice involvement and high rates of compulsory admissions for ethnic minority groups (within the UK).[12] Studies from Nigeria[13] and rural South Africa[14] found significant delays in treatment in first episode psychosis patients where traditional healers were the predominant first contact. In contrast, a study from Zimbabwe[15] found no increase in delays in patients referred by traditional healers. Interestingly, some studies highlighted the beneficial aspect of traditional care and social support system in developing world[16] and thus McKenzie et al.[17] commented that “Services in low income countries are often greatly under-resourced, under strain and leave most people with mental health problems with no care. But there are examples of different ways to treat or prevent mental illness from which high-income countries can learn. Some are born from the ingenuity of necessity, others from cultural knowledge.” Studies of PPC in five Asian countries (India, Bangladesh, Nepal, Japan and Mongolia) showed four major care pathways: direct access, referrals from private practitioners, referrals from general hospitals, and referrals from native or religious healers. General practitioners did not play a pivotal role in any of the areas, whereas native or religious healers had an important place in all countries except in Japan.[18] A study from South Africa found that traditional Zulu healers were perceived “more or less equally helpful” as that of modern practitioners by the patients.[19] Considering the ground reality of traditional healers’ role in mental health care in developing countries, many national governments are adopting health care policy that involve the traditional healers, namely in South Africa, Swaziland, Nepal, Cambodia, and Zambia.[20–24] So it would be more pragmatic, not to implicate traditional healers and cultural myth of people as hindrance to whatever PPC is practicable for India, but to involve intelligently the local health care providers as Kapur[25] commented “any scheme for introducing modern psychiatry into rural areas should make use of the locally popular healers, both traditional and modern”. To improve the situation of mental health care in India, a paradigm shift is needed from the current “biomedical model”to a “sociocultural model” to meet the needs of millions of rural population.[26]