ORIGINAL RESEARCH


https://doi.org/10.5005/jp-journals-10067-0106
Indian Journal of Private Psychiatry
Volume 16 | Issue 1 | Year 2022

How Lengthy and Tortuous is the Pathway to Psychiatric Care among Patients Visiting a Tertiary Care Hospital in South India? A Cross-sectional Study

Manjula Simiyon1, Swetha Joju2, Pradeep Thilakan3, Manikandan Mani4

1Department of Psychiatry, Wrexham Maelor Hospital, Wrexham, United Kingdom

2,3Department of Psychiatry, Pondicherry Institute of Medical Sciences, Puducherry, India

4Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India

Corresponding Author: Manjula Simiyon, Department of Psychiatry, Wrexham Maelor Hospital, Wrexham, United Kingdom, Phone: +447831449630, e-mail:manjula.simiyon@yahoo.co.in

How to cite this article: Simiyon M, Joju S, Thilakan P, et al. How Lengthy and Tortuous is the Pathway to Psychiatric Care among Patients Visiting a Tertiary Care Hospital in South India? A Cross-sectional Study. Ind J Priv Psychiatry 2022;16(1):3–9.

Source of support: Nil

Conflict of interest: None

ABSTRACT

Background: Mental illnesses (MI) are commonly linked with a higher burden of disease. A large number of patients with mental illnesses do not present to the mental health services directly rather they adopt a pathway that is usually prolonged and tortuous. By the time they reach the mental health services the illness becomes chronic and the resources are exhausted. It is all the more relevant in countries like India where traditional healing practices are easily accessible in contrary to mental health services.

Aims and objectives: The aims and objectives of this study were to measure the number of encounters patients with psychiatric illnesses had before meeting a mental health professional and the duration of untreated illness (DUI).

Materials and methods: In this cross-sectional questionnaire-based study, we interviewed 150 patients and their caregivers visiting the outpatient services of a tertiary care teaching hospital in South India.

Results: The median time taken for any help, from traditional healers, general hospitals, or a mental health practitioner was 12 months (IQR 2–47.25). The median DUI was 18 months (IQR 2.75–60), and the median total duration of illness was 24 months (IQR 4–87). The mean number of encounters was 2.7 (SD ± 1.77). As the first point of contact, 12% had met a traditional healer and 40% had met a psychiatrist. Friends and relatives in 80% of the patients initiated help-seeking. In multivariate analysis, age, male gender, and lower educational status were significant predictors for a longer duration of illness.

Conclusion: Patients in India continue to take a long and tortuous pathway to psychiatric care that goes through many encounters.

Keywords: Duration of untreated illness, India, Pathway, Traditional healers.

INTRODUCTION

Mental illnesses (MI) are commonly linked with a higher burden of disease. In countries like India only a limited proportion of patients with psychiatric disorders attend mental healthcare facilities and only when the condition becomes severe.1 Many patients are treated inadequately, which delays their presentation to hospitals, and they become chronically ill, which depletes their resources.2 Duration of untreated illnesses (DUI) not only poses a major challenge in the prognosis of mental disorders but also is associated with high levels of disability.3,4 Hence, the earlier they reach an appropriate system of care better is the outcome.

This is of special interest in India because of the shortage of access to trained mental health professionals and unique cultural diversity. Pathways to care for mental illnesses are more complicated and prolonged than other illnesses. Analyzing the pathway of care helps us to understand the health service utilization, recognizing reasons for the delay in reaching appropriate carers, and strategically plan solutions.2

NMHS5 revealed that a huge treatment gap exists in India, with a range of 28–83% for other mental disorders and 86% for alcohol use disorders. The availability of psychiatrists (per 1 lakh population) in the 12 states studied by NMHS varied from 0.05 in Madhya Pradesh to 1.2 in Kerala. The limited availability of trained mental health professionals is a major challenge. Also, there is a huge disparity in the distribution of mental health practitioners (MHPs), as most of them live in urban areas.

Mental health problems, from the onset of illness to course and outcome, at every phase are influenced by cultural beliefs. In India, blind beliefs and faith in the supernatural etiology of mental illness are highly prevalent among the majority of the population, especially in rural and tribal areas.6 Traditional healing has a long and significant history in India.7

Many studies have been conducted in different parts of the world to analyze the pathways to care.2,810 Also many years ago, World Health Organization (WHO) has conducted a multicentric study including India, to understand various pathways.11 A recent study conducted in North India included only 50 in-patients which cannot be generalized as, in-patients may represent severely ill population.12 It is important to have regional research in this aspect, as it differs depending upon various factors such as culture and religion and only minimal work has been done in South India. It is not only important to research these geographical regions but also in different periods, as customs and cultural beliefs change over time which can impact the pathway.

AIMS AND OBJECTIVES

To assess the following:

  1. The number of encounters (NOE) patients had and the cost involved, before visiting an MHP. (Encounter was defined as the first ever help-seeking effort taken for a specific mental health condition).

  2. Duration of untreated illness (DUI): The duration between onset of symptoms and presentation to any mental health professional (MHP).

  3. To study the association between sociodemographic factors, clinical variables, and the pathway.

MATERIALS AND METHODS

This hospital-based, cross-sectional study was conducted to collect retrospective information from patients and their caretakers on their care-seeking pathways that lead them to the department of psychiatry, Pondicherry Institute of Medical Sciences of a tertiary care teaching hospital in South India. After obtaining Institutional ethical clearance (PIMS/IEC/20-19) and written informed consent, 150 adult patients accompanied by primary caregivers attending the out-patient department of psychiatry for the first time in the 2 months were selected through purposive sampling. As this was a period-based study, sample size was calculated based on the hospital census. The details were collected from both the patient and caregivers. Caregivers who had cognitive deficits, intellectual disability, hearing deficits, and psychiatric disorders (evaluated clinically), except for nicotine dependence, were excluded. Those who fulfill the inclusion criteria were interviewed using a semi-structured questionnaire and the WHO encounter form.13 The details of their diagnosis were collected directly from the hospital information system and coded according to the International classification of diseases–Edition 10 (ICD-10). The study adopted the WHO’s collaborative “Pathway Study” encounter form, which was designed for use in a series of studies to understand care-seeking and treatment pathways of patients with mental disorders before they seek formal mental health care. This form was translated to Tamil and back-translated to English by language experts, after getting permission from WHO.

Tools Used

  1. A semi-structured questionnaire to collect the sociodemographic data.

  2. Pathway to care encounter form by WHO.

Statistics

Data were analyzed using the statistical package for social sciences, (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.). Continuous variables were studied using the median (as the data was highly skewed). Mean values have been mentioned only for descriptive purposes of few data. The Chi-square test was used to determine the association between independent categorical variables and the outcome variables. Mann–Whitney U test and Kruskal–Wallis were used for continuous data. Multivariate analysis was performed to assess the predictors of DUI and NOE. Two linear regression models were created. The first model predicted the DUI with the sociodemographic variables as explanatory variables. The second model predicted the number of encounters as the main outcome using the same sociodemographic variables. Statistical significance was evaluated at a p-value of 0.05 using two-sided tests.

RESULTS

The mean age of the participants was 36.1 (±14.9). Table 1 illustrates the sociodemographic profile of the participants. The striking feature was the unemployment rate (59.3%) among the patients.

Table 1: Sociodemographic detail of the patients
S. no. Sociodemographic factors of the patients Frequency Percentage
1 Gender    
Male 90 60
Female 60 40
2 Socioeconomic status    
Lower 63 42
Lower middle 82 54.7
Upper middle  5 3.3
3 Area of residence    
Rural 35 23.3
Semi-urban 111 74
Urban  4 2.7
4 Education    
Illiterate 16 10.7
Primary  5 3.3
Middle school 29 19.3
High school 33 22
HSC 25 16.7
Graduate 36 24
Postgraduate  6 4
5 Occupation    
Unemployed 89 59.3
Unskilled worker 10 6.7
Semi-skilled worker 26 17.3
Skilled worker  8 5.3
Clerical worker  6 4
Semi profession  1 0.7
Profession 10 6.7
6 Religion    
Hindu 130 86.7
Christian  8 5.3
Muslim 12 8

Table 2 depicts the psychiatric diagnostic profiles of the participants.

Table 2: Psychiatric diagnostic profiles of the participants
S. no. Diagnosis No. of patients Percentage
1 Substance use disorders 35/150 23
2 Schizophrenia and related psychosis 35/150 23
3 Mood disorders 29/150 19
4 Anxiety disorders/obsessive compulsive disorder 22/150 14.7
5 Personality disorders 5/150 3
6 Conduct disorder 6/150 4
7 Organic brain syndromes 6/150 4
8 Intellectual disability 3/150 2
9 Dissociative/somatoform disorders 5/150 3
10 Adjustment disorder 11/150 7
11 Deliberate self-harm 11/150 7
12 Nil psychiatry 7/150  4.7
13 Postpartum illness 2/150 1

Even though we had participants diagnosed with the whole spectrum of psychiatric disorders, the majority was suffering from substance use, psychosis, and mood disorders.

Details of the Pathway

The median time taken for any help, from traditional healers, general hospitals or MHP was 12 months (IQR 2–47.25). The median DUI was 18 months (IQR 2.75–60). The median total duration of illness was 24 months (IQR 4–87). Mean number of encounters was 2.7 (SD ± 1.77). Figure 1 shows the pathway to psychiatric care taken by the participants.

Fig. 1: Pathway to psychiatric care taken by the participants

Expenditure

It was possible to collect details of the expenditure only from 88 patients. Many have forgotten, and some were reluctant to disclose. The range of expenditure was ₹100–6,00,000. The median amount was ₹2,000 (IQR 700–7,000).

Table 3 represents the DUI and NOE participants had before meeting an MHP, among different diagnostic categories. Intellectual disability followed by substance use disorder had a long DUI. Except for adjustment disorder, all other patients had more than 6 months of DUI.

Table 3: Duration of untreated illness (DUI) and number of encounters (NOE) in different diagnostic categories
S. no. Diagnosis DUI (months) NOE (mean ± SD)
1 Organic brain syndromes 33 1.8 (±0.75)
2 Substance use disorder 90 2.3 (±1.12)
3 Schizophrenia and related psychosis 12 3.2 (±1.7)
4 Mood disorders  9 3.6 (±2.8)
5 Anxiety disorders/obsessive compulsive disorder 36 2.5 (±1.2)
6 Adjustment disorder  2 1.8 (±0.75)
7 Dissociative/somatoform disorders 15 2 (±1.15)
8 Intellectual disability 120 2.3 (±1.15)

Figure 2 depicts the nature of our participants’ first encounter. Among these patients, 84% had medical practitioners including general practitioner (GP) or a psychiatrist as their first contact.

Fig. 2: Nature of the first encounter

Figure 3 illustrates the diagnosis of patients who had met the traditional healer as their first contact. Predominantly, patients with major mental illness have met the traditional healers.

Fig. 3: Diagnosis of patients who had their first encounter with a traditional healer

Figure 4 shows the diagnosis of patients who had met an MHP as their first contact. Patients with varied diagnoses had met the MHP before seeking help anywhere else.

Fig. 4: Diagnosis of patients who had their first encounter with an MHP

Figure 5 shows who has initiated the help-seeking for the mental health problem. For 80% of them, the suggestion to seek help for behavioral problems came from friends and relatives.

Fig. 5: Help-seeking behavior was initiated

Analytical Statistics

Table 4 depicts the association between the sociodemographic and outcome variables.

Table 4: Association between sociodemographic and outcome variables
Socio-demographic variable Descriptive statistics n (%) DUI (months) (median) p value NOE (median) p value
Gender          
Male 90 (60) 24 0.03* 2 0.664
Female 60 (40) 12   2  
SES          
Lower 63 (42) 18 0.279 3 0.129
Lower middle   82 (54.7) 24   2  
Upper middle   5 (3.3)  5   3  
AOR          
Rural   35 (23.3) 18 0.281 2 0.863
Semi-urban 111 (74)  2   2  
Urban   4 (2.7)    7.5    2.5  
Education          
Illiterate   16 (10.7) 15 0.655 2 0.100
Primary   5 (3.3) 60   3  
Middle school   29 (19.3) 30   3  
High school 33 (22) 12   2  
Higher secondary   25 (16.7) 12   2  
Graduate 36 (24) 18   2  
Postgraduate 6 (4) 26      1.5  
Occupation          
Unemployed   89 (59.3) 12 0.65 2 0.496
Unskilled worker   10 (6.7) 36    2.5  
Semi-skilled worker   26 (17.3) 60   2  
Skilled worker   8 (5.3) 10   2  
Clerical 6 (4) 108   2  
Semi profession   1 (0.7)  1   2  
Profession   10 (6.7) 10   2  
Religion          
Hindu   130 (86.7) 18 0.38 2 0.86
Christian   8 (5.3) 15   2  
Muslim 12 (8) 42    2.5  
Family history of MI          
Present   77 (51.3) 18 0.195 2 0.427
Absent   55 (36.7) 18   2  
Don’t know 18 (12) 36    2.5  
*Significant at <0.05; SES, socioeconomic status; AOR, area of residence; DUI, duration of untreated illness; MI, mental illness; NOE, no. of encounters

Males had a longer DUI than females, which was statistically significant.

Correlation between the Duration of Untreated Illness and Number of Encounters

The DUI did not correlate (p-value = 0.729; r = 0.028) with the number of encounters.

With regard to caregiver variables, the education of the caregivers had a significant positive correlation (p value = 0.014; r = 0.718) with the number of encounters.

Multivariate Analysis

Linear regression was carried out to identify the predictors of the DUI and NOE. Variables that had a significant association in the simple regression analysis were taken for multiple linear regressions. The results of both the regression models have been combined in Table 5. It shows that after adjusting for sociodemographic characteristics, multiple linear regression analysis revealed that DUI was significantly associated with older age (B = 0.784; p = 0.036) and lower educational status (B = −26.941: p = 0.024) of the participants. Compared to males, females had a shorter DUI.

Table 5: Multivariate analysis of factors predicting DUI and NOE
  DUI NOE
  Unstandardized coefficients 95.0% confidence interval for B Unstandardized coefficients 95.0% confidence interval for B
Predicting variables B t Sig. Lower bound Upper bound B t Sig. Lower bound Upper bound
(Constant) 23.107 0.612 0.542 −51.607 97.821  3.573  3.278 0.001  1.417 5.728
Age 0.784 2.118    0.036*  0.052  1.516  0.007  0.701 0.484 −0.014 0.029
Sex −26.941 −2.305    0.023* −50.052 −3.830 −0.010 −0.031 0.975 −0.677 0.656
SES 13.679 1.275 0.204 −7.532 34.890 −0.223 −0.722 0.472 −0.835 0.389
Area of residence 2.531 0.212 0.832 −21.064 26.126 −0.122 −0.353 0.724 −0.802 0.559
Education −8.128 −2.275    0.024* −15.191 −1.064  0.071  0.684 0.495 −0.133 0.274
Occupation 3.827 1.149 0.252 −2.758 10.411 −0.156 −1.626 0.106 −0.346 0.034
Religion 12.186 1.383 0.169 −5.232 29.604 −0.187 −0.737 0.462 −0.690 0.315
Family history of MI −0.503 −0.067 0.947 −15.434 14.428  0.386  1.772 0.079 −0.045 0.817
Education (CG) 6.383 1.652 0.101 −1.257 14.023 −0.159 −1.424 0.157 −0.379 0.062
Occupation (CG) −3.972 −1.353 0.178 −9.777  1.832 −0.079 −0.933 0.353 −0.246 0.088
*Significant at <0.05; SES, socioeconomic status; CG, caregiver; DUI, duration of untreated illness; MI, mental illness; NOE, no. of encounters

DISCUSSION

This was a project initiated by the institute to promote practical knowledge of research among undergraduate medical students. The student participated in every phase of designing the research and collects data under the guidance and supervision of the faculty. The student presented the protocol in the institutional research and ethics committee. The faculty analyzed the results and wrote them up while teaching the student each step of the research.

As with other states of India, Puducherry and Tamil Nadu have unique but have overlapping healthcare practices. The study center caters to the population of the Union Territory (UT) of Puducherry as well as adjacent districts of Tamil Nadu. In a country like India, where people have the freedom to choose their treatment methods in combination with the scarcity of the MHP, the pathway to psychiatric care becomes long and tortuous.1

The sociodemographic profile of the participants, in general, reflects the demographic characteristics of the region. Sixty-nine percent of them had more than 8 years of education. This again reflects the literacy rate of the UT of 76%, which is higher than the national average of 59.5%.14 Among our participants, 59% were unemployed compared to a study from Delhi15 where only 6% were unemployed. Whether this is secondary to the illness or not was not analyzed in this study. In the 2011 Census of India, patients who self-reported to have mental illness had 78.6% unemployment.16 Our participants were in the most productive phase of life with a mean age of 36. Unemployment at this phase will lead to a lack of productivity and a poor quality of life. A qualitative study exploring this further would be beneficial. The median total duration of illness was 2 years, that is, longer than what was found by Mishra et al. as 1 year.15 More than 50% of our participants had a positive family history of psychiatric illnesses, which did not have any impact on the pathway. We cannot assume that previous exposures to similar or related symptoms in the family may help in earlier help seeking.

In our study, 4.7% of the participants who visited the psychiatric facility had not received any psychiatric diagnosis. In the multicentric study by Gater et al.11 conducted across 11 centers, it was between 2 and 4%.

The DUI was highest for intellectual disability similar to the study by Jain et al.1 Intellectual disability was included in the study, as patients with this condition are seen in the general psychiatric facilities in India. Substance use disorders had a median duration of 90 months. This could be due to the common attribution of alcohol use as a habit rather than an illness. These patients visited the health care facilities only when there was a complication related to the substance. Also, males had a longer DUI than females, which was statistically significant. This can be explained by the fact that substance dependence was the most common diagnosis among males. Another study conducted in the same region in 2017 found that most of the patients sought help within a month, and around half of them directly contacted psychiatric facilities.17 This could be due to the fact that this study included only those with severe mental illnesses.

There were lots of difficulties in calculating the cost spent on help-seeking. In chronic conditions, the caregivers did not exactly remember how much they spent. Even if they remember, the possibility of recall bias cannot be ignored. But it varied from ₹100 to ₹6,00,000. The mean amount was ₹12,823 which is not so different from what was found in Jaipur,1 i.e., ₹15,475.68. The irony is that all the government hospitals provide psychiatry services for free of cost. Puducherry has two multidisciplinary tertiary care governmental healthcare systems with fully functioning psychiatric departments with in-patient units. In such circumstances, more than accessibility, poor awareness, and sociocultural beliefs could have played a major role.

The mean number of encounters was 2.7, which is comparable to another study in India,18 but lower than what was found in Jaipur,1 i.e., 3.93. This can be attributed to regional differences in cultural beliefs and attitudes, accessibility to MHP that prevail in different states. In our study, 83.4% made the first contact with allopathic practitioners, which shows a healthy development, compared to previous studies. And 39.4% met the psychiatrist at first contact. This is higher when compared to other countries (Table 6). This can be attributed to many factors such as the availability of MHP and accessibility. However, this is still a lower proportion considering the development in other areas such as technology and social connectedness. But there are not many differences in the proportion of patients visiting an MHP or traditional healer compared to the study done in Bengaluru, India, three decades earlier in 1991 (Table 7).

Table 6: Comparison of our participants’ pathway to psychiatric care with other countries
SI. No. Country Year of study First encounter with an MHP First encounter with a TH DUI (months) NOE
1 Bali9 2006 4% 78% 6.5  
2 China24 2014 4.2%   30.4 3.6
3 Malawi8 2015 11.7% 22.7%    
4 Ghana10 2016 52.3% 23.3%    
5 Singapore22 2018 21.8 % 1.3% 1.1  
6 The current study, Puducherry 2019 39.4% 12% 18 2.7
DUI, duration of untreated illness; MHP, mental health professional; NOE, no. of encounters, TH, traditional healer
Table 7: Comparison of our participants’ pathway to psychiatric care with other Indian studies
SI. No. Place Year of study Cost ( ) DUI (months) NOE Percentage of patients with their first visit to faith healers Percentage of patients with their first visit to MHP
1 Bengaluru11 1991 1.5 12 39
2 Central India2 2010 10.54 68.5 9.2
3 New Delhi15 2011 822.11 6 2.11 8 45
4 Jaipur1 2012 15475.68 36.7 3.93 39.5 27.6
5 Delhi25 2012 2,00,000 4.5 56 28
6 Bilaspur25 2012 500.00 3 64 12
7 Mysuru26 2012 6.53 26.9 22.1
8 The current study (Puducherry) 2019 2000.00* 18 2.7 12 39.4
DUI, duration of untreated illness; MHP, mental health professional; NOE, no. of encounters

Among the 150 participants, 44% had visited other nonpsychiatric allopathic practitioners. In a country like India with a scarcity and unequal distribution of resources, this can’t be avoided. At the same time, it is well established that GPs do not have appropriate training to diagnose or treat psychiatric conditions.19 Delayed or misdiagnosis by them will lead to a lack of trust in the health system. Also, only six patients were referred by the GP to psychiatrists. Neither the existing medical curriculum nor the continuing medical services (CMEs) for the practitioners seem to do justice for psychiatric training.

Patients had visited different health providers even after meeting a psychiatrist. In this study, six participants have met traditional healers, after meeting the psychiatrists. The nature of the illness’ delayed response to treatment or side effects could be the reason for this.

In the majority (80%), help-seeking was initiated by friends or relatives. Only 16% sought help on their own. This can be understood, in the closely knit culture of the Indian context. People volunteer suggestions, whether asked or not, and most of them don’t consider that as an intrusion. Sometimes, they go out of the way to help their friends who are ill. This cannot be fully explained by Indian culture alone as studies done in Europe,20 Ethiopia,21 and Singapore22 also found that most of the time others initiate the treatment rather than the patients.

The education of the caregiver had a positive correlation with the number of encounters. This is a surprising finding if we assume that educated people seek direct psychiatric help earlier. Probably they are more distressed by the symptoms of the patient and take them to various health care providers. However, direct causality cannot be established.

In multivariate analysis, age and education of the patients were significant predictors for longer DUI. It was surprising to know that education doesn’t have a positive impact on the pathway to care. A qualitative study conducted by the authors among these participants explained their experiences during their pathway to psychiatric care.23

Strength and Limitations

We have used the WHO’s encounter form that has been validated in India. We included all the patients visiting the psychiatric outpatient unit without restricting to any diagnosis. However, the participants were recruited from a tertiary care teaching hospital, and the findings may not be generalizable to community settings. Being a retrospective study, the risk of recall bias cannot be ignored. Allopathic practitioners who might be biased toward their system of treatment conducted this research. We could not calculate the exact expenditure.

The implications of this study would be to reiterate the incorporation of adequate psychiatric training in the undergraduate curriculum and CMEs for practitioners. It’s a combined responsibility of all the stakeholders to break the myths and enhance the awareness of the public and traditional/and alternative healers so that they can make early referrals.

CONCLUSION

In Puducherry, a coastal town in South India, nearly 40% of the patients had their first visit to psychiatrists. The DUI was seen more in males than in females. Neither education of the caregiver nor the patient had any impact on the number of encounter (NOE).

REFERENCES

1. Jain N, Gautam S, Jain S, et al. Pathway to psychiatric care in a tertiary mental health facility in Jaipur, India. Asian J Psychiatry 2012;5(4):303–308. DOI: 10.1016/j.ajp.2012.04.003.

2. Lahariya C, Singhal S, Gupta S, et al. Pathway of care among psychiatric patients attending a mental health institution in central India. Indian J Psychiatry 2010;52(4):333. DOI: 10.4103/0019-5545.74308.

3. Farooq S, Large M, Nielssen O, et al. The relationship between the duration of untreated psychosis and outcome in low-and-middle income countries: a systematic review and meta analysis. Schizophr Res 2009;109(1–3):15–23. DOI: 10.1016/j.schres.2009.01.008.

4. Thirthalli J, Channaveerachari NK, Subbakrishna DK, et al. Prospective study of duration of untreated psychosis and outcome of never-treated patients with schizophrenia in India. Indian J Psychiatry 2011;53(4):319. DOI: 10.4103/0019-5545.91905.

5. Gururaj G, Varghese M, Benegal V, et al. National mental health survey of India, 2015–16: summary. Bengaluru Natl Inst Ment Health Neurosci.

6. Biswal R, Subudhi C, Acharya SK. Healers and healing practices of mental illness in India: the role of proposed eclectic healing model. J Health Res Rev 2017;4(3):89. DOI: 10.4103/jhrr.jhrr_64_17.

7. Schoonover J, Lipkin S, Javid M, et al. Perceptions of traditional healing for mental illness in rural Gujarat. Ann Glob Health 2014;80(2):96–102. DOI: 10.1016/j.aogh.2014.04.013.

8. Kauye F, Udedi M, Mafuta C. Pathway to care for psychiatric patients in a developing country: Malawi. Int J Soc Psychiatry 2015;61(2):121–128. DOI: 10.1177/0020764014537235.

9. Kurihara T, Kato M, Reverger R, et al. Pathway to psychiatric care in Bali. Psychiatry Clin Neurosci 2006;60:204–210. DOI: 10.1111/j.1440-1819.2006.01487.x.

10. Ibrahim A, Hor S, Bahar OS, et al. Pathways to psychiatric care for mental disorders: a retrospective study of patients seeking mental health services at a public psychiatric facility in Ghana. Int J Ment Health Syst 2016;10:63. DOI: 10.1186/s13033-016-0095-1.

11. Gater R, Sousa DBAE, Barrientos G, et al. The pathways to psychiatric care: a cross-cultural study. Psychol Med 1991;21(3):761–774. DOI: 10.1017/s003329170002239x.

12. Gupta D, Sidana R, Behari M, et al. Help-seeking behavior and pathways to care among patients seeking treatment at a private psychiatric hospital in North India. J Ment Health Hum Behav 2018;23(1):63. DOI: 10.4103/jmhhb.jmhhb_49_17.

13. Janca A, Chandrashekar CR, World Health Organization. Division of Mental Health. Catalogue of WHO psychiatric assessment instruments/prepared by A. Janca and C. R. Chandrashekar. 1995. Available from: https://apps.who.int/iris/handle/10665/62036.

14. Population of Puducherry. 2017. Available from: http://indiapopulation2017.in/population-of-pondicherry-2017.html [Accessed October 13, 2018].

15. Mishra N, Nagpal SS, Chadda RK, et al. Help-seeking behavior of patients with mental health problems visiting a tertiary care center in north India. Indian J Psychiatry 2011;53(3):234. DOI: 10.4103/0019-5545.86814.

16. Ramasubramanian C, Mohandoss AA, Namasivayam RK. Employability of mentally ill persons in India: a self-report-based population study. Ind Psychiatry J 2016;25(2):171–178. DOI: 10.4103/ipj.ipj_72_16.

17. Khemani MC, Premarajan KC, Menon V, et al. Pathways to care among patients with severe mental disorders attending a tertiary health-care facility in Puducherry, South India. Indian J Psychiatry 2020;62(6):664. DOI: 10.4103/psychiatry.IndianJPsychiatry_512_19.

18. Mishra N, Nagpal SS, Chadda RK, et al. Help-seeking behavior of patients with mental health problems visiting a tertiary care center in north India. Indian J Psychiatry 2011;53(3):234–238. DOI: 10.4103/0019-5545.86814.

19. Chaudhary R, Mishra B. Knowledge and practices of general practitioners regarding psychiatric problems. Ind Psychiatry J 2009;18(1):22. DOI: 10.4103/0972-6748.57853.

20. Gater R, Jordanova V, Maric N, et al. Pathways to psychiatric care in Eastern Europe. Br J Psychiatry J Ment Sci 2005;186:529–535. DOI: 10.1192/bjp.186.6.529.

21. Girma E, Tesfaye M. Patterns of treatment seeking behavior for mental illnesses in Southwest Ethiopia: a hospital based study. BMC Psychiatry 2011;11:138. DOI: 10.1186/1471-244X-11-138.

22. Jeyagurunathan A, Abdin E, Shafie S, et al. Pathways to care among psychiatric outpatients in a tertiary mental health institution in Singapore. Int J Soc Psychiatry 2018;64(6):554–562. DOI: 10.1177/0020764018784632.

23. Joju S, Simiyon M, Thilakan P, et al. A qualitative analysis of patients’ experiences during their pathway to psychiatric care. Ind J Priv Psychiatry 2019;13(2):37–43. DOI: 10.5005/jp-journals-10067-0046.

24. Li X, Zhang W, Lin Y, et al. Pathways to psychiatric care of patients from rural regions: a general-hospital-based study. Int J Soc Psychiatry 2014;60(3):280–289. DOI: 10.1177/0020764013485364.

25. Naik SK, Pattanayak S, Gupta CS, et al. Help-seeking behaviors among caregivers of schizophrenia and other psychotic patients: a hospital-based study in two geographically and culturally distinct Indian cities. Indian J Psychol Med 2012;34(4):338. DOI: 10.4103/0253-7176.108214.

26. Faizan S, Raveesh B, Ravindra L, et al. Pathways to psychiatric care in South India and their sociodemographic and attitudinal correlates. BMC Proc 2012;6(Suppl. 4):P13, 1753-6561-6-S4-P13. DOI: 10.1186/1753-6561-6-S4-P13.

________________________
© The Author(s). 2022 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.