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Pathways of care and attitudes toward psychotropics in patients with depressive disorders and psychotic disorders
*Corresponding author: Naresh Nebhinani, Department of Psychiatry, All India Institute of Medical Science, Jodhpur, Rajasthan, India. drnaresh_pgi@yahoo.com
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Received: ,
Accepted: ,
How to cite this article: Nebhinani N, Pareek V, Choudhary S, Tripathi S, Singh P, Kumar M. Pathways of care and attitudes toward psychotropics in patients with depressive disorders and psychotic disorders. J Neurosci Rural Pract 2022;13:785-90.
Abstract
Objectives:
Delay in institution of appropriate mental healthcare is closely linked with attitudes, stigma, and availability of services, which further directs the help seeking pathways. This study was aimed to assess the pathway of care and attitudes toward psychotropic medications among patients with depressive disorder and psychotic disorders.
Materials and Methods:
Eighty outpatients with depressive disorder and 40 patients with psychotic disorder were assessed in a tertiary care center for pathways to care and attitude toward psychotropics through Attitude toward Psychotropic Medications Questionnaire and Drug attitude inventory-10.
Results:
The psychiatrist remained the most common first treatment contact (46% in depression and 62% in psychosis). Greater number of patients in psychotic disorder group had first treatment contact with faith healers or exorcist (17.5%), compared to depressive disorder (6.2%). Patients in depressive group had more favorable attitude toward psychotropics compared to psychosis group. Majority of patients had favorable attitude toward psychotropic medications, but they also had substantial misconceptions about side effects, utility, and need of taking lesser than prescribed doses.
Conclusions:
Although majority of patients had favorable attitude, they also had substantial misconceptions about medications. These issues need to be addressed for better delivery of comprehensive mental healthcare.
Keywords
Care pathways
Attitudes
Help-seeking
Depression
Psychosis
INTRODUCTION
In the resource poor settings of low- and middle-income countries such as India, a vast gap between the treatment need and available resources exists.[1] The pathway taken by a patient to reach the appropriate treatment setting is known as pathways of care. The widely prevalent culturally sanctioned and magico-religious beliefs are associated with the mental illnesses, and associated stigma, unavailability of resources, and poor mental health literacy act as the contributing to delay in treatment seeking.[2] There are limited studies from India but studies have shown that a major number of patients seek non-professional help at first point of contact.[2-5]
Another challenge in treating the mental illnesses is the compliance to the medications which has been seen to be poor in multiple studies. Attitude toward medications determines the extent to which an individual remains adherent. About half of the psychiatric patients reported to be non-adherent to the prescribed treatment.[6] Three-fourth of the patients with negative attitude toward psychotropics found to have poor adherence to treatment.[7]
Proper understanding of mental health care-seeking behavior and the factors influencing the attitude toward the psychotropics is essential for the better access to the appropriate health-care system and ensuring the compliance toward treatment. With this background, index study was aimed to assess the pathway of care and the attitudes toward psychotropic medications among patients with depressive and psychotic disorders attending a tertiary care center.
MATERIALS AND METHODS
Setting and sample
After the approval by Ethics Review Committee of the Institute, the study was carried out at the Psychiatric outpatient clinic, AIIMS, Jodhpur. Using a cross-sectional design, 40 patients with psychotic disorders and 80 patients with depressive disorders were recruited by purposive sampling. Informed consent was ascertained from all patients and in case of the patient being incompetent for providing consent, the primary caregiver staying with the patient was approached for the same.
Patients between 18 and 60 years of either gender were recruited, who fulfilled the criteria of mood (affective), disorders (first episode depression, recurrent depressive disorder, and dysthymia), or psychotic disorders (schizophrenia and psychosis unspecified) as per International Classification of Diseases, Tenth Revision as confirmed by Consultant Psychiatrist.[8] Patients with comorbid psychiatric disorders, organic brain syndromes, or chronic physical illness were excluded from the study.
In addition to sociodemographic and clinical profile sheet, following tools were used in the study:
Pathway to care
Semi-structured questionnaire was used to assess their care pathways along with the duration of treatment and sequence of contact with different agencies (e.g., Ayurved, Homeopath, Faith healers, physician, and psychiatrists) was prepared. It was also used in earlier study.[9]
Self-report attitude toward psychotropic medications questionnaire
It has 18 items with 3-point Likert scale to assess their attitude toward psychotropic medications, in which eight items have favorable attitude and ten items unfavorable attitude. Total score is 18–54, higher score reflects more positive attitudes, as item scoring is reversed for assessing negative attitudes. It has been used in earlier studies and has also shown good psychometric properties.[6]
Drug attitude inventory (DAI-10)
It is a 10-item scale, with six items being scored as true and four as false. Total score is derived from summing up the total correct answers (positive score) and incorrect answers (negative score). Positive total score points toward compliance and negative total score toward non-compliance.[10]
Statistical analysis
Analysis was done using the SPSS version 21.0 for Windows (Chicago, Illinois, USA). Nominal and ordinal variables were depicted with frequency (percentage) and continuous variables with mean (standard deviation). For comparisons of categorical and continuous data, Chi-square test and t-test were used, respectively, and in case of non-normal distribution, non-parametric tests were used.
RESULTS
Demographic and clinical profile
A total of 80 patients with depressive disorder and 40 patients with psychotic disorder were recruited. Their mean age was comparable, but duration of illness was longer for patients with psychotic disorder group (137 months) compared to depressive disorder (67 months). Majority of patients in both the groups were married, Hindu by religion and staying in urban locality and less than half of the patients were employed [Table 1].
| Variables | Depressive disorder group (n=80) | Psychotic disorder group (n=40) | t-value (P-value) |
|---|---|---|---|
| Mean (SD) | |||
| Age (in years) | 37.75 (11.57) | 39.75 (10.80) | −0.91 (0.36) |
| Education (in years) | 9.05 (5.75) | 10.8 (5.46) | −1.64 (0.10) |
| Monthly family income (INR)# | 20668.75 (21994.66) | 28250.0 (48275.65) | 1502.5 (0.58) |
| Duration of illness (months) | 67.78 (66.53) | 137.87 (110.85) | −4.31 (<0.001) |
| Frequency (%) | X2(P-value) | ||
| Gender | |||
| Male | 37 (46.2) | 26 (65) | 3.75 (0.053) |
| Female | 43 (53.8) | 14 (35) | |
| Marital status | |||
| Currently single | 13 (16.2) | 12 (30) | 3.05 (0.08) |
| Married | 67 (83.8) | 28 (70) | |
| Religion | |||
| Hindu | 70 (87.5) | 35 (87.5) | 0.31 (0.85) |
| Muslim | 10 (12.5) | 5 (12.5) | |
| Family | |||
| Nuclear | 38 (47.5) | 20 (50) | 0.06 (0.79) |
| Joint/extended | 42 (52.5) | 20 (50) | |
| Locality | |||
| Urban | 56 (70) | 32 (80) | 1.36 (0.24) |
| Rural | 24 (30) | 8 (20) | |
| Occupation | |||
| Employed | 29 (36.2) | 18 (45) | 0.85 (0.35) |
| Unemployed | 51 (63.8) | 22 (55) | |
#Mann–Whitney test
In depressive disorder group – 42 patients were diagnosed with recurrent depressive disorder, 34 with first episode major depressive disorder, and four patients had dysthymia. In psychotic disorder group – 37 patients were diagnosed with schizophrenia and three patients had unspecified psychosis.
Pathways of care
In both the groups, psychiatrist remained the most common first treatment contact (46% in depression group and 62% in psychosis group). Significantly, greater proportion of patients in depressive disorder group (27.5%) had first treatment contact with physician, compared to psychotic disorder group (2.5%). On other side, significantly, greater number of patients in psychotic disorder group had first treatment contact with faith healers or exorcist (17.5%), compared to depressive disorder group (6.2%) [Table 2].
| Depressive disorder group (n=80) | Psychotic disorder group (n=40) | Fischer exact (P-value) | |
|---|---|---|---|
| Frequency (%) | |||
| First treatment contact | |||
| Help at home/relative or friends | 10 (12.5) | 5 (12.5) | 19.72 (0.016) |
| General Physician | 22 (27.5) | 1 (2.5) | |
| Psychiatrist | 37 (46.2) | 25 (62.5) | |
| Faith healer/Exorcist | 5 (6.2) | 7 (17.5) | |
| Others$ | 5 (6.2) | 1 (2.5) | |
| Overall treatment contacts | |||
| Help at home | 9 (11.2) | 5 (12.5) | 0.40 (1.00) |
| Relatives-friends outside | 8 (10) | 2 (5) | 0.87 (0.49) |
| Drug store-pharmacy (advice) | 6 (7.5) | 1 (2.5) | 1.21 (0.42) |
| General physician – Government hospital | 21 (26.2) | 2 (5) | 7.77 (0.006) |
| Psychiatrist at Government hospital | 55 (68.7) | 32 (80) | 1.69 (0.27) |
| General physician – Private | 27 (33.7) | 7 (17.5) | 3.81 (0.08) |
| Psychiatrist at private setting | 35 (43.7) | 24 (60) | 5.30 (0.04) |
| Ayurvedic doctor | 10 (12.5) | 0 | 5.45 (0.03) |
| Unani Practitioner | 2 (2.5) | 1 (2.5) | 0.00 (1.0) |
| Homeopathic doctor | 3 (3.75) | 2 (5) | 0.10 (1.0) |
| Registered medical practitioner (RMP) | 7 (8.75) | 7 (17.5) | 1.98 (0.22) |
| Faith Healer | 27 (33.7) | 19 (47.5) | 2.13 (0.16) |
| Exorcist | 4 (5) | 9 (22.5) | 8.45 (0.006) |
| Yoga | 10 (12.5) | 5 (12.5) | 0.00 (1.0) |
$Others: AYUSH professionals, Registered medical practitioner (RMP), Directly came at our center, Bold value P<0.05
On asking about overall treatment contacts, majority of the patients contacted to psychiatrist at government hospitals (68% in depression group and 80% in psychosis group). Patients with depressive disorder had greater contact with physician at government hospital (26%) and Ayurvedic doctor (12.5%), compared to patients with psychotic disorder. On other side, patients with psychotic disorder had greater contact with psychiatrist at private setting (60%) and exorcist (22.5%), compared with patients with depressive disorder [Table 2].
Attitude toward psychotropic medications
Mean score on DAI-10 was significantly greater in patients with depressive disorder (4.72) compared to psychosis group (3.10). Greater proportion of the patients with depressive disorder reported intake of medications with their own choice (90%), compared to psychosis group (67.5%). In both the groups, larger proportion of patients reported beneficial effects with psychotropic medications such as preventing breakdown (relapse/exacerbation), feeling relaxed, and more normal with clear thinking with medications. However, substantial proportion of patients in both the groups had certain unfavorable attitude toward psychotropics such as feeling of controlled with medications, feeling doped, tired, or sluggish with medications, and taking medications only on feeling ill [Table 3].
| Variables | Depressive disorder group (n=80) | Psychotic disorder group (n=40) | X2 test (P-value) |
|---|---|---|---|
| Frequency (%) | |||
| For me, the good things about medication | |||
| outweigh the bad | 66 (82.5) | 34 (85) | 0.12 (0.72) |
| I feel strange, “doped up,” on medication | 38 (47.5) | 25 (62.5) | 2.40 (0.12) |
| I take medications of my own free choice | 72 (90) | 27 (67.5) | 9.35 (0.002) |
| Medications make me feel more relaxed | 71 (88.7) | 32 (80) | 1.67 (0.19) |
| Medication makes me feel tired and sluggish | 32 (40) | 23 (57.5) | 3.29 (0.07) |
| I take medication only when I feel ill | 25 (31.2) | 18 (45) | 2.19 (0.13) |
| I feel more normal on medication | 70 (87.5) | 35 (87.5) | 0.00 (1.0) |
| It is unnatural for my mind and body to be controlled by medications | 52 (65) | 28 (70) | 0.00 (1.0) |
| My thoughts are clearer on medication | 70 (87.5) | 33 (82.5) | 0.54 (0.45) |
| Taking medication will prevent me from having a breakdown | 67 (83.7) | 33 (82.5) | 0.30 (0.86) |
| Mean (SD) | MW (p value) | ||
| DAI mean score# | 4.72 (3.70) | 3.10 (3.50) | 1103.5 (0.005) |
#Mann–Whitney test, Bold value P<0.05
Medication attitude score was comparable in the both the groups (as per self-report attitude toward psychotropic medications questionnaire). Majority of patients in both the groups had favorable attitude toward psychotropic medications on several items such as benefits outweigh the risks, preventing relapse, and better option for the treatment of mental illness than other alternative options. Lesser proportion of patients had negative attitude toward psychotropics in both the groups [Table 4].
| Variables | Depressive disorder group (n=80) | Psychotic disorder group (n=40) | X2 test (P-value) | ||||
|---|---|---|---|---|---|---|---|
| Completely agree | Somewhat agree | Completely disagree | Completely agree | Somewhat agree | Completely disagree | ||
| Frequency (%) | |||||||
| Most effective way to treat mental illness. | 46 (57.5) | 34 (42.5) | 00 | 26 (65) | 13 (32.5) | 01 (2.5) | 2.93 (0.23) |
| Benefits outweigh risks. | 46 (57.5) | 29 (36.2) | 05 (6.2) | 25 (62.5) | 14 (35) | 01 (2.5) | 0.87 (0.64) |
| Do not cure but lead to substantial improvement. | 51 (63.7) | 23 (28.7) | 06 (7.5) | 33 (82.5) | 03 (7.5) | 04 (10) | 7.09 (0.02) |
| Have S/E, but these can be managed. | 39 (48.7) | 34 (42.5) | 07 (8.7) | 23 (57.5) | 12 (30) | 05 (12.5) | 1.85 (0.43) |
| Use of psychotropic along with counseling help a lot of people with mental illness. | 67 (83.7) | 08 (10) | 05 (6.2) | 35 (87.5) | 05 (12.5) | 00 | 2.69 (0.26) |
| Psychotropic can prevent relapse. | 50 (62.5) | 18 (22.5) | 12 (15) | 25 (62.5) | 11 (27.5) | 04 (10) | 0.77 (0.67) |
| Rarely can cause permanent damage/harm. | 44 (55) | 32 (40) | 04 (5) | 21 (52.5) | 14 (35) | 05 (12.5) | 2.20 (0.33) |
| These are better options for Rx of mental illness than alternative treatments. | 61 (76.2) | 13 (16.2) | 06 (7.5) | 30 (75) | 07 (17.5) | 03 (7.5) | 0.03 (0.98) |
| Have a high risk of dependency. | 31 (38.7) | 36 (45) | 13 (16.2) | 21 (52.5) | 11 (27.5) | 08 (20) | 3.46 (0.17) |
| Unnatural and poisonous substance which are harmful. | 11 (13.7) | 28 (35) | 41 (51.2) | 07 (17.5) | 13 (32.5) | 20 (50) | 0.30 (0.85) |
| Are sedatives, these just calm down the patients. | 45 (56.2) | 29 (36.2) | 06 (7.5) | 21 (52.5) | 15 (37.5) | 04 (10) | 0.28 (0.87) |
| In long run, worsen the illness. | 18 (22.5) | 15 (18.7) | 47 (58.7) | 08 (20) | 10 (25) | 22 (55) | 0.64 (0.72) |
| Make the body unnaturally warm or cold. | 16 (20) | 32 (40) | 32 (40) | 08 (20) | 16 (40) | 16 (40) | 0.00 (1.00) |
| Are very expensive. | 29 (36.2) | 24 (30) | 27 (33.7) | 17 (42.5) | 09 (22.5) | 14 (35) | 0.82 (0.66) |
| Not necessary for the Rx of mental illness as they can be controlled by other means also. | 10 (12.5) | 32 (40) | 38 (47.5) | 04 (10) | 07 (17.5) | 29 (72.5) | 0.72 (0.02) |
| Make the subjects weak and cause irreparable damage. | 14 (17.5) | 25 (31.2) | 41 (51.2) | 07 (17.5) | 12 (30) | 21 (52.5) | 0.02 (0.98) |
| Sole cause of unproductive life in mental illness. | 12 (15) | 15 (18.7) | 53 (53.7) | 06 (15) | 10 (25) | 24 (60) | 0.66 (0.71) |
| It is better to take less than the prescribed dose. | 16 (20) | 16 (20) | 48 (60) | 06 (15) | 07 (17.5) | 27 (67.5) | 0.69 (0.70) |
| Mean (SD) | t-test (P-value) | ||||||
| Medication Attitude score | 29.71 (4.50) | 29.12 (4.41) | 0.67 (0.49) | ||||
Greater proportion of patients with psychotic disorder group was completely agree with lack of cure with the medications (82%) compared to depression group (63%). Compared to depression group, greater proportion of patients with psychotic disorder completely disagreed with lack of necessity of psychotropic medications compared to other measures (72%), that is, they considered the medications as effective measure.
However, as reported earlier, substantial proportion of patients in both the groups had certain unfavorable attitude toward psychotropics like better to take less than prescribed dose, having concern with risk of dependency, irreparable damage, worsening of illness in longer run due to medications, or concern about unnatural coldness or heat in the body with poisonous substance related to medications [Table 4]. Duration of illness was found to have significant negative correlation with attitude score.
DISCUSSION
This study highlighted on important patterns and factors influencing the mental health seeking behavior through pathways of care and their attitude toward psychotropic medications. The study depicts that the patients with mental illnesses seek treatment from a wide range of services such as psychiatrists, general medical practitioners, AYUSH practitioners, and religious faith healers. This is similar to the earlier research, which recognized the utilization of a variety of healing modalities varying from different systems of medicine to magico-religious practices by psychiatric patients.[2-5] In this study, the most common first contact of treatment was with psychiatrist in both the groups. About two-fifth of the patients in depressive group and three-fifth of the patients in psychosis group visited a psychiatrist during first consultation followed by general physicians, including the primary care doctors. This finding is similar to other study from a tertiary care center in North India,[3] but different from other Indian studies where majority of the patients visited a faith healer before consulting a mental health professional.[2,5] Although in index study, more than one-third of the patients sought help from faith healer or exorcist at different point of time. In the pathways to mental healthcare,[11] it is noted that the interval before seeking mental healthcare is much longer in Asia and South America, extending from few months to several years. The pattern seen in the developing countries where faith healers play a key role in the pathway has been demonstrated in various international studies also[12-14] and similar findings were also seen in the index study.
Proportion of patient seeking first consultation from a psychiatrist was higher in the psychotic disorder group and these findings are similar to an Indian center from a cross-cultural study.[15] This probably can be explained with the severity of illness and associated disturbances due to psychotic symptoms.
Similar to other studies,[16-18] attitude toward psychotropics remained largely favorable in index study along with substantial misconceptions about psychotropics, while others have indicated that negative attitudes.[19,20] In index study, DAI attitude score of psychosis group (3.10) was comparable with earlier study by Kondrátová et al. (3.2).[17] DAI attitude score of depression group (4.72) was greater in index study than earlier study by De Las Cuevas and Sanz (3.6),[16] in which psychiatric outpatients were assessed.
Similar to earlier study,[18] comparisons of attitudes toward psychotropic medications between depressive disorder group and psychotic disorder group in index study did not reveal any significant differences.
In index study, patients with longer duration of illness were found to have poorer attitude toward psychotropics. Otherwise, there was no significant difference overall in attitudes toward medications between both groups, it may suggest that instead of illness-related factors such as symptoms, severity, and insight, their belief system and sociocultural factors play a crucial role in shaping their attitudes.
The findings of this study have to be considered in the light of following limitations – due to time limited nature, the study included a small number of patients from a single center. All the participants were recruited from the outpatient clinic; hence, these findings cannot be generalized to other severely ill/hospitalized patients.
To further emphasize, such studies provide a vital information regarding the individual’s attitude toward psychotropics, health seeking behavior, pathways of care, and potential barriers in reaching to mental health professionals along with subsequent guidance for addressing these issues and planning for efficient service delivery models.
CONCLUSION
To conclude, index study explored various care-seeking pathways of patients with depressive and psychotic disorders. The care pathways of these patients are generally long due to consultations with various care providers. Although majority of patients had favorable attitude about efficacy of psychotropics, they also had substantial misconceptions about side effects, utility, and need of taking lesser than prescribed doses.
Declaration of patient consent
Patient’s consent not required as there are no patients in this study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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