Pathways to care for substance use treatment among tribal patients at a psychiatric hospital: A comparative study

INTRODUCTION

Substance use disorders (SUDs) are a considerable burden affecting significant sections of society. According to a national mental health survey (2015–2016), SUDs contributed mainly by alcohol and tobacco were more in middle-aged individuals among males in rural areas. SUDs are prevalent in 22.4% of the population above 18 years in all the states in India. The recent national survey on substance use has found a high magnitude of substance use prevalence in the country. The current prevalence of alcohol use was 14.6%, while other substances were found to be prevalent. The prevalence of cannabis (2.8%), opioids (2.1%), and sedatives (1.08%) were found to be high in India.^[1] According to the 2011 census, India consists of 8.6% of the tribal population in total population; The tribal population is a marginalized community and lives relatively in isolation with poor socioeconomic and poorer health indices.^[2]

The treatment gap is higher in SUDs than in other psychiatric disorders. Help-seeking and access to treatment are only 25%; there is an 86% treatment gap in alcohol use disorders. Accessibility to health-care services and attitudes toward professional treatment vary according to different populations.^[3] Moreover, the prevalence of alcohol and tobacco is higher in rural and tribal populations than in urban areas due to various sociocultural reasons.^[4-6] The previous studies on pathways to care for SUD do not focus on any ethnic community and are specific to opioid dependence only from India.^[7,8] Hence, this study aimed to examine the pathway of care, attitude to seek professional help, and treatment delay for substance use among tribal patients and compare those with non-tribal patients at a tertiary psychiatric hospital.

MATERIALS AND METHODS

The study was approved by the institute ethics committee. It was a hospital-based, cross-sectional, and comparative study. The hospital is in a state whose population consists of 26.21% of tribes.^[9] The inclusion criteria were (1) age of more than 18 years, (2) seeking treatment from the outpatient department of addiction psychiatry unit of the hospital on Wednesday, and Saturday except government holidays, (3) diagnosed with mental and behavioral disorder due to use of psychoactive substances as per international classification of disease-10^th version by the World Health Organization (WHO, 1993) criteria, and (4) providing informed consent. Patients those (1) were diagnosed with psychiatric comorbidity and (2) were not accompanied by any family member were excluded from the study. Belonging to tribes was recorded by self-report during registration at the outpatient department as per the hospital outpatient registration policy. Every first tribal and non-tribal patient fulfilling inclusion criteria was included in the study using a consecutive sampling technique. Informed consent was obtained from all participants. Data were collected between August 2021 and February 2022. The sample consisted of 40 each from tribal and non-tribal treatment-seeking populations. The following tools were administered –

RESULTS

The median age of the tribal patient group was higher 31.00 (14.75) (Mean = 32.60 ± 9.23) years, while that of the non-tribal patients’ group was 26.50 (14.00) (Mean = 28.87 ± 8.29) years (P = 0.071). The majority of tribal patient group hailed from rural compared to the non-tribal group (P = 0.025). Furthermore, There was a difference in the distance of the nearest general health-care system between tribal and non-tribal populations, tribal group patients had to travel longer to access the general health care system (P = 0.051). The distance to a psychiatric health-care system is high in both populations. [Table 1] Compares sociodemographic characteristics between two groups.

Addiction severity for alcohol severity was significantly higher in the tribal patients (P = 0.008) and the same for the illicit drugs (cannabinoids, and opioids) was high in the non-tribal patients (P = 0.035). Family issues were higher in tribal patients (P = 0.013) [Table 2].

In both groups, family members noticed the problem first. In the tribal group, spouses mostly noticed the changes among patients, while the same for non-tribal group parents (P = 0.020). In both groups, parents and spouses commonly recognized the need for psychiatric care. In tribal groups, siblings also recognized the same (P = 0.028). Referral from the general health-care system is very minimal in both groups. Time passed to identify patient problems since its onset was longer in the tribal patient group (P = 0.002), and both groups have minute differences on treatment gap to access the psychiatric care. [Table 3] describes and compares the pathways of care between the two groups.

The reason for treatment delay was comparable between groups. It was found that lack of proper awareness about psychiatric treatment place and person, financial problems, problems in taking the patient to mental health facilities, poorly functional social networks low social support to family were higher among tribal patients [Table 4]. On comparison of attitude stoward seeking professional psychological help, both groups have a relatively poor attitude toward seeking psychological help in [Table 5].

DISCUSSION

The pattern of substance use was different in the two groups. Compared to the previous studies, the tribal were less educated, and most of them were engaged in agricultural activities and came from low socioeconomic conditions.^[5] In the case of occupation, the findings contradict previous studies.^[5,13] The prevalence of alcohol use was high in tribal individuals with low occupational and uneducated. The comparable age of initiation of substance use lower in tribal patients is consistent with earlier studies.^[5,14] Both groups had moderate problems in employment, but the tribal population reported more severe problems than the non-tribal populations. The alcohol and other illicit drugs opioids and cannabinoids showed a significant difference between the groups. The previous studies also show that the prevalence of alcohol use is high in tribal populations.^[2,15-18] However, in the non-tribal population, most of them have illicit drugs use in high severity. The severity of family/social problems were higher in tribal populations, and it leads to various negative consequences in families such as domestic violence, family discord, and burden on spouses.^[17,19]

Very few studies systematically assessed the pathways to care among persons diagnosed with SUDs in India. These studies were conducted with alcohol use disorders^[19] and opioid use disorders.^[7,21] Globally, common pathways fall under three categories, physician, specialist, and traditional healer.^[22] In the present study, the most common pathway was the delayed pathway, which takes years to seek psychiatric help after recognizing the symptoms of family members. In our study, the mean duration taken to access psychiatric services after identifying the problem was 2 years in the tribal population. The comparison of the duration of the problem identified for the first time between the two groups was significant. This could be because the caregivers do not think substance intake is a problem, and in tribal, they accept it as part of the culture. In others, studies about psychiatric disorders to look at the generic pathway to psychiatric care found a more significant delay between the onset of first symptoms and seeking the first health care with a mean delay of 2.8 years.^[23]

Noticing the change most commonly by spouses instead of by parents in the tribal group despite early onset of substance use, unlike in non-tribal group, might reflect more familial and cultural acceptance. Here, the direct pathway is more among tribal and non-tribal populations than two-step referral pathways. Earlier studies have expressed the strong possibility of pathways to care differences based on the psychiatric diagnosis. A study conducted in North India reported that 58% of patients with mental illness and SUDs are to be consulted a psychiatrist for the first time for treatment.^[24] Despite that, 33% of the patients sought help from traditional faith healers for the treatment primarily. In the index study, 65.0% of patients from the tribal population consulted a psychiatrist, including whoever directly comes to central institute of psychiatry (CIP), and 62.5% from the non-tribal population directly consulted a psychiatrist for the SUD. In a previous study, 56.9% of the subjects had the first point of contact with a tertiary care addiction psychiatrist, and traditional healers were consulted by about 5.2% of the patients seeking help for the first time.^[20] No patients visited a practitioner of an alternate system of medicine in the present study. This was also comparable to the earlier study.^[25] It shows that most patients with SUDs do not seek treatment from alternate systems of medicine. This observation has an important implication for policies as, over the past years, there has been prominence on the promotion of alternate systems of medicine in the country. In India, the treatment provided by non-specialists for SUDs might be ineffective by patients; or non-specialists might prefer other disorders for the treatment rather than SUDs. In our study, fewer patients consulted faith healers as the first treatment mode compared to consulting a psychiatrist directly.

Most of the tribal population gave the reason for the delay in psychiatric care was a lack of proper awareness about psychiatric care (treatment, place, and person), and financial problems were another reason for delaying treatment. The previous studies and surveys substantiate the results. Most alcohol use disorders identified with the treatment gap had not been taken care of or could not access appropriate care. More than lack of awareness, affordability of care, which varied between rural and urban areas, appear s to influence these wide treatment gaps critically.^[3] Fear and social stigma were considered major issues among non-tribal populations compared to the tribal population. A previous study reported high internalized stigma among alcohol-dependent patients.^[26] Research has indicated that the differences in psychiatric disorders might explain the differences in the pathway of care.^[24] Both groups have a poor attitude toward seeking professional psychological help. If the patient with higher education, they have a more positive attitude to seek professional help. Our findings show that respondents with higher education viewed them as more positive toward seeking psychological help. The treatment gap is high in substance abuse disorders and current community-based programs are not adequately reaching grassroots levels; all other important stakeholders need to be trained. Furthermore, programs for prevention and early detection measures are needed. Technology-based interventions need to reach unreached tribal populations. Even though pathways to care among tribal with SUD are not studied much, the sample size is inadequate to generalize to tribal communities, both genders could have been a better representation, and future studies need to address the treatment gaps with community-based interventions in tribal communities.

CONCLUSION

Pathways to care for patients diagnosed with SUDs represent a crucial link in health-care delivery for these disorders. In India, the situation appears to be less than satisfactory. There is a long-time gap between the onset of substance use-related problems and the first help-seeking attempt. Lack of awareness about the health-care facility, problems taking patients to mental health facilities/ severity of symptoms was high in tribal population, social stigma and fear reported by non-tribal population for delayed psychiatric care, and financial problems were also reasons to delay seeking psychiatric care. Attitude toward seeking psychological help is low in both groups. This study adds to the scant literature on treatment-seeking behavior characteristics among tribal patients with SUD and would provide insight both at individual and policy-making levels.