East Asian Arch Psychiatry 2014;24:58-67

ORIGINAL ARTICLE

Dr Sandeep Grover, MD, Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh 160012, India.
Dr Naresh Nebhinani, MD, Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh 160012, India.
Dr Subho Chakrabarti, MD, Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh 160012, India.
Dr Ruchita Shah, MD, Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh 160012, India.
Dr Ajit Avasthi, MD, Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh 160012, India.

Address for correspondence: Dr Sandeep Grover, Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh 160012, India.
Tel: (91-172) 2756 807; Fax: (91-172) 2744 401; Email: drsandeepg2002@yahoo.com

Submitted: 25 March 2014; Accepted: 25 April 2014

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Introduction

Schizophrenia imposes a significant burden on the individual, family, and community due to its chronic course, associated disability, social dysfunction, along with poor adherence with treatment, and need for frequent hospitalisation.¹ Functional recovery in patients with schizophrenia is influenced by several factors such as pre-morbid functioning, symptom profile, and duration of illness (including duration of untreated psychosis).² Delay in institution of appropriate treatment is closely linked with the community’s awareness about causes and available treatment modalities, which further directs their help- seeking behaviour and pathways.

Explanatory models refer to patients’ and their families’ causal attributions of illness³ and have been shown to affect their coping,^4,5 treatment preferences,⁵ compliance, and outcome.⁶ Thus, investigating family members’ causal beliefs regarding schizophrenia is an important step in the management of the illness as it further influences the help- seeking pathway of individuals with schizophrenia.⁷

Pathways of psychiatric care have been defined as the sequence of contacts with individuals and organisations, initiated by the patients or families in their effort to seek appropriate help.⁸ Such studies provide vital information regarding the individual’s help-seeking and illness behaviour, and possible sources of delay in presenting to appropriate treatment facilities. Knowledge about these parameters, subsequently, helps in organising mental health services, coordinating psychiatric referrals, and enhancing the treatment-seeking attitude.⁹

Few studies have evaluated the aetiological models (mostly, by using semi-structured interviews) including supernatural beliefs held by patients with schizophrenia and their caregivers from developed^3,10-14 and developing countries including India.^5,7,15-27 Non-biomedical causal models of schizophrenia including magico-religious causes were more commonly reported from developing countries.^5,18,25

Few studies have also evaluated pathways to care in patients with psychiatric disorders, and most of these are from developed countries^28-31; few are from developing countries like China³² and Nigeria.³³ The Indian literature on help-seeking patterns in psychiatric populations is mainly about common mental disorders,^34-40 with only few studies on schizophrenia.^26,27

Although studies have evaluated the aetiological models and pathways to care, none of the studies has evaluated the relationship of supernatural beliefs with pathways to care and initial help-seeking behaviour. In India, family provides supports to patients with psychosis, and when a patient is ill, the help-seeking behaviour is more or less determined by the caregivers. In view of this, the present study aimed to evaluate the relationship between the magico-religious beliefs held by the primary caregivers of patients with schizophrenia and first treatment contact pathways to care.

Methods

Study Setting and Sample Selection

The study was carried out at the outpatient clinic of the psychiatry department in a multi-specialty tertiary care hospital in North India. Consecutive newly registered patients diagnosed with schizophrenia by a qualified psychiatrist were approached. To be included in the study, the patients were required to be aged ≥ 15 years and fulfil the diagnosis of schizophrenia as per the ICD-10.⁴¹ Those with co-morbid mental retardation and organic brain syndromes were excluded. Informed consent was sought from all patients and their caregivers. In case a patient was incompetent, consent was obtained from the primary caregiver.

Family members accompanying the patients were included in the study if they were living with the patients and were involved in their care for ≥ 1 year. When more than one family member was available, the caregiver staying with the patient for most part of the day and more involved in the care of the patient and decision-making about treatment was selected. To be included in the study, caregivers were required to be aged ≥ 18 years.

The study was approved by the Ethics Review Committee of the Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Instruments

Supernatural Attitude Questionnaire (Caregiver Version)

The questionnaire consists of 28 items worded in simple language with ‘yes’ and ‘no’ responses designed to study the various types of magico-religious beliefs held by an individual, the role of magico-religious beliefs in causation of mental illness / behavioural abnormalities, and the role of treatment based on such beliefs. Various items of the questionnaire are based on commonly prevalent magico- religious beliefs in our society.²⁵ This questionnaire has been used in earlier studies from our centre.²⁵

Assessment on Pathways to Care

Pathways to care were assessed by a self-designed questionnaire. By using a semi-structured interview, patients and their caregivers were asked about their help- seeking behaviour for symptoms of schizophrenia. The sequence of contact with different agencies was prepared. This questionnaire had been used in an earlier study.²⁶

Statistical Analysis

Analysis was done using the Statistical Package for the Social Sciences Windows version 14.0 (SPSS, Chicago [IL], US). Frequencies with percentages were calculated for nominal and ordinal variables, and means and standard deviations (SDs) were calculated for continuous variables. Chi-square test, t test, and one-way analysis of variance were used for comparisons. Correlation analysis was employed to study the association between different variables by using Pearson product-moment correlations and Spearman’s rank correlation.

Results

Socio-demographics and Clinical Profiles

The study included 122 patients with schizophrenia contacting the psychiatric services of our institute for the first time. The mean (± SD) patient age was 30.6 ± 12.6 years and they received education with a mean of 8.9 ± 4.7 years. Nearly half of the patients were males (50.8%), single (54.9%), and from a rural background (54.9%). The majority of patients was Hindu (77.0%).

As stated in Table 1, the most common subtype of schizophrenia was undifferentiated (61.5%) followed by paranoid (34.4%), with a median duration of illness of 36 months. One-fourth (23.8%) of patients had co-morbid substance abuse / dependence and slightly more than a quarter (28.7%) had physical co-morbidities. Nearly two-thirds of the patients were receiving antipsychotic medications. Other details are depicted in Table 1.

Pathways to Care

Prior to contacting our treating agency, the patients had a mean of 2.04 ± 1.07 treatment contacts. As shown in Table 1, over half of the patients (n = 65; 53.3%) were first taken to a psychiatrist for their symptoms. One-sixth (n = 22; 18.0%) of the patients were first taken to a physician (including the registered medical practitioners), whereas nearly one-fourth (n = 29; 23.8%) were first taken to faith healers and other traditional healers for their symptoms.

Agency of First Contact

In our study, 24 patients had first contact with psychiatrists in a government hospital. Of these 24 patients, 6 had second contact with our institution. Eleven patients had 1 contact with other helping agencies (4 patients contacted private psychiatrists, 3 patients contacted a faith healer, 1 patient contacted an ayurvedic physician, 1 patient contacted a homeopathic physician, and 1 was helped at home) before reaching our centre. Seven patients had 3 contacts before reaching our centre. The pathways for these patients are shown in Figure 1.

In our study, 31 patients had first contact with a psychiatrist in the private setup. Of them, 9 contacted our institution as the second place of consultation. Fifteen patients had contact with 1 helping agency and 7 patients had contact with 2 helping agencies before reaching our centre. The pathways for these patients are shown in Figure 2.

In our study, 29 patients had first contact with faith healers. Of these, 5 patients contacted our institution as the second contact; 20 had contact with 1 helping agency (5 to private psychiatrist, 1 to a government psychiatrist, 4 to an ayurvedic physician, 3 to a government physician, 3 to a private physician, 1 to a homeopathic physician, 2 to registered medical practitioners [RMP], and 1 was helped at home); the remaining 4 patients contacted with 2 helping agencies before reaching our centre.

Caregivers’ Supernatural Beliefs

Of the 122 caregivers, 46 (37.7%) had supernatural beliefs. In all, 31 (25.4%) believed in sorcery / witchcraft (jaadu tona), 29 (23.8%) believed in ghosts / evil spirits (bhoot pret), and 40 (32.8%) believed in spirit intrusion (opari kasar). Overall, 32 (34.4%) caregivers had > 1 supernatural belief. Further details are provided in Table 2.

On exploring about the patients’ supernatural beliefs, 54 (44.3%) caregivers reported that their patients had ≥ 1 supernatural belief. Of them, 36 (29.5%) had ≥ 2 supernatural beliefs about mental illness and 9 (7.4%) had all the 6 supernatural beliefs.

In all, 64 (52.5%) caregivers of patients with schizophrenia stated that community also held magico- religious beliefs regarding causation and treatment of mental illness. When asked about their belief in supernatural causation of mental illness in general, 91 (74.6%) caregivers stated they had belief in any one supernatural cause. Other details are shown in Table 2. In all, 38 (31.1%) caregivers felt that offering prayers (puja, rituals, jhad-phook) could change patients’ behaviour and 49 (40.2%) agreed that their families had actually arranged such rituals for the betterment of their patients. Also, 56 (45.9%) caregivers had also visited faith healers for their patients’ illness (Table 2).

Association of Socio-demographic and Clinical Variables with Supernatural Beliefs and First Treatment Contact

Based on the first treatment contact, the study group was divided into 3 groups: (1) those who chose to seek treatment from a psychiatrist as first contact (i.e. those who first contacted a psychiatrist in a government hospital, private clinic, or those who came directly to our psychiatry outpatient clinic); (2) those who first sought treatment from a physician (from the government / private sector); and (3) those who first contacted faith healers and other traditional healers.

The socio-demographic and clinical variables did not differ significantly between the 3 groups. However, those seeking treatment from faith healers were more commonly from the urban locality compared with those contacting physicians as the first treatment contact (51.7% vs. 22.7%, χ² = 4.41, p = 0.03). Details are depicted in Table 3.

When compared with the groups of seeking psychiatrists and physicians as first treatment contact, a higher proportion of caregivers who first took their patients to faith healers believed in spirit intrusion (p = 0.04) and ghosts (p = 0.02), had ≥ 1 supernatural belief (p = 0.05), had > 1 supernatural belief (p = 0.01), attributed mental illnesses of their patients to sorcery / witchcraft (p = 0.02) , ghosts (p = 0.01), spirit intrusion (p = 0.002), evil spirits (p = 0.002), and considered mental illnesses to be caused by bad deeds in previous life (p = 0.04).

Relationship between First Treatment Contact and Total Number of Contacts before Contacting the Tertiary Care Centre

Those who had first contact with a psychiatrist had a mean of 1.83 ± 1.15 treatment contacts before contacting us; respective value for a physician was 2.27 ± 0.98 treatment contacts and for a faith healer it was 2.41 ± 0.9 treatment contacts. The difference between the 3 groups was statistically significant (F = –3.53, p = 0.03).

Discussion

Family is the key resource in the care of mentally ill in India.⁴² The causal attribution by families of patients of schizophrenia is strongly influenced by multiple sociocultural factors, which also modulate their health perceptions, illness presentations, and interaction between the patients and health providers.^18,43 It also directs the pathways of care, sometimes delays professional medical treatment, and also alters the outcome of this illness.⁴⁴

Although public health implications of chronic physical disorders are widely accepted, knowledge about mental disorders (mental health literacy) remains broadly neglected.⁴⁴ Thorough understanding of the layman’s understanding about psychiatric disorders and help-seeking pathways is of great importance for planning locally relevant and sustainable mental health services.³¹ Therefore, this study aimed to evaluate caregivers’ magico-religious beliefs, role of magico-religious beliefs in causation of symptoms from the carers’ perspectives, and help-seeking behaviour of patients with schizophrenia.

Slightly more than half (53.3%) of the patients had psychiatrists (government setup / private setup) and 23.8% of the patients had faith healers as their first treatment contact. Few patients (18.0%) first contacted a physician for their psychotic symptoms. Similar to earlier studies^34,36 which have evaluated patients with other psychiatric disorders from India, psychiatrists were most commonly contacted at first level in our study. However, our findings are in contrast with a study from India²⁷ which evaluated caregivers of schizophrenia and reported faith healers as the commonest first contact. When we compare our findings with studies from other countries, certain important differences emerge. A recently published population-based survey of patients with first-episode psychosis from United Kingdom⁴⁵ showed that the primary care physicians were the most common first contacts in about one-third (35.2%) of the cases, followed by criminal justice agencies (25.4%) and emergency rooms of general hospitals (21.3%), whereas a recent study from Nigeria⁴⁶ showed that more than two-thirds (69%) of the subjects with psychosis seek their first help from traditional and religious healers. These differences reflect the sociocultural differences in the conceptualisation of illness and organisation of health care services in different countries.

The study from Nigeria⁴⁶ also noted that patients who first contacted non-orthodox healers, ultimately, had higher number of treatment contacts during the course of the help-seeking compared with those who had first contact with mental health services. This finding is also validated by our study which showed that those who first contacted a faith healer had significantly more treatment contacts prior to reaching our treatment agency when compared with psychiatrists as first contact. This finding suggests that there is a need to improve collaboration between mental health care facilities and traditional faith healers. Efforts should be made to educate faith healers about the symptoms of mental illnesses, so that these patients can be referred to appropriate treating agencies at the earliest to reduce the duration of untreated psychosis.

In our study, around three-quarters (74.6%) of the caregivers attributed their patients’ symptoms to ≥ 1 supernatural belief (sorcery / witchcraft, ghosts, spirit intrusion, divine wrath, planetary influences, evil spirits, and bad deeds in previous life) and more than half (57.4%) of the caregivers attributed patients’ symptoms to > 1 supernatural belief. Our findings in the caregiver population are more or less similar to those in earlier reports on caregivers²⁵ and patients with schizophrenia,²⁶ pointing towards a stable pattern of predominance of supernatural beliefs in caregivers and patients with schizophrenia in the Indian setting. This suggests that there is a need for awareness campaigns at the community level to address this issue.

Similar to earlier studies from India^5,25,27 and other countries,^{17,18,20-22,32,47,48} we also found high prevalence (74.6%) of belief in supernatural aetiology of mental illness. Few studies^7,14,23 have reported higher prevalence of belief in psychosocial and biological aetiologies than supernatural aetiology of mental illness.

Aetiological beliefs also influence the societal response towards the mentally ill and, sometimes, generate stigmatising attitudes.⁴⁹ It further contributes to delay in treatment⁵⁰ which results in greater functional disability and poorer outcome.⁵¹ An earlier study³² found an association between first psychiatric contact and chronic onset of illness, a mixed syndrome of positive and negative symptoms, and better economic status. Another study¹⁸ reported that patients who believe in supernatural causation of schizophrenia were more likely to have family members with schizophrenia who had never received psychiatric medical treatment. We could not find any such associations in our study.

Our findings suggest that first treatment contact is influenced by poor knowledge and awareness about psychiatric illness causation as well as treatment modalities, and high prevalence of supernatural beliefs in causation of mental illness. It signifies the urgent need for mental health literacy in India. Fostering effective mental health care requires a thorough understanding of patients’ and caregivers’ perspectives as well as improved literacy about psychosis in the community and other treatment agencies. Therefore, there is a need for sensitisation programmes for physicians, complementary alternative therapists, and faith healers about the need of early identification, timely referral, and proper management of common mental disorders. These measures might reduce the delays in treatment and cost of treatment.³⁶

The study has several limitations. It was a hospital- based sample from an outpatient clinic, and the help- seeking processes and beliefs may be different in patients attending other psychiatric services and in community populations. Recall bias might have affected the help- seeking information provided by caregivers. A self-rated instrument was used to evaluate the supernatural beliefs and aetiological models. Hence, findings should be interpreted with caution. We included a heterogeneous group of patients with schizophrenia in various stages of illness. This could have affected the attribution of illness, and the results must be interpreted against this background. We also did not evaluate the duration of untreated psychosis and its relationship with first treatment contact and supernatural beliefs.

To conclude, the present study demonstrates that supernatural beliefs are quite common in the north Indian community, and the majority of caregivers attribute their patients’ symptoms to ≥ 1 supernatural cause. A significant proportion of patients had belief in magico- religious causation of mental illness and also sought such treatment in different settings. To improve patients’ and caregivers’ understanding about causation and treatment of psychiatric disorder, integrated efforts for raising public awareness and gatekeeper education are required. Future large-scale studies across various regions of India may help in determining societal aetiological models, beliefs in supernatural causation, and pathways of care.

Declaration

The authors declared no conflict of interest in this study.

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