Predictors of treatment delay in depressive disorders in Pakistan

The study used Andersen's socio-behavioral model (SBM) as the theoretical basis to study the role of various factors influencing delay in help seeking. Current help-seeking literature guided the selection of predisposing, enabling and need variables. This cross-sectional study was conducted at Aga Khan University Medical Hospital, Karachi, Pakistan among patients visiting the outpatient psychiatric clinic, inpatient unit and emergency department. It assessed the duration of delay duration from the onset of first episode of depression to first contact with a psychiatrist and identified factors which facilitated or delayed first contact with a psychiatrist. The survey tool adapted from WMH-CIDI and CCHS 1.2, Multidimensional Perceived Social Support Scale and Stigma Module of the Family Experiences Schedule. Negative binomial regression model was used for multivariate analysis to identify predictors of delay. A total of 205 patients met the study inclusion criteria. Of these, 142 agreed to participate in the survey and were interviewed (response rate=69.3%). Affective disorders (major depression, bipolar disorder and dysthymia) are among the most common mental disorders around the world, and account for a large amount of disability. Those suffering from depressive disorders also have high premature mortality, both from suicide and from physical illness. Once recognized, depression can often be treated effectively. The mental health services utilization literature provides evidence that despite high prevalence of mental disorders substantial numbers of patients do not receive treatment. Although there is relatively large literature on help-seeking, considerably less is known about the speed of treatment contact among incident cases over longer time periods, except research on the treatment lag following first episodes of schizophrenia in the developed countries. Despite high prevalence, significant disability and presence of effective treatment, there is little information available on the issue of timing of treatment entry for the depressive disorders. Furthermore, there are no formal studies on factors related to treatment delay in mental illness in developing countries. Therefore, it was important to study the factors affecting delay in help-seeking in developing countries. The results indicated that there was mean delay of 4.50 years from the onset of first episode of depression to the first contact with a psychiatrist. On the whole Andersen's model was useful in identifying several predictors of delay in care seeking. In the full model, age and education predicted delay. Older people and those with higher education made contact with a psychiatrist later than young people and those with lower education. Among the enabling variables, social support was negatively and significantly associated with duration of delay. Of the need variables, suicide plan was positively and significantly associated with duration of delay indicating that respondents who had made a suicide plan ever in their life delayed care seeking for their psychological problems. Our study did not find any significant association between duration of delay and past contact with a professional. The findings of the study are relatively straight forward and suggest that substantial need exists to reach many depressed individuals earlier with effective interventions. The results indicate that more effort is needed to increase prompt initial treatment contact among people with incident episodes of depression in Pakistan. The present study confirms the importance of improving "Mental Health Literacy", that is public awareness about the symptoms of depression and routes to treatment. Appropriate training of general practitioners and developing a referral system would lead to better provision of mental health care. The study also indicates that western help-seeking behavior theoretical models can be applied in developing countries with different cultural and geographical settings. However, besides traditional predisposing, enabling and need variables, other variables need to be considered.

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