Mental disorders were the sixth leading cause of disabilityadjusted life-years (DALYs) in 2017, globally. Mental health has been included in the Sustainable Development Goals [1]. Though mental health services and resources are available, they are not accessed due to different factors such as stigma, poverty, unawareness of the symptoms [2], and discrimination toward patients with mental health conditions. This discrepancy may affect access to mental health services and may worsen the mental health disorders of the patients [3].

Studies indicate that major barriers to mental healthcare access are limited availability and affordability of mental healthcare services, insufficient mental healthcare strategies, lack of education about mental disorders, negative attitudes toward mentally disordered patients, and perceived quality of service [4], and stigma [3]. Decentralizing mental health services will help address local needs (3). There is always a mismatch between the prevalence of mental disorders and healthseeking behavior [5]. Mentally ill patients may have poor health outcomes and increased morbidity and mortality due to delayed or inappropriate health-seeking behavior [4]. Other reasons for patients to not seek treatment were economic problems, lack of awareness about the availability of mental health services, unsatisfied with medical services, fear of social stigma, and lack of transport to the treating institutions [6].

Health-seeking behavior depends on individual and/ or household members’ attitudes, community norms, and expectations [7]. Health-seeking behavior also depends on the interaction of mentally ill patients with the local community [8]. It was observed that the caregivers of mentally ill patients had poor knowledge about mental illness and a negative attitude toward mental illness [9].

Seeking care from traditional healers for the treatment of mentally ill patients is routine and cultural in some countries [10]. In many countries, mentally ill people sought treatment from traditional healers due to a lack of mental health facilities in their vicinity [9]. Both social stigma, anticipated stigma [11], along with negative attitudes toward psychiatrist medicines are some of the factors that influence health-seeking behavior, as shown in various studies [4]. Initial positive help-seeking experiences and severe functional impairments will improve the health-seeking behavior [11]. Easy accessibility to mental services, faith, and the good reputation of the treating institutions were some of the reasons for seeking treatment in tertiary or secondary care institutions. Belief in the supernatural causation of mental illness was a major reason for seeking a faith healer [12]. Other than these factors, health-seeking behavior also depends on the type of illness.

Mental disorders contributed to 4·7% of the total DALYs in India in 2017. More than 14 percent of the total population in India has some form of mental disorder [13]. There is only one psychiatrist for four lakh Indians [14]. India launched its first National Mental Health Policy (NMHP) in 2014 and a revised Mental Healthcare Act in 2017. The objective of this policy was to provide equitable, affordable, and universal access to mental health care [1]. Despite the implementation of a national health program, the majority of the patients remain untreated or there is a treatment gap. The high treatment gap may be due to poor awareness about symptoms of mental illness, stigma related to mental illness, and lack of knowledge on the treatment availability [15]. The majority (75%) of all adult mental health problems have their origins in adolescence and young adulthood [16]. Public stigma prevents people from seeking counseling and treatment [16]. Suicide is connected to mental health [17]. Suicide was the leading cause of death among the young population in India (ages 15 to 39).

NMHP recommends all districts should have District Mental Health Programme (DMHP) unit. The aim of DMHP is to extend mental health services to persons with mental illness in the district through the existing healthcare personnel and institutions [18].

Specific objectives of DMHP were

• To develop and implement a decentralized training program in mental health for all categories of health personnel in a way that would be the least disruptive to ongoing general healthcare activities.
• To provide a range of essential drugs such as antipsychotics, antidepressants, anticonvulsants, and minor tranquilizers for the management of mental illness
• To develop a system of simple recording and reporting of care by mental health personnel
• To monitor the effect of the service of the mental health program in terms of treatment utilization and outcomes
• To reduce the stigma by bringing about a change of attitude through public health education

Treatment and rehabilitation of patients within the community by adequate provision of medicines and strengthening the family support system [18].

Activities proposed under District Mental Health Program at the district level were the provision of mental health out-patient & in-patient mental health services with a 10 bedded inpatient facility in the district headquarters hospital, arranging outreach services through 4 satellite clinics per month at Community Health centers or primary health centers by the DMHP team, Life skills education & counseling in school, college counseling services, workplace stress management, suicide prevention services, and awareness camps for dissemination of awareness regarding mental illnesses and related stigma through the involvement of local bodies, faith healers, teachers, leaders, etc. [19].

The state of Tamil Nadu in India has around 3000 psychiatrists and there are at least 10 beds in each district for treating psychiatric patients [20]. District mental health program evaluation done in 2014 showed that the majority of the districts in Tamil Nadu had, in-patients facilities and psychotropic drugs were available at all taluk and district headquarters hospitals [21]. The Institute of mental health, in the capital of Tamil Nadu state, is offering all mental health services. This institute has outpatient (OP) and inpatient (IP) facilities, in addition to a de-addiction ward [22]. We wanted to understand if the decentralization of services was done effectively at the district level through the study of the pattern of illness and the reasons for the patients to turn up at IMH, despite all services being available at the district level. We also wanted to study the health-seeking behavior among the patients.

Moreover, though IMH documents all services, earlier no study had been done to describe the pattern of mental illness among the patients attending the IMH. The study on health-seeking behavior may help to plan the necessary human resources and training for the capacity building of the service providers [23]. This may help to reallocate the human resources, logistics, and funds, needed for the institution. This may help to identify the issues in the implementation of DMHP. Based on the patient’s health-seeking behavior from the different districts of Tamil Nadu, we can give an evidence-based recommendation to the district mental health program to improve the program activities.

The objectives of the study were

1. To describe the pattern of mental illness among the patients attending IMH, Chennai.
2. To describe the health-seeking behavior of the patients and their families.
3. To identify the reasons for seeking treatment in districts other than their residential districts.

Study setting

Our study setting was the Institute of mental health, Chennai.

Study population

Our study population were the outpatients attending the Institute of Mental health.

Study Period

Our study period was from January 2022 to March 2022.

Study design

Our study design was a descriptive study.

Operational case definitions

Health-seeking behavior: Healthcare-seeking behavior (HSB) has been defined as, “any action or inaction undertaken by individuals who perceive themselves to have a health problem or to be ill to find an appropriate remedy”[4]

Mental illness: Mental illnesses are defined as “health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning” [1].

Sampling method and sample size

We included all patients attending OP, to describe the burden of mental illness. For the second and third objectives, we interviewed 808 patients, As the sample calculated was 369 for simple random sampling, we arrived at 808 for the cluster sampling method. We did two-stage cluster sampling, our clusters being day clusters. We had to select 25 patients per day to achieve the sample size. We conducted the study on all days except Sundays.

Procedure for sample size calculation: Patients seeking a psychiatrist as their first choice for treatment was 45% according to the literature. {(Mishra, N., Nagpal, S. S., Chadda, R. K., & Sood, M. (2011). Help-seeking behavior of patients with mental health problems visiting a tertiary care center in north India. Indian Journal of Psychiatry, 53(3), 234–238. https:// doi.org/10.4103/0019-5545.86814)}. With a 95% confidence level,10% as a non-response rate, and 5% absolute precision, we arrived at this sample size. Our population was around 11,700 patients per month.

Data needed: We needed data on socio-demographic details, investigations, and psychiatric diagnoses. For health-seeking behavior, we needed data on the time of seeking treatment after the onset of symptoms, choice of doctors/healers, willingness to continue treatment and compliance to drugs/therapy, and reasons for seeking treatment in districts other than the residential districts.

Data collection methods: We reviewed records for sociodemographic details, diagnosis, treatment, and investigations. We used a semi-structured questionnaire for health-seeking behavior.

Data analysis: We computed proportions to describe the pattern of mental illness, to describe the health-seeking behavior among the patients, and the reasons for seeking treatment in districts other than residential districts.

We enrolled 808 patients in our study. Out of which 68% (547/808) were males and 32% (261/808) were females. The mean age of the females was 38 years (Range: 9 years to 86 years) and the mean age of males was 34 years (Range: 6 years to 90 years). Among them, the majority of the males (42%, n= 227) and females (36%, n= 93) had education up to Higher Secondary level. The median income of the study population was Rs. 8000, ranging between 500 to 1 lakh Indian rupees. Around half of the males (263/547) were unemployed and more than two third of females were unemployed. (207/261). Among the males, onefourth were doing unskilled labor (139/547) (Table 1).

The majority of the study population belonged to the Hindu religion, both among males {83%, (449/547)} and females {77%, (201/261)}. Among the males, 13% were Christians (72/547) and 4% were Muslims (24/547). Among the females, 16% were Christians (41/261) and 7% were Muslims (18/261). Among the patients, 70% were residents of Chennai (43%, n=354), Thiruvallur (17%, n=135), and Kanchipuram (10%, n=77). Eight out of 808 patients came from Andhra Pradesh and three patients were residents of Kerala.

Among the parents of the patients, 27% had consanguineous marriages. A history of mental illness was present among the patient’s family members 57% (n=458). Among the 458, only 409 responded to the query, “Which family member had a mental illness?” In our study, the majority of the respondents said their father 24% (n=98), or their paternal side relatives 12% (n=50) had mental illness. The prevalence of mental illness in the mother was 11% (n=43) and maternal side relatives were also 11% (n=44). The presentation of mental illness was lower in brothers 10% (n=41) and sisters 5% (n=19). In our study, 301 persons had one family member with a mental illness. 108 persons had more than one family member with mental illness (Flow chart).

Most of the patients (70%), sought treatment within 6 months after the onset of symptoms (n=564). Among them, 15% sought treatment within one week (n=123), 25% sought treatment within one month (n=199), 30% sought treatment within two to six months (n=242), 10% sought treatment within one year, and 20% sought treatment after one year (n=164), (Figure 2). Five hundred and twenty (64%) out of 808 patients, went to the Government sector for initial treatment and 36% went to the private sector for initial treatment.

Schizophrenia {33% (n=268)} and Substance Abuse {25% (n=204)} were the major illnesses among the patients. Hundred and seven (13%) patients had Bipolar disorders. Intellectual Disability (n=48) and organic disorder (n=50) were found among 6% of patients. Anxiety disorders were found among 41 patients (5%). Depressive disorders were found among 67 patients (8%) (Figure 1).

More than 90% of the patients had visited psychiatrists working in government {61%, (n=493)} or private hospitals, {33%, (n=270)}. Only 6 patients (0.7%) had visited traditional healers for initial treatment (Figure 3).

The major reasons for seeking treatment in IMH were insomnia {88% (n=714)}, aggression {69% (n=557)}, and unmanageable behavior at home {61% (n=495)}. Other reasons for seeking treatment were talking to self {43% (n=344)}, public nuisance {39% (n=315)}, paranoia {38% (n=306)}, not going to work {31% (n=251)}, substance abuse {30% (n=242)}, poor selfcare {26% (n=208)}, hearing voices {26% (n=210)}, loss of appetite {18% (n=147)}, low mood {15% (n=122)}, suicidal ideation {14% (n=114)}, self-harm {7% (n=55)}, no one to take care at home {1% (n=11)}(Figure 4).

Among the patient’s attending IMH OPD, 29% (n=231) had comorbid illnesses. Among these patients, 8% had Hypertension (n=65), 8% had Diabetes (n=62), Seizure was present in 5% (n=39), heart disease was present in 0.9% (n=7), 0.5% of the patients had a stroke (n=4), Kidney disease was present in 0.4% (n=3), Liver disease was present in 0.3% (n=2). Thirteen percent of the patients had other comorbid illnesses (n=104).

The stigma of having a mental illness was a major issue 81% (n=656), faced by the patients and their caregivers.

Among the patients who came to IMH for treatment, 66% (n=533) came because the treatment was good in IMH, 30% (n=245) felt caregivers were not needed to be present with the patient during their stay in IMH, 3% (n=26) felt the treatment was not satisfactory in their residential districts and only 0.5% (n=4) felt there were no medical centers in their district.

In our study, the mean age of male was 34 years and female were 38 years. A major proportion of patients had higher secondary grade education and the median income was 8000 rupees. Nearly half of the male and two-thirds of the female subjects were unemployed. One-fourth of the males were involved in unskilled labor. About a quarter of the subjects were born from consanguineous parents. Mental illness was present in the family tree among half of the study subjects. Around 70% of the study subjects sought treatment within 6 months after the onset of symptoms. Around 64% of the study subjects visited government hospitals for their first treatment. Schizophrenia followed by substance use was among the major psychiatric illnesses found in the study subjects. The majority of them had visited psychiatrists working in government setups. The major reasons for consultation at the Institute of Mental Health, were insomnia, aggression, and unmanageable behavior at home. The other reasons were talking to self, public nuisance, paranoia, not going to work, substance abuse, poor self-care, hearing voices, loss of appetite, low mood, suicidal ideation, and self-harm behavior. Around 29% of the subjects had a comorbid illness. Hypertension, diabetes, and seizure disorder were among the common comorbid illnesses. The majority of the patients and their families were affected by the stigma of mental illness. More than half of the study participants said they opted for consultation at IMH as they felt the treatment was good in IMH.

Half of the patient’s parents had mental illness in our study. This was similar to the prevalence of mental illness among family members in another study done in Denmark. Among them the father’s and paternal side relatives had a majority of mental illness, nearly one-third, followed by mother and maternal side relatives at 22%, last came along siblings with the prevalence of mental illness in them at 15%. Nearly one-eighth of our study population had more than one family member with mental illness.

In our study, one-fourth of the parents of our study patients had a consanguineous marriage, This was similar to another study, where there was an association found between consanguineous marriage and the incidence of mental illness among the offspring of the parents who had a consanguineous marriage [24].

A major clinical illness was schizophrenia in IMH. This was similar to a study done in Arunachal Pradesh, India. There also, schizophrenia was the commonest illness followed by bipolar disorders [25]. But substance use was low in the Arunachal Pradesh study when compared to the IMH study. Substance use was the second-highest illness in the study conducted in IMH. The prevalence of schizophrenia was similar in a study done in Gwalior [26]. Around 36% had schizophrenia in the Gwalior study, while the prevalence of schizophrenia was 33% in IMH. But bipolar prevalence was 45% at Gwalior Institute, while it was low (13%) in IMH.

Insomnia was the common reason for seeking treatment in our study. This was similar to another study done in Kochi, India [27]. Other reasons for seeking treatment were also similar to our study. But talking to self was present among 43% in the IMH study while in the Kochi study, it was less than 8%. This difference could be due to the different populations in the Kochi study, as the study population there was mental illness among the COVID patients.

Most of the patients in our study had visited psychiatrists for the initial treatment. This is similar to another study done in Pondicherry [28]. Most patients did not seek traditional healers, similar to other studies done in Delhi, India [29], But another study done in Gwalior, India showed that the majority of the patients had sought faith healers as the first choice for treatment [26].

Stigma was found among patients regarding mental illness in our study. This was similar to another study done in Arab countries [30] .As per a few studies stigma is more prevalent among Western nations [31], than in Asian countries. In one study done in Gwalior, the prevalence of stigma was similar to our study. Around 70% had a stigma [26]. Stigma may cause underreporting of mental disorders. [32]. Studies conducted in Indonesia showed that stigma delays or prevents health-seeking [33]. Evidence shows that stigma affects not only the patients but also the family members and friends of mentally ill patients [34]. Stigma has not only delayed health-seeking behavior, but it also impacts marital life, causing separation and divorce [35].

The most common comorbid conditions in our study were diabetes, hypertension, and seizure disorders. While our study population had 8% diabetes as a comorbidity, another study done in Qatar, showed that 16% of mentally ill patients had diabetes. Another meta-analysis done in developing and emerging countries showed that the prevalence was 16% among mentally ill patients [36]. But the mean age of the patients in that study was 55 years, while the mean age in our study was 38 years in females and 34 years in males. The prevalence of hypertension was similar in our study and a study done in Qatar. (8%) [36]. In our study, seizures were prevalent among 5% of the patients. This was similar to another study done in Norway, where the prevalence of epilepsy was 4% [37].

In our study, only 40% of the patients sought treatment within one month after the onset of symptoms. This was in contrast to another study done in Delhi, where more than 80% of patients had sought treatment within one month [37]. Another study done in Jaipur, India showed that the median duration to seek treatment among mentally ill patients was 6 months [40]. But another study done in Gwalior showed that the mean duration to visit a psychiatrist for treatment was 21.5 months [26].

Satisfactory treatment was one of the reasons quoted by the patients for seeking consultation in IMH. Reasons are given for visiting another tertiary care center according to a study done in North India, recommendations, unsatisfactory treatment in previous centers, earlier experience in the hospital, affordable treatment costs, adverse drug reactions, and for second expert consultation [29].

Human Subject Protection

We submitted the protocol to the ethics committee. We translated the semi-structured questionnaire into the local language. We took informed consent from the participants.

Expected Benefits

We generated a report about the pattern of illness to streamline the resources. Evidence-based recommendations have been given to improve the health-seeking behavior of the patients and the District Mental Health Program.

We thank all patients who participated in our study.

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