Dual diagnosis and their care pathways for help-seeking: a multi-center study from India
Introduction: Patients with dual diagnosis (DD) have higher morbidity, worse course and outcome, and an elevated treatment gap. Understanding pathways to DD care will help organize DD services and facilitate training and referral across healthcare sectors. The aim of our study was- to characterize the stepwise healthcare and other contacts among patients with DD, compare the characteristics of the first contact persons with common mental illness (CMI) vs. severe mental illness (SMI), and estimate the likelihood of receiving appropriate DD treatment across levels of contacts.
Methods: This multicentre, cross-sectional study in India focused on integrated DD care in eight centers. Conducted between April 2022 and February 2023, it enrolled consecutive patients over 18 years, with substance dependence and other mental disorders. The descriptive study collected demographic and clinical data, identified eight healthcare contact levels, and categorized treatment. A WHO collaborative encounter form facilitated real-time data collection. Potential biases included selection bias due to tertiary care patients and addressed recall bias. Statistical analysis utilized SPSS, applying chi-square, Fisher's exact test, and t-tests.
Results: The sample (n=589) had a median age of 32, mostly males (96%). Alcohol was the commonest substance; SMI (50.8%) and CMD were equally represented. Traditional healers were a common first contact choice (18.5%); however, integrated DD care dominated subsequent contacts. Comparing first contact characteristics between Common Mental Disorder (CMD) and SMI groups, the CMD group predominantly visited government general hospitals and private medical practitioners (10.7% and 5.8%), with contacts initiated by patients (21.7%) and relatives (23.1%). Addiction-related symptoms were the primary reason for seeking help (35.2%). In contrast, the SMI group was more likely to seek assistance from religious practices (11.1%), with contacts initiated mostly by relatives (43%) and driven by psychiatry-related symptoms (51.2%). Notably, both groups showed no significant treatment differences, except for a higher frequency of substance use disorder medications in the CMD group. These between-group differences were statistically significant (p<.001). Assistance likelihood increased from the first to the second contact (23.1% to 62.1%) but declined in subsequent contacts, except for a significant rise in the fifth contact (97.4%).
Conclusion: Recognizing the cultural nuances, advocating for integrated care, and addressing systemic challenges pave the way to bridge the gap in DD treatment.
