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สนับสนุนการจัดทำโดย
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วารสารสมาคมจิตแพทย์แห่งประเทศไทย Pattern of help-seeking by relatives of psychotic patients* Chadapan Ratanatikanon,
M.D.** Abstract Objective To describe patterns of help-seeking by relatives of psychotic patients. Methods The relatives of 47 psychotic patients who first visited the psychiatric out-patient clinic, Songklanagarind Hospital, from September 1, 1995 to May 31,1996 were interviewed using a structured questionnaire. The factors of interest included demographic characteristics of the patients and relatives, knowledge, beliefs, and attitude of relatives towards psychotic illness and mental health services, and the clinical manifestation of the patients. Results Most patients relatives knew the manifestation of psychotic symptoms but not the etiology. A few believed that psychoses were caused by stress and worry, or supernatural influences. Most of them never obtained information about psychoses and health services from public health personnel. Relatives were worried about patients symptoms and not reluctant to see psychiatrists. In 90% of the cases, family members were the first persons who detected the patients psychotic symptoms. The symptoms first manifested included abnormal content and form of speech, delusions and psychomotor slow down. After detection, only one third of the relatives immediately sought help from physicians, 28% sought help from non- medical practitioners and 38% just observed and hoped that the symptoms would spontaneously improve. Conclusion This study revealed that knowledge and beliefs might play an important role in help-seeking by relatives of psychotic patients. J Psychiatr Assoc Thailand 1997 ; 42(4) :226-33. Key words help-seeking, psychosis, relatives * Present
in the 6th congress of Asean Federation for psychiatry
and Mental Health and the 10th ASEAN Forum on child and
Adolescent Psychiatry. Bangkok, Thailand, 4-7 November 1996. ** Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. *** Department of Psychiatry, Songklanagarind hospital, Hadyai, Songkla, 90112 Thailand.
พฤติกรรมการแสวงหาการรักษาของญาติผู้ป่วยโรคจิต * ชฎาพรรณ
รัตนติกานนท์ พ.บ. ** บทคัดย่อ วัตถุประสงค์ เพื่อศึกษาพฤติกรรมการแสวงหาการรักษาของญาติผู้ป่วยโรคจิต วิธีการ สัมภาษณ์ญาติของผู้ป่วยโรคจิตจำนวน 47 คน ที่มารับการรักษาที่โรงพยาบาลศรีนครินทร์เป็นครั้งแรก โดยใช้แบบสอบถามที่ประกอบด้วยคำถามด้านข้อมูลประชากรศาสตร์ ของผู้ป่วยและญาติ ความรู้ ความเชื่อ และเจตคติที่ญาติมีต่อผู้ป่วยและสถานพยาบาล รวมทั้งลักษณะอาการของผู้ป่วย ผลการศึกษา ส่วนใหญ่ของญาติทราบถึงอาการของโรคจิตแต่ไม่ทราบสาเหตุ จำนวนหนึ่งเชื่อว่าเป็นจากความกดดันและความวิตกกังวล หรือจากอำนาจเหนือธรรมชาติ ส่วนใหญ่ไม่เคยทราบข้อมูลเรื่องโรคจิตหรือการบริการทางการแพทย์ของภาวะนี้ ญาติจะกังวลใจกับอาการของผู้ป่วยและไม่ลังเลใจที่จะมาพบแพทย์ ร้อยละ 90 ของผู้ที่สังเกตเห็นความผิดปกติของผู้ป่วยเป็นคนแรกเป็นบุคคลในครอบครัว อาการแรกเริ่มได้แก่ การพูดผิดปกติ มีความหลงผิด และพฤติกรรมการเคลื่อนไหวเชื่องช้าลง หลังจากเห็นอาการมีเพียงหนึ่งในสามของญาติที่ไปพบแพทย์ทันที ร้อยละ 28 ไปพบผู้รักษาอื่นๆ และร้อยละ 38 ใช้วิธีรอดูอาการโดยมีความหวังว่าจะหายไปเอง สรุป ความรู้และความเชื่อเรื่องโรคมีบทบาทสำคัญต่อพฤติกรรมการแสวงหาการรักษาของญาติผู้ป่วยโรคจิต วารสารสมาคมจิตแพทย์แห่งประเทศไทย 2540; 42(4) :226-33. คำสำคัญ พฤติกรรมการแสวงหาการรักษา ญาติผู้ป่วย โรคจิต * นำเสนอในการประชุม the 6th Congress of ASEAN Federation of Psychiatry Mental Health and the 10th ASEAN Forum on Child and Adolescent Psychiatry, กรุงเทพ, 4-7 พฤศจิกายน 2539. ** ภาควิชาจิตเวชศาสตร์ คณะแพทยศาสตร์จุฬาลงกรณ์มหาวิทยาลัย กรุงเทพ *** ภาควิชาจิตเวชศาสตร์ คณะแพทยศาสตร์ มหาวิทยาลัยสงขลานครินทร์ หาดใหญ่ สงขลา 90112 INTRODUCTION Today psychoses are an important public health problem in Thailand. Psychoses are prevalent in about 1% of population1. Management of psychotic patients is a burden to their relatives both psychologically and financially. Severity of the disease can be controlled or diminished if the treatment is established early. For example, bipolar disorder often responds to drug therapy rapidly2. Psychosis due to general medical condition responds well to specific treatment. It would help the family if the patient recovered rapidly3, but usually most of the patients are taken to the hospital by relatives when they are very sick. The problem, therefore, is delayed help-seeking behavior. This study aims to describe patterns of help-seeking by relatives of psychotic patients and factors that cause delayed help-seeking. MATERIALS AND METHODS Subjects were relatives of psychotic patients who firstly visited the psychiatric outpatient department of Songklanagarind Hospital between September 1, 1995 and May 31,1996 (n=47). The psychotic disorders included here were psychotic disorder NOS, bipolar disorder with psychotic features, major depressive disorder with psychotic features, psychotic disorder due to general medical condition, substance induced psychotic disorder, schizophrenia, schizophreniform disorder, schizoaffective disorder, brief psychotic disorder, and delusional disorder using DSM-IV criteria. The diagnosis was made by psychiatrists and psychiatric residents. The interview schedule used composed of 44 questions assessing knowledge, attitude, and help-seeking behavior of the relative for the first psychotic episode. All data were computerized, analyzed, and expressed as percentage. RESULTS
The sample consisted of 47 subjects-22 males and 25 females. Two patients lived alone while 17 (36%) lived with their family with 2 -3 household members and the rest were with four or more members. The family income ranged from 1,000 baht to over 30,000 baht per month with 21% earned less than 5,000 baht and 21% earned more than 30,000 baht. Most of the patients families had income of 5,000-30,000 baht/month. Most subjects had some knowledge about symptoms of psychoses (see table 2). Most of the subjects (94%) did not know about the etiology of psychoses. Six (13%) thought that psychoses were caused by stress and worry while nine (19%) thought that psychoses were caused by supernatural influences. Regarding information about psychotic diseases, 57% of the relatives reported of never receiving information about common symptoms, and 19% had received information from public health personnel (see table 3). Medical treatments for a psychotic disease as reported by the subjects were medicine (85%), injection (59%), ECT (28%), radiotherapy (9%), and surgery (6.5%) respectively. 3. Attitude towards psychoses Most subjects (73%) were worry about symptoms of the patients and were not reluctant to see a psychiatrist (72%). They thought that a psychotic disease was not contagious (78%) and could be cured (76%). 4. Help-seeking behavior Family members were almost always the first person who detected patients symptoms (91%). In 36% of the cases, symptoms were firstly detected by their father, mother or spouse, 9% by their sons or daughters and 6% by their siblings. One case was detected by a grandmother and another by an uncle. Friends were the first people to detect the symptoms in four patients. Symptoms detected by relatives were frequently incoherent speech (94%), delusions (79%), psychomotor retardation (75%), and paranoid idea (72%) (table 4). When the relatives detected patients symptoms, they managed the symptoms by observation first and hoped that the symptoms would spontaneously improve (38%) (table 5). Thirty eight percent (18/47) of relatives took the patients to see the doctors within one day, and fifteen of those came to the psychiatric outpatient department of Songklanagarind Hospital (table 6). Thirty-eight percent of relatives did not delay taking patients to see the doctor. Sixty-seven percent of patients saw a psychiatrist first, 33% saw a general practitioner physician first. Psychiatrists made the diagnosis of psychosis in 65% (20/31) of the cases, while general practitioners made the diagnosis in 20% (3/15) of the cases. Most of the doctors treated patients with medicine (62%). Most subjects asked other relatives for general advice (75%), 51% went to see folk healers (table 7). DISCUSSION From this study, 62% of relatives did not take patients too see a doctor within one day of detection of symptoms. This number may not be accurate because of small sample size; subjects consisted of only 22 males and 25 females. Kumrat4 reported that 28% and 12% of relatives believed that supernatural influences and karma were the causes of psychoses. (The Buddha defined karma as physical, verbal and mental ethical action5). This study showed that supernatural influences were believed to be the cause of psychoses among 19% of relatives, and most relatives had never obtained information about psychosis and the health service system from any public health personnel. This lack information might have impacted the pattern of help-seeking. In this study, if relatives met an untreated patient, most of them would be willing to take that patient to see the doctor (81%), which is similar to Kumrat's study (96.95%)4. In this study 74% of subjects thought that psychoses could be cured. They worried about the patient's symptoms (73%) and were not reluctant to see a psychiatrist (72%). Twenty-eight percent of relatives waited for more than one month before taking the patient to see a doctor. When the patients symptoms first detected, 55% of relatives employed observation and hoped the symptoms would recover spontaneously, 24% went to pharmacists, 10% went to see folk healers, 7% took herbs and 4% consulted their friends or relatives. The finding of Kumrat4 seemed to be similar in that he reported 58.92% of relatives taking patients to seek non-medical treatment first. Ninety-two percent of psychotic patients were detected by family members. Predominant symptoms were incoherent speech (94%), delusions (79%) and psychomotor retardation (75%). Doctors whom relatives took the patients to see first were psychiatrists (67%) and general practitioners (33%). This finding might partly reflect the suggestion of outpatient department personnel. Psychiatrists diagnosed psychosis 65% and general practitioners 20%. Help-seeking is a dynamic condition. The relatives may simultaneously take the patients to many places for treatment. Therefore, visiting a doctor does not mean not going to elsewhere. Further study is needed for more details in this regard. The limitation of this study is a small sample size and the terms delayed and severity should be defined for more precise information. Also the evaluation of the treatment provided by general practitioners was not possible. CONCLUSION This study found that most subjects knew about psychotic symptoms but all of them did not know about etiology in the scientific aspect. Nineteen percent of them believed that supernatural influences cause psychoses. Few of the subjects received information from public health personnel (19%). Ninety-two percent of those who first detected patients symptoms were family members. Thirty-eight percent of the total relatives of psychotic patients visited a doctor immediately, 28% of the relatives who did not take the patients to see a doctor immediately sought help from non-medical sources and 55% observed and hoped the symptoms would spontaneously recover. This study reveals that beliefs may impact the pattern of help-seeking behavior, result in poor outcomes and personality deterioration3. Strategies for improving the patterns of help-seeking behavior should be established; such as providing knowledge about psychoses to the public, setting up an outreach program for psychotic patients, and more psychiatric education to general practice physicians. REFERENCES
Table 1 Diagnosis of psychotic patients
Schizophrenia 13 28 Psychotic disorder NOS 7 15 Bipolar disorder with 6 13 psychotic features Major depressive disorder 6 13 with psychotic features Psychotic disorder due to general medical condition :-
Schizophreniform disorder 4 8 Brief psychotic disorder 3 6 Substance-induced psychotic disorder 1 2 Delusional disorder 1 2
Table 2 The subjects perception about psychotic symptoms
* Information was lost 1 record. Table 3 The sources of information about psychoses
* The relatives of psychotic patients who had received information about psychosis were twenty six. Table 4 Patients first symptoms detected by relatives
Table 5 Methods first used to manage patients symptoms for those who did not see the doctor immediately (within one day)
Table 6 Duration between detecting of symptoms and visiting a doctor
Table 7 Sources of information that the relatives get the general advice
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