Untreated Psychosis and Healthcare-Seeking Behaviour in Pakistan: A Qualitative Study With Young People, Carers, Traditional Healers, and Healthcare Professionals

Abstract

Background

Prolonged delay between the onset of the first episode of psychosis (FEP) and initiation of treatment is common in lower- and middle-income countries (LMICs), including Pakistan. This qualitative study explored perspectives of young persons with FEP, carers, healthcare professionals, and traditional and spiritual healers (TSHs) on drivers of delayed diagnosis and treatment of FEP, to suggest interventions aimed at addressing factors contributing to prolonged duration of untreated psychosis (DUP) in Pakistan and similar contexts.

Methods

We conducted a qualitative study in Peshawar, Pakistan using focused ethnography as a research design. We first conducted focused ethnography using participant observation with 15 TSHs. Subsequently, data was collected through semi-structured interviews (n = 26) and focus group discussions (n = 6) with FEP individuals (age 14–25), their carers, and healthcare professionals. We used framework analysis, combining inductive and deductive thematic approaches to analyse the data.

Results

Three themes emerged from the analysis in relation to care pathways in psychosis: (1) moral-spiritual explanations legitimise spiritual healings; (2) stigma renders psychiatric disclosure socially risky; and (3) structural exclusion of inaccessibility of mental health from primary care.

Conclusion

Psychosis remains untreated for a prolonged time as families navigate a moral-spiritual landscape that makes TSHs the only legitimate healers, stigma makes psychiatric disclosure a threat to family honour, and absent or dismissive services make biomedical care unreachable. Engagement with TSHs represents an underutilised opportunity to develop collaborative care models that reduce the duration of untreated psychosis.