Facilitators in treatment pathways for depression or anxiety among adults in Nepal: A qualitative study

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Luitel, Bishnu Lamichhane, Kabita Sah, Baidahee Basnet, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5711655/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Jun, 2025 Read the published version in BMC Public Health → Version 1 posted 8 You are reading this latest preprint version Abstract Background: Depression and anxiety are prevalent mental health issues globally, yet many individuals in low- and middle-income countries lack access to treatment. Limited research exists on mental health service utilization in these regions. Understanding the factors that impact access to care and treatment pathways can enhance mental health services. This study investigates the factors that support the initiation and continuation of treatment for depression or anxiety in Nepal. Methods: The study was conducted in Jhapa, Chitwan, and Kailali districts in Nepal, representing the eastern, central, and far-western regions. The participants were adults receiving treatment for depression or anxiety from a range of healthcare providers. A total of 24 participants were purposively recruited, including 13 with symptoms of depression, 9 with symptoms of anxiety, and 2 with both conditions. We utilized the McGill Illness Narrative Interview, a semi-structured protocol commonly used in mental health research, to gather detailed narratives on symptom experiences, illness accounts, and help-seeking behaviors. Data analysis was performed using a framework and thematic analysis approach with NVIVO software. Results: Treatment pathways for depression and anxiety in Nepal were found to be complex, involving multiple service providers and recurrent treatment from the same providers. Out of a total of 137 sessions across 24 patients, the majority of sessions were with traditional faith healers (27.7%), followed by private hospitals (19.7%), primary healthcare facilities (16.1%), government hospitals (13.1%), neighboring countries (8.0%), and private clinics (11.7%). Traditional healers were the most popular places for initial visits, followed by private clinics and government hospitals. Factors such as service quality, providers behavior, availability of trained providers, appointment process, confidentiality, and types of services offered influenced care-seeking decisions. Support from family or friends, awareness of mental health issues, and recommendations from trusted individuals also played a significant role. Conclusion: Treatment pathways for depression and anxiety disorders are complex, often involving multiple sessions with different service providers and a combination of services. Improving healthcare providers' behavior, appointment scheduling, and consultation quality is essential to encourage individuals to seek care. Raising awareness about mental health conditions and available services through various channels as well as training traditional healers in mental health could enhance access to care. Depression and anxiety treatment pathway facilitators Nepal Figures Figure 1 Introduction Depression and anxiety are prevalent mental health conditions worldwide with depression affecting over 322 million individuals ( 1 ), and anxiety disorders affecting 374 million individuals ( 2 ). These conditions have a significant emotional and financial impact on individuals, families, and communities ( 3 – 6 ). Moreover, they often co-occur with around 46% of individuals with depression also experiencing one or more anxiety disorders during their lifetime ( 7 ). These disorders not only result in high rates of morbidity and mortality, but also increase the risk of other diseases such as type-2 diabetes and ischemic heart disease ( 8 – 10 ), substance abuse ( 11 ) chronic pain ( 12 ), immune system dysfunction ( 13 ). Depression alone contributes to 40.5% of disability-adjusted life years (DALYs) caused by mental illness ( 14 ). Despite the availability of evidence-based treatments, a large proportion of people in low- and middle-income countries do not receive treatment for anxiety, and mood disorders ( 15 , 16 ). Many individuals who do receive treatment, experience significant delays between the onset of their symptoms and actually receiving treatment. According to Wang et al. (2007), patients with mood disorders waited anywhere from 1 to 14 years to seek care, while those with anxiety waited 3 to 30 years ( 17 ). The consequences of delaying treatment for depression and anxiety can be severe, including an increased risk of developing other health issues ( 18 , 19 ), reduced responsiveness to medication ( 19 , 20 ) and a lower likelihood of achieving positive treatment outcomes ( 21 , 22 ). Additionally, individuals with these conditions often seek help from informal sources such as traditional healers, friends, or family members rather than seeking assistance from healthcare professionals ( 23 – 25 ). The factors hindering access to mental health care include financial constraints, personal priorities, stigma, lack of knowledge about mental health, dissatisfaction with previous treatments, time and distance constraints, reliance on traditional or religious healers, and lack of social support ( 26 ). Many studies have examined help-seeking behavior for mental health issues in high-income settings ( 27 – 30 ), but there is limited understanding of the predictors for mental health service use and pathways to care in low- and middle-income countries (LMICs). Limited research in Nepal has focused on pathways to mental health treatment, with little exploration of facilitators in accessing and continuing care. Studies show that only 17% of patients with mental health issues seek treatment from mental health specialists through direct pathways ( 31 ), while 28.2% turn to traditional healers or religious faith healers and 40% to non-specialists ( 32 ). Common pathways to seeking help include direct access, referrals from private practitioners, general hospitals, and traditional or religious healers ( 33 ). Reasons for delaying care include lack of knowledge about- mental health problems, where to seek care, and not considering the issues serious enough ( 34 – 36 ). Similarly, poor service quality, including lack of confidential space, insufficient time, and poor communication, has been a barrier to continued care in low- and middle-income countries ( 37 ). Despite the limited number of studies conducted in Nepal, there were several methodological issues, as most studies recruited participants from hospitals or primary healthcare facilities only ( 31 , 33 , 38 – 40 ), making it difficult to estimate the actual pathways because these studies did not recruit participants receiving care from multiple providers. The current study aims to investigate the pathways to care for depression or anxiety, along with their causative factors as reported by individuals with lived experience of depression or anxiety using qualitative methods. Understanding the pathways to mental health care and identifying possible facilitators could help in developing strategies to reduce barriers, and improve the quality of mental health services, ultimately encouraging more people to seek care. Methods Setting Nepal, a low and middle-income country in South Asia has a population of approximately 29.1 million with an annual growth rate of 0.92% as per the National Census 2078 ( 41 ). In 2015, Nepal adapted a federal government system, resulting in 7 provinces, 77 districts, and 753 local units ( 42 ). The study was conducted in the Jhapa, Chitwan, and Kailali districts, located in the eastern, central, and far western regions of Nepal, with total populations of 994,090, 722,168, and 911,155 respectively. The reason for selecting these districts is that the primary healthcare providers in these areas have received training on the World Health Organization's mental health gap action program intervention guides (mhGAP-IG), and specialized mental health services are available in the districts. All three districts share a border with India. Nepal is a diverse country with 142 castes/ ethnicities and 124 languages. Each district has its own unique ethnic makeup, with Jhapa having a higher population of Rai, Limbu, and Meche, Chitwan having a significant Tamang and Magar population, and Kailali having a majority of Tharu people ( 41 ). Each caste/ethnic group in Nepal has its own traditional treatment practices, beliefs, and caste specific traditional healers and religious leaders to provide services. Nepal’s health care system comprises the public sector, private for-profit sector, and non-governmental organizations (NGOs) ( 43 ). The country has 0.76 psychologists, and 0.66 psychiatrists per 100,000 population ( 44 ). Specialist mental health services are primarily located in urban hospitals, leading to traditional healers being the main mental health providers in rural areas ( 45 ). While mental health services are concentrated in major cities ( 46 ), all three districts have a higher number of World Health Organization Mental Health Gap Action Program Intervention Guide (mhGAP-IG) trained healthcare providers, female community health volunteers (FCHVs), and free psychotropic medications available at some primary healthcare facilities ( 37 , 47 ). Study design The study utilized a qualitative design to investigate the pathways to care, available resources, and challenges encountered by adults in Nepal when seeking treatment for depression and anxiety. This approach enabled a thorough exploration of a topic with limited prior research and empowered participants to contribute to the generation of new knowledge ( 48 ). Individual interviews (IDI) provided an optimal environment for understanding personal experiences and challenges, as they offered depth, flexibility, and the opportunity to establish a trusting, confidential relationship. Participants and sample size The participants in this study were adults receiving treatment for depression or anxiety from trained primary healthcare providers or mental health specialists. In our study, we adhered to Guba and Lincoln's ( 49 ) five criteria for ensuring trustworthiness in qualitative research. This involved conducting the study in multiple districts to ensure diversity in terms of caste/ethnicity, cultural practices, and geography. We also used a range of service providers for participant recruitment, employed trained and experienced interviewers who matched the gender of the participants, involved multiple individuals in data analysis, and utilized both thematic and framework analysis methods. We recruited 24 participants, including 13 with depression, 9 with anxiety disorder, and 2 with both depression and anxiety disorders. Out of the total, 7 participants were from Kailali, 4 were from Chitwan, and 13 were from Jhapa district. Participants were recruited through primary healthcare providers (N = 7), psychosocial counselors (N = 7), and psychiatrists (N = 10). Inclusion criteria included being 18 years or older, currently receiving treatment from primary healthcare providers or mental health specialists, able to provide informed consent, and fluent in Nepali. Recruitment and interview process Qualitative interviews were conducted by two researchers with prior experience in qualitative research. Female interviewers conducted interviews with female participants, and male interviewers conducted interviews with male participants to prevent gender bias. The first authors supervised the interviewers by reviewing the recordings. Trained interviewers visited participants at their residences to explain the interview process, objectives, benefits, and potential risks of participating in the study. If participants agreed to take part, the interviews were conducted either at their home or in a confidential outpatient department (OPD) at a health center after obtaining written consent. All interviews were recorded in the participants' original voices and lasted between 45 to 60 minutes, depending on the depth of their shared experiences. The interviews were conducted between January and July 2023. Interview guideline We adapted the McGill Illness Narrative Interview (MINI), a semi-structured interview protocol commonly used in mental health research, to gather detailed narratives on symptom experiences, illness accounts, and help-seeking behaviors ( 50 , 51 ). The interview guide comprised five sections: history and understanding of the illness, effects and perceived causes, experience of stigma and discrimination, treatment pathways, and barriers and facilitators to treatment. Prior to data collection, the interview guide underwent pilot testing with a small group of participants. For this study, we focused on the data from the treatment pathways section, as well as barriers and facilitators to treatment. Data management and analysis The audio recordings were transcribed into notes immediately after the interviews by the interviewers. The first author conducted periodic proofreading of transcriptions to ensure accurate translation and retention of meaning in the translation. Two researchers independently familiarized themselves with the data by reading the translated interviews. Themes were developed based on the initial reviews and study objectives, and these themes were imported into NVIVO version 20 by QSR International. Subsequently, two researchers read more files separately to generate codes and sub-codes. Any disagreements on codes and sub-codes were resolved through discussions with the first author. Once there was agreement between the two researchers on the generated codes, they independently coded and entered the data. The independently coded files by the two researchers were merged weekly to ensure the inclusion of both researchers' codes. Data analysis was carried out using a framework and thematic analysis approach. Finally, all interviews were indexed and charted according to the thematic framework, and data from the charts were interpreted. Results The participants' ages ranged from 18 to 60, with a mean age of 38.9 (SD, 13.2). The majority of participants were female (62.5%), identified as Brahmin/Chhetri (50%), were married (83.3%), had up to a secondary level of education (62.5%), and identified as Hindu (83.3%). Most participants were from Jhapa (54%) and reported experiencing symptoms of depression (54%). Treatment pathway Table 1 illustrates the complex treatment pathways for depression or anxiety, involving multiple service points and treatments from various health facilities or providers. For example, Patient 8 (P8) initially sought treatment at a private clinic, then visited a traditional faith healer, followed by a primary healthcare facility, and returned to a traditional faith healer. P8 also visited a private hospital and traditional healers before receiving care from a primary healthcare facility. Patient 17 (P17) started treatment with a traditional faith healer, consulted multiple traditional faith healers before seeking care at a primary healthcare facility, and also visited a private clinic. P17 consulted with the private clinic twice and met a traditional faith healer before continuing care at a primary healthcare facility. Patient 4 had 11 consultations with different traditional faith healers before moving to a private hospital after a suicide attempt, then visited a primary healthcare facility, and continued care at a private hospital. Among the 24 patients, one had 14 consultations, three had 9 consultations, and two had 8 consultations at the time of the interview (Table 1). [Table-1 here] Figure 1 illustrates the healthcare-seeking preferences of patients for the treatment of mental health issues. Participants reported contacting various service providers, including traditional healers, once or multiple times. We defined each interaction or visit with a service provider as a session. Out of a total of 137 sessions across 24 patients, the majority of sessions were with traditional faith healers (27.7%), followed by private hospitals (19.7%), primary healthcare facilities (16.1%), government hospitals (13.1%), neighboring countries (8.0%), and private clinics (11.7%). For the first visit when seeking care, 25% of participants consulted traditional healers, 21% visited primary health facilities, and 21% went to private clinics. Only 8.33% visited government or community hospitals for their first consultation. In the second consultation, almost half (46%) sought treatment from traditional faith healers, with some continuing treatment and others visiting traditional faith healers for the first time. Additionally, 21% preferred government hospitals for their second visit. Government or community hospitals were the most preferred places for the third visit (21%), followed by traditional faith healers (16.7%). Some participants visited traditional faith healers in subsequent visits, with a few visiting them in the 4th to 8th visits (figure-1). Traditional healers were the preferred choice for 33.3% of female participants, who also had more sessions with traditional healers, making up 33% of their total sessions. In contrast, only 11.1% of sessions for male participants were with traditional healers. Treatment pathways did not vary based on caste/ethnicity or age, with one-third (33%) of participants with depression initially seeking treatment from traditional healers. [Figure-1 here] Facilitators for seeking care Participants reported several factors that encouraged them to initiate or continue treatment for their problems. The most commonly cited facilitators included the quality of services, awareness of mental health conditions and available services, recommendations from trusted individuals, affordable treatment cost, and support from family. Quality of service The quality of services was the most frequently reported factor that helped participants initiate and continue care for their problems. Participants emphasized factors such as the process for scheduling consultations, the behavior of service providers, availability of confidential place for consultation, and the types of services available as determinants of service quality. They also highlighted the importance of the amount of time spent with service providers. Participants considered it a quality service when a provider spent enough time listening to their feelings and asking detailed questions about their problems. This personalized approach encouraged them to seek regular follow-up care. For example, P8, a female with anxiety disorder from Jhapa, initially sought treatment at a private clinic but eventually switched to a primary health care facility after visiting multiple providers. She visited the primary health care facility five times because she perceived the services provided there to be superior. She mentioned how the supportive behavior of the service provider at the primary health care facility encouraged her to continue with regular follow-up care. I found a health worker at PHCC to be very good. He does check-ups of one patient at a time, while other healthcare providers look at 10 patients at a time. He spends enough time in asking questions and listening to us which is why I found him to be very good. Therefore, I have been receiving treatment with him for the past year. [P8] Another patient from Jhapa with anxiety shared their experience of receiving treatment at a health facility. They mentioned that when there are long wait times, health personnel tend to rush through consultations, making it difficult for patients to express their health concerns. The health personnel were always in a hurry, with a long line of 20 to 25 people waiting. How could I share my problems in such a situation? They didn't give me the chance to talk, and they would quickly prescribe medication without fully understanding my issues. [P17] Similarly, participants also believed that if service providers in primary health care facilities or government hospitals spend enough time in consultations and allow patients to ask questions or share their problems in detail, they would not need to go to private hospitals where get enough time to discuss their issues. Participant 4 (P4) initially sought treatment from traditional healers and visited multiple places during her treatment journey. Despite travelling to a tertiary hospital, she ultimately chose a primary health care center as the most suitable place for her treatment. I felt that the doctor (health worker) in Sanischare PHCC was better because he asked as many questions as the doctor in a private hospital in Biratnagar does. I believe that the doctor at Sanischare PHCC is just as competent as the doctor at a private hospital in Jhapa. Overall, I felt that everyone was similar and I had a good experience. After returning from Biratnagar, I went to Sanischare and found that the prescribed medicine was effective. That's why I preferred it. I had faith in the doctor's advice and found everything to be good. It's not just about going to a big hospital; I should go to a place where I feel comfortable. [P4] Participants emphasized the positive impact of healthcare providers' behavior on encouraging patients to share their problems and engage in treatment. They valued compassionate and empathetic care during consultations, emphasizing the importance of a personalized and holistic approach to their care. Participants stressed the need for healthcare providers to be humble, trustworthy, and maintain confidentiality. For instance, a female patient from Chitwan with depression shared how a primary healthcare worker's behavior made her feel comfortable enough to open up about her problems. I visited the health post. The provider asked me about my condition in a caring manner, as if he were a family member rather than a healthcare professional. He inquired about all the details of my health issues. His behavior is very kind; he speaks to me with humility and treats me like his own children. He offers helpful suggestions and guidance. I only go to the hospital after visiting the health post. [P11] Participants expressed a preference for privacy and comfort during consultations, avoiding sharing personal issues in public settings. They also expected for a separate room for their case management. They reported that patients do not want to share their problems in front of other people. If healthcare providers ensure confidentiality, patients will choose to go there. One participant shared their experience with a healthcare provider and the importance of a separate room: Health worker and I talked in a separate room. I shared my problem with him there. He is not an arrogant person. From what I have learned about him, he is not the type to seek fame by disclosing others’ secrets to the public. He has counseled me multiple times. However, it has now been a very long time since I have spoken to him. [P15] On the contrary, some participants had differing opinions regarding the services provided by private versus public health centers. They reported that private treatment centers were more accessible and convenient. For example, a male participant from Jhapa, living with depression, shared his perspective on the comparison of services. Clinics and private medical facilities now frequently call upon psychiatric doctors. There are many doctors available, providing a variety of options for medical care. Therefore, finding the right medical care is not difficult. Initially I sought psychological care. [P22] Support from family and friends Many participants reported that family support positively influenced their utilization of health care services. Individuals with strong family support were more inclined to seek formal mental health services compared to those with poor family support. Generally, family members such as spouse, sons, and daughters were identified as valuable sources of support. My daughter took me for check-up. She is the one who took me because she is nearby. My daughter is my only support now, so if something happens, I quickly call her to solve my issues. It's easy to call her because she is nearby. [P18] Participants also noted that when a family member, typically a husband or wife, assists them, they are more likely to adhere to their medication treatment. They expressed that they can discuss their health conditions and medication situation more comfortably with their spouse than with others. A female participant with anxiety disorder in Chitwan district shared: One day, when my medication had run out, I sent my husband to the health post. I did not tell him (husband) anything about my illness. I told him (my husband) the health worker has called me to the health post. Can you go and also bring me the medicine?' My husband asked me, 'Medicine for what illness?' I replied, 'don’t ask about the medicine details. I have already called B. He said if I cannot visit the health post, then I can send you. So, my husband went there and bought medicine for me. [P15] A male participant stated that he visited the psychiatric service on both occasions because his family members insisted, even though he was reluctant. He mentioned that he would not have attended the visit if his family members had not pleaded. He received treatment from a private clinic and a community hospital as part of his help-seeking pathway. I have a lot of support from my family, who love me and are doing well financially. I visited Dr. C (psychiatrist) at the insistence of my family, even though I was initially hesitant. I thought my mental health issues would resolve on its own, but the insistence from my family pushed me to seek help. They made an appointment for me and insisted that I go that day when the doctor was available. My son even took me to the appointment on his bike. [P9] Awareness about available services Access to information about available mental health services is crucial for individuals to seek help for their mental health conditions. Participants emphasized the importance of targeted and affordable information to help people find appropriate care. Many individuals face challenges in accessing services due to a lack of awareness. Participants highlighted the effectiveness of advertising, distributing brochures, and radio broadcasts in raising awareness about mental health services. Moreover, participants mentioned that hospitals and clinics in Jhapa and Kailali districts used auto-rickshaws to disseminate information to the community, facilitating access to health services. A male patient with depression in Jhapa (P22) shared his experience of seeking help, highlighting the influence of advertisements in directing him to the appropriate treatment facility. He mentioned that he was initially unaware of anxiety and depression but learned about them through a marketing campaign. Upon discovering that a psychiatrist, was visiting Jhapa from Kathmandu, he decided to seek treatment from him for his condition. In a similar incident in Kailali, participants noted that those leading awareness campaigns were discussing symptoms of depression and anxiety. A female participant in Kailali, who was struggling with anxiety, found the awareness campaigns and brochures helpful for her treatment. Participant 14 first sought treatment in India and then consulted traditional healers. Upon receiving advertisements from private hospitals, she opted to begin treatment at a private hospital. People from private clinics and hospitals approached me, providing information and brochures about their services and my illness. I decided to seek treatment at a private clinic, where my condition gradually improved after a thorough check-up. They promoted the clinic through loudspeaker announcements attached to vehicles. [P14] On the contrary, a female patient with anxiety had been undergoing treatment for frequent panic attacks and anxiety by a psychiatrist, despite denying any mental health issues. Initially, she became upset when her doctor suggested that her symptoms might be related to stress so refused to see that doctor again. However, she had been receiving treatment from the same mental health specialist and found it helpful. She believed her symptoms might indicate anxiety but did not think that she was suffering from it. She shared her experience of visiting multiple health centers for treatment before deciding to seek help from a mental health specialist after seeing information at a hospital while seeking treatment for her child. The information made her feel like her illness was not serious and was not related to her mental health. I had taken my child to Manmohan Hospital for treatment where I noticed a board on the wall listing symptoms that matched my own. After reading the information, I decided to return to Manmohan Hospital for a health check-up. I am feeling much better now. [P24] Participants highlighted the significance of self-awareness in making informed decisions and enhancing self-confidence. For example, a retired teacher in Jhapa (P9) mentioned that he would have utilized mental health services at a government health facility if he had been aware of them. I was unaware of the availability of mental health services in government facilities. If I had known earlier, I would have sought counseling from a health worker at a primary health care facility. [P9] Awareness of mental health problems Participants also shared their experiences of receiving care from mental health specialists or medical professionals due to their awareness of mental health problems. They reported learning about mental health issues from personal knowledge, family experiences, and information from various sources, including training programs. For example, a male patient with depression in Jhapa sought help directly from a psychiatrist when he recognized the need for professional assistance. However, he faced challenges during the lockdown, leading to incomplete recovery. I noticed some effects on my mind and body, but I initially thought they might improve on their own. Eventually, I decided to see a doctor, unsure if it would help, but believing that a doctor could offer suggestions. I visited a private clinic to consult with psychiatrist. [P9] Participants also mentioned obtaining knowledge about mental health through mobile health camps and training organized by government or non-governmental organizations. This increased awareness led them to seek help directly from mental health professionals. For instance, a female patient from Kailali shared her experience of receiving training on depression and counseling, which helped her recognize her symptoms and seek appropriate care. I have received training related to depression from [XYZ organization] and counseling training at an institution called [ABC] in Kailali. One of my sisters is also a counselor. During the counseling training, I learned about the symptoms of depression. I believe that I am suffering from depression based on the symptoms I am experiencing and what I have heard and read about it. [P12] Recommendations from trusted persons Participants emphasized the significant role of trusted individuals in encouraging and referring them to seek help for their mental health conditions. Recommendations from counselors, school teachers, and traditional faith healers played a crucial role in motivating participants to access care. For example, Participant 22 shared how a counselor's recommendation led him to seek treatment from who had a strong reputation for providing effective care in the eastern Nepal. A counselor from Organization N recommended a doctor saying she is well-known for providing good treatment. So, I started visiting her and have been on follow-up with her since then. has built a reputation for herself in the eastern part of Nepal, seeing around 108 patients daily. She has gained the trust of the people in the east, including myself. [P22] Similarly, P10 mentioned that seeking a referral from a school teacher helped him in addressing his anxiety disorder. I first sought advice from my school teacher and then consulted a doctor at a private clinic who diagnosed me with anxiety. [P10] Moreover, participants expressed trust in traditional faith healers (dhami) and their supernatural powers. When traditional healers recommended consulting healthcare providers, participants were more inclined to seek medical help. P8, for instance, started seeking treatment at a hospital based on a traditional healer's advice, which resulted in positive outcomes for her anxiety disorder. Dhami (traditional healer) advised me to go to the hospital for a thorough health check-up, and things have been improving since then. I follow the traditional healer's advice for seeking help which has been effective for me. [P8] Treatment cost The cost for treatment has also been reported as an important factor for encouraging help-seeking for depression and anxiety. Participants highlighted how the medical insurance helped them to encourage seeking mental health care. As per the current health insurance system in Nepal, a family of five members can receive treatment of up to one hundred thousand Nepali Rupees in a year when they pay NPR 3,500 annually. Participants from Kailali and Chitwan shared their experience of receiving free services from their insurance. As not all health facilities offer treatment under the health insurance program, they reported that they visited the health facilities where treatment cost would be covered by the insurance system. The insurance now covers medical treatment, encouraging people to seek help when they are sick. It provides coverage up to one lakh with certain conditions. [P23] Another patient from Kailali expressed similar experience about the insurance policy. Participants would opt for more affordable and larger hospitals if insurance coverage is not available. P14 initially sought treatment from a neighboring country and traditional faith healers before coming across advertisements from private hospitals. She ultimately chose starting treatment at a private hospital and continued visiting primary health care centers and private clinics regularly. She was undergoing regular follow-up at a primary health care facility. I purchased a year's supply of medication from a private hospital, which was covered by my insurance. Due to financial constraints and my husband's illness, I opted to obtain the medication through my health insurance. [P14] Discussion This study investigated the treatment pathways of individuals with depression or anxiety in different regions of Nepal. The study involved 24 participants receiving treatment from various healthcare providers, such as psychiatrists, psychologists, medical doctors, and primary healthcare providers. The aim was to analyze these pathways and identify factors that facilitate access to and continuation of mental health care. The findings showed that participants followed diverse treatment routes, often seeking help from traditional faith healers in the beginning. Most participants (91.7%) consulted multiple providers. Common facilitators of treatment initiation and continuation included the quality of services, scheduling process, healthcare providers' behavior, time spent with providers, awareness of available mental health services, knowledge about mental health issues, treatment cost, support from family and friends, and recommendations from trusted community members. The complex treatment pathways reported in our study align with a systematic review of studies on pathways to mental health care ( 52 ). The results did not indicate a clear treatment preference, but traditional healers were frequently chosen for initial consultations (25% consulted traditional healers in the first consultation and 46% in the second). Patients also explored different healthcare facilities, such as government hospitals, primary healthcare centers, and private hospitals, even when opting for modern health services. Some individuals initially sought help from traditional faith healers and continued to do so after consulting with various healthcare providers, including mental health professionals. Reasons for visiting traditional healers included family pressure, lack of awareness about available medical services, inaccessibility of services, and a belief that medical treatments were ineffective for depression or anxiety disorders. Some participants believed that medical treatment would be ineffective if the problem was caused by a ghost or supernatural power. Those who chose traditional faith healers had a concern that receiving injections (as a part of their treatment) from healthcare providers could worsen their condition. They also felt uncomfortable discussing their issues in healthcare settings due to a lack of privacy leading them to seek help from traditional faith healers. Participants also turned up to traditional faith healers when they did not see immediate improvements in their health condition following treatment from healthcare providers. Our findings align with a study conducted in 14 healthcare facilities across Nepal, where about one-fourth (23%) of individuals with depression consulted traditional healers initially ( 32 ). Beliefs in supernatural powers as the cause of mental health conditions also influenced participants to consult traditional faith healers, as they believed that traditional healers were the only ones capable of treating such conditions ( 53 , 54 ). Similar to our study, traditional faith healers or religious leaders were the first contact points for over one-fourth (27%) ( 55 ) and over one-third (35%) of individuals with mental health problems in South India( 56 ). The results indicated that female participants preferred traditional healers as their primary choice (33.3%) compared to other providers. Females also had more sessions with traditional healers, accounting for 33% of their sessions, while only 11.1% of sessions for male participants were with traditional healers. These findings contrast with a study in eastern Nepal where gender did not influence treatment pathways ( 57 ). We did not observe any discernible differences in treatment pathways based on caste/ethnicity, except for one participant from a Dalit community who received multiple sessions from traditional healers. Similarly, there was no variation in treatment pathways based on the age of the participants, consistent with previous research ( 57 ). However, participants with co-morbid conditions had a tendency to visit private hospitals first, while approximately one-third (33%) of participants with depression sought treatment from traditional healers initially. There were no notable differences in treatment pathways for participants with anxiety. It is important to note that patients often seek out various healthcare services, including government hospitals, primary healthcare facilities, and private hospitals, when choosing modern healthcare providers. Factors like service quality, support from family or friends, and mental health awareness influence care-seeking behavior. Improving healthcare providers' behavior, streamlining appointment scheduling, and providing quality consultation time are essential to encourage care-seeking The quality of services, including healthcare providers’ behavior, scheduling appointments, time spent with patients, availability of confidential space, and continuity of care with the same provider in follow-up visits, significantly influenced patients' decisions to initiate and continue treatment at a specific health facility or with particular providers. These factors were identified as both facilitators and barriers to seeking and maintaining care. Participants mentioned that they were more likely to return to the same health facility if there was a confidential consultation space or if they could see the same provider in follow-up visits. Previous research has also emphasized the importance of supportive behaviour of health workers, availability of confidential space, and time provided by healthcare providers as key indicators of quality services ( 37 ). Poor service quality has been a significant barrier to continued care in low- and middle-income countries due to lack of confidential space for consultation, insufficient time and poor communication with providers. For example, a recent systematic scoping review identified accessibility, provider relationships, clear communication, and perception of interventions as facilitators for implementing mental health services ( 58 ). A study in Colombia also emphasized the importance of privacy and confidentiality in improving patient engagement and retention in community-based psychosocial support interventions ( 59 ). Similarly, a qualitative study among adults in Germany highlighted the supportive behaviour from general practitioners, and positive relationships between patients and therapists to engage patients in mental health care ( 60 ). Our study found that awareness of mental health conditions and available services play a significant role in self-initiating treatment for mental health conditions from healthcare providers. Participants who were aware of their own health conditions, had family members with mental health issues, or were receiving services for mental health conditions were more likely to seek treatment from healthcare providers. This is supported by evidence showing a positive relationship between mental health literacy and help-seeking behavior, indicating that improved mental health literacy can increase the likelihood of seeking help ( 61 – 63 ). Studies have also shown that mental health literacy indirectly facilitates professional help-seeking behaviors by enhancing the perception of social support and reducing the stigma associated with seeking help ( 64 ). Our results also revealed that participants sought treatment from traditional faith healers or religious leaders because they believed their condition could not be treated medically due to supernatural causation. Studies have shown that mental health education is a promising tool for raising awareness ( 65 ) and reducing mental health stigma and misconceptions about mental illness ( 66 ). Implications The findings of this study have implications on reducing the treatment gap in mental health care by improving help-seeking behavior. First, participants expressed comfort in receiving services from primary or community health care facilities if the quality of services is improved. They emphasized healthcare providers' behavior, availability of confidential consultation spaces, time spent with providers, and continuity of care as crucial aspects of service quality. These factors are essential for encouraging individuals to access mental health services from trained primary healthcare providers. The government of Nepal has started training primary healthcare providers in WHO mhGAP-based interventions ( 67 ). However, it is important to ensure that they have the necessary skills and competencies to address mental health conditions effectively. Second, a lack of awareness about mental health conditions and available resources was identified as a key factor influencing individual decisions to seek mental health care. Leaflets, brochures, and social media were reported as effective tools for increasing awareness about mental health issues and treatment options. Community awareness programs should focus on improving awareness about mental health issues and available services through a combination of channels including leaflets, brochures, public announcements and social media. Third, support from family members was crucial in motivating patients to initiate and continue mental health care. Evidence shows that family can play a vital role in the treatment process of patients with mental illness, particularly in reducing healthcare costs, helping to access appropriate treatment, and advocating for their needs within the healthcare system ( 68 ). Therefore, future programs should engage family members in the treatment process of patients with mental health conditions. Finally, support from traditional faith healers and trusted individuals in the community was considered as valuable source of support in seeking treatment from health care providers. If traditional faith healers and trusted persons in the community receive training on mental health issues, they can help identify people in need of mental health services and refer them to health facilities with available mental health services. Based on the experience and results of this study, the following recommendations are made for future research on this topic in Nepal and similar settings. First, conducting a longitudinal qualitative study could offer a more comprehensive understanding of the treatment pathway. Second, future research should include samples from mountainous and hilly regions to expand the scope of the study. Third, a quantitative study with a larger sample size could help analyze the variations in treatment pathways among different subpopulations. Strength and limitations The study has several strengths, including: (a) a sample from three different regions of Nepal (eastern, central, and western), (b) including participants with both depression and anxiety, (c) recruitment of participants through a range of providers, and (d) the use of standardized interview guides, specifically the McGill Illness Narrative Interview (MINI), which allows participants to provide detailed narratives on their symptom experiences, illness accounts, and help-seeking behaviors ( 50 , 51 ). The study also has some limitations. First, it was conducted with a purposively selected sample of 24 participants currently undergoing treatment for depression or anxiety disorder. So, the findings may not be generalizable to the entire population. Second, the participants were still in the process of receiving care and had not completed their treatment pathways. So, the results do not provide a comprehensive overview of the entire treatment pathway. Third, the facilitators reported in the study primarily pertain to facilitating access to formal mental health care and do not address facilitators for receiving informal care, such as from traditional providers not included in this study, friends, or family members. Conclusion Treatment pathways for depression and anxiety disorders are complex, with 91.7% of patients requiring multiple sessions, and 100% involving a combination of services. While the results did not show a clear treatment preference, traditional healers were often chosen for initial consultations. Patients commonly utilize various healthcare facilities, including government hospitals, primary healthcare facilities, and private hospitals, when seeking modern healthcare services. Factors such as service quality, support from family or friends, and mental health awareness influence care-seeking behavior. Improving healthcare providers' behavior, optimizing appointment scheduling, and ensuring quality consultation time are crucial to encourage care-seeking. Increasing awareness about mental health conditions and available services through social media, miking, posters, and pamphlets, as well as training traditional healers in mental health, could improve access to mental health care. Abbreviations FCHV – Female Community Health Volunteer HP – Health Post mhGAP-IG – Mental Health Gap Action Program Intervention Guide NGO – Non-governmental Organization OPD – Out Patient Department PHCC – Primary Health Care Facility WHO – World Health Organization Declarations Ethics statements This study was conducted in compliance with the Declaration of Helsinki and received ethical approval from the Nepal Health Research Council (NHRC) (Registration number: 527/2022 P). Each participant signed a written informed consent before enrolling in the study. Only those who voluntarily agreed to participate were included in the study. Consent for publication Not applicable Availability of data and materials Interested individuals can contact the principal investigator of this study to express their interest in collaboration and request access to the dataset analyzed here by emailing: [email protected] . Competing interest The authors declare that they have no competing interests. Funding This work was supported by the National Institute for Health Research (NIHR) (using the UK’s Official Development Assistance (ODA) Funding) and Wellcome [222001_Z_20_Z] under the NIHR-Wellcome Partnership for Global Health Research. The views expressed are those of the authors and not necessarily those of Wellcome, the NIHR or the Department of Health and Social Care. Authors' contributions NPL designed the study and drafted the manuscript. BL and PS conducted interviews. BAK and MJDJ mentored NPL, provided inputs and feedback on the study design and manuscript. KG provided inputs and feedback on the study design and data analysis. BL, BB and KS supported NPL in data analysis and drafting the manuscript. All authors have reviewed and approved the final version of the manuscript. Acknowledgement We are grateful to the participants for sharing valuable information, even on personal matters. This study would not have been possible without their cooperation. We would like to thank Dr. Sandarba Adhikari and Dr. Avash Niraula for their support in identifying participants for interviews. Special thanks to Ms. Ruta Rangel for her support in creating tables and figures. References WHO. Depression and other common mental disorders: global health estimates. Geneva: World Health Organization 2017. COVID-19 Mental Disorders Collaborators. 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Journal of mental health (Abingdon, England). 2020;29(3):270-6. Yang J, Li Y, Gao R, Chen H, Yang Z. Relationship between mental health literacy and professional psychological help-seeking attitudes in China: a chain mediation model. BMC psychiatry. 2023;23(1):956. Yang X, Hu J, Zhang B, Ding H, Hu D, Li H. The relationship between mental health literacy and professional psychological help-seeking behavior among Chinese college students: mediating roles of perceived social support and psychological help-seeking stigma. Frontiers in psychology. 2024;15:1356435. Shim YR, Eaker R, Park J. Mental Health Education, Awareness and Stigma regarding Mental Illness among College Students. J Ment Health Clin Psychol. 2022;6(6):6-15. Segal DL, Coolidge FL, Mincic MS, O'Riley A. Beliefs about mental illness and willingness to seek help: a cross-sectional study. Aging & mental health. 2005;9(4):363-7. Mental Health Innovation Network. 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Supplementary Files Table.docx Cite Share Download PDF Status: Published Journal Publication published 02 Jun, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 28 Apr, 2025 Reviews received at journal 19 Apr, 2025 Reviews received at journal 18 Apr, 2025 Reviewers agreed at journal 04 Apr, 2025 Reviewers agreed at journal 29 Mar, 2025 Reviewers invited by journal 29 Mar, 2025 Submission checks completed at journal 26 Mar, 2025 First submitted to journal 25 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5711655","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":435728102,"identity":"cd0fb1fc-4e19-454b-909c-50720bb97bc6","order_by":0,"name":"Nagendra P. 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competing interests reported.","formattedTitle":"Facilitators in treatment pathways for depression or anxiety among adults in Nepal: A qualitative study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDepression and anxiety are prevalent mental health conditions worldwide with depression affecting over 322\u0026nbsp;million individuals (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), and anxiety disorders affecting 374\u0026nbsp;million individuals (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). These conditions have a significant emotional and financial impact on individuals, families, and communities (\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Moreover, they often co-occur with around 46% of individuals with depression also experiencing one or more anxiety disorders during their lifetime (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). These disorders not only result in high rates of morbidity and mortality, but also increase the risk of other diseases such as type-2 diabetes and ischemic heart disease (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), substance abuse (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) chronic pain (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), immune system dysfunction (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Depression alone contributes to 40.5% of disability-adjusted life years (DALYs) caused by mental illness (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the availability of evidence-based treatments, a large proportion of people in low- and middle-income countries do not receive treatment for anxiety, and mood disorders (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Many individuals who do receive treatment, experience significant delays between the onset of their symptoms and actually receiving treatment. According to Wang et al. (2007), patients with mood disorders waited anywhere from 1 to 14 years to seek care, while those with anxiety waited 3 to 30 years (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The consequences of delaying treatment for depression and anxiety can be severe, including an increased risk of developing other health issues (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), reduced responsiveness to medication (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) and a lower likelihood of achieving positive treatment outcomes (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Additionally, individuals with these conditions often seek help from informal sources such as traditional healers, friends, or family members rather than seeking assistance from healthcare professionals (\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The factors hindering access to mental health care include financial constraints, personal priorities, stigma, lack of knowledge about mental health, dissatisfaction with previous treatments, time and distance constraints, reliance on traditional or religious healers, and lack of social support (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Many studies have examined help-seeking behavior for mental health issues in high-income settings (\u003cspan additionalcitationids=\"CR28 CR29\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), but there is limited understanding of the predictors for mental health service use and pathways to care in low- and middle-income countries (LMICs).\u003c/p\u003e \u003cp\u003eLimited research in Nepal has focused on pathways to mental health treatment, with little exploration of facilitators in accessing and continuing care. Studies show that only 17% of patients with mental health issues seek treatment from mental health specialists through direct pathways (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), while 28.2% turn to traditional healers or religious faith healers and 40% to non-specialists (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Common pathways to seeking help include direct access, referrals from private practitioners, general hospitals, and traditional or religious healers (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Reasons for delaying care include lack of knowledge about- mental health problems, where to seek care, and not considering the issues serious enough (\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Similarly, poor service quality, including lack of confidential space, insufficient time, and poor communication, has been a barrier to continued care in low- and middle-income countries (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Despite the limited number of studies conducted in Nepal, there were several methodological issues, as most studies recruited participants from hospitals or primary healthcare facilities only (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), making it difficult to estimate the actual pathways because these studies did not recruit participants receiving care from multiple providers. The current study aims to investigate the pathways to care for depression or anxiety, along with their causative factors as reported by individuals with lived experience of depression or anxiety using qualitative methods. Understanding the pathways to mental health care and identifying possible facilitators could help in developing strategies to reduce barriers, and improve the quality of mental health services, ultimately encouraging more people to seek care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eNepal, a low and middle-income country in South Asia has a population of approximately 29.1\u0026nbsp;million with an annual growth rate of 0.92% as per the National Census 2078 (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). In 2015, Nepal adapted a federal government system, resulting in 7 provinces, 77 districts, and 753 local units (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). The study was conducted in the Jhapa, Chitwan, and Kailali districts, located in the eastern, central, and far western regions of Nepal, with total populations of 994,090, 722,168, and 911,155 respectively. The reason for selecting these districts is that the primary healthcare providers in these areas have received training on the World Health Organization's mental health gap action program intervention guides (mhGAP-IG), and specialized mental health services are available in the districts. All three districts share a border with India. Nepal is a diverse country with 142 castes/ ethnicities and 124 languages. Each district has its own unique ethnic makeup, with Jhapa having a higher population of Rai, Limbu, and Meche, Chitwan having a significant Tamang and Magar population, and Kailali having a majority of Tharu people (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Each caste/ethnic group in Nepal has its own traditional treatment practices, beliefs, and caste specific traditional healers and religious leaders to provide services.\u003c/p\u003e \u003cp\u003eNepal\u0026rsquo;s health care system comprises the public sector, private for-profit sector, and non-governmental organizations (NGOs) (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). The country has 0.76 psychologists, and 0.66 psychiatrists per 100,000 population (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Specialist mental health services are primarily located in urban hospitals, leading to traditional healers being the main mental health providers in rural areas (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). While mental health services are concentrated in major cities (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e), all three districts have a higher number of World Health Organization Mental Health Gap Action Program Intervention Guide (mhGAP-IG) trained healthcare providers, female community health volunteers (FCHVs), and free psychotropic medications available at some primary healthcare facilities (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy design\u003c/h3\u003e\n\u003cp\u003eThe study utilized a qualitative design to investigate the pathways to care, available resources, and challenges encountered by adults in Nepal when seeking treatment for depression and anxiety. This approach enabled a thorough exploration of a topic with limited prior research and empowered participants to contribute to the generation of new knowledge (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Individual interviews (IDI) provided an optimal environment for understanding personal experiences and challenges, as they offered depth, flexibility, and the opportunity to establish a trusting, confidential relationship.\u003c/p\u003e\n\u003ch3\u003eParticipants and sample size\u003c/h3\u003e\n\u003cp\u003eThe participants in this study were adults receiving treatment for depression or anxiety from trained primary healthcare providers or mental health specialists. In our study, we adhered to Guba and Lincoln's (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e) five criteria for ensuring trustworthiness in qualitative research. This involved conducting the study in multiple districts to ensure diversity in terms of caste/ethnicity, cultural practices, and geography. We also used a range of service providers for participant recruitment, employed trained and experienced interviewers who matched the gender of the participants, involved multiple individuals in data analysis, and utilized both thematic and framework analysis methods. We recruited 24 participants, including 13 with depression, 9 with anxiety disorder, and 2 with both depression and anxiety disorders. Out of the total, 7 participants were from Kailali, 4 were from Chitwan, and 13 were from Jhapa district. Participants were recruited through primary healthcare providers (N\u0026thinsp;=\u0026thinsp;7), psychosocial counselors (N\u0026thinsp;=\u0026thinsp;7), and psychiatrists (N\u0026thinsp;=\u0026thinsp;10). Inclusion criteria included being 18 years or older, currently receiving treatment from primary healthcare providers or mental health specialists, able to provide informed consent, and fluent in Nepali.\u003c/p\u003e\n\u003ch3\u003eRecruitment and interview process\u003c/h3\u003e\n\u003cp\u003eQualitative interviews were conducted by two researchers with prior experience in qualitative research. Female interviewers conducted interviews with female participants, and male interviewers conducted interviews with male participants to prevent gender bias. The first authors supervised the interviewers by reviewing the recordings. Trained interviewers visited participants at their residences to explain the interview process, objectives, benefits, and potential risks of participating in the study. If participants agreed to take part, the interviews were conducted either at their home or in a confidential outpatient department (OPD) at a health center after obtaining written consent. All interviews were recorded in the participants' original voices and lasted between 45 to 60 minutes, depending on the depth of their shared experiences. The interviews were conducted between January and July 2023.\u003c/p\u003e\n\u003ch3\u003eInterview guideline\u003c/h3\u003e\n\u003cp\u003eWe adapted the McGill Illness Narrative Interview (MINI), a semi-structured interview protocol commonly used in mental health research, to gather detailed narratives on symptom experiences, illness accounts, and help-seeking behaviors (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). The interview guide comprised five sections: history and understanding of the illness, effects and perceived causes, experience of stigma and discrimination, treatment pathways, and barriers and facilitators to treatment. Prior to data collection, the interview guide underwent pilot testing with a small group of participants. For this study, we focused on the data from the treatment pathways section, as well as barriers and facilitators to treatment.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData management and analysis\u003c/h2\u003e \u003cp\u003eThe audio recordings were transcribed into notes immediately after the interviews by the interviewers. The first author conducted periodic proofreading of transcriptions to ensure accurate translation and retention of meaning in the translation. Two researchers independently familiarized themselves with the data by reading the translated interviews. Themes were developed based on the initial reviews and study objectives, and these themes were imported into NVIVO version 20 by QSR International. Subsequently, two researchers read more files separately to generate codes and sub-codes. Any disagreements on codes and sub-codes were resolved through discussions with the first author. Once there was agreement between the two researchers on the generated codes, they independently coded and entered the data. The independently coded files by the two researchers were merged weekly to ensure the inclusion of both researchers' codes. Data analysis was carried out using a framework and thematic analysis approach. Finally, all interviews were indexed and charted according to the thematic framework, and data from the charts were interpreted.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe participants' ages ranged from 18 to 60, with a mean age of 38.9 (SD, 13.2). The majority of participants were female (62.5%), identified as Brahmin/Chhetri (50%), were married (83.3%), had up to a secondary level of education (62.5%), and identified as Hindu (83.3%). Most participants were from Jhapa (54%) and reported experiencing symptoms of depression (54%).\u003c/p\u003e\n\u003cp\u003eTreatment pathway\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;1 illustrates the complex treatment pathways for depression or anxiety, involving multiple service points and treatments from various health facilities or providers. For example, Patient 8 (P8) initially sought treatment at a private clinic, then visited a traditional faith healer, followed by a primary healthcare facility, and returned to a traditional faith healer. P8 also visited a private hospital and traditional healers before receiving care from a primary healthcare facility. Patient 17 (P17) started treatment with a traditional faith healer, consulted multiple traditional faith healers before seeking care at a primary healthcare facility, and also visited a private clinic. P17 consulted with the private clinic twice and met a traditional faith healer before continuing care at a primary healthcare facility. Patient 4 had 11 consultations with different traditional faith healers before moving to a private hospital after a suicide attempt, then visited a primary healthcare facility, and continued care at a private hospital. Among the 24 patients, one had 14 consultations, three had 9 consultations, and two had 8 consultations at the time of the interview (Table 1).\u003c/p\u003e\n\u003cdiv\u003e\n\u003c/div\u003e\n\u003ch3\u003e[Table-1 here]\u003c/h3\u003e\n\u003cp\u003eFigure 1 illustrates the healthcare-seeking preferences of patients for the treatment of mental health issues. Participants reported contacting various service providers, including traditional healers, once or multiple times. We defined each interaction or visit with a service provider as a session. Out of a total of 137 sessions across 24 patients, the majority of sessions were with traditional faith healers (27.7%), followed by private hospitals (19.7%), primary healthcare facilities (16.1%), government hospitals (13.1%), neighboring countries (8.0%), and private clinics (11.7%).\u003c/p\u003e\n\u003cp\u003eFor the first visit when seeking care, 25% of participants consulted traditional healers, 21% visited primary health facilities, and 21% went to private clinics. Only 8.33% visited government or community hospitals for their first consultation. In the second consultation, almost half (46%) sought treatment from traditional faith healers, with some continuing treatment and others visiting traditional faith healers for the first time. Additionally, 21% preferred government hospitals for their second visit. Government or community hospitals were the most preferred places for the third visit (21%), followed by traditional faith healers (16.7%). Some participants visited traditional faith healers in subsequent visits, with a few visiting them in the 4th to 8th visits (figure-1). Traditional healers were the preferred choice for 33.3% of female participants, who also had more sessions with traditional healers, making up 33% of their total sessions. In contrast, only 11.1% of sessions for male participants were with traditional healers. Treatment pathways did not vary based on caste/ethnicity or age, with one-third (33%) of participants with depression initially seeking treatment from traditional healers.\u003c/p\u003e\n\u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003e[Figure-1 here]\u003c/h2\u003e\n \u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003eFacilitators for seeking care\u003c/h2\u003e\n \u003cp\u003eParticipants reported several factors that encouraged them to initiate or continue treatment for their problems. The most commonly cited facilitators included the quality of services, awareness of mental health conditions and available services, recommendations from trusted individuals, affordable treatment cost, and support from family.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\"\u003e\n \u003ch2\u003eQuality of service\u003c/h2\u003e\n \u003cp\u003eThe quality of services was the most frequently reported factor that helped participants initiate and continue care for their problems. Participants emphasized factors such as the process for scheduling consultations, the behavior of service providers, availability of confidential place for consultation, and the types of services available as determinants of service quality. They also highlighted the importance of the amount of time spent with service providers. Participants considered it a quality service when a provider spent enough time listening to their feelings and asking detailed questions about their problems. This personalized approach encouraged them to seek regular follow-up care.\u003c/p\u003e\n \u003cp\u003eFor example, P8, a female with anxiety disorder from Jhapa, initially sought treatment at a private clinic but eventually switched to a primary health care facility after visiting multiple providers. She visited the primary health care facility five times because she perceived the services provided there to be superior. She mentioned how the supportive behavior of the service provider at the primary health care facility encouraged her to continue with regular follow-up care.\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003e\u003cem\u003eI found a health worker at PHCC to be very good. He does check-ups of one patient at a time, while other healthcare providers look at 10 patients at a time. He spends enough time in asking questions and listening to us which is why I found him to be very good. Therefore, I have been receiving treatment with him for the past year.\u003c/em\u003e \u003cstrong\u003e[P8]\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eAnother patient from Jhapa with anxiety shared their experience of receiving treatment at a health facility. They mentioned that when there are long wait times, health personnel tend to rush through consultations, making it difficult for patients to express their health concerns.\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003e\u003cem\u003eThe health personnel were always in a hurry, with a long line of 20 to 25 people waiting. How could I share my problems in such a situation? They didn't give me the chance to talk, and they would quickly prescribe medication without fully understanding my issues.\u003c/em\u003e \u003cstrong\u003e[P17]\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eSimilarly, participants also believed that if service providers in primary health care facilities or government hospitals spend enough time in consultations and allow patients to ask questions or share their problems in detail, they would not need to go to private hospitals where get enough time to discuss their issues. Participant 4 (P4) initially sought treatment from traditional healers and visited multiple places during her treatment journey. Despite travelling to a tertiary hospital, she ultimately chose a primary health care center as the most suitable place for her treatment.\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003e\u003cem\u003eI felt that the doctor (health worker) in Sanischare PHCC was better because he asked as many questions as the doctor in a private hospital in Biratnagar does. I believe that the doctor at Sanischare PHCC is just as competent as the doctor at a private hospital in Jhapa. Overall, I felt that everyone was similar and I had a good experience. After returning from Biratnagar, I went to Sanischare and found that the prescribed medicine was effective. That's why I preferred it. I had faith in the doctor's advice and found everything to be good. It's not just about going to a big hospital; I should go to a place where I feel comfortable.\u003c/em\u003e \u003cstrong\u003e[P4]\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eParticipants emphasized the positive impact of healthcare providers' behavior on encouraging patients to share their problems and engage in treatment. They valued compassionate and empathetic care during consultations, emphasizing the importance of a personalized and holistic approach to their care. Participants stressed the need for healthcare providers to be humble, trustworthy, and maintain confidentiality. For instance, a female patient from Chitwan with depression shared how a primary healthcare worker's behavior made her feel comfortable enough to open up about her problems.\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003e\u003cem\u003eI visited the health post. The provider asked me about my condition in a caring manner, as if he were a family member rather than a healthcare professional. He inquired about all the details of my health issues. His behavior is very kind; he speaks to me with humility and treats me like his own children. He offers helpful suggestions and guidance. I only go to the hospital after visiting the health post.\u003c/em\u003e \u003cstrong\u003e[P11]\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eParticipants expressed a preference for privacy and comfort during consultations, avoiding sharing personal issues in public settings. They also expected for a separate room for their case management. They reported that patients do not want to share their problems in front of other people. If healthcare providers ensure confidentiality, patients will choose to go there. One participant shared their experience with a healthcare provider and the importance of a separate room:\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003e\u003cem\u003eHealth worker and I talked in a separate room. I shared my problem with him there. He is not an arrogant person. From what I have learned about him, he is not the type to seek fame by disclosing others’ secrets to the public. He has counseled me multiple times. However, it has now been a very long time since I have spoken to him.\u003c/em\u003e\u003cstrong\u003e[P15]\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eOn the contrary, some participants had differing opinions regarding the services provided by private versus public health centers. They reported that private treatment centers were more accessible and convenient. For example, a male participant from Jhapa, living with depression, shared his perspective on the comparison of services.\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003e\u003cem\u003eClinics and private medical facilities now frequently call upon psychiatric doctors. There are many doctors available, providing a variety of options for medical care. Therefore, finding the right medical care is not difficult. Initially I sought psychological care.\u003c/em\u003e \u003cstrong\u003e[P22]\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\"\u003e\n \u003ch2\u003eSupport from family and friends\u003c/h2\u003e\n \u003cp\u003eMany participants reported that family support positively influenced their utilization of health care services. Individuals with strong family support were more inclined to seek formal mental health services compared to those with poor family support. Generally, family members such as spouse, sons, and daughters were identified as valuable sources of support.\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003e\u003cem\u003eMy daughter took me for check-up. She is the one who took me because she is nearby. My daughter is my only support now, so if something happens, I quickly call her to solve my issues. It's easy to call her because she is nearby.\u003c/em\u003e \u003cstrong\u003e[P18]\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eParticipants also noted that when a family member, typically a husband or wife, assists them, they are more likely to adhere to their medication treatment. They expressed that they can discuss their health conditions and medication situation more comfortably with their spouse than with others. A female participant with anxiety disorder in Chitwan district shared:\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003e\u003cem\u003eOne day, when my medication had run out, I sent my husband to the health post. I did not tell him (husband) anything about my illness. I told him (my husband) the health worker has called me to the health post. Can you go and also bring me the medicine?' My husband asked me, 'Medicine for what illness?' I replied, 'don’t ask about the medicine details. I have already called B. He said if I cannot visit the health post, then I can send you. So, my husband went there and bought medicine for me.\u003c/em\u003e\u003cstrong\u003e[P15]\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eA male participant stated that he visited the psychiatric service on both occasions because his family members insisted, even though he was reluctant. He mentioned that he would not have attended the visit if his family members had not pleaded. He received treatment from a private clinic and a community hospital as part of his help-seeking pathway.\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003e\u003cem\u003eI have a lot of support from my family, who love me and are doing well financially. I visited Dr. C (psychiatrist) at the insistence of my family, even though I was initially hesitant. I thought my mental health issues would resolve on its own, but the insistence from my family pushed me to seek help. They made an appointment for me and insisted that I go that day when the doctor was available. My son even took me to the appointment on his bike.\u003c/em\u003e \u003cstrong\u003e[P9]\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\"\u003e\n \u003ch2\u003eAwareness about available services\u003c/h2\u003e\n \u003cp\u003eAccess to information about available mental health services is crucial for individuals to seek help for their mental health conditions. Participants emphasized the importance of targeted and affordable information to help people find appropriate care. Many individuals face challenges in accessing services due to a lack of awareness. Participants highlighted the effectiveness of advertising, distributing brochures, and radio broadcasts in raising awareness about mental health services. Moreover, participants mentioned that hospitals and clinics in Jhapa and Kailali districts used auto-rickshaws to disseminate information to the community, facilitating access to health services.\u003c/p\u003e\n \u003cp\u003eA male patient with depression in Jhapa (P22) shared his experience of seeking help, highlighting the influence of advertisements in directing him to the appropriate treatment facility. He mentioned that he was initially unaware of anxiety and depression but learned about them through a marketing campaign. Upon discovering that a psychiatrist, was visiting Jhapa from Kathmandu, he decided to seek treatment from him for his condition.\u003c/p\u003e\n \u003cp\u003eIn a similar incident in Kailali, participants noted that those leading awareness campaigns were discussing symptoms of depression and anxiety. A female participant in Kailali, who was struggling with anxiety, found the awareness campaigns and brochures helpful for her treatment. Participant 14 first sought treatment in India and then consulted traditional healers. Upon receiving advertisements from private hospitals, she opted to begin treatment at a private hospital.\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003e\u003cem\u003ePeople from private clinics and hospitals approached me, providing information and brochures about their services and my illness. I decided to seek treatment at a private clinic, where my condition gradually improved after a thorough check-up. They promoted the clinic through loudspeaker announcements attached to vehicles.\u003c/em\u003e \u003cstrong\u003e[P14]\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eOn the contrary, a female patient with anxiety had been undergoing treatment for frequent panic attacks and anxiety by a psychiatrist, despite denying any mental health issues. Initially, she became upset when her doctor suggested that her symptoms might be related to stress so refused to see that doctor again. However, she had been receiving treatment from the same mental health specialist and found it helpful. She believed her symptoms might indicate anxiety but did not think that she was suffering from it. She shared her experience of visiting multiple health centers for treatment before deciding to seek help from a mental health specialist after seeing information at a hospital while seeking treatment for her child. The information made her feel like her illness was not serious and was not related to her mental health.\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003e\u003cem\u003eI had taken my child to Manmohan Hospital for treatment where I noticed a board on the wall listing symptoms that matched my own. After reading the information, I decided to return to Manmohan Hospital for a health check-up. I am feeling much better now.\u003c/em\u003e \u003cstrong\u003e[P24]\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eParticipants highlighted the significance of self-awareness in making informed decisions and enhancing self-confidence. For example, a retired teacher in Jhapa (P9) mentioned that he would have utilized mental health services at a government health facility if he had been aware of them.\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003e\u003cem\u003eI was unaware of the availability of mental health services in government facilities. If I had known earlier, I would have sought counseling from a health worker at a primary health care facility.\u003c/em\u003e \u003cstrong\u003e[P9]\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\"\u003e\n \u003ch2\u003eAwareness of mental health problems\u003c/h2\u003e\n \u003cp\u003eParticipants also shared their experiences of receiving care from mental health specialists or medical professionals due to their awareness of mental health problems. They reported learning about mental health issues from personal knowledge, family experiences, and information from various sources, including training programs. For example, a male patient with depression in Jhapa sought help directly from a psychiatrist when he recognized the need for professional assistance. However, he faced challenges during the lockdown, leading to incomplete recovery.\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003e\u003cem\u003eI noticed some effects on my mind and body, but I initially thought they might improve on their own. Eventually, I decided to see a doctor, unsure if it would help, but believing that a doctor could offer suggestions. I visited a private clinic to consult with psychiatrist.\u003c/em\u003e\u003cstrong\u003e[P9]\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eParticipants also mentioned obtaining knowledge about mental health through mobile health camps and training organized by government or non-governmental organizations. This increased awareness led them to seek help directly from mental health professionals. For instance, a female patient from Kailali shared her experience of receiving training on depression and counseling, which helped her recognize her symptoms and seek appropriate care.\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003e\u003cem\u003eI have received training related to depression from [XYZ organization] and counseling training at an institution called [ABC] in Kailali. One of my sisters is also a counselor. During the counseling training, I learned about the symptoms of depression. I believe that I am suffering from depression based on the symptoms I am experiencing and what I have heard and read about it.\u003c/em\u003e \u003cstrong\u003e[P12]\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\"\u003e\n \u003ch2\u003eRecommendations from trusted persons\u003c/h2\u003e\n \u003cp\u003eParticipants emphasized the significant role of trusted individuals in encouraging and referring them to seek help for their mental health conditions. Recommendations from counselors, school teachers, and traditional faith healers played a crucial role in motivating participants to access care. For example, Participant 22 shared how a counselor's recommendation led him to seek treatment from who had a strong reputation for providing effective care in the eastern Nepal.\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003e\u003cem\u003eA counselor from Organization N recommended a doctor saying she is well-known for providing good treatment. So, I started visiting her and have been on follow-up with her since then. has built a reputation for herself in the eastern part of Nepal, seeing around 108 patients daily. She has gained the trust of the people in the east, including myself.\u003c/em\u003e\u003cstrong\u003e[P22]\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eSimilarly, P10 mentioned that seeking a referral from a school teacher helped him in addressing his anxiety disorder.\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003e\u003cem\u003eI first sought advice from my school teacher and then consulted a doctor at a private clinic who diagnosed me with anxiety.\u003c/em\u003e \u003cstrong\u003e[P10]\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eMoreover, participants expressed trust in traditional faith healers (dhami) and their supernatural powers. When traditional healers recommended consulting healthcare providers, participants were more inclined to seek medical help. P8, for instance, started seeking treatment at a hospital based on a traditional healer's advice, which resulted in positive outcomes for her anxiety disorder.\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003e\u003cem\u003eDhami (traditional healer) advised me to go to the hospital for a thorough health check-up, and things have been improving since then. I follow the traditional healer's advice for seeking help which has been effective for me.\u003c/em\u003e \u003cstrong\u003e[P8]\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\"\u003e\n \u003ch2\u003eTreatment cost\u003c/h2\u003e\n \u003cp\u003eThe cost for treatment has also been reported as an important factor for encouraging help-seeking for depression and anxiety. Participants highlighted how the medical insurance helped them to encourage seeking mental health care. As per the current health insurance system in Nepal, a family of five members can receive treatment of up to one hundred thousand Nepali Rupees in a year when they pay NPR 3,500 annually. Participants from Kailali and Chitwan shared their experience of receiving free services from their insurance. As not all health facilities offer treatment under the health insurance program, they reported that they visited the health facilities where treatment cost would be covered by the insurance system.\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003e\u003cem\u003eThe insurance now covers medical treatment, encouraging people to seek help when they are sick. It provides coverage up to one lakh with certain conditions.\u003c/em\u003e\u003cstrong\u003e[P23]\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eAnother patient from Kailali expressed similar experience about the insurance policy. Participants would opt for more affordable and larger hospitals if insurance coverage is not available. P14 initially sought treatment from a neighboring country and traditional faith healers before coming across advertisements from private hospitals. She ultimately chose starting treatment at a private hospital and continued visiting primary health care centers and private clinics regularly. She was undergoing regular follow-up at a primary health care facility.\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003e\u003cem\u003eI purchased a year's supply of medication from a private hospital, which was covered by my insurance. Due to financial constraints and my husband's illness, I opted to obtain the medication through my health insurance.\u003c/em\u003e \u003cstrong\u003e[P14]\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated the treatment pathways of individuals with depression or anxiety in different regions of Nepal. The study involved 24 participants receiving treatment from various healthcare providers, such as psychiatrists, psychologists, medical doctors, and primary healthcare providers. The aim was to analyze these pathways and identify factors that facilitate access to and continuation of mental health care. The findings showed that participants followed diverse treatment routes, often seeking help from traditional faith healers in the beginning. Most participants (91.7%) consulted multiple providers. Common facilitators of treatment initiation and continuation included the quality of services, scheduling process, healthcare providers' behavior, time spent with providers, awareness of available mental health services, knowledge about mental health issues, treatment cost, support from family and friends, and recommendations from trusted community members. The complex treatment pathways reported in our study align with a systematic review of studies on pathways to mental health care (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe results did not indicate a clear treatment preference, but traditional healers were frequently chosen for initial consultations (25% consulted traditional healers in the first consultation and 46% in the second). Patients also explored different healthcare facilities, such as government hospitals, primary healthcare centers, and private hospitals, even when opting for modern health services. Some individuals initially sought help from traditional faith healers and continued to do so after consulting with various healthcare providers, including mental health professionals. Reasons for visiting traditional healers included family pressure, lack of awareness about available medical services, inaccessibility of services, and a belief that medical treatments were ineffective for depression or anxiety disorders. Some participants believed that medical treatment would be ineffective if the problem was caused by a ghost or supernatural power. Those who chose traditional faith healers had a concern that receiving injections (as a part of their treatment) from healthcare providers could worsen their condition. They also felt uncomfortable discussing their issues in healthcare settings due to a lack of privacy leading them to seek help from traditional faith healers. Participants also turned up to traditional faith healers when they did not see immediate improvements in their health condition following treatment from healthcare providers. Our findings align with a study conducted in 14 healthcare facilities across Nepal, where about one-fourth (23%) of individuals with depression consulted traditional healers initially (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Beliefs in supernatural powers as the cause of mental health conditions also influenced participants to consult traditional faith healers, as they believed that traditional healers were the only ones capable of treating such conditions (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Similar to our study, traditional faith healers or religious leaders were the first contact points for over one-fourth (27%) (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e) and over one-third (35%) of individuals with mental health problems in South India(\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe results indicated that female participants preferred traditional healers as their primary choice (33.3%) compared to other providers. Females also had more sessions with traditional healers, accounting for 33% of their sessions, while only 11.1% of sessions for male participants were with traditional healers. These findings contrast with a study in eastern Nepal where gender did not influence treatment pathways (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). We did not observe any discernible differences in treatment pathways based on caste/ethnicity, except for one participant from a Dalit community who received multiple sessions from traditional healers. Similarly, there was no variation in treatment pathways based on the age of the participants, consistent with previous research (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). However, participants with co-morbid conditions had a tendency to visit private hospitals first, while approximately one-third (33%) of participants with depression sought treatment from traditional healers initially. There were no notable differences in treatment pathways for participants with anxiety.\u003c/p\u003e \u003cp\u003eIt is important to note that patients often seek out various healthcare services, including government hospitals, primary healthcare facilities, and private hospitals, when choosing modern healthcare providers. Factors like service quality, support from family or friends, and mental health awareness influence care-seeking behavior. Improving healthcare providers' behavior, streamlining appointment scheduling, and providing quality consultation time are essential to encourage care-seeking\u003c/p\u003e \u003cp\u003eThe quality of services, including healthcare providers\u0026rsquo; behavior, scheduling appointments, time spent with patients, availability of confidential space, and continuity of care with the same provider in follow-up visits, significantly influenced patients' decisions to initiate and continue treatment at a specific health facility or with particular providers. These factors were identified as both facilitators and barriers to seeking and maintaining care. Participants mentioned that they were more likely to return to the same health facility if there was a confidential consultation space or if they could see the same provider in follow-up visits. Previous research has also emphasized the importance of supportive behaviour of health workers, availability of confidential space, and time provided by healthcare providers as key indicators of quality services (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Poor service quality has been a significant barrier to continued care in low- and middle-income countries due to lack of confidential space for consultation, insufficient time and poor communication with providers. For example, a recent systematic scoping review identified accessibility, provider relationships, clear communication, and perception of interventions as facilitators for implementing mental health services (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). A study in Colombia also emphasized the importance of privacy and confidentiality in improving patient engagement and retention in community-based psychosocial support interventions (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e). Similarly, a qualitative study among adults in Germany highlighted the supportive behaviour from general practitioners, and positive relationships between patients and therapists to engage patients in mental health care (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur study found that awareness of mental health conditions and available services play a significant role in self-initiating treatment for mental health conditions from healthcare providers. Participants who were aware of their own health conditions, had family members with mental health issues, or were receiving services for mental health conditions were more likely to seek treatment from healthcare providers. This is supported by evidence showing a positive relationship between mental health literacy and help-seeking behavior, indicating that improved mental health literacy can increase the likelihood of seeking help (\u003cspan additionalcitationids=\"CR62\" citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e). Studies have also shown that mental health literacy indirectly facilitates professional help-seeking behaviors by enhancing the perception of social support and reducing the stigma associated with seeking help (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e). Our results also revealed that participants sought treatment from traditional faith healers or religious leaders because they believed their condition could not be treated medically due to supernatural causation. Studies have shown that mental health education is a promising tool for raising awareness (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e) and reducing mental health stigma and misconceptions about mental illness (\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eImplications\u003c/h2\u003e \u003cp\u003eThe findings of this study have implications on reducing the treatment gap in mental health care by improving help-seeking behavior. First, participants expressed comfort in receiving services from primary or community health care facilities if the quality of services is improved. They emphasized healthcare providers' behavior, availability of confidential consultation spaces, time spent with providers, and continuity of care as crucial aspects of service quality. These factors are essential for encouraging individuals to access mental health services from trained primary healthcare providers. The government of Nepal has started training primary healthcare providers in WHO mhGAP-based interventions (\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e). However, it is important to ensure that they have the necessary skills and competencies to address mental health conditions effectively. Second, a lack of awareness about mental health conditions and available resources was identified as a key factor influencing individual decisions to seek mental health care. Leaflets, brochures, and social media were reported as effective tools for increasing awareness about mental health issues and treatment options. Community awareness programs should focus on improving awareness about mental health issues and available services through a combination of channels including leaflets, brochures, public announcements and social media. Third, support from family members was crucial in motivating patients to initiate and continue mental health care. Evidence shows that family can play a vital role in the treatment process of patients with mental illness, particularly in reducing healthcare costs, helping to access appropriate treatment, and advocating for their needs within the healthcare system (\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e). Therefore, future programs should engage family members in the treatment process of patients with mental health conditions. Finally, support from traditional faith healers and trusted individuals in the community was considered as valuable source of support in seeking treatment from health care providers. If traditional faith healers and trusted persons in the community receive training on mental health issues, they can help identify people in need of mental health services and refer them to health facilities with available mental health services.\u003c/p\u003e \u003cp\u003eBased on the experience and results of this study, the following recommendations are made for future research on this topic in Nepal and similar settings. First, conducting a longitudinal qualitative study could offer a more comprehensive understanding of the treatment pathway. Second, future research should include samples from mountainous and hilly regions to expand the scope of the study. Third, a quantitative study with a larger sample size could help analyze the variations in treatment pathways among different subpopulations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eStrength and limitations\u003c/h2\u003e \u003cp\u003eThe study has several strengths, including: (a) a sample from three different regions of Nepal (eastern, central, and western), (b) including participants with both depression and anxiety, (c) recruitment of participants through a range of providers, and (d) the use of standardized interview guides, specifically the McGill Illness Narrative Interview (MINI), which allows participants to provide detailed narratives on their symptom experiences, illness accounts, and help-seeking behaviors (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe study also has some limitations. First, it was conducted with a purposively selected sample of 24 participants currently undergoing treatment for depression or anxiety disorder. So, the findings may not be generalizable to the entire population. Second, the participants were still in the process of receiving care and had not completed their treatment pathways. So, the results do not provide a comprehensive overview of the entire treatment pathway. Third, the facilitators reported in the study primarily pertain to facilitating access to formal mental health care and do not address facilitators for receiving informal care, such as from traditional providers not included in this study, friends, or family members.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTreatment pathways for depression and anxiety disorders are complex, with 91.7% of patients requiring multiple sessions, and 100% involving a combination of services. While the results did not show a clear treatment preference, traditional healers were often chosen for initial consultations. Patients commonly utilize various healthcare facilities, including government hospitals, primary healthcare facilities, and private hospitals, when seeking modern healthcare services. Factors such as service quality, support from family or friends, and mental health awareness influence care-seeking behavior. Improving healthcare providers' behavior, optimizing appointment scheduling, and ensuring quality consultation time are crucial to encourage care-seeking. Increasing awareness about mental health conditions and available services through social media, miking, posters, and pamphlets, as well as training traditional healers in mental health, could improve access to mental health care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eFCHV \u0026ndash; Female Community Health Volunteer\u003c/p\u003e\n\u003cp\u003eHP \u0026ndash; Health Post\u003c/p\u003e\n\u003cp\u003emhGAP-IG \u0026ndash; Mental Health Gap Action Program Intervention Guide\u003c/p\u003e\n\u003cp\u003eNGO \u0026ndash; Non-governmental Organization\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOPD \u0026ndash; Out Patient Department\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePHCC \u0026ndash; Primary Health Care Facility\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWHO \u0026ndash; World Health Organization\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics statements\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in compliance with the Declaration of Helsinki and received ethical approval from the Nepal Health Research Council (NHRC) (Registration number: 527/2022 P). Each participant signed a written informed consent before enrolling in the study. Only those who voluntarily agreed to participate were included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eInterested individuals can contact the principal investigator of this study to express their interest in collaboration and request access to the dataset analyzed here by emailing: [email protected].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eCompeting interest\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Institute for Health Research (NIHR) (using the UK\u0026rsquo;s Official Development Assistance (ODA) Funding) and Wellcome [222001_Z_20_Z] under the NIHR-Wellcome Partnership for Global Health Research. The views expressed are those of the authors and not necessarily those of Wellcome, the NIHR or the Department of Health and Social Care.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNPL designed the study and drafted the manuscript. BL and PS conducted interviews. BAK and MJDJ mentored NPL, provided inputs and feedback on the study design and manuscript. KG provided inputs and feedback on the study design and data analysis. BL, BB and KS supported NPL in data analysis and drafting the manuscript. All authors have reviewed and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eAcknowledgement\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to the participants for sharing valuable information, even on personal matters. This study would not have been possible without their cooperation. We would like to thank Dr. Sandarba Adhikari and Dr. Avash Niraula for their support in identifying participants for interviews. Special thanks to Ms. Ruta Rangel for her support in creating tables and figures.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO. Depression and other common mental disorders: global health estimates. Geneva: World Health Organization 2017.\u003c/li\u003e\n\u003cli\u003eCOVID-19 Mental Disorders Collaborators. Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic. Lancet (London, England). 2021;398(10312):1700-12.\u003c/li\u003e\n\u003cli\u003eFerrari AJ, Charlson FJ, Norman RE, Patten SB, Freedman G, Murray CJL, et al. Burden of Depressive Disorders by Country, Sex, Age, and Year: Findings from the Global Burden of Disease Study 2010. 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WHO Special Initiative for Mental Health: Mental Health Innovation Network; 2023 [\u003c/li\u003e\n\u003cli\u003eFakhrou AA, Adawi TR, Ghareeb SA, Elsherbiny AM, AlFalasi MM. Role of family in supporting children with mental disorders in Qatar. Heliyon. 2023;9(8):e18914.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 1","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Depression and anxiety, treatment pathway, facilitators, Nepal","lastPublishedDoi":"10.21203/rs.3.rs-5711655/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5711655/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Depression and anxiety are prevalent mental health issues globally, yet many individuals in low- and middle-income countries lack access to treatment. Limited research exists on mental health service utilization in these regions. Understanding the factors that impact access to care and treatment pathways can enhance mental health services. This study investigates the factors that support the initiation and continuation of treatment for depression or anxiety in Nepal.\u003cbr\u003e\n\u003cstrong\u003eMethods:\u003c/strong\u003e The study was conducted in Jhapa, Chitwan, and Kailali districts in Nepal, representing the eastern, central, and far-western regions. The participants were adults receiving treatment for depression or anxiety from a range of healthcare providers. A total of 24 participants were purposively recruited, including 13 with symptoms of depression, 9 with symptoms of anxiety, and 2 with both conditions. We utilized the McGill Illness Narrative Interview, a semi-structured protocol commonly used in mental health research, to gather detailed narratives on symptom experiences, illness accounts, and help-seeking behaviors. Data analysis was performed using a framework and thematic analysis approach with NVIVO software.\u003cbr\u003e\n\u003cstrong\u003eResults:\u003c/strong\u003e Treatment pathways for depression and anxiety in Nepal were found to be complex, involving multiple service providers and recurrent treatment from the same providers. Out of a total of 137 sessions across 24 patients, the majority of sessions were with traditional faith healers (27.7%), followed by private hospitals (19.7%), primary healthcare facilities (16.1%), government hospitals (13.1%), neighboring countries (8.0%), and private clinics (11.7%). Traditional healers were the most popular places for initial visits, followed by private clinics and government hospitals. Factors such as service quality, providers behavior, availability of trained providers, appointment process, confidentiality, and types of services offered influenced care-seeking decisions. Support from family or friends, awareness of mental health issues, and recommendations from trusted individuals also played a significant role.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Treatment pathways for depression and anxiety disorders are complex, often involving multiple sessions with different service providers and a combination of services. Improving healthcare providers' behavior, appointment scheduling, and consultation quality is essential to encourage individuals to seek care. Raising awareness about mental health conditions and available services through various channels as well as training traditional healers in mental health could enhance access to care.\u003c/p\u003e","manuscriptTitle":"Facilitators in treatment pathways for depression or anxiety among adults in Nepal: A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-02 08:53:32","doi":"10.21203/rs.3.rs-5711655/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-28T08:01:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-19T10:25:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-18T05:41:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"283847955072348442382509595695936165450","date":"2025-04-04T05:58:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"316999873774635501001921822469411889184","date":"2025-03-29T13:55:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-29T13:47:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-26T08:15:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-03-25T06:11:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fc00ef87-5e9b-44e8-9329-707e3c09055e","owner":[],"postedDate":"April 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-06-09T16:01:33+00:00","versionOfRecord":{"articleIdentity":"rs-5711655","link":"https://doi.org/10.1186/s12889-025-23225-x","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-06-02 15:57:24","publishedOnDateReadable":"June 2nd, 2025"},"versionCreatedAt":"2025-04-02 08:53:32","video":"","vorDoi":"10.1186/s12889-025-23225-x","vorDoiUrl":"https://doi.org/10.1186/s12889-025-23225-x","workflowStages":[]},"version":"v1","identity":"rs-5711655","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5711655","identity":"rs-5711655","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}