The main finding of this study is that the data reveal the benefits of community-based service management policies for severe mental disorders in reducing the delay in diagnosis of patients with severe mental disorders in the community, although the government has adopted a series of support policies (including financial and social support, etc.) to reduce the family burden of patients, it is still unable to eliminate the great delay in diagnosis. Using a severe mental disorder management information system, we analysed the delayed diagnosis of patients with severe mental disorders. The median delayed diagnosis was 3.2 months but varied widely (interquartile range 0– 849.2 months). Previous studies have shown that the delay time of patients with bipolar disorder from the first symptom to diagnosis is approximately 10 years [13, 17, 18], which indicates that the time from the first symptom to diagnosis and treatment is quite long. Other studies have shown that the median delay in the diagnosis of bipolar disorder is 2.07 months ( interquartile range: 0.57–8.1)[8]. In a study of patients with severe mental disorders in Vietnam, the median delay in diagnosis was 11.5 months (0–168.0). Overall, 46.3% of patients were delayed in diagnosis for more than one year[10].
In terms of demographic factors, we found that there were several factors related to the delayed diagnosis. First, older age was found to be positively associated with the delayed diagnosis. This result is different from that of an Australian study on bipolar disorder patients. It found that the delayed duration decreased when the age of the study participants was increased[13]; in another study, we found that older age at onset was associated with a shorter duration of untreated psychosis[19]. However, in Trang Nguyen's research[10], older age was associated with a delay of more. This may be explained by the fact that in our research, caregivers may pay more attention to young people, so they are more likely to identify the onset of psychotic symptoms. Therefore, young people may seek diagnosis with a short delay or no delay. However, the older patients had the onset symptoms, and the family members and caregivers paid less attention to them compared with the younger patients. They thought that the abnormal behavior was caused by work pressure or emergency events and less attracted the attention of family members. In these people, it may lead to a longer delay in diagnosis. Second, we also found that higher levels of education were more likely to delay diagnosis, and individuals with higher education backgrounds were more likely to succeed in their work and had difficulty receiving medical advice from others. When patients have some abnormal behaviors, they would be considered as their personality characteristics; only when serious harmful behaviors appear would they be treated and diagnosed, resulting in delayed diagnosis. Third, the floating population was more likely to have a delayed diagnosis than native patients. It is difficult for floating patients to find their mental symptoms when they go out to work alone without stable income and residence. Finally, our study suggested that the rate of delayed diagnosis among patients who were unmarried was higher than that among those who were married, which might be due to social stigma and lack of partner care, and related research has also proven that social stigma could cause delayed diagnosis[9, 16].
In terms of social support factors, we found that SMD patients with medical insurance and subsistence allowances were less likely to have delayed diagnosis. Because of sufficient medical insurance, when patients have abnormal behavior or mental symptoms, they will seek medical services in time, while patients without medical insurance find it difficult to seek medical help because of high medical expenses, delaying their illness. In addition, patients who receive subsistence allowances are more likely to be concerned by the community and civil affairs departments. When mental illness was observed, they would receive more economic and social support to reduce delayed diagnosis and receive treatment[20]. In terms of diagnosis and treatment factors, mental retardation with mental disorder was more likely to delay diagnosis, but mental disorders caused by epilepsy were less likely to delay diagnosis compared with schizophrenic patients. Analysis of the reasons may be that patients with mental retardation with mental disorder have symptoms such as mental retardation in childhood and adolescence, which would receive more attention from parents and teachers, and caregivers or relatives paid more attention to intellectual and physical development than mental symptoms. However, mental disorders caused by epilepsy would receive timely medical advice and family care because of serious physical symptoms such as epilepsy. Due to the particularity of mental illness and the lack of popularization of mental health knowledge, when patients, especially in rural areas, have mild mental symptoms, they receive irregular antipsychotic drugs to alleviate the development of mental illness from village doctors or traditional Chinese medicine, thus delaying the formal diagnosis and treatment of patients. Patients with physical diseases who visit general hospitals 1–2 or 3–4 times a year receive more professional doctors' advice and enjoy more medical service resources, and these patients are less likely to delay diagnosis.
The generalizability and authority of our findings is strengthened because they were derived from a severe mental disorder information system that is representative of a population served by the Chinese 686 project (the central government subsidizes local health funds for the management and treatment of severe mental diseases). Furthermore, the large sample data in our study were collected and analysed, thereby reducing the risk of information and selection bias. Meanwhile, our study has survey administration by trained personnel.
Our study has several limitations. First, the data collected were based on the recall of patients, as all of the patients had completed the full course of treatment, and it has been a while since their first onset. Therefore, when asked about situations related to their disease, they may not remember it clearly, resulting in a recall bias inevitably. Second, the subjects of our study were all patients registered in the severe mental disorder information system; thus, patients not being diagnosed or registered in the system were excluded from our study. Finally, factors associated with delay diagnosis are numerous, whereas we have explored only a few of them; for example, one study showed that different economic regions and policies are important factors in the development of SMD[13], and we suppose that different economic and policy backgrounds affect the timeliness of diagnosis. In addition, we ignore some important factors that affect delayed diagnosis, such as understanding mental health knowledge and the accessibility of mental health resources and services .