Generally, most of the respondents 250 (65.1%) contacted a modern psychiatric treatment facility after significant delay from the onset of their symptoms. The median time of delay with this study was higher (52.1 weeks) than a study conducted in Addis Ababa, Ethiopia at Amanuel mental specialized hospital (38 weeks) [11
]. It was also extremely high in comparison with a study conducted in Eastern Europe in which the median time was only 3 weeks [6
]. Around 35.2% of the study subjects contacted JUSH as the first place of care, but the remaining subjects have visited either other biomedical or traditional care. In comparison to the study from Addis Ababa where 41% sought treatment directly from the mental hospital [11
], less patients came directly to JUSH for treatment. One possible explanation for this discrepancy is that the majority of the subjects in this study was from rural areas and was faced with much longer geographic distances from the psychiatric facility than those in the study conducted in Addis Ababa. These larger distances may have increased the likelihood to contacting traditional healers before seeking treatment at JUSH.
A significant proportion of the study subjects (52.3%) were suggested to seek care at JUSH by either family or former patients. Similarly, a finding from Eastern Europe showed that the suggestion to seek care most often came from family or friends [6
]. This might reflect the general lack of awareness on mental illness and the availability of mental health care among Ethiopians. The most common types of medically diagnosed mental illnesses were major depression, schizophrenia and other psychosis respectively. The most prevalent diagnosis in the Eastern Europe study was mood and neurotic disorders followed by schizophrenia [6
A number of people did not know the causes of mental illness and most said that the perceived causes of mental illnesses were supernatural power and evil eye. A community based study conducted in Agaro town which is around 50 Kms away from Jimma town showed that poverty was the most commonly perceived cause of mental health problems followed by 'God's will' [16
]. The finding that 98.7% of the respondents believed that mental illnesses are curable is alarming because it might reflect the lack of awareness regarding the chronic course of mental illnesses--particularly those more severe in nature. This could imply that there is an unrealistic expectation from whatever help is sought, and there is a risk of consequent dissatisfaction with the outcome and which may perhaps lead to poor adherence to treatment. On the other hand, the social desirability bias might have contributed to such a high figure since the study was conducted in a psychiatric facility and the data collectors were psychiatric nurses. The paradoxical finding that most of our study participants believed that spiritual factors caused the mental illness and that modern medications helped to cure the illness suggest that despite their belief in supernatural causes, their treatment seeking behavior was pragmatic.
Most of the respondents perceived that mental illnesses generally are severe health problems. Their perception was similar to another general community based study which found that Epilepsy was considered as the most serious problem followed by schizophrenia [16
]. Most of the study participants perceive that mental illnesses are considered as a shame in the community. This perception about the community attitude towards mental illnesses contrasts with a study on community attitude towards mental illnesses where more than forty percent had positive attitude towards living with persons with mental illnesses [16
]. This might be because of felt stigma by the person with mental illness. Such negative feelings as shame and guilt might contribute to delayed treatment seeking for mental illness. Unlike that of the study conducted in Addis Ababa [11
], our study demonstrated that age of the patient had significant statistical association with early treatment seeking behavior. Somatic problems were also predictors of early treatment seeking behavior for mental illness. Persons with somatic symptoms may present to the primary care early in the course and may then get referred for psychiatric assessment. The reason for the association between having attempted suicide and delayed treatment seeking is unclear from our study. It is possible that people who are depressed might have not sought treatment for a long time which led to a worsening of their symptoms which rendered them too depressed to attempt suicide. Another explanation could be that the majority of respondents being either Muslim or Coptic Christians which stigmatize suicide and hence people might be hesitant to show up. Nevertheless, this needs further investigation.
Our study suffers social desirability bias as the setting is a psychiatric facility and the data collectors were staff members of the hospital. There might be recall bias on the onset of the mental illness and settings for treatment which were sought. It may not be generalizable to community as only a small proportion of persons with mental illness present to modern psychiatric treatment.