The pattern of substance use was different in the two groups. Compared to the previous studies, the tribal were less educated, and most of them were engaged in agricultural activities and came from low socioeconomic conditions.^[5] In the case of occupation, the findings contradict previous studies.^[5,13] The prevalence of alcohol use was high in tribal individuals with low occupational and uneducated. The comparable age of initiation of substance use lower in tribal patients is consistent with earlier studies.^[5,14] Both groups had moderate problems in employment, but the tribal population reported more severe problems than the non-tribal populations. The alcohol and other illicit drugs opioids and cannabinoids showed a significant difference between the groups. The previous studies also show that the prevalence of alcohol use is high in tribal populations.^[2,15-18] However, in the non-tribal population, most of them have illicit drugs use in high severity. The severity of family/social problems were higher in tribal populations, and it leads to various negative consequences in families such as domestic violence, family discord, and burden on spouses.^[17,19]

Very few studies systematically assessed the pathways to care among persons diagnosed with SUDs in India. These studies were conducted with alcohol use disorders^[19] and opioid use disorders.^[7,21] Globally, common pathways fall under three categories, physician, specialist, and traditional healer.^[22] In the present study, the most common pathway was the delayed pathway, which takes years to seek psychiatric help after recognizing the symptoms of family members. In our study, the mean duration taken to access psychiatric services after identifying the problem was 2 years in the tribal population. The comparison of the duration of the problem identified for the first time between the two groups was significant. This could be because the caregivers do not think substance intake is a problem, and in tribal, they accept it as part of the culture. In others, studies about psychiatric disorders to look at the generic pathway to psychiatric care found a more significant delay between the onset of first symptoms and seeking the first health care with a mean delay of 2.8 years.^[23]

Noticing the change most commonly by spouses instead of by parents in the tribal group despite early onset of substance use, unlike in non-tribal group, might reflect more familial and cultural acceptance. Here, the direct pathway is more among tribal and non-tribal populations than two-step referral pathways. Earlier studies have expressed the strong possibility of pathways to care differences based on the psychiatric diagnosis. A study conducted in North India reported that 58% of patients with mental illness and SUDs are to be consulted a psychiatrist for the first time for treatment.^[24] Despite that, 33% of the patients sought help from traditional faith healers for the treatment primarily. In the index study, 65.0% of patients from the tribal population consulted a psychiatrist, including whoever directly comes to central institute of psychiatry (CIP), and 62.5% from the non-tribal population directly consulted a psychiatrist for the SUD. In a previous study, 56.9% of the subjects had the first point of contact with a tertiary care addiction psychiatrist, and traditional healers were consulted by about 5.2% of the patients seeking help for the first time.^[20] No patients visited a practitioner of an alternate system of medicine in the present study. This was also comparable to the earlier study.^[25] It shows that most patients with SUDs do not seek treatment from alternate systems of medicine. This observation has an important implication for policies as, over the past years, there has been prominence on the promotion of alternate systems of medicine in the country. In India, the treatment provided by non-specialists for SUDs might be ineffective by patients; or non-specialists might prefer other disorders for the treatment rather than SUDs. In our study, fewer patients consulted faith healers as the first treatment mode compared to consulting a psychiatrist directly.

Most of the tribal population gave the reason for the delay in psychiatric care was a lack of proper awareness about psychiatric care (treatment, place, and person), and financial problems were another reason for delaying treatment. The previous studies and surveys substantiate the results. Most alcohol use disorders identified with the treatment gap had not been taken care of or could not access appropriate care. More than lack of awareness, affordability of care, which varied between rural and urban areas, appear s to influence these wide treatment gaps critically.^[3] Fear and social stigma were considered major issues among non-tribal populations compared to the tribal population. A previous study reported high internalized stigma among alcohol-dependent patients.^[26] Research has indicated that the differences in psychiatric disorders might explain the differences in the pathway of care.^[24] Both groups have a poor attitude toward seeking professional psychological help. If the patient with higher education, they have a more positive attitude to seek professional help. Our findings show that respondents with higher education viewed them as more positive toward seeking psychological help. The treatment gap is high in substance abuse disorders and current community-based programs are not adequately reaching grassroots levels; all other important stakeholders need to be trained. Furthermore, programs for prevention and early detection measures are needed. Technology-based interventions need to reach unreached tribal populations. Even though pathways to care among tribal with SUD are not studied much, the sample size is inadequate to generalize to tribal communities, both genders could have been a better representation, and future studies need to address the treatment gaps with community-based interventions in tribal communities.