Association of Stigma and Psychiatry co-morbidity in Leprosy patients

Samrat Kar 1, G.C.Kar 2, T.Pati 3, N.M.Rath 4, S.P.Swain 5

ABSTRACT Background: Stigma experienced by Leprosy patients can lead to Psychiatry co-morbidity in them. Objective: association of Stigma and Psychiatry morbidity in Leprosy patients.. Setting: The study was conducted at Dept of SCB Medical College Hospital, Cuttack and Leprosy centre, Gandhipalli, Cuttack. Methods: A survey of patients admitted for delivery was conducted for one month, using a questionnaire designed for this purpose. Results: In the present study, 65 patients reported stigma related behavior at different places. Further it was observed that (73.84%) of patients with psychiatric morbidity reported about stigma in comparison to (26.15%) without. Highest no of patients reported regarding stigma at work place (57%) INTRODUCTION Leprosy is one of the oldest diseases known to mankind. The word "leper" was derived from a Greek word meaning "Scaly. Besides the emotional burden, stigma appears to be one of the foremost stumbling blocks. Stigma associated with leprosy is perpetuated due to different factors like prevalent myths of causation by hereditary factors, divine curse or ill deeds of past life and disfiguring physical deformities (Kaur et al, 2002). Elissen et al (1991) opined that leprosy patients tend to discriminate themselves. Kumar et al (1983) observed that leprosy patients experienced negative reactions from their families, spouses and society members too. Stigma coupled with physical deformity, reduced productivity and social isolation grossly increases the level of stress. (Vlassoff et al, 1996; Vasundhra et al, 1983; Kumar et al, 1983; Chaturvedi et al, 1990). All these factors have obvious mental health consequences.
47

Zodpey et al (2000) in a study involving 486 patients observed that leprosy patients were isolated and refrained from various activities in the family and more so in females. Further women were found to suffer more isolation and rejection from the society. But Cakiner et al (1993) opined that women with leprosy have problems in common with other women. Kumar et al (1983) interviewed 225 adult leprosy patients to study various aspects of their lives. It was observed that 17.34%, 14.33% and 45.78% of patients experienced negative reactions from their families, spouses and society members, respectively. Out of 79 unmarried patients, 53 (67.1%) attributed leprosy as the only reason for not getting a partner for marriage. Out of 146 married patients, 34 (23.3%) were not living with their spouses; this also included 9 (6.2%) patients, deserted by their partners. Leprosy uprooted 44 (13.55%) patients from their residences, of whom 27 settled in leprosy village/settlement. Mhasawade et al (1983) also highlighted the social stigma and considered the psychiatric hazards of the disease to be as bad as its physical manifestations. Kushwah et al (1991) in a longitudinal study on stigma found that 26.45% cases had to face one or more than one type of social stigma. The stigma was more prevalent in males, illiterates and low socio-economic group. Divorcing a leprosy-afflicted spouse is one of the manifestations of social stigma attached to leprosy and depends on the decision resulting from perceived physical and social threat. Raju et al (1995) conducted an attitude study on this aspect involving 1199 community members from Orissa and Andhra Pradesh. A large number of respondents from Orissa suggested divorce. Vlassoff et al (1996) in a study on 2495 patients found that both men and women were negatively affected in terms of their family and marital lives but women appeared more vulnerable because they were deprived of personal contact with others in the domestic environment where they were accustomed to receiving their greatest emotional rewards. Women reported that indifference to them by other family members, or seeming negation of their presence, caused them the greatest suffering. Self-stigmatization is another concern, which reflects an improper and psycho-pathogenic response by leprosy patients. Elissen et al (1991) was of the opinion that leprosy patients tend to discriminate themselves, while more tolerance is found in their healthy contacts. Pal et al (1985) also observed that 75% of patients did not encounter any adverse reaction from
48

the fami l y m e m b e r s , o r n e i g h b o u r s e v e n t h o u g h m o s t o f t h e m k n e w about the disease. Arole et al (2002) observed, in a population receiving vertical control programme, a high level of selfstigmatization among leprosy patients besides social stigma in their communities leading to reduced interaction between the leprosy patients and their communities. Stigma associated with leprosy is mainly due to the prevalent myths, misconceptions and a dreaded perception about the physical deformities caused (Kaur et al, 2002). It is a social malady that has to be solved. Even now a days people affected by leprosy have to leave their village or are socially isolated (Senturk et al, 2004). Fr i s t e t a l ( 1 9 8 0 ) i n t e r v i e w e d 1 0 4 e m p l o y e r s t o s t u d y t h e i r attitudes toward hiring the leprosy patient and persons with five other handicapping conditions. The single most cited reason by employers for having a negative attitude toward hiring handicapped candidates as a group was functional--the candidate would be "unable to do the job." The most cited justification for not hiring the leprosy patient was that "customers and other employees wouldn't like it." Zodpey et al (2000) carried out a study at the Leprosy to investigate gender differentials in the social and family life of leprosy patients involving 486 patients. It was observed that leprosy patients w e r e i s o l a t e d a n d r e f r a i n e d f r o m v a r i o u s a c t i v i t i e s i n t h e f a m i l y. H o w e v e r, w o m e n s u f f e re d f r o m m o re i s o l a t i o n a n d s o c i a l re j e c t i o n . Richardus et al (1999) observed that New case detection rate (NCDR) was lower for females than males in Bangladesh. This may b e d u e t o t h e s o c i o c u l t u r a l c h a r a c t e r i s t i c s o f t h e s o c i e t y, w i t h g e n d e r differences in exposure, health seeking behavior and opportunities for case. In a meta-analysis study of women and Leprosy in Kenya, Le Grand (1997) also observed gender inequalities in health have a significant impact on women's health. In leprosy gender inequalities could be even more serious, as it is a highly stigmatized disease OBJECTIVE In the above back ground; the present study was taken up at D e p t o f Ps y c h i a t r y, S C B M C H a n d L e p r o s y h o s p i t a l , G a n d h i p a l l i , Cuttack with the object to find out association of Stigma and Ps y c h i a t r y m o r b i d i t y i n L e p r o s y p a t i e n t s
49

MATERIALS AND METHODS Place of study The present study was undertaken at Leprosy centre Outpatients, Gandhipalli,Cuttack, in liaison with Mental Health Institute, Sriram Chandra Bhanja Medical College Hospital, Cuttack in the one-month period of 1st June, 2005 to 3oth June, 2005. Gandhipalli is a state leprosy center run by the Government of Orissa. It is manned by three specialists and caters outpatient, inpatient and palliative care to the leprosy patients from the adjoining districts. Mental Health Institute is the premier psychiatric institute of the state of Orissa. It is the ultimate referral center for psychiatry in Orissa. The Study Sample The study sample was collected from the outpatient attendance of fifteen to twenty during the one-month period. But all the patients could not be considered as the initial interview involved a period of about 45 minutes. Criteria for selection Inclusion criteria 1. 2. 3. Age is between 15-60 Years Should be physically fit to answer the questions Availability of reliable informants

Exclusion criteria 1. Patients more than 60 years age were excluded to rule out the possibility of organic involvement. 2. Patients previously diagnosed as a case of leprosy and under cover of any psychiatric drugs 3. Patients taking any medication, which can produce cognitive and other psychological defect 4. Patients with other co-morbid dermatological and general medical condition, those needing urgent attention for physical problems. 5. Patients without reliable informants Methodology Out of 116 cases so considered 16 were excluded according to fixed criteria. Diagnosis of leprosy was done by clinical examination, associated cardinal sign and supported by histopathology and bacteriological examination
50

DISCUSSION: It will be worthwhile to discuss certain inherent aspect of the study sample as well as the environment of the leprosy center before proceeding on analysis of the findings presented in the previous chapter. State Leprosy center at Gandhipalli, Cuttack was source for collecting the sample. It is a dedicated hospital with both inpatient and outpatient facility and is manned by three specialist doctors. In the present study only outpatient was taken into consideration with a view to avoid the possible bias of over representation of patients with deformity. However the outpatients' attendance in a labeled leprosy hospital may or may not be strictly representative of leprosy patients in the general population. The factors that influence in such hospital are awareness, as well as chronicity of illness, appearance of deformity, financial problem, and proximity of the institute. Some of these may constitute an unavoidable limitation. Further it was not possible to take up all the patients attending the OPD of leprosy hospital for initial evaluation. This was so because it required about 45 minutes for initial case taking. Hence it was only feasible to consider a case after considering a preceding one. Resistance for referral to Mental Health Institute, though with support was another factor that influenced inclusion of cases. However 116 cases were initially considered for study and 13.79%(16) cases had to be excluded as depicted in table no 1.The common reason for exclusion were lack of reliable informant and refusal of relative or patient for psychiatric referral. The fact that - patients of leprosy having given initial consent for inclusion in the study declined for psychiatric referral clearly indicates the prevalent stigma in respect of mental disorder. The interface of leprosy and psychiatry, thus involves the effect of pervasive taboos against leprosy as well as psychiatric disorder. Stigma is a pervasive social phenomenon. Available literature highlights adverse consequence of stigma in leprosy (Kushwah et al, 1991; Vlassoff et al, 1996; Kumar et al,1983 ). The domain of stigma involves not only the society, but also one's own family, public institution, school as well as work place. In the present study, 65 patients reported stigma related behavior at different places. Further it was observed as in Table no.2 that (73.84%) of patients with psychiatric morbidity reported about stigma in comparison to (26.15%) without.

53

It was further attended to examine areas of stigma faced by the leprosy patients i.e., at school, work place, in family and in society. The resultant finding as in Table no.3 imply that highest no of patients reported regarding stigma at work place (57%). It was followed by stigma faced in family (19%), at school (16%) and in society (15%). Different stigmas were also compared with respect to co-morbid mental illness. The proportion of Psychiatric comorbidity was highest for these with stigma at work places (75.44%) followed by stigma at school(68.75%), stigma in family(68.43%) and society(60%). This is similar to observations made by Kaur et al (2002);Senturk et al( 2004) and Frist et al (1980). CONCLUSION & SUGGESTION The following conclusion may be derived on the basis of the observations of the present study as summarized in the previous section. 1. 2. 3. 4. 5. Majority of the leprosy patients have simultaneous psychiatric disorders. Stigma, which is an important negative social factor related both to mental disorder and leprosy is more experience by the patients with comorbidity. Facilities for psychiatric consultation liaison ought to be developed in centers dealing with leprosy. This can be facilitated by having psychiatric units in such centers or developing appropriate and effective referral services. Medical and paramedical personnel dealing with leprosy should be provided appropriate orientation is psychiatry. This would be helpful in primary prevention and early detection and removal of Stigma in Leprosy Patients

LIMITATION 1. 2. 3. 4. 5. The study had to be conducted within limited time frame. It was not a longitudinal follow-up study. Cases excluded could be with or without psychiatric comorbidity Those leprosy patients who did not/never attend OPD were obviously out of study. On direct enquiry, there could be chances of wrong information.

54

REFERENCE
l

Arole, S., Premkumar, R., Arole, R., Maury, M. and Saunderson, P. (2002) Social stigma: a comparative qualitative study of integrated and vertical care approaches to leprosy. Leprosy Review, 73, (2 Suppl), 186-96. Chaturvedi, R.M. and Kartikeyan, S. (1990) Employment status of leprosy patients with deformities in a suburban slum. Indian Journal of Leprosy, 62, (1 suppl), 109-112. Elissen, M.C. (1991) Beliefs of leprosy patients about their illness. A study in the province of South Sulawesi, Indonesia. Trop Geogr Med, 43, (4 suppl), 379-382. Frist, T.F. (1980) Employer acceptance of the Hansen's disease patient and other handicapped persons. International Journal of Leprosy Other Mycobacteria Disease, 48, (3 suppl), 303-308. Kaur, H. and Van Brakel, W. (2002) Dehabilitation of leprosy-affected people--a study on leprosy-affected beggars. Leprosy Review, 73, (4 Suppl), 346-355. Kopparty, S.N. (1995) Problems, acceptance and social inequality: a study of the deformed leprosy patients and their families. Leprosy Review, 66, (3 Suppl), 239-249. Kumar, A. and Anbalagan, M.( 1983) Socio-economic experiences of leprosy patients. Leprosy India, 55, (2 suppl), 314-321. Kushwah, S.S., Govila, A.K, Upadhyay, S. and Kushwah, J.( 1981) A study of social stigma among leprosy patients attending leprosy clinic in Gwalior. Leprosy India, 53, (2 suppl), 221-5. Le Grand, A. (1997) Women and leprosy: a review. Leprosy Review, 68, (3 suppl), 203-211. Mhasawade, B.C. (1983) Leprosy-a case for mental health care. Leprosy India, 55, (2 suppl), 310-313. Pal, S. and Girdhar, B.K. (1985) A study of knowledge of disease among leprosy patients and attitude of community towards them. Indian Journal of Leprosy, 57, (3 Suppl), 620-623. Raju, M.S. and Reddy, J.V. (1995) Community attitude to divorce in leprosy. Indian Journal of Leprosy, 67, (4 suppl), 389-403.
55

Raju, M.S. and Reddy, J.V. (1995) Community attitude to divorce in leprosy. Indian Journal of Leprosy, 67, (4 suppl), 389-403. Richardus, J.H., Meima, A., Croft, R.P. and Habbema, J.D. (1999) Case detection, gender and disability in leprosy in Bangladesh: a trend analysis. Leprosy Review, 70, (2 suppl), 160-173. Senturk, V. and Sagduyu, A. (2004) Psychiatric disorders and disability among leprosy patients; a review. Turk Psikiyatri Derg. Fall, 15, (3 suppl), 236-243. Vasundhra, M.K., Siddalingappa, A.S.and Srinivasan, B.S. (1983) A study of medico-social problems of the inmates of a leprosy colony in Mysore. Leprosy India, 55, (3 suppl), 553-559. Vlassoff, C., Khot, S. and Rao, S. (1996) Double jeopardy: women and leprosy in India.World Health Statistic, 49, (2 suppl), 120-126. Zodpey, S.P., Tiwari, R.R. and Salodkar, A.D. (2000)Gender differentials in the social and family life of leprosy patients, Leprosy Review, 71, (4 suppl),505-510.

Dr. Samrat Kar M.D. Trainee, Mamata Medical College & Hospital, Khammam, Andhra Pradesh Dr. G.C.Kar Ex-Prof. MHI, SCB MC, Cuttack. Dr. T. Pati Consultant Psychiatrist, Cuttack Dr. N.M.Rath Assoc. Professor, Dept of Psy., VSS MC, Burla Dr.S.P.Swain Asst Prof., MHI, SCB MC, Cuttack.

56