|Year : 2022 | Volume
| Issue : 6 | Page : 693-698
|Prevalence of anxiety and depression among people living with leprosy and its relationship with leprosy-related stigma
Pawan Sharma1, Rabi Shakya1, Swarndeep Singh2, Anup Raj Bhandari1, Rajesh Shakya3, Amit Amatya4, Chunauti Joshi1, Grisha Gurung1
1 From the Department of Psychiatry, Patan Academy of Health Sciences, School of Medicine, Lalitpur, Nepal
2 Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
3 Khokana Arogya Ashram, Lalitpur, Nepal
4 Department of Dermatology, Patan Academy of Health Sciences, School of Medicine, Patan Academy of Health Sciences, School of Medicine, Lalitpur, Nepal
|Date of Web Publication||23-Feb-2023|
Assistant Professor, Department of Psychiatry, Patan Academy of Health Sciences, School of Medicine, Lalitpur
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Leprosy, a chronic infectious disease, is associated with a high risk of psychiatric disorders. Aims and Objectives: We aim to estimate the prevalence of anxiety and depressive symptoms among people living with leprosy at a special community residence in Nepal. We also aimed to find the correlation between anxiety and depression. Materials and Methods: This is a cross-sectional descriptive study conducted in a community of people with leprosy staying at a centre in Nepal using all enumerative sampling. The semi-structured schedule, hospital anxiety and depression scale and stigma assessment and reduction of impact (SARI) stigma scale were applied among 119 participants. Results: About 10.1% (n = 12) and 12.6% (n = 15) of participants scored above the threshold score indicative of definitive clinically significant anxiety and depression symptoms. In multivariable analysis, leprosy-related stigma and attribution of leprosy to bad deeds were significant correlates of anxiety; whereas leprosy-related stigma and duration of stay at the centre were significant correlates of depression. Conclusion: The prevalence of depression and anxiety symptoms among people living with leprosy is higher than that in the general population. Sigma is a significant correlation for both. It is important to screen for mental health issues while managing patients with leprosy and implement strategies aimed at leprosy-related stigma reduction.
Keywords: Leprosy, mental health, Nepal, stigma
|How to cite this article:|
Sharma P, Shakya R, Singh S, Bhandari AR, Shakya R, Amatya A, Joshi C, Gurung G. Prevalence of anxiety and depression among people living with leprosy and its relationship with leprosy-related stigma. Indian J Dermatol 2022;67:693-8
|How to cite this URL:|
Sharma P, Shakya R, Singh S, Bhandari AR, Shakya R, Amatya A, Joshi C, Gurung G. Prevalence of anxiety and depression among people living with leprosy and its relationship with leprosy-related stigma. Indian J Dermatol [serial online] 2022 [cited 2023 Mar 23];67:693-8. Available from: https://www.e-ijd.org/text.asp?2022/67/6/693/370348
| Introduction|| |
Leprosy is a chronic infectious disease that has been known for more than 3000 years. People with leprosy have been reported to be at a higher risk of developing psychiatric disorders, with the prevalence of psychiatric disorders among them being higher than that among the general population. The long duration of illness and the physical disability associated with leprosy might contribute towards this increased risk of psychiatric disorders. A study assessing psychiatric comorbidity in 100 confirmed patients with leprosy from India revealed that about 76% of them had some psychiatric illness. Of these, a large number of the patients were having depression (55%) and anxiety (21%). Another study from India also reported that depression and anxiety were the common psychiatric morbidities among patients with leprosy. A study done in Bangladesh among 140 patients with leprosy reported that depression was more common in patients than in control groups, and the symptoms of depression increased with a higher degree of leprosy-related stigma and physical disability in them.
In the Nepalese context, though the prevalence rate of leprosy has been maintained at below 1 per 10,000 population since the declaration of its elimination, a high case detection rate and pockets of endemic areas still exist. Those patients who are sick for a longer time and those who develop physical deformities have been observed to have a higher prevalence of comorbid psychiatric disturbances. However, most of the studies have been conducted among patients with leprosy visiting the hospital or clinical settings. Furthermore, there is a dearth of literature on mental health-related aspects of people living with leprosy, especially in the context of Nepal. Thus, the present study aimed to estimate the prevalence of anxiety and depressive symptoms among people living with leprosy at a special community centre or ashram in Nepal. Furthermore, the relationship between leprosy-related stigma and associated physical disability with the severity of depression and anxiety symptoms experienced by people living with leprosy was explored.
| Material and Methods|| |
This was a cross-sectional descriptive study conducted at Khokana Arogya Ashram, Lalitpur, Nepal. The Department of Psychiatry of Patan Academy of Health Sciences, School of Medicine has been providing regular services at this centre or ashram. The ashram is a community of people living together with leprosy, having some disability and having been discarded or repudiated by their family members. All the residents have the option to have their own separate home and kitchen within this centre. All enumerative sampling technique was used, and all the people living with leprosy at the centre were approached for inclusion in the present study. However, those not willing to give consent to the study, and children below 18 years of age were excluded. The calculated sample size as per the formula Sample size: N = [Z2 × P (1 − P)]/d2 where, Z = 1.96 (Taking alpha error to be 5%), d = 0.05 (For 95% precision), P = 10%, N = 138.29 (approx. 139). This sample was available in the centre, 143. However, among them, three had moved out and 21 were working outside and would come to centre at the night time. Hence, 119 respondents were available for the study. Two researchers travelled to the centre after contacting the caretaker of the centre over phone to manage the timing and provide study-related information to the patients. The researchers went to each house inside the centre and data were collected by paper and pencil method after giving information and taking informed content. The following tools were used for assessment:
A semi-structured proforma collecting information pertaining to sociodemographic and clinical profiles of participants was applied. In the sociodemographic profile, details regarding age, gender, ethnicity, address, duration of stay, family history and family visits were assessed. In the clinical profile, details regarding attribution to the cause of leprosy and history of psychiatric illness was assessed.
Hospital anxiety depression scale
The Hospital Anxiety and Depression Scale (HADS), developed by Zigmond and Snaith in 1983, is recognised as a reliable, valid and practical tool in hospital populations for identifying and quantitatively evaluating the two most common mental health conditions. In addition to hospital settings, HADS has been found useful for psychiatric screening in the general population. This scale has been translated and validated in the Nepalese language.
Stigma Assessment and Reduction of Impact (SARI) stigma scale
This is a comprehensive scale with good reliability and cultural validity to assess four aspects of stigma among people affected by leprosy. This scale has been modified from the Berger Scale, which was initially developed to assess HIV/AIDS-related stigma. It has 22 items to measure the following four domains: experienced stigma, disclosure concerns, internalised stigma and anticipated stigma. This tool was translated into Nepali language using the WHO method of translation for scale or study instruments in different languages. Ethical clearance was obtained from the intuitional review committee prior to the start of data collection.
The data were analysed using Statistical Package for the Social Sciences (SPSS) version 16.0 (Armonk, NY, IBM Corp). Descriptive statistics using mean, standard deviation, frequency and percentage were used to describe the sociodemographic profile, clinical characteristics, leprosy-related stigma and HADS score. In addition, median and interquartile range was described for skewed data. The data were checked for normal distribution using the Kolmogorov–Smirnov test, and non-parametric tests were applied as the HADS score for anxiety and depressive symptoms had a skewed distribution. Bivariate analysis using appropriate inferential statistics (Spearman correlation, Mann–Whitney U test and Kruskal–Wallis test) was conducted to examine the associations between different variables and the anxiety and depressive symptoms scores on HADS. Separate multiple linear regression analysis was performed with variables having a significant bivariate relationship to determine the correlates of anxiety and depression, respectively. The level of statistical significance was set at P value < 0.05 for all the tests.
| Results|| |
The females slightly outnumbered the males in the study sample, with 63 out of 119 participants belonging to the female gender (52.9%). The average age of the study sample was 62.09 years (Range: 22–95 years; Standard deviation [SD]: 16.74). The median age of the study sample was 63.0 years (IQR: 53.0–73.0). The detailed sociodemographic and clinical description of the study sample has been given in [Table 1].
|Table 1: Sociodemographic and clinical profile of study participants (n=119)|
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The mean and median score of HADS for anxiety was 5.58 (SD: 3.60) and 5.00 (IQR: 3.00–8.00), respectively. About 26.9% (n = 32) and 10.1% (n = 12) of participants scored above the threshold score indicative of doubtful (>7) and definitive (>10) clinically significant anxiety symptoms, respectively. The mean and median score of HADS for depression was 6.92 (SD: 2.88) and 7.00 (IQR: 5.00–8.00), respectively. About 39.5% (n = 47) and 12.6% (n = 15) of participants scored above the threshold score indicative of doubtful (>7) and definitive (>10) clinically significant depression symptoms, respectively. The mean and median stigma score was 17.88 (SD: 14.53) and 14.00 (IQR: 7.00–24.00), respectively.
[Table 2] described the results of bivariate analysis assessing the relationship between sociodemographic and clinical characteristics with anxiety and depression symptoms among study participants. People attributing leprosy to bad deeds reported significantly higher median anxiety (8.00 vs. 5.00; U = 527.50, P < 0.01) and depressive (8.00 vs. 6.00; U = 675.50, P = 0.04) symptom scores on HADS as compared with others. Leprosy-related stigma was significantly associated with both anxiety (rs = 0.23, P = 0.01) and depressive (rs = 0.25, P < 0.01) symptoms. Participants who belonged to the male gender (6.00 vs. 7.00; U = 1362.50, P = 0.03), or were currently married (6.00 vs. 7.00; U = 1225.50, P = 0.03) reported significantly lower median depressive symptom scores on HADS as compared with others. Whereas, duration of stay was significantly associated with greater severity of depressive symptoms (rs = 0.23, P = 0.01).
|Table 2: Bivariate relationship between sociodemographic and clinical characteristics with anxiety and depression symptoms among study participants (n=119)|
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Multiple linear regression analyses were conducted with all the variables showing a significant relationship with anxiety and depressive symptoms in the above described bivariate analysis entered as independent variables. Two different models were constructed with the HADS anxiety or depression score as the dependent variable. The model for anxiety symptoms [see [Table 3]] was statistically significant (F = 11.28; P < 0.01), and explained 16.3% of the variance in anxiety score. Leprosy-related stigma (β = 0.26, P < 0.01) and attribution of leprosy to bad deeds (β = 0.23, P < 0.01) were significant correlates of anxiety. Similarly, the model for depressive symptoms [see [Table 4]] was statistically significant (F = 6.98; P < 0.01), and explained 23.6% of the variance in depression score. Leprosy-related stigma (β = 0.29, P < 0.01) and duration of stay at the centre (β = 0.22, P < 0.01) were significant correlates of depression. Finally, tolerance statistics and variance inflation factor were examined to check for multicollinearity between dependent variables for the above described regression models, and no significant multicollinearity was observed. The recommended maximum value of 10 for the variation inflation factor and a minimum value of 0.1 for the tolerance statistics were used as cutoffs for deciding the acceptable level of multicollinearity.
|Table 3: Multiple linear regression equation for correlates of anxiety symptoms among study participants (n=119)|
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|Table 4: Multiple linear regression equation for correlates of depression symptoms among study participants (n=119)|
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| Discussion|| |
The present study showed that about 10% and 13% of participants had definitive clinically significant anxiety symptoms and depressive symptoms, respectively. Leprosy-related stigma and attribution of leprosy to bad deeds were significant correlates of anxiety, whereas leprosy-related stigma and duration of stay at the centre were significant correlates of depression. The prevalence of definitive clinically significant depressive symptoms found in our study is lesser as compared with that reported in a previous study from Nepal, where it was about 24.6% (95% CI 16.9–31.1) of the leprosy-affected people had depression. Another study was conducted in India among a total of 220 respondents, prevalence of depression and anxiety symptoms was, 33% (73) and 19% (42), respectively using PHQ-9 and GAD-7 tools, which is higher than that observed in our study. If we take the clinically doubtful symptoms, then the percentage in our study would reach 26.9% and 9.5%, respectively, for anxiety and depression. This variation in the prevalence of depression and anxiety symptoms could be due to different assessment tools used across different studies. This could be because our study population comprised exclusively of people living with leprosy at the special community centre for them, unlike clinical samples or general mixed community living samples in previous studies. Thus, the present study adds to the available literature suggesting that people living with leprosy have multiple psychiatric morbidities, especially depression, anxiety disorders and suicide (attempts). Importantly, our study findings of 10.1% anxiety and 12.6% depression symptoms are clearly higher than the prevalence of anxiety (3.0%) and depression (2.9%) reported among the general population in the recently published National Mental Health Survey of Nepal.
The mean stigma score of 17.88 (SD: 14.53) among the study participants was comparable with the findings from another study conducted in a cohort of patients with leprosy in Indonesia, where the same stigma scale as in our study was used. It was seen that 67 counselling clients had a score of 21.55 (SD: 13.31), and 57 controls had a score of 15.42 (SD: 11.11) before the intervention. The findings that the participants with male gender and currently married status reporting significantly lower median depressive symptom scores on HADS in the bivariate analysis could be an important finding and is in keeping with most of the available literature even in the general population.,, However, this was not found significant in the multivariable analysis. This could be because of a complex interaction between multiple bio-psycho-social and cultural factors impacting mental health- and disease-related stigma among leprosy patients. Alternatively, it is possible that a larger study sample would be needed to detect significant correlates with smaller effect sizes.
The multiple linear regression analyses showed that leprosy-related stigma was a significant predictor of both anxiety and depression. The studies done on HIV patients have shown that the disease-related stigma can affect the mental health condition, and have a detrimental effect on the overall health of the individual. A study from Bangladesh among 140 patients of leprosy showed that actual experiences of discrimination based on stigma were associated with depressive status in them. Another study from Bangladesh among 189 patients with leprosy, showed a similar association between poor mental health status and a greater degree of perceived stigma. It was seen that the attribution of leprosy to bad deeds was a significant correlate of anxiety. Whereas, duration of stay at the centre was a significant correlate of depression. There is a need to carry out awareness campaigns among the general public focussed on dispelling myths and delivering facts related to the infective aetiology of leprosy and the availability of effective medical treatment for leprosy among other things. This shall also help in the reintegration of patients cured of leprosy albeit with some physical disfigurement or disability, but who are no more infective to others around them with their family and friends in society.
The strength of the current study is the homogeneity of the sample as this is a single-centre study. With the availability of very effective treatment and awareness, there are very few asylum/communities of leprosy-affected patients throughout the world. Thus, the current study provides a unique opportunity to look at the mental health-related aspects of people living with leprosy in a special separate community together. Though, the present study is not devoid of limitations. The HADS scale used in this study could only detect clinically significant depressive and anxiety symptoms based on self-reports by participants. Thus, a confirmed diagnosis of depressive or anxiety disorder or any other mental health disorder could not be made in this study. This being a cross-sectional study, we cannot assess the cause-effect relationship between leprosy-related stigma and the poor mental health status of study participants. Finally, caution should be exercised while generalising the findings of the present study to all the people affected with leprosy in Nepal.
| Conclusion|| |
The prevalence of depression and anxiety symptoms among people living with leprosy is higher than that in the general population. Hence, it is imperative to screen for common mental health problems such as anxiety and depressive disorders while managing patients with leprosy. Leprosy-related stigma was a significant correlate of both anxiety and depression. Thus, there is a need to implement a combination of effective contact- and education-based anti-stigma strategies aimed at the reduction of leprosy-related stigma.
It was obtained from the Institutional Review Committee
Informed consent was obtained from all the patients or their legal guardians.
Financial support and sponsorship
The research was awarded the Psychiatrists' Association of Nepal Research Grant.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]
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