6.1 Socio-demographic/Clinical Characteristic of Respondents
The Leprosy respondents had an older mean age – 44.48(11.76) years, compared to the PTB respondents whose mean age was 33.45(10.25). An earlier study in northern Nigeria reported a similar older mean age (20). However, Some studies on psychiatric morbidity on Leprosy patients have reported younger mean age (15,17) .The older age of the Leprosy respondents could be due to the aggressive Leprosy control programme in the country that has resulted in the reduced incidence of Leprosy. There was a preponderance of male respondents in either study groups. This is similar to findings in earlier studies among Leprosy patients (8,15–17,158).
However, other researchers observed a higher number of female Leprosy respondents (20,125).
The higher male preponderance in this study may be due to the discriminatory attitude towards women. Women with leprosy suffer greater neglect and isolation and may not have the same opportunity for medical care as their male counterparts (159,160).
There were more married people among the Leprosy respondents compared with the PTB respondents – 71% and 44% for Leprosy and PTB, respectively. Several other studies have also observed a higher proportion of married persons among the Leprosy subjects they studied (15–
17,20,125). However, VanBrakel et al. reported a lower proportion of those who were married in the Leprosy cases studied (158). The observed high proportion of married people in this study
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may be due to the high premium placed on marriage in the study environment and to the common practices of early marriage and polygamy.
Most of the Leprosy and PTB respondents were Hausa and Fulani. For Leprosy 71% and 19%
were Hausa and Fulani, respectively; while for PTB 49% and 9% were Hausa and Fulani, respectively. These two ethnic groups are the major ethnic groups in the area where the study was conducted.
Of all the Leprosy respondents only 20% had formal education compared with 79% of the PTB respondents who had formal education. The observed decreased level of formal education among Leprosy respondents in this study was corroborated by the observations made in similar studies (8,125,161). Erinfolami et al., in southwest Nigeria, observed formal education among leprosy patients to be 83.9% compared to 93.2% and 97.7% among those with Tinea vesicolor and normal controls, respectively (17). Attama et al. in southeast Nigeria, observed 58% formal education among leprosy respondent compared to 86% among albinos (16). Bakare et al. in northwest Nigeria, reported 95.3% primary/quaranic education among leprosy patients (20).
Leprosy patients are often isolated and discriminated against making it difficult for them to acquire any form of education. The wider margin in formal education between leprosy patients in the north and those in the south may be explained by the already existing disparity in education between the north and the south, the south having more formal education than the north. The observed difference in education between this study and the study by Bakare et al. may be because of the study settings. While this study was done in a hospital setting, the study by Bakare et al. was carried out in a leprosy camp. Leprosy camps are often times organized around Mosques in northern Nigeria where the lepers are engaged in quoranic studies.
Unemployment was more among the Leprosy respondents than among the PTB respondents.
Among other reasons this may be due to the higher level of formal education and the lower level of stigma among the PTB respondents. Other studies have also reported higher unemployment rates among Leprosy respondents (8,57,125). Studies in Nigeria also reported a high unemployment rate, though the rate reported in the south of Nigeria are lower (16,20). The lower rate of employment among leprosy patients is likely the result of stigma and discrimination that makes difficult for this group of people to acquire the skills or schooling to make them
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employable. The higher rate of employment among leprosy patients in southern Nigeria compared to the north may be because of the higher level of western education observed among the leprosy patients in southern Nigeria.
A higher proportion of both Leprosy and PTB respondents lived with someone, though more Leprosy respondents lived with someone. This is in agreement with the findings of Leekasa et al (8). The high rate of marriage, the commonly practiced extended family system and the disability associated with leprosy may explain this finding.
More Leprosy respondents than PTB respondents were stigmatized. This observation is corroborated by observations in related studies that have also shown increased stigma experience among Leprosy cases (19,123,158,161–163). The social meaning leprosy patients attach to the illness results in the high level of stigma and psychiatric disorders in leprosy patients (163).
The observed range and mean duration of illness in this study are similar to findings Bakare et al;
they noted a range of 1-55 years and a mean of 22.4 (11.62) years (20).
6.2 Hospital Anxiety and Depression Scale (HADS) Positive Respondents
Though not statistically significant, more leprosy respondents than PTB respondents scored 8 and above on either or both the anxiety (HADS-A) and depression (HADS-D) subscales of the Hospital Anxiety and Depression scale.
6.3 Prevalence of ICD-10 Depression and Generalized Anxiety Disorder in Leprosy and PTB Respondents
The prevalence of depression and generalized anxiety disorder in leprosy respondents with positive HADS score were 14% and 22%, respectively, while PTB respondents had prevalence of 11% and 8% for depression and generalized anxiety disorder, respectively. Ten percent (10%) of the leprosy respondents fulfilled the criteria for the diagnosis of both depression and generalized anxiety disorder while 1% of PTB respondents fulfilled the same criteria. Chatterjee et al. also showed a higher prevalence of both anxiety and depression in leprosy patients compared to PTB patients, though in that study depression was more prevalent than anxiety in the leprosy cases and the prevalence of both anxiety and depression was also higher than in this
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study (19). The observed higher prevalence of depression and generalized anxiety disorder in leprosy compared to PTB may be due to the poorer education, lower employment rate, greater self-stigma and longer duration of illness observed among the leprosy patients compared to PTB controls in this study.
The finding of higher prevalence of generalized anxiety disorder than depression in this study is similar to that of Bhatia et al. (15). Bhatia et al. and Jindal et al. also observed lower prevalence of generalized anxiety disorder and depression among leprosy cases as in this study (15,125).
Previous studies in Nigeria have shown higher prevalence figures in leprosy patients compared to controls (16,17). In southwest Nigeria Erinfolami et al noted the prevalence of depression and anxiety among leprosy patients to be 36.7% and 20.8%, respectively; while, in southeast Nigeria, Attama et al.observed the prevalence of depression and anxiety among leprosy patients were 49% and 16.4%, respectively. Both studies reported higher prevalence of depression than this study while the prevalence of anxiety in both studies is comparable to the rate of anxiety observed in this study (16,17). Other studies have also observed that the commonest mental illness among leprosy patients is depression (57,125,163). Socio-cultural factors and the instruments used for the study may account for the difference in prevalence observed. Bakare et al. in Sokoto, northwestern Nigeria, reported the prevalence of CIDI generated diagnosis of moderate depression, severe depression and generalized anxiety disorder to be 14%, 5.5% and 19.2%, respectively, which is similar to the finding in this study (128). Similar to the observation in this study, Nagargoje et al. reported a high prevalence of comorbid depression and generalized anxiety disorder in leprosy patients (164).
HADS has been shown in previous studies to be useful in detecting anxiety and depression in non-psychiatric hospital settings (46,144,165). The high sensitivity and specificity observed in this study is similar to observation made in other studies. In a systematic review of the literature it was observed that seventeen studies using the English version of HADS had average sensitivity and specificity of 80% or higher (145). The observations are often affected by patient characteristics.
6.4 Socio-demographic/Clinical Variable in Leprosy Patients with and without Depression or with or without Generalized Anxiety Disorder
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Leprosy patients often stigmatize themselves, and there is a close relationship between self-stigma and depression. This association has been demonstrated in previous studies (161). Stigma in any form decreases self-esteem thereby heightening the risk of depression (166).
Generalized anxiety disorder among leprosy patients has a close association with self-stigma and unemployment. Studies done in the past have shown an association between generalized anxiety disorder and stigma(167) and unemployment(102). Self-stigmatization and unemployment engender feeling of suffering and of anxiety in the leprosy patient.
Comorbid depression and generalized anxiety disorder in leprosy patient shows greater association with internalized stigma than the diagnosis of depression or generalized anxiety disorder alone in those patients. This is similar to the observation made in a previous study (167).
Widespread stigma in persons afflicted with leprosy negatively impacts on their quality of life, general sense of wellbeing, making them prone to having more frequent psychiatric comorbidity.
Self-stigma was significantly associated with psychiatric morbidity among leprosy patients in this study. This is similar to the finding of Tsutsumi et al. in which leprosy patients with perceived stigma were shown to have worse general mental health than those without and the finding of Kar et al. where it was observed that 78.84% of leprosy patients with psychiatric morbidity reported about stigma in comparison to 26.15% without psychiatric morbidity (161,168). The finding of no statistically significant association between physical deformity and psychiatric morbidity in this study is similar to that of Bhattia et al (15). Some other studies done in the past do not agree with this observation (57,125). The finding of no significant association between psychiatric morbidity and gender, education, occupation and marital status in this study is in agreement with observation made in a previous study (125). Erinfolami and Adeyemi also found no significant association between psychiatric morbidity in leprosy patients and age, gender, educational level and marital status (17). However, others have reported a significant association between psychiatric morbidity and leprosy with respect to occupation and marital status (57,128).
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