Impact of ethnicity , unemployment and economy on mental disorders : A study from Western Nepal

Background: The causes of mental health problems and ethnic variation are poorlyunderstood. The main objective of the study was to find out about psychiatricdiseases which frequently occur in Western Nepal for which hospitalization isrequired. The specific objective was to research about theeconomic condition ofthe psychiatric patients and the prevalence of common psychiatric disorderwitnessed among hospitalized patients who belong to diverse ethnic and culturalgroups in Western Nepal. Materials and Methods: It was a cross sectional studywhich was conducted in between 1st October 2009 and 31th March 2010 between at Manipalteaching hospital, Pokhara, Nepal. Odds ratios and adjusted odds ratio andtheir 95% confidence intervals (95% CI) were calculated. p < 0.05 wasconsidered as statistically significant. Results: Out of 240 cases the commonestcases of psychiatric disorders include Schizophrenia, Schizotypal and DelusionDisorders 36.3%, Mood Disorders 27.9%, Neurotic, stress-related and somatoformdisorders 15.8%. Study based on ethnicity revealed that the majority ofpatients were Dalit [n= 72] followed by Brahmin [n = 66], Chettri [n = 46],Newar [n = 19], Gurung [n = 17], others [n = 13] and Magar and Pun [n = 7].Most of the patients were <40yrs [n=191] unemployed [n=199], monthly familyincome <10000 NPR/month [n= 187], students [n = 102] housewives [n = 74,], job holders [n= 17]. Study showed that Mental and Behavioural disorder due toPsychoactive Substance abuse, Schizophrenia, Schizotypal and Delusion DisordersMood (Affective) Disorders, Neurotic, stress-related and somatoform disorderswere prevalent among unemployed patients [OR 8.170(CI 1.062, 62.853)], [OR3.033(CI 1.334, 6.897)], [OR 0.413(CI 0.199, 0.856)[OR 0.228(CI 0.089,0.583)]as compared to employed patients(p=0.001). Conclusion: Schizophrenia was the commonestpsychiatric disorder among the low socio-economic class of like Dalits. The study showed that culture based differences concerning mental health is furthermediated by poverty, unemployment and dearth of family income which leads tohigh prevalence of psychiatric illness among Nepalese population. Based on thefinding of the study, interventions should target these factors to minimise theload of various psychiatric illness among poor Dalit Nepalese population.DOI: http://dx.doi.org/10.3126/nje.v4i1.10132Nepal Journal of Epidemiology 2014;4 (1): 306-315Keywords:Culture, Ethnicity,Nepal, Psychiatry


Introduction
The causes of mental health problems and ethnic variation are poorly understood 1 .From Income point of view, Nepal is a poor developing country which is situated in South East Asia 2 .Its population structure includes multi-lingual and multi ethnic diverse population.The main source of income of Nepalese people is agriculture.Most parts of Nepal are occupied by mountainous and hills where people don't have good access to health care facilities.Many health related researches that have been undertaken in Nepal are mainly about the prevalence of mental illnesses.A study carried out in Janakpur, Eastern Nepal reports that the commonest forms of disorder is schizophrenia 30% followed by bipolar disorder 25% 3 .Another research finding indicates that Schizophrenia 50.1% was the commonest psychiatric disorder followed by mood disorders 33.5% and substance use disorder 9.3% 4 whereas study conducted by Risal confirms that the commonest psychiatric disorder were anxiety disorder as seen in a primary care setting followed by depressive and unexplained somatic symptoms 5 .Nepalese population consists of a wide range of ethnic/tribal groups namely the Brahmin, the Chettri, the Gurung, the Newar, the Puns, the Magar, the Dalit .The data related to ethnic variation and corresponding mental illness is lacking in western region in particular and Nepal in general.The main objective of the study was to research about the commonest psychiatric disease which occurs in Western Nepal for which hospitalization is required.The specific objective of the study was to research about the economic condition of the psychiatric patients and to identify prevalence of common psychiatric disorder among hospitalized patients in different ethnic/cultural groups.

Study design and the participants:
This research involves was a cross sectional study which was conducted at Manipal teaching hospital, Pokhara, Nepal, a tertiary care hospital situated in Western Nepal.

Inclusion criteria:
A total number of 240 cases of critical nature with all types of Psychiatric disorders were included in the study.The diagnosis of the disease was based on ICD-10 (Tenth revision) Classification of mental and Behavioural disorders; Diagnostic Criteria for Research

7
. The total number of cases

Exclusion criteria:
All the outpatients were excluded as the research aims to study about the psychiatric patients who were critically ill for which hospitalization is required.

Sample size calculation:
For 95% confidence interval and, significance level α =5%, P=70%, Q=30%, allowable error=10% of P, required sample size was 165.Prior to the study a pilot study was done in 50 patients admitted in the psychiatric inpatients and it was found that 70%of the patients were having monthly income <10000NPR/month 8 .

Outcome Variable:
The main outcome variable was the commonest disorder seen among the psychiatric inpatients.

Explanatory variables:
The Socio demographic and psychiatric disorders have been defined at individual level.Factors which were taken into consideration at individual level were Age (<40 years and >40 years), gender (male and female), monthly income (<10000/month and >10000/month), employment of the patient (employed and unemployed), occupation (housewife, laborer, student, farmer, retired and others), religion (Hindu, Buddhist, Muslim), ethnicity (Brahmin, Chettri, Newar, Dalit and others).The causes of mental health problems and ethnic variation are poorly understood.

Ethical committee approval:
The Research was conducted in accordance to latest version of the Declaration of Helsinki.Prior the study, ethical committee approval was taken from the institutional ethical committee, Manipal Teaching hospital, Pokhara, Nepal.

Data management and statistical analysis:
The data collected was analyzed using Excel 2003, R 2.8.0 Statistical Package for the Social Sciences (SPSS) for Windows Version 16.0 (SPSS Inc; Chicago, IL, USA) and EPI Info 3.5.1 Windows Version.Chi square test was used to observe the difference between different variables and strength of the relationship with logistic regression.p< 0.05 was considered as statistically significant.We calculated odds ratios and adjusted odds ratio) and their 95% confidence intervals (95% CI).p< 0.05 was considered as statistically significant 9 .

Result: Prevalence of Psychiatric disorders
The research finding revealed that common forms of psychiatric disorders were Schizophrenia, Schizotypal and Delusion Disorders 36.3%,Mood (Affective) Disorders 27.9%, Neurotic, stress-related and somatoform disorders 15.8%, Mental and behavioural disorder due to Psychoactive Substance abuse 11.3%, Behavioural syndromes associated with physiological disturbances and physical factors 4.2%, Organic including symptomatic mental disorders 2.9% and Mental retardation 1.7% respectively.The majority of psychiatric patients were <40yrs (191), 49 patients were >40yrs.Among 191 patients who were<40 years, the common psychiatric disorders were Schizophrenia, Schizotypal and Delusion Disorders(35.6%)followed by Mood (Affective) Disorders 25.1%, Neurotic, stress-related and somatoform disorders 17.8%, Mental and behavioural disorder due to Psychoactive Substance abuse 12.6% respectively.Among the patients >40yrs, most common disorders were Schizophrenia, Schizotypal and Delusion Disorders and Mood (Affective) Disorders (38.8%).Out of 110 female patients, most of them suffered from Mood (Affective) Disorders 30.9%,Schizophrenia, Schizotypal and Delusion Disorders 27.3% followed by Neurotic, stress-related and somatoform disorders 24.5% respectively.Out Of total figure, 130 patients were concerned Schizophrenia, Schizotypal and Delusion Disorders 43.8% was the commonest followed by Mood (Affective) Disorders 25.4% respectively (P = 0.002).Most of the patients were unemployed (n=199) and among them 39.2% suffered from Schizophrenia, Schizotypal and Delusion Disorders followed by Mood (Affective) Disorders 25.1% and Neurotic, stress-related and somatoform disorders 13.6% respectively.Among the employed patients (n = 41) most of the patients had been suffering from mood and affective disorders 41.5% followed by Neurotic, stressrelated and somatoform disorders and Schizophrenia, Schizotypal and Delusion Disorders 26.8% and 22% respectively (p = 0.02).Most of the patients had monthly income <10000 per month (n=187).They were suffering from Schizophrenia, Schizotypal and Delusion Disorders (n=67), mood affective disorders Neurotic, stress-related and somatoform disorders (n=33).Religion wise, the majority of the patients were Hindus (an=200) followed by Buddhist (n=25), Christian (n=9) and Muslim (n=6).Among Hindus, Schizophrenia, Schizotypal and Delusion Disorders were common types of psychiatric disorders followed by mood affective disorders 28.5%, Neurotic, stress-related and somatoform disorders 18.5% Mental and behavioural disorder primarily caused due to Psychoactive Substance abuse 11% respectively.On the basis of ethinic backround, most of the patients were Dalit [n= 72] followed by Brahmin (n = 66), Chettri (n = 46), Newar (n = 19), Gurung (n = 170), others (n = 13) and Magar and Pun (n = 7).9% respectively.None of the students were found to be suffering from Organic including symptomatic mental disorder 0% and mental retardation 0%.Among housewives, the commonest psychiatric disorder was Mood (Affective) Disorders and Schizophrenia, Schizotypal and Delusion Disorders 31%, followed by Neurotic, stress-related and somatoform disorders 24.3%, Behavioural syndromes associated with physiological disturbances and physical factors 6.8%, Mental and behavioural disorder because of Psychoactive Substance abuse 4.1% and Organic including symptomatic mental disorder 2.7% respectively.None of the housewives were diagnosed to be suffering from Mental retardation 0%.
All the values are found to be statistically significant.(P value = 0.000) (Table 1).

Determinants of socio demographic factors and various psychiatric disorders by logistic regression
Logistic regression analysis finding shows that the psychiatric disorders like Mental and behavioural disorder due to Psychoactive Substance abuse F10-19, Schizophrenia, Schizotypal and Delusion Disorders F20-29 and Neurotic, stress-related and somatoform disorders F40-48 was found more prevalent in males [OR 2.675,95%(CI  All the values were found to be statistically significant (Table 3).respectively.Similar findings was reported by Banerjee et al which has showed that Psychiatric disorders like schizophrenia was commonly found in Hindus followed by Buddhists.This could be primarily owing to reason that Nepal is a Hindu population dominated country and it is expected that the majority of patients will be Hindus 21 .Most of the patient were students (n = 102) followed by housewives (n = 74) but service holders were very limited in numbers (n=17).Among students, the commonest psychiatric disorder was Schizophrenia, Schizotypal and Delusion Disorders 47.1%, Mental and Behavioural disorder due to Psychoactive Substance abuse 21.6%, Mood (Affective) Disorders 19.6%, Neurotic, stress-related and somatoform disorders 7.8%, Behavioural syndromes associated with physiological disturbances and physical factors 3.9% respectively.None of the students were diagnosed to be suffering from Organic including symptomatic mental disorder 0% or mental retardation 0%.However, among housewives, the commonest psychiatric disorder was Mood (Affective) Disorders and Schizophrenia, Schizotypal and Delusion Disorders 31% whereas none of the housewives were found to be suffering from Mental retardation 0%.Similar finding was reported by Fahmida A et al in Bangladesh and it revealed that the occupation related Psychiatric disorders were rather common among housewives and students .Other social problems such as broken families, living apart from husband or husband residing in foreign country for employment purpose can also be attributed to this fact 13 .However, among students, some causes of high prevalence psychiatric disorders could be due to stressful life and inability to cope up with their studies

Conclusion
Psychiatric disorders namely Schizophrenia was the commonest psychiatric disorder among the low socioeconomic group among the culture Dalit.In Nepal it is also found that culture based differences in mental health in mediated by poverty, unemployment, dearth of family income could lead to high prevalence of psychiatric illness among the Nepalese population.Depending on these finding of the study interventions should target these factors to decline the load of various psychiatric illness among the Nepalese population

Limitation of the study
This research is based on the hospital study from Western Development Region of Nepal.A multi centric hospital based study with higher sample size will be beneficial to assess the psychiatric disorders in different cultures all over Nepal.

Relevance of the study:
Psychiatric disorders namely Schizophrenia was the commonest psychiatric disorder among low socio-economic group of people who belong to Dalit community.It is also revealed that culture based differences have worsened the quality of mental health and moreover it has been further complicated by poverty, unemployment, dearth of family income leading to high prevalence of psychiatric illness among Nepalese population.Based on these findings, interventions should target to address these factors to minimize the load of various psychiatric illnesses.

Future scope of the study:
This study is exclusively based on the research which was carried out in the territory hospital located in Western Development Region in Nepal.A multi centric hospital based research having bigger sample size would be beneficial to assess the psychiatric disorders in the light of different ethnic and cultural backgrounds of Nepalese people.

Author's Contribution:
IB designed the study, deduced the data, drafted the manuscript, and revised it.IB2, BR, PKC and SK planned the study with IB, acquired the data, conducted the data analysis, interpreted the data, and revised the manuscript.IB2 has also participated in the language editing along with IB and SK.BS participated in statistical analysis, interpreted the data, and revised the manuscript.PKS, PB and ACS critically revised the manuscript.All the authors approved the final document.

18 .
Study done by Banerjee et al inNepal also showed that psychiatric disorders such as mood affective disorders; Neurotic, stress-related and somatoform disorders are commonly noted among housewives and students.The most convincing reason behind this fact is stressful life pattern and the effects resulted due to child birth which may lead to various psychiatric disorders among housewives18

Table 2 : Logistic Regression Table of Socio Economic, Demographic factors and various Psychiatric Disorders
† p<0.05, statistically significant.× p>0.05, statistically not significant.

Economic and demographic Factors Organic including symptomatic mental disorder F00-F9 Mental and behavioral disorder due to Psychoactive Substance abuse F10-19 Schizophrenia, Schizotypal and Delusion Disorders F20-29 Mood (Affective) Disorders F 30-39 Neurotic, stress- related and somatoform disorders F40-48
Among the Dalits, 30.6% of them had been suffering from Schizophrenia, Schizotypal and Delusion Disorders followed by Mental and behavioural disorder due to Psychoactive substance abuse 20.8%, mood and affective disorders 18.1%, Neurotic, stress-related and somatoform disorders 12.5%, Behavioural syndromes associated with physiological disturbances and physical factors 11.1%, Organic including symptomatic mental disorder 6.9% respectively.Psychiatric disorders prevalent among the Brahmins are characterized as Mood (Affective) Disorders 34.8%, Schizophrenia, Schizotypal and Delusion Disorders 25.8%, Neurotic, stress-related and somatoform disorders 21.2%, Mental and behavioural disorder resulted owing to Psychoactive Substance abuse 9.1%, Organic including symptomatic mental disorder 3%, Behavioural syndromes associated with physiological disturbances and physical factors 3% and Mental retardation 3% respectively.Among the Chettri, the commonest psychiatric disorder was Schizophrenia, Schizotypal and Delusion Disorders 45.7% which is followed by Mood (Affective) Disorders 28.3%, Neurotic, stress-related and somatoform disorders 26 Schizotypal and Delusion Disorders F20-29, it revealed that it was more prevalent among unemployed patients [OR 2.292, 95 %(CI 1.038, 5.062)].All the values were found to be statistically significant (Table2).Considering the adjusted Odds ratio, it was found that Mental and behavioural disorder due to Psychoactive Substance abuse F10-19, Schizophrenia, Schizotypal and 1.086, 6.591)], [OR 2.082,95%(CI 1.208, 3.588)], [OR 0.284,95%(CI 0.134, 0.605)] respectively as compared to female patients.However, in the case of Schizophrenia,
Nepal is an under developed country having poor financial status which could lead to high prevalence of psychiatric illness.Nepal is a mountainous country and her main source of income is agriculture.Many Nepalese people are financially poor and therefore can't afford to have health care facility timely and in course of time it may result in various psychiatric disorders.A research conducted in Nepal by Kohrt BA et al also concluded that the caste-based disparity, poverty, lack of social support and stressful life events have adversely affected the mental health of Nepalese people 1 .