Psychiatric illnesses among Dalit Nepalese population

2Professor, Department of Pharmacology, Manipal College of Medical Sciences, Pokhara, Nepal 3 Post Doctorate Trainee, M.Ch Urology, SMS Medical College, India 4Professor, Department of Psychiatry, Manipal College of Medical Sciences, Pokhara, Nepal 5Professor, Department of Pharmacology, Manipal College of Medical Sciences, Pokhara, Nepal 6Assistant Professor, Department of Community Medicine, Manipal College of Medical Sciences, Pokhara, Nepal


Background
Nepalese population includes a wide variety of ethnic groups namely, the Brahmin, Chettri, Dalit, Gurung, Newar, Puns, Magar [1][2][3] .Dalits population in Nepal are a traditionally victimised, underprivileged community who have been obliged to lag at the base of the public constitution in Nepal.Dalits Nepalese has poor income, education and other human development indicators.They are often landless and much poorer than the dominant caste population like the Brahmins, chetris, newars.Almost half of Nepal's Dalits exist beneath the poverty line 4 .Dalit women, comprises of about one-fifth of the total population of Nepali women and more than half of the total Dalit population 5 .Dalit women are often forced to prostitution and often the victims of trafficking, labour and sexual slavery.This leads to various mental illnesses among the poor dalit Nepalese population.The main objective of the study was to find out the commonest psychiatric disorder found in the poor Dalit Nepalese population in western development region of Nepal for which hospitalization is required.

Study design and the participants:
The study was a cross sectional study carried out between .Pokhara is its regional headquarter 8 .It was expected that all the critically ill cases of psychiatric disorders will be referred to MTH from Western Development Region of Nepal.

Data collection:
Data was collected from 1st October 2009 and 30th September 2010.The outpatients were excluded as the research aims to study about the psychiatric illnesses among dalit Nepalese population who were critically ill.

Inclusion criteria:
A total number of 72 Dalit 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 behavioral disorders, Diagnostic Criteria for Research (WHO.1992) 9 .

Exclusion criteria:
The outpatients were excluded as the research aims to study about the psychiatric illnesses among dalit Nepalese population who were critically ill.

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

Explanatory variable:
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, Christian).

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

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 11 .

Result:
Among all the psychiatric diseases Schizophrenia, Schizotypal and Delusion Disorders 30.6% was the commonest disease seen in the Dalit Population followed by Mental and behavioral disorder due to Psychoactive Substance abuse 20.8%, Mood (Affective) Disorders 18.1%, Neurotic, stress-related and somatoform disorders 12.5%, Behavioral syndromes associated with physiological disturbances and physical factors 11.1% and Organic including symptomatic mental disorder 6.9%.Psychiatric diseases were more common in male patients 52.8%.87.5% of the cases were <40 yrs of age, 72.2% of the patients were Hindus by religion followed by Christian 27.8%.87.5% of the patients were unemployed and 84.7% of the patients were having monthly income <10000/month.45.8% of the patients were students followed by housewife 34.7%, farmer and retired 6.9%, labour 4.2% and shopkeeper 1.4% respectively (Table 1).Chi square test of Socio demographic details and various Psychiatric illnesses among Dalit Nepalese population is shown in Table 2.

Determinants of socio demographic factors and various psychiatric disorders among dalits by logistic regression
Logistic regression analysis finding shows that the psychiatric disorders like Mental and behavioural disorder due to Psychoactive Substance abuse F10-19 was found more prevalent in males [OR 8.320,95%(CI ( 1.717, 40.311)] as compared to female Dalit patients.In Schizophrenia, Schizotypal and Delusion Disorders F20-29 was found more prevalent in males [OR 1.896, 95%(CI 0.676, 5.314)] as compared to females, [OR 1.628 95%(CI 0.31, 8.55)]in age group <40 yrs as compared to > 40 yrs and [OR 1.457, 95% CI ( 0.454, 4.677)] in Hindus as compared to Christian.In Neurotic, stress-related and somatoform disorders F40-48 [OR 1.509, 95% CI ( 0.17, 13.432) was more common in patients with monthly income less than 1000/month as compared to more than 1000/month ( Table 3).

Discussion:
Common Psychiatric illnesses: Among all the psychiatric diseases Schizophrenia, Schizotypal and Delusion Disorders was the commonest disease seen in the Dalit Population followed by Mental and behavioral disorder due to Psychoactive Substance.Study conducted by Kohrt et al reported that psychiatric disorders are commonly found in Dalit in Nepal .Study done by Banerjee et al in 2012 13 also reported that schizophrenia is commonly found among Dalit patients.Similar findings were reported Khattri et al in 2013 14 in the research conducted in the Rural Community of Nepal as well.It is because Nepal is an under developed country having poor financial status which could lead to psychiatric illness.Nepal is a mountainous country and her main source of income is agriculture.Many Dalit 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 et al in 2013 also concluded that the caste-based disparity, poverty, lack of social support and stressful life events have adversly affected the mental health of Nepalese people 12 .

Gender and Age:
Psychiatric diseases were more common in male patients.Most of the cases were <40 yrs of age.Similar findings were found by Banerjee et al, 2011 in Nepal.Similar findings were found by Maki et al in 2005 15 , which has shown that the psychiatric disorder is common in younger populations.

Religion:
Most of the patients were Hindus by religion followed by Christian It is quite evident from the finding that Nepal is a Hindu country and it is expected that most of the patients were Hindus.

Monthly income and employment:
87.5% of the patients were unemployed and were having monthly income <10000/month which has lead to psychiatric illness.

Occupation:
Most of the patients were housewife followed by farmer and retired, labour and shopkeeper.Similar finding was reported by Fahmida et al in 2009 and Banerjee et al in 2011 which has revealed that the occupation related Psychiatric disorders were rather common among housewives and students in Bangladesh and Nepal [18][19][20][21] .

Conclusion
Among the low socio-economic class Dalits, Schizophrenia was the commonest psychiatric disorder followed by Mental and behavioral disorder due to Psychoactive Substance abuse.Psychiatric illnesses are mediated by poverty, unemployment and dearth of family income which leads to psychiatric illness among dalit 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 useful to find the burden of psychiatric illness among poor dalit population all over Nepal.

Future scope of the study:
This study is based on the research carried out in the tertiary hospital located in Western Development Region in Nepal.A multi centric hospital based research with high sample size would be beneficial to assess the psychiatric disorders among Dalit Nepalese population in Nepal.

12
1 st October-31 st March 2010.at Psychiatric ward in Manipal Teaching hospital.Out of two tertiary care centres of Western Development region of Nepal, MTH was chosen for the study because it is the largest tertiary care centre of western Development region of Nepal.It is a 750 bedded private hospital which is providing the health care facilities to Western development region from 1998 onwards

Table : 2: Socio demographic details and various Psychiatric illnesses among Dalit Nepalese population
† p<0.05, statistically significant.

Table 3 : Logistic regression analysis and various Psychiatric illnesses among Dalit Nepalese population
17.