Psychiatric morbidities among mentally ill wives of Nepalese men working abroad.

INTRODUCTION: Husband working abroad may have not only favorable outcomes for wives and other family members but also adverse consequences, including psychological problems. Present study intended to look into psychiatric morbidity profiles of the Nepalese female psychiatric patients and the stressors related with their husband working abroad.
MATERIALS AND METHODS: This is a hospital-based descriptive study with convenient sampling method. Hundred consecutive female psychiatric patients, with the particular stressor, coming into the contact of the investigating team were enrolled within the study period of 12 months. The psychiatric morbidities/diagnoses were sorted out according to the International classification of disease and infirmity, 10(th) edition (ICD-10) criteria.
RESULTS: Average age of the enrolled cases was 29 years. Nearly half of the women were illiterate or barely literate. Some other stressors, besides the one of husband working abroad were found to precipitate the illness in about 60%, main being relational and health problems. Common presenting complaints were mood, anxiety, and physical symptoms. Almost 30% of the subjects had some mental illness in their past too and similar proportion had in their blood relatives. About one-third admitted to use substances, mainly alcohol and cigarettes. The common psychiatric diagnoses were mood, anxiety, neurotic, and stress-related disorders. Nearly 10% had presented for suicide attempt.
CONCLUSIONS: The status of husband working abroad may have adverse consequences in mental health of women. Mood affect, anxiety, and stress-related disorders are common psychiatric illness among them.

Currently, many people move across and within country; both in compelling situations and in searches of better education, income, and progress.[1] Besides benefits e.g. remittance, ill-prepared movements might bring adverse consequences for the individuals and their families.[234]

Many Nepalese abroad workers return home in mentally ill state.[5] Family members, particularly their spouses are at risk of psychological problems. Information about their morbidity profiles helps uplift awareness and facilitates the management at all levels. This research intended to study psychiatric morbidity profiles and other precipitating factors among Nepalese female psychiatric patients whose husband were working abroad.

MATERIALS AND METHODS

This is a hospital-based descriptive cross-sectional study with convenient sampling.

The subjects for this study consisted of 100 consecutive female psychiatric patients with the stressor of their husband working outside Nepal who consulted with the investigating team in the department of psychiatry, B. P. Koirala Institute of health Sciences (BPKIHS), a tertiary-care hospital in eastern Nepal within 1-year-study period since December 2007. After an explanation about the study to the subjects and significant care-givers, consent was collected. The information was kept confidential.

The socio-demographic profile and information about the illness (source of referral, stressors, and psychiatric diagnosis) were recorded in the proforma sheet particularly designed for the purpose. Detailed psychiatric work-up was done in all subjects. Referrals and investigations were advised as per the individual need. The final psychiatric diagnoses were made according to the International classification of disease and infirmity, 10th edition (ICD-10) criteria.[6] Physical diagnoses were recorded as per the departments who referred or to whom patients were referred. The proforma included and in all subjects, an effort was put to explore and record: (a) Other perceived stressors (besides the particular stressor of husband working abroad), (b) significant illness in past and close blood relatives, and (c) pre-morbid prominent personality traits/disorders clinically assessed significant enough to have effect in clinical course of illness. Despite of reliance on the ICD-10 for the diagnosis of personality disorder, the cluster concept of personality disorder (DSM-IV) was adopted for comprehensive organization of prominent personality problems (we included here prominent personality traits and disorders clinically assessed to affect the clinical course of the subjects).

Data were entered into a computer and analyzed using Statistical Package for Social Science (SPSS) software.

The study was approved by the institute ethical review board and was presented in the scientific forum/program of the institute.

RESULTS

Majority of cases (95%) were below 40 years. The average age was 29 years, with minimum of 14 and maximum 50. Two of them were separated after the husband had gone abroad.

Most of the subjects were: Mongols, Brahmins, and indigenous Terai tribes by caste/ethnicities and Hindu, Buddhist, and Kirat by religion [Table 1].

Table 1

Socio-demographic profiles of psychiatric help seeking wives of Nepalese men working abroad-I: Age, marital status, caste/ ethnicity, and religion

Significant proportions of these female Nepalese patients were illiterate or less educated. Majority of them were homemakers, only a few employed.

One-third of the patients were brought by family and about two-fifths referred from other specialties/departments of the institute [Table 2].

Table 2

Socio-demographic profiles of psychiatric help seeking wives of Nepalese men working abroad-II: Education, occupation, residential setting, and referral source

Mood, anxiety, somatic, and physical symptoms were the most common symptoms [Table 3].

Table 3

Clinical profiles of psychiatric help seeking wives of Nepalese men working abroad-III: Duration, onset, course of illness, and presenting complaints*

The countries where the husbands of the most number of these Nepalese female psychiatric patients work were Saudi Arab, India, Qatar, and Malaysia [Figure 1].

Figure 1

Countries where their husband worked

More than a half of these subjects had reported other precipitating stressors too, the most common being strained interpersonal relationship, recent major life events, and health problems [Table 4].

Table 4

Types of stressors reported by the female patients*

Thirty-five patients had a significant mental illness, mainly mood disorders in their past and almost similar number had in their close blood relatives [Table 5].

Table 5

Past and family history of illness among psychiatric help seeking wives of Nepalese men working abroad*

Nearly half of these mentally ill Nepalese women pre-morbidly used substances, mainly alcohol and nicotine [Figure 2].

Figure 2

Substance abuse among the subjects*

About one-fourth had some personality traits affecting the clinical course of their illness [Figure 3]. Almost half had comorbid physical diseases; mainly neurological, gynecological, and gastrointestinal diseases [Figure 4]. “Mood affective” and “anxiety, neurotic, and stress-related disorders” were the most common psychiatric diagnoses. Deliberate self-harm/suicide attempts were main problem among 11% of these women [Table 6].

Figure 3

Pre-morbid personality traits/problems among psychiatric help seeking wives of Nepalese men working abroad*

Figure 4

Comorbid physical diseases among psychiatric help seeking wives of Nepalese men working abroad*

Table 6

ICD-10 psychiatric diagnosis among psychiatric help seeking wives of Nepalese men working abroad*

DISCUSSION

Nepal is basically a patriarchal country: Males work outside and female counterparts look after household chores and family. Being bread winners, males receive more attention when they fall a sick. Gender discrimination is prevalent.[7] Mental health and illness is still behind people's priority; mentally ill people receive less attention.[8] Though we have few studies, it is apparent that women's health and illness get even less consideration. The psychological health and psychiatric disorders of Nepalese women, hence is one of the most neglected issues.

Abroad work and remittance have become an integral part of current day Nepalese life.[9] Many Nepalese work outside Nepal, as revealed in recent census.[10] Unprepared and unplanned leaving home for abroad work affects health including psychological well-being of the working person.[5] The psychological problem receives less attention and only during crisis, they are brought to medical attention.[8] The unprepared foreign job may not only disturb the working person but also the family members in different respects.[4] This paper highlights the findings which evidence that the wives of these people do suffer psychologically and display the diagnostic patterns among them. It aims to draw attention to this unrealized, unrecognized, and unmet need of female spouses of foreign job holders which are forgotten in the light of the gains of foreign job. The author does not mean that he is against foreign job but strongly advocates for the adequate preparation for and management of possible adversities associated with the foreign job as indicated in reports and literature from countries with similar problems and situations.[11] Though we studied the subjects coming into the service setting representing probably even less than a tip of iceberg of the problem, we assume that it would reveal some striking facts regarding psychiatric morbidity pattern and their causes. The limitation of this bias warrants community-based studies to clarify the actual situation and factors behind the morbidity.

The subjects suffering from some mental ailments and expressing or associating the status of their husband working abroad (or stated by their informant as precipitating the current condition) were analyzed in this study. More in-depth community studies might reveal the problem even among those who do not seek help from medical set-up/psychiatric service. Hence, this study might have picked up only those with more severe symptom profiles compelling them for the psychiatric consultation. Among these women, mood, anxiety, somatic, and physical symptoms were common presenting complaints which are similar to findings among the wives of US Army soldiers deployed abroad.[12] In other profile studies of the same institute carried out among other psychiatric subjects of same out-patient setting too, these are among the commonly reported symptoms,[131415] whereas abnormal behavior, altered consciousness, and self-harm were more common in emergency psychiatry of the same institute.[816] Feeling sad, dysphoric, hopeless, helpless, worthless, irritable, elevated are some mood complaints. Though many writers talk about less report of psychological symptoms among people from this region possibly because of their less psychological mindedness, a recent meta-analysis negates it.[17] This study also has finding in favor of the later; we had people with mood and anxiety symptoms the most. This is most likely because mood disorders are the prevalent disorders in this service setting[13] and they had already got the sense of nature of illness by visiting many other places and being referred to psychiatric service. However, next to these complaints were related with somatic (sleep, appetite, libido, bowel, bladder habits, and menstrual periods) and physical (aches, pain, palpitation, etc.) symptoms themselves.

The presenting complaints and the diagnostic profile kept conformity to each other in this study. Mood (affective) and anxiety, neurotic, and stress-related disorders were the most common psychiatric disorders. This finding is consistent with the study among the US Army wives by Mansfield AJ et al. showing that the common mental illnesses (including depression, anxiety, sleep, and stress related disorders) all were higher among the wives of the Army soldiers deployed in abroad duty than among non-deployed ones.[12] Mood (affective) disorders included depression, mania, and others (e.g. dysthymia). The later “anxiety, neurotic, and stress-related disorders” included all disorders of this category according to the ICD-10, e.g. panic, generalized anxiety, obsessive compulsive, post-traumatic stress, adjustment disorders. The representation of manic/bipolar affective disorder (BPAD) (11%), somatoform (9%), and schizophrenia and related disorders (7%) is clearly in excess and disproportionate to the community data.[18] The severe clinical profile of BPAD and schizophrenia requiring clinical attention and management mostly explains their pre-ponderance in this service setting. This study being carried out in psychiatric set-up probably led to the high rate of somatoform disorder. A remarkable proportion of the subjects reported to use psycho-active substance, mainly alcohol and cigarettes. This is consistent with the high rates of this problem reported among women from this region both in community[1920] and in clinical settings.[2122] Among these women, stressor is common,[23] money is available also for drinking, and husband was not together there to control the behavior. An intensive study will clarify this commonly held accusation and belief about this common substance-use problem among these women.

Some stressors besides the one related with husbands’ foreign job were reported among 56% of the subjects. Dispute, mainly with in-laws was the most reported as also reported from neighboring countries,[11] followed by some major life events, e.g. child birth while husband away. Some health problems and the need for treatment was another common stressor among them. The striking result of this study revealed that majority of the subjects were illiterate or barely educated and were homemakers (i.e. financially not income-generating) reflecting the status or position of common Nepalese women. The status compelling to remain dependent on others and in that the unsupportive behavior of the family members staying in home, i.e. in-laws precipitated the onset of current illness for many patients. Some of them were even attempting a suicide. The representation of deliberate self-harm is remarkable among these subjects. Eleven subjects had attempted deliberate self-harm and ten had ill physical effects due to the attempt. These factors need to be studied in-depth and addressed well to uplift the women's situation as a whole.

Our subjects were the wives of working people. Hence, it is understandable to have productive age among the majority though the range was quite alarming, from 14 years (legally not approved for marriage) to 50 years (age when children become productive). This reflects the reality of adverse conditions of common Nepalese women.

CONCLUSION

In current day Nepal, status of husband working abroad is one of the common stressors for Nepalese female psychiatric patients. Mood affect, anxiety, and stress-related disorders are common psychiatric disorders among the female Nepalese psychiatric patients whose husbands were working abroad.