Disfiguring skin disorders like leprosy may pose some psychological consequences as they have negative impact on a patient’s body image and often lead to stigmatization 1. Leprosy is a chronic infectious disease of the skin associated with high physical and psychological morbidity and social stigma. Deformities and disabilities led to deterioration in the functional capabilities of the patients and their psychological state of mind 2.
Patients with Hansen’s disease are associated with a high risk of developing psychiatric disorders. The prevalence of psychiatric disorders among these patients is higher than that among the general population; in some series, up to 65% of patients have psychological morbidity 3,4.
Low testosterone levels are associated with an earlier onset and greater incidence of depressive illness. Men with low testosterone levels who had high medical morbidity or were aged 50 to 65 years had an increased risk for depressive illness 5.
This study aimed to evaluate psychiatric comorbidity among male patients with leprosy and its relation to low levels of free testosterone.
Patients and methods
The study was a cross-sectional, questionnaire-based interview study that was conducted at the leprosy clinic of Beni Suef after official permissions were obtained from the administration of Beni Suef General Hospital and the participants were asked to give an informed consent before taking the interview.
The study was conducted on 40 male, married patients with leprosy, referred from the leprosy clinic in Beni Suef. Their age ranged between 18 and 60 years.
The history of the disease and its duration were taken from all patients including (medical history, e.g. diabetes, hypertension, cardiovascular disease, renal disease). Then, all patients were diagnosed using the Structured Clinical Interview for Diagnostic and statistical manual of mental disorders, 4th ed. disorders (SCID-I) 6. The following instruments were administered: Beck Anxiety Inventory 7 to assess the level of anxiety symptoms and Beck Depression Inventory 8 to assess the level of depressive symptoms and measurement of free testosterone level.
Hormonal assay (free testosterone level)
In order to ensure consistency due to diurnal variation and in accordance with the recommendation of an earlier study 9, the blood sample was drawn in the morning. The exact time frame of the blood sample collection lay between 08:55 a.m. and 10:34 a.m., 01:45–03:51 h after the patient’s awakening following an overnight fast. Blood was centrifuged (10 min; 3000 rpm) 30 min after the sample was taken and stored at −80°C until delivered for biochemical analysis. Free testosterone was derived from serum and measured by enzyme-linked immunosorbent assay using a kit from IBL International (Hamburg, Germany).
The study was conducted after obtaining approval of the ethics committee of the Faculty of Medicine and of the ethics committee of Beni Suef University Hospital. An informed consent of the study patients was signed by all study patients.
Paired t-test was used for dependent variables and unpaired t-test for independent variables. One-way analysis of variance test was used to compare the different study group variables and post-hoc Tukey test was used to identify significance in between different test variables. Mann–Whitney test and Kruskal–Wallis test were used for nonparametric measures. Data were collected, tabulated and statistically analyzed by an IBM compatible personal computer with SPSS statistical package version 23.0 (SPSS Inc., IBM Corp., Armnok, New York, USA). Descriptive statistics were applied frequency, percentage, mean, SD. Cross-tables, χ 2 tests, and correlation coefficient were performed to compare ordinal data (P>0.05, not significant; P<0.05, significant; P<0.01, highly significant).
Some demographic and clinical data are shown in Table 1. The patients’ age ranges from 25 to 60 years (mean, 41.4±9.6 years). All patients in the study are married. The duration of the disease ranges from 1 to 48 years (mean, 11.5±9.5 years). Also, 12 (30%) patients had a positive family history of leprosy, while 28 (70%) patients had a negative family history; 17.5% (n=7) were infertile. Regarding the types of leprosy, 25% (n=10) are pauci-bacillary (PB), 75% (n=30) multi-bacillary (MB). There is deformity in 37.5% (n=15), 67.5% (n=27) shows negative history of reaction to leprosy while 32.5% (n=13) positive history of reaction to leprosy.
The patients’ free testosterone level ranges from 0.62 to 185 ng/ml (mean, 70.2±41.5 ng/ml). Twenty-nine (72.5%) had normal free testosterone, 11 (27.5%) had abnormal free testosterone (Table 1).
Psychiatric comorbidities in patients with leprosy according SCID-I are shown in Table 2. Of the patients, 50% had a history of anxiety disorders. The patients’ Beck Anxiety Inventory scores range from 5 to 27 (mean, 13.7±5.1) (50% mild, 32.5% moderate, and 5% severe regarding Beck Anxiety Inventory); 32.5% of patients had history of depressive disorders. The patients’ Beck Depression Inventory ranges from 5 to 21 (mean, 12.9±4.7) (42.5% mild, 10% moderate regarding Beck Depression Inventory). Mixed anxiety depressive disorder was present in 30% of the patients (Table 2).
On comparing between the types of leprosy as regarding Beck Anxiety, Depression Inventory scores, free testosterone level, deformity, and reaction to leprosy, Table 3 shows that there is no statistical significance between the type of leprosy and anxiety and depression scores (P>0.05, not significant).
Also there is no statistically significant difference between the type of leprosy and free testosterone level. In patients with normal free testosterone 21 patients are MB and eight patients are PB. In the number of patients with abnormal free testosterone nine patients are MB and two patients are PB. Also, there is no statistical significance between the type of leprosy and history of reaction in leprosy as the P value=0.083 (P>0.05 was considered nonsignificant). There is no statistical significance between the type of leprosy and deformity as P value=0.857 (P>0.05, not significant, as shown in Table 3).
On comparing between deformity and duration of disease and both Beck Anxiety and Depression Inventory scores, Table 4 shows that there was no significant difference between deformity and both Beck Anxiety and Depression scales scores as a P value more than 0.05 is considered nonsignificant. Also, there is no significant difference between the duration of disease and both Beck Anxiety and Depression scales scores as the P value more than 0.05 which is nonsignificant.
On comparing between free testosterone level and both Beck Anxiety Inventory and Depression Inventory scores, Table 5 shows that patients with low testosterone level showed more anxiety and depressive scores on Beck Anxiety and Depression Inventory, respectively, than those with normal hormonal level as P value=0.001 (P<0.01, highly significant).
Regarding comparison between history of infertility and both Beck Anxiety, Depression Inventory scores, and free testosterone level, Table 6 shows that the patients with a history of infertility showed a significant higher anxiety and depressive scores on Beck Anxiety and Depression Inventory, respectively; moreover, they had a significant lower level of testosterone than those with no history of infertility (fertile patients).
Patients with Hansen’s disease are associated with a high risk of developing psychiatric disorders. The prevalence of psychiatric disorders among these patients is higher than that among the general population, similar to other chronic diseases 10,11.
In two studies from North India 12,13, the prevalence of psychiatric morbidity had been reported to be as high as 56–78%.
The various psychiatric disorders commonly reported in leprosy patients were depressive neurosis and anxiety neurosis 14,15.
Serum total testosterone levels in patients decrease as a result of testicular atrophy. Testicular atrophy emerges most frequently in lepromatous leprosy. Testicular atrophy in lepromatous cases might be due to leprosy-related orchitis, which is associated with a reduction in prostatic volume 16,17.
In our study, free testosterone level is abnormal in 27.5% of the patients (11 patients), so testicular involvement happened in 27.5% of the patients. Nine out of 11 (81.8%) patients with abnormal free testosterone levels have MB leprosy. But the others two patients are PB; one of them is diseased with leprosy from 37 years and the second patient is 60 years old. This was consistent with Saporta and Yuksel 16 and Grabstald and Swan 18, who found that testicular involvement was reported to be at a rate of 10–15%. But, Aglamis et al. 19 reported that testicular involvement was found in 69% of the patients in their study. The reason why the rate was higher in this study may be associated with the length of exposure to the disease and clinical severity of lepromatous leprosy in this elderly patient group.
Leal and Foss 20 and Saporta and Yuksel 16 reported that basal testosterone levels decrease in the presence of testicular atrophy; in contrast, basal luteinizing hormone and follicle-stimulating hormone levels increase because of the decreased negative feedback from testosterone and increased estradiol levels.
Also, Aglamis et al. 19 found that the serum basal testosterone levels in the patient group decreased as expected; estrogen, follicle-stimulating hormone, and luteinizing hormone levels also increased.
In the present study, similar to other studies, anxiety disorders were the commonest psychiatric disorder followed by mixed anxiety depressive disorder and then depressive disorders.
The present study examined 40 confirmed patients with Hansen’s disease and revealed patients to have anxiety disorders (12.5% minimal, 50% mild, 32.5% moderate, 5% severe), followed by mixed anxiety depressive disorder (52.5%) and then depressive disorders (47.5% no or minimal, 42.5% mild, 10% severe).
Similar to the present study, Bhatia et al. 21, in a study on psychiatric morbidity and pattern of dysfunction in patients with leprosy showed that the predominant psychiatric illness in the study group was generalized anxiety disorder (27.8%), followed by mixed anxiety and depressive disorders (13.3%).
Also, in Rocha-Leite et al. 22, generalized anxiety disorder was the commonest psychiatric disorder, followed by mixed anxiety depressive disorder.
But Verma and Gautam 13 in New Delhi examined psychiatric comorbidity in 100 confirmed patients with Hansen’s disease and it was revealed that 76% of the patients were found to be having psychiatric illness. Of these, a large number of the patients (55%) were having neurotic depression and 21% had anxiety neurosis.
In the present study, the physical deformity ratio is ∼27.5% in these patients. No significant relation was found between physical deformity and anxiety as the P value=0.97 (P>0.05, significant) and no significant correlation was found between physical deformity and depression as P value=0.17 (P>0.05, significant).
Also Bhatia et al. 21 reported that there was no significant association between the severity of physical deformity and psychiatric disorders.
But Senturk and Sagduyu 23 in a study on psychiatric disorders and disability among Hansen’s disease patients showed that the social stigma connected to these patients makes this disease completely different from others. The physical deformity ratio is ∼25% in these patients. Philip 24 demonstrated the effect of deformity on the psychosocial aspects of people with Hansen’s disease. Some studies also have reported the relevance of physical deformities to the psychiatric morbidity in patients with leprosy 15,25.
In the present study, there was no significant correlation between duration of leprosy and depression as P value=0.290 (P>0.05, not significant), but the correlation is negative. Moreover, there was no significant correlation between duration of leprosy and anxiety as the P value=0.246 (P>0.05, not significant) but the correlation is negative.
Also in some previous studies, there was no association between duration of leprosy and psychiatric disorders 15,26.
But Bhatia et al. 21 reported that there was association between duration of leprosy and psychiatric disorders.
Another important finding is that the long duration of illness and physical handicaps raise the risk of psychiatric disorders 27.
In the present study, there is high positive significant correlation between free testosterone level and depression as the P value=0.001 (P<0.01, highly significant). Also, there is high statistical significance between free testosterone level and anxiety as P value=0.001 (P<0.01, highly significant).
Also, Shores et al. 5 reported that low testosterone levels are associated with an earlier onset and greater incidence of depressive illness. Men with low testosterone levels who had high medical morbidity or were aged 50–65 years had an increased risk for depressive illness.
In the present study, there is a positive significant correlation between Beck Anxiety Inventory scores and history of infertility as the P value=0.031 (P<0.05, significant).
Also, there is a positive significant relation between Beck Depression Inventory scores, and history of infertility as P value=0.011 (P value <0.05, significant).
Also, Band et al. 28 reported that there was evidence for elevated depression and state anxiety in some infertile men. Three significant predictors of depression were identified: an anxious disposition, a tendency to appraise situations as stressful, and an avoidant coping style. In relation to state anxiety two predictors were identified: trait anxiety and failure to seek social support.
Most patients with leprosy have psychiatric morbidity. It was observed that the psychiatric disorders largely go unrecognized by health care professionals and service providers of these patients. So, there is a growing need to treat these psychiatric disorders. Psychiatric intervention in these patients would be of much help to them. Psychiatric care should be practiced as a part of comprehensive health care in patients with leprosy.
Conflicts of interest
There are no conflicts of interest.
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