Arsenic is not only a physical but also a social phenomenon [9]. Besides arsenic toxicity and arsenicosis diseases, arsenic poisoning creates extensive social implications for its victims and their families in affected areas. A number of socio-economic problems like social uncertainty, social injustice, social isolation and problematic family issues are reported due to arsenicosis [15,16]. Arsenicosis is found to be more prevalent among the poor [12,17–19] who suffer from dietary deficiency, who have no alternative sources of safe drinking water and who are unable to get proper care and treatment because of financial constraints. The effects of long-term arsenicosis are also severe in the poor and could cause social problems, interrupt the societal ties [18] and trigger the social problems. Unfortunately, these social problems in affected areas are still not fully recognized and understood [18].

There is a strong link between poverty and arsenicosis diseases. Arsenicosis enhances the economic burden of the poor. The majority of victims are considered as a burden to their family and society. Most of the poor arsenicosis patients remain untreated due to financial restraints. For example, 20–70% of the patients did not receive any treatment in Bangladesh due to financial problems [18]. This lack of treatment further deteriorates the overall health and economic conditions of arsenicosis victims. Because poverty rises as the untreated poor victims are incapable of doing hard work and gradually lose strength to move. This disease is associated with social discriminations such as losing jobs, barriers to access new jobs and social rejections. Again, if the poor arsenicosis patients go for treatment, they need to spend a big proportion of their money on this, which finally diminishes the household income and increases the economic burden on the poor victims and their families [12]. Moreover, the cost of obtaning arsenic free water also diminishes household income [18].

Chowdhury et al. [18] and Nasreen [9] have described the extreme instability of social life in Bangladesh due to arsenicosis. Arsenic is producing social stigmatization and discrimination [18]. Unaffected people are generally scared of arsenicosis, therefore they tend to avoid and isolate arsenic victims [9,18,20,21]. Social conflicts over contaminated water destroy the social harmony and network relationships [9,18]. Arsenic victims are often wrongly identified as leprosy patients and isolated from their close relations [22]. In many cases the victims attribute their diseases to their fate [23]. Arsenicosis disease hampers socialization by social stigmatization and discrimination [9]. For instance, arsenic patients often remain ostracized in all age-groups and barred from social activities. Children of arsenicosis patients are not allowed to attend social and religious functions as well as denied to take water from a neighbour’s tube well and students debarred from school [9,24]. Affected families are also not allowed to take baths in any of the village ponds [9]. Some unaffected people behave in a hostile manner and think that patients should either stay in their homes or leave the village [15].

Arsenic victims are abandoned, not only by society but also by their family members. There are some instances that arsenicosis leads to a break-down of the marital relationships. For instance, wives were divorced or separated or sent back to their parents’ house because of the arsenicosis disease [18,24]. There are also some evidences that wives left arsenic affected husbands because they were afraid of arsenicosis [9]. Problems before marriage are also notable. For example, it is difficult to find a spouse for an arsenic victim. Generally people are reluctant to establish marital relationships with those families suffering from arsenicosis. Young women and men in the affected families are advised to remain unmarried [18]. Such incidents cause unlimited anxiety for both patients and parents of arsenic-affected adult children [9,18]. In Bangladesh, arsenicosis women are the worst victims of ostracism than arsenicosis men, because they are vulnerable by two ways: firstly by the disease itself and secondly by becoming outcast. Affected women also experience socially undesirable events like dowry, physical torture, and polygamy [18]. Due to the patriarchal system and lower socio-cultural position of women in the society, unmarried women and women abandoned by husband and families live inhumanly [9,18].

Public awareness is necessary to fight against arsenicosis [18]. Unfortunately poor people living in rural areas of Bangladesh are not adequately informed about arsenic contamination and arsenicosis [9,12,15,25,26]. As a result of ignorance, mainly among the illiterate people in the remote villages, some people believe in superstitions, prejudices and fairy tales [9,18]. For instance, some people think that the disease is ‘an act of the devil/impure air’ or ‘a curse of God’ or ‘the work of evil spirits’ [9,18]. Due to such superstitions and prejudices, 30 to 80% of the patients in an arsenic affected village in Bangladesh did not receive any treatment [18].

Areas of neurotoxicological impairments include poor cognitive performance and disturbances in visual perception, psychomotor speed, attention, speech and memory [27]. Various studies have reported the neurologic sequelae of acute and chronic arsenic exposure in adults and children [28–33]. Various studies [34–37] also confirmed that some chemical toxicants have the potential to modify brain physiology and can lead to mental retardation and developmental disabilities such as physical, cognitive, psychological, sensory and speech impairments including socially undesirable outcomes (also see Table 1). Two studies conducted in an arsenic affected area of Bangladesh showed that exposure to arsenic from drinking water was associated with reduced intellectual function (such as performance and processing speed) in a dose-response manner even after adjusting the impact of important sociodemographic covariates [31,33]. The study of Calderon et al. [29] in Mexico (n=80) found negative relationships between children’s urinary arsenic and verbal intelligence after controlling for a small set of demographic factors. Another recent study based on Mexican schoolchildren reported significantly inverse associations between urinary arsenic and visual-spatial abilities (cognitive performance) such as the Peabody picture vocabulary test, visual search, and letter sequencing tests by a covariate-adjusted model [27]. Comparing high school students from an arsenic-affected area with a non-affected area in Taiwan (n=109), poorer scores of neurobehavioral performance were found in 3 of 4 tests in adolescents from the arsenic affected area [30]. There are some other studies which also confirmed the detrimental effects of arsenic on children intellectual functions [32,38,39]. The underlying mechanism is not yet clear but the ATSDR [36] stated that perhaps chronic long-term exposure to arsenic may intefere with neurotransmitters associated with depressions. Arsenic crosses the blood-brain barrier and has a wide range of effects on the white matter in the brain. Arsenic inhibits the synthesis and liberation of acetylcholine in brain slices and increases the monoamine activity in nervous system [27]. Decreased locomotors activity and oxidative stress reactions due to arsenic toxicity may also affect central nervous system [32]. Cognitive impairment was reported in two workers in the USA and mental functions returned to normal after withdrawal from arsenic [28].

As health is defined by the World Health Organization as “a state of complete physical, mental and social wellbeing” [2], therefore the mentioned psychical and social dimensions have a large impact on individual’s mental health. Chronic illness affects all kind of activities, including the activities of daily living, which deteriorates the quality of life of the victims, as well as subjective well-being and mental health [24]. Therefore persons with chronic illness are often in a state of crisis marked by physical, social and mental adverse effects. Taylor and Aspinwall [40] have described some common feelings like feelings of fear, anxiety and disorganization due to chronic diseases.

According to the study of Havenaar and van den Brink [14], exposure to toxic substances is not only causing physical harms but also psychological harms Although there are few studies available regarding arsenic exposure and mental health in literature, the mental health burden caused by arsenic poisoning seems to be remarkable. For instance, 36% of the arsenic victims (n=63) were suffering from a full or partial Post-traumatic Stress Disorder (PTSD) after the arsenic poisoning in 1998 in an arsenic affected community of West Japan [41]. Although Bangladesh is the most arsenic-affected country in the world, only one study has focused on mental health among arsenic victims (n=147) living in Rajarampur area of Chapainawabganj district (one of the arsenic hotspots) in Bangladesh [24]. According to this study, mental health scores differed significantly between arsenic-affected and healthy people, with poorer mental health (based on General Health Questionnaire 12) among arsenic-affected people [24]. Employing a case-control study in an arsenic-affected rural area in Bangladesh, Khan et al. [12] also found significantly higher level of depression, weakness, restlessness, insufficient sleep, drowsiness and loss of appetite among the arsenicosis cases as compared to controls. Around 61% of the cases and only around 44% percent of the controls reported depressive feelings with p-value= 0.011. In the same study, the authors also found significant associations between chronic arsenic exposure and subjective symptoms, such as fatigue and gastrointestinal symptoms [12] which might reflect mental health problems.

Besides the above-mentioned studies in Bangladesh, a study in the United States reported that people with higher arsenic contamination suffered more from depression [42]. The study investigated arsenic exposure and nine self-reported chronic diseases, including depression from a total of 1185 people. Individuals with wells in the mid-strata of arsenic concentrations (between 2 ug/L and 10 ug/L) were significantly more likely to report depression than individuals in the lowest strata (arsenic concentration <2 ug/L) in the United States (adjusted OR=2.74; 95% CI=1.14–6.63) [42]. Furthermore, a cross-sectional study in two villages in Inner Mongolia, China found that the mental health of the subjects in the arsenic-affected village was worse than in those in the arsenic-free village (OR= 2.5, 95% CI=1.1.–6.0) [43]. In addition, experiences with animals have pointed out that perinatal arsenic exposure was associated with depressive-like behaviors in the affected mouse offspring [44].