Measuring discrimination experienced by people with a mental illness: replication of the short-form DISCUS in six world regions.

BACKGROUND: The Discrimination and Stigma Scale (DISC) is a patient-reported outcome measure which assesses experiences of discrimination among persons with a mental illness globally. METHODS: This study evaluated whether the psychometric properties of a short-form version, DISC-Ultra Short (DISCUS) (11-item), could be replicated in a sample of people with a wide range of mental disorders from 21 sites in 15 countries/territories, across six global regions. The frequency of experienced discrimination was reported. Scaling assumptions (confirmatory factor analysis, inter-item and item-total correlations), reliability (internal consistency) and validity (convergent validity, known groups method) were investigated in each region, and by diagnosis group. RESULTS: 1195 people participated. The most frequently reported experiences of discrimination were being shunned or avoided at work (48.7%) and discrimination in making or keeping friends (47.2%). Confirmatory factor analysis supported a unidimensional model across all six regions and five diagnosis groups. Convergent validity was confirmed in the total sample and within all regions [ Internalised Stigma of Mental Illness (ISMI-10): 0.28-0.67, stopping self: 0.54-0.72, stigma consciousness: -0.32-0.57], as was internal consistency reliability (α = 0.74-0.84). Known groups validity was established in the global sample with levels of experienced discrimination significantly higher for those experiencing higher depression [Patient Health Questionnaire (PHQ)-2: p < 0.001], lower mental wellbeing [Warwick-Edinburgh Well-being Scale (WEMWBS): p < 0.001], higher suicidal ideation [Beck Hopelessness Scale (BHS)-4: p < 0.001] and higher risk of suicidal behaviour [Suicidal Ideation Attributes Scale (SIDAS): p < 0.001]. CONCLUSIONS: The DISCUS is a reliable and valid unidimensional measure of experienced discrimination for use in global settings with similar properties to the longer DISC. It offers a brief assessment of experienced discrimination for use in clinical and research settings.

Accuracy of the Arabic HCL - 32 and MDQ in detecting patients with bipolar disorder.

BACKGROUND: Studies about the two most used and validated instruments for the early detection of Bipolar Disorder (BD), the 32 - item Hypomania Checklist (HCL - 32) and the Mood Disorder Questionnaire (MDQ), are scarce in non-Western countries. This study aimed to explore the reliability, factor structure, and criterion validity of their Arabic versions in a sample of Tunisian patients diagnosed with mood disorders. METHODS: The sample included 59 patients with BD, 86 with unipolar Major Depressive Disorder (MDD) and 281 controls. Confirmatory factor analysis was applied to show that a single global score was an appropriate summary measure of the screeners in the sample. Receiver Operating Characteristic analysis was used to assess the capacity of the translated screeners to distinguish patients with BD from those with MDD and controls. RESULTS: Reliability was good for both tools in all samples. The bifactor implementation of the most reported two-factor model had the best fit for both screeners. Both were able to distinguish patients diagnosed with BD from putatively healthy controls, and equally able to distinguish patients diagnosed with BD from patients with MDD. CONCLUSION: Both screeners work best in excluding the presence of BD in patients with MDD, which is an advantage in deciding whether or not to prescribe an antidepressant.

Highlighting successes and challenges of the mental health system in Tunisia: an overview of services, facilities, and human resources.

BACKGROUND: Tunisia is a lower-middle-income country located in North Africa with strengths and challenges to its mental health system. AIMS: We present an overview of available services, facilities, and human resources to offer mental health care in Tunisia. METHODS: We conducted a cross-sectional study, where data for the year 2017 was collected between May 2018 and May 2019 by consulting stakeholders involved in the health field in Tunisia. We compare this information with data published in the WHO-AIMS report (2008), which presents mental health data in Tunisia for the year 2004. RESULTS: Successes of the mental health system in Tunisia include an increase in the ratios of psychiatrists and psychologists, with these ratios being higher than those of other lower-middle-income countries; a flourishing child-psychiatry practice; and an increase in people being treated for mental health conditions. Challenges include psychiatrists being over-represented in large cities along the coastline and in the private sector, and most people receiving treatment in specialized mental health facilities. CONCLUSIONS: The further operationalization of the National Strategy for Mental Health Promotion is envisioned, through the training of non-specialists in mental health care and incentives offered to psychiatrists to work in the country's interior and the public sector.

Knowledge, attitudes and mental health of sub-Saharan African migrants living in Tunisia during COVID-19 pandemic.

COVID-19 pandemic potentially impacted the mental health of migrants. Our objective was to measure the prevalence of psychological distress among a group of sub-Saharan African migrants living in Tunisia, and its association with knowledge about COVID-19. The Questionnaire of Knowledge towards COVID-19 (QK-COVID-19) was used to evaluate the level of Knowledge about COVID-19. The participants were asked about their attitudes for seeking information and healthcare services related to the pandemic using a multiple-choice questionnaire. The Hopkins Symptoms Checklist (HSCL-25)) was used to screen for anxiety and depression. A logistic regression was used to estimate the adjusted odds of having psychological distress across levels of QK-COVID-19 score. Among the 133 participants, 34.6% (95% CI: 26.5, 42.67) had psychological distress, 91% were unemployed and 96% uninsured. Of the respondants, 20% had low QK-COVID-19 score , and 44.36% had medium score. The adjusted odds of psychological distress for those with high and medium QK-COVID-19 scores were respectively 3.9 (95% CI: 1.08, 14.13) and 6.39 (95% CI: 1.79, 22.9) times that of those with low scores. Screening and early treatment of anxiety and depression among migrants during outbreaks is an imperative. Further investigations of the determinants of mental health of sub-Saharan African migrants are needed.

Clinical predictors of response to clozapine in Tunisian patients with treatment resistant schizophrenia.

INTRODUCTION: Treatment resistant schizophrenia (TRS), affecting approximately one-third of patients with schizophrenia, is associated with a serious impairment in global psychosocial functioning. Clozapine is the only licensed drug for TRS. However its prescription remains limited by its side effects requiring mandatory monitoring. The need to identify clinical factors associated with good response to clozapine in TRS has been established. The presence of ethnic differences in these factors and the scarcity of data on the Tunisian or more generally the North-African population warrants the conduct of a clinical study on the subject. The aim of this study was to investigate demographic, clinical, and biochemical patient characteristics as potential predictors of response to clozapine. METHODS: This is a cross-sectional and retrospective study, at the "F and A psychiatry departments" of Razi Hospital in Manouba, Tunisia. All patients, with DSM 5 diagnosis of schizophrenia in its resistant form, on clozapine for at least 12 months and who consulted from June 1, 2018 to November 30, 2018 were included. We investigated premorbid functioning by the premorbid adjusment scale, demographic and clinical characteristics, and clozapine plasma level as potential clozapine response predictors. The response to clozapine was defined by a total BPRS score of 35 or less. RESULTS: Sixty-three patients were included in the study. The mean age at clozapine introduction was 30,84 ±9,25 years. The mean duration of clozapine treatment was 7,22 ± 4,02 years. There were 16 clozapine responders (25%) who had BPRS total scores below or equal to 35 and 47 non-responders (75%). A higher premorbid social functioning in childhood (p = 0,018) and early adolescence (p = 0,024) was associated with better response to clozapine. A delay clozapine initiation shorter than 7 years(p = 0,036), one atypical antipsychotic trial (p = 0,029) and schizophrenia paranoid subtype (p< 0.01) were found to be significantly predictive of good clozapine response. None of the demographic factors or biochemical characteristics were associated with clozapine response. CONCLUSIONS: Our work is consistent with previous studies suggesting the need for clinicians to be aware of the clinical predictors of a good response to clozapine to overcome their reluctance to prescribe it. It also highlighted the major prognostic role of premorbid adjustment in the clinical response to treatment. However, prospective studies including therapeutic drug monitoring would be very useful to better delineate the sub-group of patients to whom clozapine would benefit the most and to improve prescription modalities.

The impact of the COVID-19 pandemic on the mental health of healthcare workers: study protocol for the COVID-19 HEalth caRe wOrkErS (HEROES) study.

BACKGROUND: Preliminary country-specific reports suggest that the COVID-19 pandemic has a negative impact on the mental health of the healthcare workforce. In this paper, we summarize the protocol of the COVID-19 HEalth caRe wOrkErS (HEROES) study, an ongoing, global initiative, aimed to describe and track longitudinal trajectories of mental health symptoms and disorders among health care workers at different phases of the pandemic across a wide range of countries in Latin America, Europe, Africa, Middle-East, and Asia. METHODS: Participants from various settings, including primary care clinics, hospitals, nursing homes, and mental health facilities, are being enrolled. In 26 countries, we are using a similar study design with harmonized measures to capture data on COVID-19 related exposures and variables of interest during two years of follow-up. Exposures include potential stressors related to working in healthcare during the COVID-19 pandemic, as well as sociodemographic and clinical factors. Primary outcomes of interest include mental health variables such as psychological distress, depressive symptoms, and posttraumatic stress disorders. Other domains of interest include potentially mediating or moderating influences such as workplace conditions, trust in the government, and the country's income level. RESULTS: As of August 2021, ~ 34,000 health workers have been recruited. A general characterization of the recruited samples by sociodemographic and workplace variables is presented. Most participating countries have identified several health facilities where they can identify denominators and attain acceptable response rates. Of the 26 countries, 22 are collecting data and 2 plan to start shortly. CONCLUSIONS: This is one of the most extensive global studies on the mental health of healthcare workers during the COVID-19 pandemic, including a variety of countries with diverse economic realities and different levels of severity of pandemic and management. Moreover, unlike most previous studies, we included workers (clinical and non-clinical staff) in a wide range of settings.

Prevalence of Mood Disorders and Associated Factors at the Time of the COVID-19 Pandemic: Potocol for a Community Survey in La Manouba Governorate, Tunisia.

Aims: The present survey aims to assess the overall mood disorder prevalence and identify associated socio-demographic and clinical factors in a Tunisian community sample, with special attention to the COVID-19 pandemic. Background: Mood disorders are one of the leading causes of all non-fatal burdens of disease, with depression being at the top of the list. The COVID-19 pandemic may have increased the prevalence of mood disorders, especially in Low and Middle-income countries (LMICs) and in vulnerable populations. Objective: 1/ Assess point and lifetime prevalence of depressive and bipolar disorders as well as subthreshold bipolarity in a representative population sample of La Manouba governorate and assess treatment patterns for these disorders; 2/Study socio-demographic and clinical correlates of mood disorders 3/ Assess the association between mood disorders and quality of life 4/ Study the impact of the COVID-pandemic on the prevalence of mood disorders 5/ Assess coping mechanisms to the COVID-pandemic and whether these mechanisms moderate the appearance of mood disorders or symptoms since the beginning of the pandemic. Methods: This is a household cross-sectional observational survey to be conducted in La Manouba Governorate in a sample of 4540 randomly selected individuals aged ≥ 15 years. Data collection will be carried out by trained interviewers with clinical experience, through face-to-face interviews and the use of the computer assisted personal interviewing approach (CAPI). The following assessment tools are administered. Results: Structured clinical Interview for DSM IV-TR (Mood disorder section and Screening questions on Anxiety), Mood Disorder Questionnaire (MDQ), Suicide Behaviors Questionnaire-Revised (SBQ), 12-item Short Form Survey (SF-12), the Brief-COPE, and a questionnaire about a headache. In addition, socio-demographic and clinical data will be collected. Conclusion: This will be one of the very few household surveys in a general population sample to assess mental health problems and COVID-19-related variables since the beginning of the pandemic. Through this research, we aim to obtain an epidemiological profile of mood disorders in Tunisia and an estimation of the impact of the COVID-19 pandemic on their prevalence. Results should contribute to improving mental health care in Tunisia.

Women's mental health: acute impact of COVID-19 pandemic on domestic violence.

The coronavirus disease 2019 (COVID-19) pandemic created a situation of general distress. Although the focus has been initially more on the physical health during the pandemic, mental health concerns linked to the lockdown have quickly risen. This study aims to assess the effect of the COVID-19-related lockdown on Tunisian women's mental health and gender-based violence. An online survey was conducted, using the Depression Anxiety and Stress Scales (DASS-21) and the Facebook Bergen Addiction Scale (FBAS). We chose a female-exclusive social group on Facebook and used the snowball sampling method. A total of 751 participants originating from all the Tunisian regions completed the questionnaire. More than half of the participants (57.3%) reported extremely severe distress symptoms, as per the DASS-21. Those who had a history of mental illness and who were allegedly abused during lockdown were found to have more severe symptoms of depression, anxiety, and stress. Around 40% of women reported problematic social media use. Violence against women also reportedly increased significantly during the lockdown (from 4.4 to 14.8%; p < 0.001). Psychological abuse was the most frequent type of violence (96%). Women who had experienced abuse before the lockdown were at an increased risk of violence during lockdown (p < 0.001; OR = 19.34 [8.71-43.00]). To our knowledge, this is the first study that evaluates the acute impact of COVID-19 on mental health and violence against women in Tunisia, Africa, and the Arab world. It may be a sound basis for developing a more effective psychological intervention aimed at women in these regions.

The Factor Structure of the Mood Disorder Questionnaire in Tunisian Patients.

BACKGROUND: The Mood Disorder Questionnaire (MDQ) is a frequently used screening tool for the early detection of Bipolar Disorder (BD), which is often unrecognized or misdiagnosed at its onset. In this study, data from Tunisia has been used to evaluate the psychometric properties of the Arabic MDQ. METHODS: The sample included 151 patients with a current major depressive episode. The Arabic adapted version of the Structured Clinical Interview for DSM-IV-TR was used to formulate a diagnosis, yielding 62 patients with BD and 89 with unipolar Major Depressive Disorder (MDD). Principal component analysis with parallel analysis was used to establish the spontaneous distribution of the 13 core items of the MDQ. Confirmatory Factor Analysis (CFA) was used to check the available factor models. Receiver Operating Characteristic (ROC) analysis was used to assess the capacity of the MDQ to distinguish patients with BD from those with MDD. RESULTS: Cronbach's α in the sample was 0.80 (95%CI: 0.75 to 0.85). Ordinal α was 0.88. Parallel analysis suggested two main components, which explained 59% of variance in the data. CFA found a good fit for the existing unidimensional, the two-factor, and the three-factor models. ROC analysis showed that at a threshold of 7, the MDQ was able to distinguish patients with BD from those with MDD with extraordinary negative predictive value (0.92) and a positive diagnostic likelihood ratio of 3.8. CONCLUSION: The Arabic version of the MDQ showed good measurement properties in terms of reliability, factorial validity and discriminative properties.

Staff Perception of Respect for Human Rights of Users and Organizational Well-being: A Study in Four Different Countries of the Mediterranean Area.

BACKGROUND: The perception by mental health service staff of respect for users' rights is a fundamental component of organizational well-being. The objective of this work is to examine how cultural differences and the working context can influence the perception of respect for users' rights in mental health professionals in the Mediterranean area. METHODS: An observational survey carried out in four different mental health networks in four countries of the Mediterranean area (Tunisia, North-Macedonia, Italy, Palestine). Each invited participant fulfilled a format on socio-demographic information and coded the Well-Being at Work and Respect Right Questionnaire (WWRR). All data were encrypted and analysed using the Statistical Package for Social Sciences (SPSS) version 20. The Games-Howell post-hoc test was used to assess differences between countries. The Games-Howell test does not assume equal variances and sample sizes. Eta-squared (η2) was used as a measure of effect size in the ANOVA (η2 around 0.01, 0.06, and 0.14 are considered small, medium, and large, respectively). RESULTS: The sample included 590 professionals working in the mental health field. The four countries showed statistically significant differences with regards to the quality rights assessment tool. Participants from Italy reported, on average, the highest scores across the questions. There were also differences across the countries about the perception of the impact of available resources on the effectiveness of care (η2 = 0.106). CONCLUSION: Our findings offer a useful insight into the perception of the quality of mental health services, especially from a users' rights point of view.

Principal Component Analysis of the Well-Being at Work and Respect for Human Rights Questionnaire (WWRRR) in the Mediterranean Region.

BACKGROUND: The Well-Being at Work and Respect for human Rights Questionnaire (WWRR) was conceived based on the hypothesis that the perception of respect for users' rights is an essential element of well-being in the workplace in healthcare. The objective of the study is to examine the principal components of the WWRR. METHODS: A random sample representative of a set of professionals working in three different healthcare networks in Tunisia, North-Macedonia, and Italy was enrolled (n=426). Each professional completed a questionnaire on sociodemographic data and the WWRR. The WWRR consists of six items on beliefs about: satisfaction at work, users' satisfaction, organization at work, respect of users' and staff human rights, adequacy of resources. A seventh item assesses the perceived needs of personnel. Correlation between the items was evaluated by analysing the principal components with Varimax rotation and Kaiser normalization (which included all components with an Eigen value> 1). RESULTS: A single factor covered over 50% of the variance, all the items of the questionnaire were closely related and compose a single factor. Tunisia presented some differences regarding the item about the human rights of staff. CONCLUSION: Satisfaction with the respect for the rights of users is strongly correlated with the other factors that are part of the concept of the organizational well-being of health care providers. The WWRR provides a means of measuring this important and often neglected dimension.

Atopic dermatitis and mother-child interaction: a comparative study of 48 dyads.

BACKGROUND: Psychological factors and family environment may play a role in the pathogenesis and the persistence of atopic dermatitis (AD). AIM: To evaluate the interactions between mothers and their children suffering from AD and to look for the presence of maternal depression and anxiety. METHODS: A sample of 24 children with AD and their mothers and 24 matched control dyads participated in the study. Maternal depression and anxiety were assessed using the Beck Depression Inventory-short form (BDI) and the Hamilton Anxiety Rating Scale (HAM-A). The mother-child interaction was evaluated by video recording, and through scores established after analyses of the video: M-score for the mother's attitude towards the child and C-score for the child's behavior. RESULTS: AD group mothers showed significantly higher scores on the HAM-A,but not on the BDI. The analysis of the video recording conveyed a significant difference in M-scores between the two groups but no difference in C-scores.. M-score was correlated with the mother's anxiety. CONCLUSION: Our study found evidence in favor of a disturbance of the mother- child interaction in the case of AD, noted on the mother's side, and more anxiety in AD group mothers than in the control group. Our findings suggest the need for psychological support for mothers of children suffering from AD.

Satisfaction with psychiatric in-patient care as rated by patients at discharge from hospitals in 11 countries.

PURPOSE: There is disregard in the scientific literature for the evaluation of psychiatric in-patient care as rated directly by patients. In this context, we aimed to explore satisfaction of people treated in mental health in-patient facilities. The project was a part of the Young Psychiatrist Program by the Association for the Improvement of Mental Health Programmes. METHODS: This is an international multicentre cross-sectional study conducted in 25 hospitals across 11 countries. The research team at each study site approached a consecutive target sample of 30 discharged patients to measure their satisfaction using the five-item study-specific questionnaire. Individual and institution level correlates of 'low satisfaction' were examined by comparisons of binary and multivariate associations in multilevel regression models. RESULTS: A final study sample consisted of 673 participants. Total satisfaction scores were highly skewed towards the upper end of the scale, with a median total score of 44 (interquartile range 38-48) out of 50. After taking clustering into account, the only independent correlates of low satisfaction were schizophrenia diagnosis and low psychiatrist to patient ratio. CONCLUSION: Further studies on patients' satisfaction should additionally pay attention to treatment expectations formed by the previous experience of treatment, service-related knowledge, stigma and patients' disempowerment, and power imbalance.

Screening for Depression using the PHQ-9 questionnaire: a study for Tunisian individuals consulting in the primary health care centers.

INTRODUCTION: Depression is considered a global public health problem especially in the developed countries, where depression is the leading cause of morbidity. OBJECTIVES: To determine the point prevalence and the severity of depression in primary health care, to define the profile of patients suffering from depression and consulting in primary health care. To identify risk factors for depression, in particular chronic co-morbid conditions. METHODS: Our study was a descriptive and analytical cross-sectional study of 1000 patients aged over 18 years consulting in ten primary care structures. It took place during a period of six successive days from 8 to 13 April 2012. Depression was assessed by the 9-item-Patient Health Questionnaire (PHQ-9). RESULTS: In our sample, the average age was 42,4 years ranging from 18 to 89 years. Females were predominant with 66,6 %. According to the PHQ-9, the prevalence of major depressive episode (MDE) was 12,1 %. It was higher among women (13,5%) compared with men (9,3%) with an odds ratio of 1,5. The highest prevalence of MDE (19%) was noted in the age group of 45-54 years. The most prevalent clinical signs found in our population were sleep disorders (29,7%) and suicidal ideation (28,4%). Among patients with MDE, only 10% were followed up for depression. Major depressive disorder was significantly associated with comorbid chronic diseases (p < 0,001), especially diabetes (p = 0,043, OR = 2,1), musculoskeletal diseases (p = 0,028, OR = 2,1) and pulmonary diseases (p = 0,001 , OR = 5,5). Having one comorbid chronic condition multiplied the risk of having a MDE by 2,2. This risk was 3,2 for two or more comorbid chronic conditions. CONCLUSION: Depression in primary care remains a largely underdiagnosed and undertreated condition. Patients with chronic disorders are particularly vulnerable.

Anticipated and experienced stigma and discrimination in the workplace among individuals with major depressive disorder in 35 countries: qualitative framework analysis of a mixed-method cross-sectional study.

OBJECTIVES: Workplace stigmatisation and discrimination are significant barriers to accessing employment opportunities, reintegration and promotion in the workforce for people with mental illnesses in comparison to other disabilities. This paper presents qualitative evidence of anticipated and experienced workplace stigma and discrimination among individuals with major depressive disorder (MDD) in 35 countries, and how these experiences differ across countries based on their Human Development Index (HDI) level. DESIGN: Mixed-method cross-sectional survey. PARTICIPANTS, SETTING AND MEASURES: The qualitative data were gathered as part of the combined European Union Anti-Stigma Programme European Network and global International Study of Discrimination and Stigma Outcomes for Depression studies examining stigma and discrimination among individuals with MDD across 35 countries. Anticipated and experienced stigma and discrimination were assessed using the Discrimination and Stigma Scale version 12 (DISC-12). This study used responses to the open-ended DISC-12 questions related to employment. Data were analysed using the framework analysis method. RESULTS: The framework analysis of qualitative data of 141 participants identified 6 key 'frames' exploring (1) participants reported experiences of workplace stigma and discrimination; (2) impact of experienced workplace stigma and discrimination; (3) anticipated workplace stigma and discrimination; (4) ways of coping; (5) positive work experiences and (6) contextualisation of workplace stigma and discrimination. In general, participants from very high HDI countries reported higher levels of anticipated and experienced discrimination than other HDI groups (eg, less understanding and support, being more avoided/shunned, stopping themselves from looking for work because of expectation and fear of discrimination). Furthermore, participants from medium/low HDI countries were more likely to report positive workplace experiences. CONCLUSIONS: This study makes a significant contribution towards workplace stigma and discrimination among individuals with MDD, still an under-researched mental health diagnosis. These findings illuminate important relationships that may exist between countries/contexts and stigma and discrimination, identifying that individuals from very high HDI countries were more likely to report anticipated and experienced workplace discrimination.

Inequality on the frontline: A multi-country study on gender differences in mental health among healthcare workers during the COVID-19 pandemic.

Healthcare workers (HCWs) were at increased risk for mental health problems during the COVID-19 pandemic, with prior data suggesting women may be particularly vulnerable. Our global mental health study aimed to examine factors associated with gender differences in psychological distress and depressive symptoms among HCWs during COVID-19. Across 22 countries in South America, Europe, Asia and Africa, 32,410 HCWs participated in the COVID-19 HEalth caRe wOrkErS (HEROES) study between March 2020 and February 2021. They completed the General Health Questionnaire-12, the Patient Health Questionnaire-9 and questions about pandemic-relevant exposures. Consistently across countries, women reported elevated mental health problems compared to men. Women also reported increased COVID-19-relevant stressors, including insufficient personal protective equipment and less support from colleagues, while men reported increased contact with COVID-19 patients. At the country level, HCWs in countries with higher gender inequality reported less mental health problems. Higher COVID-19 mortality rates were associated with increased psychological distress merely among women. Our findings suggest that among HCWs, women may have been disproportionately exposed to COVID-19-relevant stressors at the individual and country level. This highlights the importance of considering gender in emergency response efforts to safeguard women's well-being and ensure healthcare system preparedness during future public health crises.