Selected psychiatric problems among college students in two Arab countries: comparison with the USA.

BACKGROUND: Psychiatric problems among college students on USA campuses are common. Little is known about similar problems in developing countries, particularly the Arab region. The goal of this study was to assess the frequency of selected psychiatric problems among college students in two Arab countries: Qatar and Lebanon, and to compare them to the USA. METHODS: The Healthy Minds Study, an online confidential survey of common psychiatric symptoms designed for college campuses was used. We used the Patient Health Questionnaire-9 (PHQ-9) to screen for major depression, the Generalized Anxiety Disorder-7 (GAD-7) to screen for generalized anxiety and the SCOFF questionnaire to screen for eating disorders. Comparisons were made using ANOVA, Chi-Square tests and logistic regressions. RESULTS: A total of 1841 students participated in the study. The rates of depression (PHQ-9 ≥ 12), generalized anxiety (GAD-7 ≥ 10) and eating disorders (SCOFF≥3) at the combined Arab universities were 34.6, 36.1 and 20.4% respectively. The corresponding rates in the USA were: 12.8, 15.9 and 6.8% (p < 0.001 for all measures). The impact of psychiatric problems on functioning in general and academic performance in particular was more severe in the Arab countries compared to the USA (p < 0.001). Independent predictors of psychiatric problems in general included location, female gender, financial difficulties and poor grades. Being religious had a protective association with mental health. CONCLUSION: The rates of depression, anxiety and eating disorders were significantly higher among college students in Qatar and Lebanon compared to the USA. Additional research is needed to determine whether these results reflect methodological limitations or true differences in psychopathology across these populations. If replicated, the results indicate that the psychiatric problems on college campuses in the USA are a microcosm of a global problem that needs global solutions.

Bipolar disorders in the Arab world: a critical review.

Bipolar disorders are common psychiatric disorders that affect 1-5% of the population worldwide. Major advances in the epidemiology, pathophysiology, and treatment of the disorders have recently occurred. The majority of published reports, however, originate from the Western hemisphere, mostly Europe and the United States. There is a shortage of data from the Arab world on bipolar disorders. In an era of globalization and rapid communication, it is not clear to what extent research findings pertaining to one part of the world are by necessity applicable to other parts. Psychiatric disorders are known to be affected by the culture in which they occur, and knowledge of variations in illness presentation in different ethnic groups is also increasing. However, knowledge of variations affecting Arab populations remains quite limited. This paper provides a critical review of the literature on bipolar affective disorders in the Arab world, pointing to major gaps in knowledge and future opportunities to fill these gaps.

Mental health issues among migrant workers in Gulf Cooperation Council countries: literature review and case illustrations.

More than 15 million non-nationals are currently living and working in Gulf Cooperation Council (GCC) states. The majority are blue-collar or domestic workers coming from the Indian Subcontinent or South East Asia. They often work under very harsh conditions. There are reports of a high rate of psychosis and suicide among these people but no reliable data are available. To address this issue we conducted a literature search both in English and in Arabic to review the available articles on the psychological well-being of this population. Very few articles were found. We hereby review the available literature and contribute by presenting several brief vignettes to illustrate the various clinical aspects of this at risk population. We also discuss possible reasons for underreporting and underscore the need for more research in this area.

Blunt traumatic bladder rupture: a 10-year perspective.

The purpose of this study was to determine the incidence, features, and associated injuries of intraperitoneal (IP) and extraperitoneal (EP) bladder rupture (BR) resulting from blunt trauma. A retrospective study from September 2001 to August 2011 was performed for blunt traumatic BR in adults. Demographics, mean Injury Severity Score (ISS), mean length of stay (LOS), incidence, mortality, operative repair, and associated injuries were evaluated. Of 15,168 adult blunt trauma admissions over 10 years, 54 patients had BR (EP = 22, IP = 27, EP + IP = 5; incidence = 0.36%). Sixty-three per cent were male. The mean age, ISS, and LOS were 40 years, 29, and 15 days, respectively. The mortality rate was 11 per cent. Fifty-two per cent of BR was the result of a motor vehicle crash. Most BRs were diagnosed by computed tomography cystogram. Eighty per cent had pelvic fracture. Hollow viscus injury was present in 34.5 per cent of patients. Colonic injury was seen in 24 per cent and 9.3 per cent had a rectal injury. Although BR is rare in adult blunt trauma, it is associated with high ISS, LOS, and mortality. Pelvic fractures are essentially present in all patients with EP BR. Hollow viscus injuries, especially colonic and rectal injuries, are more prominent in IP BR.

No increase in depression with low-dose maintenance peginterferon in prior non-responders with chronic hepatitis C.

BACKGROUND: Peginterferon and ribavirin treatment of chronic hepatitis C (CHC) is frequently associated with dose-limiting neuropsychiatric toxicity. The purpose of this study is to determine whether prolonged administration of low-dose peginterferon-α2a is associated with an increase in the rate and severity of depression compared to untreated controls. METHODS: 129 non-responders to full-dose peginterferon and ribavirin treatment were randomized to low-dose maintenance treatment with peginterferon-α2a 90 µg/week or no treatment for 3.5 years. Depression was assessed using the Beck Depression Inventory (BDI-II) and the Composite International Diagnostic Interview (CIDI) at baseline and at 12, 24, 36, and 48 months. "Clinical depression" was defined as BDI-II ≥11 and/or meeting DSM-IV criteria for major depression on the CIDI. Serial cortisol and serotonin plasma concentrations were obtained in a subgroup of patients. RESULTS: Rates of clinical depression did not significantly differ over time or between treatment groups. Baseline clinical depression was the only significant predictor of clinical depression over time (p<0.001). Rates of clinical depression were also significantly higher in patients experiencing liver disease progression (p=0.016). Antidepressant use did not significantly differ between groups. Adjusted whole blood serotonin levels dropped significantly over time (p=0.04), but there was no group by time effect. LIMITATIONS: Lack of significant group differences in antidepressant use does not completely preclude significant mood changes masked by antidepressants. Results may differ in treatment naïve CHC patients or in those receiving full-dose peginterferon. CONCLUSIONS: Prolonged low-dose peginterferon-α2a treatment is not associated with an increase in the frequency or severity of clinical depression in prior non-responder patients with chronic hepatitis C.

Depression following open-heart surgery: a path model involving interleukin-6, spiritual struggle, and hope under preoperative distress.

Faith factors (i.e., factors pertaining to religion/spirituality) have been linked with well-being and adequate coping. Few studies have investigated negative aspects of religious coping, such as spiritual struggle. Based on the multidisciplinary literature and on previous findings, the study's analysis estimated parallel psychophysiological pathways from preoperative distress to postoperative depression in patients undergoing open heart surgery. Plasma samples for interleukin(IL)-6 were obtained before surgery. The results showed that a link between spiritual struggle and IL-6 mediated the indirect effects of preoperative anxiety on postoperative depression. Avoidant coping also mediated the influence of anxiety on postoperative maladjustment. Further, hope played a protective mediating role to moderate the undesirable influences of the spiritual struggle-IL-6 link and maladaptive coping on postoperative mental health attributes.

Pathways to postoperative hostility in cardiac patients: mediation of coping, spiritual struggle and interleukin-6.

Using structural equation modeling, we estimated major pathways from preoperative distress, indicated by anxiety and other factors, to postoperative hostility in cardiac patients. Sequential interviews were conducted before and after surgery. Standardized medical and surgical indices were selected from a national database. Results showed that preoperative spiritual struggle mediated indirect effects of anxiety and anger coping on Interleukin-6 (IL-6) immediately before surgery. The link between spiritual struggle and IL-6 further mediated the indirect effects of anxiety and anger coping on postoperative hostility. Anger coping mediated the harmful influence of anxiety and counteracted the protection of positive religious coping on adjustment.

Cognitive function does not worsen during long-term low-dose peginterferon therapy in patients with chronic hepatitis C.

OBJECTIVES: Neuropsychiatric toxicity is a common dose-limiting side effect of interferon therapy. The primary aim of this study was to determine whether patients receiving long-term low-dose peginterferon therapy had a higher incidence of cognitive side effects compared with untreated patients enrolled in the Hepatitis C Antiviral Long-Term treatment against Cirrhosis (HALT-C) Trial. METHODS: A total of 129 patients with chronic hepatitis C and advanced fibrosis completed a battery of 10 neuropsychological tests and the Beck Depression Inventory at pretreatment baseline and at months 12, 24, 36, and 48 while receiving long-term peginterferonalpha2a (90 microg/week) or no therapy during the randomized phase of the HALT-C Trial. Cognitive impairment was defined as a global deficit score (GDS) > or = 1.0. RESULTS: The mean age was 51.2 years, 67% were male, and 42% had cirrhosis. After accounting for baseline GDS scores, the mean GDS scores did not significantly change over time (P=0.46) nor with treatment group (P=0.49). Cognitive function was also not influenced by medication adherence in the 66 patients receiving maintenance peginterferon (P=0.14) after controlling for baseline GDS scores and time. Beck Depression scores did not significantly increase over time (P=0.60), nor did they vary by treatment group (P=0.74). Although 32% of patients experienced objective worsening of their liver disease during follow-up, the frequency and severity of cognitive impairment did not differ in those with and without disease progression (P=0.71). CONCLUSIONS: Measures of cognitive function were neither influenced by low-dose peginterferon treatment nor with objective evidence of liver disease progression in patients with advanced chronic hepatitis C prospectively followed up for 3.5 years.

Changes in mood states and biomarkers during peginterferon and ribavirin treatment of chronic hepatitis C.

OBJECTIVE: Depression is a frequent side effect of interferon therapy in patients with chronic hepatitis C (CHC). The aim of this study was to identify baseline and on-treatment predictors of depression in CHC patients receiving peginterferon and ribavirin. METHODS: In total, 201 prior nonresponders with advanced fibrosis were treated with peginterferon alfa-2a and ribavirin for 24 wk in the Hepatitis C Antiviral Long-term Treatment against Cirrhosis trial. Of these, 74 continued on antiviral therapy through week 48. Mood states were assessed with the Beck Depression Inventory II and the Composite International Diagnostic Interview. Plasma cortisol and whole blood serotonin levels were measured in 101 subjects at weeks 0, 4, 24, 48, and 72. RESULTS: The incidence of interferon-induced depression was 23% and 42% at weeks 24 and 48, respectively. Although 22% of patients had baseline depression, the absence of a week 20 virological response was the only independent predictor of interferon-induced depression at week 24 (P = 0.0009). Plasma cortisol levels did not change during treatment nor correlate with depression. In contrast, whole blood serotonin/platelet levels significantly decreased during treatment, but did not correlate with interferon-induced depression through week 24 (P = 0.35), nor through week 48 (P = 0.51). CONCLUSION: Depression during peginterferon and ribavirin therapy was associated with a lower antiviral response. The significant reduction in whole blood serotonin levels over time suggest that further studies of the serotonergic pathway are warranted to identify the mediators of interferon-induced depression.

Cognitive reserve and neuropsychological functioning in patients infected with hepatitis C.

This study evaluated the influence of cognitive reserve on neuropsychological test performance in 198 patients infected with the hepatitis C virus. IQ scores, educational level, and occupational rating were combined to calculate a Cognitive Reserve Score (CRS) for each patient. Similar to studies of infection with the human immunodeficiency virus, there was a significantly increased risk of impairment in neuropsychological test performance in individuals with lower CRSs. It is important to account for CRS when assessing cognitive findings in large-scale clinical trials.

Cognitive function does not worsen during pegylated interferon and ribavirin retreatment of chronic hepatitis C.

UNLABELLED: Treatment of chronic hepatitis C with pegylated interferon (peginterferon) and ribavirin can cause or exacerbate depression but its effects on cognitive function are largely unknown. The aim of this study was to determine whether treatment with peginterferon and ribavirin adversely impacts cognitive function in patients with chronic hepatitis C. Prior nonresponders to interferon were retreated with peginterferon alfa-2a and ribavirin for 24 (n=177) or 48 weeks (n=57) in the Hepatitis C Antiviral Long-term Treatment Against Cirrhosis trial. Cognitive function was prospectively assessed using a battery of 10 standardized neuropsychological tests at weeks 0, 24, 48, and 72. Cognitive impairment was defined based upon a global deficit score. The Beck Depression Inventory and Brief Symptom Inventory were used to assess mood status. The 57 subjects who completed 48 weeks of antiviral therapy reported significant increases in difficulty concentrating, emotional distress, and symptoms of depression, all of which improved after cessation of therapy [P<0.0001, analysis of variance (ANOVA)]. Nonetheless, the frequency of cognitive impairment did not increase during the first 24 weeks of treatment in 177 patients (34% versus 32%, P=0.64) nor in the 57 patients completing 48 weeks of treatment (P=0.48, ANOVA). CONCLUSION: Retreatment of prior non-responders with peginterferon and ribavirin was not associated with objective evidence of cognitive impairment as measured by a comprehensive battery of neuropsychological tests. The lack of cognitive impairment is reassuring and suggests that self-reported symptoms of cognitive dysfunction are more likely related to the systemic and psychiatric side effects of antiviral treatment rather than measurable changes in cognition.

Clinical relevance of cognitive scores in hepatitis C patients with advanced fibrosis.

Mild neuropsychological impairment has previously been reported in chronic hepatitis C (CHC) patients. The aim of this study was to assess the presence and severity of cognitive impairment among a cohort of CHC patients with advanced fibrosis using clinician ratings compared to classification based upon statistical methods. In addition, we set out to determine the relationship between cognitive scores and functional status. Two experienced neuropsychologists provided "clinician ratings" on a battery of 10 neuropsychological tests performed in 100 randomly selected patients participating in the HALT-C clinical trial. The overall kappa between the 2 graders on level of impairment was 0.59. Clinician ratings (the gold standard) were similarly sensitive to identifying cognitive impairment as was classification based on standard scores (44% vs. 40%). Global Deficit Scores (GDS), derived from pooling standard scores, also identified 44% of patients as having mild impairment and were highly correlated with clinician ratings (r = .81 p = < 0.0001). Neither clinician ratings nor deficit scores correlated with SF-36 subscale or summary scores but did correlate with depression scores (p < .0007). In summary, clinician ratings and deficit scores identified a similar prevalence of cognitive impairment amongst CHC patients with advanced fibrosis. There was a significant correlation between cognitive impairment and self-reported depression.

Cognitive function in hepatitis C patients with advanced fibrosis enrolled in the HALT-C trial.

BACKGROUND/AIMS: Prior studies have demonstrated neuropsychological abnormalities in chronic hepatitis C (CHC) patients even with mild fibrosis. The aim of this study was to determine the frequency, type, and severity of cognitive impairment in a large group of CHC patients with advanced fibrosis. METHODS: Ten validated neuropsychological tests were administered to 201 CHC patients. Standard scores for individual tests were calculated using normative population data that controlled for age, gender, and/or education. Lifetime psychiatric history, alcohol consumption, and mood status were also determined. RESULTS: 33% of patients met criteria for cognitive impairment (i.e. standard score <40 on at least 4 tests). Mild impairment in verbal recall and working memory were noted with other domains remaining intact. Liver disease severity and lifetime psychiatric/substance abuse history did not correlate with group mean cognitive test results or the presence of cognitive impairment. In contrast, IQ and depression scores were significant and independent predictors of cognitive impairment (ROC = 0.84). CONCLUSIONS: 33% of patients entering the HALT-C trial have evidence of a mild, non-focal subcortical processing deficit which was highly correlated with IQ, education, and occupation. Future studies of cognitive function in CHC patients should control for general cognitive ability.

Effects of mood state and psychosocial functioning on plasma Interleukin-6 in adult patients before cardiac surgery.

OBJECTIVE: The purpose of this study was to examine the potential effect of mood states and psychosocial functioning during the waiting weeks prior to major cardiac surgery on the plasma Interleukin-6 (IL-6) levels in 236 patients immediately before their operation. METHOD: The sample was recruited from patients at the cardiac clinic of the University of Michigan Medical Center (Ann Arbor). Two weeks before cardiac surgery, trained research assistants conducted a face-to-face interview with these middle-aged and older patients on their preoperative physical examination date at the clinic. Standardized instruments were used to assess mood states and psychosocial functioning. The blood samples of 236 patients, obtained on the morning of the operation, were analyzed for plasma IL-6. RESULTS: In bivariate analysis, poor psychological functioning and anxiety, as well as bodily pain and body mass index (BMI), were correlated with plasma IL-6 (p < .05), but sociodemographics, chronic illness and use of psychotropic medications were not. When the effect of bodily pain and BMI were taken into account, partial correlation analysis showed that psychological functioning continued to be associated with plasma IL-6 (p < .05); the association of IL-6 with depression now became significant (p < .05), whereas that with anxiety became even more significant (p < .001). CONCLUSIONS: Preoperative psychological disturbances during the waiting weeks before cardiac surgery may influence the plasma levels of IL-6 immediately prior to the procedure. The clinical implications of these findings remain to be determined.

Immune dysregulation in major depression: a critical review of existing evidence.

It is now well established that depression is associated with immune dysregulation. It is not, however, known whether this immune dysregulation plays a role in the pathophysiology of major depression or whether it increases the susceptibility of the depressed patient to immune-related disorders. This article presents a critical review of existing evidence for immune dysregulation in major depression, including changes in leucocyte trafficking, lymphocyte function, and markers of immune activation. Possible mediators of immune dysregulation in major depression are briefly discussed. Finally, the relationship between major depression and several medical conditions such as infection, allergy and autoimmune disorders, cardiovascular diseases, cancer and AIDS is critically reviewed.

Acute effects of electroconvulsive therapy on lymphocyte natural killer cell activity in patients with major depression.

BACKGROUND: Major depression has been associated with a reduction in lymphocyte natural killer cell activity (NKCA). The effects of biological treatment of depression on the immune system have not been systematically investigated. The present study addresses the acute effects of electroconvulsive therapy (ECT) on NKCA. METHODS: Thirteen patients undergoing ECT for major depression were studied. NKCA at four different effector:target (E:T) ratios (E:T = 50:1; 25:1; 12.5:1 and 6.25:1, respectively) was assessed serially in relation to the first ECT session prior to and up to 1 h following treatment (-30', -10', -3' before ECT and +3', +10', +30' and +60' following ECT). On several patients, NKCA data were also available in relation to the sixth ECT session. Comparisons between mean NKCA values for each of the E:T ratios at the different time points were made using ANOVA. RESULTS: There were significant changes in NKCA values with time at E:T=25:1 (P < 0.05). Mean NKCA values for the 30 min following ECT were significantly higher than the mean NKCA values for the 30 min preceding ECT for all four E:T ratios used (P < 0.05). Differences in NKCA values between ECT no. 1 and ECT no. 6 were small and not statistically significant. CONCLUSION: ECT is associated with a significant albeit transient increase in NKCA. The clinical implications of these findings are unknown at the present time. LIMITATIONS: A small number of patients has been investigated, particularly for the sixth ECT session. No control group for ECT was available. No correlations with clinical outcome variables have been obtained.