From QAAPAPLE 1 to QAAPAPLE 2: how do we move from one algorithm to another one with Long Acting Antipsychotics (LAIs).

BACKGROUND: In 2011, the authors published an algorithm summarizing practice guidelines related to the use of long-acting antipsychotics (LAIs) called the Québec Algorithme Antipsychotique à Action Prolongée (QAAPAPLE), and proposed that it be revised every 5-10 years to update it according to most recent scientific knowledge. Therefore, a re-evaluation of the algorithm was conducted to determine which recommendations were still relevant and which needed modification. METHODS: The authors conducted a two-fold approach: a review of the literature to include new evidence since 2011 (controlled trials, meta-analyses, and practice guidelines); and a participatory component involving electronic surveys, conferences, encounters with opinion leadres, and patients' representatives. RESULTS: Overall, prescribers tended to make decisions based on personal experience and conversations with colleagues rather than consulting evidence-based guidelines. To test if the algorithm was useful worldwide, it was presented in the United Arab Emirates, where the feedback was in agreement with the algorithm and its limitations. CONCLUSIONS: Since its initial publication, the QAAPAPLE algorithm has been updated to guide clinicians on the use of LAIs. The new algorithm has also been assessed outside Canada to test its generalizability worldwide, and indicated its flexibility, efficiency, and user-friendliness in order to guide clinicians on the use of LAIs.

Trauma-Informed Care Survey of Psychiatrists and Primary Care Physicians in the Middle East.

OBJECTIVE: To explore in Arab communities the prevalence, dynamics, and resources available to address the physical and psychological consequences that may arise from psychiatric disorders. METHODS: An online survey of psychiatrists and primary care physicians from 17 Arab countries was conducted between September 2011 and June 2012. The survey serves as a needs assessment in a scientifically valid and culturally sensitive manner. Additionally, it focuses attention on the clinical strengths and weaknesses of Middle Eastern primary health care and mental health centers in identifying and treating trauma-related health and mental health issues. RESULTS: The 90 survey respondents comprised psychiatrists (n = 53) and primary care physicians (n = 37). They practiced in 3 clinical settings: primary mental health (27%), inpatient mental health (43%), and primary health care (29%). Traumas frequently reported by their patients were attributed to recent death of a close relative or friend (62.3%), domestic violence (41.4%), divorce/separation (72.1%), serious traffic accident (45.6%), sexual assault/rape (20.3%), child abuse (20.3%), psychological effects of war (30.9%), victims of crime (15.9%), refugees/internally displaced persons (20.6%), physical effects of war (19.1%), torture (13.2%), elderly abuse (11.6%), psychological effects of a natural disaster (7.4%), physical effect of a natural disaster (7.2%), and child soldiers (4.3%). Psychiatrists had significantly more patients with the following traumatic experiences: divorce/separation (81.4% vs 57.1%, P = .039), recent death of a close relative or friend (72.7% vs 47.6%, P = .048), and domestic violence (51.1% vs 19.0%, P = .014). Clinical teams comprised substantial numbers of students but small numbers of community volunteers and school counselors. CONCLUSIONS: This study highlights the need to develop awareness and training programs in Arab communities to identify and properly treat traumatized individuals in psychiatric and primary care settings.

Prevalence, Severity, and Correlates of Premenstrual Dysphoric Disorder Symptoms Among Women in the Arabian Peninsula.

OBJECTIVE: To study the prevalence of premenstrual dysphoric disorder (PMDD) symptom patterns among women in the United Arab Emirates and to measure the debilitating nature of PMDD symptoms and sociodemographic correlates. METHODS: This cross-sectional sample study used the Mini-International Neuropsychiatric Interview-Plus (MINI-Plus) and Premenstrual Symptoms Screening Tool (PSST) to screen for presence and severity of PMDD symptoms in Arab women attending ambulatory health services in Alain city, Emirate of Abu Dhabi, United Arab Emirates, for routine health care between May 2005 and September 2005. RESULTS: The study participants include 508 women (76% Emiratis, 15% Omanis, and 8% other Arabs) of childbearing age. In total, 94 women (18.6%) met MINI-Plus criteria for PMDD; of these, 21 (4.1%) met PSST criteria for severe symptoms, 29 (5.7%) for moderate symptoms, and 44 (8.7%) for mild or less symptoms. One woman (0.2%) with severe symptoms and 12 women (2.4%) with moderate symptoms had negative MINI-Plus scores. Presence of PMDD symptoms was significantly associated with higher education (P = .000), single marital status (P = .001), major life stressors (P = .001), and personal/family use of psychotropic medications (P = .000/P = .006), personal/family psychological problems (P = .000/P = .001), irregular/painful menses (P = .043/P = .001), and functional impairment on the Sheehan Disability Scale (P = .000). Multilogistic regression analysis showed higher education, major life stressor, personal use of psychotropic medications, personal/family psychological problem, and painful menses were independent predictors of PMDD symptoms. CONCLUSIONS: PMDD symptoms were common among the Arab women in our study. The cyclically triggered mood disturbances were clustered in women with personal/familial psychological problems, perhaps linking biologic constitution to genetic predisposition for the development of PMDD symptomatology.

Psychological Assessment of Emirati Patients Pursuing Bariatric Surgery for Obesity.

BACKGROUND: Obesity is currently a rapidly growing global problem of epidemic proportions and is especially prevalent in economically developed countries such as the United Arab Emirates. Obese individuals are increasingly considering bariatric surgery as their preferred means of choice for the reduction of excess body fat. This study explored the psychological characteristics that may potentially complicate the surgical management of obesity. METHODS: This was a cross-sectional study of Emirati patients attending a bariatric clinic at Tawam Hospital, Al Ain, United Arab Emirates, between December 2010 and February 2012. Participants were assessed using standard clinical psychiatric interviews. Also used were screening instruments such as the Hospital Anxiety and Depression Scale, Sheehan Disability Scale (SDS), Body Image Quality of Life Inventory (BIQLI), and Multidimensional Body-Self Relations Questionnaire-Appearance Scale (MBSRQ-AS). RESULTS: A total of 105 patients, 70% of whom were female, participated in this study. Participants were found to have frequencies of anxiety and depressive symptoms at levels of 24% and 13%, respectively. Participants also reported perceived functional disabilities in the following: work/school (27%), social life (36%), family/home (35%), and religious duties (39%). A total of 13 participants (12%) had BIQLI scores showing slight-to-moderate effects on their quality of life. The mean MBSRQ-AS subscale on self-classified weight was higher than the reported norms. Anxiety and depressive symptoms positively correlated with functional impairment (SDS) and negatively correlated with quality of life (BIQLI) (P = .000). MBSRQ-AS subscales significantly correlated with depression, functional impairment, and quality of life (P ≤ .035). CONCLUSIONS: Anxiety, depression, perceived functional disability, impairment in quality of life, and disturbance of self-image were found to be common among participants in the study pursuing bariatric surgery for obesity. Recognition, assessment, and treatment of these symptoms are expected to be conducive to positive outcomes of bariatric surgery.

Attentiveness of Dermatologists in the Middle East to Psychocutaneous Medicine.

OBJECTIVE: Patients with skin diseases often have psychological problems and complications that require assessment and treatment. The main objective of this study was to explore attentiveness of dermatologists to psychiatric symptoms in their patients. METHODS: A previously validated online questionnaire was used to explore the attitude and experience of dermatologists practicing in the Middle East toward the assessment of the psychiatric needs of their patients. The survey also inquired about awareness of available resources in dealing with psychodermatology. This online survey was conducted between October 2011 and October 2012. RESULTS: Of 70 invited dermatologists, 57 (81%) completed the survey. Fifteen respondents (31%) received no training and had attended no educational events on psychodermatology. Only 19 respondents (33%) were able to identify psychodermatology as psychiatric components of skin diseases and dermatologic symptoms of psychiatric disorders. Twenty respondents (41%) reported frequent experience with psychodermatology, and 14 (28%) were "very comfortable" in diagnosing and treating psychodermatology patients. Twenty-two respondents (47%) recognized psychocutaneous involvement in 10% to 25% of their patients, while 18 (36%) recognized it in < 10% of their patients. Recognized diagnoses that required referral for psychiatric assessment included trichotillomania (34%), delusion of parasitosis (22%), depression (18%), dysmorphophobias (16%), dermatitis (10%), and venereophobia (10%). Forty-five respondents (90%) were unaware of psychodermatology resources. The majority of respondents expressed interest in education on depression, anxiety, adjustment disorders, and body dysmorphic disorder. CONCLUSIONS: Psychocutaneous involvements are common among dermatologic patients. A large number of the surveyed dermatologists had no training or education in psychodermatology. A lack of familiarity with patient and family resources on psychocutaneous conditions was also evident. These findings support the need for improvement in training and education in psychodermatology.

Basal Ganglia Calcification in Psychiatric Inpatients: A Case-Control Study.

BACKGROUND AND OBJECTIVE: Several case reports have noted basal ganglia calcification (BGC) as an incidental radiologic finding in patients presenting with psychiatric manifestations. In this study, we examined the clinical correlates of mental disorders in two groups of psychiatric patients, one with BGC and one with normal radiologic studies. METHODS: In a retrospective cross-sectional case-control study of patients admitted to the psychiatric ward in Al Ain Hospital between January 2011 and December 2013, we compared all 15 patients diagnosed with BGC and 30 control patients who had normal radiologic findings. RESULTS: The BGC group's psychiatric symptoms began when they were aged in their 30s and 40s, later than the controls' 20s and 30s (P=0.001). More of the BGC group than the controls had cognitive symptoms (60% versus 6.7%, P=0.001). The BGC group was more likely to have chronic medical comorbidities (66.7% versus 20%, P=0.003). The BGC group's mean serum calcium was lower than the controls' (P=0.003) and the C-reactive protein was higher (P=0.049). We did not find significant differences between the groups in psychiatric diagnoses; five of the 15 patients with BGC had mood disorders and four of the 15 had psychotic disorders. CONCLUSIONS: Patients with BGC tend to develop psychiatric symptoms later in life than other psychiatric patients, and have higher rates of medical comorbidities. Many patients with BGC have cognitive symptoms, which can be concurrent with a mood or psychotic disorder.

Mental health law profile: the United Arab Emirates.

There are two federal laws in the UAE from 1981 that are specific to people with mental illnesses and disabilities. Efforts are presently being made to develop other laws addressing the protection of the vulnerable population, including women, children and the elderly. A new updated Mental Health Act is needed to keep in line with the UAE's major leaps achieved in healthcare.

Alcohol-related road traffic injuries in Al-Ain City, United Arab Emirates.

OBJECTIVE: We aimed to prospectively study the demography, severity of injury and outcome of alcohol-related road traffic collision (RTC) injuries in the United Arab Emirates. METHODS: Data of RTC Registry of Al-Ain City were prospectively collected from Al-Ain and Tawam hospitals during the period of April 2006 to October 2007. It included all RTC trauma patients who were admitted or those who died after arrival to these hospitals. Car occupants with complete data on alcohol use were included in the study. Patients were divided into two groups, those who reported using alcohol and those who did not. RESULTS: Out of the 771 car occupants, sixteen (16) used alcohol (2.1%), 15 (94%) of them were males. The median (range) age of the alcohol group was significantly higher than those without alcohol (35 (15-53) years compared with 26 (1-78) years, p = 0.02). The UAE nationals were significantly more (P = 0.01) and the revised trauma score was significantly less in the alcohol group (P = 0.03). Head/face was the most commonly injured region in the alcohol group (94%). CONCLUSION: Self reported alcohol-related car collisions in Al-Ain City had a low incidence. It affected older Emirati male nationals and was associated with lower revised trauma score, mainly due to head injury. There is a need for a national registry with data on alcohol abuse so as to assess its effects and strategies for its prevention.

Overview of research on the mental health impact of violence in the Middle East in light of the Arab Spring.

This is a baseline of published research in the trauma field by Arab researchers. It highlights groundbreaking attempts by Arab researchers to investigate the mental health impact of violence in their countries before the Arab Spring. Peer-reviewed articles (N = 157) were identified through computerized searches in PubMed, PsycINFO, Google Scholar, and Pilots Database, 1995 to 2012. A synopsis of the published research included (a) country, (b) screening instruments, (c) sample size, (d) methods, and (e) results. The findings reveal that domestic violence attracted most attention after civil strife in Palestine and Lebanon. Torture survivors and victims of sexual violence received little attention. Study instruments were borrowed from Western researchers without being validated within local Arab cultures. No clinical outcome studies were found. In light of the Arab Spring, it is urgent that Arab researchers conduct studies that are evidence based and culturally valid addressing the mental health care of all traumatized citizens.

A case of Gorlin-Goltz syndrome presented with psychiatric features.

We report a case of a 34-year-old male who presented with an acute onset of pleomorphic psychiatric features. Upon examination we later diagnosed him with Gorlin-Goltz syndrome based on clinical and radiological findings that are characteristic for this rare autosomal dominant syndrome. His psychiatric manifestations included irritability, aggressive behavior, labile mood, hallucinations, paranoid delusions, and transient cognitive impairment. His past history indicated surgical excision of pigmented lesion in the left lower eyelid which turned out to be a basal cell carcinoma. His past visits to dermatology clinics indicated pitted keratosis involving hands, callosities, and seborrheic dermatitis. There were numerous palmar pits, and Brain CT Head scan revealed extensive calcification along falx cerebri and around the cerebellar vermis. He had low (20 ng/L) vitamin D level and high parathyroid hormone level. The patient improved using antipsychotic medications and vitamin D supplementations for symptomatic management and was discharged with a plan for multispecialty outpatient follow-up. This case highlights the importance of considering rare organic etiologies in the differential diagnosis of patients presenting with psychiatric symptoms. This is of vital importance for early intervention to prevent complications and for better outcomes of the coexistent diseases.

Interpersonal violence in the United Arab Emirates.

We aimed to study the anatomical distribution, severity and outcome of hospitalised interpersonal violence-related injured patients in Al-Ain, United Arab Emirates so as to give recommendations regarding the magnitude of this problem, its causes and priorities of prevention. Data were retrieved from Al-Ain Hospital Trauma Registry, which was prospectively collected over three years. There were 75 patients (males = 85.3%) having a mean age of 30 years. Eighty-one percent had blunt trauma. The estimated annual injury hospitalisation of interpersonal violence in Al-Ain city was 6.7 per 100,000 population. Females were significantly more injured by a family member (p = 0.02), at home (p = 0.005), and had more severe injuries (p = 0.003). There was a trend for children less than 18 years old to have more penetrating trauma (p = 0.06) and to be injured by a family member (p = 0.09). There was only one case of woman sexual assault and two cases of child abuse. The mean (SD) hospital stay was 7.87 (14.1) days. Less than 3% (n = 2) were admitted to the intensive care unit with no deaths. In conclusion, the majority of patients in our study had minor injuries. Nevertheless, the psychological impact may be major. This highlights the need to develop suitable mental health services in support of victims of interpersonal violence.

Medical Students Learning Communication Skills in a Second Language: Empathy and expectations.

OBJECTIVES: Communications skills (CS) training for medical interviewing is increasingly being conducted in English at medical schools worldwide. In this study, we sought to identify whether Arabic-speaking medical students experienced difficulty with the different components of the CS training that were conducted in English. METHODS: Individual third-year preclinical medical students (N = 45) were videotaped while interviewing simulated patients. Each student assessed his/her performance on a 13-item (5-point scale) assessment form, which was also completed by the tutor and other students in the group. RESULTS: Of the 13 components of their CS training, tutors awarded the lowest marks for students' abilities to express empathy, ask about patients' feelings, use transition statements, ask about functional impact, and elicit patients' expectations (P <0.001). CONCLUSION: The expression of empathy and the ability to elicit patients' feelings and expectations are difficult to develop in medical students learning CS in a second language.

A review of body dysmorphic disorder and its presentation in different clinical settings.

OBJECTIVE: Body dysmorphic disorder (BDD) is a relatively common psychiatric disorder characterized by preoccupations with perceived defects in physical appearance. This review aimed to explore epidemiology, clinical features, comorbidities, and treatment options for BDD in different clinical settings. DATA SOURCE AND STUDY SELECTION: A search of the literature from 1970 to 2011 was performed using the MEDLINE search engine. English-language articles, with no restriction regarding the type of articles, were identified using the search terms body dysmorphic disorder, body dysmorphic disorder clinical settings, body dysmorphic disorder treatment, and body dysmorphic disorder & psychodermatology. RESULTS: BDD occurs in 0.7% to 2.4% of community samples and 13% of psychiatric inpatients. Etiology is multifactorial, with recent findings indicating deficits in visual information processing. There is considerable overlap between BDD and obsessive-compulsive disorder (OCD) in symptom etiology and response to treatment, which has led to suggestions that BDD can be classified with anxiety disorders and OCD. A recent finding indicated genetic overlap between BDD and OCD. Over 60% of patients with BDD had a lifetime anxiety disorder, and 38% had social phobia, which tends to predate the onset of BDD. Studies reported a high level of comorbidity with depression and social phobia occurring in > 70% of patients with BDD. Individuals with BDD present frequently to dermatologists (about 9%-14% of dermatologic patients have BDD). BDD co-occurs with pathological skin picking in 26%-45% of cases. BDD currently has 2 variants: delusional and nondelusional, and both variants respond similarly to serotonin reuptake inhibitors (SRIs), which may have effect on obsessive thoughts and rituals. Cognitive-behavioral therapy has the best established treatment results. CONCLUSIONS: A considerable overlap exists between BDD and other psychiatric disorders such as OCD, anxiety, and delusional disorder, and this comorbidity should be considered in evaluation, management, and long-term follow-up of the disorder. Individuals with BDD usually consult dermatologists and cosmetic surgeons rather than psychiatrists. Collaboration between different specialties (such as primary care, dermatology, cosmetic surgery, and psychiatry) is required for better treatment outcome.

Identification of new alleles and the determination of alleles and genotypes frequencies at the CYP2D6 gene in Emiratis.

CYP2D6 belongs to the cytochrome P450 superfamily of enzymes and plays an important role in the metabolism of 20-25% of clinically used drugs including antidepressants. It displays inter-individual and inter-ethnic variability in activity ranging from complete absence to excessive activity which causes adverse drug reactions and toxicity or therapy failure even at normal drug doses. This variability is due to genetic polymorphisms which form poor, intermediate, extensive or ultrarapid metaboliser phenotypes. This study aimed to determine CYP2D6 alleles and their frequencies in the United Arab Emirates (UAE) local population. CYP2D6 alleles and genotypes were determined by direct DNA sequencing in 151 Emiratis with the majority being psychiatric patients on antidepressants. Several new alleles have been identified and in total we identified seventeen alleles and 49 genotypes. CYP2D6*1 (wild type) and CYP2D6*2 alleles (extensive metaboliser phenotype) were found with frequencies of 39.1% and 12.2%, respectively. CYP2D6*41 (intermediate metaboliser) occurred in 15.2%. Homozygous CYP2D6*4 allele (poor metaboliser) was found with a frequency of 2% while homozygous and heterozygous CYP2D6*4 occurred with a frequency of 9%. CYP2D6*2xn, caused by gene duplication (ultrarapid metaboliser) had a frequency of 4.3%. CYP2D6 gene duplication/multiduplication occurred in 16% but only 11.2% who carried more than 2 active functional alleles were considered ultrarapid metabolisers. CYP2D6 gene deletion in one copy occurred in 7.5% of the study group. In conclusion, CYP2D6 gene locus is heterogeneous in the UAE national population and no significant differences have been identified between the psychiatric patients and controls.

Troubled minds in the Gulf: mental health research in the United Arab Emirates (1989-2008).

This article aims to describe the characteristics of the United Arab Emirates (UAE) mental health research published from 1989 to 2008 in PubMed indexed journals to identify gaps and to suggest recommendations. Our sensitive PubMed search for general and mental health publications in Gulf Cooperation Council (GCC) countries and the UAE revealed a total of 192 mental health studies published in GCC countries over the past 20 years, which constituted less than 1% of the GCC total biomedical research. Most of the studies were from the UAE University and were either epidemiologic (48.98%) or psychometric (24.49%) with no studies addressing mental health systems research. Underrepresented were studies on health promotion and interdisciplinary, cross-cultural, ethnic, and gender research. There is a need for more international collaboration and for policies that link research conducted to services provided with longitudinal studies to test the long-term impact of early preventive interventions.