Mental health research in the Arab world.

PURPOSE: To assess the progression of mental health research over four decades in the Arab world. METHODS: Publications on mental health in 21 Arab countries from 1966 to 2006 were screened using PubMed and Psychinfo. Data were collected and analyzed for Arab authors and affiliations, publication year, topic and type of journal. RESULTS: In 40 years (1966-2005), the Arab world published 2,213 articles on a vast variety of topics, most common being mood, anxiety and substance use disorders, and mostly in international journals. By the last decade, the total yearly publications increased about eightfold since the first two decades, and nearly doubled from the third one. The disparity of output was high across countries. The highest yearly output was from Egypt, Saudi Arabia, Kuwait and Lebanon. Per million population, the top four producing countries were Kuwait, Bahrain, Lebanon and United Arab Emirates. CONCLUSIONS: Over a decade, the Arab world produced approximately 17% of the global output of mental health publications/million population and was comparative to Latin American and Caribbean countries. There is a wide gap in comparison with the industrialized world, with a fertile ground for cross-cultural and genetic studies.

Treatment of mental disorders and pathways to care in Arab countries.

INTRODUCTION: The available studies on the treatment of mental disorders in the Arab world are uncommon. METHODS: A literature review was conducted aiming at identifying studies related to the rate and type of treatment of mental disorders in Arab countries from the Middle Eastern Mediterranean region. RESULTS: A total of 23 articles were included in this review. These articles focused mainly on type of services used and/ or the rate of treatment. Findings from several articles showed a paucity of treatment of mental disorders, and when present, individuals were more likely to receive it from the general medical than from the mental health sector. Only two studies have assessed patterns of treatment of mental disorders on a national level from the Arab Middle Eastern countries (Lebanon and Iraq). CONCLUSION: The need for national studies on mental disorders in this part of the world and the improvement of public awareness in this field were highlighted.

The role of anxious and hyperthymic temperaments in mental disorders: a national epidemiologic study.

Temperament has been demonstrated clinically to be linked to mental disorders. We aimed to determine the possible role of temperament in mental disorders in a national epidemiologic study. A nationally representative sample of adults (n=1320) was administered the Lebanese-Arabic version of the Temperament Evaluation of the Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A), and the Arabic CIDI 3.0, as part of the LEBANON study. The association among temperaments and DSM-IV mood, anxiety, and impulse control disorders was assessed. The anxious temperament was shown to be a robust predictor of most disorders, especially within the anxiety and depressive clusters. The hyperthymic temperament had a uniquely protective effect on most mental disorders, with the exception of separation anxiety, bipolar, substance abuse and impulse control disorders. These effects were moderated by age and education. Temperaments, previously largely neglected in epidemiologic studies, could play a major role in the origin of mental disorders.

A rapid situation assessment (RSA) study of alcohol and drug use in Lebanon.

BACKGROUND: Research on substance use and misuse in Lebanon is scarce and, when available, focuses on a specific substance or a limited segment of the population. The objective of this Rapid Situation Assessment (RAS) study was to survey the use of multiple substances in diverse segments of the Lebanese population. METHODS: A multi-method and multi-sample survey was conducted to collect quantitative and qualitative data from the academic sector (high school and university students), substance users in treatment or under arrest (prison, detention), and non-institutionalized "street" users. RESULTS: Age of first use of substances started as early as 9 years in the youth sample. Moreover, 12% of the high school students reported smoking one or more packs of cigarettes per day and 9% of the university students met criteria for DSM-IV alcohol abuse. Cannabis represented the most commonly used illicit drug in both high school and university students, and tranquilizers were the most frequently misused medicinal substance. Heroin was responsible for 50% of the treatment admissions, followed by cocaine (20%), and alcohol (20%); heroin was also the most common substance of arrest. Recidivism was almost the rule for heroin users across all treatment settings. Unperceived need for treatment was the most common reason for not seeking treatment in non-institutionalized drug users (47.6%). Injecting drug use was a common behavior noted within substance using populations, in treatment and non-institutionalized (about 50% of them), with a high rate of needle sharing practices. About half of all patients in treatment had a history of police arrests, and about one-third of those in prison ever received prior treatment for substance use. CONCLUSION: The study points towards a growing trend for substance use problems in early adolescence that warrants close monitoring. Further investigation of these patterns is needed since the Lebanese population might have specific pathways of abuse. There is a need to bring together various health, legislative, and academic stakeholders for a continuous appraisal of data from substance abuse studies as evidenced by the recent, although slow, progress in the fields of legislation and treatment that follow such concerted efforts.

Dissemination of an evidence-based intervention to parents of children with behavioral problems in a developing country.

This project describes the dissemination of an evidence-based parenting skills intervention by training social and health workers with little or no mental health background so that they themselves train mothers of children with behavioral problems in impoverished communities in a developing country. The Strengths and Difficulties Questionnaire was completed by mothers to screen for children with behavioral problems and was repeated at the end of the intervention. Pre- and post-tests of knowledge and parenting attitudes were administered to mothers. Mental health workers trained social and health workers in social development centers and dispensaries. Each social and health worker trained mothers of children with behavioral problems under supervision utilizing an Arabic adaptation of the treatment manual for externalizing disorders "Helping Challenging Children" developed by the Integrated Services Taskforce of the World Psychiatric Association Child Mental Health Presidential Programme. A total of 20 workers and 87 mothers participated in the training. The proportion of children who obtained an SDQ total difficulties score in the abnormal range decreased from 54.4 to 19.7% after the training. Whereas 40.2% of mothers used severe corporal punishment with their children before the intervention, this decreased to 6.1% post-intervention. Three-fourths of mothers related that the program helped them develop new parenting skills. This pilot project demonstrated the feasibility of dissemination of a manual-based intervention and training of workers who have little background in mental health to offer effective services to families in impoverished communities who otherwise would have not received them. Successful replication in other developing countries would pave the way to incorporating such programs in national policies given their potential sustainability and cost-effectiveness.

ADHD in the Arab world: a review of epidemiologic studies.

OBJECTIVE: Epidemiological studies on psychiatric disorders are quite rare in the Arab World. This article reviews epidemiological studies on ADHD in all the Arab countries. METHOD: All epidemiological studies on ADHD conducted from 1966 through th present were reviewed. Samples were drawn from the general community, primary care clinical settings, and populations of traumatized children. Data on prevalence, gender differences, risk factors, comorbidity, and burden of ADHD were reviewed. RESULTS: ADHD rates in Arab populations were similar to those in other cultures. Comparisons within Arab studies were difficult given the variability of methodology and instruments used. CONCLUSION: There is an important need for research on ADHD in the Arab World, not only to assess the national prevalence in children and adolescents, but also to look at the differential burden and treatment of this disorder, which has high levels of mental comorbidities and high impact across the life span.

The epidemiology of anxiety disorders in the Arab world: a review.

Epidemiological studies are quite rare in the Arab world. The Institute for Development Research Advocacy and Applied Care (IDRAAC) has conducted a systematic review of all epidemiologic research on anxiety disorders in the Arab world up to 2006. Specific keywords were used in the search for affective disorders, namely anxiety, generalized anxiety disorder, GAD, panic, separation anxiety disorder, SAD, overanxious disorder, OAD, phobia, fear, post-traumatic stress disorder, PTSD, obsessive compulsive disorder (OCD), obsessive compulsive symptom (OCS), obsession, compulsion, obsessive, compulsive. All results were screened and categorized. Epidemiological data on prevalence, gender differences, age of onset, comorbidity, risk factors and treatment of anxiety disorders in the Arab world were found in clinical and community samples. There is an evident need for national data on anxiety disorders in the Arab world in order to identify the magnitude of these diseases and their burden on the individual and community.

Bereavement related and non-bereavement related depressions: a comparative field study.

BACKGROUND AND METHOD: In the otherwise a-theoretical diagnostic manual, the DSM-III and IV bereavement exclusion for the diagnosis of major depression (MDD) stands out as the sole exception to the rule. No other life event excludes the diagnosis of any other axis I disorder. Since this diagnostic convention has important diagnostic and treatment implications, it is important to evaluate the validity of this exception. By comparing multiple features of bereavement related to non-bereavement related MDD, this prospective community study critically evaluates the validity of the bereavement exclusion. RESULTS: The prevalence of conditional criteria was common in the total sample (N=685) and did not differ between bereaved and non-bereaved groups. The global 'symptom profile' of depressed individuals was similar in both groups. 'Duration' was found to be longer in the bereaved group. Among all conditional criteria required by DSM-IV to accept bereavement-related episodes under the category of MDD, only 'marked dysfunction' predicted treatment. Neither the 'four conditional symptoms' nor the 'duration' criterion predicted marked dysfunction. The 'risk for recurrence' was similar whether the first episode was bereavement related or not. LIMITATIONS: 'Psychotic symptoms' were not assessed, and 'marked dysfunction' was not assessed on a continuous scale. The number of DSM-IV excluded episodes was too small to allow for generalization. CONCLUSION: Our results suggest that the conditional criteria do not seem to serve the purpose of the originators of the bereavement exclusion criteria. The 'conditional symptoms' and the 'duration' criterion seem not to be markers of severity. We propose that the descriptive and etiologically neutral approach the DSM presumes in reaching a diagnosis should be applied in the case of MDD until more convincing data point to the contrary.

Suitability of the TEMPS-A for population-based studies: ease of administration and stability of affective temperaments in its Lebanese version.

BACKGROUND: The Temperament Evaluation of Memphis Pisa Paris and San Diego Auto-questionnaire (TEMPS-A) has been translated and validated into several languages, and used in different subgroups (e.g. clinical, students, company, employees and those with different educational levels). METHODS: Lebanon is the only country that has validated the TEMPS-A in a national cohort, as part of the Lebanese Evaluation of the Burden of Ailments and Needs Of the Nation (LEBANON). In this paper, we test the suitability of the TEMPS-A for large scale epidemiologic population-based studies. RESULTS: 82.1% of the respondents found the TEMPS-A to be easy to understand. The global reports of the Lebanese of their own temperaments paralleled those of the formal sub-scores on the five affective temperament subscales. The majority of respondents (90.3%) felt that their answers on the Lebanese-Arabic TEMPS-A scale represented them throughout their adulthood; the minority who did not were more likely to be older, and to have scored higher on the cyclothymic, and lower on the hyperthymic subscales. LIMITATION: Although the TEMPS-A has been designed for self-administration (auto-questionnaire), this was not practical in all subjects. We nonetheless feel that the interview format is viable as it introduces flexibility with certain subjects in population studies. CONCLUSIONS: The TEMPS-A appears to be suitable for use in epidemiologic surveys and research.

Incidence of urinary tract infection following transrectal ultrasound guided prostate biopsy at a tertiary-care medical center in Lebanon.

OBJECTIVE: To determine the incidence of urinary tract infections (UTIs) following transrectal ultrasound guided needle biopsy of the prostate (TRUBP) and the bacteriology of these infections. DESIGN: Retrospective evaluation of the charts and records of all patients who underwent TRUBP between June 1, 2002, and August 31, 2003. SETTING: American University of Beirut Medical Center, a tertiary-care center in Lebanon. PATIENTS: Two hundred seven patients underwent TRUBP. All received prophylactic antibiotics. One hundred twenty (58%) received ciprofloxacin alone, whereas 87 (42%) received both ciprofloxacin and gentamicin. Sixty-one patients (29.5%) had an enema prior to the procedure, whereas 146 (70.5%) did not. RESULTS: Thirteen patients (6.3%) were admitted with UTI. All had rigors and fever on admission. Symptoms appeared at a mean of 2.7 days and the mean hospital stay was 9.2 days. The mean duration of antibiotic treatment was 23.2 days. Ten (77%) of the patients had positive bacteriology. Urine cultures were positive in 8 (61.5%) of the patients and blood cultures in 6 (46.2%). All positive cultures grew Escherichia coli resistant to ciprofloxacin, with 5 isolates producing extended-spectrum betalactamases. CONCLUSIONS: TRUBP continues to be associated with significant infectious complications, especially UTI. Given the increasing incidence of antibiotic resistance mainly among the Enterobacteriaceae, antimicrobial prophylaxis practices should be reevaluated and the universal administration of quinolones alone or in combination with aminoglycosides should be reconsidered.