Mental health research in the Arab world

Workforce estimate to treat mental disorders in the Kingdom of Saudi Arabia

BACKGROUND

Mental, neurological, and substance abuse (MNS) disorders describe a range of conditions that affect the brain and cause distress or functional impairment. In the Middle East and North Africa (MENA), MNS disorders make up 10.88 percent of the burden of disease as measured in disability-adjusted life years. The Kingdom of Saudi Arabia (KSA) is one of the main providers of mental health services and one of the largest contributors to mental health research in the region. Within the past decade, mental health resources and services has increased.

METHODS

We employ a needs-based workforce estimate as a planning exercise to arrive at the total number of psychiatrists, nurses, and psychosocial care providers needed to meet the epidemiological need of mental health conditions of the population of KSA. Estimates for a potential mental health workforce gap were calculated using five steps: Step 1-Quantify target population for priority mental health conditions. Step 2-Identify number of expected cases per year. Step 3-Set target service coverage for each condition. Step 4-Estimate cost-effective health care service resource utilization for each condition. Step 5-Estimate service resources needed for each condition.

RESULTS

The planning exercise indicates an epidemiologic need for a total of 17,100 full-time-equivalent (FTE) health care providers to treat priority MNS disorders. KSA appears to have a need-based shortage of 10,400 health workers to treat mental disorders. A total of 100 psychiatrists, 5700 nurses, and 4500 psychosocial care providers would be additionally needed (that is, above and beyond current levels) to address the priority mental health conditions. The shortfall is particularly severe for nurses and psychosocial workers who make up 98.9 percent of the shortfall. This shortage is substantial when compared to other high-income countries. Overall, the workforce needed to treat MNS conditions translates to 49.2 health workers per 100,000 population.

CONCLUSION

Challenges to addressing the shortfall are Saudi specific which includes awareness of cultural customs and norms in the medical setting. These challenges are compounded by the lack of Saudi nationals in the mental health workforce. Saudi nationals make up 29.5 percent of the physician workforce and 38.8 percent of the nursing workforce. Policymakers and planners supplement this shortfall with non-Saudi providers, who must be mindful of Saudi-specific cultural considerations. Potential solutions to reducing the shortfall of mental health care workers includes nurse task shifting and training of general practitioners to screen for, and treat, a subset of MNS disorders.

A retrospective analysis of substance use among female psychiatric patients in Saudi Arabia

Objective

This study investigated the prevalence of substance use (SU), and its risk factors, among women attending psychiatric outpatients center in Saudi Arabia.

Design

A retrospective cross-sectional design.

Materials and methods

We reviewed outpatients' records of 200 female patients with a history of SU from a psychiatric unit in Jeddah, Saudi Arabia from December 2018 to February 2019. The researchers developed the pro forma, and 2 psychiatrists and a family medicine physician validated the form.

Results

The most common and widely used were psychoactive substances (58%), followed by central nervous system (CNS) depressants (22%), and finally cannabinols (9.5%). Overall, the highest substance use was the amphetamine-cannabis-nicotine (ACN) representing nearly half of the illicit items (46.6%), followed by heroine-alcohol-benzodiazepine (16.4%), and with the lowest being benzodiazepine-nicotine (1.7%). There was a significant difference between the single substance and multiple substance use in terms of age (p = 0.001), smoking behavior (p = 0.001), patients past history (p = 0.005), and age of the patient at the start of drug use (p = 0.005).

Conclusion

Although the prevalence of substance use among women is low in Saudi Arabia, screening of substance use disorders risks and building a rehabilitation program to control drug dependence are needed.

Mental health research in the Arab region in response to the COVID-19 pandemic: a scoping review

Background

The ongoing pandemic has led to a global surge in coronavirus disease 2019 (COVID-19)-related mental health research. However, most related publications come from Western countries or China, and their findings cannot always be extrapolated to Arab countries.

Aims

This study provides a quantitative and qualitative analysis of mental health research pertaining to Arab countries' response to the COVID-19 pandemic.

Methods

A scoping review of the World Health Organization (WHO) COVID-19 database for publications on mental health was conducted by authors affiliated with Arab institutions, including articles from inception to 24 October 2020. The included publications were evaluated for their national distribution, international collaboration, publication type, and main research themes. Methodological quality analysis of the included research studies was performed using the original and modified versions of the Newcastle–Ottawa Scale.

Results

In total, 102 articles were included in this study, averaging 4.6 articles per Arab country. Most of the articles emerged from the Kingdom of Saudi Arabia, Jordan, and Egypt. A majority of publications demonstrated international collaboration. Most of the publications were original research studies and cross-sectional in design. The predominant research theme was examining the pandemic’s mental health effects on the general population and healthcare workers. Only 28.0% of the studies were of high methodological quality, whereas 41.5% were moderate and 30.5% were low in quality.

Conclusions

Mental health research in response to the COVID-19 pandemic in the Arab region has quantitative and qualitative shortfalls. Arab institutions need to respond to the pandemic promptly in order to address the delineated research gap and to generate higher-quality research output.

Challenges of implementing psychiatric rehabilitation services: a low- and middle-income country case example

This article aims to explore the barriers and challenges of implementing psychiatric rehabilitation services at a psychiatric hospital in Iran. We performed an internal mixed-methods evaluation by adopting a multi-method approach. The data were organised, analysed and interpreted by the evaluation team. A low participation rate, administrative issues, low fidelity to protocols and incomplete documentation were the main findings.

Implementing and maintaining rehabilitation services in low- and middle-income country settings requires more than a mere transfer of models of psychiatric rehabilitation; it needs adaptation to the local context as well as continuous evaluation and quality improvement in an iterative fashion, given the rapidly changing contexts with scarce resources.

Development of a culturally sensitive Arabic version of the Mini International Neuropsychiatric Interview (M.I.N.I.-AR) and validation of the depression module

Background

Arabic represents one of the most frequently spoken languages worldwide, especially among refugee populations. There is a pressing need for specialized diagnostic tools corresponding to the DSM-5 criteria in Modern Standard Arabic, which can be administered on Arabic speakers in the West and Arab region alike.

Objectives

To develop and validate the culturally-adapted version of the most recent M.I.N.I. 7.0.2 into Modern Standard Arabic—a form of Arabic commonly used across all Arab countries.

Methods

102 participants were recruited between April 2019 to March 2020 at the Charité - Universitätsmedizin in Berlin. Symptoms were assessed with Arabic versions of rater-based and self-rated measures, including Mini International Neuropsychiatric Interview (M.I.N.I.), Patient Health Questionnaire (PHQ-9), and Harvard Trauma Questionnaire (HTQ). Arabic-speaking psychiatrists saw participants for diagnostic assessment.

Results

Cohen’s kappa (κ) values were moderate for major depression, and slight for post-traumatic stress disorder, as well as generalized anxiety disorder. Moreover, kappa values indicated moderate agreement between M.I.N.I.-AR and PHQ-9 for depression, as well as HTQ for post-traumatic stress disorder, respectively.

Conclusion

The translated and culturally adapted version of the M.I.N.I. addresses an existing need for a reliable, efficient, and effective comprehensive diagnostic tool using the most recent DSM-5 criteria in Modern Standard Arabic (MSA). Based on the obtained results, only a validation of the depression module (Module A) of the M.I.N.I-AR was possible. Study outcomes also show evidence for the validation of Module H covering Post-Traumatic Stress Disorder. Potential valuable contributions can be extended to this translation and validation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-021-00447-1.

The state of psychiatric research in the Asia Pacific region

INTRODUCTION

This study aims to review recent scientific publications and research output in the field of psychiatry, from a series of countries in the Asia-Pacific region (Australia, India, Indonesia, Iran, Lebanon, Malaysia, and Nepal), with a view to identify themes and similarities across regions, as well as to examine the barriers and challenges in mental health research faced by countries in the region.

METHODS

Seven psychiatrists from seven countries reviewed recent published and ongoing research in psychiatry in their respective nations, with respect to themes, as well as any barriers or challenges faced by mental health researchers.

RESULTS

While the seven nations included in this review vary in terms of research capabilities and economic development level, they share many similarities both in terms of research direction, and with regards to challenges faced. Limitations in the form of sociocultural differences from the West, and a lack of funding were some of the barriers identified.

DISCUSSION

Mental health research in the region has been progressing well. However, more varied research in the form of qualitative or economic studies are lacking, as are multi-center studies. The similar issues that nations face with regards to research could perhaps benefit from collaborative efforts and initiatives for the furtherance of research in the region.

Saudi service users' perceptions and experiences of the quality of their mental health care provision in the Kingdom of Saudi Arabia (KSA): A qualitative inquiry

This paper presents, as part of a larger mixed-methods design, a study generating a theoretical understanding of issues pertinent to the quality of mental health care in the KSA from the perspective of those using services. Semi-structured interviews were undertaken with thirty service users admitted to inpatient psychiatric wards, using an interview guide developed by the researchers, based on relevant literature. Findings from the thematic analysis showed five themes: (1) The hospital as a prison: a custody versus care dilemma, (2) quality of interactions between staff and service users, (3) quality of services, (4) staff qualities and (5) suggestions for achieving quality of care. A theoretical model drawing upon Donabedian Health Care Model for Evaluating quality of care and the Andersen Behavioural Model of Health Service Use is evident from the data. Structural aspects of care include staff experience and qualifications and key enablers around social and financial support, service users' health needs and status and the physical infrastructure and ward rules. These drive processes of care based upon robust rates of interaction between staff and service users and appear central to quality of mental health care in KSA. Quality of mental health care in KSA is manifested by a therapeutic ethos with a high degree of interaction between professional carers and service users, with the former being highly educated, competent, compassionate, with a high degree of self-awareness, and specialized in mental health. We have uncovered elements of Fanon and Azoulay's 'Cultural Originality' as well as contemporary examples of Goffman's mortification of the self.

Gender gap in mental health research productivity: Results from Qatar

OBJECTIVES

Qatar's contribution to biomedical research has increased significantly in the past couple of decades, but the exact participation of women researchers remains obscure. This study aims to explore the gender gap in research production of Qatar in the field of mental health.

METHODS

The authors searched five databases for published articles from Qatar in the field of mental health from 2015 to 2019. The authors examined the retrieved articles for the gender gap in 1) the number of researchers. 2) the numbers of articles produced by men-only research teams vs. the research teams included women. 3) h-index. 4) foreign collaboration. 5) research design and themes.

RESULTS

The authors identified 152 published articles in the field of mental health. Men researchers outnumbered women researchers (124 vs. 81). Men had statistically significant higher h-index compared to women (14.6 ± 1.4 vs 4.6 ± 0.9; p < 0.001). Research teams that included women had produced fewer articles compared to men-only groups (41.4 %), they also had less foreign collaborators (68 % vs. 91 %, p = 0.001). They were less involved in experimental research and more involved in observational research compared to male-only research groups (15.90 % vs. 38.6 % and 47.6 % vs. 25 % respectively; p = 0.034). In articles with women authors, women were the first authors in 50.8 % of the articles, and men were the senior authors in 79.4 % of them.

CONCLUSION

The study identifies gender gaps in some aspects of research productivity in Qatar. This data will provide a benchmark for future research in the field.

Psychosocial family interventions for relatives of people living with psychotic disorders in the Arab world: systematic review

BACKGROUND

Family interventions in schizophrenia are evidence based and have been adapted to different cultural settings to improve their effectiveness and acceptability. The Arab world has a unique set of socio-cultural norms and values that cannot be ignored when developing or implementing such interventions. There is a lack of research on the feasibility of delivering family interventions for schizophrenia in the Arab region. The aim of this review is to synthesise the available evidence about culturally-adapted psychosocial family interventions in the Arab world. The review identifies the content and characteristics of these interventions, determines the strategies used to adapt them to Arab culture successfully, assesses the feasibility and acceptability of the interventions, and evaluates the effectiveness of these interventions for service users and their families.

METHOD

Five electronic databases were searched including MEDLINE, CINAHL, Cochrane Library, PsycINFO and EMBASE for articles written in Arabic and English from inception to August 2019. Data were extracted and synthesised narratively.

RESULTS

Six studies were retrieved from the search: three randomised control studies, two non-randomised studies and one qualitative study. There is limited evidence about culturally-adapted family interventions in the Arab region. However, the cultural adaptation process was comprehensive, and the implementation was reported to be feasible and acceptable. The methodological quality of the included studies was generally poor, so there is a risk of underestimating the effect size of the interventions due to lack of rigour and the presence of bias.

CONCLUSION

The present review provides the foundation for future work regarding family interventions in the Arab world, and confirms the feasibility of implementing such interventions with some modifications. Furthermore, the data suggests that any family-oriented intervention for schizophrenia is likely to be better than standard care in improving the outcome for patients and their families.

Electronic Mental Health as an Option for Egyptian Psychiatry: Cross-Sectional Study

BACKGROUND

Egypt is a country of nearly 100 million citizens, and there are less than 1000 registered psychiatrists. The mental health care system is under resourced and nearly inaccessible for the majority of the population. In addition, youth under the age of 25 years represent 50% of Egyptian citizens; however, there are no specific services addressing their unique needs. How can the needs of the largest population in the Middle East be effectively addressed? Is a web-based framework an option for Egyptian psychiatrists to serve the population?

OBJECTIVE

The aims of this study were to better understand the opinions of psychiatrists on the current state of mental health care services in Egypt and their current knowledge on electronic mental health (EMH); assess the attitudes of Egyptian psychiatrists toward web-based interventions and telemedicine for mental health; and identify perceived advantages and barriers of EMH development in Egypt.

METHODS

A cross-sectional survey was conducted online among 640 Egyptian psychiatrists. It included a total of 36 items within a set of 16 questions asking about EMH literacy, integrating EMH into the mental health care system, and the perceived priorities and barriers of EMH. The sampling was supported by Tanta University, a large academic institution close to Cairo. Statistical analysis was performed using SPSS 25 (IBM Corp). Descriptive statistics, the chi-square test, the independent sample t test, and analysis of variance were applied.

RESULTS

A total of 188 participants responded (response rate of 29.4%), of which 54.2% (102/188) were female and 54.3% (102/188) were between 30 and 45 years old. Less than half of the participants thought that the current health care system was efficient for adults (69/155, 44.4%), and even less thought it was efficient for youth (44/155, 28.3%). Almost all participants agreed that EMH would be beneficial for patient care (147/155, 94.8%) and that integrating EMH into the current health care system would be a good idea (118/155, 76.2%). The highest rated utility of web-based solutions was documentation, followed by psychoeducation and communication with professionals. The main advantages were to improve access to care in rural areas of the country and its convenience.

CONCLUSIONS

There is scarcity of mental health resources in Egypt. Egyptian psychiatrists are interested in EMH and believe web-based platforms can become part of the solution for the Egyptian mental health care system.

The Arab Region's Contribution to Global Mental Health Research (2009-2018): A Bibliometric Analysis

Background: Mental health research output in the Arab region is increasing, yet little is known about its recent landscape. This study provides a bibliometric analysis of mental health research in all 22 Arab countries over the past decade. Method: We used 760 journals and numerous keywords to search for articles published between 2009 and 2018 by individuals affiliated with institutions located in the Arab region. We analyzed data within Arab countries and between Arab and non-Arab countries. Results: We found that research output in the Arab world has increased by almost 160% in the past ten years, in comparison to 57% for the rest of the world. The quality of publications has also steadily improved, and so did international collaboration. Despite the progress, the number of articles per capita remains remarkably lower for the Arab world compared to the rest of the world. Also, the majority of articles continue to emanate from a limited number of countries (Egypt, Saudi Arabia, and Lebanon) and institutions within these countries. Mental health research topics in the Arab region are similar to those found in low- and middle-income countries of Africa, Asia, Latin America, and the Caribbean. Conclusion: The region needs to invest more in mental health research to close the gap with other medical and healthcare research areas and with the rest of the world. The region also needs to increase its international collaboration and research training to produce higher-quality studies, attract more funding, and publish more in top journals. As the region's population continues to face increasing trauma as a result of war and terrorism, among others, the field is afforded an opportunity to establish a major standing in the healthcare domain. Researchers are uniquely poised to use their body of research evidence to effectively help people reengage with their environments and return to daily life activities.

Mental health research in the Arab region: challenges and call for action

Although mental disorders are a leading cause of disability in the Arab region, which includes 5·54% of the global population, Arab countries produce only 1·0% of the global output of peer-reviewed publications in mental health research. Various stakeholders, including Arab mental health researchers, institutional and funding agency officials, and international research collaborators, convened to identify challenges faced by Arab mental health researchers and propose an evidence-informed call for action. Challenges identified include prevalent stigma and low awareness, conflict and war, scarce institutional and funding resources, inadequate publishing opportunities, insufficient training in mental health research, and shortage of reliable and valid assessment tools. The proposed action plan includes ways of addressing stigma and spreading awareness, increasing collaborative efforts, building research infrastructure, strengthening the mental health workforce, and translating research findings into a call to action on societal and governmental levels. The proposed action plan could provide a roadmap for Arab mental health researchers and research institutions, which might ultimately increase research productivity in the Arab region and close the gap between Arab countries and the rest of the world.

Mental health research in the Kingdom of Saudi Arabia: A review of trend and visibility over four decades

In the last few decades, there has been significant advancement in higher education and research in the Kingdom of Saudi Arabia (KSA) However, no research has quantified the studies on mental health in Saudi Arabia. The aim of this review was to review literature on mental health in KSA over the last four decades and compare it with studies done in other medical and surgical specialties. This narrative review is based on research published in the global scientific database of Web of Science, Scopus and Medline/PubMed. Mental Health Research of Saudi Arabia published since 1975 was retrieved. Publications related to other medical specialties such as surgery, internal medicine and pharmacology were also retrieved for comparison. A total of 159,796 studies related to medical and non-medical specialties were conducted in Saudi Arabia. A total of 52,699 related to medical specialties, 670 of which were on mental health and 52,029 on other medical specialties. At the beginning of the last decade there was a sharp increase in medical research (including mental health) publications from Saudi Arabia. Mental health research does not differ from research in other medical specialties in its output. In spite of the huge strides made in research in KSA, the provision of support for mental health research in the Kingdom is inadequate. Possible challenges and recommendations have been identified.

Stigma on mental illness in the Arab world: beyond the socio-cultural barriers

Purpose

Research on mental illness stigma in the Arab world has traditionally focused on socio-cultural barriers that deprive persons with mental illness from their fundamental human right for privacy and informed consent. The purpose of this paper is to address the question whether or not mental health legislations in a number of Arab countries effectively safeguard the human rights of people with mental illness and protect them from stigmatizing and discriminatory practices.

Design/methodology/approach

A qualitative review of literature was performed over two rounds of search, targeting published research on mental illness stigma in the Arab world from year 2000 until now and existing national mental health legislations in the Arab world, using English and Arabic databases.

Findings

The review reveals that beyond society and culture, persistence of mental illness stigma in the Arab world may be explained by absent or inefficient monitoring mechanisms of mental health legislations and policies within the health-care setting. Although integration of mental health services into the primary health care system is being gradually implemented as a step toward de-stigmatization of mental illness, more remains to be done to change the stigmatizing behavior of the health personnel toward mental illness.

Originality/value

Mental health authorities in the Arab world need to be more aware of the public perceptions explaining people’s fear and reluctance to seek mental health care, so as to ensure that the control and monitoring mechanisms at both the primary and mental health care levels foster a human rights, culturally competent, patient-friendly and non-stigmatizing model of mental health care.

Mothers’ Perspectives on the Play of Their Children with Attention Deficit Hyperactivity Disorder

Background. Play, which is fundamental to children’s lives, can be utilised to enrich their daily experience. However, the available knowledge regarding the impact of play on children with attention deficit hyperactivity disorder (ADHD) is limited. Therefore, this study is aimed at investigating mothers’ perspectives on their children with ADHD in Kuwait regarding their play preferences, the impact of play on ADHD behaviours, and the strategies used to regulate their children’s ADHD symptoms. Methods. Eight mothers of children aged five to ten years old with ADHD were recruited via purposive sampling. Their perspectives were qualitatively explored through one-week diaries of their children’s routines followed by semistructured interviews. The data were analysed using thematic analysis. Results. Four themes emerged: (1) play characteristics for children with ADHD, (2) play preferences, (3) play settings and their impact on ADHD symptoms, and (4) mothers’ values, understanding, and influence on play. Children were found to spend most of their playtime in indoor settings, largely playing video games. The mothers acknowledged the positive influence on their children of outdoor play and the deleterious effect of video games. However, they undervalued the contribution of play to their children’s development. Their strategies for regulating the types of play that diminish their children’s ADHD behaviours were less well understood. The weather and mothers’ other responsibilities were the main barriers. Conclusions. Understanding the play of children with ADHD revealed the requirement for more opportunities for different types of play, with more consideration of those that positively manage ADHD behaviours.

Arab Men and Women's Conceptualization of Mental Health and Depression: A Qualitative Study from the Middle East

Cardiovascular diseases are the leading cause of death worldwide. Among cardiovascular patients, depression is associated with an increased morbidity and mortality. Understanding how depression is conceptualized from cardiovascular patients' perspective can help with prevention, early detection, and treatment for depression. This might reduce cardiovascular morbidity and mortality, and save health care costs. To the best of our knowledge, there is no study in the Gulf region exploring depression among Arab cardiovascular patients. The purpose of this exploratory ethnographic qualitative research is to investigate how Arab male and female patients with cardiovascular disease conceptualize mental health and depression. Two theoretical frameworks guided this research: (1) The Ecological Perspective, and (2) Kleinman's Explanatory Model of Health and Illness. Using maximum variation purposive sampling, thirty (30) male and twenty-five (25) female, self-identified, Arab cardiovascular patients were recruited as research participants. Individual in-depth interviews were conducted using a semi-structured questionnaire. Thematic analysis was performed to generate themes. Nvivo 10, a qualitative data analysis software, was used to organize the narrative data. The participants in this study placed great emphasis on the manifestations of mental illness and their impact on both themselves and their families. Four major themes were identified from their narratives: psychological and physical disturbances; unfavorable personal characteristics; work issues and financial constraints; lack of family and social support. The knowledge generated in this study might help increase awareness, prevention of and treatment for depression among cardiovascular patients in Qatar. The findings from this study can also be used to inform a multi-disciplinary and multi-sectoral intervention approach that is contextualized to meet the mental health care needs of Arab cardiovascular patients, thus reducing cardiovascular diseases morbidity and mortality in Qatar and the Gulf region.

Mental health research in the Arab world: an update

Publications on mental health were collected using PubMed and PsychINFO for 21 Arab countries. The data were then categorised according to the first author's country of affiliation, the year of publication, the topic of research and the type of journal. In 2006–12, the Arab world published 1029 articles (an average of 147 per year). The estimated increase in yearly productivity during this period was about 25% over the 7 preceding years. When considering the research output per million population, Kuwait, Bahrain and Lebanon were the top three producers, as they had been over the preceding four decades. After adjusting for gross domestic product (GDP) per capita, the five top producers were Egypt, Jordan, Tunisia, Lebanon and Morocco. Based on child and adolescent mental health research only, the Arab world's productivity was around one-sixth that of the United States and Europe.

Depression in Cardiovascular Patients in Middle Eastern Populations: A Literature Review

Cardiovascular disease (CVD) is increasing in Middle Eastern countries. Depression is associated with increased morbidity and mortality rates among cardiovascular (CV) patients. Early detection of and intervention for depression among CV patients can reduce morbidity and mortality and save health care costs. Public information on mental health care needs of Arab CV patients living in Middle East regions is scattered and limited. This literature review surveyed and summarized research studies to learn what is known about the relationship between depression and CVD in Middle Eastern populations. The information will raise awareness among health care professionals and policy makers regarding the clinical significance of depression in Arab CV patients. It might contribute to development of culturally appropriate and effective mental health care services. Multiple databases were searched and 60 articles were assessed, including studies that investigated depression in Arab CV patient populations, physiological mechanisms of depression-CVD comorbidity, and intervention strategies that affect CV risk in depressed Arab patients. We discuss the extent to which this issue has been explored in Arab populations living in Middle East regions and Arab populations living abroad. We recommend that more comprehensive and in-depth research studies be conducted with Arab cardiac patients to enable implementation of culturally appropriate and effective mental health care interventions.

The Epidemiology of Major Depressive Episode in the Iraqi General Population

OBJECTIVE

To assess the prevalence, symptom severity, functional impairment, and treatment of major depressive episode (MDE) in the Iraqi general population.

METHODS

The Iraq Mental Health Survey is a nationally representative face-to-face survey of 4,332 non-institutionalized adults aged 18+ interviewed in 2006-2007 as part of the WHO World Mental Health Surveys. Prevalence and correlates of DSM-IV MDE were determined with the WHO Composite International Diagnostic Interview (CIDI).

FINDINGS

Lifetime and 12-month prevalence of MDE were 7.4% and 4.0%, respectively. Close to half (46%) of the 12-month MDE cases were severe/very severe. MDE was more common among women and those previously married. Median age of onset was 25.2. Only one-seventh of 12-month MDE cases received treatment despite being associated with very substantial role impairment (on average 70 days out of role in the past year).

CONCLUSIONS

MDE is a commonly occurring disorder in the Iraqi general population and is associated with considerable disability and low treatment. Efforts are needed to decrease the barriers to treatment and to educate general medical providers in Iraq about the recognition and treatment of depression.

Factor structure and reliability of the Arabic adaptation of the Hypomania Check List-32, second revision (HCL-32-R2)

OBJECTIVE

To assess the psychometric properties of the Arabic adaptation of the Hypomania-Check-List 32-item, second revision (HCL-32-R2) for the detection of bipolarity in major depressive disorder (MDD) inpatients suffering a current major depressive episode (MDE).

METHOD

The "Bipolar Disorders: Improving Diagnosis, Guidance, and Education" Arabic module of the HCL-32-R2 was administered to mother-tongue Arabic MDE inpatients between March 2013 and October 2014. Diagnostic and Statistical Manual Fourth edition (DSM-IV) diagnoses were made adopting the mini-international neuropsychiatric interview, using bipolar disorder (BD) patients as controls.

RESULTS

In our sample (n=500, of whom, BD-I=329; BD-II=70; MDD=101), using a cut-off of 17 allowed the HCL-32-R2 to discriminate DSM-IV-defined MDD patients between "true unipolar" (HCL-32-R2(-)) and "sub-threshold bipolar depression" (HCL-32-R2(+)) with sensitivity=82% and specificity=77%. Area under the curve was .883; positive and negative predictive values were 93.44% and 73.23% respectively. Owing to clinical interpretability considerations and consistency with previous adaptations of the HCL-32, a two-factor solution (F1="hyperactive/elated" vs. F2="irritable/distractible/impulsive") was preferred using exploratory and confirmatory factors analyses. Item n.33 ("I gamble more") and n.34 ("I eat more") introduced in the R2 version of the HCL-32 loaded onto F1, though very slightly. Cronbach's alphas were F1=.86 and F2=.60.

LIMITATIONS

No cross-validation with any additional validated screening tool. Inpatients only sample; recall bias; no systematic evaluation of eventual medical/psychiatric comorbidities, current/lifetime pharmacological history, or record of severity of current MDE.

CONCLUSIONS

In our sample, the HCL-32 fairly discriminated between MDD and BD-I but not BD-II, therefore soliciting for replication studies for use in Arabic-speaking depressed inpatients.

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.

Substance use disorders in Arab countries: research activity and bibliometric analysis

BACKGROUND

Substance use disorders, which include substance abuse and substance dependence, are present in all regions of the world including Middle Eastern Arab countries. Bibliometric analysis is an increasingly used tool for research assessment. The main objective of this study was to assess research productivity in the field of substance use disorders in Arab countries using bibliometric indicators.

METHODOLOGY

Original or review research articles authored or co-authored by investigators from Arab countries about substance use disorders during the period 1900-2013 were retrieved using the ISI Web of Science database. Research activity was assessed by analyzing the annual research productivity, contribution of each Arab country, names of journals, citations, and types of abused substances.

RESULTS

Four hundred and thirteen documents in substance use disorders were retrieved. Annual research productivity was low but showed a significant increase in the last few years. In terms of quantity, Kingdom of Saudi Arabia (83 documents) ranked first in research about substance use disorders while Lebanon (17.4 documents per million) ranked first in terms of number of documents published per million inhabitants. Retrieved documents were found in different journal titles and categories, mostly in Drug and Alcohol Dependence Journal. Authors from USA appeared in 117 documents published by investigators from Arab countries. Citation analysis of retrieved documents showed that the average citation per document was 10.76 and the h - index was 35. The majority of retrieved documents were about tobacco and smoking (175 documents) field while alcohol consumption and abuse research was the least with 69 documents.

CONCLUSION

The results obtained suggest that research in this field was largely neglected in the past. However, recent research interest was observed. Research output on tobacco and smoking was relatively high compared to other substances of abuse like illicit drugs and medicinal agents. Governmental funding for academics and mental health graduate programs to do research in the field of substance use disorders is highly recommended.

Current state of psychiatry in Saudi Arabia

BACKGROUND

In 1983, an article and accompanying editorial was published on the state of psychiatry in the Kingdom of Saudi Arabia (KSA), which was described as "a mental health system in statu nascendi."

METHODS

We provide a 30-year update on advances in mental health care in KSA. Data are reported from a wide range of sources, including the 2007 Saudi Arabian Mental and Social Health Atlas, which compares services in KSA with the rest of the world.

RESULTS

We examine how the current mental health system operates in KSA, including recent changes in mental healthcare policy and development of a national mental healthcare plan. Discussed are current needs based on the prevalence and recognition of mental disorders; availability of services and providers (psychiatrists, psychiatric nurses, psychologists, and social workers); education and training in psychiatry; developments in consultation-liaison, addictions, child-adolescent, and geriatric psychiatry; and progress in mental health research.

CONCLUSIONS

Mental healthcare in Saudi Arabia has come a long way in a very short time, despite cultural, religious, social, and political challenges, although there still remain areas where improvement is needed. The development of psychiatry in KSA serves as a model for countries in the Middle East and around the world.

Conformance to schizophrenia treatment guidelines in North West-Bank, Palestine: focus on antipsychotic dosing and polytherapy

BACKGROUND

Analysis of the prescribing patterns of antipsychotic drugs can improve therapeutic outcomes. The purpose of this study was to evaluate the prescribing pattern of antipsychotics and its conformance to international treatment guidelines.

METHODS

A cross sectional study at primary psychiatric centers was carried out. Patients' medical files were used to obtain demographic, medication and clinical information. International guidelines for schizophrenia were used to create conformance indicators. All statistical analyses were conducted using Statistical Package for Social Sciences.

RESULTS

250 patients were included in this study. A total of 406 antipsychotic agents were used; 348 (85.7%) were first generation antipsychotics (FGA). The prevalence of antipsychotic combination was 50.4% (n=126). There was no significant difference in positive (p=0.3), negative (p=0.06) and psychopathology (p=0.5) scores of schizophrenia symptoms among patients on monotherapy versus those on antipsychotic combination. Furthermore, no significant difference was observed in the annual cost of antipsychotic monotherapy versus combination therapy. One hundred and five patients (42%) were using optimum dose of (300 - 600 mg CPZeq) while the remaining were using sub or supra therapeutic doses. Analysis showed that use of depot, use of anticholinergic agents and increasing amount of total CPZeq were significant factors associated with antipsychotic combination.

CONCLUSIONS

This study indicated that antipsychotic prescribing was not in conformance with international guidelines with respect to maintenance dose and combination therapy. Type of antipsychotic treatment regimen, combination versus monotherapy, was not associated with better clinical or economic outcome.