Preliminary psychiatric observations in Egypt

Role of traditional healers in the pathway of service for a sample of obsessive compulsive disorder patients in Egypt

BACKGROUND

The diagnosis and treatment of an illness using traditional medicine is in most cases culture-specific and based on beliefs in the community. The majority of mentally ill patients prefer to attend to traditional healers because of the trust problems in the system, affordability, accessibility, and ease of the service.

AIM

To assess the role of traditional healers among the pathway of psychiatric services of OCD patients, and to highlight its clinical correlates.

METHODS

we assessed 93 patients with OCD after confirmation of the diagnosis with fifth version of MINI semi structured interview, using a questionnaire designed and accustomed by authors to assess help seeking behavior in OCD patients and its sociodemographic and clinical correlates. Type of symptomatology and its severity were assessed using Y-BOCS.

RESULTS

A total of 39.8% sought traditional healers help, 94.6% were before psychiatric advice, main symptoms related to traditional healers seeking were religious and sexual obsessions. Main causes of traditional healers' preference were stigma of seeking psychiatric advice in 89.2% of cases, considering disease related to religion in 81.1%, considering that religious commitment help in treatment 75, 7%, and considering disease related to magic and superstitions in 45.9%. Religious origin of illness was the most statistically significant factor related to seeking advice at traditional healers.

CONCLUSION

This study shows that a significant percentage of the patients suffering from OCD prefer to approach traditional healers first due to their own beliefs mainly religious, and society acceptance.

Knowledge, attitude and health-seeking behavior among family caregivers of mentally ill patients at Assiut University Hospitals: a cross-sectional study

Background

Mental illness is associated with misunderstanding and unfavorable attitude worldwide. The belief in its spiritual nature made traditional healers the main service consultants for mentally ill patients. The present study is a cross-sectional study conducted among 425 main family caregivers of mentally ill patients at Assiut University Hospital. The objective of the study was to assess the caregivers’ knowledge and attitude towards mental illness as well as their health-seeking behavior for their mentally ill relatives.

Results

The studied caregivers had low scores of knowledge and attitude towards mental illness. Age of the caregivers, their education, and the type of first consulted care and aggressive behavior of the mentally ill relatives were the significant predictors of caregivers’ knowledge and attitude towards mental illness. The majority of caregivers (80.2%) sought advice for the first time from traditional healers. Traditional healers referred only 16.4% of caregivers’ mentally ill relatives to psychiatric care.

Conclusion

The studied caregivers had poor knowledge and a negative attitude towards mental illness. Traditional healers were the main consulted care. So, increasing awareness of mental illness is highly recommended.

Stigma and burden of mental illness and their correlates among family caregivers of mentally ill patients

Background and objectives

Family caregivers play a curial role in supporting and caring for their mentally ill relatives. Their struggle for facing stigma and shouldering caregiving burden is marginalized, undervalued, and invisible to medical services. This study assessed the stigma and burden of mental illnesses, and their correlates among family caregivers of mentally ill patients.

Methods

A cross-sectional study design was used to collect data from 425 main family caregivers of mentally ill patients at Assiut University Hospital. A structured interview questionnaire was designed to collect socio-demographic data of both patients and their caregivers. Stigma scale for caregivers of people with mental illness (CPMI) was used to assess the affiliate stigma, while the associative stigma was assessed by the explanatory model interview catalogue stigma scale (EMIC-Stigma scale). The caregivers’ burden was assessed using Zarit burden Interview, and Modified Attitude toward Mental Illness Questionnaire was used to assess caregivers’ knowledge and attitude towards mental illness.

Results

Bipolar disorder (48%) and schizophrenia/other related psychotic disorders (42.8%) were the most common mental illnesses among the study patients. The mean scores of CPMI total scale, EMIC-Stigma scale, and Zarit Burden scale were 56.80 ± 7.99, 13.81 ± 5.42, and 55.20 ± 9.82, respectively. The significant correlates for affiliate stigma were being parents of patients (ß = 4.529, p < 0.001), having higher associate stigma (ß = 0.793, p < 0.001), and aggressive behavior of mentally ill patients (ß = 1.343, p = 0.038). The significant correlates for associate stigma of the study caregivers were being caregivers’ relatives other than parents (ß = 1.815, p = 0.006), having high affiliate stigma (ß = 0.431, p < 0.001), having poor knowledge and negative attitude towards mental illness (ß = − 0.158, p = 0.002), and aggressive behavior of mentally ill relatives (ß = 1.332, p = 0.005). The correlates for the high burden were being male (ß = 3.638, p = 0.006), non-educated caregiver (ß = 1.864, p = 0.045), having high affiliate stigma (ß = 0.467, p < 0.001), having high associative stigma (ß = 0.409, p < 0.001), having poor knowledge and negative attitude toward mental illness (ß = − 0.221, p = 0.021), seeking traditional healers and non-psychiatrist’s care from the start (ß = 2.378, p = 0.018), and caring after young mentally ill relatives (ß = − 0.136, p = 0.003).

Conclusion

The studied caregivers suffered from stigma and a high level of burden. Psycho-educational programs directed toward family caregivers are highly recommended.

Psychiatric services in Egypt – an update

For over a thousand years, the Hippocratic system of medicine prevailed in Europe. It went into oblivion during the Dark Ages, when there was a reversion to the demoniacal theories of mental illness. Hippocrates’ works survived, however, in the library at Alexandria, where they were translated into Arabic. These and other classical works were retranslated into Latin and Greek from the 12th century on, ushering in the Renaissance.

Duration of untreated psychosis and pathway to care in Riyadh, Saudi Arabia

AIM

Recent studies of 'duration of untreated psychosis' (DUP) indicate that some patients remain untreated in the community for some time. Considerable emphasis has been placed on reducing the DUP. However, most studies investigating DUP have been conducted in Western countries, where well-developed primary care systems are available. This study aims to describe DUP and its association with both demographic factors and pathways to care in Riyadh, Saudi Arabia.

METHODS

A retrospective study of 421 new case records of all Saudi schizophrenia patients over a 2-year period in six governmental hospitals in Riyadh, Saudi Arabia.

RESULTS

The median DUP was 1.41 years (interquartile range 0.35-2.81 years). The longest time to contact was 9.86 years but 90% had a DUP shorter than 5 years. Older age at onset, single marital status and higher educational level were associated with shorter DUP. Long DUP was associated with help seeking from traditional healers.

CONCLUSION

In Saudi Arabia, it usually takes longer for patients to seek help from psychiatric services after their first psychosis onset than it does in Western countries. The results suggest that the DUP is influenced by both demographic factors and pathways to care.

Duration of untreated psychosis in an Egyptian sample: Sociodemographic and clinical variables

BACKGROUND

Duration of untreated psychosis (DUP) has been considered as a poor prognostic factor for psychotic disorder. Several studies have been investigating different predictors of DUP in Western countries, while in Egypt only a few studies have examined various predictors of DUP.

AIMS

To study DUP in Egyptian patients with psychotic disorders and to investigate how certain illnesses, patient, socio-cultural risk factors and help-seeking behaviour are correlated with prolonged DUP.

METHOD

The sample included 100 patients with Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) diagnosis of psychotic disorder were selected and interviewed to assess DUP. They were interviewed using the Structured Clinical Interview for DSM-IV axis I disorders (SCID-I), Positive and Negative Syndrome Scale (PANSS) and Global Assessment of Functioning (GAF) scale.

RESULTS

Mean (±standard deviation ( SD)) of DUP was found to be 36.93(±45.27) months. DUP was correlated with various sociodemographic and clinical variables. Following log transformation of DUP, correlation with PANSS scores was done and revealed highly significant statistical relation of DUP to PANSS negative and PANSS positive scores. In linear regression analysis, it was found that age of patients, the age of onset, residence, being illiterate, the insidious mode of onset, negative family history of psychiatric disorder and the severity of illness as indicated by PANSS are among DUP predictors.

CONCLUSION

Longer DUP results from multiple patient- and illness-related factors. This has many implications in targeting early intervention with specific consideration to cultural factors.

Role of traditional healers in the pathway to care of patients with bipolar disorder in Egypt

BACKGROUND

A large number of mentally ill patients prefer to visit non-medical practitioners such as traditional healers because of the confidence in the system, affordability and accessibility of the service. This may lead to delay in seeking psychiatric services and has prognostic impact.

AIM

To assess the rate of bipolar affective disorder (BAD) patients seeking traditional healers, the sociodemographic and clinical correlates of those patients.

METHODS

We assessed 350 patients with BAD after confirmation of diagnosis with Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I) research version and assessment of functioning with Global Assessment of Functioning scale. They were assessed for percent, rate and timing of seeking traditional healers.

RESULTS

In all, 40.8% sought traditional healers, with 34.9% more than four times. Of those, 62.2% were before seeking psychiatric services and 37.8% after. Lower educational level, less impairment of functioning and presence of hallucinations were significant correlates.

CONCLUSION

This study shows that most of the patients suffering from mental illness prefer to approach faith healers first, which may delay entry to psychiatric care and thereby negatively impact the prognosis of BAD. This highlights the importance of mental health education and developing a positive collaborative relationship with traditional healers.

Trends of indigenous healing among people with psychiatric disorders: comparative study of Arabic and Kurdish ethnicities in Iraq

Indigenous healing is commonly practiced in Middle East. Little is known about trends of indigenous therapies among patients with psychiatric disorders in Iraq. To determine and compare rates and predictors of indigenous healings by individuals with psychiatric disorders, and the practiced rituals among Arabic and Kurdish ethnicities in Iraq, patients aged 18 year and older attending outpatients in Erbil and Najaf were assessed for their prior contacts with indigenous healers. About 48.9 % had indigenous healer's consultations before visiting their psychiatrists; the figure was three times higher among Arabs than Kurds. Higher consultation rate was detected among younger and less formally educated patients. Fourteen types of religious therapeutic rituals have been practiced. Indigenous healing is widespread in Iraq. It is more common among Arabs, younger and less educated people with psychiatric disorders. Participants consider indigenous healing for their psychiatric more than non-psychiatric disorders.

Trauma profile in Egyptian adolescents with first-episode schizophrenia: relation to psychopathology and plasma brain-derived neurotrophic factor

We aimed to investigate the relation of trauma profile to schizophrenia psychopathology in a sample of Egyptian drug-naïve adolescent patients with first-episode schizophrenia. In addition, a hypothesized mediating effect of brain-derived neurotrophic factor (BDNF) in this relation was formally tested. We assessed 74 eligible outpatients using the Positive and Negative Syndrome Scale (PANSS) for measuring psychopathology. Trauma histories were recorded with the help of the Cumulative Trauma Measure. Serum BDNF levels were estimated by enzyme-linked immunosorbent assay. Total cumulative trauma, personal identity trauma, and survival trauma were found to be the significant predictors for schizophrenia psychopathology. BDNF fully mediated the associations between total cumulative trauma and overall schizophrenia psychopathology. BDNF also mediated the associations between some types of trauma and both PANSS-positive and PANSS-negative symptom factors. We concluded that total cumulative trauma and certain trauma types are linked with schizophrenia psychopathology. BDNF appears to mediate these links.

Mental illness and Egyptian families

People from Egypt have cultural belief systems about mental illness and its causes that are at variance from Anglo-Saxon-derived understandings that predominate in Australian psychiatry. These differences in understanding can affect how mental health services are experienced and accepted by this cultural group. This paper is a review of the literature on Egyptians' beliefs about mental illness and how families in Egypt cope with a relative with mental illness. Because of limited literature on Egyptians' experience with mental illness in Australia, this paper will be used to shed some light on the way in which people experience mental illness and communicate this suffering in the Australian context, based on what has been known to occur in Egypt. The Zar cult and related practices focusing on belief in the evil eye, magic, and evil possession will be explored. Historical and contemporary mental health care systems in Egypt, and the influence of education and religion are discussed. In order to provide culturally sensitive care, nurses need to be aware of possible influences on belief systems about mental illness. This paper has the potential of helping nurses to gain a deeper understanding of cultures that differ from theirs and to provide care to clients and their families based on respect for the others' beliefs, values, and practices.

Focus on psychiatry in Egypt

Mental disorders have been recognised in Egypt for millennia; 5000 years ago, they were considered to be physical ailments of the heart or uterus, as described in the Ebers and Kahun papyri (Okasha, 2001). These disorders carried no stigma, as there was no demarcation then between psyche and soma. In the 14th century – 600 years before similar institutions were founded in Europe – the first psychiatric unit was established, in Kalaoon Hospital in Cairo.

Narrative strategies in medical discourse: constructing the psychiatric 'case' in a non-western setting

The organizing goal of the present study was to analyze and understand the 'discursive presentation' of the Egyptian psychiatric patient through the texts, or narratives, contained within the patient medical charts. It is argued that the medical record, as a written document blending overt medical imperatives with more unexamined cultural assumptions about self-hood and abnormality, is an unusually rich source of discursive data concerning the 'cultural negotiations' implicit in the construction of the patient according to the two (often competing) world views represented by western biomedicine and traditional Egyptian culture. Psychiatry in Egypt is much more than a 'foreign transplant'; to assume this is to deny the culturally constructed nature of western biomedicine and psychiatry, which have their roots in historical and cultural notions of self, society, the individual, and normality versus abnormality (Transcultural Psychiat. 35(3) (1998) 352). Egyptian psychiatry is the product of an ongoing active blending of two very different conceptualizations of these issues.

Phenotypic characteristics of Obsessive-Compulsive Disorder ascertained in adulthood

Over the past decade, the increased awareness and knowledge of Obsessive-Compulsive Disorder (OCD) has allowed the in-depth study of its phenotypic characteristics. The largest studies to date have described the symptom and syndrome characteristics of treatment-seeking patients. While usefully homogeneous with regard to their current state, the clinical characteristics of patients seeking treatment may only partially represent the OCD population. We report findings from 100 self-selected volunteers at various stages of their OCD illness who were participating in a genetic study. Many similarities with past reports were found, including high rates of mood disorder, significantly more mood disorder in females as compared with males, and increased social impairment among males despite an equal amount of time in episodes of disorder. On the other hand, mean age of onset in this nontreatment seeking population was younger. Lifetime rates of obsessions and compulsions in this population were substantially higher than previous reports, suggesting that the content of obsessions and compulsions shifted over time, and evolved into a lifetime repertoire. Furthermore, a separate analysis of the age of clinically significant O-C symptom onset without impairment revealed that males and females did not differ, suggesting that previous reports of earlier onset age in males may actually reflect earlier onset of impairment. Future genetic studies may benefit from the analysis of both significant O-C symptom onset, as well as the onset of full-syndromal OCD. These findings may suggest phenotypic characteristics that define homogeneous subgroups of patients with OCD.

Phenomenology of obsessive-compulsive disorder: a transcultural study

Ninety patients suffering from obsessive-compulsive disorder (OCD) and diagnosed according to International Classification of Diseases (10th edition [ICD-10]) criteria attending the outpatient clinic of the Institute of Psychiatry in Cairo in 1991-1992 were assessed by the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) for symptomatology and severity of symptoms. Sixty-nine percent of the patients were males, and 32% were females. The mean age of the sample was 23.7 years, with a mean duration of OCD of 3.2 years. Twenty percent of patients had a positive family history for OCD. Forty percent of patients presented with a mixture of obsessions and compulsions, whereas 29% presented with obsessions and 31% with compulsions. The most commonly occurring obsessions were religious and contamination obsessions (60%) and somatic obsessions (49%), and the most commonly occurring compulsions were repeating rituals (68%), cleaning and washing compulsions (63%), and checking compulsions (58%). Seventy-one percent of patients were rated severe on the Y-BOCS, and all of them had impaired insight; 9% were insightless. The age of patients was found to correlate positively with the total compulsive score and the total Yale BOCS score, but it correlated negatively with the total obsessive score. One third of patients had a comorbid depressive disorder. Regarding premorbid personality disorders, 14% had obsessive personality disorder, 34% had paranoid, anxious, or emotionally labile personality disorder, and 52% had no premorbid personality disorder. The role of religious upbringing has been evident in the phenomenology of OCD in Egypt, which is similar to the outcomes of studies in Jerusalem and different from results in India and Britain.(ABSTRACT TRUNCATED AT 250 WORDS)

Inpatient sociodemographic and diagnostic study from a psychiatric hospital in Libya

Sociodemographic and diagnostic characteristics of 1009 patients admitted to the Psychiatry Hospital, Benghazi (Libya) in one calendar year are reported. Five hundred and four (50%) were 'first admission' cases. There were an average of 2.05 admissions for each 'readmission' case. Eighty nine percent of patients were of Libyan origin, of whom 62% were males; 66% were between 15-34 years of age, 37% were married, 28% were unemployed and 16% were in military service. ICD-9 schizophrenic psychosis was the commonest diagnosis (39%), followed by affective psychosis (17%), neurotic disorders (12%), organic psychosis (8%) and acute psychosis (7%). Neurotic depression was the commonest type of neurotic disorder and antisocial personality was the commonest among personality disorders. Relationship of sociodemographic variables with major diagnostic categories was studied in Libyan patients. Sociodemographic profiles of 'first admission' and 'readmission' cases of Libyan origin were also compared. These findings are discussed in relation to the sociocultural context.

Psychiatric diagnostic categories in Saudi Arabia

This study involves 324 new cases referred to the Psychiatric Department of King Faisal University, Dammam, Saudi Arabia, over a period of 6 months. Men outnumbered women, which is in contrast to most Western studies. There was a preponderance in the younger age groups. The interaction of cultural factors and the rapid urbanization of the Saudi society may to some extent explain the pattern.

Parents of patients with obsessive-compulsive disorder

Family histories obtained from 27 patients with obsessive-compulsive disorder failed to find a single parent with the disorder. To augment the family history data the Leyton Obsessional Inventory was completed by a subset of 10 patients and by their 20 parents. Although as a group parents showed lower Leyton Obsessional Inventory symptom scores than their obsessional offspring, 3 parents who had not been identified by family history were distinguished by high symptom scores in the absence of significant resistance or interference.

Regional differences in obsessionality and obsessional neurosis

The Leyton Obsessional Inventory was administered to 69 orthopaedic patients in Glasgow, and their responses were compared with those of 77 similar subjects in London and 73 in Cork. The responses of the Scots and the English did not differ, but both of these groups were significantly less obsessional than the Irish subjects, who were particularly likely to regard cleanliness and tidiness as virtues in themselves. Obsessionality was unrelated to age, sex, social class, family size and birth order, but higher Leyton scores were found among bachelors, and among women living in the country and without outside employment. It is suggested that the common factor among these 3 subgroups is emotional or geographic isolation, and that this may enhance any tendency to obsessional ruminations and routines. This could also account for the higher Leyton scores and greater incidence of obsessional neurosis in the Irish.

Psycho-demographic study of anxiety in Egypt: the PSE in its Arabic version

This is the first attempt to study the socio-demographic aspects of anxiety disorders in Egypt and to apply the Arabic version of the PSE in evaluating the profiles of clusters and symptoms of anxiety in a sample of 120 patients with anxiety. There were significant differences in some presentations between males and females, between illiterate and educated groups, and between those exposed to mild and severe crowding. Structured interviews like PSE will help in transcultural comparisons of clinical psychiatric disorders.

Attempted suicide. An Egyptian investigation

This study comprises 200 cases from a total of 1,155 patients who attempted suicide in 1975 and were admitted to the casualty department of Ain Shams University Hospital in Cairo, which has a catchment area comprising approximately 3 million people. A crude rate of suicide attempts in Cairo would be 38.5/100,000. There was a high percentage among the age group 15--44 years with no major differences between the two sexes. Single patients represented 53% of the total, with students showing the highest risk (40%). Depressive illnesses, hysterical reactions, and situational disorders, in that order of frequency, were the main causes of the attempt. Overdose by tablet ingestion was the most common method used (80%). Official government records are misleading and do not represent the true rate.

Thoughts on cross-cultural studies on the epidemiology of depression

A considerable number of studies have been conducted on the epidemiology of depression across cultures. These studies have relied on two basic research methods: treated cases and untreated cases. However, limitations in these two methods make it impossible to arrive at any substantive conclusions about ethno-cultural variations in the rates of depression. The treated cases approach fails to control for the fact that individuals in a culture do not have equal access to psychiatric facilities nor equal motivation to psychiatric care. The untreated cases approach, which is based on community surveys, is limited by differences in the definition of depression, the diagnostic signs used to identify depression, and variations in the degree of professional contact with the potential "cases.' In addition, current cross-cultural depression studies are faced with the problems of poor diagnostic reliability for depressive disorders and profound differences in the manifestation and experience of depression among different ethno-cultural groups. Many ethno-cultural groups do not demonstrate any of the psychological components of depression associated with its presence among Western groups. An entirely new approach to the cross-cultural study of depression appears warranted. Four steps are suggested to facilitate future studies: (1) An emic determination of disorder categories in different cultures; (2) The establishment of symptom frequency, intensity, and duration baselines, (3) Objective symptom pattern determination through multivariate data processing techniques: (4) Comparative studies using similar methodologies with culturally relevant definitions of disorder.

Psychiatric morbidity among university students in Egypt

During a nine-month period (1974-75), 1,050 students (846 male, 204 female) at Ain Shams University, Cairo, attended the Student Health Centre. Fifty-two per cent were referred there by their general practitioners, 5 per cent by their families and 3 per cent through their faculties; the remainder (41 per cent) were self-referred. Male patients represented 2-8 per cent of the male students, but female patients only 0-9 per cent of the female students. In faculties dealing with practical subjects the male-female ratio was higher than in those dealing with more theoretical subjects. The diagnoses included anxiety neurosis (36 per cent of the cases), schizophrenia (18 per cent), depression (15 per cent) and neurotic depression (12 per cent).