Psychiatric disorders following the Tunisian revolution

Acute Stress Symptoms, Intolerance of Uncertainty and Coping Strategies in Reaction to the October 7 War

BACKGROUND

On 7 October 2023, hundreds of armed Hamas fighters breached the security border fence and entered Israel from the Gaza Strip. More than 1400 Israeli citizens were murdered, and 239 individuals were kidnapped. Many Israeli citizens experienced these occurrences as psychologically traumatic events that caused stress and uncertainty.

OBJECTIVES

The present study aimed to examine the relationship between exposure to war (in more distant circles), intolerance of uncertainty (IU) and disengaged coping on acute stress symptoms (ASS). First, we examined whether exposure to war and IU were directly associated with ASS. Second, we tested the mediating role of disengaged coping in the relationship among war exposure, IU and ASS.

METHODS

This cross-sectional study involved 393 Israeli citizens. Participants answered questionnaires on exposure to war, IU, coping strategies and ASS.

RESULTS

The study results indicate that higher exposure and higher levels of IU were directly associated with more intensive ASS, and this association was partially mediated by higher use of disengaged coping strategies.

CONCLUSIONS

Individuals during wartime are at risk of experiencing high levels of ASS and developing ASD. However, degree of exposure to war alone was not associated with ASS, but it was related to personal resources and coping strategies.

Highlighting successes and challenges of the mental health system in Tunisia: an overview of services, facilities, and human resources

BACKGROUND

Tunisia is a lower-middle-income country located in North Africa with strengths and challenges to its mental health system.

AIMS

We present an overview of available services, facilities, and human resources to offer mental health care in Tunisia.

METHODS

We conducted a cross-sectional study, where data for the year 2017 was collected between May 2018 and May 2019 by consulting stakeholders involved in the health field in Tunisia. We compare this information with data published in the WHO-AIMS report (2008), which presents mental health data in Tunisia for the year 2004.

RESULTS

Successes of the mental health system in Tunisia include an increase in the ratios of psychiatrists and psychologists, with these ratios being higher than those of other lower-middle-income countries; a flourishing child-psychiatry practice; and an increase in people being treated for mental health conditions. Challenges include psychiatrists being over-represented in large cities along the coastline and in the private sector, and most people receiving treatment in specialized mental health facilities.

CONCLUSIONS

The further operationalization of the National Strategy for Mental Health Promotion is envisioned, through the training of non-specialists in mental health care and incentives offered to psychiatrists to work in the country's interior and the public sector.

Prevalence of Mood Disorders and Associated Factors at the Time of the COVID-19 Pandemic: Potocol for a Community Survey in La Manouba Governorate, Tunisia

Aims

The present survey aims to assess the overall mood disorder prevalence and identify associated socio-demographic and clinical factors in a Tunisian community sample, with special attention to the COVID-19 pandemic.

Background

Mood disorders are one of the leading causes of all non-fatal burdens of disease, with depression being at the top of the list. The COVID-19 pandemic may have increased the prevalence of mood disorders, especially in Low and Middle-income countries (LMICs) and in vulnerable populations.

Objective

1/ Assess point and lifetime prevalence of depressive and bipolar disorders as well as subthreshold bipolarity in a representative population sample of La Manouba governorate and assess treatment patterns for these disorders; 2/Study socio-demographic and clinical correlates of mood disorders 3/ Assess the association between mood disorders and quality of life 4/ Study the impact of the COVID-pandemic on the prevalence of mood disorders 5/ Assess coping mechanisms to the COVID-pandemic and whether these mechanisms moderate the appearance of mood disorders or symptoms since the beginning of the pandemic.

Methods

This is a household cross-sectional observational survey to be conducted in La Manouba Governorate in a sample of 4540 randomly selected individuals aged ≥ 15 years. Data collection will be carried out by trained interviewers with clinical experience, through face-to-face interviews and the use of the computer assisted personal interviewing approach (CAPI). The following assessment tools are administered.

Results

Structured clinical Interview for DSM IV-TR (Mood disorder section and Screening questions on Anxiety), Mood Disorder Questionnaire (MDQ), Suicide Behaviors Questionnaire-Revised (SBQ), 12-item Short Form Survey (SF-12), the Brief-COPE, and a questionnaire about a headache. In addition, socio-demographic and clinical data will be collected.

Conclusion

This will be one of the very few household surveys in a general population sample to assess mental health problems and COVID-19-related variables since the beginning of the pandemic. Through this research, we aim to obtain an epidemiological profile of mood disorders in Tunisia and an estimation of the impact of the COVID-19 pandemic on their prevalence. Results should contribute to improving mental health care in Tunisia.

Systematic Review and Meta-Analysis on Acute Stress Disorder: Rates Following Different Types of Traumatic Events

Studies investigating rates of acute stress disorder following exposure to a traumatic event report widely varying results, even when examining the same types of traumatic events. The first purpose of this systematic review and meta-analysis was to describe rates of acute stress disorder following five different types of traumatic events. The second goal was to assess the methodological and trauma-related factors influencing these rates. Between May 2017 and October 2019, studies were identified by searching through the PsychINFO, PubMed/Medline, OVID, CINAHL, Scopus, and PILOTS databases. Records were included if (1) participants were 16 years old and over, (2) the assessment was completed within 30 days of the event, (3) a standardized assessment instrument was utilized, (4) the type of traumatic event was specified, and (5) the acute stress disorder rate was reported. The list of traumatic events used for the search strategy was based on the Diagnostic and Statistical Manual of Mental Disorders and was complemented by those listed in the Life Events Checklist and the National Comorbidity Survey Replication. Seventy-three samples from 70 studies totaling 20,065 participants met inclusion criteria. Results revealed that rates of acute stress disorder ranged from 14.1% for war-related trauma to 36.0% for interpersonal trauma. Interpersonal trauma was significantly more likely to lead to acute stress disorder than other types of events, except for disaster-related trauma. Differing assessment instruments, types of exposure and geographical locations, and the intentional nature of certain events contributed to heterogeneity in rates within each type of traumatic event.

Building capacity in mental health care in low- and middle-income countries by training primary care physicians using the mhGAP: a randomized controlled trial

To address the rise in mental health conditions in Tunisia, a training based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) was offered to primary care physicians (PCPs) working in the Greater Tunis area. Non-specialists (such as PCPs)' training is an internationally supported way to target untreated mental health symptoms. We aimed to evaluate the programme's impact on PCPs' mental health knowledge, attitudes, self-efficacy and self-reported practice, immediately following and 18 months after training. We conducted an exploratory trial with a combination of designs: a pretest-posttest control group design and a one-group pretest-posttest design were used to assess the training's short-term impact; and a repeated measures design was used to assess the training's long-term impact. The former relied on a delayed-intervention strategy: participants assigned to the control group (Group 2) received the training after the intervention group (Group 1). The intervention consisted of a weekly mhGAP-based training session (totalling 6 weeks), comprising lectures, discussions, role plays and a support session offered by trainers. Data were collected at baseline, following Group 1's training, following Group 2's training and 18 months after training. Descriptive, bivariate and ANOVA analyses were conducted. Overall, 112 PCPs were randomized to either Group 1 (n = 52) or Group 2 (n = 60). The training had a statistically significant short-term impact on mental health knowledge, attitudes and self-efficacy scores but not on self-reported practice. When comparing pre-training results and results 18 months after training, these changes were maintained. PCPs reported a decrease in referral rates to specialized services 18 months after training in comparison to pre-training. The mhGAP-based training might be useful to increase mental health knowledge and self-efficacy, and decrease reported referral rates and negative mental health attitudes among PCPs in Tunisia and other low- and middle-income countries. Future studies should examine relationships among these outcome variables.

Homicide committed by individuals with severe mental illnesses: A comparative study before and after the Tunisian revolution of January 14th, 2011

BACKGROUND

Many studies have established a correlation between the increase of homicide rates, and economic crises and rapid social changes following historical events. We propose to analyse the impact of the Tunisian Revolution on homicide rates in Tunisia in a clinical population.

METHODS

We conducted a retrospective comparative study of all individuals who commited an homicide and were admitted, at least once, to the forensic psychiatry unit in Razi Hospital between January 1st, 2004 and December 31st, 2018 after a decision of irresponsibility by reason of insanity.

RESULTS

The number of homicides committed by the individuals with mental illness included in our study was multiplied by a factor of 1.3 after the revolution, with a prevalence of 11.0% between 2004 and 2011, compared to a prevalence of 14.7% during the period 2011-2018. No significant difference was noted between the two groups regarding the socio-demographic characteristics or the characteristics of the act committed.

CONCLUSION

Our results highlighted that political and socio-economic crises following the Tunisian revolution significantly contributed to an increase of homicide rates in people with severe mental illness. Thus, macro-level socioeconomic determinants would be important to consider in homicide prevention strategies.

Mental health during and after protests, riots and revolutions: A systematic review

OBJECTIVES

Protests, riots and revolutions have long been a part of human history and are increasing globally, yet their impact on mental health remains largely unknown. We therefore systematically reviewed studies on collective actions and mental health.

METHOD

We searched PubMed, Web of Science, PsycINFO and CINAHL Plus for published studies from their inception until 1 January 2018. Study quality was rated using the Newcastle-Ottawa Scale.

RESULTS

We identified 52 studies (n = 57,487 participants) from 20 countries/regions. The prevalence of post-traumatic stress disorder ranged from 4% to 41% in riot-affected areas. Following a major protest, the prevalence of probable major depression increased by 7%, regardless of personal involvement in the protests, suggestive of community spillover effects. Risk factors for poorer mental health included female sex, lower socioeconomic status, exposure to violence, interpersonal conflicts, frequent social media use and lower resilience and social support. Nevertheless, two studies suggested that collective actions may reduce depression and suicide, possibly due to a collective cathartic experience and greater social cohesion within subpopulations.

CONCLUSION

We present the first systematic review of collective actions and mental health, showing compelling evidence that protests even when nonviolent can be associated with adverse mental health outcomes. Health care professionals therefore need to be vigilant to the mental and psychological sequelae of protests, riots and revolutions. Further research on this emerging sociopolitical determinant of mental health is warranted.

IgA is the predominant isotype of anti-β2 glycoprotein I antibodies in rheumatoid arthritis

Background

The aim of this study was to determine the frequency of anti‐cardiolipin antibodies (aCL) and anti‐β2 glycoprotein I antibodies (aβ2GPI) among Tunisian patients with rheumatoid arthritis (RA).

Methods

Ninety RA patients with positive anti‐cyclic citrullinated antibodies (anti‐CCP) and 90 healthy blood donors (HBD) were studied. aCL and aβ2GPI of isotype IgG, IgA and IgM were detected by ELISA.

Result

The frequency of antiphopholipid antibodies (aPL) (aCL and/or aβ2GPI) was significantly higher in patients with RA than in HBD (35.5% vs 11.1%, P = .0001). The frequencies of aCL and aβ2GPI were significantly higher in patients than in healthy subjects (15.5% vs 5.5%, P = .04 and 32.2% vs 11.1%, P = .0005 respectively). aβ2GPI‐IgA were significantly more frequent in patients than in the control group (26.7% vs 7.8%, P = .0007). In patients, aβ2GPI‐IgA were significantly more frequent than aβ2GPI‐IgG (26.7% vs. 6.7%, P = .0003) and aβ2GPI‐IgM (26.7% vs 5.6%, P = .0001). In RA patients, the frequency of aβ2GPI was significantly higher than that of aCL (32.2% vs 15.5%, P = .008). aβ2GPI‐IgA was significantly more frequent than aCL‐IgA (26.7% vs 4.4%, P = .00005). The average titer of anti‐CCP in aPL positive patients was significantly higher than in aPL negative patients (170.6 ± 50 RU/mL vs 147.7 ± 51 RU/mL, P = .04). Significant correlation was found between aβ2GPI‐IgA and anti‐CCP (r = .235, P = .026).

Conclusions

aPL and particularly aβ2GPI‐IgA are frequent in RA and are correlated with anti‐CCP.

"We find what we look for, and we look for what we know": factors interacting with a mental health training program to influence its expected outcomes in Tunisia

BACKGROUND

Primary care physicians (PCPs) working in mental health care in Tunisia often lack knowledge and skills needed to adequately address mental health-related issues. To address these lacunas, a training based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) was offered to PCPs working in the Greater Tunis area between February and April 2016. While the mhGAP-IG has been used extensively in low- and middle-income countries (LMICs) to help build non-specialists' mental health capacity, little research has focused on how contextual factors interact with the implemented training program to influence its expected outcomes. This paper's objective is to fill that lack.

METHODS

We conducted a case study with a purposeful sample of 18 trained PCPs. Data was collected by semi-structured interviews between March and April 2016. Qualitative data was analyzed using thematic analysis.

RESULTS

Participants identified more barriers than facilitators when describing contextual factors influencing the mhGAP-based training's expected outcomes. Barriers were regrouped into five categories: structural factors (e.g., policies, social context, local workforce development, and physical aspects of the environment), organizational factors (e.g., logistical issues for the provision of care and collaboration within and across healthcare organizations), provider factors (e.g., previous mental health experience and personal characteristics), patient factors (e.g., beliefs about the health system and healthcare professionals, and motivation to seek care), and innovation factors (e.g., training characteristics). These contextual factors interacted with the implemented training to influence knowledge about pharmacological treatments and symptoms of mental illness, confidence in providing treatment, negative beliefs about certain mental health conditions, and the understanding of the role of PCPs in mental health care delivery. In addition, post-training, participants still felt uncomfortable with certain aspects of treatment and the management of some mental health conditions.

CONCLUSIONS

Findings highlight the complexity of implementing a mhGAP-based training given its interaction with contextual factors to influence the attainment of expected outcomes. Results may be used to tailor structural, organizational, provider, patient, and innovation factors prior to future implementations of the mhGAP-based training in Tunisia. Findings may also be used by decision-makers interested in implementing the mhGAP-IG training in other LMICs.

Exposure to community and collective violence during childhood and tobacco use patterns among young adults in Tunisia

Accumulating evidence demonstrates that experiencing intrafamilial adversities (abuse, neglect and household dysfunction) during childhood is linked to addictive behaviours. However, the impact of social adversities (peer, community and collective violence) as well as gender, on tobacco initiation and dependence has received much less attention. The aim of this study was to examine the relationships between social childhood adversities and tobacco use patterns by gender among young adults in Tunisia. We performed a cross-sectional study from May to December, 2014 on 1,200 respondents using the validated Arabic version of the World Health Organization Adverse Childhood Experiences-International questionnaire (WHO ACE-IQ). Data on smoking characteristics among current smokers were also collected. Data analysis was performed using logistic and linear regression models. The rate of current tobacco use was significantly higher for males (43.9%) than for females (9.3%). Female and male respondents differed significantly on almost every examined adversity. Males were more likely to have experienced all types of social violence than females. The odds of tobacco use were significantly higher regardless the mental health status and the occurrence of intrafamilial early life adversity for both genders. Smokers exposed to social violence during childhood had a strong association between nicotine dependence and the overall burden of adversity. That is, 74 and 58% of nicotine dependence was explained by the number of childhood social adversities in females and males respectively. The findings underscore the role of community and collective violence in addictive behaviours among young adults. Multisectorial and population-based strategies are needed to minimise the occurrence of social early life adversity and related tobacco patterns.

Mental health knowledge, attitudes, and self-efficacy among primary care physicians working in the Greater Tunis area of Tunisia

BACKGROUND

Non-specialists' involvement in mental health care is encouraged in the field of global mental health to address the treatment gap caused by mental illness, especially in low- and middle-income countries. While primary care physicians (PCPs) are involved in mental health care in Tunisia, a lower-middle-income country in North Africa, it is unclear to what extent they are prepared and willing to address mental health problems, substance use disorders, and suicide/self-harm. In this context, we aim (1) to report on mental health knowledge, attitudes, and self-efficacy among a sample of PCPs working in the Greater Tunis area, prior to the implementation of a mental health training program developed by the World Health Organization; and (2) to identify what characteristics are associated with these competencies.

METHODS

In total, 112 PCPs completed questionnaires related to their socio-demographic and practice characteristics, as well as their mental health knowledge, attitudes, and self-efficacy. Descriptive analyses and regression models were performed.

FINDINGS

PCPs had more knowledge about depression, symptoms related to psychosis, and best practices after a suicide attempt; had favourable attitudes about distinctions between physical and mental health, learning about mental health, and the acceptance of colleagues with mental health issues; and believed most in their capabilities related to depression and anxiety. However, most PCPs had less knowledge about substance use disorders and myths about suicide attempts; had unfavorable attitudes about the dangerousness of people with mental health problems, personal disclosure of mental illness, non-specialists' role in assessing mental health problems, and personal recovery; and believed the least in their capabilities related to substance use disorders, suicide/self-harm, and psychosis. Participation in previous mental health training, weekly hours (and weekly hours dedicated to mental health), weekly provision of psychoeducation, and certain work locations were associated with better mental health competencies, whereas mental health knowledge was negatively associated with weekly referrals to specialized services.

CONCLUSIONS

Findings suggest that PCPs in our sample engage in mental health care, but with some gaps in competencies. Mental health training and increased interactions/involvement with people consulting for mental health issues may help further develop non-specialists' mental health competencies, and integrate mental health into primary care settings.

Tailoring a training based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) to Tunisia: process and relevant adaptations

BACKGROUND

In order to make mental health services more accessible, the Tunisian Ministry of Health, in collaboration with the School of Public Health at the University of Montreal, the World Health Organization office in Tunisia and the Montreal World Health Organization-Pan American Health Organization Collaborating Center for Research and Training in Mental Health, implemented a training programme based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) (version 1.0), developed by the World Health Organization. This article describes the phase prior to the implementation of the training, which was offered to general practitioners working in primary care settings in the Greater Tunis area of Tunisia.

METHODS

The phase prior to implementation consisted of adapting the standard mhGAP-IG (version 1.0) to the local primary healthcare context. This adaptation process, an essential step before piloting the training, involved discussions with stakeholder groups, as well as field observations.

RESULTS

Through the adaptation process, we were able to make changes to the standard training format and material. In addition, the process helped uncover systemic barriers to effective mental health care.

CONCLUSIONS

Targeting these barriers in addition to implementing a training programme may help reduce the mental health treatment gap, and promote implementation that is successful and sustainable.