Parental alienation in Lebanon: a case report

BACKGROUND

Parental alienation is a relatively newly described disorder, with a growing prevalence, as divorce and custody battles are becoming more and more complex with increased difficulty of joint custody. In parental alienation, one parent, the alienating parent, forms an alliance with the child involved in the custody dispute and manages to effectively alienate the targeted parent completely. The child and the alienating parent manifest a form of folie à deux and, hence, are in complete synchrony in the hatred and denigration of the targeted parent. Issues, such as potentially false allegations of sexual, physical, and emotional abuse of the child by the targeted parent, arise. The child and the alienating parent become mutually convinced of the targeted parent's transgressions. Consequently, it becomes difficult for the courts and psychiatric professionals to differentiate true abuse from parental alienation.

CASE PRESENTATION

In this case study, we aimed to conduct an in-depth psychological and psychiatric evaluation of a Lebanese family (white race) where a father was wrongly accused by the mother and his 11-year-old white boy of both physical and sexual abuse. The data for this study were collected through unstructured and semi-structured interviews, observations, and psychological tests (Rorschach test for the parents and Blacky test for the child), and through the analysis of documented evidence presented in the trial.

CONCLUSION

This case manifested most criteria set forth for the diagnosis of parental alienation and created serious doubt regarding the validity of the allegations set forth by the mother and the child. Uncovered parental alienation often misleads mental health professionals at the expense of the child's mental health .

The association between long-distance migration and PTSD prevalence in Syrian refugees

BACKGROUND

Refugees are forced migrants but there is a large variation in the distance that refugees cover and there is a paucity in the evidence of how this may affect refugees' health and health care needs.

OBJECTIVE

We investigated the association between long-distance migration and post-traumatic stress disorder (PTSD), a serious psychiatric disorder associated with deteriorating mental and somatic health.

METHODS

Included from 2016-2019 were adult Syrian refugees in Lebanon and Denmark that arrived up to 12 months prior to inclusion. PTSD was assessed using the Harvard Trauma Questionnaire and the estimate of association was obtained by multiply imputing missing data and adjusting for confounding by propensity score-weighting with covariates age, sex, socioeconomic status, trauma experience and general mental well-being, reporting the bootstrap 95-percentile confidence interval (95% CI). Additionally, a number of sensitivity analyses were performed.

RESULTS

Included were 599 participants in Lebanon (mean age 35 years old, 73% being female) and 133 participants in Denmark (mean age 30 years old, 47% being female). After multiply imputing missing data and propensity score-weighted adjustment for confounding, migration to Denmark instead of Lebanon was associated with an increase in PTSD prevalence of 9 percentage point (95% CI [-1; 19] percentage point).

CONCLUSIONS

Long-distance migration may be associated with an increase in PTSD prevalence in refugees. The migration could be an important factor to consider when assessing refugees' and asylum seekers' health. Practitioners should consider "long-distance migration" in refugee health screenings and in particular when assessing the risk of post-traumatic stress disorder. Future research should be designed to ultimately lead to studies of relevant interventions to lower the risk of post-traumatic stress disorder in refugees.

The prevalence of post-traumatic stress disorder increased in refugees after long-distance migration

Background

Refugees are forced migrants but there is a large variation in the distance that refugees cover. This may importantly affect their health needs. Previous studies suggest an inverse association between long-distance migration and self-rated health in the general population, possibly related to difficulty in acculturation but there is a knowledge gap in the health effects of migration in refugee populations. Here, we estimate the association between long-distance migration and post-traumatic stress disorder (PTSD), a severe mental health disorder associated with deteriorating psychiatric and somatic health and highly prevalent in refugees.

Methods

Included were 712 adult Syrian refugees and asylum seekers in Lebanon and Denmark arriving no more than 12 months prior to inclusion. The Harvard Trauma Questionnaire was used to assess PTSD and the estimate of association was obtained by multiply imputing missing data and adjusting for confounding by propensity score-weighting with covariates age, sex, socioeconomic status, trauma experience, and WHO-5-score, reporting the bootstrap 95-percentile confidence interval (CI). Additionally, a number of sensitivity analysis were carried out.

Results

The prevalence of PTSD was high in both Lebanon (55%) and Denmark (60%). After adjusting for biases the prevalence difference increased from 5 percentage point (95-percentile CI [-5; 15] percentage point) to 9 percentage point (95-percentile CI [-1; 19] percentage point). All sensitivity analysis produced estimates of the same direction and magnitude, except when grossly violating the assumption of multiple imputation which halved the magnitude of the association.

Conclusions

We found that long-distance migration was associated with an increase in the prevalence of PTSD among newly arrived Syrian refugees and asylum-seekers. This is a first step in examining the effects of migration in refugee health.

Key messages

Long-distance migration was positively associated with prevalence of post-traumatic stress disorder in Syrian refugees. This is a first step to investigate the impact of migration in refugee health.

1217The prevalence of post-traumatic stress disorder in Syrian refugees increased after long-distance migration

Background

Refugees are forced migrants but there is a large variation in the distance that refugees cover. Previous studies suggest an inverse association between long-distance migration and self-reported health in the general population but there is a knowledge gap in the health effects of migration in refugee populations. Here, we estimate the association between long-distance migration and post-traumatic stress disorder (PTSD), a severe mental health disorder associated with deteriorating mental and somatic health.

Methods

Included were 712 adult Syrian refugees and asylum seekers newly arrived in Lebanon and Denmark. PTSD was assessed using the Harvard Trauma Questionnaire, confounding was handled by propensity score-weighting with covariates age, sex, socioeconomic status, trauma experience, and WHO-5-score after multiply imputing missing data, and the 95-percentile confidence interval (CI) was computed by bootstrapping.

Results

The prevalence of PTSD was high in both Lebanon (55%) and Denmark (60%). After adjusting for biases the prevalence difference increased to 9 percentage point (95-percentile CI: [-1; 19] percentage point). All sensitivity analysis produced estimates of the same magnitude and direction, except when grossly violating the assumption of multiple imputation which halved the magnitude of the association.

Conclusions

Long-distance migration was associated with an estimated 87 additional cases of PTSD for every 1000 Syrian refugees. This is a first step in examining the effects of migration in refugee health.

Key messages

Long-distance migration was positively associated with prevalence of post-traumatic stress disorder in Syrian refugees.

Asylum seekers' and Refugees' Changing Health (ARCH) study protocol: an observational study in Lebanon and Denmark to assess health implications of long-distance migration on communicable and non-communicable diseases and mental health

INTRODUCTION

By end of 2018, the European Union countries hosted approximately 2.5 million refugees and Lebanon alone hosted more than 1 million. The majority of refugees worldwide came from Syria. The prevailing study design in published studies on asylum seekers' and refugees' health leaves a number of fundamental research questions unanswerable. In the Asylum seekers' and Refugees' Changing Health (ARCH) study, we examine the health of a homogeneous group of refugees and asylum seekers in two very different host countries with very different migration histories. We aim to study the health impact of the migration process, living conditions, access to healthcare, gene-environment interactions and the health transition.

METHODS AND ANALYSIS

ARCH is an international multisite study of the health of adult (>18 years old) Syrian refugees and asylum seekers in Lebanon and Denmark. Using a standardised framework, we collect information on mental and physical health using validated scales and biological samples. We aim to include 220 participants in Danish asylum centres and 1100 participants in Lebanese refugee camps and settlements. We will use propensity score weights to control for confounding and multiple imputation to handle missing data.

ETHICS AND DISSEMINATION

Ethical approval has been obtained in Lebanon and Denmark. In the short term, we will present the cross-sectional association between long-distance migration and the results of the throat and wound swab, blood and faeces samples and mental health screenings. In the longer term, we are planning to follow the refugees in Denmark with collection of dried blood spots, mental health screenings and semistructured qualitative interviews on the participant's health and access to healthcare in the time lived in Denmark. Here, we present an overview of the background for the ARCH study as well as a thorough description of the methodology.

Aripiprazole-Induced Hyperlipidemia: An Update

OBJECTIVE

To review the literature on the metabolic side effects of aripiprazole. Three cases of aripiprazole-induced hypertriglyceridemia are also presented.

DATA SOURCES

A search was conducted of English-language articles and abstracts (meta-analyses, randomized controlled trials, clinical trials, naturalistic open-label trials, reviews, and case reports) published up to August 31, 2014, in electronic databases (PubMed, MEDLINE).

STUDY SELECTION

Free-text and MeSH search keywords included aripiprazole, cholesterol, triglyceride, lipid profile, hyperlipidemia, and hypercholesterolemia and their differing terminations and combinations. The search was supplemented by a manual review of reference lists from the identified publications. Pediatric studies were excluded.

DATA EXTRACTION

Twenty-two articles were found and 3 aspects of the metabolic side effects of aripiprazole were reviewed: (1) the prevalence of the metabolic syndrome in mentally ill patients prior to any antipsychotic use to highlight the initial predisposition of this group of patients to develop the metabolic syndrome, (2) the prevalence of metabolic changes depending on the choice of antipsychotic (aripiprazole compared to other antipsychotics), and (3) metabolic changes reported after switching from an antipsychotic to aripiprazole.

RESULTS

Patients with mental disorders are at high risk for developing dyslipidemia, diabetes, and the full criteria of the metabolic syndrome. Antipsychotic use exacerbates this risk, thus increasing the mortality in this population. Nevertheless, it seems that the risk for these side effects varies with each antipsychotic. Although by and large the literature supports the supposition that aripiprazole causes less metabolic effects than other antipsychotics, we report 3 cases of serious aripiprazole-related dyslipidemia in young subjects.

CONCLUSION

On the basis of these 3 cases, aripiprazole can cause hypertriglyceridemia. Triglyceride levels should be carefully monitored in patients with mental disorders taking aripiprazole.

Prevalence of Depression in Medical Students at the Lebanese University and Exploring its Correlation With Facebook Relevance: A Questionnaire Study

Background

The prevalence of major depression is particularly high in medical students, affecting around one-third of this population. Moreover, online social media, in particular Facebook, is becoming an intrinsic part in the life of a growing proportion of individuals worldwide.

Objective

Our primary objective is to identify the prevalence of depression in medical students at the Lebanese University Faculty of Medicine, a unique state university in Lebanon, its correlation with the utilization of the interactive features of Facebook, and the way students may resort to these features.

Methods

Students of the Lebanese University Faculty of Medicine were assessed for (1) depression and (2) Facebook activity. To screen for major depression, we used the Patient Health Questionnaire-9 (PHQ-9) scale. To test for Facebook activity, we developed the Facebook Resorting Questionnaire (FbRQ), which measures the degree to which students resort to Facebook.

Results

A total of 365 out of 480 students (76.0%) participated in the survey. A total of 25 students were excluded, hence 340 students were included in the final analysis. Current depression was reported in 117 students out of 340 (34.4%) and t tests showed female predominance. Moreover, PHQ-9 score multiple regression analysis showed that feeling depressed is explained 63.5% of the time by specific independent variables studied from the PHQ-9 and the FbRQ. Depression varied significantly among the different academic years (P<.001) and it peaked in the third-year students. One-way analysis of variance (ANOVA) showed that depression and resorting to Facebook had a positive and significant relationship (P=.003) and the different FbRQ categories had significant differences in resorting-to-Facebook power. The like, add friend, and check-in features students used when resorting to Facebook were significantly associated with depression.

Conclusions

This study showed that depression was highly prevalent among students of the Faculty of Medicine at the Lebanese University. Moreover, Facebook may be a promising, helpful, psychological tool for optimizing the management of depression. Our study brought to bear further questions that now prompt further observation and scrutiny to know more about the high rates of depression in this student population, more so in the part of the world studied, and to the growing role of social media.

A Critical Comprehensive Review of Religiosity and Anxiety Disorders in Adults

Over the past three decades, there has been increasing research with respect to the relation of religion and mental health disorders. Consequently, the current article aims to first provide a comprehensive literature review of the interplay between different domains of religiosity and a wide variety of categorical anxiety disorders in adults, and secondly, to uncover the major methodological flaws often yielding mixed, contradictory and unreliable results. The search was conducted using the PubMed/Medline database and included papers published between 1970 and 2012, under a rigorous set of inclusion/exclusion criteria. A total of ten publications were retained as part of the current study, and three main outcomes were identified: (1) certain aspects of religiosity and specific religious interventions have mostly had a protective impact on generalized anxiety disorder (40% of the studies); (2) other domains of religiosity demonstrated no association with post-traumatic stress disorder (30% of the studies); and (3) mixed results were seen for panic and phobic disorders.

Hyperammonemia induced by interaction of valproate and quetiapine

INTRODUCTION

Hyperammonemia is one of the rare nevertheless serious side effects associated with valproic acid treatment. Two cases of valproic acid induced hyperammonemia are detailed in this article.

CASES

Case one describes an adult male who developed hyperammonemia after acute exposure to valproic acid as a treatment for his bipolar disorder-manic episode. Case two developed a similar pattern of toxicity but after chronic exposure to valproic acid. Both patients were receiving a combination of valproic acid and quetiapine.

DISCUSSION

Measurement of the ammonium level should be considered where there is a decreased level of consciousness in patients receiving valproic acid irrespective of the diagnosis and even after a long term exposure. A possible risk of hyperammonemia can result from a combination of valproic acid and quetiapine, however further studies are yet needed to confirm this hypothesis.

A general population survey on patterns of benzodiazepine use and dependence in Lebanon

OBJECTIVE

In Lebanon, benzodiazepines are often available without medical prescription. We aimed to carry out the first community-based pharmaco-epidemiological study on benzodiazepine consumption in the Middle East Area.

METHOD

The prevalence of past-month benzodiazepine use was assessed in a 1000-subject randomized sample from the Lebanese community, and risk factors were studied in a group of 496 current users.

RESULTS

Benzodiazepine use during the past month was found in 9.6% of subjects. Four variables were significantly associated with use: age higher than 45 years, female sex, cigarette smoking and the existence of a recent life event. Benzodiazepine dependence was found in 50.2% of users.

CONCLUSION

Benzodiazepine use in Lebanon is particularly high, and can be related to well-known factors such as female sex and age, but other potent specific variables, such as war stress or the lack of control on drug access, can be hypothesized.

[Atypical neuroleptics in the child and adolescent]

The FDA approval for clozapine in 1990 under several hematologic surveillance conditions has reactualized the debate on the use of atypical neuroleptics for adults with schizophrenia. The use of conventional neuroleptics in children and adolescents has always been a subject of controversy due to their side effects and the absence of controlled studies. The pharmacological action of clozapine and risperidone is mainly on D2 and 5HT. Since 1992 several studies concerning children and adolescents show the efficiency and the tolerance of the clozapine and risperidone in various disorders, especially in very early onset schizophrenia (VEOS). Controlled trials are necessary to confirm the data obtained in open studies.