ARAB FEDERATION OF PSYCHIATRISTS
اﻟﻤﺠﻠﺪ ٣١ اﻟﻌﺪد اﻟﺜﺎﻧﻲ ﻧﻮﻓﻤﺒﺮ٢٠٢٠ Vo.31 No .2 Nov. 2020
The Arab Journal of Psychiatry (2020) Vol. 31 No.2
The Arab Journal of Psychiatry Editorial Board
Editor in Chief Associate Editors Statistics Consultant Walid Sarhan - Jordan Abdul Manaf Aljadri - Jordan Kathy Sheehan - USA Founder and Past Editor in Chief Numan Ali - Iraq Adnan Takriti - Jordan Adib Essali - New Zealand Executive Secretary Deputy Editors Fakher Eleslam - Egypt Raja Nasrallah - Jordan Momtaz Abdelwahab - Egypt Elie Karam - Lebanon Jamel Turkey - Tunisia Treasurer Tarek Al Habib - Saudi Arabia English Language Editor Hussein Alawad - Jordan Honorary Editors Tori Snell – UK Website: Ahmad Okasha - Egypt http://arabjournalpsychiatry.com
Editorial Board Nasser Shuriquie - Jordan Nayel Aladwan - Jordan Elham Khatab - Iraq Basil Alchalabi - Iraq Amjad Jumaian - Jordan Mohamad Abo Saleh - UK Wail Abohemdy - Egypt Abdalhamid Al Ali - Jordan Malek Bajbouj - Germany George Karam - Lebanon Tareq Okasha - Egypt Charlotte Kamel - Bahrain Adel Zayed - Kuwait Samah Jaber - Palestine Ahmad Alhadi - Saudi Arabia Afaf Hamed - Egypt Ali Alqam - Jordan Khaled Abd El Moez - Egypt Maha Yonis - Iraq Ziad Alarandi- Palestine Hassan Almaleh - Syria Issam Alansari - Kuwait Aimee Karam - Lebanon Hamed Alsinawi - Oman Munther Al Muqbali -Oman Suhaila Ghuloum - Qatar Yousra Alatiq - Saudi Arabia Medhat Elsabbahy - UAE Nasser Loza - Egypt Mazen Hedar - Syria Mazen Hamoudi - UAE Hani Hamed - Egypt Munir Al Aboushi Saudi Arabia Charles Baddoura -Lebanon Qassim Al-Awadi - Iraq Driss Moussaoui - Morocco Tareq Molokhia - Egypt Mai Eisa – Egypt Hisham Ramy - Egypt
Editorial Assistants - Jordan Radwan Bani Mustafa Mohamad Dabbas Nayel Al Adwan Tayseer Elias Basma Kilani Hashem Fakhouri Bahjat Abderrahim Ahmad Jaloudi Ahid Husni Jana Zabalawi Walid Shnaiqat Mohamad Shoqirat Nesrin Dabbas Ahmad Alsalem Nasri Jasser Lara Alqam Ayman Rabie Mohamad Shakour Lyali Abbasi Naim Jaber Zuhair Dabagh Saed Al-Shunnaq Nabil Alhmoud Alaa Albeshtawi Maher Al-Asasleh Ahmad yousef Maen Alabki Maxim Obaisat Raafat Abo Rumman Mohamad Awab Abu Danoon Saleh El Helou Abdallah Abu Adas Nader Smadi Najib Alqsous Ahmad Dabour Malik Alwan Tareq Hijawi Faris Barham Faiq Shaban Mohamad AbuSalih Awni Abu Halimah Ahmad Al Masri Ahmad Alghzawi Laith Abbadi Montaser Hyari
The Arab Journal of Psychiatry (2020) Vol. 31 No.2
Instruction to Authors
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Example of references: Zeigler FJ, Imboden, JB, Meyer E. Contemporary conversion reactions: a clinical study. Am. J. Psychiatry 1960: 116:901 – 10. Mosey AC. Occupational therapy. Configuration of a profession. New York: Raven Press, 1981.
Mailing Address: Dr. Walid Sarhan - The Chief Editor -The Arab Journal of Psychiatry P.O. Box 541212 Postal Code 11937 Amman – Jordan Tel: 00962 – 6 – 5335446 Fax: 00962 – 6 – 5349763 Email: [email protected], [email protected] Journal Website: http://arabjournalpsychiatry.com/ The Arab Journal of Psychiatry (0202) Vol. 31 No.2
Letter from the Editor
November 2020
Dear Colleagues, COVID-19 continues to hold the world’s attention and focus during these unprecedented times. The current volume of the Arab Journal of Psychiatry includes several articles in which the mental health effects of the virus are well considered. Important themes are emerging that point to notable areas of required study, such as the neuropsychological sequelae for survivors of the disease and the psychological and psychiatric morbidity experienced by frontline staff.
I encourage you to keep going with your investigations into these burgeoning areas of scientific research and to submit what you discover to the AJP for publication. Together we provide strong representation for the Middle East and North Africa to the rest of the world by showcasing the best possible articles that reflect our knowledge of the impact of war and conflict on our communities; our insights into culture and mental health; and our rich history. I hope you enjoy this latest edition, which reflects the collaborative efforts of many Arab and Western researchers as well as the singular efforts of esteemed colleagues.
Sincerely, Walid Sarhan
Editor-in-Chief Amman, Jordan The Arab Journal of Psychiatry (2020) Vol. 31
Table of Contents
Review article
. Current Pharmacological Treatment of Obsessive-Compulsive Disorder Sudad Jawad Al-Timimi, Nahla Fawzi Jamil ………………………………………………………………...……. 98
COVID-19
. Anxiety in Lebanon during the COVID-19 Pandemic Emilio Alhachem, Georges Haddad, Eliane Nagib, Werner Ikdais, Myriam Akkari …………………………….. 105 . COVID-19 Outbreak in a Locked Psychiatric Rehabilitation Unit and the Impact on Patients Treated with Clozapine Sudad J Al-Timimi, Alistair Sinfield, Nahla F Jamil ………………………………………………………………120 . Neurological and Psychiatric Consequences of COVID-19 Epidemic Adib Essali ……………………………………………………………………………………………………..….124
Original papers
. Saudi Adolescents’ Reports of the Relationship between Parental Factors, Social Support and Mental Health Problems Nouf Abdullah Alshehri, Murat Yildirim & Panos Vostanis ……………………………………………………. 130 . Attitudes of Undergraduate Medical Students in Baghdad Toward Mental Disorders and People with Mental Health Difficulties Raad Saady Madhloom, Numan S Ali, Tori Snell ………………………………………………………………....144 . Body Image Disturbance and Self-Esteem after Hysterectomy in Egyptian Women Mohamed Adel El-Hadidy; Abdelhady Zayed ………………………………………………………………….... 150 . Assessment of Mental Health Literacy of Depression and Suicide among Undergraduate Medical Students: A Cross-Sectional Study Eman Elsheshtawy, Miriam Simon, Sirous Golchinheydari, Jawaher Al Kharusi ……………………………...…159 . Mental Health and Psychosocial Challenges Facing Adolescent Girls in Conflict-Affected Settings: The Case of the Gaza Strip Bassam Abu Hamad, Nicola Jones and Fiona Samuels …………………………………………………………... 169 . Eating Disorder Symptoms among Medical Students at Suez Canal University Sarah E. Bakr, Magda T. Fahmy, Khaled A. Mohamed, Haydy H. Said …………………………………………. 181
History
. Bimaristan Arghun Al-Kamili in Aleppo, Syria: A Mental Hospital with Unique Architecture Designed to Meet Patient Need in Medieval Islam (1354 AD) Mohammed T Abou-Saleh, Ihsan M Salloum ……………………………………………………………………. 191
Book review
. I Lived Life Jana Zabalawi…………………………………………………………………………………………………….. 196
The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (98 - 104) (doi-10.12816/0056860)
Current Pharmacological Treatment of Obsessive-Compulsive Disorder
Sudad Jawad Al-Timimi, Nahla Fawzi Jamil
العالج الدوائي الحالي الضطراب الوسواس القهري
سداد جواد التميمي ونهلة فوزي جميل
Abstract
bsessive-Compulsive Disorder (OCD) has moved from an anxiety disorder to a new distinct group of mental O disorders. The pharmacological basis for management of OCD is now better understood, and the guidelines for use of medication have proliferated in the past few years. This article reviews the current recommendations and the basis for the use of medication for the treatment of OCD.
Key words: Obsessive-Compulsive Disorder, drug treatment
Declaration of interest: None
Introduction
Obsessive Compulsive Disorder (OCD) remains one of is further qualified according to insight (fair-good, and the most challenging mental disorders to manage in poor-absent), and with panic attacks. clinical practice. The symptoms of OCD are often detected in other psychiatric disorders, and their Body Dysmorphic Disorder (BDD) is classified under management could be equally challenging. OCD affects OCRD. Although BDD criteria aresimilar to the 2-3% of the population. Indeed, the relationship between Diagnostic and Statistical Manual of Mental Disorders, various psychiatric disorders and OCD are largely Fifth Edition (DSM-5), but even if the beliefs are speculative. Individuals with OCD might experience considered delusional by the examining psychiatrist, a additional diagnoses during the course of their illness diagnosis of Delusional Disorder is not made. starting from early teens, which further complicates the Hypochondriasisis grouped underneath OCRD as well clinical picture as well as the management of the OCD as secondary under anxiety and fear related disorders. itself and the co-morbid psychiatric disorder. OCD might Absent insight does not qualify for a diagnosis of a coexist with organic disorders, autism, tics, affective Delusional Disorder similar to BDD. disorders, schizophrenia, anxiety disorders, and personality disorders. All these factors have contributed Other diseases classified under OCRD include Hoarding to the challenges faced by clinicians in managing OCD Disorder, Hair-Pulling Disorder, Excoriation Disorder, using psychological therapies, and most importantly and Tourette Syndrome. pharmacological treatments. The current review focuses on drug treatment of OCD and Obsessive-Compulsive Treatment of OCD Related Disorders as defined by the forthcoming Treatment of OCD should not differ from any mental th International Classification of Diseases, 11 Revision disorder, and there is always a need to measure the (ICD-11). severity of symptom and their impact on a person’s functioning. Mild to moderate OCD as evident by the Current Classification of OCD Yale-Brown Obsessive Compulsive Scale (Y-BOCS),2 of It is essential to have an overview of the forthcoming a score 8-23, is initially treated by Exposure and ICD-11 as OCD and related disorders will be Response Prevention (ERP)3 if available with or without incorporated in Obsessive-Compulsive and Related pharmacological treatment.4 However, it is not disorders (OCRD).1 OCD diagnosis remains largely uncommon for patients to prefer pharmacological unchanged focusing on the presence of obsessions and/or therapy alone following initial presentation. It is compulsions, with a range of affective components and generally accepted that psychodynamic psychotherapy is in particular obsessions commonly causing anxiety. OCD ineffective in the treatment of OCD.5 Combined
98 Current Pharmacological Treatment of Obsessive-Compulsive Disorder
treatment of ERP and pharmacotherapy is indicated in all leads to recurrence of the disorder.7 Patients with OCD severe cases. do not experience the latter phenomena, and depletion of serotonin levels in patients recovered by use of an SSRI SRIs and OCD levels do not experience a relapse probably as a result of The use of Serotonin Reuptake Inhibitors (SRIs) in the post synaptic 5-HT receptor changes following 7 treatment of OCD started with Clomipramine6 a potent treatment. It is likely that the latter mechanism also SRI, which is classified as a Tricyclic Antidepressant explains the late onset of therapeutic effect in OCD (TCA) that clarified the role of serotonin in the estimated at 12 weeks compared to less than six weeks in 8 neurochemistry of the disease. Clomipramine proved to cases of depression. be superior to other TCAs, Mono Amine Oxidase SSRIs are the most commonly used medication in the (MAO) inhibitors, benzodiazepines, and wasreferred to treatment of OCD because of their benign side effects as anti-obsessional drug. It targets the 5-HT transporter profile and strong evidence of efficacy.9 Their use is now protein, which mediates the uptake of intrasynaptic 5-HT generally accepted in children (aged >7 years)10,11,12 as leading to increase of intrasynaptic 5-HT concentrations. well as adults suffering from OCD. A longer initial Treatment of depression with SRI and Selective period of treatment is required to assess clinical response Serotonin Reuptake Inhibitors (SSRIs) requires preferably based on the Y-BOCS8 compared to the continued availability of Presynaptic 5-HT for treatment of depression. Similarly, higher doses are often maintenance treatment, and in patients receiving an SSRI required to achieve a response in comparison to the whose depression is in remission, decreased serotonin treatment of depression.8
Figure 1. 5-HT reuptake inhibition constitute the main mode of managing OCD. Patients with OCD do not experience disruption of SSRI therapeutic effects under conditions of 5-HT depletion pointing towards long-term postsynaptic 5-HT receptor changes.7,8 TRP: Tryptophan. Please refer to text.
Table 1. SRIs in OCD
Drug Initial dose(mg) daily Maximum dose(mg)daily Fluoxetine 20 80 Fluvoxamine 50 300 Sertraline 50 200 Paroxetine 20 60 Citalopram 20 60 Escitalopram 20 40 Clomipramine 25 250
99 Al-Timimi SJ, Jamil NF
Fluoxetine 20mg daily is the starting dose in adults with inhibitor. It is available as immediate - release or increments adjusted by clinical response every two to extended release preparation and can be used in children. three weeks up to 60mg daily. Higher doses of 80 and The usual starting dose is 25-50mg daily with 25mg 100mg daily are often reserved to specialist center increments every seven days guided by clinical response. dealing with severe OCD and should not be attempted in The usual daily dose range is 100-300mg daily. routine outpatient settings.9 The relative potency of Fluoxetine for 5-HT reuptake inhibition is less than other Citalopram has minimal drug-drug interaction potential 14 SSRIs, and equivalent to Clomipramine, with increased and is a potent 5-HT reuptake inhibitor. Citalopram is potential of drug- drug interactions. The starting dose for also available as an IV preparation used in refractory children is 10mg daily with 10mg increments every two cases. The usual starting dose is 20mg daily with to three weeks according to clinical response. increments every two to three weeks of 10mg daily with maximum daily dose of 60mg daily. Escitalopram15is a Sertraline7,9 has superior relative potency of 5-HT more potent enantiomer of Citalopram, and its daily dose reuptake inhibition, and potentially more rapid is 50% of the dose of its parent drug. improvement of OCD symptomatology, which is probably attributed to its Dopamine (DA) reuptake Clomipramine efficacy in treating OCD dates to the inhibition. The starting dose is often 50mg daily in adults 1960s, and it remains the drug of first choice in many 6 and 25mg in children with 50mg increments guided by centers. Its relative 5-HT reuptake inhibition is response. The usual daily dose is 100-200mg daily, and equivalent to Fluoxetine but possess a DA reuptake higher doses of up to 400mg daily should be reserved for inhibition effect. It is metabolized to trialingat specialized units for refractory OCD. desmethylclomipramine, which is primarily a noradrenaline reuptake blocker. It is cardiotoxic in Paroxetine possesses a very potent 5-HT reuptake overdose, and epileptogenic in higher doses especially inhibition, and mild DA reuptake inhibition.8 The more than 225mg daily. The usual starting dose is 2mg starting dose is 20mg daily with weekly increments of daily with weekly 25mg daily increments up to 100mg 10mg daily according to response. The drug has daily. The dose can be titrated upwards after two weeks anunfavorable reputation because of its discontinuation to a maximum of 250mg daily. It is contraindicated in symptoms and should be avoided in children. patients with epilepsy.
Fluvoxamine13 has more potential for drug-drug interactions because it is a potent CYP-3A4 isoenzyme
Augmentation therapy
Response to SRIs in OCD is often delayed for up to 12 Increasing Fluoxetine to 80-100mg daily should be weeks during which the dose of medication is titrated to reserved to management in a specialist center for OCD. achieve a therapeutic response with minimal side effects Citalopram is notorious for its effect on prolonging the profile.16 A change of medication might be an option, but QTc interval, an ECG is required prior to increasing the augmentation therapy17 is usually considered after 12 dose of medication to maximum tolerated level and weeks if there is unsatisfactory or partial response to should be avoided inthe older age group. It is good medication. The augmentation strategies could be practice to have a baseline ECG and a measure of QTc summarized as follows: interval in all patients with OCD managed with pharmacotherapy. 1. Increasing the dose to the maximum tolerable level.17 Intravenous Citalopram19 20mg daily titrated up to 40- 2. Clomipramine SSRI combination.18 80mg daily for 21 days followed by Oral Citalopram 3. Intravenous Citalopram.19 have shown to be beneficial but should be reserved to 4. Intravenous Clomipramine.20 management in a specialist center. Similar regime for 5. Adding Antipsychotic medication.17 Clomipramine in dose of 25-250mg daily is used in 6. Adding Mirtazapine to an SSRI.21 refractory cases.20
100 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (98 - 104) (doi-10.12816/0056860)
Figure 2. 5-HT modifies glutamate and GABA mediated effects acting on distinct 5-HT receptor subtypes. It is postulated that there is a hyperactivity in the Frontal Neocortex and Striatum in patients with OCD. 5-HT stimulates the release of either Glutamate or GABA. 5-HT2 receptors were shown to stimulate GABA release and either increase or reduce glutamate release.
Augmentation with antipsychotic medication,17 is widely through antagonism in the medial frontal cortex. It is also used in the treatment of difficult to treat OCD. It is also postulated that such an effect would be counter- noted that antipsychotic monotherapy is ineffective in therapeutic with higher doses because of blockade 5- treating OCD and should only be used as adjuvant to HT2A receptors in orbito-frontal region. There is also SRI. It is hypothesized that 5-HT2A receptor activation evidence of increase dopaminergic activity in the antagonize the behaviour aspects of other 5-HT receptor midbrain and basal nuclei, which is compatible with the subtypes,22 and atypical antipsychotics as well as addiction models of compulsive behaviours.22 Mirtazapine,20 that possess such activity, would function
Table 2. Antipsychotic drugs in OCD based on randomized controlled trials
Drug Initial dose(mg) daily Maximum dose(mg)daily Haloperidol 1 5 Quetiapine 25 300 Risperidone 0.5 4 Olanzapine 2.5 10 Aripiprazole 10 30
Haloperidol23 is a potent D2 receptor antagonist but has activation of a feedback mechanism mediated by 5- no 5-HT2A receptor antagonism. Atypical HT1A receptors which may reduce the firing in 5-HT antipsychotic17 listed in Table2 are relatively potent 5- neurons and attenuated 5HT neurotransmission. HT2A receptor antagonists as well. Clozapine is Risperidone23 has been demonstrated to be effective in ineffective as an add on therapy in OCD probably as a randomized controlled trials while paliperidone did result of 5HT1-A antagonism. Aripiprazole24is a partial demonstrate such efficacy.17 Olanzpine25 is effective as D2 and 5-HT1A agonist, and it is postulated that the an add- therapy with a dose range of 2.5-10mg daily. latter mechanism could modulate or reduce SSRI
101 Al-Timimi SJ, Jamil NF
Notes on other medication
There are many drugs referred to in the literature for might be considered as an emerging therapy for managing OCD. These notes refer to some of them. augmentation.29
D-cycloserine: May lead to more rapid response to Topiramate: Causes an alteration of the glutamatergic exposure treatment26 although studies have found no tone30 of the corticostriatal pathway. However, a double- difference in treatment outcome with D-cycloserine blind, placebo-controlled trial of topiramate augmentation in either adult or pediatric patients. augmentation in OCD-resistant patients suggested that it might be beneficial only for compulsions, and not for Dextroamphetamine and caffeine: It is postulated that obsessions.31 dopamine induced by both drugs may increase D1 receptor stimulation in the pre-frontal cortex, and thus Riluzole: Causes an alteration of the glutamatergic tone helping to shift attention away from obsessions as well as of the corticostriatal pathway. It is still an emerging reducing urges to perform compulsions. Two small therapy with no controlled studies. double-blind placebo -controlled studies tested the hypothesis and concluded significant improvement in Venlafaxine: Probably less effective than SSRI in 32 OCD symptoms.27 treatment of OCD. It is neither a first nor a second choice for treatment of OCD. Memantine: one open label small study demonstrated meaningful improvement in treatment resistant OCD patients treated with memantine, which is a non- competitive glutamate antagonist.28
Ondansetron: anti-obsessional effect involves dopaminergic inhibition by 5-HT3 receptor blockade. It Conclusion
The role pharmacotherapy of OCD has become more OCD remains challenging and less than 60% of patients clarified in recent years, and is probably more distinct achieve significant remission of symptoms. The review from treatment of psychotic, anxiety, and affective highlights current practice in managing OCD according disorders.5 Pharmacotherapy is often used in conjunction to guidelines and scientific evidence. with ERP, but not uncommonly on its own. Treatment of References
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disorder (OCD). Cochrane Database Syst Rev. Clomipramine: A Placebo-Controlled Study. 2008; 1:CD001765. Arch Gen Psychiatry. 1998; 55(10):918-924. 10. Freeman J, Sapyta J, Garcia A, et al. Family- 21. Koran LM, Gamel NN, Choung HW, et al. based treatment of early childhood obsessive- Mirtazapine for obsessive-compulsive disorder: compulsive disorder: the Pediatric Obsessive- an open trial followed by double-blind Compulsive Disorder Treatment Study for discontinuation. J Clin Psychiatry. 2005; Young Children (POTS Jr) - a randomized 66(4):515-20. clinical trial. JAMA Psychiatry. 2008; 22. Ciranna L. Serotonin as a Modulator of 71(6):689-98. Glutamate- and GABA-Mediated 11. Ipser JC, Stein DJ, Hawkridge S, et al. Neurotransmission: Implications in Pharmacotherapy for anxiety disorders in Physiological Functions and in Pathology. children and adolescents. Cochrane Database CurrNeuropharmacol. 2006; 4(2) 101-114. Syst Rev 3:CD00517051. 2009; (4):373-9. 23. Li X, May RS, Tolbert LC. Risperidone and 12. Skapinakis P, Caldwell D, Hollingworth W, et haloperidol augmentation of serotonin reuptake al. A systematic review of the clinical inhibitors in refractory obsessive-compulsive effectiveness and cost-effectiveness of disorder: a crossover study. J Clin. 2005; pharmacological and psychological 66(6):736-43. interventions for the management of obsessive- 24. Muscatello MR, Bruno A, Pandolfo G, et al. compulsive disorder in children/adolescents and Effect of aripiprazole augmentation of serotonin adults. Health Technol Asss. 2016; (43):1-392. reuptake inhibitors or clomipramine in 13. Goodman WK, Price LH, Rasmussen SA, et al. treatment-resistant obsessive-compulsive Efficacy of fluvoxamine in obsessive- disorder: a double-blind, placebo-controlled compulsive disorder. A double-blind study. J Clin Psychopharmacol. 2011; comparison with placebo. Arch Gen Psychiatry. 31(2):174-9. 1989; 46(1):36-44. 25. Shapira NA, Ward HE, Mandoki M, et al. A 14. Katzman MA, Bleau P, Blier P, et al. Canadian double-blind, placebo-controlled trial of clinical practice guidelines for the management olanzapine addition in fluoxetine-refractory of anxiety, posttraumatic stress and obsessive- obsessive-compulsive disorder. Biol Psychiatry. compulsive disorders. BMC Psychiatry. 2014; 2004; 1; 55(5):553-5. 14 suppl 1:S1. 26. Andersson E, Hedman E, Enander J, et al. D- 15. Fineberg NA, Tonnoir B, Lemming O, et al. cycloserine vs placebo as adjunct to cognitive Escitalopram prevents relapse of obsessive- behavioral therapy for obsessive-compulsive compulsive disorder. Eur disorder and interaction with antidepressants: a Neuropsychopharmacol. 2007; (6-7):430-9. randomized clinical trial. JAMA Psychiatry. 16. Bloch MH, McGuire J, Landeros-Weisenberger 2015; 72(7):659-67. A, et al. Meta-analysis of the dose-response 27. Koran LM, Aboujaoude E, Gamel NN. Double- relationship of SSRI in obsessive-compulsive blind study of dextroamphetamine versus disorder. Mol Psychiatry. 2010; 15(8):850-5. caffeine augmentation for treatment-resistant 17. Thamby A, Jaisoorya. Antipsychotic obsessive-compulsive disorder. J Clin augmentation in the treatment of obsessive- Psychiatry. 2009; 70(11):1530-5. compulsive disorder. Indian J Psychiatry. 2019; 28. Aboujaoude E, Barry J, Gamel N. Memantine 61(1): S51-S57. augmentation in treatment-resistrant obsessive 18. Szegedi A, Wetzel H, Leal M, et al. compulsive disorder: an open label study. J Clin Combination treatment with clomipramine and Psychopharamcol. 2009; 29(1):51-5. fluvoxamine: drug monitoring, safety, and 29. Soltani FS, Sayyah M, Feizy F. A double-blind, tolerability data. J Clin Psychiatry. 1996; placebo-controlled pilot study of ondansetron 57(6):257-64. for patients with obsessive-compulsive disorder. 19. Pallanti S, Quercioli L, Koran LM. Citalopram Hum Psychopharmacol. 2010; 25(6):509-13. intravenous infusion in resistant obsessive- 30. Ciranna L. Serotonin as a Modulator of compulsive disorder: an open trial. J Clin Glutamate- and GABA-Mediated Psychiatry. 2002; 63(9):796-801. Neurotransmission: Implications in 20. Fallon, BA, Liebowitz MR, Campeas R, et al. Physiological Functions and in Pathology. Intravenous Clomipramine for Obsessive- CurrNeuropharmacol. 2006; 4(2)101-114. Compulsive Disorder Refractory to Oral
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الملخص الملخ ص
تغيرتصنيف اضطراب الوسواس القهري في السنوات األخيرةوانتقل الى موقع جديد خاص به بعيداًعن اضطرابات القلق واالضطرابات الوجدانية صاحب. ذلك صاحب. الوجدانية واالضطرابات القلق اضطرابات بعيدا استيعاب أفضل أللية استعمال العقاقيرالمختلفة في عالج االضطراب واإلرشادات العامة الستعمالها . هذاالمقال يوضح أوال صنيفالت الجديد المرتقب لمنظمة المرتقب الجديد صنيفالت أوال يوضح هذاالمقال الصحة العالمية الضطرابات الوسواس القهري ٬ ويتطرق الى التوجيهات العامة الستعمال العقاقيروالخلفيةالعلمية الستعمالها.
يتطرقالمقال ً أواللدوربعض مضادات االكتئاب في عالج االضطراب وتوضيح التوجيهات العامة . .
بعد ذلك يتطرق المقال الى عملية تعزيزالعقاقيراألوليةمع استعمال عقاقيرأخرى. في النهاية يسطرالمقال موقع بعض العقاقيراألخرى في العالج . .
Corresponding Author Dr Sudad Jawad Al-Timimi, Consultant Psychiatrist, The Copse, Elysium Health Care, Weston Super Mare, England - UK [email protected]
Authors Dr Sudad Jawad Al-Timimi, Consultant Psychiatrist, The Copse, Elysium Health Care, Weston Super Mare, England - UK
Dr Nahla Fawzi Jamil, Consultant Psychiatrist, Aneurin Bevan University NHS Trust, Newport, Gwent, Wales - UK
104 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (105 - 119) (doi-10.12816/0056861)
Anxiety in Lebanon during the COVID-19 Pandemic
Emilio Alhachem, Georges Haddad, Eliane Nagib, Werner Ikdais, Myriam Akkari القلق في لبنان خالل جائحة فيروس كورونا المستجد
الهاشم،اميليو حداد،جورج نجيب،اليان قديس،فرنر مريام عكاري قديس،فرنر نجيب،اليان حداد،جورج الهاشم،اميليو
Abstract
Objective: To evaluate the anxiety level among a heterogeneous Lebanese population during the COVID-19 pandemic and find any correlation between the two. Method: We collected, using an online questionnaire, the sociodemographic characteristics of 2858 randomly selected Lebanese individuals (>18 years), and evaluated their level of anxiety using the State Trait Anxiety Inventory. Results: We found a significant correlation between an increased level of anxiety and the following characteristics: female sex, younger age, low levels of education, lower monthly income, unemployment, being single, living with family/friends, living in Beirut, smoking, medical history of respiratory diseases, personal and family history of mental illness, taking psychiatric medications, history of anxiety suggested by a physician, and experiencing any kind of confinement/isolation. On the other hand, no significant association was found between a higher anxiety score and personal infection by the virus, the infection of relatives or friends, or the duration of the confinement. Conclusion: Infectious outbreaks have a heavy impact on people’s mental health, and this impact is underestimated and neglected as the main focus is on controlling and limiting the disease transmission. It is important to raise awareness on the matter to be able to prevent anxiety outbreaks following the COVID-19 pandemic.
Key words: COVID-19, pandemic, mental health, anxiety, Lebanon.
Declaration of interest: none
Introduction
Coronavirus disease, or COVID-19, is an infectious as not being able to deal with the threat of a certain disease caused by a new virus discovered for the first time situation. in December 2019 in China.1 It has a human-to-human transmission through the droplets of an infected person, This fear is, at the core of the anxiety, associated with the 5 and causes respiratory symptoms ranging from mild to need to preserve ‘one’s own being’. In other words, severe, especially in older people or those who present anxiety often accompanies uncertain situations, especially prior medical comorbidities.2 It has quickly become a those that include dealing with a widespread illness, as global concern, and has been announced by the WHO as research has made it evident how fear is heightened in a pandemic on March 11, 2020.3 one’s brain when exposed to a novel threat versus a familiar one.6 This would ultimately affect the Given what we know about the psychological impact of individual’s coping abilities, as it was concretely shown in outbreaks on the population, we were intrigued by a survey conducted in Canada during the H1N1 pandemic studying the level of anxiety in the Lebanese population which found that people who were least able to tolerate during the COVID-19 pandemic. uncertainty overall experienced the most anxiety during the pandemic, and were less likely to believe they could Being more transmissible than viruses that caused prior protect themselves.7 pandemics (i.e SARS) and deadlier than the seasonal flu, and the fact that a lot of uncertainties still surround this We can cite the example of ‘SARS-Phobia’ that was seen new virus in terms of its incubation period and possible in 2003 following the outbreak of the ‘Severe Acute asymptomatic transmission, COVID-19 might be Respiratory Syndrome’ which became, according to some associated with an increasing level of anxiety4 and a state sources, more dangerous than the virus itself,8 and further of ‘generalized panic’ that we are witnessing today. worsened the state of healthcare facilities by overwhelming centers with an influx of low risk patients In fact, anxiety during outbreaks is not unseen before, and due to high levels of worry and anxiety.9 has long been explained by philosophers and theologians
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This is one of the many reasons why it is important to Another interesting study published in 2016 by Jeong et evaluate anxiety in a population when a new disease al. showed that, during quarantine, anxiety symptoms emerges, as the response of public policies and the public were reported in 7.6% of people, whereas a follow-up four opinion should be understood from a large socio-cognitive to six months after quarantine ended showed a drop to frame and measured in proportion to the threat. 3%.17 Thus, some centers have implemented psychological support units to accompany patients Realistically, the people’s reaction may be influenced by infected, and found that to be highly effective in reducing the representations of prior outbreaks and pandemics and the impact that an outbreak can cause.18 It is interesting to blown out of proportion, which can be counterproductive add that the suggestion of quarantine by the government when mobilization is needed by healthcare organizations could, by itself, raise anxiety levels in the population, as it 10 in the case of more serious threats. indicates that the authorities believe the situation to be 9 On another note, with the rise of this new outbreak, severe. quarantine has been suggested as a public health measure Several factors in the literature were described as possible to try to limit the transmission speed of the virus. This predictors of the impact an outbreak might have on a method can range from social distancing to isolation and person, including the history of a psychiatric illness, age, mass quarantine. While this is highly effective to serve the education level, marital status, gender, and working in the public health, it can also have psychological repercussions healthcare sector.9 on the quarantined individuals, their loved ones, and on healthcare workers.11,12 Fear of infecting others represented an important stressor during pandemics as well as the fear of loss of job/finances Outbreaks anxiety is known to usually peak following the that could ultimately follow outbreaks and quarantine.19 In death of the first case and the escalation in the number of addition to that, an important thing to mention is the fear cases, but also in the way that the media coverage handles of being stigmatized and discriminated, which can worsen the situation and the intensity and quality with which it the fear and anxiety accompanying an outbreak.20 provides the public with news.13 All this knowledge about outbreak anxiety has made it Not only that, but quarantine itself, as we have mentioned, especially interesting to be able to investigate the levels of plays the role of a catalyst in unmasking anxiety. anxiety in the Lebanese population, particularly when we As we know, psychiatric conditions including anxiety and know that studies related to the mental health sector are depression worsen when the patient is in isolation and still lacking in Lebanon. That being said, one study lacks interpersonal communication, and this is exactly conducted in 2006 showed that mental disorders in what happens in the context of quarantine.14 Isolation can Lebanon might be present at rates comparable to those also trigger a feeling of entrapment and freedom loss, as found in Western Europe, but that the number of patients 21 well as feelings of anger that could have dramatic not receiving any treatment is considerably higher, consequences on a person’s mental wellbeing.9 Studies which is also an important angle and one of the main have even suggested that the length of the quarantine was reasons why studies like ours are necessary to shed more the most important factor in determining the level of light on the mental health field in the country, and to the stress,15 and one study by Sprang et al. found that importance of early screening and management. Another posttraumatic stress disorders and anxiety in quarantined interesting study conducted in 2008 on a national individuals was four times the level found in non- Lebanese level showed that 25.8% of the population met quarantined individuals.16 at least one of the DSM-IV criteria at some point in their lives, and that anxiety ranked as the most common.22
Materials and Methods
Study design and setting
A descriptive, cross-sectional study was conducted over a Tool for data collection period of one month (15 March 2020 - 15 April 2020). It targeted Lebanese individuals’ aged 18 years and older A questionnaire was developed by the investigators in living in different regions of Lebanon. The required Arabic and English and pilot-tested before administration sample size was calculated to be 2000 participants to to ensure validity and clarity of included questions. A achieve significance, and a randomized sampling method brief cover letter was provided to participants, detailing was adopted. the purpose of the questionnaire and reassuring
106 Alhachem E, Haddad G, Nagib E, Ikdais W, Akkari M confidentiality. Participants were asked to voluntarily and COVID-19 pandemic. Lebanese people living abroad anonymously fill out the questionnaire that included the were excluded. Upon completion of the questionnaire, the following sections: 1) demographics and personal medical collected data was submitted to the primary investigators information, 2) personal information regarding COVID- at the end of each day. At the end of data collection, the 19 pandemic, 3) the State Trait Anxiety Inventory (STAI), sample size included 2858 Lebanese individuals who which is a commonly used measure of trait and state matched the inclusion criteria. anxiety.23 This inventory can be used in clinical settings to diagnose anxiety and to distinguish it from depressive No participant’s identifiable information (name or contact syndromes, and it is often used in research as an indicator information) was collected, and the obtained information of caregiver distress. Two versions of the STAI are was processed confidentially. The study was performed in available, the original English version and the validated accordance with the ethical standards as laid down in the Arabic version that has been previously used in 1964 Declaration of Helsinki and its later amendments Lebanon.24 and was reviewed by the institutional review board.
The STAI has 20 items for assessing trait anxiety (describing the general anxiety state) and 20 items for Statistical analysis state anxiety (describing the actual anxiety state). Each participant filled the two parts of the inventory. Every Completed questionnaires were entered in an excel form item is rated on a 4-point scale (e.g. from “Almost Never” throughout the study duration using a coding system, and to “Almost Always”) based on the frequency of the then data were analyzed using the SPSS Statistics version feelings mentioned in them, making a range of 20-80 for 25 with a confidence interval of 95% and a margin of error each part of the scale, and a total range of 40-160, with of 5%. higher scores indicating greater anxiety. Double data entry was performed to minimize the risk of Demographic and personal medical information included error, and the persons responsible for data entry were gender, age, marital status, number of children, education blinded. Demographic data, information about personal level, employment status, monthly income, habitation medical history, and information about experiences with status, area of habitat, the type of health coverage, COVID-19 were summarized using descriptive statistics. personal medical and psychiatric history, family history of To ensure the reliability and the validity of the psychiatric illnesses and smoking. Information regarding questionnaire, reliability analysis was executed and tested the COVID-19 pandemic included the infection of the using Cronbach’s alpha, which turned out to be 0.934 for subject by COVID-19 or the infection of family and the State Anxiety Scale, and 0.919 for the Trait Anxiety friends, and whether or not the individual is experiencing Scale. quarantine, social distancing or isolation. Qualitative variables are represented as percentages and After filling out the aforementioned data, the State Trait quantitative variables as mean ± SD type. A value of p Anxiety Inventory (STAI) was completed by each <0.05 was considered significant. individual in order to assess the anxiety level in the Lebanese population during the COVID-19 pandemic. The independent sample T test was implemented to compare the means of variables between two groups, and Data collection the ANOVA test to compare means of variables between Four psychiatry residents from the Holy Spirit University three or more groups. The Bonferroni test was used for of Kaslik - Faculty of Medicine and Medical Sciences second step analysis after ANOVA for pairwise were properly trained by their supervising medical comparison, and the Pearson correlation was used to study practitioner to survey the Lebanese population the correlation between two numerical values. electronically through an online-built questionnaire. The study centered on the overall anxiety score gathered Lebanese individuals were eligible for inclusion if they from the STAI and its relationship with each of the were 18 years and older and living in Lebanon during the characteristics collected.
Results
Characteristics of the sample (N=2858)
107 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (105 - 119) (doi-10.12816/0056861)
Table 1 sums up all the characteristics of the sample of our respiratory problems, 31.9% are smokers, 4% have study. The mean age of the participants is 30.9 years ± immunodeficiency states, and 9.1% have other chronic 10.74, 66.7% of them being women, 57.2% have a disorders. 7.9% have a history of mental illness, 5.8% are university level education, 28% a postgraduate degree, on psychiatric medications, and 13.8% have family and 14.7% are illiterate or only reached primary, history of psychiatric disorders. Moreover, 21.3% of the complementary, and secondary levels. 24.9% are students, participants were once told by their physician that they 49.9% are employed, 11.9% have liberal professions, have anxiety. 0.8% are retired, and 12.5% are unemployed among which 4.9% are housewives. Of all participants, 25.9% have Concerning the COVID-19 pandemic, the virus has worked in the healthcare/medical field. personally affected only 1.8% of the enrolled participants, while 6.5% have/had a family or friend that has been Almost half of the individuals enrolled in the study have a affected by it. During this outbreak, 87.4% claim to monthly income of less than $1000US (47.7%), and only having experienced social distancing, social isolation or 16.6% have an income of more than $2000US; 66% of all quarantine, while 12.6% have continued to live their life participants are single, 31.6% are married, 1.8% are normally. Of the 1114 individuals who experienced social divorced, and 0.6% are widowed. Among the individuals distancing, 43.4% have done so for less than two weeks, who are not single, the number of children ranged between 54.1% for two to four weeks, and 2.4% for more than a 0 and six, with a median of two children. Most of the month. Among the 368 participants who experienced participants lived with their families or friends (91.6%), social isolation, 44.6% have done so for less than two with 63% living in Mount Lebanon, followed by 14.8% in weeks, 50.3% for two to four weeks, and 5.2% for more Beirut, 13.8% in North Lebanon, 4.9% in the Bekaa than a month. As for the 1017 individuals who region, and 3.5% in the South. 86.1% of the applicants experienced quarantine, 38.6% have done so for less than have health coverage. As for the medical history, 5.2% two weeks, 57.8% for two to four weeks, and 3.5% for have diabetes, 5.1% have cardiac disorders, 10.2% have more than a month.
Table 1. Descriptive statistics of the participants Independent Variables Number Percentage Gender of participants Male 952 33.3% Female 1906 66.7% Education Illiterate/Primary 16 0.6% Complementary 52 1.8% Secondary 353 12.4% University 1635 57.2% Postgraduate studies 802 28% Employment Student 712 24.9% Employed 1426 49.9% Liberal profession 340 11.9% Unemployed 216 7.6% Housewife 140 4.9% Retired 24 0.8% Healthcare/Medical Field Yes 741 25.9% No 2117 74.1% Income per month Less than $1000US 1364 47.7% $1000-2000US 1020 35.7% More than $2000US 474 16.6% Marital status Single 1886 66%
108 Alhachem E, Haddad G, Nagib E, Ikdais W, Akkari M Married 904 31.6% Divorced 51 1.8% Widowed 17 0.6% Habitation status Alone 240 8.4% With friends/family 2618 91.6% Area Mount Lebanon 1801 63% Beirut 423 14.8% Bekaa 139 4.9% North Lebanon 395 13.8% South Lebanon 100 3.5% Health coverage Yes 2462 86.1% No 396 13.9% Medical history Diabetes 150 5.2% Cardiac diseases 146 5.1% Respiratory diseases 291 10.2% Immunodeficiency state 115 4% Other chronic diseases 260 9.1% Smoking history Yes 912 31.9% No 1946 68.1% History of mental Yes 227 7.9% illness No 2631 92.1% Taking psychiatric Yes 166 5.8% medications No 2692 94.2% Family psychiatric Yes 393 13.8% History No 2465 86.2% Suggested as having Yes 610 21.3% anxiety by their physician No 2248 78.7% Personally affected by COVID-19 Yes 51 1.8% No 2807 98.2% Family or friend affected by Yes 185 6.5% COVID-19 No 2673 93.5% Experienced social distancing, Nothing 359 12.6% isolation, or quarantine Social distancing 1114 39%
Social isolation 368 12.9% Quarantine 1017 35.6% Mean age of participants 30.9 ± 10.74 Median number of children (excluding the single group) 2
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110 Alhachem E, Haddad G, Nagib E, Ikdais W, Akkari M
State Trait Anxiety Inventory (STAI) with an increased anxiety score (p-value = 0.000). Moreover, medical history of respiratory diseases The mean overall score was 92.12 ± 23.339. As it is (asthma, COPD, etc.), personal and family history of displayed in the following graphs, when taking each part mental illness, and currently taking psychiatric of the inventory separately, the mean score for the State medications also suggest a strong link with a higher STAI Anxiety Scale is 47.88 ± 12.977, while it summed up to score (p=0.000) as does having been assessed to have be 44.24 ± 11.838 for the Trait Anxiety Scale. anxiety by a physician. Finally, yet importantly, a strong association is also demonstrated with experiencing social distancing, isolation, and quarantine compared to STAI overall anxiety score experiencing none of them (p=0.000). As shown in Table 2, no significant association was Employment status also displays a strong relationship observed between a higher overall anxiety score using the with anxiety levels (p=0.000). In fact, unemployed STAI and the following characteristics: working in the participants have the highest scores, followed by students, medical/healthcare field, the number of children, health then employees, housewives, individuals with liberal coverage, medical history of diabetes, cardiac diseases, professions, and lastly retirees. and immunodeficiency states, personal infection by COVID-19 or the infection of family and friends by the Lower levels of education (p=0.043), living with family virus. Table 3 shows, in addition, that the length of and friends (p=0.048), living in the Beirut area (p=0.012), experiencing social distancing, isolation, or quarantine a medical history of unspecified chronic diseases does not affect the STAI score. (p=0.001), and smoking (p=0.048) also appear to be connected to an increased overall STAI score. On the other hand, being female, younger age, lower monthly income, and being single seem to be associated
Table 2. Association Between STAI scores and independent variables Independent variables STAI Scores p-value Gender of participants Male 86.86 ± 22.572 0.000 Female 94.75 ± 23.278 Age of participants ≤22 96.85 ± 24.152 0.000 23-26 94.83 ± 22.890 27-30 91.45 ± 23.228 31-39 90.01 ± 23.159
111 Anxiety in Lebanon During the COVID-19 Pandemic
40+ 86.36 ± 21.811 Education Illiterate/Primary 99.44 ± 19.765 0.043 Complementary 95.4 ± 22.216 Secondary 94.48 ± 25.173 University 92.21 ± 23.242 Postgraduate studies 90.56 ± 22.738 Employment Student 95.64 ± 23.601 0.000 Employed 91.70 ± 22.597 Liberal profession 85.44 ± 22.737 Unemployed 97.88 ± 23.758 Housewife 88.33 ± 24.399 Retired 78.08 ± 25.600 Healthcare/Medical Field Yes 90.92 ± 23.082 0.103 No 92.54 ± 23.419 Monthly income Less than $1000US 95.62 ± 24.053 0.000 $1000-2000US 89.71 ± 22.106 More than $2000US 87.27 ± 22.337 Marital status Single 93.93 ± 23.389 0.000 Married 88.58 ± 22.900 Divorced 92.45 ± 21.734 Widowed 79.59 ± 21.963 Habitation status Alone 89.28 ± 23.59 0.048 With friends/family 92.39 ± 23.303 Area Mount Lebanon 91.63 ± 22.94 0.012 Beirut 94.90 ± 24.564 Bekaa 88.47 ± 22.85 North Lebanon 93.39 ± 23.851 South Lebanon 89.32 ± 22.748 Health coverage Yes 92.14 ± 23.350 0.915 No 92.01 ± 23.300 Medical history Diabetes 93.97 ± 24.093 0.321 Cardiac diseases 93.27 ± 22.749 0.544 Respiratory diseases 97.54 ± 21.993 0.000 Immunodeficiency state 94.55 ± 22.450 0.256 Other chronic diseases 96.72 ± 24.139 0.001 Smoking history Yes 93.39 ± 23.512 0.048 No 91.53 ± 23.240 History of mental Yes 107.63 ± 23.007 0.000 illness No 90.79 ± 22.885 Taking psychiatric Yes 100.72 ± 23.831 0.000 medications No 91.59 ± 23.209
112 Alhachem E, Haddad G, Nagib E, Ikdais W, Akkari M Family psychiatric Yes 97.53 ± 23.102 0.000 History No 91.26 ± 23.266 Suggested as having Yes 103.21 ± 23.343 0.000 anxiety by their physician No 89.11 ± 22.416 Personally affected by Yes 95.27 ± 25.705 0.331 COVID-19 No 92.07 ± 23.295 Family or friend Yes 91.65 ± 23.647 0.777 Affected by COVID-19 No 92.16 ± 23.322 Experienced social distancing, Nothing 82.71 ± 23.693 0.000 isolation, or quarantine Social distancing 91.94 ± 21.971
Social isolation 96.17 ± 23.397 Quarantine 94.18 ± 23.788 Age of Participants - Pearson correlation r = -0.168 0.000 Number of children (excluding single group)- Pearson correlation r = -0.026 0.417
Table 3. Association Between STAI scores and duration of social distancing, social isolation, and quarantine Duration Number of individuals STAI Score p-value Individuals who Less than 2 weeks 484 91.72 ± 21.922 0.955 experienced social 2-4 weeks 603 92.09 ± 22.166 distancing More than 4 weeks 27 92.48 ± 18.970 1114 Individuals who Less than 2 weeks 164 94.71 ± 24.104 0.563 experienced social 2-4 weeks 185 97.38 ± 22.963 isolation More than 4 weeks 19 96.89 ± 21.797 368 Individuals who Less than 2 weeks 393 92.50 ± 23.665 0.056 experienced 2-4 weeks 588 94.86 ± 23.668 quarantine More than 4 weeks 36 101.42 ± 25.795 1114
Table 4. Association between independent variables and both State Anxiety scores and Trait Anxiety scores Independent Variables State Anxiety Score Trait Anxiety Score Gender of participants 0.000 0.000 Age of participants 0.000 0.000 Education 0.813 0.000 Employment 0.000 0.000 Healthcare/medical field 0.628 0.007 Monthly income 0.000 0.000
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Marital status 0.003 0.000 Habitation status 0.164 0.018 Area 0.002 0.075 Health coverage 0.103 0.115 Medical history of diabetes 0.223 0.534 Medical history of cardiac diseases 0.310 0.933 Medical history of respiratory diseases 0.000 0.002 Medical history of immunodeficiency states 0.095 0.680 Medical history of other chronic diseases 0.001 0.004 Smoking history 0.082 0.046 History of mental illness 0.000 0.000 Taking psychiatric medication 0.002 0.000 Family psychiatric history 0.000 0.000 Suggested as having anxiety by their physician 0.000 0.000 Personally affected by COVID-19 0.427 0.295 Family or friend affected by COVID-19 0.742 0.844 Experienced social distancing, isolation, or 0.000 0.000 quarantine
When taking each part of the inventory alone, as shown in higher education level, working in the medical field, Table 4, most of the variables that correlate with a higher living alone, and not smoking were associated with a overall anxiety score are also found to be associated with lower trait anxiety score only, whereas living in Beirut a higher score for each of the state and the trait anxiety was found to be associated to a higher state anxiety score. scores alone. However, it is important to mention that
Discussion
To our knowledge, the current study is one of the first It should be noted that Lebanon has been suffering from a studies to address anxiety in Lebanon during the COVID- major economic crisis since late 2019, which can explain 19 pandemic. In total, 2858 individuals participated in the the high rate of unemployment and the low income per survey, which was higher than the calculated sample size capita found in this study. required to achieve significance (2000). The total population of Lebanon is estimated at 6.8 million, with a On the other hand, the medical profiles of the subjects median age of 29.6 years, which is reflected by the median enrolled in this study are consistent with the prevalence of age of the participants is this survey (28 years old). these diseases in the Lebanese population, which supports that the sample was randomly selected. Given the fact that, during the period of this study, Lebanon was undergoing strict confinement and safety Furthermore, the low number of persons infected with measures, and that the questionnaire was exclusively COVID-19 who participated in this study is also online, some groups of individuals were unreachable in concordant with the fact that Lebanon had registered a remote areas of Lebanon (e.g. the Bekaa and the South small number of cases at that time (109 cases on 16 March region). 2020; 650 cases on 15 April 2020). However, the representation of people affected by COVID-19 in this The high percentage of educated individuals enrolled in study is higher than the percentage of affected people in this study can be explained by the fact that this particular the country (1.78% vs 0.01%). category has more access to the internet and social networking. As we have already mentioned, the Lebanese government implemented strict rules to confront the COVID-19
114 Alhachem E, Haddad G, Nagib E, Ikdais W, Akkari M outbreak, which could explain the high percentage (88%) When assessing employment status, the unemployed (97) of people who were abiding to the law by performing and the students (95) scored a higher level of anxiety than social distancing, isolation or quarantine. the employed individuals (91), the ones with liberal professions (85) and retirees (78). This variation may be Beyond the demographic characteristics and concerning explained by the financial stability provided to individuals the State Trait Anxiety Inventory (STAI), the collected who have a job and could at the same time explain the data showed a mean overall score of 92.12 ± 23.339. results showing that individuals who have a higher When separating the two different parts of the STAI, the income, have a lower STAI score. These results are in line mean score for the State Anxiety Scale is 47.88 ± 12.977 with studies suggesting that financial instability and strain while it is 44.24 ± 11.838 for the Trait Anxiety Scale. This are correlated with anxiety and/or depressive disorders.29 difference, showing higher scores for the State Anxiety Scale, is logical and in agreement with the literature as it On a side note, when separating the two parts of the STAI, could in fact be attributed to how stressful a pandemic is our results suggest a decreased trait anxiety score for on a population. individuals working in the medical field, which opposes available data on the subject advocating a positive In this study, we assessed the relationship between various correlation between being in the medical/healthcare field demographic/medical variables and the STAI score. From and anxiety30, 31, 32. these assessments we were able to retain many associations that were statistically significant (p<0.05) Single and divorced participants displayed more anxiety regarding: gender, age, employment status, lower levels of than married ones with STAI scores of 93, 92, and 88 education, living with family and friends, living in the respectively. This supports a publication by Scott et al. capital (i.e the city of Beirut), low monthly income, which concluded that a decreased risk of first onset of relationship status, medical history of respiratory diseases most mental disorders is markedly noticed in married (asthma, COPD, etc.), smoking, and personal and family individuals.33 However, our results display an association history of mental illness. Also, experiencing social between living with family or friends and an increased distancing, isolation, and quarantine display a strong level of anxiety. This could be due to worries of relationship with anxiety levels. transmitting the disease, if ever caught, to the cohabitants,19 or even to the prolonged time spent together Starting with the first demographic variable that is gender, which can bring up the worst in some people and make the women were found to have a higher STAI score (94) than confinement unbearable. men (86), which is compatible with literature stating that women are more prone to anxiety than men.25,26 Concerning the area of habitat, living in Beirut was found to be significantly associated with an increased overall When the age of the participants was assessed, younger STAI score, along with an elevated State anxiety score individuals were found to have higher anxiety levels than when taking each part of the scale alone. This could be their older counterparts. This variation amongst age explained by the fact that the COVID-19 spread was groups corroborates with a study conducted by Carmin et dominant in Beirut, and that it is the most populated and al. showing that the prevalence of anxiety disorders drops crowded city in Lebanon. from 30-35% in adults under 60 years old, to 15% in individuals aged more than 60 years.27 In Lebanon, this When it comes to the medical history of participants, the may be due to the fact that the senior Lebanese generation ones who have respiratory diseases showed a significant had to cope with multiple significant stressful events in association with an increased level of anxiety, which is the past (Lebanese civil war, economic crises, political sustained by previous research inferring that the and social problems…) that may have allowed them to debilitating effects of dyspnea may lead to anxious develop a certain level of resilience to stress. states.34,35 This could possibly be worsened by the worry of having an increased risk of mortality due to COVID-19 On another note, the results of our study showed that the in people with respiratory co-morbidities. Smoking has higher the education level, the lower the STAI score. This been associated with an increase in both the overall STAI could be explained by the fact that people who have higher score and the trait anxiety score in our study. The education seek credible information in times of stress to relationship between smoking/nicotine and anxiety is cope with their anxiety. In other words, the more you already well recognized, and thus may explain the results understand the problem, the less you are anxious about it. that we have.36 This suggestion is supported by a study published in 2008 by Bjelland et al., which claims that a higher educational Finally, and of equal importance, a positive personal and level appears to be protective against depression and family history for mental illness, being on psychiatric anxiety.28 medications, and a history of anxiety also showed a strong association with an increased STAI score. This finding is
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reasonable and expected, as it is widely known that a Emerging research suggests that the experience of personal or a family history of mental illness is a risk quarantine, social distancing and isolation are associated factor for developing a mental illness.37 with increased anxiety. This could be explained by the notion that individuals who decided to abide by these However, and contrary to our predictions, personal measures are ones who are more anxious about infection due to COVID-19 or the infection of a family contracting the disease, and by the fact that loneliness and member or a friend by the virus showed no association to social withdrawal are known to be perpetuating factors in an increased STAI score. Unfortunately, there is still no anxiety and other mental illnesses.15, 38 However, what is data that elaborates the impact of being infected or having interesting is that the duration of quarantine showed no a close contact infected by the novel coronavirus on association with the levels of anxiety which contradicts anxiety. some articles published during previous pandemics suggesting otherwise.17, 18, 39, 40
Limitations
Our study has some limitations. First, the data collection conducted over a one-month period during the peak of the process, which is the online form, fails to reach certain pandemic, but it would have been interesting to compare individuals such as elderly people and individuals who do our results to the ones that could have been collected at not have access to phones and social media. Another one the very beginning and the end of the pandemic. is the timing of the study; it is true that our study was
Conclusion
In Lebanon, mental health is still overlooked, even during and quarantine seem to be associated with an increased times of crises, such as the COVID-19 pandemic, when STAI score as well, and thus increased anxiety as the main focus is on preventing the contraction of the virus compared to experiencing no confinement, even if the and flattening the transmission curve. duration of quarantine has not shown to be significant. Going through a major pandemic like this one is clearly Meanwhile, marked associations with a lower trait anxiety associated with an increase in the level of anxiety reflected score is seen for higher education levels, working in the by the State Trait Anxiety Inventory, as seen in our study. medical field, living alone, and being a non-smoker. Factors markedly associated with this increased anxiety are: female sex, younger age, lower levels of education, Consequently, this research is another way of drawing unemployment, lower monthly income, being single, attention to the psychological burden of the COVID-19 living with family or friends, living in Beirut, smoking, a pandemic in Lebanon, particularly anxiety, highlighting positive medical history for respiratory diseases (asthma, the risk of an anxiety outbreak following the viral one, and COPD, etc.), a personal and a family history of mental encouraging health authorities and professionals to take illness, and a history of anxiety suggested by a physician. necessary actions. Moreover, experiencing social distancing, social isolation,
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الملخص الملخ ص
الهدف: تقييم مستوى القلق لدى السكان اللبنانيين خالل جائحة COVID19، وإيجاد أي ارتباط بينهما. الطريقة: جمعنا، باستخدام استبيان على اإلنترنت، الخصائص اإلنترنت، االجتماعية والديموغرافية لـ 0282 ًشخصا لبنانيًا تم اختيارهم عشوائيًا )< 82 ًعاما(، وقيِّ منا مستوى قلقهم باستخدام مقياسState Trait Anxiety Inventory . النتائج: وجدنا ًارتباطا ًواضحا بين زيادة مستوى القلق والخصائص التالية: الجنس األنثوي، العمر األصغر، انخفاض مستويات التعليم، انخفاض الدخل الشهري، البطالة، العزوبية، العيش مع العائلة / األصدقاء، العيش في بيروت، التدخين، التاريخ الطبي ألمراض الجهاز التنفسي، التاريخ الشخصي يواألسر لألمراض العقلية، تناول األدوية النفسية، تاريخ سابق من القلق، وتجربة أي نوع من العزلة أو الحجر الصحي. من ناحية أخرى، لم يتم العثور على ارتباط بين درجة أعلى من القلق والعدوى الشخصية بالفيروس، إصابة األقارب أو األصدقاء، أو مدة الحجر. الخالصة: الفاشيات المعدية لها تأثير كبير على الصحة النفسية، وهذا التأ ثير ث يتم التقليل من أهميته وإهماله حيث أن التركيز الرئيسي ينصب على السيطرة على انتقال المرض والحد منه. من المهم رفع مستوى الوعي حول هذه المسألة لمنع تفشي القلق بعد جائحة.COVID19
Corresponding Author Dr Emilio Alhachem, Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Byblos - Lebanon
E-mail: [email protected]
Authors
Dr Emilio Alhachem, Psychiatry Resident, Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Jounieh - Lebanon
118 Alhachem E, Haddad G, Nagib E, Ikdais W, Akkari M
Dr Georges Haddad, Psychiatrist at Hôpital Psychiatrique de la Croix, Jal Eddib - Lebanon
Dr Eliane Nagib, Psychiatry Resident, Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Jounieh, Lebanon
Dr Werner Ikdais, Psychiatry Resident, Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Jounieh, Lebanon Dr Myriam Akkari, Psychiatry Resident, Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Jounieh, Lebanon
119 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (120 - 123) (doi-10.12816/0056862)
Short Report COVID-19 Outbreak in a Locked Psychiatric Rehabilitation Unit and the Impact on Patients Treated with Clozapine
Sudad J Al-Timimi, Alistair Sinfield, Nahla F Jamil :تقرير موجز تفشي عدوى كوفيد -٩١ في وحدة مقفلة للتأهيل النفسي وتأثير ذلك على مرضى معالجين بعقار كلوزابين
سداد جواد التميمي ، ،الستر سنفيلد ونهلة فوزي جميل
Abstract
The novel coronavirus outbreak (COVID-19), which began in December 2019, has created an unprecedented challenge for services, especially medical services, throughout the world. In this short report, we consider the impact an outbreak of COVID-19 in a locked psychiatric rehabilitation unit in the United Kingdom, and its effect on two patients treated with Clozapine. Findings suggests an epidemiological model for COVID-19.
Key words: Clozapine, COVID-19, outbreak
Declaration of interests: none
Introduction
This short report describes the experience of an outbreak (2007) and received antipsychotic medication within the of the coronavirus pandemic (COVID-19) at the start of a British National Formulary limits. Patients had access to national lockdown in the United Kingdom (UK) in escorted and unescorted leave determined by their March 2020. We report on the impact the lockdown had clinical needs and risks. However, all leave was on two patients in a 24-bed secure unit for psychiatric suspended following a national lockdown in response to rehabilitation. Overall, patients ranged in age from 25 to the pandemic at the end of March 2020 when the death 64 years (18 men, 6 women) who had been enduring rate in the UK had reached an estimated 450 deaths per significant mental illness such that they required day. The national guidelines for social distancing and specialist support within a locked setting. All 24 patients hygiene were strictly followed within the hospital had been formally detained under the Mental Health Act concerned.
Covid-19 outbreak
On 29 April 2020, a regular senior member of the patient who was on clozapine developed persistent fever. nursing staff reported feeling unwell with fever and mild Clozapine was stopped on the day. Blood tests were cough, his last contact with patients and other staff was requested, and the patient was referred for an assessment during the night shift on the 27/28th April 2020. He was at a general medical unit with a request for COVID-19 tested for COVID-19, and the result returned positive on status. His blood count revealed low white cell the 30th April 2020. Distancing measures within the unit count(WBC 3.6 x109//l, Neutrophils 1.7, Lymphocytes were tightened, and all his contacts were traced. He had 1.7, Platelets 123), but COVID-19 testing was denied on been in close contact with another member of staff the basis that his full blood count was inconsistent with during medication administration on 28 April 2020. COVID-19 infection. He was not admitted and returned to the unit. The nurse who was in close contact with him on27 April reported similar symptoms on 1 May 2020 and tested The patient’s clozapine dose was reduced by 50% positive for COVID-19. On the same day, another male despite the fact that the blood result did not warrant
120 discontinuation of clozapine, but close weekly ten patients who required close monitoring during monitoring. His condition did not improve, and another administration of medication and were in contact with assessment at the acute medical unit was requested on the infected staff member. Five patients tested positive the 2May 2020. Chest X ray was clear, but his full blood (men aged 38 to 55 years) and were all isolated in one count revealed further reduction in white cell count ward. (white cell count 2.5, Neutrophils 1.7, Lymphocytes 0,.4, Platelets 75), which required immediate discontinuation All Fourteen staff members who had contact with the of clozapine. The patient was again not tested for first infected patient were offered testing, and seven COVID-19 because the clinical picture was inconsistent tested positive (age range 25-50 years). Testing for all with clinical manifestations observed in patients with the staff members were offered at the end of the week. For virus. The patient was returned to the unit with antibiotic the purpose of the current short report, the service’s cover. ethics procedure for case reporting was followed and, the consent of all nursing staff obtained. The unit requested support to carry its own testing of the patients because another patient developed fever and lethargy on 2 May 2020. The tests were carried out on
Clozapine
Clozapine is commonly used for treatment-resistant full blood count normalized after twelve days. The schizophrenia and requires close monitoring of physical second patient was asymptomatic with normal full blood health including regular full blood count because of bone count. Clozapine was discontinued in the symptomatic marrow suppression. It is often associated with Type 2 patient, but unfortunately, his mental state deteriorated Diabetes and obesity. and was managed by high dose Olanzapine, and subsequently Zuclopenthixol was added to his treatment Two patients who tested positive for COVID-19 were on regime. No further trial of Clozapine is possible at this Clozapine (dose 400mg daily). The first diagnosed stage. patients reacted with leucopoenia and lymphopenia. His
Staff Reaction
There is currently no cure for Covid-19, and it is not the use of self-medicating via non-evidence-based use of surprising that people are desperate to search for medication as well as Vitamin D and Zinc. Five staff protection.1Self-isolation among staff was evident before members who had been in close contact with first patient the outbreak, and many talked about their fear of were using such medication on the assumption that it can contracting the virus during work. The term COVID ward off COVID-19, and accidentally were tested Phobia may be used to describe the intense anxiety felt negative for COVID-19. by staff in health care services. One desperate measure is
Results
The unit is divided into two wings, and each wing number of staff diagnosed with COVID-19 were seven consists of two six bedded wards. The outbreak took out of fourteen staff involved in the affected wing and place in one wing with all patients suffering from had contact with the patient. The incubation period was moderate to severe psychotic symptoms and challenging also calculated to be four to five days in the staff behaviors. The staff member who was first infected with members. COVID-19 was in contact with that wing and infected another staff member as well as five out of ten patients Only two patients suffered from symptoms of fever, loss present at the time of outbreak. The incubation period of appetite and tiredness. The first diagnosed patient had was calculated to be four days. fever for eight days but did not receive antipyretic. The duration of symptoms in the other symptomatic patient The first patient diagnosed with COVID-19 had high lasted five days and did not receive antipyretics. All complex physical and mental health needs, and the staff other patients, who tested positive, were asymptomatic who tested positive had also been directly involved in his care during the first two days of his illness. The total
121
Among staff who tested positive were four who were symptomatic with fever, cough, and tiredness, and recovered within four to seven days.
Discussion
Experience now suggests that it is not uncommon for their age group, which was in the age range of 30 to 40 COVID-19 outbreaks to happen in community care years. However, it is interesting that more than 50% of settings. It follows that psychiatric units are not immune patients and staff tested positive were entirely to the spreading of the virus within its walls. There has asymptomatic. been heightened anxiety about the impact of COVID-19 on patients receiving antipsychotic medication, The use of non-evidence-based medication by some staff specifically Clozapine.2 There was a delay in diagnosis members is understandable, because of the stress of the of the first case because of atypical presentation with pandemic. It is quite possible that this group tested leucopoenia, while leukocytosis is more often observed. negative, not because of the medication they used, but On the other hand, another patient on Clozapine testing because they were more careful than others in using positive for COVID-19 was asymptomatic. protective measures and social distancing as much as possible during work. The symptoms of COVID-19 in the above patients and staff were relatively mild or absent probably because of
Conclusions
Since at least March 2020, when the coronavirus appear to react differently with leucopoenia rather than pandemic became more apparent in the UK, there was an leukocytosis, which might have a major impact on expectation that in inpatient psychiatric settings would be treatment plan because of subsequent discontinuation of impacted, which became a significant source of stress, Clozapine and worsening of mental state. However, anxiety and apprehension for staff and patients alike. there is no indication for discontinuing Clozapine COVID-19 has interfered with management plans and because of the Covid-19 pandemic, which at the time the care pathways for patients with serious mental disorder current report was published remains an unprecedented treated in a hospital setting not least because its virulence challenge for many health and care services throughout appears to vary considerably depending on age group the world. and co-morbidity. Patients treated with Clozapine also
Recommendation
1. It is essential to follow and adhere strictly to 3. Full blood count results should not be relied on COVID-19 public health guidelines in as guidance to offer COVID-19 testing. psychiatric inpatient units. 4. Leucopoenia with Fever might be a sign of 2. Any case of fever should be treated as potential COVID-19 infection in patients treated with COVID-19 case till proved otherwise and Clozapine. testing offered to contacts. All positive cases should be managed in an isolation ward.
References
1. Editorial (2020). COVID-19: Protecting health- care workers. The Lancet 395(10228) P922, March 21, 2020. 2. Pandarakalam J (2020). COVID-19: outbreak could last until spring 2021 and see 7.9 million hospitalized in the UK BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1071 (Published 16 March).
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الملخص
ادى تفشي جائ 91حة كوفيد والتي بدات في شهر كانون االول 0291 الى حدوث تحديات للخدمات يشكل عام وللطبية منها يشكل خاص في كل دول العالم ,هذا تقرير موجز عن تفشي عدوى كورونا او ك -فيدو ٩١ في وحدة مقفلة للتأهيل النفسي لمرضى مصابين بأمراض عقيلة جسيمة في المملكة المتحدة. ويوضح التقرير تأثير العدوى على المرضى الذين يتم عالجهم بعق .ار كلوزابين
Corresponding Author Dr Sudad Jawad Al-Timimi, Consultant Psychiatrist, The Copse, Elysium Health Care, Weston Super Mare, England-UK [email protected] Authors
Dr Sudad Jawad Al-Timimi, Consultant Psychiatrist, The Copse, Elysium Health Care, Weston Super Mare, England - UK
Mr Alistair Sinfield, Assistant Psychologist, The Copse, Elysium Health Care, Weston Super Mare, England-UK
Dr Nahla Fawzi Jamil, Consultant Psychiatrist, Aneurin Bevan University NHS Trust, Newport, Gwent, Wales - UK
123 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (124 – 129) (doi-10.12816/0056863)
المضاعفات العصبية النفسية لجائحة كوفيد -91
أديب العسالي Neurological and Psychiatric Consequences of COVID-19 Epidemic
Adib Essali
الملخص
سجلت المضاعفات العصبية والنفسية إلنتان كوفيد 91- أوالً في تقارير حاالت أو سالسل حاالت، مما استدعى إجراء بحوث مصممة لدراسة العواقب الصحية العقلية لجائحة كوفيد 91- . تم أيضا ًاستقصاء اآلليات المرضية لتلك العواقب، وكانت الدراسات األولية محصورة بالمرضى المقبولين في المشافي، لكن سرعان ما امتدت لتشمل مرضى كوفيد 91- المعالجين في المجتمع. تمت أيضا ًدراسة إمكانية اإلصابة باضطرابات عقلية مديدة عقب شفاء مرض كوفيد -91 . .
أجريت أيضاً بحوث لتحديد المضاعفات النفسية للحجر الصحي، ولدراسة الحالة النفسية للعاملين بالرعاية الصحية أثناء جائحة كوفيد 91- ، وأيضاً حالة الصحة العقلية عند الجمهرة العامة . .
تهدف هذه المقالة إلى تلخيص نتائج البحوث المتوفرة حاليا ً . .
المقدمة
تم تسجيل أولى حاالت انتان كوفيد 91- في كانون األول 0291 في ووهان المضاعفات العصبية النفسية عند مرضى كوفيد 91- الذين ال تتطلب درجة في الصين، وانتشرت اإلصابات خالل األشهر التالية حول العالم، فتم مرضهم القبول في المشفى بغية تحديد األشخاص األكثر تعرضا ًلإلصابة 02بحلول 0202أيار تبليغ منظمة الصحة العالمية عن 5945219 حالة بها ومن ثم تحديد أفضل الطرق لعالجها. يلزم أيضاً تحديد إنذار مضاعفات 91-كوفيد تضمنت 334232 وفاة 9. مع توسع انتشار الجائحة، بدأ تدريجياً 91-كوفيد العصبية النفسية التي يفترض نظرياً أن تزول بتحسن االنتان، تسجيل مضاعفات عصبية نفسية إلنتان كوفيد 91- فأنشأت جامعة ليفربول ولكن ال يتوفر حتى اآلن برهان يسند هذا االفتراض، بل قد تكشف موقعCoroNerveااللكتروني للتبليغ عن االختالطات العصبية النفسية الدراسات المجتمعية حدوث موجة من العواقب العصبية النفسية بعد تراجع المشاهدة في حاالت كوفيد 91- . تم التبليغ بين 0 04و 0202نيسان عن الجائحة وشفاء حاالت كوفيد 91- الخفيفة، فقد لوحظ استمرار أعراض 953 مريضاً )وسطي أعمارهم 19 سنة( قبلوا في المشافي في كافة أنحاء االكتئاب والقلق لوقت مديد أثناء وعقب حدوث جائحات انتانية سابقة مثل المملكة المتحدة بسبب كوفيد 91- ولديهم نمط ما من االختالطات العصبية المتالزمة التنفسية الحادة الشديد )سارس( ومتالزمة الشرق األوسط النفسية. 0 التنفسية )ميرس( وداء فيروس ايبوال 3، ،2 ويبدو أن هذه المالحظة تنطبق على جائحة كوفيد 91- ،أيضاً فقد أجري في الواليات المتحدة مسح تلفوني ً توفرت معلومات سريرية كاملة لما مجموعه 905 %10) ( مريضا من لمرضى خارجيين تعافوا من اإلصابة بكوفيد 91- ، فوجد أن نسبة الذين لم المرضى المبلغ عنهم، وتم تصنيف ما أصيبوا به من اختالطات عصبية يعودوا لحالتهم الصحية السابقة خالل 92 09- يوماً من إيجابية فحص نفسية تحت عنوانين، اشتمل األول على الحوادث الوعائية الدماغية مثل 91-كوفيد %04كانت من الفئة العمرية 32-91 سنة، 30 % من الفئة % احتشاء الدماغ والنزف ضمن القحف، وتضمن الثاني تغيرات الحالة العقلية العمرية 35 و21- %21، في األعمار فوق 52 سنة. كان احتمال عدم المعرفة على أنها تغير حاد في الشخصية أو السلوك أو المعرفة أو الوعي. استرجاع الوضع الصحي السابق أكبر عند وجود مشاكل صحية مزمنة، ً كانت الحوادث الوعائية الدماغية أكثر االختالطات شيوعا، حيث بلغ عنها ولكن لوحظ أيضاً أن واحد من كل خمسة أشخاص بعمر 32-91 عاماً 91-32 ً 11في مريض، وكانت هذه الحوادث الوعائية الدماغية أكثر شيوعا عند وغير مصاب بأمراض مزمنة لم يعد لصحته السابقة، مما بين أن كوفيد- من تجاوز عمر 42 سنة . 91 قد يتسبب بمرض مديد حتى بين الشباب غير المصابين بأمراض 5 كانت تغيرات الحالة العقلية ثاني أكثر االختالطات العصبية النفسية حدوثاً مزمنة. ً حيث أصابت 31 مريضا أصيب تسعة منهم باعتالل الدماغ وسبعة بالتهاب اآللية اإلمراضية لألعراض النفسية إلنتان كوفيد -91 الدماغ، بينما حقق بقية المرضى الثالثة والعشرون المعايير التشخيصية الضطرابات نفسية، وكان االضطراب النفسي جديد البدء عند 09 مريضاً تشكلت تدريجياً حاجة ماسة لبحوث توضح اآلليات البيولوجية الممكنة منهم . للمضاعفات العصبية النفسية إلنتان كوفيد 91- وتفسح المجال أمام استقصاء معالجات ممكنة، فأجريت دراسة استهاللية على 992 91-حالة كوفيد مثبتة 91-حالة كوفيد 992 تم التبليغ عن ذهان جديد البدء عند عشرة من هؤالء الثالثة وعشرين مخبريا ًبغية تحديد عبء القلق واالكتئاب المشاهد في هذه الحاالت ودرجة ً ً مريضا مصابا باضطراب نفسي، وتم تشخيص متالزمة عصبية معرفية ترافقه بخواص المرض األخرى، حيث تم قياس مستوى االكتئاب والقلق )شبه خرف( عند ستة منهم، بينما شخص عند سبعة المرضى الباقين باستخدام استبيان صحة المريض PHQ‐2 واستبيان اضطراب القلق اضطراب نفسي آخر، وكان حوالي نصف المرضى المصابين بتغير الحالة GAD‐2، كما تم قياس شدة فقد حاسة الشم وحاسة الذوق ودرجة احتقان ً العقلية أصغر عمرا من 42 سنة . وسيالن األنف ووجود الحمى والسعال وضيق النفس.6
كانت هذه الدراسة خطوة أولى في طريق تحديد اختالطات كوفيد 91- تميزت الحاالت المشتملة بهذه الدراسة بوجود أعراض إصابة شديدة العصبية النفسية، وفي تقديم معلومات تفيد مخططي السياسات الصحية، 91-بكوفيد ، وبينت نتائجها ازدياد وقوع االكتئاب والقلق بعد تشخيص وفي توجيه بحوث العلوم العصبية المستقبلية. فقد وضحت ضرورة دراسة
124 المضاعفات العصبية النفسية لجائحة كوفيد -91
اإلصابة بكوفيد 91- . كشفت هذه النتائج وجود ترافق بين معدل وقوع يبدون بعض العالمات العصبية، وأنه يمكن تقسيم تأثيرات كوفيد 91- على -91 االكتئاب والقلق وبين درجة فقد حاسة الشم وحاسة الذوق، بينما لم يالحظ الجملة العصبية المركزية إلى ثالث مراحل.8 مثل هذا الترافق مع شدة أعراض المرض األخرى 4. قادت هذه النتائج إلى ُ استنتاج أن االضطرابات النفسية المشاهدة في انتان كوفيد 91- هي نتيجة يبقى التخريب الفيروسي في المرحلة األولى محصورا بالخاليا الشمية تأثر الجملة العصبية المركزية، وقد توفر دعم لهذا االستنتاج من مناقشات والذوقية في األنف والفم، وتتشكل في المرحلة الثانية خثرات في الرئة ً متعددة االختصاصات بدأت في آذار 0202 في المشفى الوطني، كوين تنتقل إلى الدماغ مسببة النشبة، ويعبر الفيروس في المرحلة الثالثة الحاجز سكوير، لندن بهدف فهم األعراض العصبية النفسية إل 91-نتان كوفيد 1. الوعائي الدماغي ليغزو الدماغ. يغلب أن يشفى مرضى المرحلة األولى ً تمت في هذه المناقشات مراجعة الموجودات السريرية والمخبرية تماما بدون عالج، ويحرض الفيروس في المرحلة الثانية استجابة مناعية والشعاعية لثالثة وأربعين حالة كوفيد 91- مترافقة بأعراض عصبية نفسية، شديدة تسبب التهاب األوعية الدموية وتشكل خثرات دموية في الشرايين وتبين أنه يمكن ترتيب هذه األعراض في خمس فئات هي : واألوردة الدماغية فيصاب المريض بنشبات صغيرة أو كبيرة. وتظهر في المرحلة الثالثة اعراض إضافية تتضمن التعب والشلل النصفي وفقد الحس .9 اعتالل دماغ: شوهد عند عشرة مرضى أصيبوا بتخليط أو والرؤية المضاعفة والشلل الرباعي والحبسة الكالمية واضطراب التوازن، ذهان دون أي عالمات في الرنين المغناطيسي أو في فحص وتكون عاصفة السايتوكين في األوعية الدموية من الشدة بحيث أنها تسبب السائل الدماغي الشوكي، وقد شفي ًشفاء تاماً أو جزئياً تسعة من "استجابة التهابية انفجارية" وتخترق الحاجز الوعائي الدماغي مسببة هؤالء المرضى العشرة بالرعاية الداعمة فقط . دخول السايتوكينات ومكونات الدم وجزيئات الفيروس إلى النسيج الدماغي .0 متالزمات التهاب الجملة العصبية المركزية: شوهدت عند 90 مما يؤدي لموت الخاليا العصبية واللتهاب الدماغ. يمكن أن تتظاهر هذه مريضاً أصيب اثنان منهم بالتهاب الدماغ، وأصيب مريض المرحلة باالختالج وعدم التوجه والتخليط الذهني والسبات وفقد الوعي أو واحد بالتهاب نخاع معزول، وأصيب تسعة بالتهاب الدماغ الوفاة، ومرضى المرحلة الثالثة هم أكثر تعرضاً من غيرهم لإلصابة والنخاع الحاد المزيل للنخاعين الذي ترافق بنزف في خمس بعقابيل مديدة . . حاالت وبتنخر في حالة واحدة وبالتهاب نخاع في حالتين. ً ً عولج عشرة من هؤالء المرضى بالكورتيكوستيروئيد، وتلقى اتضح أيضا أنه يصعب تمييز وتدبير اإلصابات العصبية باكرا، وأن هناك ثالثة منهم غلوبيولينات مناعية وريدياً. شفي تماماً مريض حاجة ماسة لتحديد واسمات تشخيصية ريرس ية وشعاعية ومخبرية وشعاعية ً واحد، وشفي جزئياً عشرة مرضى، وتوفي مريض واحد . وإمراضيه بغية توجيه المعالجة. كما تأكدت مجددا ضرورة إجراء دراسات .3 نشبه إقفارية: حدثت عند ثمانية مرضى توفي واحد منهم . متابعة طويلة األمد لفهم العواقب العصبية النفسية المديدة . . .2 إصابة عصبية محيطية: شوهدت عند ثمانية مرضى وتمثلت أوصت هذه المراجعة بإجراء فحص عصبي نفسي وتصوير دماغ بالرنين بمتالزمة غيالن-باريه عند سبعة منهم، وبحالة واحدة من المغناطيسي لكل المقبولين في المشفى بسبب كوفيد 91- بحثاً عن إصابة اعتالل الضفيرة العضدية، وقد حدث شفاء جزئي تدريجي عند عصبية وتمهيداً لمتابعة المرضى بعد الخروج من المشفى بحثاً عن خلل ستة مرضى . معرفي . . .5 خمس حاالت اضطراب عصبي مركزي متنوعة لم يمكن تصنيفها في هذه الفئات .
وضحت هذه الحاالت أن انتان كوفيد 91- يترافق باختالطات عصبية نفسية متنوعة تصيب كامل المحور العصبي، وأن شدة هذه االختالطات ال تتعلق . بشدة اإلصابة التنفسية .
بينت مراجعة لكل الدراسات ذات الصلة التي نشرت بين كانون الثاني 0202وأيار أن ثلث إلى نصف مرضى كوفيد 91- المقبولين بالمشفى
تأثير جائحة كوفيد 91- على الصحة العقلية للعاملين في الرعاية الصحية يعمل مقدمو الرعاية الصحية تحت ضغط هائل وهم يوازنون بين واجبهم بينت هذه المراجعة المنهجية شيوع وقوع أعراض القلق واالكتئاب بين المهني واحتياجاتهم الشخصية، وتتزايد مخاوفهم بسبب عدم كفاية إجراءات مقدمي الرعاية الصحية، وأنها مترافقة بالتعرض لكوفيد 91- ؛ وباعتبارات ضبط اإلنتان والخوف من العدوى الشخصية أو األسرية، مما قد يقود إلى وبائية؛ وبالموارد المادية؛ وبالموارد البشرية؛ وبعوامل شخصية. فقد كان اإلصابة باالكتئاب أو القلق أو اضطراب الكرب التالي للرض، وقد أجريت حدوث القلق واالكتئاب مرتفعاً عند المعرضين لعدوى كوفيد 91- من -91 دراسات عديدة هدفت إلى تحليل تأثير جائحة كوفيد 91- على الصحة العقلية العاملين في خط الرعاية الصحية األول مع مسؤوليات سريرية عالية، للعاملين في الرعاية الصحية. كانت الصين سباقة بإجراء هذه الدراسات 1 وعند الذين أصيبوا بالعدوى. ًوإضافة إلى خشية العدوى الشخصية، شكل ولحقت بها دول أخرى 2، 92، 99 منها األردن 90. وقد بين معظم هذه الخوف على األهل والزمالء من العدوى سبباً رئيساً للكرب . . الدراسات ارتفاع وقوع أعراض القلق )ما بين 32 )%12و ( واالكتئاب 02 02 ً %22الى ( 2، 92 -90، إضافة إلى إصابة مقدمي الرعاية الصحية باألرق وبائيا، تناسب احتمال تطوير اإلصابة بأعراض نفسية مع معدالت وقوع واالحتراق واالنهاك العاطفي واألعراض الجسدية 2، 93 -95. وقد تمكنت االنتان في المنطقة أو البلد ومع مرحلة الجائحة عند تنفيذ الدراسة، حيث مراجعة منهجية غايتها تحليل المعلومات المسندة بالبرهان حول تأثير كانت المعاناة على أشدها أثناء تزايد عدد اإلصابات، وعند عدم توفر خبرة 91-جائحة كوفيد على الصحة العقلية لمقدمي الرعاية الصحية من تحديد من التعامل مع جائحات مماثلة، وعند عدم توفير الحكومات لمعلومات 052 دراسة منشورة باللغة اإلنكليزية أو االسبانية بين كانون األول 0291 شفافة ولخطط وقاية ومعالجة واضحة ومجدية . . 0202وأيار ، بقي منها بع 32د التصفية، دراسة بحثية أصلية أو تقرير ترافق نقص الموارد المادية، السيما وسائط الوقاية الشخصية، بخشية 16 سريري. العدوى بين مقدمي الرعاية الصحية والسيما العامليين في الخط األول
125 العسالي أ.
للرعاية، بينما خفف تأمين أماكن ووقت راحة من تأثير اإلعياء الجسدي أيضاً من الموت. كان متوسطو العمر أكثر مناعة ضد الكرب، ولكن كان والنفسي عند مقدمي الرعاية الصحية سواء أكان ذلك في أماكن عملهم أو الخوف من العدوى أعلى عند مقدمي الرعاية الذين لديهم أوالد. كما ازداد خارجها، وهناك برهان على أن تأمين هذه األماكن هو أكثر جدوى من احتمال معاناة أعراض القلق واالكتئاب بوجود بعض خواص الشخصية تقديم دعم نفسي أثناء الجائحة.17 مثل العصابية، أو عند الشعور بالوحدة أو وجود إصابة سابقة باضطراب عقلي أو بشكاوى جسدية . . أما بالنسبة للموارد البشرية، فقد كان احتمال معاناة الكرب العقلي مرتفعاً عند االحتكاك اللصيق بمرضى كوفيد 91- وعند ارتفاع مستوى المسؤولية لم تتعرض الدراسات المشتملة بهذه المراجعة المنهجية لعواقب الصحة السريرية، وقد لوحظ ذلك عند العاملين في خط الرعاية األول في أقسام العقلية المديدة، ربما بسبب حداثة جائحة كوفيد 91- ، ولكن من المعروف أنه االسعاف، ووحدات العناية المركزة، ووحدات استشفاء كوفيد 91- ، قد شوهدت عقب جائحة سارس اضطرابات نفسية مزمنة شملت متالزمة وسيارات اإلسعاف، وفي الرعاية الصحية األولية. ولكن لوحظ أن هذه الكرب التالي للرض واالكتئاب وتعاطي الكحول والعقاقير السيما عند الكوادر تكتسب بسرعة خبرة العناية بمرضى كوفيد 91- مما يزيدها اللذين كان خطر تعرضهم للعدوى مرتفعاً والذين احتاجوا للحجر 91، 91، صمودا ً . ويخشى أن مقدمي الرعاية الصحية قد ال يطلبوا المساعدة عندما تلزم، وقد يلجؤوا إلى آليات دفاع نفسي أولية مثل المعالجة الذاتية واإلنكار والعقلنة ً تتدخل أيضا عوامل شخصية، فقد اشارت معظم الدراسات إلى أن الصحة لمواجهة الظروف المكربة. تؤكد هذه الخشية ضرورة إجراء دراسات الجسدية والعقلية كانت أسوأ عند النساء أثناء الجائحة، وإلى أن مقدمي متابعة مديدة لتحديد العواقب النفسية المديدة للكرب الحاد عند مقدمي ً الرعاية الشباب كانوا أكثر خشية من العدوى بينما كان المسنين خائفين الرعاية الصحية المتصديين لهذه الجائحة . .
المضاعفات النفسية االجتماعية لجائحة كوفيد -91 أصاب انتان كوفيد 91- أقل من واحد بالمئة من سكان األرض، ولكن %( عند الشباب بعمر 91 02إلى سنة، كما كانت مرتفعة عند األقليات الخوف من هذا الفيروس أصاب كل البشر، فالوفيات في كل مكان العرقية والعاملين األساسيين ومقدمي الرعاية المتطوعين بدون أجر.21 واإلحصائيات مخيفة، وأعراض اإلصابة متفاوتة الشدة، وهناك حاالت ال عرضية مستمرة بنشر العدوى. أضف إلى ذلك أن هذه الجائحة استدعت وجدت نتائج موافقة في لبنان عندما أجري مسح عبر االنترنت لتقييم تغييرات حياتية مكربة، فحجرتنا في بيوتنا واستنزفت أموالنا وتحدت العوامل المرافقة للقلق أثناء جائحة كوفيد 91- . تم تنفيذ هذا المسح خالل ً وجودنا، كما انها استنفرت كل إمكانياتنا العقلية لمواجهة التهديد . فترة شهر اعتبارا من منتصف شهر آذار 0202، واشتمل على 0151 0151 شخصاً بالغاً من عدة مناطق من لبنان. وجد ترافق بين اشتداد مستوى القلق كانت االستجابة النفسية للجائحة مماثلة لالستجابة المناعية للفيروس التي قد وخواص عديدة تضمنت الجنس األنثوي، وعمر الشباب، وانخفاض تكسب مناعة كما قد تتسبب بأذى ألعضاء الجسم. استجاب البعض بشكل المستوى التعليمي، وانخفاض الدخل الشهري، والبطالة، والعزوبية، إيجابي فاتبع تعليمات الوقاية والتباعد االجتماعي، ولكن كانت استجابة والعيش مع أسرة أو أصدقاء، والعيش في بيروت، والتدخين، والسوابق غيرهم سلبية ففقد الشعور باألمان، وعانى من كرب مازال يختبر مقدرته المرضية التنفسية، وسوابق إصابة شخصية أو عائلية بمرض عقلي، على الصمود، وحل محل شعوره بالحصانة شعور بقرب زواله، وتكثفت وتناول أدوية نفسية، والمرور بتجربة عزل أو حجر. هذا، ولم يالحظ مخاوفه ًدافعة إلى اإلفراط في التسوق والتخزين، وربما إلى اإلصابة ترافق هام بين شدة القلق وبين اإلصابة بكوفيد 91- ، أو إصابة األهل باالكتئاب والقلق وما يرافقهما من تدهور األداء واألفكار الزورية واألصدقاء به، وال بين شدة القلق وطول فترة الحجر.22 واالنتحارية . . نبهت هذه الدراسات إلى أهمية اشتمال الصحة العقلية بالتداخالت العالجية قام مركز اإلحصاء األمريكي بقياس تأثير جائحة كوفيد 91- على معدالت والوقائية إلنتان كوفيد وإل91- ، ى ضرورة إعطاء أولوية لبعض فئات حدوث االكتئاب والقلق عند الشعب األميركي عن طريق إجراء مسوح المجتمع السيما بسن الشباب. ولتعميق فهم مخاوف الناس المتعلقة بتأثير اشتملت على 334505 مواطناً بالغاً من خمس عينات ممثلة للشعب 91-جائحة كوفيد على الصحة العقلية، تم إجراء مسحين اونالين 03: مسح األمريكي. كانت إحدى هذه العينات قد استقصيت في النصف األول من لناس لديهم صلة مع المرض العقلي )مرضى عقليين ومن يعتني بهم 0291العام فقورنت نتائجها بنتائج أربع عينات استقصيت أثناء الجائحة ومقدمي رعاية صحية وباحثين( بين 05 01و 0202آذار ، ومسح لعينة في نيسان وأيار 0202 02 . بينت هذه المقارنة ازدياد حدوث االضطرابات ممثلة للجمهرة العامة بين 04 32و 0202آذار . تم سؤال المشاركين في اإلكتئابية و/أو القلقية ثالثة أضعاف في العام 0202 ًمقارنة بالعام 0291، المسحين عن مخاوفهم بخصوص تأثير جائحة كوفيد 91- الحالية على -91 حيث وجد اضطراب اكتئابي و/أو قلقي عند واحد من كل ثالثة أشخاص صحتهم العقلية، وعن األمور التي وجدوها مفيدة لصحتهم العقلية أثناء 0202عام ، وقد خف انتشار القلق بشكل طفيف، وازداد انتشار االكتئاب الجائحة. اشتمل مسح ذوي الصلة بالمرض العقلي ع 0911لى شخصاً 0911لى بشكل طفيف، بين أواخر نيس 0202ان وأواخر أيار 0202 . %12معظمهم ) ( لديه مرض عقلي طرحوا 2352 فكرة حول تأثر الصحة العقلية بجائحة كوفيد 91- وصنفت طروحاتهم حسب أولويات المخاوف تم الحصول على نتائج مماثلة من مسح عينة ممثلة للمجتمع األمريكي بلغ وتواترها. وشمل مسح الجمهرة العامة عينة ممثلة مؤلفة من 9211 9211 ً ً 5290عددها شخصا بالغا بعمر 91 سنة فما فوق. أجري هذا االستقصاء شخصا ً . . باستخدام اإلنترنت بين 02 32و 0202حزيران ، فوجد اضطراب عقلي أو سلوكي واحد على األقل عند %22.1 من المشاركين. اشتملت هذه تبين بنتيجة هذين المسحين أن أهم المخاوف المتعلقة بتأثير جائ -حة كوفيد االضطرابات على الرض النفسي ذو الصلة بكوفيد 91- وتعاطي العقاقير 91 على الصحة العقلية هي القلق؛ والعزلة؛ والخوف من تدهور الحالة لتخفيف الكرب واالنفعاالت ذات الصلة بكوفيد 91- ، ًإضافة إلى القلق العقلية؛ ومن صعوبة توفر خدمات الصحة النفسية والدعم الصحي النفسي؛ واالكتئاب. وقال 92.1 % من المشاركين أنهم فكروا جديا ًباالنتحار خالل ومن التأثير على األسرة وعلى العالقات . . الشهر السابق للمشاركة بالدراسة، وكانت هذه النسبة على أشدها ) 05.5 05.5 كان القلق موضوعاً مهماً جداً عند كل من ذوي العالقة بالمرض العقلي والجمهرة العامة، فوصف ذوي الصلة قلقاً وجودياً عاماً ناجماً عن
126 المضاعفات العصبية النفسية لجائحة كوفيد -91
الغموض الطاغي على الجائحة، ووصفوا اشتداد قلقهم بفعل صعوبات كانت هناك خشية كبيرة عند مئات من المشاركين بمسح ذوي الصلة عملية )مالية، مهنية، الحصول على الطعام والدواء والسكن، الخروج إلى بالمرض العقلي حول كيفية حصول الناس على الدعم الصحي النفسي الهواء الطلق( وبسبب احتمال اإلصابة أو إصابة األحبة أو وفاتهم، وبمدى الالزم للحاالت الموجودة سابقاً ولالضطرابات العقلية المستجدة أثناء تقيد الناس بالتعليمات الحكومية، وبتكرار استخدام السوشيال ميديا. أما الجائحة، وتم التأكيد على ضرورة توفير الدعم الصحي النفسي للناس العزلة فقد ولدت عند ذوي الصلة بالمرض العقلي خوفاً شديداً من تأثير األكثر تعرضاً لالضطراب العقلي مثل النساء الحوامل واألشخاص ذوي التباعد االجتماعي والحجر على صحتهم النفسية وعلى صحة غيرهم، ومن صعوبات التعلم والمشردين واألسر الفقيرة واألطفال في الرعاية تأثير االنفصال عن األحبة وتحديد النشاطات االجتماعية والرياضية والمالجئ، وعبر البعض عن خشية أن الصحة العقلية قد ال تُعطى أولوية وإمكانية تلقي العالج النفسي وجهاً لوجه. أما الجمهرة العامة فعبرت عن مقارنة ًبعالج انتان كوفيد 91- وغيره من الحاالت الصحية الفيزيائية . . مخاوف شخصية متعلقة بالوحدة وحس األسر وبالحاجة لتعلم طرق للتغلب ً على العزلة وللتمكن من مساعدة اآلخرين . أخيرا، عبَّر عدد هام من ذوي الصلة بالمرض العقلي عن مخاوف متعلقة بتأثير الجائحة على األسرة والعالقات بشكل يضر بالصحة العقلية، فوصف تضمنت استجابات ذوي الصلة بالمرض العقلي خشية عامة من تدهور البعض خوفاً طاغيا ًمن إصابة أفراد األسرة بكوفيد 91- ، بينما كان غيرهم الحالة العقلية نتيجة للضغوط المرافقة للجائحة بما فيها الغموض وفقد قلقاً من أن إصابته بالعدوى ستفقده المقدرة على دعم أفراد أسرته المعتمدين السيطرة وخشية الموت وعواقب الحداد والتحديات العملية واالقتصادية، عليه. وقد كان كثيرون مشغولين بالصحة العقلية ألعضاء أسرهم أثناء كما تضمنت استجاباتهم خوفاً من حدوث اضطراب عقلي عندهم أو عند الجائحة السيما منهم المتقدمين بالعمر المحجورين واألطفال والشباب األهل واألصدقاء ومقدمي الرعاية الصحية العاملين مع مرضى كوفيد 91- ، المتخلفين عن المدارس واالمتحانات. من جهة أخرى، عبر البعض عن وكانت هذه المواضيع أقل ظهوراً في بيانات الجمهرة العامة . احتمال زيادة التوتر والعنف األسري أثناء الحجر . .
العوامل المساعدة على السالمة العقلية أثناء جائحة كوفيد -91 لخصت نتائج هذين المسحين العوامل المساعدة على الحفاظ على الصحة .2 المحافظة على الهدوء: وضح كثيرون التأثير المهدئ العقلية أثناء الجائحة بما يلي : لالسترخاء والتأمل، وشدد غيرهم على أهمية التعبد والصالة، وقال البعض أن حيواناتهم المنزلية ساعدتهم على البقاء هادئين . . .9 البقاء على تواصل: قال المشاركون بالمسحين أن البقاء على .5 ترشيد االطالع على المعلومات: وضح كثيرون ضرورة ترشيد ً تواصل منتظم مع األهل واألصدقاء، عادةً أونالين، كان عامال استخدام المعلومات المتوفرة، فخفف البعض من استخدام ً رئيسا في الحفاظ على صحتهم العقلية. وقد تمتع كثيرون السوشيال ميديا ونشرات األخبار بغية تخفيف مستوى قلقهم، ً بصرف وقت معا كعائلة، واستفاد البعض من التطوع ومساعدة ووجد البعض راحة في اتباع التعليمات الرسمية بخصوص غيرهم . التباعد االجتماعي والبقاء بأمان . . .0 االنشغال: اشترك جميع المشاركين بالمسحين بعديد من .4 استمرار الروتين: كان وجود خطة أو روتين يومي مساعداً النشاطات التي شغلت وقتهم وحسنت مشاعرهم أثناء الجائحة، للبعض في الحفاظ على صحتهم العقلية، السيما فيما يخص وتضمنت الهوايات والرسم والموسيقى والقراءة والتلفزيون الدعم والرعاية التي يتلقونها من الجهات الصحية ومن واألفالم وتحسين المنزل . أقربائهم. وكان هناك إجماع في المسحين على أهمية العمل في .3 الرياضة: وصف الجميع فائدة ممارسة رياضات مثل المشي منح شعور باألهمية أثناء هذا الوقت العصيب . . والركض والدروس الرياضية اونالين. كان هناك تأثير مفيد للتمكن من الخروج إلى الهواء الطلق والتمتع بالطبيعة . .
اآلثار اإليجابية لجائحة كوفيد -91 رغم كل المتاعب التي أثارتها جائحة كوفيد 91- ، هناك مظاهر يمكننا علمتنا الجائحة عادات صحية يجب الحفاظ عليها لتحسين الصحة الجسدية استخدامها لتحسين حياتنا في المستقبل، فقد اضطر الناس لتوجيه اهتمام أشد والنفسية مثل النوم المنتظم وممارسة الرياضة بانتظام. كما علمتنا أن اتخاذ لمظاهر مهمة من الحياة وتخفيف االندفاع وراء مساعٍ تافهة، حيث ترافق مواقف إيجابية وعرفان الجميل وتقنيات استرخاء العضالت والتنفس الحجر في كثير من األحيان بتمتين العالقات األسرية وبزيادة تقدير أفراد العميق تخفف القلق وتحسن المزاج، وأن تجريب أفكار وفعاليات جديدة األسرة لبعضهم البعض . يقوي المهارات المعرفية ويحسن المشاعر، وأن للحفاظ على التواصل االجتماعي أهمية خاصة خالل أوقات العزلة، وأنه يمكن الحفاظ على اضطرت أنظمة الرعاية الصحية للتأقلم فانتشر إجراء االستشارات عبر الترابط االجتماعي حتى أثناء التباعد الفيزيائي. يجب أن يقود الدرس الذي الهاتف واالنترنت، وقد عوض ذلك في مجال الرعاية الطبية النفسية عن تعلمناه إلى تمتين تقديرنا وسعينا للترابط اإلنساني . . أخصائينقص الصحة النفسية وعن صعوبة تقديم العالج الطبي النفسي وجهاً لوجه. تطلب ذلك أن تتأقلم أنظمة الرعاية الصحية لتجنب مشاكل مهمة مثل خصوصية المرضى وأمن المعلومات وتمويل الخدمات، إضافةً لتأمين عدالة تقديم الخدمات الصحية . .
127 العسالي أ.
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Cai H, Tu B, Ma J, Chen L, et al. Psychological Mood, anxiety and olfactory dysfunction in COVID Impact and Coping Strategies of Frontline Medical ‐19: evidence of central nervous system Staff in Wuhan Between January and March 2020 involvement? Laryngoscope 2020. First published: During the Outbreak of Coronavirus Disease 2019 02 July 2020. https://doi.org/10.1002/lary.28964 (COVID‑19) in Hubei, China. Med Sci Monit. 2020; 7. Paterson RW, Brown RL, Benjamin L et al. The 15:26:e924171. doi: 10.12659/MSM.924171. emerging spectrum of COVID-19 neurology: clinical, 18. Wu P, Liu X, Fang Y, et al. Alcohol radiological and laboratory findings. Brain 2020. DO abuse/dependence symptoms among hospital 10.1093/brain/awaa240 employees exposed to a SARS outbreak. Alcohol https://doi.org/10.1093/brain/awaa240 Alcohol. 2008; 43(6): 706–12.doi: 8. Fotuhia M, Mianc A, Meysamid S, Rajic CA. 10.1093/alcalc/agn073. Neurobiology of COVID-19. Journal of Alzheimer’s 19. Wu P, Fang Y, Guan Z, et al. The psychological Disease 76 (2020) 3–19. DOI 10.3233/JAD-200581 impact of the SARS epidemic on hospital employees 9. Chen Q, Liang M, Li Y, Guo J, Fei D, Wang L, et al. in China: Exposure, risk perception, and altruistic Mental health care for medical staff in China during acceptance of risk. Can J Psychiatry. 2009; the COVID-19 outbreak. Lancet Psychiatry. 2020; 54(5):302-11. doi:10.1177/070674370905400504 7(4), e15-e16. doi:10.1016/S2215-0366(20)30078-X 20. Twenge JM, Joiner TE. U.S. Census Bureau‐assessed 10. Zhang SX, Liu J, Jahanshahi A et al. At the height of prevalence of anxiety and depressive symptoms in the storm: Healthcare staff’s health conditions and 2019 and during the 2020 COVID‐19 pandemic. job satisfaction and their associated predictors during Depression and Anxiety. First published: 15 July the epidemic peak of COVID-19. Brain Behav 2020 https://doi.org/10.1002/da.23077 Immun. [Preprint], 2020.Available from: 21. Czeisler ME, Lane RI, Petrosky E, et al. Mental https://doi.org/10.1016/j.bbi.2020.05.010 Health, Substance Use, and Suicidal Ideation During 11. Chew N, Lee G, Tan B et al. A multinational, the COVID-19 Pandemic — United States, June 24– multicentre study on the psychological outcomes and 30, 2020. MMWR Morb Mortal Wkly Rep 2020; associated physical symptoms amongst healthcare 69:1049–1057. DOI: http://dx.doi.org/10.15585/mmwr.mm6932a1
128 المضاعفات العصبية النفسية لجائحة كوفيد -91
22. Anxiety in Lebanon During the COVID19 Pandemic. science. Lancet Psychiatry 2020; published online Arab J Psychiatry. 2020; 31(2). April 15, 2020. https://doi.org/10.1016/S2215- 23. Holmes EA, O’Connor RC, Perry VH, et al. 0366(20 )30168-1 Multidisciplinary research priorities for the COVID- 19 pandemic: a call for action for mental health Abstract eurological and psychiatric complications of the novel coronavirus (COVID-19) appeared initially in case reports N and case series. The observed complications have stimulated further research addressing the mental health consequences of the COVID-19 epidemic. The pathological mechanisms of these consequences have also been explored. Initial studies were limited to patients treated in hospitals, but soon involved patients treated in the community. The possibility of experiencing long lasting mental health difficulties after recovery from the COVID-19 virus has also been studied. Research has also addressed the psychological impact of quarantine, the mental health of healthcare professionals during the COVID-19 epidemic, and the mental health status of the general population.
The current paper is an attempt at summarizing the results of the research that has been done so far.
Author Author
Dr Adib Essali, MD PhD MRCPsych Affiliate RANZC, Consultant Psychiatrist, Counties Manukau DHB
Honorary Senior Lecturer, University of Auckland, New Zealand
E-mail [email protected]
المؤلف
الدكتور –اديب عسالي مستشار الطب النفسي
نيوزيالندا-جامعة اوكالند
129 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (130 – 143) (doi-10.12816/0056864)
Saudi Adolescents’ Reports of the Relationship between Parental Factors,
Social Support and Mental Health Problems
Nouf Abdullah Alshehri, Murat Yildirim, Panos Vostanis تقارير المراهقين السعوديين عن العالقة بين العوامل األبوية، الدعم اإلجتماعي والصحة النفسية
نوف عبدهللا الشهري، مراد يلديريم، بانوس فوستانيس
Abstract
ackground: It is important to understand how parental and community factors can impact on the development of B mental health problems in young life, particularly by capturing young people’s voices. Aim: This cross-sectional study aimed to determine to what extent parental rearing style, attachment security and social supports were associated with mental health problems among young people living in disadvantaged areas of Saudi Arabia, as reported by young people. Method: Of 451 adolescents recruited to the study, 215 (48%) were girls and 237 (52%) were boys aged between 12 and 16 years. They completed the Strengths and Difficulties Questionnaire, Parental Authority Questionnaire, Attachment Security Scale, and Multidimensional Scale of Perceived Social Support rating scales. A series of hierarchical regression analyses were performed to identify predictors of mental health problems. Results: Results showed that 23.50% of adolescents reported scores that indicated likely mental health problems. Authoritative parenting style, attachment security and social support were associated with positive mental health, after controlling for age and gender. Conclusion: Findings highlight the importance of establishing adolescents’ views and understanding of protective factorsaddressed through early interventions.
Key Words: Adolescents, mental health problems, parenting, attachment, Saudi Arabia
Declaration of Interest: None
Introduction
Improving the mental health of children and young Protective factors are often dynamically inter-linked, people is becoming a policy priority worldwide.1 hence the importance of studying their impact in According to the World Health Organization (WHO)1, it conjunction, in order to inform the development of multi- is estimated that approximately 10% of young people modal preventive and responsive interventions.7 globally suffer from mental health problems, with higher rates among those living in disadvantaged communities, Most evidence relates to the role of different parental due to the multiple risk factors they may face, and factors, with studies largely involving children rather limited access to interventions and services.2,3 A large than adolescents, and relying on parental reports. Several body of evidence has established the role of risk factors authors reported that positive parenting (usually warm, on young people’s mental health.4, 5 nurturing and/or authoritative) styles promote children’s mental wellbeing.8,9 In contrast, negative parenting Relatively more recently, the focus of research has (authoritarian and permissive) styles have been found to shifted towards the parallel understanding of how be associated with the development of emotional individual and environmental factors can also protect (internalizing) and behavioral (externalizing) problems.8 adolescents by ‘buffering’ the effect of adversities and This evidence largely originates from western countries, traumatic events.6 A number of protective factors have with limited and often inconclusive findings from other thus been shown to promote adolescents’ personal societies. These maybe explained by the lack of cross- growth and to strengthen their resilience. These are cultural validation of parenting constructs and linked to individual characteristics such as coping measures.10 strategies, family and wider community supports.4,6
130 Parental Factors and Saudi Adolescent Mental Health
More in-depth knowledge of the context of parental health problems in young life.20 Similarly, Raheel found factors is particularly important for Arab countries, that depression was more prevalent among Saudi girls where a number of studies indicated that authoritarian who had insecure attachments to their family, lived with parenting style is widespread, without always being a single parent, had low monthly income, and were associated with mental health problems.11 Obedience to exposed to emotional abuse.21 authority and respecting parents are thus strongly emphasized in Arab societies.12 Consequently, some In addition to the inter-linkage between different parental authors have argued that a parental authoritarian style factors, these are also often influenced by and related to applied within certain sociocultural contexts may not wider social and community variables, in particular the have adverse effects on children’s mental wellbeing,13 extent and quality of social supports. Perceiving a high albeit without substantive supporting evidence. In level of social support has thus been found to improve 22 contrast, other studies found a similar pattern as in the quality of parent-child relationships. Support from Western societies. For example, Ghazwani et al. found a family, friends and others is considered as an important prevalence of almost 12% of social anxiety problems positive resource, especially for adolescents who among Saudi adolescents in Abha; with negative increasingly function within a wider social 23,24 parenting styles such as parent anger, emotional environment. maltreatment and criticism, particularly in front of As already stated, the relationship between parental, 14 others, acting as risk factors. community factors and children’s (and to a lesser extent Parenting styles and rearing practices are conceptually adolescents’) mental health has been widely investigated. different from the quality of the parent-child However, evidence in this field is largely based on adult (attachment) relationship, although significant reports. There is, however, a growing acknowledgement associations have been established between these two on the importance of capturing children’s and young constructs. Most attachment-focused research also relied people’s voices in informing both research and services, 25 on younger samples and parent reports. Several studies especially on decisions related to the care they receive. established a relationship between mother-child Some studies suggested that adolescents’ perceptions of attachment insecurity with children’s behavioral and parenting style and family supports may have a great emotional problems.15 There has been less research with impact on their mental health outcomes than their 26,27 adolescents; however, insecure attachment with their parents’ reports. As with the previously considered parents has also been found to be associated with more parenting literature, the majority of evidence on authoritarian and less authoritative parenting style.16 This adolescent reports of family- and community-related in turn poses a risk factor for their mental health.17 A factors in relation to their wellbeing originates from young person’s capacity to form secure relationships is western countries. These may not necessarily apply to especially important in the face of ongoing stressors and societies such as Saudi Arabia, which have different 28 experience of trauma.18 norms on young people’s position and beliefs. Providing youth-centered evidence from an understudied Allen et al. examined the relationship between secure culture and population can thus contribute to the existing attachment and multiple domains of adolescent literature in enhancing our understanding of the psychosocial functioning. Mother-adolescent secure relationship between parental, community and adolescent attachment was linked to low levels of depression and mental health related factors, as perceived by young behavioral problems among young people.19 Abbas and people.29 Addressing this research gap was the rationale Al Buhairan carried out a study with Saudi adolescents for the current study. and young adults aged between 10 and 24 years. They found that insecure parent-adolescent relationships and family conflict contributed to higher rates of mental
Methods
The aim of this study was to examine the role of adolescents’ mental health (lower mental health parenting style, attachment relationships and social problems scores). supports in predicting mental health problems of adolescents living in disadvantage areas in Saudi Arabia, Participants as reported by adolescents themselves. It was Initially, the Ministry of Education discussed the hypothesized that positive parenting styles, secure proposed study with the first author. According to the attachment and social supports would be associated with
131 Alshehri NA, Yildirim M, Vostanis P data collected by the Ministry of Education, each area of items rated on a 3-point scale (0=Not True, 1=Somewhat the country is given an index of disadvantage according True, 2=Certainly True). Subscale scores range between to average monthly income, illiteracy, and 0-10. A total difficulties score is generated by summing unemployment. The researcher was subsequently the four problems subscales. Satisfactory internal referred to the Education Departments of three consistency reliability was reported in this study for the disadvantaged areas of Saudi Arabia (south of Jeddah, total difficulties score (a=.80). The SDQ version has south and mid of Asir). All three Education Departments been validated in various cultures, including with Arab agreed to the study, selected secondary schools, and children and young people.4,28 Cut-off scores between 0- circulated the research protocol and information letters to 15, 16-19 and 20-40 are referred to as normal, borderline the school principals. The latter were subsequently and abnormal range, respectively; while for prosocial visited by the researcher. Participants were recruited behaviors, cut-off scores of 6-10, 5 and 0-4 indicate a from eleven schools (five girls and six boys’ schools) normal, borderline and abnormal range, respectively. from these areas. Bandings within the ‘abnormal’ range indicate the likelihood of a psychiatric disorder that requires an Initially, 980 adolescents aged 12 to 16 years were assessment with a view to receiving treatment.3 approached. However, of those eligible participants, parents of 529 adolescents either did not give their The Parental Authority Questionnaire (PAQ)31 assesses a consent or did not return the questionnaires. This resulted young person’s perceptions of their parents’ rearing style in 451 adolescents taking part in the study and and practices. The questionnaire includes 30 items, under completing the data. Their age ranged between 12 and 16 three subscales: authoritarian, authoritative, and years, with a mean age of 14.87 (SD=.94). Of those, 236 permissive. Subscales scores range between 10 and 50, (52%) were boys and 215 (48%) were girls. The majority and each includes ten items rated on a 5-point Likert- (n=331, or 73%) lived in an urban area. Consistent with type scale ranging from 1=not agree to 5=agree. In this Saudi society, participants came from large families: study, internal consistency was .64 for permissive, .61 57% had between five to nine siblings, 35% had less than for authoritarian and .81 for authoritative styles scores. five, and 8% had more than nine siblings. Overall, 85% 32 lived with both parents and 15% lived either with a The Security Scale measures young people’s perceived single parent or with other relatives. attachment security from each of their parents. A maternal and paternal attachment security subscale Research Procedure includes 15 items. Items are rated on a 4-point scale. Participants are asked to choose the closest statement The study received the ethical approval from the that represents their perceptions of the quality of the Ministry of Education in Saudi Arabia and the University relationship. They then rate whether this statement is true of Leicester Research Ethics Committee in the UK. The or ‘sort of true’ for themselves. To generate the total research was conducted in accordance with the score of maternal and paternal attachment, items are Declaration of Helsinki ethical principles. Written summed separately, and a higher score indicates more informed consent was provided by parents, after sending secure attachment. In this study, internal consistency information letters through schools. In addition, young reliability was .81 for maternal attachment and .87 for people provided verbal assent, even if their parents had paternal attachment subscales scores. previously agreed. After a detailed explanation about the study had been provided, they were reassured that their The Multidimensional Scale of Perceived Social Support participation was completely voluntary, and that their (MSPSS)33 was used to assess adolescents’ perceptions responses were confidential and anonymous. For the of different social supports. This includes 12 items, with current study, all scales were translated into Arabic. three subscales: family support, friends support and Participants completed the questionnaires in paper significant others. Each subscale includes four items format. These were administrated in their classrooms rated on a 7-point scale (1=very strongly disagree; during a lesson time (40-45 minutes). 7=very strongly agree). Internal consistency reliability was found to be satisfactory (family a=.80; friends a=.77 Measures and significant others a=.80). The Strengths and Difficulties Questionnaire (SDQ)30 is Statistical Analysis a widely used measure of common mental health problems across many cultures. It includes 25 items split The distribution of the data was tested using skewness into five subscales: emotional, conduct, and kurtosis statistics, and no violation was found hyperactivity/inattention, and peer relationship problems; regarding normality (skewness range: -0.11 and -0.84; and prosocial behaviors. Each subscale includes five kurtosis range: -.10 and 1.29). No concerns about
132 Parental Factors and Saudi Adolescent Mental Health multicollinearity were reported, as variance inflation the relationship between continuous variables. Multiple factor (VIF) values were below 10, and tolerance values regression was used to examine whether parenting style, were higher than 0 (tolerance range: 0.64-0.96; VIF attachment and social support could predict mental range: 1.05-1.57). No outliers were observed within the health scores. Data were analyzed using SPSS Statistics dataset. Correlation analysis was conducted to explore 25.0 for Windows.
Results
Rates of likely mental health problems where clinical score referred to scores within the ‘abnormal’ range. In this study, almost a quarter of the Table 1 shows the rates of likely mental health problems adolescents (n=106, 23.50%) scored within the clinically reported by adolescents according to established cut-off significant range (20-40) of mental health problems, i.e. 3 scores (normal, borderline and abnormal) on the SDQ. adolescents who would benefit from an assessment with These were categorized as clinical and non-clinical, a view to receiving appropriate treatment (Table 1).
Table 1. Reported rates of likely mental health problems
Variable Cut-off score Interpretation Frequency Percent
Emotional problems (ES) 0 ≤ ES ≤ 5 Normal 346 76.72
ES = 6 Borderline 41 9.09
7 ≤ ES ≤ 10 Abnormal 64 14.19
Conduct problems (CP) 0 ≤ CP ≤ 3 Normal 275 60.98
CP = 4 Borderline 80 17.74
5 ≤ CP ≤ 10 Abnormal 96 21.29
Hyperactivity problems (H) 0 ≤ HP ≤ 5 Normal 355 78.71
HP = 6 Borderline 47 10.42
7 ≤ HP ≤ 10 Abnormal 49 10.9
Peer problems (PP) 0 ≤ PP ≤ 3 Normal 161 35.70
4 ≤ PP ≤ 5 Borderline 83 18.40
6 ≤ PP ≤ 10 Abnormal 207 45.90
Total difficulties (SDQ 0 ≤ SDQ ≤ 15 Normal 231 51.22 total) 16 ≤ SDQ ≤ 19 Borderline 114 25.28
20 ≤ SDQ ≤ 40 Abnormal 106 23.50
Prosocial behaviors (P) 6 ≤ PB ≤ 10 Normal 364 80.71
PB = 5 Borderline 48 10.64
0 ≤ PB ≤ 4 Abnormal 39 8.65
133 Alshehri NA, Yildirim M, Vostanis P
Relationship between parental, social support and The analysis also indicated a negative relationship mental health scores between mental health problems (total SDQ scores) and child-parent secure attachment scores (father r=-.39, We performed a Pearson correlation to explore the p<0.01; mother r=-.33, p<0.01). Authoritative parenting relationship between mental health, parenting style, style was positively correlated with parent-child secure attachment style and social supports (Table 2). The attachment (father r=.30, p<0.01; mother r=.35, p<0.01) results showed that authoritative style was negatively and total social supports (r=.37, p<0.01). Total social correlated with emotional (r=-.18,p<0.01), conduct (r=- supports were negatively correlated with hyperactivity .09, p<0.05), hyperactivity(r=-.21, p<0.01), and peer (r=-.14, p<0.05), peer (r=-.13, p<0.05) and overall problems (r=-.10, p<0.05); as well as with overall mental health problems (r=-.14, p< 0.05). There was a difficulties (r=-.21, p<0.01). In contrast, this was strong negative correlation between family support and positively correlated with prosocial behaviors (r=.24, total SDQ scores (r=-.36, p<0.01), while a positive p<0.01). correlation was found between significant other supports and prosocial behaviors (r=.12, p<0.05).
134 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (130 – 143) (doi-10.12816/0056864)
Table 2. Relationship between parental, social support and adolescent mental health scores
Variable 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Mental health 1. Emotional symptoms 1 2. Conduct problems .39** 1 3. Hyperactivity .41** .29** 1 4. Peer problems .28** .25** .19** 1 5. Prosocial 0.08 -.14** -0.03 -0.09 1 6. Total difficulties .78** .68** .67** .63** -0.06 1 Parenting style 7. Permissive 0.01 .13** -0.02 .12* 0.03 0.081 1 8. Authoritarian .09* .09* .12* .13** 0.09 .157** .36** 1 9. Authoritative -.18** -.09* -.21** -.10* .24** -.213** .40** .27** 1 Attachment style 10. Security to mother -.32** -.20** -.26** -.15** 0.09 -.334** 0.09 -0.04 .35** 1 11. Security to father -.41** -.23** -.27** -.19** 0.05 -.399** .15** 0.01 .30** .45** 1 Social support 12. Family social support -.32** -.20** -.30** -.19** 0.07 -.367** .19** 0.07 .42** .43** .47** 1 13. Friends social support 0.08 .14** -0.01 -0.07 0.06 0.052 .09* .13** .15** 0.07 -0.01 .14** 1 14. Significant others 0.02 -0.01 -0.03 -0.05 .12** -0.024 .15** 0.03 .28** .21** .11* .27** .53** 1 15. Total social support -0.09 -0.02 -.15** -.14** .11* -.141** .20** .10* .38** .31** .24** .61** .77** .82** 1 **. p< 0.01; *. p< 0.05
135 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (130 – 143) (doi-10.12816/0056864)
Gender effects difficulties alongside reporting more prosocial behaviors. Girls also reported that they received more social support Independent sample t-tests were conducted to establish from significant others and friends. However, boys any gender differences on mental health, attachment scored higher on the scores of the security to mother and security, social support, and parenting styles scores father, family support, permissive styles, and (Table3). Girls reported more problems that were authoritarian styles. emotional, hyperactivity, peer problems, and total
Table 3. Independent sample t-test comparing boys and girls across the study variables
Variable Group N Mean SD t df p Emotional problems Boys 236 3.18 2.40 -5.54 449 0.00 Girls 215 4.41 2.32 Conduct problems Boys 236 2.97 2.06 -1.62 449 0.10 Girls 215 3.28 1.98 Hyperactivity Boys 236 3.72 1.88 -2.34 449 0.02 Girls 215 4.15 2.09 Peer problems Boys 236 4.21 2.26 -2.84 448.50 0.00 Girls 215 4.78 1.99 The total difficulties Boys 236 14.08 6.17 -4.64 449 0.00 Girls 215 16.62 5.43 Prosocial behavior Boys 236 7.02 1.94 -2.45 449 0.01 Girls 215 7.46 1.86 Security to mother Boys 235 48.27 7.40 4.72 408.40 0.00 Girls 215 44.50 9.31 Security to father Boys 221 44.07 10.82 4.07 429 0.00 Girls 210 40.01 9.85 Significant other supports Boys 236 20.16 5.47 -4.11 449 0.00 Girls 215 22.22 5.16 Family supports Boys 236 21.44 5.02 4.14 449 0.00 Girls 215 19.51 4.88 Friends supports Boys 236 18.47 5.95 -3.69 448 0.00 Girls 214 20.42 5.14 Permissive style Boys 236 29.89 5.71 2.69 449 0.01 Girls 215 28.51 5.17 Authoritarian style Boys 235 32.49 5.93 2.39 448 0.02 Girls 215 31.23 5.20 Authoritative style Boys 236 35.48 6.56 0.52 449 0.60 Girls 215 35.15 7.04
The role of parental factors and social supports in variables. In step 1, age negatively predicted emotional predicting mental health problems after controlling for problems (B=-.30, p< 0.05), while female gender demographic factors are considered. positively predicted emotional problems (B=1.00, p<0.01), peer problems (B = 0.8, p <0.01), and total SDQ Several hierarchical regression analyses were carried out scores (B =2.4, p<0.01). to examine whether parenting style, attachment style and social support could predict mental health problems, Inclusion of parenting style, attachment style and social after controlling for age and gender (Table 4). Age and support scores in Step 2 significantly predicted emotional gender were entered in Step 1 of the model, while problemsF(10,429)=14.22,p<0.01,∆r2=.18. parenting style, attachment and social support scores Authoritarian style positively predicted emotional were entered in Step 2 as independent variables. SDQ problems (B=.04, p< 0.05), while security with the father total and subscales scores were treated as outcome (B=-.06, p<0.01) and family social support scores (B=- .05, p=0.05) were significant negative predictors.
136 Parental Factors and Saudi Adolescent Mental Health
Security to father (B =-.03, p<0.05) negatively predicted However, authoritarian (B=.06, p<0.01) and permissive conduct problems, while permissive parenting style style (B=.07, p<0.01) positively contributed to the model (B=.06, p<0.05) positively predicted conduct problems in predicting peer problems in Step 2 F (10, 428)=6.05, F(10, 428)=6.19, p<0.01, ∆r2=.12. Authoritative style p<0.01, ∆r2=.10. Authoritative style (B=-.13, p<0.01), (B=-.04, p<0.05), security to father (B=-.02, p<0.05) and secure relationship with father (B=-.13, p<0.01), and family supports (B=-.07, p<0.01) negatively predicted family supports (B=-.22, p<0.01) negatively predicted hyperactivity scores; while authoritarian style (B=.05, total SDQ scores. While permissive (B=.18, p<0.01) and p<0.01) positively predicted hyperactivity scores F (10, authoritarian style (B=.17, p< 0.01), positively predicted 428)=7.42, p<0.01, ∆r2=.14. total SDQ scores, after controlling for gender (B=2.41, p<0.01) F(10, 428)=16.69, p<0.01, ∆r2=.24. Authoritative parenting style (B=-.04, p<0.05) and Furthermore, only authoritative style (B =.07, p<0.01) family supports (B=-.05, p<0.05) negatively contributed positively has a significant contribution to prosocial to the model in predicting peer problems in Step 2. behaviors in Step 2F(10, 428)=4.08, p<0.01, ∆r2=.08.
137 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (130 – 143) (doi-10.12816/0056864)
Table 4. Role of parental and social support factors in predicting adolescent mental health scores, after controlling for age and gender
Emotional problems Conduct problems Hyperactivity problems Variable B Beta t p B Beta t p B Beta t p Step 1 F (2, 428) = 17.70, p< 0.01, r2 = .08 F (2, 428) = 1.22, p> 0.05, r2 = .01 F (2, 428) = 2.28, p> 0.05, r2 = .01 Age -0.30 -0.12 -2.23 0.03 -0.07 -0.03 -0.59 0.55 -0.02 -0.01 -0.22 0.83 Gender 1.00 0.21 3.98 0.00 0.23 0.06 1.04 0.30 0.39 0.10 1.82 0.07 Step 2 F (10, 429) = 14.22, p< 0.01, ∆r2 = .18. F (10, 428) = 6.19, p< 0.01, ∆r2 = .12 F (10, 428) = 7.42, p< 0.01, ∆r2 = .14. Security mother -0.03 -0.10 -1.88 0.06 -0.01 -0.06 -1.10 0.27 -0.02 -0.10 -1.75 0.08 Security father -0.06 -0.27 -5.37 0.00 -0.03 -0.15 -2.68 0.01 -0.02 -0.12 -2.14 0.03 Significant others 0.03 0.07 1.31 0.19 -0.02 -0.06 -0.99 0.32 0.04 0.10 1.69 0.09 Family support -0.05 -0.11 -2.00 0.05 -0.05 -0.11 -1.90 0.06 -0.07 -0.16 -2.84 0.00 Friends support 0.02 0.04 0.86 0.39 0.07 0.19 3.51 0.00 -0.02 -0.04 -0.82 0.41 Permissive 0.03 0.07 1.39 0.16 0.06 0.17 3.27 0.00 0.01 0.04 0.71 0.48 Authoritarian 0.04 0.10 2.22 0.03 0.01 0.04 0.72 0.47 0.05 0.14 2.88 0.00 Authoritative -0.03 -0.08 -1.58 0.11 -0.02 -0.07 -1.18 0.24 -0.04 -0.15 -2.63 0.01 Peer relationships problems Total difficulties Prosocial behaviors B Beta t p B Beta t p B Beta t p Step 1 F (2, 428) = 6.41, p< 0.01, r2 = .03 F (2, 428) = 11.36, p< 0.01, r2 = .05 F (2, 428) = 2.89, p> 0.01, r2 = .01 Age 0.11 0.05 0.94 0.35 -0.28 -0.04 -0.83 0.41 0.00 0.00 0.04 0.97 Gender 0.80 0.19 3.52 0.00 2.42 0.20 3.86 0.00 0.45 0.12 2.18 0.03 Step 2 F (10, 428) = 6.05, p< 0.01, ∆r2 = .10 F (10, 428) = 16.69, p< 0.01, ∆r2 = .24 F (10, 428) = 4.08, p< 0.01, ∆r2 = .08 Security mother 0.01 0.02 0.42 0.68 -0.06 -0.09 -1.66 0.10 0.01 0.04 0.68 0.50 Security father -0.02 -0.10 -1.73 0.08 -0.13 -0.23 -4.70 0.00 0.00 0.00 -0.02 0.98 Significant others 0.01 0.03 0.50 0.61 0.06 0.05 0.99 0.32 0.01 0.04 0.71 0.48 Family support -0.05 -0.12 -2.11 0.04 -0.22 -0.18 -3.41 0.00 0.00 0.00 0.00 1.00 Friend support -0.04 -0.10 -1.86 0.06 0.03 0.03 0.64 0.52 -0.01 -0.03 -0.58 0.56 Permissive 0.07 0.18 3.38 0.00 0.18 0.16 3.40 0.00 -0.04 -0.10 -1.87 0.06 Authoritarian 0.06 0.15 2.96 0.00 0.17 0.16 3.41 0.00 0.03 0.09 1.68 0.09 Authoritative -0.04 -0.13 -2.25 0.02 -0.13 -0.15 -2.95 0.00 0.07 0.25 4.25 0.00
138 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (130 – 143) (doi-10.12816/0056864)
Discussion
The current study investigated the association between caregiver, i.e. the mother,19 or with different family parenting style, attachment, social supports, and mental members.20,21 Adolescents’ perceptions within this health among Saudi adolescents, as perceived by the cultural context could be a possible explanation for this young people themselves. This contributes to the limited finding, as they may feel more protected by their fathers, literature on factors that protect adolescents from especially in disadvantaged areas, where the rates of risk developing mental health problems in Arab countries. factors are expected to be high.37 Since these findings The findings can thus inform the development and relied only on self-reports, further research on parents’ implementation of preventive and responsive own beliefs would enhance our understanding of interventions. Almost a quarter (23.50%) of Saudi underpinning mechanisms. Nevertheless, this finding adolescents living in disadvantaged areas reported SDQ highlights the importance of engaging fathers in scores within the clinical range, which indicates a interventions.38 substantial risk of developing mental health problems. This prevalence rate is double what is expected in the As hypothesized, authoritative parenting style was general population globally, but consistent with rates in negatively associated with adolescents’ total SDQ scores, deprived communities, as poverty is confounded by a and this finding is broadly consistent with previous 8,9 number of psychosocial risk factors.34 This indicates the findings. In contrast, a significant positive association importance of multi-modal interventions that ideally was found between authoritarian parenting style and address risk factors in conjunction.7 adolescent mental health problems. This result does not support the position claiming that authoritarian style Gender differences could be attributed to both generic within certain cultural contexts has no negative impact trends in the development of mental health problems, as on children or young people.11 As Arab societies are not consistent with the wider literature, and culture-specific homogeneous,39 this hypothesis would need to be tested factors. In the current study, girls reported higher levels in different cultural and socio-economic groups, as our of emotional and peer problems than boys. This finding findings could be partly explained by families’ low could be partly explained by other family and cultural socioeconomic status and living in poor neighborhoods. factors, whereas girls in the Saudi culture are more likely Bronfenbrenner emphasized that parenting is only one to be overprotected by family, relatively more sheltered, factor among many that influence a child’s mental and less likely to engage with community compared with health,40 including attitudes and beliefs, immediate and teenage boys.35 Another explanation could be that, since wider environment.20,21 Therefore, the impact of Saudi girls may spend more time at home, they may parenting may vary across ‘sub-cultures’ within the same become more vulnerable to negative rearing strategies.36 society. Similarly, parenting styles may be perceived These risk factors, however, also increase with differently by adolescents from different backgrounds.36 socioeconomic deprivation across all societies. Supports from family and significant others were Furthermore, authoritative style, secure attachment to negatively associated with adolescentreported mental father and family support were found to be negatively health problems. This is largely consistent with the associated with total SDQ scores while a positive literature from both western24 and, particularly, Arab association was found between authoritative style and countries with strong extended family networks, where significant other supports with adolescents’ prosocial young people seek extra support from other family behaviors. The essential role of parent-child secure members such as grandparents.41 In contrast, there was attachment on children’s development and mental health no contribution to the model from friend supports. This has been widely studied with younger age groups.15 finding could also be influenced by cultural factors since There has been less research with adolescents, although adolescents in Arab countries are more likely to be available evidence is largely consistent, in also connected and dependent on their parents and family demonstrating that secure attachment to at least one rather than other external resources such as school and parent is a significant protective factor for adolescents’ community.42,43 mental health.20,21 In this study, girls reported higher score of secure attachment to their mother while boys The results of this study indicate the inter-linkage of reported higher score of secure attachment to their family and community factors in influencing fathers. Overall, i.e. across both genders, secure adolescents’ mental health. This is consistent with attachment to the father was shown to be a significant Bronfenbrenner’s socio-ecological theory and the 40 protective predictor on most SDQ subscales. This pattern dynamic impact of different systems. The micro-system is clearly different from findings in other countries on the is closest to the young person, who has direct contact influence of attachment relationships with the primary with family members, friends, and teachers. The meso-
139 Alshehri NA, Yildirim M, Vostanis P system includes relationships or interactions between cross-sectional design would provide better different micro-systems, e.g. between family and school. understanding of underpinning mechanisms of protective The exo-system may not directly or actively involve the factors. Young people’s views and experiences, young person, nevertheless, can still impact on them, for including on potential cultural influences, could be example if a parent loses their job. The macro-system explored in more depth through qualitative interviews, or relates to wider cultural and socio-economic factors such in conjunction with quantitative data through mixed as attitudes and beliefs. Finally, the chrono-system methods.44 consists of environmental events and transitions occurring in a young person’s life.40 A change in any one Findings have implications for policy, services and of these systems can instigate changes in the others, practice. Although there is increasing attention in therefore impact on a young person’s mental health. improving mental health services for young people in Saudi Arabia, there is still limited evidence-base to Although this framework has been hugely influential in inform their development.45 The established high rates of child development and resilience research, evidence on mental health problems among Saudi adolescents require its implications for practice and service development, concerted efforts by policy makers and service providers, remains scarce.7 Several studies demonstrated the effect especially in areas of deprivation, where mental health that some of these parental and social factors have on and social care needs are complex and closely linked. As each other.16,21 Their concurrent evaluation is, therefore, engagement with mental health services is often crucial in understanding how they may contribute to influenced by attitudes and stigma of mental illness,46 it preventing or reducing mental health problems during is essential to establish awareness initiatives. In a childhood and adolescence. Such research should be previous study in Saudi Arabia, for example, we found informed by young people’s cultural context and their that child protection initiatives could not be successfully own voices. grounded if not complemented by awareness campaigns.47 As cultural beliefs and concepts of mental A number of limitations need to be acknowledged. health are strongly linked with help-seeking from young Participants were recruited from schools in certain people and their parents, both awareness programs and disadvantaged areas whose characteristics may not be services should be informed by and co-produced with generalizable to other parts of the country. Since the key communities, including young people’s voices. Family aim was to establish adolescents’ perspectives on the role support and parenting skills interventions should take of family and community factors on their mental health, into consideration local sociocultural contexts in only self-reported data were utilized in this study. engaging parents, including fathers and extended family Parents’ views should also be considered in future members.48 Early identification of emerging mental research, and these should be contrasted with those of health problems by schools, welfare and primary health young people. This will be important in establishing care services can be enhanced by training,49 and should similarities and differences, and thus informing be supported by clear pathways for young people with appropriate interventions. A longitudinal rather than emerging psychiatric disorders to specialist services.
Acknowledgements
We are grateful to all adolescents who participated in this head teachers and gatekeepers of all schools for their study, and their parents for their consent. We also thank help and kind support.
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الملخص
الخلفية: من المهم فهم كيف لعوامل الوالدين والمجتمع أن تؤثر على تطور مشاكل الصحة النفسية عند المراهقين، خاصة من وجهة نظر المراهقين أنفسهم .
هدفت هذه الدراسة إلى تحديد مدى ارتباط أسلوب تربية الوالدين، عالقة الوالدين بالمراهقين والدعم اإلجتماعي بمشاكل الصحة النفسية لدى المراهقين الذين يعيشون في مناطق نائية وفقيرة في المملكة العربية السعودية . .
البحث:طريقة تضمنت الدراسة ١٥٤ ٥٤٥مراهقآ )١٤٪( منهم كانوا فتيات و٥٣٢ )٥٥٪( كانوا من األوالد الذين تتراوح أ عمارهم بين ٤٥ و٤١ عاماً.أكمل عاما المشاركون تاالستبيانا ةالتالي The SDQ, PAQ, Security Scale :وSMSPS تم تحليل البيانات بإستخدام االنحدار الهرمي . .
أوضحت النتائج بأن ٪٥٣.٥٢ من المراهقين يعانون من مشاكل نفسية. أوضحت النتائج كذلك بأن أسلوب التربية الموثوق(Authoritative) ، والعالقة اآلمنة بين األباء واألبناء والدعم اإلجتماعي كلها عوامل حماية للصحة النفسية لدى المراهقين . .
تسلط هذه النتائج الضوء على أهمية األخذ بآراء المراهقين في تحديد وفهم عوامل الحماية والخطر على صحتهم النفسية لحمايتهم والتصدي لهذه العوامل من خالل التدخالت المبكرة . .
142 Parental Factors and Saudi Adolescent Mental Health
Corresponding Author Professor P. Vostanis, Department of Neuroscience, Psychology and Behaviour; University of Leicester, Leicester - UK
E-mail: [email protected]
Authors Ms. Nouf Abdullah Alshehri, PhD student, Department of Neuroscience, Psychology and Behaviour; University of Leicester, Leicester - UK. Dr Murat Yildirim, Assistant Professor of Psychology, Ağrı İbrahim Çeçen University, Department of Psychology, Faculty of Science and Letters, Ağrı - Turkey.
Professor Panos Vostanis, Professor of Child Mental Health; Department of Neuroscience, Psychology and Behaviour; University of Leicester, Leicester - UK
143 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (144 – 149) (doi-10.12816/0056865)
Attitudes of Undergraduate Medical Students in Baghdad Toward Mental Disorders and People with Mental Health Difficulties
Raad Saady Madhloom, Numan S Ali, Tori Snell أتجاهات طالب الطب الجامعيين في بغداد نحو االضطرابات النفسية واألشخاص الذين يعانونمن تصعوبا في الصحة العقلية
رعد سعدي مظلوم، نعمان سرحان علي، توري سنيل
Abstract
Background: Stigma associated with mental health disorders is a widespread problem linked to prejudices, attitudes, and misconceptions in society, which are also held by health professionals. Few studies in the Arab world have evaluated how medical students perceive people with mental health difficulties. Understanding the attitudes and perceptions of undergraduate medical students toward mental health disorders is important given the likelihood they will be involved, throughout their career, in the care of people with such difficulties. Aims: The current study explored the beliefs and attitudes of medical students in Baghdad toward mental illnesses and toward people who experience mental health difficulties. Methods: A cross-sectional design was used for a two-part survey containing sociodemographic information and the Beliefs Towards Mental Illness Scale, which was distributed to 4th and 5th year medical students attending the University College of Medicine in Baghdad. Results: Fifty students, ranging in ages 21 to 26 years, completed the survey. Findings suggest most students would not be embarrassed about having a relative or dating someone with a mental disorder. However, most held negative views about the capability of people with mental illnesses and 60% feared what others would think if they were diagnosed with a mental health difficulty. Conclusion: Awareness raising and review of course materials could go some way to reduce stigma. Normalization of mental illnesses through psychoeducation may also address the barriers that prevent undergraduate medical students and doctors from seeking help and thus avoiding burnout. Training courses and researchers also have a responsibility to update material and remove any stigmatizing language.
Keywords: undergraduate medical students, Baghdad, stigma, mental illnesses
Declaration of interest: None
Introduction
An estimated 792 million people live with a mental health stigma at the personal level, someone may be health disorder, which is approximately one in ten people more likely to agree with the statement that ‘it is best to globally.1 Mental health disorders are complex and can avoid people with schizophrenia’ while a perceived take on many forms, including depression, anxiety, belief describes what a person thinks others believe, e.g. bipolar, eating disorders, and schizophrenia. Despite how ‘most people think that a person with schizophrenia is common such conditions are, it is less common for dangerous’. Such bias appears to be more common in people who experience them to seek professional help or medical students,3,4 and may arise from a range of receive the appropriate support. This may be exacerbated factors, including societal norms. Research also by strongly held beliefs that people with mental health highlights how their training does not adequately address conditions are somehow ‘different’, ‘crazy’, or negative beliefs and stereotypes.5 ‘dangerous’.2 In many parts of the world, such underlying prejudice and discrimination is both a product As with many countries, there is a need in Iraq for of and a perpetuating factor for stigma. training courses to review the existing teaching curricula for undergraduate medical students so that it sufficiently The way in which language is used to describe people prepares them to provide holistic care to people with with mental health difficulties is also a problem in mental health difficulties, but also – given the many developing and developed countries, which can also be years of war, conflict and sanctions – greater training on stigmatizing. Stigma is a way of associating a person or a the links between trauma and mental health. Studies on thing with shame or disgrace. The process of student attitudes toward mental health have evidenced stigmatization arises from personal and perceived ideas, stigmatization by medical students in developed and which potentially ‘spoils identity’.2 As relates to mental developing nations alike, including deep-seated
144 Attitudes of Undergraduate Medical Students in Baghdad Toward Mental Disorders and People with Mental Health Difficulties
stereotypes and expressions of reticence about having people they support.11 The WPA has been concerned any social connections with people experiencing poor with the fate of those who experience mental health mental health.6,7,8 difficulties by emphasizing the importance of ensuring the best available interventions, protecting the dignity of In 2005, the World Psychiatric Association (WPA) patients, the dignity of their relatives and that of mental Section on Stigma and Mental Health was created, with a health personnel.12 broad mandate to reduce stigma and discrimination caused by mental health conditions in general.9 In light Understanding the perceptions of medical students on of these important developments, and the growing public these matters could inform how their training might health interest in stigma reduction, organizations such as usefully be improved, which has the potential to reduce the World Health Organization (WHO), the WPA and stigma toward patients. Normalizing mental health and the World Association for Social Psychiatry to name a associated difficulties may also lead to reduced symptom few, have all recognized stigma as a major public health concealment by medical students and doctors and challenge.10 alleviate burnout.13 The primary objective of the current study was to assess the beliefs and attitudes of The role that psychiatrists can play in the prevention of undergraduate medical students in Baghdad toward stigmatization of psychiatry is important when stressing mental illnesses and people with mental health the need to develop a respectful relationship with all difficulties.
Methods
The Ethics Committee at Baghdad Teaching Hospital were present during data collection. Data collection took reviewed the current study, which was conducted in place during mornings and afternoons on weekdays accordance with the Helsinki declaration on research between February to April 2018. ethics. Participation was voluntary and the responses anonymous. All participants provided verbal consent. The two-part survey included a sociodemographic section and one standardized scale – Beliefs Toward The study was conducted in the Baghdad Medical City, Mental Illness (BMI).14 The sociodemographic which is a complex of several teaching hospitals situated questionnaire included questions regarding gender, age, along the east bank of the Tigris River in the city’s religious affiliation, and student year. The BMI was used Rusafa district. The Medical City campus includes many to measure negative stereotypical views of mental health hospitals. The Baghdad Teaching Hospital is one of disorders. It is a 21-statement measure comprised of them. three subscales: social and interpersonal skills, dangerousness, and incurability. Items are rated on a 6- A convenience sample was drawn from a cohort of point Likert scale ranging from ‘completely disagree’ (0) medical students attending Al-Kindy Medical School to ‘completely agree’ (5) with higher scores reflecting who were in the 4th and 5th year of their medical greater negative belief. All responses were collected training. All were attending a two-week round in the anonymously. psychiatry department of Baghdad Teaching Hospital. Four groups, comprised of 50 students out of an overall Cronbach’s alpha was high among American (0.89) and total of 200, were selected. Groups were randomly Asian (0.91) participants14 and good (0.80) in the current selected with 12 in the first three groups and 14 in the study. The questionnaire was translated into Arabic, and fourth group. The questionnaire was delivered by two back translated to English by psychiatrists with a good psychiatrists from the Baghdad Teaching Hospital. Both knowledge of English.
Results
All 50 participants completed the questionnaires in full. (94%) lived in Baghdad. Table 1 summarizes the Participant ages ranged from 21 to 26 years (M=23, students’ responses to each of the 21 statements in the SD=2.16); 36 (72%) women and 14 (28%) men. All were BMI. These are separated by three subscales and Muslim. The majority reported in descending order from most to least agreed per subscale.
145 Madhloom RS, Ali NS, Snell T
Table 1. Proportion of respondents who completely agreed with each statement per subscale
Proportion of Respondents Who BMI Subscale Statement Completely Agree N % Social and Interpersonal Skills A person with psychological disorder should have a job with only minor 33 66% responsibilities. A person with psychological disorder is less likely to function well as a parent. 32 64% Most people would not knowingly be friends with a person who has a mental disorder. 31 62%
I am afraid of what my boss, friends, and others would think if I were diagnosed as 30 60% having a psychological disorder. It might be difficult for people with mental illnesses to follow social rules such as being 27 58% punctual or keeping promises. People with mental illness are unlikely to be able to live by themselves because they 18 36% are unable to assume responsibilities. I would not trust the work of a person with a mental health condition assigned to my 13 26% work team. The term ‘psychological disorder’ makes me feel embarrassed. 12 24% I would be embarrassed if a person in my family experienced a mental illness. 10 20% I would be embarrassed if people knew that I dated a person who once received 5 10% psychological treatment Dangerousness The behavior of people who have psychological disorders is unpredictable. 35 70% A mentally ill person is more likely to harm others than a normal person. 27 54% Mentally ill people are more likely to be criminals. 21 42% I am afraid of people who are suffering from psychological disorder because they may 12 24% harm me. It might be difficult for people with mental illness to follow social rules, such as being 7 14% punctual or keeping promises. Incurability Psychological disorders are recurrent. 45 90% Psychological disorders would require a much longer period of time to be cured than 38 76% would other general diseases. People who have received psychological treatment are likely to need further treatment 19 38% in the future. Individuals diagnosed with mental illness suffer from the symptoms throughout their 15 30% life Mental disorder is unlikely to be cured regardless of treatment. 7 14% I believe that mental disorders can never be completely cured. 4 8%
146 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (144 – 149) (doi-10.12816/0056865)
Overall responses indicated that most students held negative beliefs about the capability of people with mental health difficulties and about the attitudes of Perceived dangerousness of people with mental illnesses others towards them, but were far more optimistic about Negative beliefs as to the dangerousness of people with how they would treat someone with mental health mental illnesses were expressed by a greater number of difficulties compared to how society might. respondents as relates to their unpredictability (70%) and Perceived social and interpersonal skills of people with likelihood of causing harm (54%). Just under half mental illnesses believed criminal behavior was also likely (42%). Given their roles as medical professionals, a higher than Responses highlight that over half of students perceived expected number of respondents expressed fear of being people with mental illnesses as less capable of holding harmed by people with mental disorders (24%) and the significant job responsibilities (66%); unable to function belief that it is best to stay away due to the risk of harm well as parents (64%); and, unable to follow simple (14%). social rules, such as being punctual or reliable (58%). More than half also held negative views about how Perceived incurability of mental illnesses others might feel toward anyone with a mental disorder Views as to prognosis seemed reasonable with 90% with 62% stating that people would not knowingly be stating mental disorders are recurrent and 76% believing friends with a person having such conditions and 60% these might require more time to cure compared with stating that they would be afraid of what their boss, general diseases. The numbers, who viewed mental friends or others might think if they had a diagnosed disorders as being beyond treatment, while not high, mental disorder. However, far fewer were less negative were nevertheless higher than what might be expected about having a family member (10%) or dating someone from 4th and 5th year medical students. Fourteen percent (5%) with a mental disorder. Sixty percent worried about held the view that mental disorders were unlikely to be what others would think if they were diagnosed with a cured and 8% stated these can never be cured. mental health difficulty. Discussion The current study assessed the attitudes of 4th and 5th should also incorporate anti-stigma lectures or seminars. year undergraduate medical students in Baghdad toward These seminars might involve close interactions and mental illnesses and people with such conditions. discussions between students and persons with mental Compared with studies in developing countries, response illness who are recovered and their caregivers on how rates indicated negatively held beliefs about risk posed they perceive stigma including its adverse effects on by people with mental health difficulties and the their lives. Studies have noted the positive effect of prognosis for treatment of mental health conditions were familiarity on mental illnesses and aspects of stigma such high.15,16 as reduced social distance17,18,19 and false beliefs and doubts about people with mental disorders.20 However, responses appeared much less negative compared with students from Nigeria4 India5, Iran9 When examining possible causes for and consequences although the methodologies were not homogenous and, of stigma, it would be important to consider that 60% of therefore, not directly comparable. Most participants students in the current study feared what others would shared negative attitudes about the ability of people with think if they were diagnosed with a mental disorder. Fear mental health difficulties to parent well, hold a of exposure to stigmatization not only perpetuates demanding job, or follow social rules. Such views reflect stigma, it is a crucial factor contributing to symptom an unhelpful stereotype that associates mental illnesses concealment in medical students and doctors and is a with personal shortcomings; however, poor social skills barrier to accessing mental health services.19,21 Increased are also causes, consequences, or vulnerability factors for perceptions of stigma were also strongly associated with various types of mental health difficulties including less positive attitudes toward seeking psychological schizophrenia, depression, substance use, and social support among students.21 Burnout is a common anxiety. experience within the medical profession.13 Prevention should include normalization of mental disorders in One strategy to improve attitudes towards persons with training. mental health difficulties would be to increase student contact with patients in community settings; particularly Another important consideration is the way in which given student, beliefs about the need for social distance language can influence perceptions of mental health and due to risk of harm. The undergraduate curriculum people with mental health difficulties.3,22 Language is
147 Madhloom RS, Ali NS, Snell T
powerful. Improving both the written and the spoken refer to people with mental health difficulties as ‘the word as communicated by researchers and professionals mentally ill’ and go on to compare them to a ‘normal can go some way to ending discrimination. Training person’. It can be argued that this is dehumanizing in the programs for undergraduate medical students in same way that using the terms ‘learning disabled’ or developing countries, or post conflict countries such as ‘retarded’ is dehumanizing for people with intellectual Iraq, may rely upon outdated materials or have limited disabilities and comparing them to ‘normal people’ access to reliable sources of new information through equally debasing. How such ideas are communicated can their universities. Researchers who assess attitudes and contribute to the stigma that people with severe and beliefs toward mental illnesses must reflect on the tone enduring mental health conditions experience throughout and language used when designing questionnaires to their lives and, therefore, ensuring a more compassionate explore what perceptions because the statements can ‘tone of voice’ can be educative for the public, for people equally influence what people think. For example, the with mental health conditions and their families as well BMI and the Attitude Toward Mental Illness (AMI)13 as for the medical professionals who support them. Conclusion
Findings highlight the need for ongoing awareness a mental disorder and this should be of concern since it raising and review of course materials to ensure a better reflects the degree to which stigma can lead to self- knowledge of mental health difficulties. More stigmatization and the perpetuation of unhelpful views opportunities for undergraduates to work alongside around mental health. Burnout in medical students and psychiatry and psychology colleagues may help further doctors is not uncommon; such reticence may be a with awareness raising. Participants were in the final contributing factor. More globally, researchers must years of their undergraduate study and would soon move consider the power of language when designing on to more specialist training, which is a time for questionnaires like the BMI, which are of course, consolidating the learning gained at the undergraduate reflective of their time. Rather than replicating studies level. In terms of what the findings may highlight about (including this one), more can be done to challenge the self-care, most students stated they would worry about narrative to improve the quality of future research, which the views of others towards them were they to experience in turn, could help to reduce stigma.
Limitations and Recommendations
The current study used a convenience sample of The findings offer an opportunity to broaden the undergraduates in their final years of study, which limits knowledgebase for those working with people the generalizability of the findings. Further, the complex experiencing mental health difficulties inside Iraq. Iraqi nature of mental disorders makes assessing perceptions society has endured many decades of war and conflict. and attitudes rather more difficult to quantify through the Reducing stigma associated with mental illnesses in Iraq reductionist lens of a brief self-report questionnaire. It may also help to normalize the consequences of war- was also difficult to offer consistency when related trauma, which we would suggest, based on our communicating to students about mental health clinical experience, and are often missed in psychiatric difficulties given the language used in the BMI. assessments.
References
1. Murray, Christopher JL, Lopez, Alan D. Global, 4. Ogunsemi, OO, Odusan O, Olatawura, MO. Stigmatising regional, and national age-sex specific all-cause and Attitudes of medical students toward a psychiatry label’. cause-specific mortality for 240 causes of death, 1990- Ann Gen Psychiatry. 2008;7(1):15. 2013: a systemic analysis for the Global Burden of Disease Study 2013. The Lancet. 2015;385(9963):117- 5. Chawla JM, Balhara YP, Sagar R, Shivaprakash. Medical 171. students’ attitudes toward psychiatry: a cross-sectional 2. Goffman, E (1963). Stigma. Notes on the Management of study. Ind J Psychiatry. 2012;54(1):37-40. Spoiled Identity. Prentice Hall, Inc. England. 6. Kerby J, Calton T, Dimambro B, Flood C, Glazebrook C. 3. Hill, J. Attitudes toward mental disorders among college Anti-stigma films and medical students' attitudes towards students. Am J Undergrad Res. 2005;Viii 1-8. mental illness and psychiatry: randomised controlled trial. B Psych Bull. 2008;32(9):345-349.
148 Attitudes of Undergraduate Medical Students in Baghdad Toward Mental Disorders and People with Mental Health Difficulties
7. Desai ND, Chavda PD. Attitudes of undergraduate 17. Corrigan PW, Green A, Lundin R, Kubiak MA, Penn medical students toward mental illnesses and psychiatry. DL. Familiarity with and social distance from people J Edu Health Promot. 2018;7:50. who have serious mental illness. Psychiatr Serv. 2001; 8. Ayp, Save D, Fidanoglu O. Does stigma concerning 52(7):953-8. mental disorders differ through medical education? A 18. Hankir AK, Northall A, Zaman R. Stigma and mental Survey among Medical Students in Istanbul. Soc health challenges in medical students. BMJ. Case Rep. Psychiatry Epidemiol. 2006; 41(1):63-7. 2014. 9. Fighting the stigma caused by mental disorder. World 19. Ponizovsky AM, Finkelstein I, Poliakova I, Mostovoy D, Psychiatry. 2008;7(3):185-188. Goldberger N, Rosca P. Interpersonal distances, coping 10. Sartorius N. Stigma and discrimination because of strategies and psychopathology in patients with schizophrenia: a summary of the WPA Global Program depression and schizophrenia. World Psychiatry. 2013; Stigma and Discrimination because of Schizophrenia. 3(3):74-84. World Psychiatry. 2005; 4(Suppl. 1):11-15. 20. Corrigan PW, Watson AC. Understanding the impact of 11. WPA guidance on how to combat stigmatization of stigma on people with mental illness. World Psychiatry. psychiatry and psychiatrist. World Psychiatry. 2010; 2002; 1(1):16-20. 9(3); 131-144. 21. Vogel L, Wade NG, Ascheman PL. Measuring 12. The WPA and the fight against stigma because of mental perceptions of stigmatization by others for seeking disease. World Psychiatry. 2002; (1); 30-31. psychological help: reliability and validity of a new 13. Lemaire JB, Wallace JE. Burnout among doctors. BMJ. stigma scale with college students. J Couns Psychol. 2017; 358: j3360 2009; 56(2):301-308. 14. Hirai M, Clum GA. Development, reliability, and 22. Van Riel, R. What Is Constructionism in Psychiatry? validity of the beliefs toward mental illness scale. J From Social Causes to Psychiatric Classification. Front Psychopath Behav Assess. 2000; 22(3):221-236. Psychiatry. 2016; 7:57. 15. Lauber C, Nordt C, Braunshweig C, Rossler W. Do mental health professionals stigmatise their patients? Acta Psychiatr Scand Suppl. 2006;(429):51-9. 16. Ineland L, Jacobsson L, Salander, RE, Sjölander P. Attitudes towards mental disorders and psychiatric treatment - changes over time in a Swedish population. Nord J Psychiatry. 2008;62(3):192-197. الملخص
الخلفية: وصمة العار المرتبطة باضطرابات الصحة العقلية هي مشكلة واسعة النطاق مرتبطة بالتحيزات والمواقف والمفاهيم الخاطئة في المجتمع، والتي يتم المجتمع، االحتفاظ بها ًأيضا من قبل المهنيين الصحيين. قيمت دراسات قليلة في العالم العربي كيف ر ينظطالب الطب إلى األشخاص الذين يعانون من صعوبات في الصحة العقلية. إن فهم موقف وتصورات طالب الطب الجامعيين تجاه اضطرابات الصحة العقلية أمر مهم بالنظر إلى احتمالمشاركتهم، طوال حياتهم المهنية، في رعاية في المهنية، األشخاص الذين يعانون من هذه الصعوبات.األهداف: استكشفت الدراسة الحالية معتقدات واتجاهات طالب الطب في بغداد تجاه األمراض العقلية، ونحو العقلية، األشخاص الذين يعانون من صعوبات في الصحة العقلية.الطريقة: تم استخدام تصميم مقطعي مستعرض لمسح من جزأين يحتوي على معلومات ديموغرافية اجتماعية وتم توزيع مقياس المعتقدات تجاه المرض العقلي على طالب كلية طب الكندي في السنة الرابعة والخامسة الذين يتدربون في الطب النفسي لمدة اسبوعين الطب النفسي لكل مجموعة في مستشفى بغداد التعليمي.النتائج: أكمل االستطالع خمسون طالبًا تتراوح أعمارهم بين 02 02و عام .اً تشير النتائج إلى أن معظم الطالب لن يشعروا بالحرج من وجود قريب أو مواعدة شخص يعاني من اضطراب عقلي. ومع ذلك، كان لدى معظمهم آراء سلبية حول قدرة األشخاص الذين يعانون من أمراض 22وعقلية ٪ خافوا مما قد يعتقده اآلخرون إذا تم تشخيصهم بصعوبة في الصحة العقلية.الخالصة: رفع مستوى الوعي ومراجعة مواد الدورة يمكن أن يقطع شوطا إلى حد ما للحد من وصمة العار. تطبيع األمراض العقلية من خالل التعليم النفسي قد يعالج ًا أيضالعوائق التي تمنع طالب الطب واألطباء الجامعيين من طلب المساعدة وتجنب اإلرهاق. تتحمل الدورات التدريبية والباحثون ًأيضا مسؤولية تحديث المواد وإزالة أي لغة وصمة.
Corresponding Author
Dr Raad SaadyMadhloom, MBChB FIBMS Specialist Psychiatrist, Mahmoodya General Hospital - Baghdad
Email: [email protected]
Authors Dr Raad SaadyMadhloom, MBChB FIBMS, Specialist Psychiatrist, Mahmoodya General Hospital - Baghdad
Dr Numan S. Ali, FRCPsych DPMDCN, Consultant Psychiatrist, Baghdad Teaching Hospital - Baghdad
Dr Tori Snell, DClinPsy CPsychol AFBPsS, Consultant Clinical Psychologist - London
149 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (150 – 158) (doi-10.12816/0056866)
Body Image Disturbance and Self-Esteem after Hysterectomy in Egyptian Women
Mohamed Adel El-Hadidy, Abdelhady Zayed الخلل في صوره الجسد والثقة بالنفس بعد جراحه استئصال الرحم لدي عينه من النساء المصريات
محمد عادل الحديدي، عبد الهادي زايد
Abstract
ntroduction: Hysterectomy is the surgical removal of the uterus. Women undergoing hysterectomy are worried about I possible side effects of the surgery on their sexuality. The aim of this study was to assess the association between body image disturbance and hysterectomy. Method: Using a cross-sectional comparative designacross one-year, all cases (n=498) and control group (n=702) were examined using the Mini-International Neuropsychiatric Interview (MINI), Rosenberg Self Esteem Scale and Body Image Scale. Results: Body image disturbance was higher in cases than controls with statistically significant difference. Self-esteem was higher among controls than women with hysterectomy. Body image disturbance was higher in obstetric than gynecological cases. In addition, self-esteem was higher among gynecological cases than women with hysterectomy due to obstetric causes. Women below 50 years old showed higher body image disturbance and lower self-esteem than women above 50 years old. Age directly correlated with self-esteem and inversely with body image disturbance. Conclusion: In the Arab culture, hysterectomy can have an adverse impact on women’s body image and self-esteem, especiallyfor thoseof young age. More needs to be done to support them and to educate society about the impact on a woman’s mental wellbeing.
Keywords: self-esteem, hysterectomy, body image, gynecology, obstetric
Declarations of interest: None
Introduction
Hysterectomy is the surgical removal of the uterus. Its endoscopic. Removal of the uterus renders the patient incidence varies between and within countries. An unable to bear children. Women undergoing estimated 5 out of 1000 women above age 15 underwent hysterectomy may worry about possible side effects of hysterectomy in 2004 in the United States, compared to 3 the surgery on their sexuality. Factors such as hormonal, out of 1000 women in Australia,1,2 and Germany where anatomical, vascular, neurogenic, and psychological can estimates range from 2.1 to 3.6 per 1000 women.3In low have a detrimental effect on various aspects of sexual andmiddle-income countries, the incidence of functioning.8,9,10,11,12 These experiences may affect body hysterectomy is lower than that in developed image and self-esteem. For some women, negative countries.4,5,6 Nearly 70% of hysterectomies are aspects of body image are persistent and remain performed for benign conditions7 which may be prevalent years after treatment.13,14 gynecologic, such as fibroids and adenomyosisor obstetrical, such as severe intrapartum or postpartum The current study hypothesized that hysterectomy may hemorrhage. Other categories include gynecologic adversely affect body image and self-esteem. The aim cancers, (ovarian, uterine cervical cancers).7The was to explore the experiences of body image and self- procedure is mostly carried out by a gynecologist. esteem among women who had undergone hysterectomy Hysterectomy may be total (removing the body, fundus, in comparison to those who did not. and cervix of the uterus) or partial (removal of the uterine body while leaving the cervix intact). It may also involve removal of ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures.
The surgical routes include abdominal, vaginal and
150 Body Image Disturbance and Self-Esteem after Hysterectomy Experienced by Egyptian Women
Method
Design Participants were classified into social classes I, II, III, or IV according to an Egyptian classification method.16 IQ A cross-sectional comparative study wascarried out in were assessed using Wechsler Adult Intelligence Scale- the Mansoura University Gynecology Department Revised (WAIS-R).17 The Arabic translations of st Outpatient Clinic (MUH-GD-OPC) from 1 March 2018 Rosenberg Self Esteem Scale and Body Image Scale th to 28 February 2019. were used to assess self-esteem and attitudes about body 18,19,20,21 Participants image. All participants attended the outpatient clinic (MUH- Exclusion criteria GD-OPC) for follow up with both researchers. For The exclusion criteria of this study included intellectual experimental condition, 512 women were interviewed disability (IQ below 70 using the Arabic version of the and recruited to the study of which nine declined. Five WAIS-R. Any organic cause associated with loss of met the exclusion criteria (four had mental health organ or body shape change. Clinically diagnosed conditions: two reported major depressive disorders; one language or hearing impairment, which might render it had obsessive-compulsive disorder, and one had a difficult for participants to understand or to complete the diagnosis of schizophrenia). The fifth person had facial instrument used in this study. burn. A matched control group of 702 womenwere recruited by contacting relatives of patients who The Mansoura Faculty of Medicine, ethics committee, attendedthe clinic. and IRB (institutional research board) approved this study. It was conducted in accordance with the ethical Participants were interviewed using the Mini- standards laid down in the 1964 Declaration of Helsinki. International Neuropsychiatric Interview (MINI) version Written informed consent was obtained from all 5.0 to exclude any cases with psychiatric disorders. participants before their inclusion in the study. MINI is a short structured diagnostic interview, which has been translated and validated into Arabic.15 Statistical analysis
Measures Parametric data were summarized as means and standard deviations. Non-parametric data were described as A self-report questionnaire for demographic frequencies and percentages. Chi-square and t-test were characteristics included participantage, education, used to measure associations found in different non- residence, socioeconomic standing, religious parametric data and parametric data respectively. The background, and their feeling or reaction toward results were computed using SPSS Statistics 20.0. hysterectomy.
Results
The mean age for both groups (case/control) was 56.67 oopherectomy although with there were no statistically years and 56.28 years, respectively with no statistically significant differences (Table 4). Body image significant difference (Table 1). There were no disturbance scores were higher in cases when compared statistically significant differences in marital status, with the control group and the differences were education, residence or socioeconomic status between statistically significant. Moreover, there was a case and control groups (Table 2). Table 3 shows that all statistically significant difference in the reporting of self- obstetric hysterectomies were due to bleeding associated esteem with higher positive self-assessment within the with pregnancy and delivery while gynecological causes control group compared withwomen who had undergone were linked to fibroids adenomyosis followed by hysterectomy (Table 5). Conversely, body image endometrial hyperplasia after failure of therapy, then disturbance scores were higher in obstetric than ovarian tumors, uterine body carcinoma, lastly cervical gynecological cases with statistically significant cancer with statistically significant difference.For difference. In addition, self-esteem scores were higher hysterectomy operations due to obstetric causes, a among gynecological cases than women with subgroup did not involve removal of the cervix. Most hysterectomy due to obstetric causes and showed hysterectomy operations due to gynecological causes statistically significant difference (Table 6). Younger involved complete hysterectomy with salpingo- women (below 50 years old) showed higher body image
151 El-Hadidy MA, Zayed A
disturbance and lower self-esteem than older women that higher self-esteem was reported by those in the (above 50 years old) with statistically significant control group followed by hysterectomy with difference (Table 7). Age was directly correlated with oophorectomy and lastly hysterectomy without self-esteem and with body image disturbance (Table 8). oophorectomy. The table also suggests that a high level of body image disturbance was reported by women who Table 9 compares control group, hysterectomy cases had undergone hysterectomy without oophorectomy with oophorectomy, hysterectomy without oophorectomy followed by hysterectomy with oophorectomy and lastly in body image disturbance and low self-esteem. It shows by control group with statistically significant difference.
Table 1. Age-related data in case and control group
Group N Mean Std. t p Deviation Age control 702 56.2877 14.48103 -0.4 0.639 case 498 56.6727 13.27269
Table 2. Sociodemographic data in both groups
Group Control Case Total X 2 p Marital status Single 26 16 42 0.655 0.721 3.3% 3.2% 3.2% Married 592 380 972 74.4% 76.3% 75.1%
Widowed 178 102 280 or divorced 22.4% 20.5% 21.6%
Education Illiterate 389 245 634 0.013 0.909 48.9% 49.2% 49% School 407 253 660 education 51.1% 50.8% 51% Residence Rural 581 368 949 0.072 0.747 73% 73.9% 73.3% Urban 215 130 345 27% 26.1% 26.7% Socioeconomic Very low 503 317 820 0.029 0.986 class 63.2% 63.7% 63.4% Low 220 136 356 27.6% 27.3% 27.5% Moderate 73 45 118 9.2% 9% 9.1%
152 Body Image Disturbance and Self-Esteem after Hysterectomy Experienced by Egyptian Women
Table 3. Frequency of different diagnosis requiring hysterectomy (gynecological/obstetric causes)
Cause Obstetric Gynecology Total X 2 p Diagnosis Peripartum bleeding 20 0 20 459.676 0.000 100.0% 0.0% 100.0% Intrapartum bleeding 24 0 24 100.0% 0.0% 100.0% Postpartum bleeding 25 0 25 100.0% 0.0% 100.0% Fibroids adenomyosis 5 160 165 3.0% 97.0% 100.0% Ovarian tumors 0 72 72 0.0% 100.0% 100.0% Endometrial hyperplasia 0 95 95 after failure of therapy 0.0% 100.0% 100.0% Uterine body cancer 0 58 58 0.0% 100.0% 100.0% Cancer cervix 0 39 39 0.0% 100.0% 100.0% Total Count 74 424 498 % within type of operation 14.9% 85.1% 100.0%
Table 4. Frequency of type of hysterectomy operation performed for gynecological or obstetric causes
Cause Obstetric Gynecology Total X 2 p
Type of Subtotal: no removal 74 30 104 329.27 0.000 operation of cervix 71.2% 28.8% 100.0% Remove whole uterus 0 394 394 with salpingo- 0.0% 100.0% 100.0% oopherectomy
Total Count 74 424 498 % within type of 100% 85.1% 100.0% operation
153 El-Hadidy MA, Zayed A
Table 5. Body image and self-esteem scores according to healthy and hysterectomy groups
Group N Mean Std. t p Deviation
Body image Control 796 13.4673 3.86048 23.069 0.000
Case 498 20.4659 7.03225
Self-esteem Control 796 22.6445 1.84915 26.601 0.000
Case 498 15.8313 6.83903
Table 6. Body image scale and self-esteem scores according to cause of hysterectomy (obstetrics and gynecology) in women with hysterectomy group
Group N Mean Std. t p Deviation Body image Gynecology 424 17.5676 8.32241 -3.8 0.000 Obstetric 74 20.9717 6.66519 Self-esteem Gynecology 424 17.9459 5.28604 2.9 0.004 Obstetric 74 15.4623 7.01525
Table 7. Body image and self-esteem scores according to age in women with hysterectomy group
Group N Mean Std. t p Deviation Body image Above 50 years old 349 18.8188 8.38842 -3.4 0.001 Below 50 years old 149 21.1691 6.24845 Self-esteem Above 50 years old 349 16.9060 6.31958 2.30 0.02 Below 50 years old 149 15.3725 7.00771
154 Body Image Disturbance and Self-Esteem after Hysterectomy Experienced by Egyptian Women
Table 8. Correlation between age, body image and self-esteem scores in hysterectomy group
Age Body image scale Rosenberg self esteem r p r p r p Age 1 - -0.040 0.378 0.075 0.094
Body image -0.040 0.378 1 - -.532** 0.000
Self-esteem 0.075 0.094 -.532** 0.000 1 -
Table 9. Comparison between control groups, hysterectomy cases with oophorectomy, hysterectomy without oophorectomy in body image disturbance and low self-esteem
Group Mean Std. f p LSD Deviation
* ** *** Self-esteem Control 22.65 1.95 368.7 0.000 0.000 0.000 0.000
Hysterectomy 17.95 5.29 with oophorectomy
Hysterectomy 15.46 7.02 without oophorectomy
Body image Control 13.47 3.86 384.53 0.000 0.000 0.000 0.000
Hysterectomy 17.57 8.32 with oophorectomy
Hysterectomy 20.97 6.67 without oophorectomy
155 El-Hadidy MA, Zayed A
* control vs hysterectomy without oophorectomy ** control vs hysterectomy with oophorectomy *** Hysterectomy without oophorectomy vs hysterectomy with oophorectomy
Discussion
The present study assessed the attitudes of women, in compared with older women. This is not unexpected relation totheir body image and self-esteem following a given the pressures on women during child-bearing years hysterectomy compared with those who did not have to produce children and given their own identify around hysterectomies. Those who had such operations reported sexuality and femininity. Women may feel concern when a high level of body image disturbance and low self- thinking about how life might be after hysterectomy. esteem. Although the uterus is an intra-abdominal organ Conversely, older women who have had a hysterectomy, and its presence or absence may not be easily felt, it has will likely have completed their family, and might not a strong and important cultural value that is associated necessarily regard the loss of their uterus as a with femininity. From this point of view, women who hinderance. Moreover, women with hysterectomy were have had a hysterectomy can sometimes feel themselves either widow, divorced or reported a diminished interest as incomplete, which in-turn can contribute to a decrease in sexuality and femininity due to the very natural in their self-esteem. What was notable was the process of aging. experience of distress in relation tobody image. A study from Turkey found that hysterectomies have negative In this study, we undertake any hormonal assessment effects on body image, self-esteem, and dyadic with participants. The study was a comparison study adjustment in women affected by gynecologic cancer.22 between control group, hysterectomy cases with oophorectomy, hysterectomy without oophorectomy in In the present study, women with hysterectomy due to body image disturbance and low self-esteem. (Table 9) obstetric causes showed lower self-esteem and higher shows that higher self-esteem was found in control group distress around body image than women with participants followed by those who had hysterectomy hysterectomy due to gynecological causes. This could be with oophorectomy and lastly hysterectomy without explained by the fact that, women requiring oophorectomy. In addition, same table shows that a high hysterectomy due to obstetric causes in most cases, had level of body image disturbance was found in those who not expected the operation and were, therefore, not well had hysterectomy without oophorectomy followed by prepared psychologically for having their uterus removed hysterectomy with oophorectomy and lastly by control as an emergency procedure. Women who did have a group with statistically significant difference. hysterectomy due to gynecological causes had typically describe chronic experience of multiple gynecological A strength of this study is that it may be the first study to symptoms, which often led to self-referral for the discuss this important issue in the Arab world. operation to eradicate such symptoms. The study is limited in that only one center was In the current study, we observed that younger women contacted and, therefore, recruitment was from a limited with hysterectomy were more likely to show high levels pool. Further, no hormonal assessments were undertaken of body image disturbance and poorer self-esteem to determine the impact of hormone levels on self-esteem and body image. Conclusion
In the Arab culture, it remains the case that women and image, especially in younger women. More needs to be society often regardthe uterus as having an important done to support them and to educate society as to the role self-esteem in women. It appears that hysterectomy impact such an emphasis can have on a woman’s mental operationsmay adversely affect self-esteem and body wellbeing.
References
156 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (150 – 158) (doi-10.12816/0056866)
1. Whiteman MK, Hillis SD, Jamieson DJ, et al. 13. Falk Dahl CA, Reinertsen KV, Nesvold IL, Inpatient hysterectomy surveillance in the Nesvold IL, Fosså SD, Dahl AA. A study of United States. 2000-2004. Am J Obstet Gynecol body image in long-term breast cancer 2008; 198:34 e1-7. survivors. Cancer 2010. 116:3549-3557. 2. Hill EL, Graham ML, Shelley JM. https://doi.org/10.1002/cncr. 25251 Hysterectomy trends in Australia–between 14. Rhoten BA, Murphy B, Ridner SH. Body image 2000/01 and 2004/05. Aust NZ J Obstet in patients with head and neck cancer: a review Gynaecol. 2010; 50:153-8. of the literature. Oral Oncol. 2013; 49: 753-760. 3. Stang A, Merrill RM, Kuss O. Hysterectomy in https://doi.org/10.1016/j.oraloncology.2013.04. Germany: a DRG-based nationwide analysis. 005 2005-2006. Dtsch Arztebl Int. 2011;1 08:508- 15. Sadek A. Mini international neuropsychiatric 14. interview (MINI): the Arabic translation 4. Byles JE, Mishra G, Schofield M. Factors Volume 2. Psychiatry Update, Cairo, Institute of associated with hysterectomy among women in Psychiatry. 2000; 23-31. Australia. Health & Place. 2000; 6: 301-8. 16. El Gilany A, El Wehady A, El Wasify M. 5. Ong S, Codd MB, Coughlan M, O'Herlihy C. Updating and Validation of the socioeconomic Prevalence of hysterectomy in Ireland. Int J status scale for health research in Egypt. East Gynecol Obstet. 2000; 69:243-7 Mediterr Health J. 2012; 8(9): 962-968. 6. Erekson EA, Weitzen S, Sung VW, Raker CA, 17. Melikeh LK and Ismail ME: Wechsler review Myers DL. Socioeconomic indicators and Adult Intelligence Scale. Arabic version, Cairo, hysterectomy status in the United States, 2004. J Elnahda Elmasria, 1987. Reprod Med. 2009; 54:553-8. 18. Rosenberg M. Society and the adolescent self- 7. Carlson KJ, Nichol DH, Schiff I. Indications for image. Princeton, NJ: PrincetonUniversity Press hysterectomy. New Engl. 1993. J Med 328- 1965. 856,60. 19. Schmitt DP, Allik J. Simultaneous 8. Laumann EO, Paik A, Rosen RC. Sexual administration of the Rosenberg self-esteem dysfunction in the United States: prevalence and scale in 53 nations: Exploring the universal and predictors. JAMA. 1999; 281(6):537-44. culture-specific features of global self-esteem. J 9. Hayes RD, Bennett CM, Fairley CK, et al. What Personal Soc Psychol 2005; 89:623-642 can prevalence studies tell us about female 20. Banfield SS, McCabe MP: An evaluation of the sexual difficulty and dysfunction? J Sex Med. construct of body image. Adolescence. 2002; 2006; 3:589-95. 37(146):373-393. 10. West SL, D’Aloisio AA, Agans RP, et al. 21. Ashraf M Shoma, Madiha H Mohamed, Prevalence of low sexual desire and hypoactive NashaatNouman, Mahmoud Amin1, Ibtihal M sexual desire disorder in a nationally Ibrahim, Salwa S Tobar, Hanan E Gaffar, representative sample of US women. Arch Warda F Aboelez, Salwa E Ali and Soheir G Intern Med. 2008; 168:1441-9. William, Body image disturbance and surgical 11. DeRogatis LR, Graziottin A, Bitzer J, et al. decision making in Egyptian post-menopausal Clinically relevant changes in sexual desire, breast cancer patients. World J Surg Oncol. satisfying sexual activity and personal distress 2009; 7:66 doi10.1186/1477-7819-7-66. as measured by the profile of female sexual 22. Pinar G1, Okdem S, Dogan N, Buyukgonenc L, function, sexual activity log, and personal Ayhan A. The effects of hysterectomy on body distress scale in postmenopausal women with image, self-esteem, and marital adjustment in hypoactive sexual desire disorder. J Sex Med. Turkish women with gynecologic cancer. Clin J 2009; 6:175-83. Oncol Nurs. 2012; 16(3):E99-104. doi: 12. Dennerstein L, Guthrie JR, Hayes RD, 10.1188/12.CJON.E99-E104. DeRogatis LR, Lehert P. Sexual function, dysfunction, and sexual distress in a prospective, population-based sample of mid- aged, Australian-born women. J Sex Med. 2008; 5:2291-9.
الملخص
157 El-Hadidy MA, Zayed A
:المقدمة عمليه استئصال الرحم هي عمليه جراحيه يتعرض من تجرى لهن للعديد من االعراض الجانبية المتعلقة بالجراحة والقدرة الجنسية. الغرض من الدراسة الحالية هو قياس تأثير هذه العملية على الخلل في النظرة الجسد. الطريقة: دراسة مقطعيه استغرقت سنه كامله على كل الحاالت اللواتي قد اجريت لهن عمليه استئصال الرحم وعددهن ٨٩٤ وعلى مجموعه ضابطه من ٢٠٧ من النساء اللواتي لم تجرى لهن هذه العملية. وتم الكشف على كل المشاركين في الدراسة بواسطة المقابلة المختصرة الدولية النفس عصبيه وكذلك اختبار روزن برج للثقه بالنفس ومقياس صوره الجسد. النتائج: اظهرت النتائج ان الخلل في صوره الجسد كان أكبر بصوره ملحوظه احصائيا بين السيدات اللواتي أجريت لهن جراحه االستئصال أكثر من األُلى لم تجرى لهن العملية. وكذلك الثقة بالنفس كانت اقل لدي السيدات اللواتي أجريت لهن الجراحة ألسباب متعلقة بالوالدة أكثر من المتعلقة باألمراض النسائية.الخالصة: في مجتمعنا العربي هناك تأثير سلبي لعمليه استئصال الرحم على نظره المراة لجسدها وكذلك على ثقتها بنفسها وخاصة بين االصغر عمرا.من الضروري دعم هذه الفئة من النساء .
Corresponding Author Prof Mohamed Adel El-Hadidy, MD. Professor of Psychiatry, Psychiatric Department, Faculty of Medicine, Mansoura University - Egypt
Email: [email protected]
Authors Prof Mohamed Adel El-Hadidy, MD Professor of Psychiatry, Psychiatric Department, Faculty of Medicine, Mansoura University - Egypt Dr Abdelhady Zayed MD, Assistant Professor of Gynecology and Obstetrics, Faculty of Medicine, Mansoura University, Mansoura - Egypt
158 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (159 – 168) (doi-10.12816/0056867)
Assessment of Mental Health Literacy of Depression and Suicide among Undergraduate Medical Students: A Cross-Sectional Study Eman Elsheshtawy, Miriam Simon, Sirous Golchinheydari, Jawaher Al Kharusi تقييم المعرفة بالصحة العقلية بالنسبة لالكتئاب واالنتحار بين طلبة الطب: دراسة مستعرضة ،الششتاويايمان سيمون،ميريام سيرس ،يجولشنهيدار جواهرالخروص ي ي
Abstract
ackground: Poor literacy of depression and suicide can be considered a key barrier for help seeking in mental health issues. Objective: The current study aimed to assess the differences in depression and suicide literacy B among medical students in the pre-medical level (2nd and 3rd year) and clinical level (6th and 7th year); and, to determine which factors predict higher levels of literacy. Methods: A cross-sectional study recruited 359 students who were in the pre-medical and clinical years. Measures included a socio-demographic questionnaire, the Depression Literacy Questionnaire (D-Lit), and the modified Suicide Literacy Scale (LOSS). Results: Clinical years’ students appear to have higher depression and suicide literacy (z=8.343, p=.001; z=4.563, p=.001), respectively. High depression literacy predicted higher suicide literacy (beta=.356, p=0.001) while previous exposure to psychiatric patients predicted higher depression and suicide literacy (beta=.172, p=.022; beta=.175, p=.032, respectively). Conclusion: There remains an urgent need to design and implement specific educational programs to improve awareness about depression, suicide and mental health in general starting at the highschool level of education.
Key words: medical students, depression literacy, suicide literacy, Oman
Declaration of interest: None
Introduction
Depression is a common mental health problemand the require early intervention, a high percentage of young leading cause of mental health related disease burden people do not seek help.9 Among the barriers to help globally. There is evidence to suggest that onset occurs seeking are perceived stigma and low mental health in adolescence; that it can be recurrent; and, in severe literacy in addition to an inability to recognize cases can lead to suicide.1 The prevalence of depressive symptoms.10 symptoms and suicidal ideation among medical students is reported to be higher than in the general population.2 Depression and suicide literacy are aspects of mental Students with an experience of depression may also health that affect help-seeking behaviors and influence suffer from burnout, anxiety, suicidal thoughts and treatment choices and compliance. Mental health literacy substanceuse.3,4 Research describes deterioration of their refers to the knowledge and beliefs about mental health mental health during their medical education that conditions that help with recognition, management, and 11 continues to decline even after graduation.5 prevention. Poor knowledge and understanding of depression can be a key barrier that may prevent people The estimated prevalence rate of depressive symptoms from seeking help for their mental health issues. It among medical students was 27.2% and that of suicidal follows that improving literacy among adolescentscan ideation was 11.1%, according to one meta-analysis; it is result in positive gains for their mental health in later also suggested that such symptoms were more common life.12 Research on mental health literacy tends to be in medical students than other undergraduates students of conductedin mainly Western countries. A limited number similar age.6 Despite their being symptom improvement of studies in Arab countries have demonstrated poor as students become residents and medical professionals, mental health knowledge.13,14,15 Most studies describe the they are still more likely to experience depression and need for educational intervention starting at the high distress across different stages of life. Previous studies in school level, which can help decrease stigma and Oman found the prevalence rate of depressive symptoms improve knowledge.16 among high school students was 17% while among medical students it was approximately 11%.7,8 Although The aim of the current study is to evaluate differences in mental health problems arising at a young age often the level of mental health literacy for depression and
159 Mental Health Literacy of Depression and Suicide suicide among medical students in the pre-medical level to establish which factors may predict higher levels of (2nd and 3rd year) and clinical level (6th and 7th year); and, literacy.
Method
Design Depression Literacy Questionnaire (D-Lit) A cross sectional study was conducted from September The D-Lit assesses mental health literacy specific to 2018 to March 2019 at two institutions of higher learning depression. The instrument was developed in Australia. in the Sultanate of Oman: College of Medicine and Cronbach alpha is 0.70, and its test-retest reliability is r = Health Science andNational University of Science and 0.71.17,18 The questionnaire consists of 22 items. Technology. The student population is from Oman, Respondents can answer each item with one of three India, Iran, and Bangladesh, among other countries. options: True, False, or Don’tKnow.Correct responsesare given a score of 1. Higher scores indicate greater levels Participants of depression literacy. D-Lit items are about depression Participants were recruitedfrom pre-medical years (2nd symptoms, management, treatment, and duration, as well and 3rd) and clinical years (6th and 7th). Each year had as differentiation between depression and other mental 120 students apart fromthe final year, which had 110 illnesses. students. From a total of 450 students, 359 joined the Literacy of Suicide Scale (LOSS) study: 70 from the pre-medical years (2nd and 3rd) and 189 from clinical years (6th and 7th). Participants were The modified LOSS was used, which retained eight of 12 individually approached and recruited consecutively after items measuring knowledge about suicide: signs and obtaining informed consent. Participants did not receive symptoms, causes/nature of suicide, risk factors, and any honorarium for their involvement in the study. treatment and preventionn.19,20 The modified LOSS Inclusion criteria were students who provided informed solicited True, False, Don’t Know responses. Correct consent and who had completed a course in medical responses are given a score of 1 while incorrect school for a minimum of one year, excluding those with responses are scored 0. Literacy scores are the sum of all chronic medical or psychiatric illness. correctly identified items. Higher scores indicated higher suicide literacy levels. The scale provides a total literacy Measures score.
All participants completed the following: *Scales were applied in English because Arabic was not Socio-demographic questionnairecovering information the native language for all students. relating to age, gender, nationality, year of study, etc.
Analysis
Data were analyzed using the SPSS Statistics 15 (SPSS variables, Mann-Whitney U test was used toexpress the 15.0). Descriptive statistics were used to express socio- group difference for clinical variables on the score of demographic and clinical characteristics. The distribution different scales (for comparison of two groups). Chi- and normality of the sample was assessed with the square was used to identify statistically significant Kolmogorov-Smirnov test and found to be significantly differences between groups. Linear regression was used skewed. Since analysis required comparison of two to define predictors of literacy.
Results
For the study, 359 students from the clinical and pre- previous exposure to psychiatric patients with while 119 medical yearsagreed to participate. Age distribution (33.1%) had past personnel experience of mental health ranged from 22 to 26 years of age where the mean age difficulties. was (20.4±1.7); 320 (89.1 %) were women with 265 (73.8%) living in a college hostel;315 (92.2%) were Differences on the total score of depression and suicide Omani. One hundred and five (29.2%) had a history of literacy between the two groups is shown in Table 1
160 Elsheshtawy E, Simon M, Golchinheydari S, Al Kharusi J
where the clinical group were significantly statistically symptom of depression) (X2=3.596, p= .058 and higher (z=8.343. p=.001), (z= 4.563, p=.001), X2=3.517, p=.061) and question 19 (management of respectively. As shown in Table 2, there is a significant depression) (X2=3.368, p=.060). Table 3 indicates a statistical difference between the clinical and pre- significant statistical difference between the two groups medical group of students on most items of the on most items of the suicide literacy scale except on depression literacy scale whereby the clinical group presence of suicidal plan (X2=2.788, p= .095) and the scores were higher except on question 5 (behavioral idea that people with suicidal ideation change their symptom) (X2=-.048, p=.826), question 3, 6 (psychotic minds easily (X2=.578, p=.447).
Table 1. Total depression and suicide score in the studied groups Clinical Pre-medical
Mean ± SD Mean ± SD Z P
Depressionliteracy (D-Lit)
Total score 12.05 ± 4.2 8.05 ± 3.2 8.343 .001**
Suicide literacy (LOSS)
Total score 4.05 ± 1.8 3.1 ± 1.5 4.563 .001**
Table 2. Depression literacy scale in clinical and pre-medical students
Clinical Pre-medical
No % No % X2 P
Biological symptoms
Q7 (Sleep disturbances) Correct 161(85.2) 102(60)
Incorrect 28(14.8) 68(40) 26.617 .001**
Q8 (Eating disturbances) Correct 167(88.4) 116(68.2)
Incorrect 22(11.6) 54(31.8) 22.726 .001**
Cognitive symptoms
Q2 (guilty feeling) Correct 159(84.1) 101(59.8)
Incorrect 30(15.9) 68(40.2) 26.565 .001**
Q4 (loss of confidence) Correct 168(88.9) 121(71.2)
Incorrect 21(11.1) 49(28.8) 17.838 .001**
Q9 (memory, Concentration) Correct 126(66.7) 91(53.5)
Incorrect 63(33.3) 79(46.5) 7.016 .008*
161 Mental Health Literacy of Depression and Suicide
Behavioral symptoms
Q5 (behavioral disturbance) Correct 58(30.7) 52(30.6)
Incorrect 131(69.3) 118(69.4) .048 .826
Q11 (motor symptoms) Correct 143(75.7) 88(51.8)
Incorrect 46(24.3) 82(48.2) 22.215 .001**
Psychotic symptoms
Q1 (irrelevant speech) Correct 71(37.6) 26(15.3)
Incorrect 118(62.4) 144(84.7) 23.808 .001**
Q3 (reckless behavior) Correct 64(33.9) 41(24.1)
Incorrect 125 (66.1) 129(75.9) 3.596 .058
Q6 (hearing voices) Correct 92 (48.4) 66(38.8)
Incorrect 97(51.3) 104(61.2) 3.517 .061
Q10 (multiple personalities) Correct 99(52.4) 46(27.1)
Incorrect 90(47.6) 124(72.9) 23.769 .001**
Impact of depression
Q13 (impaired functioning) Correct 96(50.8) 67(39.4)
Incorrect 93(49)2 103(60.6) 3.7463 .053
Q14(need for hospitalization) Correct 133(70.4) 78(45.9)
Incorrect 56(29.6) 92(54.1) 23.116 .001**
Q15 (famous people) Correct
Incorrect 137(72.5) 102(60)
52(27.5) 68(40) 6.828 .009*
162 Elsheshtawy E, Simon M, Golchinheydari S, Al Kharusi J
Management of depression
Q12 (role of psychologist) Correct 55(29.1) 24(14.1)
Incorrect 134(70.9) 146(85.9) 11.673 .001**
Q16 (other treatments) Correct 44(23.3) 17(10)
Incorrect 145(76.7) 153(90) 11.160 .001**
Q17 (role of counselling) Correct 21(11.1) 9(5.3)
Incorrect 168(88.9) 161(94.7) 3.943 .047*
Q18 (role of CBT) Correct 130(68.8) 66(38.8)
Incorrect 59(31.2) 104(61.2) 33.564 .001**
Q19 (role of vitamins) Correct 75(39.9) 52(30.6)
Incorrect 113(60.1) 118(69.4) 3.368 .060
Q20 (treatment duration) Correct 131(69.3) 50(29.4)
Incorrect 58(30.7) 120(70.6) 58.524 .001**
Q21 (antidepr.addictive) Correct 87(46) 30(17.6)
Incorrect 102(45) 140(82.4) 32.731 .001**
Q22 (onset of action) Correct 110(58.2) 37(21.8)
Incorrect 79(41.8) 133(78.2) 25.408 .001**
Predictors of higher depression and suicide literacy are shown in Tables 4 and 5.
Predictors of high suicide literacy are shown on Table 4 need for hospitalization (beta=-.165, p=.035). For the where for the clinical group, the total depression literacy pre-medical group, the predictor was knowledge about score (beta=.356, t=4.410, p=0.001), knowledge about eating disturbance (biological symptom) (beta=.291, duration of treatment (beta=.222,t=2.917,p=0.004) and p=0.001).
163 Mental Health Literacy of Depression and Suicide
Table 3. Suicide literacy scale in clinical and pre-medical students Clinical G Pre medical G No % No % X2 p People who have thoughts about suicide should not tell others about it
Correct 140 (74.1) 91 (53.5) Incorrect 49 (25.9) 79 (46.5) 16.420 .001** Most people who commit suicide are psychotic
Correct 117 (61.9) 75 (44.1) Incorrect 75 (44.1) 95 (55.9) 11.455 .001*
People talking about suicide always increase the risk of suicide
Correct 70 (37) 44 (25.9)
Incorrect 119 (63) 126 (74.1) 6.265 .012*
Not all people who attempt suicide plan their attempt in advance
Correct 100 (52.9) 74 (44)
Incorrect 89 (47.1) 96 (56) 2.788 .095
Very few people have thoughts about suicide
Correct 98 (51.3) 45 (26.8)
Incorrect 91 (48.7) 125 (73.2) 4.198 .040*
Men are more likely to die by suicide than women are
Correct 98 (51.3) 45 (26.8)
Incorrect 91 (48.7) 125 (73.2) 21.392 .001*
People who want to attempt suicide can change their mind quickly
Correct 54 (28.6) 50 (29.4)
Incorrect 135 (71.4) 135 (71.4) .578 .447
There is strong relationship between people’s alcoholism and suicide
Correct 101 (53.4) 61 (35.9)
Incorrect 88 (46.6) 109 (64.1) 10.462 .001**
164 Elsheshtawy E, Simon M, Golchinheydari S, Al Kharusi J
Table 4. Literacy on predictors of suicide
Clinical group B Beta T P
Total D-Lit .148± .34 .356 4.410 .001
Q20 (duration of treatment) .828 ± .284 .222 2.917 .004
Q14 (hospitalization)
-.623 ± 293 -.165 -2.130 .035
Pre-med group
Q8 (biological symptom) .948 ± .242 .291 3.924 .001
Dependent factor: total suicide literacy score
Table 5 shows that previous exposure to psychiatric patients predicted higher scores for both depression and suicide literacy (for depression literacy; beta=.172, t=2.307, p=.022, for suicide literacy; beta=.175, t=2.160, p=.032) while past personal experience predicted better suicide literacy (beta=.207, t=2.554, p=.011). Table 5. Effects of past personnel experience or past exposure to mental health difficulties
Dependent factor Past exposure to Past personal
psychiatric patients experience
Dep. Literacy
B 1.554 ±.674
Beta .172 ----
T 2.307
P .022
Suicide literacy
B 0.575 ±.266 0.683± .267
Beta .175 .207
T 2.160 2.554
P .032 .011
165 Mental Health Literacy of Depression and Suicide
Discussion
To the best of our knowledge, the current study is the Similar results were obtained on the suicide literacy first in Oman to assess depression and suicide literacy scale. Students in the clinical group scored significantly among medical students. The current study explored the higher on questionnaire items about suicide. A large differences in the level of depression and suicide literacy percentage of both groups perceived incorrectly that among medical students: pre-medical (2nd and 3rd year), talking about suicidal thoughts and ideations can increase clinical students (6th and 7th year); and, to study which the risk of suicide and that suicidal persons can change factors might predict better depression and suicide their mind easily. This is supported in studies from literacy. Canada and India, which concluded thata person’s degree of awareness about mental health issues can be The mean depression literacy score was lower for pre- influenced by stigma, social traditions and culture.20,23 medical students than students in their clinical years. Our results may be understood from the perspective of This result was similar to studies from other countries, Oman being a Muslim country where, according to such as in Saudi Arabia, Bangladesh, India, and Islamic Shari'a law, suicide is considered haram - or 21,22,23,24 Vietnam. The finding maysuggest that depression forbidden; indeed, families of suicide victims can face literacy and mental health literacy are poorly understood ostracism within the Muslim community.26,27 If a suicide in general. It is also possible that lower literacy rates happens, it is likely to be denied, which may play a role relating to depression are explained by the absence of in delaying and fragmenting any prevention efforts. any educational resources focusing on mental health in Religious restrictions against suicide can affect attitudes the academic curricula taught to students. about suicide within the Arab culture and may partially Clinical years’ students scored higher on most items of explain why there is a lower risk of suicidality. depression literacy and suicide literacy scales compared The total score and varied items on the Depression with pre-medical students. The finding is supported in a Literacy Questionnaire predicted higher suicide literacy. study from Sri Lanka and may bea consequence ofhaving This is supported in studies that concluded both 25 better quality educational programs. Of course, in the depression and suicide literacy are inter-related due to an clinical phase of training it is more likely that students overlap between symptoms of depression and will be exposed to educational programs relating to suicide.20,23 Previous exposure to psychiatric patients depression and suicide. A small number of students in (family or friends) was found to be a predictor of higher both groups correctly identified the psychotic symptoms depression and suicide literacy while past personal (incoherent speech, unpredictable behavior, and auditory experience predicted high suicide literacy. This could hallucination), management of depression (role of highlight the importanceof students being exposed to psychologist) and behavioral symptoms of depression. health information at an early age as having a positive Differences in some aspects of depression literacy in impact on their levels of literacy, which would also undergraduate students may result fromvariances in support our findings. theirpersonal experiences of and attitudes towards depression.
Conclusions and Recommendations
While possibly expected, there is clear evidence that Mental health problems commonly arise during depression and suicide literacy among pre-medical adolescence; therefore, better integration of mental students is lower than it is for students in their clinical health education, particularly in relation to depression years of medical training. Predictors of higher depression and suicide,would be beneficialduring the high school and suicide literacy include exposure to psychiatric years rather than waiting until a medical student reaches patients or personal experience of mental health the clinical years of training before such training is difficulties as well as the degree to which the students’ introduced. respective high school education may have exposed them to curricula on mental health.
166 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (159 – 168) (doi-10.12816/0056867)
References
1. Depression. 15. Mahfouz M, Aqeeli A, Makeen A, et al. Mental http://www.who.int/topics/depression/en/. Accessed health literacy among undergraduate students of a 1st March,2020. Saudi tertiary institution: a cross-sectional study. 2. Moir F, Yielder J, Sanson J, Chen Y. Depression in Mental Illness. 2016; 8(2). medical students: current insights. Adv Med Educ 16. Darraj H, Mahfouz M, Al Sanosi R, Badedi M, Sabai Pract. 2018; 9:323-33. A. The effects of an educational program on 3. Puthran R, Zhang MW, Tam WW, Ho RC. depression literacy and stigma among students of Prevalence of depression amongst medical students: a secondary schools in Jazan city, 2016 A cluster- meta-analysis. Med Educ. 2016; 50(4):456-68. randomized controlled trial study protocol. Medicine, 4. Rosiek A, Rosiek-Kryszewska A, Leksowski L, 2018; 97:18. Leksowski K. Chronic stress and suicidal thinking 17. Griffiths KM, Christensen H, Jorm AF, Evans K, among medical students. Int J Environ Res Public Groves C. Effect of web-based depression literacy Health. 2016; 13(2):212. and cognitive-behavioural therapy interventions on 5. Gramaglia C, Zeppegno P. Medical Students and stigmatising attitudes to depression: Randomised Suicide Prevention: Training, Education, and controlled trial. Brit J Psychiatr, 2004; 185: 342-49. Personal Risks. Front. Psychol., 2018: 9; 245. 18. Gulliver A, Griffiths KM, Christensen H, 6. Rotenstein LS, Ramos MA, Torre M, Segal JB, MacKinnonA, et al. Internet-Based Interventions to Peluso MJ, Guille C, et al. Prevalence of Depression, Promote Mental Health Help-Seeking in Elite Depressive Symptoms, and Suicidal Ideation Among Athletes: An Exploratory Randomized Controlled Medical Students. A Systematic Review and Meta- Trial. J Med Internet Res, 2012; 14:69. Analysis. JAMA. 2016; 316(21):2214-36. 19. Calear A, Batterham PJ, Christensen H. The Literacy 7. Afifi M, Al Riyami A, Morsi1 M, Al Kharusi H. of Suicide Scale: Psychometric properties and Depressive symptoms among high school correlates of suicide literacy. 2012; Unpublished adolescence in Oman. East Mediterr Health J. 2006; manuscript. 12 (2), S126-S 37. 20. Oliffe JL, Hannan-Leith MN, Ogrodniczuk JS, Black 8. Elsheshtawy E, Taha H, Almazroui S, Joshi K, N, et al. Men’s depression and suicide literacy: a Almazroui A. Personality Traits as Predictors of nationally representative Canadian survey. J Ment Stress and Depression among Medical Students: A Health, 2016; 25 (6):520-26. Cross-Sectional Study. Arab J Psychiatr, 2018; 29 21. Darraj H, Mahfouz M, et al. Arabic Translation and (2), 123-30 Psychometric Evaluation of the Depression Literacy 9. Gulliver A, Griffiths KM, Christensen H. Perceived Questionnaire among Adolescents Psychiatr J. 2016, barriers and facilitators to mental health help-seeking Article ID 8045262. in young people: A systematic review. BMC 22. Arafat Y, Al Mamun M, Saleh Uddin. Depression Psychiatry 2010; 110-13. Literacy among First-Year University Students: A 10. Rickwood DJ, Deane FP, Wilson CJ. When and how Cross-Sectional Study in Bangladesh. Global do young people seek professional help for mental Psychiatry. 2019. 2(1):31-6. health problems? Med J Aust 2007; 187(7 Suppl) 23. Ram D, Chandran S, Gowdappa B. Suicide and S35-S39. depression literacy among healthcare profession 11. Swami V. Mental Health Literacy of Depression: students in tertiary care center in South India. J Mood Gender Differences and Attitudinal Antecedents in a Disord. 2017; 7(3):149-55. Representative British Sample. PLoSONE7 2012; 24. Thai QCN, Nguyen TH. Mental health literacy: (11):e 49779. knowledge of depression among undergraduate 12. Rüsch N, Evans-Lacko SE, Henderson C, Flach C, students in Hanoi, Vietnam. Int J Ment Health Syst. Thornicroft G. Knowledge and attitudes as predictors 2018. 12:19. of intentions to seek help for, and disclose, a mental 25. Amarasuriya SD, Jorm AF, Reavley NJ. Quantifying illness. Psychiatr Serv. 2011; 62: 675-78. and predicting depression literacy of undergraduates: 13. Al-Yateem N,Rossiter R, Robb W, Ahmad A, Elhalik a cross sectional study in Sri Lanka BMC Psychiatry. M. Mental health literacy among pediatric hospital 2015; 15: 269. staff in the United Arab Emirates. BMC Psychiatry 26. Pridmore S, Pasha MI. Psychiatry and Islam. (2017) 17:390. Australas Psychiatry. 2004;12(4):380-85. 14. Al‑Yateem N, Rossiter R, Robb Wm Younan SH. 27. Sarfraz MA, Castle D. A Muslim suicide. Australas Mental health literacy of school nurses in the United Pychiatry. 2002; 10(1):48-50. Arab Emirates. Int J Ment Health Syst. 2018 12:6 https://doi.org/10.1186/s13033-018-0184-4.
167 Mental Health Literacy of Depression and Suicide
الملخص الملخ ص
فية:الخل يعتبر ضعف المعرفة باالكتئاب واالنتحار عائقا رئيسيا لطلب المساعدة في رعاية اضطرابات الصحة العقلية. األهداف: التحقق من االختالفات في مستوى معرفة االكتئاب واالنتحار بين طالب الطب في المستوى ما قبل الطبي )الثاني والثالث( والمستوى اإلكلينيكي )السنة السادسة والسابعة( ومعرفة العوامل التي يمكنها التنبؤ بمستوى معرفة أعلى. الطريقة: أجريت دراسة مقطعية اشتملت على 359 اطالبً في المستوى الطبي )الثاني والثالث( والمستوى اإلكلينيكي. واجرى لهم :التالي المتغيرات االجتماعية والديموغرافية، ومقياس معرفة االكتئاب(D- Lit) ، ومقياس معدل االنتحار المعدل .(LOSS) النتائج: طالب السنوات السريرية لديهم معدالت معرفة اعلى بالنسبة لالكتئاب واالنتحار (p = .001 z = 8.343, & z = 4.563, p = .001)على التوالي. وكان ارتفاع المستوى المعرفي باالكتئاب ينبئ بارتفاع مستوى المعرفة باالنتحار) ،653بيتا = . (p = 0.001في حين أن التعرض السابق لمرضى األمراض النفسية ينبئ بارتفاع ينبئ المعرفة باالكتئاب واالنتحار) ،270بيتا = . p = .022 ،260وبيتا = . p = .032 التواليعلى .االستنتاجات: هناك حاجة ماسة لتصميم وتنفيذ برامج تعليمية محددة تهدف إلى تحسين الوعي حول االكتئاب واالنتحار والصحة العقلية بشكل عام ابتداء من التعليم المدرسي . .
Corresponding Author Dr Eman Elsheshtawy, Professor of Psychiatry, School of Medicine, Mansoura University, College of Medicine and Health Science - Sultanate of Oman
Email: [email protected]
Authors Dr Eman Elsheshtawy, Professor of Psychiatry, School of Medicine, Mansoura University. College of Medicine and Health Science - Sultanate of Oman Dr Miriam Simon, Assistant Professor. Department of Psychiatry and Behavioral Science, College of Medicine and Health Science, National University of Science and Technology - Sultanate of Oman Mr Sirous Golchinheydari, Student at College of Medicine and Health Science, National University of Science and Technology, Sultanate of Oman
Ms Jawaher Al Kharusi, Student at College of Medicine and Health Science, National University of Science and Technology - Sultanate of Oman
168 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (169 – 180) (doi-10.12816/0056868)
Mental Health and Psychosocial Challenges Facing Adolescent Girls in Conflict-Affected Settings: The Case of the Gaza Strip
Bassam Abu Hamad, Nicola Jones and Fiona Samuels تحديات الصحة النفسية واالجتماعية التي تواجه الفتيات المراهقات في المناطق المتأثرة بالصراعات: حالة قطاع غزة
بسام أبو حمد ونكوال جونز وفيونا سماويل
Abstract
bjective: This article focuses on linkages between adolescent girls’ psychosocial wellbeing and socio-cultural O norms in conflict-affected contexts, with a focus on the Gaza Strip. Methods: Drawing on qualitative research undertaken with adolescent girls, their caregivers and service providers following the 2014 Gaza-Israeli War, it explores adolescent experiences and psycho-emotional responses, and the extent to which their vulnerabilities were addressed by programing interventions. Results: Our findings highlight that the conflict worsened adolescent girls’ multi-dimensional psychosocial vulnerabilities, among a population already suffering from a prolonged humanitarian crisis and limited available coping responses. We argue that programs interventions tended to focus primarily on younger children, while largely overlooking adolescents and their specific age- and gender-related vulnerabilities. Conclusion: These shortcomings must be addressed to better support adolescent girls’ psychosocial wellbeing and resilience, and that a stronger focus on adolescents’ evolving developmental needs - including the interplay of gendered social norms - urgently need to inform programing responses in conflict-affected contexts.
Keywords: psychosocial wellbeing, adolescents, girls, gender, conflict, stressors, Gaza
Declaration of interest: None
Introduction
The most recent Palestinian-Israeli conflict in July 2014 health services that are appropriately designed and exacerbated the complex psychosocial vulnerabilities and resourced can help to allay the effects of war and conflict risks already facing the Gazan population. The siege and respond to the needs of the affected population, imposed on the Gaza Strip since June 2006 and the helping people to return to the best life possible.6,7 consequences of repeated conflict episodes have taken an enormous psychological toll on children and families.1,2,3 However, when developing post-conflict psychosocial In the past five years alone, more than 4,000 Palestinians responses, it is crucial to understand not only existing have died, tens of thousands have been injured (many of support service infrastructure and gaps, but also local them children and women), and houses and buildings cultural norms and practices underpinning demand and 8 have been destroyed.4 This protracted conflict has the likelihood of service uptake. triggered acute levels of psychosocial distress, especially Adolescence is a highly influential period in the lifecycle 3 among children and adolescents. The Office for the and is critical in determining life-course potential,9,10 but Coordination of Humanitarian Affairs (OCHA) has is often overlooked in conflict-affected settings.11 The repeatedly described the situation as a chronic current study therefore aims to better understand the 4 emergency and a protracted human dignity crisis. common and often gendered challenges facing Within conflict situations globally, a new 2019 World adolescents in post-conflict Gaza, the coping strategies Health Organization (WHO) systematic review estimates they and their caregivers use, and the availability and that the prevalence of mental health conditions adequacy of mental health and psychosocial support (including depression, anxiety, posttraumatic stress (MHPSS) services that can meet their needs. The disorder, bipolar disorder and schizophrenia) was 22.1% research is part of a broader project looking at the at any point in time in the conflict-affected populations linkages between psychosocial wellbeing and gendered that their review assessed.5 Psychosocial and mental socio-cultural norms in post-conflict settings in Gaza,
169 Mental Health and Psychosocial Challenges Facing Adolescent Girls in Conflict-Affected Settings: The Case of the Gaza Strip
Liberia, and Sri Lanka, supported by the DFID-funded implications of the findings in Gaza as well as in Rebuild Consortium. The authors reflect on possible analogous fragile and conflict-affected contexts.
Conceptual framing
Adolescent mental health is an important but, until order to explore the ways in which age- and gender- recently, relatively under-researched topic globally.Not specific expectations shape experiences of and responses only do young people represent the largest part of the to conflict.18,21 global population (half is under the age of 25), the majority of mental health problems begin during Here we argue that scholarship on the social construction adolescence and continue into adulthood.12,13 It is also of childhood and adolescence can provide a useful entry- important as 10%-20% of children and adolescents are point to better understand the ways in which young estimated to experience mental disorders,14 while young people experience and interpret conflict, and highlight people are now recognized as being the group at highest how assumptions about these stages of life may constrain risk of suicide in a third of countries, both developed and the effectiveness of policy and programming responses. developing.12,13 Mental health problems can also have A key contribution of this literature is an emphasis on the negative spillover effects on an array of development ways in which ‘childhood’ and ‘adolescence’ do share outcomes for young people, including education, some common features and processes (e.g. physical and employment, safety from violence and broader health.15 cognitive developments during puberty) they are neither However, adolescent mental health needs are often natural nor universal states of being but are instead 22,23 neglected, particularly in developing countries, due to a culturally and historically specific and evolving. As a dearth of government policy, inadequate funding, result, young people are likely to be subject to a highly shortage of professionals, low capacity of non-specialist specific - rather than generalizable - set of vulnerabilities health workers, and the stigmatization of mental in conflict settings. Verma (2012), for example, illness.14,16 highlights that in the context of war-torn northern Uganda former child soldiers face significant challenges Conflict is increasingly recognized as a critical factor in in negotiating dominant community narratives of exacerbating poor mental health and undermining rehabilitation and reintegration, while McAlister et al. resilience, including for young people given the overlap (2014) underscores in the context of post-conflict with critical formative stages of life.17 Exposure to Northern Ireland the ways in which young people tend to violence, death and stressful living conditions including be marginalized and demonized due to a dearth of food insecurity, displacement, disrupted education and political will to tackle social and community divisions. In skills building opportunities, as well as compromised an analogous vein, McEvoy-Levy (2014) focusing on networks of support and weakened infrastructure, contexts of displacement in the Middle East, underscores increase the risk for mental health problems.18 Large the ways in which exclusionary economic and political scale epidemiological surveys estimate that posttraumatic structures may hinder adolescent to adulthood transitions stress disorder (PTSD) and depression in conflict- and trap young people in a situation of ‘stuckness’.24 affected populations can be up to seven or ten times the baseline in non-traumatized populations.19,20 At the same time, given the cultural and historical specificity of ‘adolescence’ young people are also likely A number of conceptual frameworks have emerged over to have diverse sources of resilience and coping the past decade aimed at better disentangling the linkages mechanisms to draw upon, shaped by their specific between mental health, psychosocial ill-being and exercise of voice and agency in a given context, and conflict. In particular, work by White (2009) and PADHI negotiation of age- and gender-specific norms. (2009) highlight the need to consider multi-dimensional Gustavsson et al. (2017), for example, highlight in the aspects of psychosocial wellbeing within a context of northern Uganda the ways in which adolescent socioecological framework - including access to girls who had been abducted by and subject to forced resources, social connectedness and close relationships, marriage by the Lord’s Resistance Army, were exercising agency, and experiencing self-worth and nevertheless able to draw on individual and collective spiritual wellbeing - and the extent to which these are support to cope with the aftermath of their experiences undermined in crisis contexts. We draw on this framing, and express hope for their and their offspring’s futures.25 but also apply a social norms lens with adolescent girls at the center of this adapted socioecological framework in
170 Abu Hamad B, Jones N, Samuels F
It is within this framing of adolescence as socially evidence base on adolescent psychosocial wellbeing in constructed, locally and historically specific that we conflict-affected settings and to highlight the intersection situate our discussion of Gazan adolescent girls’ between age- and gender-related social norms and experiences of and responses to the 2014 Gaza-Israeli practices in shaping adolescent outcomes. conflict. The paper seeks to contribute to the emerging
The Gazan political and socio-economic context
This study focuses on adolescent girls’ psychosocial In this conflict-affected context, the key socioeconomic vulnerabilities, formal and informal coping approaches and environmental determinants of health, including and service utilization during and immediately after the psychosocial wellbeing for the Gaza population, have 2014 Israel military operation in Gaza which started in been negatively affected and resulted in increased July 2014 lasting 51 days and causing widespread psychosocial vulnerabilities, particularly among women damage and destruction to livelihood resources. At least and children.3 Because of political turbulence, around 2,133 Palestinians were killed (including 187 girls and 50% of households in Gaza are food insecure, 313 boys);26 11,433 Palestinians (including 3,374 unemployment among youth reaches around 60%, and children) were injured and 15 hospitals and 45 Primary 80% of the population need humanitarian assistance and healthcare (PHC)centers were damaged during the around 100,000 are enrolled in social protection offensive.1,4 During the acute stage of the military programs and receive social assistance.30 operation, an estimated 500,000 people - 28% of the population - were internally displaced, staying in United Although health outcomes for the Gazan population Nations Relief and Works Agency for the Refugees of overall are relatively good compared to countries of Palestine (UNRWA) schools designated as emergency similar economic development, partly due to strong shelters, government schools, or in empty buildings, performance on most basic public health and PHC churches or mosques, and sometimes with host families.4 functions, given the chronic stress that people in Gaza The number of displaced people staying in these face, the area is experiencing an ‘epidemiological communal centers was much higher than had been transition’, whereby non-communicable diseases linked anticipated in contingency plans; the result was major to lifestyle and stress, (including heart disease, cancer, overcrowding, lack of privacy, inadequate sanitation and hypertension and cardiovascular diseases, and diabetes) hygiene, insufficient access to water and electricity, as are gradually replacing infectious diseases as the leading 26,31 well as heightened risks of sexual abuse and gender- cause of death. There is also a growing evidence-base based violence.27 on high levels of psychosocial ill-being, including among young people. Findings of a 2015 survey indicated, for It is also important to note the pre-existing challenges instance, that 31.9% of young people in Gaza reported facing inhabitants of Gaza prior to the 2014 conflict. The that psychological problems are the most important Gaza Strip is one of the most densely populated areas in health issue they face.32 Recent studies show that 51% of the world, and home to 1.9 million people - 66% of them Gaza’s children exhibited symptoms of PTSD30,33 and refugees,28 most of whom were forcibly displaced from the United Nations Relief and Works Agency (UNRWA) nearby areas following the Arab-Israeli conflict of 1948. estimates that, due to the impact of the blockade and Palestine’s historical lack of control over its own affairs recurrent conflicts, approximately 25% of refugee due to the Israeli occupation has been compounded by students in its schools require some form of psychosocial the fact that for decades Israel has followed a de- intervention, and that 32% of adolescents in Gaza are in development policy, especially in the Gaza Strip, which need of psychosocial support.34 Congruently, a study has resulted in widespread poverty and economic conducted by Birzeit University shows that 46.2% of collapse.4,29 A blockage, imposed on around two million adolescents in Gaza reported ill-being on the WHO Gazans since 2006, continues to restrict movement of Wellbeing Scale Index; 12.4% were moderately to people, goods and services and has seen border crossings severely distressed and the vast majority (76.5%) closed. Moreover, internecine violence between the reported moderate to high levels of human insecurity.35 political factions Hamas and Fatah has put additional Similarly, in terms of the hope scale, which measures an stress on Palestinian society. individual’s belief in their ability to complete tasks and reach goals, 40% of Gaza adolescents scored low; only Social determinants of health and psychosocial 20% scored high.36 Furthermore, recent studies show that wellbeing among Gazan adolescents there is an increase in the number of adolescents who
171 Mental Health and Psychosocial Challenges Facing Adolescent Girls in Conflict-Affected Settings: The Case of the Gaza Strip
assume risky behaviors such as substance use (10,047 married, and 43% were 18 or younger at the time of their high-risk drug users in Gaza) with over-the counter first pregnancy, and in turn heightened risks around medications like Tramadol and Pregablin the most service uptake due to high levels of surveillance from commonly used drugs;37 and suicidal ideation.38 husbands and in-laws.40
During conflict and emergency episodes, exposure to Augmented by the siege and the conflict, studies show stressors is compounded by frequent challenges in that strict conservative social norms also create accessing services and essential drugs, including drugs additional stressors particularly affecting girls such as used in the treatments of mental illnesses such as restriction on girls’ movement, overprotection, concerns antipsychotic and sedatives.39 Barriers preventing Gazan around ‘family honor’, lack of understanding/support, adolescent girls and young women seeking health sexual harassment and lack of privacy at home.11,41 These services are especially complex: not knowing where to gender-specific vulnerabilities have flourished in the go (11%); not being able to get permission (17%); not broader context of conflict, fear and uncertainty, and are being able to get money (36%); not being willing to go manifested in further restrictions on girls’ movement and alone (39%); and a lack of female health workers agency as well as in heightened exposure to ‘honor (32%).40 The United Nations Populations Fund (UNFPA, killings’.42 Despite the lack of official statistics, family 2013) further highlights that adolescent girls were found honor killings seem to have increased significantly in to face specific health risks due to socio-cultural norms recent years, rising from four reported cases in 2010 to surrounding early marriage and childbearing: 53% of 27 in 2013.43,44,45 young women were aged 18 or younger when they
Methodology and study site
The research team used multiple qualitative methods to being addressed by existing services. Finally, we explore the interplay between risks to adolescent girls’ explored through adolescent lenses, how mental health psychosocial wellbeing within a conflict setting and the services can be strengthened and tailored to meet their availability of individual and collective social support needs. mechanisms. We started by mapping the mental health and psychosocial services serving our study sites to Ethical clearance for the study was obtained first from better understand the specific context in which the Overseas Development Institute (ODI) in London adolescent girls are residing (see below), then followed and then in compliance with the regulations valid in up with focus group discussions with adolescent girls - Gaza, the team approached the Research Ethics both beneficiaries and non-beneficiaries of mental health Clearance Committee in Gaza to secure approval to and psychosocial programs,4 semi-structured in-depth conduct the study, and an official letter of approval was interviews with adolescent users of services10 and obtained from the Helsinki Committee in Gaza. All complementary interviews with their caregivers.8 A large interviews, with appropriate consent, were recorded, number of key informant interviews21 were conducted at translated, and transcribed. Immediately following the policy-making/management and service interviews, debriefing reports were prepared which implementation levels. In addition, five facility contained the most important themes, differences among checklists were administered at organizations providing those themes, important quotes, interactions, memos, psychosocial services to Shajaia residents in order to major ideas and concepts, verbal, and non-verbal understand both entry points and bottlenecks for messages. Upon completion of primary data collection, adolescent service seekers. in January 2015, the research team took part in a two-day debrief meeting to conduct a preliminary analysis of the Data collection took place between November to fieldwork findings.The approach used was an open December 2014 with pilot interviews conducted prior to coding technique based on ‘adequate immersion’, and the actual data collection. The study tools focused on then ‘categorization’ of the findings. Subsequently, the exploring psychosocial and mental health challenges research team unpacked each transcript to explore in facing adolescent girls during and immediately after the more depth specific findings around key categories that conflict, formal and informal coping strategies adopted emerged across transcripts, and collated relevant by adolescents and their communities to deal with mental interview extracts in an excel template, which was then health and psychosocial problems and the extent to used as a key reference during the final analysis process. which gender- and age-specific psychosocial stresses are
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Limitations faced by the study included the absence of neighborhood in Gaza City with more than 120,000 baseline data prior to conflict episodes, including that of residents and was selected as the study site because of its the July 2014 conflict, making it difficult to attribute the high population density as well as the prevalence of study findings to the consequences of the conflict and/or restrictive cultural norms. Additionally, on 20 July 2014, to confirm the outcomes of the mental health and around 120 Palestinians were killed in shelling in and psychosocial services provided to adolescent girls. around Shajaia, with hundreds injured and thousands of However, through retrospective interviewing techniques, houses demolished. Many people were forcefully evicted including the construction of community and individual from their houses with nowhere to go. timelines, we were able to tease out key markers and events in order to develop a clear narrative of change Shajaia is a conservative community, characterized by over time. In addition, it was challenging to recruit strict adherence to traditional cultural norms and service users of mental health institutions for the focus practices. Most women marry at a young age (the median groups because of confidentiality requirements and their marriage age for women is under 20) and most do not psychological status, which in some cases restricted their participate in the labor force. Shajaia has four ability to interact with data collectors. government-run PHCcenters, three centers run by non- government organizations (NGOs), and the only Study site rehabilitation hospital in the Gaza Strip. Residents can also access services at the UNRWA, NGOs and Shajaia neighborhood, located at the eastern border governmental premises. between the Gaza Strip and Israel, is the largest
Findings
Overview of adolescent psychosocial vulnerabilities Parents’ concerns about the safety of their daughters in such uncertain and politically turbulent contexts, often As discussed above, young people in Gaza suffer from resulted in their being overprotective which practically 3,48 elevated levels of mental distress, and our findings meant putting more restrictions on girls’ movement and highlight that the 2014 conflict was an additional stressor agency. that exacerbated pre-existing psychosocial ill-being. As one school counsellor noted: ‘Last year, I hardly During the research, adolescents repeatedly discussed the received one or two mothers in one month. After the war, traumatic effects of losing their homes, losing a loved I may see three mothers on average every day. In these family member or friend, and living in crowded and dirty post-conflict periods, our findings highlighted that shelters or other communal centers as the main sources families had often become separated, with some living in of stress. As one 14-year-old girl from Shajaia explained: relatives’ houses and others in shelters or communal ‘What happened during the war is indescribable. You centers. Many adolescents found themselves living in will not be able to imagine it. It was unbearably unfamiliar surroundings and/or with strangers, lacking terrifying - fear, dismay, death, and horror!’ For many adequate attention/care from ‘safe’ adults and therefore adolescents, the experience of the 2014 conflict, as well feeling unsafe on a day-to-day basis. as the preceding conflicts, have deeply affected them as the extreme uncertainty in this 11-year-old girls’ Our findings suggested that the conditions in these testimony highlights ‘What will happen? All years are centers contributed to deteriorating psychological and alike, year after year, war attacks us, and every year, we mental wellbeing among young people, and adolescent don’t know if war is coming this year or the year after...’ girls in particular. Women and girls in particular face many constraints and become more vulnerable during Adolescents also face a range of compounding daily life in these collective centers.21 A key informant vulnerabilities, with economic hardships and prolonged from an international organization used the following political uncertainty having a significant influence on example to illustrate this vulnerability stemming from adolescents’ deteriorating psychological status. In fact, powerful socio-cultural norms that emphasize the need respondents linked many problems to the economic for sex-segregated spaces: ‘A girl told me that her father situation: domestic violence, low educational attainment, prevented her from going to the toilet (in this non- inadequate socialization, insufficient recreational segregated collective shelter) because there were men in activities, and dysfunctional relationships between the area...’ The girl added, “I stayed hours till they adolescents and their parents. Girls in particular also moved away from the area then I used the toilet”.’
173 Mental Health and Psychosocial Challenges Facing Adolescent Girls in Conflict-Affected Settings: The Case of the Gaza Strip
reported negative feelings when they do not possess deal with the prevailing chronic stressors. Overall, our clothes or other items that their better-off peers have. findings indicated that people tend to rely on emotion- focused coping strategies rather than problem-solving Lack of electricity and other basic services or strategies because adolescents and their parents can do infrastructure also created many stressors among the little to address the root causes of the main challenges community and affected girls in particular ways. During they face. During the acute stage of the conflict, most power cuts, for instance, girls may have even less time to people (including adolescents) turned to religion, reading study or engage in leisure activities, all of which can the Quran and saying prayers to protect themselves and cause them additional stress. Similarly, while boys can their families. This was common practice, especially spend time with friends in the streets playing traditional among women and girls. When there was electricity, games, girls do not have similar opportunities for play or people watched the news, but adolescent girls recreation due to cultural norms. Generally, in the Gaza highlighted that this usually served to increase their fears Strip, focus group discussion participants highlighted and those of their caregivers. In order to distract that, due to multiple stressors, families seldom prioritize themselves, adolescent girls did household chores while creating the space adolescents need to express boys socialized with friends and relatives during the themselves, and seldom try to understand their special daytime when shelling abated. While staying in needs, concerns or capabilities. temporary communal shelters, some adolescent girls also Overall, the study found that some categories of participated in psychosocial debriefing sessions, but adolescents are more vulnerable to psychosocial generally emphasized that they had few channels to stressors. These adolescents include: girls, especially express their concerns and fears during the conflict. those over 15 years old; adolescents who have been Post-conflict coping strategies differed significantly directly affected by the war; those who have lost their along gender lines. Young girls in particular sought homes; those who have lost the main breadwinner or support from social networks such as family members, member/s of their family or friends; those who have been friends, and relatives, and turned to religion and orphaned; adolescents in child-headed families; traditional healers. There was also a tendency among adolescents who have missed out on education; those girls to cope by day-dreaming, imagining a different who are economically disadvantaged; adolescents with reality, imitation, drawing, writing, and using social disabilities; those living in shelters; those who have media, whereas boys tended to seek out recreational previously been exposed to trauma; and those living in activities such as gathering with friends on the streets, or culturally conservative and physically isolated areas. sport activities, as a way of coping. These coping 31,4 In particular, violence also emerged as a major concern approaches are also reported in other studies, and have among adolescents. While boys are more likely to important potential implications for programs experience peer violence and bullying at schools, in the interventions (as we discuss in the conclusions). home and in shelters, girls were more exposed to gender- Unlike their male peers who tended to perceive service based violence; some girls, for instance, also reported seeking behaviour as a sign of ‘weakness’, adolescent being punished when they arrived at their temporary girls sometimes approached psychosocial support residence late. Fear of being exposed to sexual available in schools and PHC clinics and tended to harassment is a key stressor for girls and for their engage in psychosocial activities. Some adolescent girls families, especially those living in remote areas and close (especially younger girls) developed psychosomatic to borders. Sexual harassment cannot only affect the symptoms such as a stammer or convulsions as a way of immediate reputation of the girl or young woman, but reducing their exposure to physical violence from their may also affect her future chances of marriage, parents by gaining their sympathy. Interestingly, in this especially when subject to strong social norms within a study as well as in others, most of the coping strategies conservative community. Similarly, conforming to used by girls were positive, while boys were more at risk expectations of ‘family honor’ is a source of of relying on negative coping strategies, including considerable stress for older adolescent girls, especially violence, choosing to be isolated, or using painkillers as violations (or perceived violations) of that honor can such as Tramadol.2,33 While adolescent girls have sought result in honor killing. to cope by investing more time in their studies, boys Adolescent resilience and coping strategies have typically tried to cope with their poor economic situation by working, with or without dropping out of Even prior to the 2014 conflict, the population of Gaza school. One key informant said: ‘I saw few females who has employed a wide range of coping mechanisms to
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use drugs; but saw males equal to the number of my encouraging people to seek mental health services hair.’ He added, ‘Females’ coping strategies are included experiencing atypical physical symptoms (such constructive, they focus on education - females spend as epileptic fits and bed-wetting), excessive nightmares, more time studying.’ Another key informant (a service and feelings of isolation. In many cases, parents of girls provider) said: ‘Females are predestined to cope well by who were suffering from bed-wetting sought support ‘Allah’…Negative coping is more common among males from psychosocial services to ready the girl for marriage. than among females.’ Typically, families would only seek formal mental health services late on and after consulting traditional healers. Adolescent interactions with psychosocial services Health providers often mentioned obtaining a medical Our findings indicate that despite there being multiple report to get financial assistance from the Ministry of psychosocial and mental health service providers in Social Affairs (MoSA) as a driver to service uptake. Gaza, organizational, cultural, and psychological barriers Teachers gave numerous reasons for referring often prevent young people accessing those services. adolescents to school counsellors, including poor Generally speaking, adolescent girls tend to have least academic performance, behavioral problems (including access to mental health services because of prevailing violence and aggression), family problems, engaging in psychological and cultural norms, which act as barriers culturally unacceptable behaviours, and mixing with to service uptake. The older the girl is, the less likely she members of the opposite sex. is to receive mental health services because the stigma Despite good coverage, key informants from both that comes with doing so could affect her reputation and UNRWA and the MOH admitted there are several her chances of marrying. One expert explained: ‘It is a weaknesses in the counselling services they provide. One million times easier for families to take girls to service provider noted: ‘The school counselling is helpful traditional healers than mental health providers’. A key to pupils. However, it is far from achieving its goals... informant explained that: ‘Access of females to mental Now it focuses on behavioural issues and academic health and psychosocial services is more restricted (than achievements... We intensified training on counselling for boys), because of the stigma and because of the through support from international organizations.’ restrictions on their movement’. According to the same Some adolescent girls reported that despite the key informant, when it comes to boys affected by the availability of counselling services, they did not use them conflict, the stigma is much less. The same key because they did not trust them and feared expressing informant also added ‘The community regard their problems. In a focus group discussion with girls psychological problems with less sensitivity than they aged 12-16, one girl said: ‘I cannot trust people, I can used to, especially when problems are related to the war, never tell them what I feel or share my problems with as it is not a personal issue. It affects many people and is them’; another added ‘But when girls don’t share their out of their control. But when the problem is not war problems, their psychological status will be harmed.’ related, that is when people feel stigma.’ Service provider attitudes Most service users/beneficiaries reported getting information about both formal and informal MHPSS- Our research produced mixed findings about the attitudes related services from relatives, friends, and neighbors. of health care providers. On the one hand, most providers However, this information was not always reliable, and were found to be enthusiastic, caring and motivated to could even be dangerous. As one caregiver said: ‘My help their service users. On the other hand, particularly at neighbors advised me to treat my daughter by reading the service delivery level, providers appeared to be Quran (Ruqia). I took her to a religious man who read neither age- nor gender-sensitive. In some cases, it would Quran (Ruqia). She got better after and was not exposed appear that prevailing cultural norms have influenced to any epileptic seizures for around two months. But she providers’ perspectives, with many adopting judgmental had a strong epileptic seizure every day during the last attitudes towards adolescents in general and gender war.’ issues in particular. One counsellor based at a clinic, showing a lack of empathy, said: ‘I don’t show any Due to the lack of proactive targeting by psychosocial empathy to females who fall in love and behave against and mental health service providers, families themselves the cultural mainstreamed behaviours. How can I support usually decide when and where to seek services. Families a girl who falls in love during the war in a collective are also involved in the treatment given by service center. The same counsellor noted, ‘All stories we hear providers, typically ensuring compliance with prescribed are related to love, stories on mobile and things that may medication and follow-up visits. The main drivers God protect us from them.’
175 Mental Health and Psychosocial Challenges Facing Adolescent Girls in Conflict-Affected Settings: The Case of the Gaza Strip
Some (male) health providers reported feeling reluctant seeking treatment but is a longer lasting and all- to treat adolescent girls unless they were accompanied by pervasive challenge. This is aptly summarized in the a family member. Others rely heavily on their faith and following narrative by a caregiver who was seeking care spiritual beliefs as a method of treatment. One for her daughters:‘The general physician stopped (psychiatrist) said: ‘The best method to treat mental following up on my daughters, especially the older one, illnesses is to be closer to God and to keep faith’; he and he asked me to stop treating her because she is now claimed that this approach had worked with almost all a young lady, and continuing receiving mental health the people he sees. services will ‘affect her reputation’ and ‘she will be stigmatized forever’… ‘It is enough; don’t take her to Again, as already noted, stigma seems to affect any doctor. This will affect her future if people know adolescent girls in particular, not just at the time of about her case.’
Conclusions
This study has identified important vulnerabilities and adopt more positive or constructive coping approaches challenges affecting the psychosocial wellbeing of such as investing in their education and communicating adolescent girls in the Gaza Strip, which have significant on social media with peers. implications for policy-makers, program designers and 3,46,48 implementers, as well as international development Also, in line with other studies, our findings agencies working in fragile and conflict-affected identified serious gaps in service provision in Gaza, contexts. especially in crisis situations. Many mental health and psychosocial services are short-term, largely A complex array of economic, social and political factors uncoordinated, donor-driven, implemented largely in the affects the psychosocial wellbeing of adolescents in immediate post-conflict period and mostly focusing on Gaza. The chronic humanitarian crisis in Gaza has been younger children.48 Not only does this result in the needs compounded by the limited capacity of mental health and of vulnerable age groups being neglected, but longer- psychosocial services to respond to the population’s term interventions and specialist mental health services multi-dimensional vulnerabilities including mental health receive less attention and support. Generally, despite the challenges, and more specifically to the unique existence of psychosocial programs in Gaza, the general opportunities and challenges that the second decade of population’s needs - and young people’s psychosocial life represents via-a-vis adolescent psychosocial and mental health needs in particular - are far from being wellbeing. In the case of adolescent girls, an additional met, especially during an emergency and immediately layer of vulnerability must be considered, namely the after. Given the unique context of Gaza combining effects of prevailing conservative socio-cultural norms, chronic insecurity and de-development punctuated by which limit their mobility, opportunities for social repeated violent conflict episodes, tailored psychosocial connectedness, as well as their ability to seek support support services are urgently needed that simultaneously services outside the family.As a result of the protracted take into account life-cycle and gender specific conflict and in congruence with other studies,3,46,47 our vulnerabilities and sources of resilience and that are research shows that adolescents in the Gaza Strip suffer developed as part of a more strategic and longer-term from PTSD as well as range of other psychosocial mental health policy and programing framework. disorders. Our findings also draw attention to the fact that attitudes Age- and gender-specific experiences of conflict are, to service delivery and in particular service uptake, however, also reflected in differential sources of reflect the social norms and values of the study resilience and deployment of specific coping strategies. communities, often hindering adolescents’ - and Our findings indicated that adolescent girls tended to especially adolescent girls’ - access to appropriate help themselves by relying on family support, and support. Services providers’ attitudes and practices often turning to emotion-focused coping strategies, including constitute additional barriers that hinder age- and gender- religious activities, rather than relying on formal services responsive service provision and require urgent attention provided by psychosocial service providers.Whereas key in professional training and refresher capacity building informants noted that adolescent boys are more likely to programs. Screening tools to better identify adolescent turn to risky coping strategies such as turning to violence mental health vulnerabilities also need to be adapted and and substance use, adolescent girls in our study tended to rolled out within schools and school counselling
176 Abu Hamad B, Jones N, Samuels F
services, primary healthcare facilities and extra- negative coping strategies, especially substance use and curricular services targeting adolescents to better detect violent behaviors, through awareness raising, policy need and to reduce stigma surrounding mental ill health setting and multi-sectoral interventions such as and psychosocial challenges. Complementary efforts also community protection networks. need to focus on raising community awareness through media, education, and community mobilization, and More broadly, the study underscores the importance of improving health workers’ awareness of the challenges developing an integrated psychosocial and mental health facing adolescents as they go through this unique life- strategy for adolescents living in fragile and conflict- cycle stage. affected contexts. Dealing with psychosocial conditions linked to and exacerbated by conflict should be re- Positive coping strategies could be promoted through conceptualized as a core component of development building basic life skills among children and adolescents; interventions, rather than seen as an optional extra. Many enhancing access to psychosocial support services; of the current gaps in psychosocial services could be strengthening ties and nurturing relationships between circumvented if more efforts were dedicated to adequate adolescents and their families (especially at an early age) planning and coordination prior to and during a crisis, through parenting classes and guidance; and investing in and were embedded into, for example, broader health formal and informal education as a means of and education programing for young people in strengthening adolescents’ self-esteem. At the same time, emergencies and conflict-affected contexts. there should be greater efforts to monitor and address
Recommendations
Strategies and policies at the national level To enhance the quality of mental health and should address the key determinants of psychosocial interventions, national technical psychosocial and mental wellbeing-positive protocols need to be collaboratively developed change in the overall context, economic growth, and enforced. community empowerment, socio-cultural These need to be accompanied by investments change and political resolution of the in building the capacity of providers to deliver Palestinian case. adolescent psychosocial and mental health Invest in programs that enhance resilience and services to those most at risk. positive coping of adolescents. Promoting the capacity of psychosocial and Develop a conceptual model and standards for mental health organizations in terms of HR, prevention, control, early identification, infrastructure, management systems. diagnosis and management of mental health and Strengthen the role of the school counselling psychosocial issues. programs in prevention, early detection, and Increase coordination among the many management of psychosocial issues. providers of psychosocial services promoting Encourage reflections, assessing impacts of regulatory frame-licensing and accreditation. intervention, sharing experiences, and learning Proactively target vulnerable groups-promoting within and among programs. girls’ early utilizations of services through awareness, reducing stigma, early detection. Providers’ attitudes about age and gender in the provision of mental health services need to be urgently addressed.
Limitations
In common with other cross-sectional studies, assessing psychosocial status of service users and beneficiaries, the situation at a particular point in time may not capture their perspectives, and views, is essential. Recruitment of all perspectives about psychosocial and mental health participants from mental health institutions was issues and services, as the situation may differ over time. complicated for various reasons, including issues of Chronological monitoring (longitudinal designs) of the confidentiality, communication (reflecting social stigma
177 Mental Health and Psychosocial Challenges Facing Adolescent Girls in Conflict-Affected Settings: The Case of the Gaza Strip
attached to mental illness), and the effect of ingested communications infrastructure), and limited time and drugs, which affected service users’ ability to resources, proved to be significant constraints. communicate. Limitations pertaining to the realities of daily life in Gaza (such as frequent electricity cuts, poor Acknowledgements The authors would like to express their deepest providers, counsellors, senior managers, and key appreciation to the many people who contributed to this informants related to psychosocial interventions. We are study and provided valuable information. In particular, grateful to senior management and staff from the MOH, the authors would like to thank service users, UNRWA and NGOs. beneficiaries and their caregivers/friends, health care
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الملخص الهدف: تركز هذه الدراسة على استكشاف العالقة بين الرفاهية النفسية واالجتماعية للفتيات المراهقات واألعراف والعادات االجتماعية والثقافية في المناطق المتأثرة بالصراع، مع التركيز على قطاع غزة.المنهجية: باالعتماد على البحث النوعي الذي تم إجراؤه مع الفتيات المراهقات وذويهم ومقدمي الخدمات بعد الحرب اإلسرائيلية على غزة عام 0202، يستكشف هذا البحث تجارب المراهقين واستجاباتهم النفسية والعاطفية، وإلى أي مدى تم التعامل مع التحديات التي تواجههم من خالل البرامج النفسية التي تم تنفيذها وقتها.النتائج: تسلط النتائج التي توصلنا إليها الضوء على أن النزاع أدى إلى تفاقم التحديات النفسية المتعددة األبعاد لدى الفتيات المراهقات، وذلك في سياق يعاني ًاصال فيه السكان من أزمات إنسانية متفاقمة مع عدم وجود وسائل استجابة وتكيف كافية. نحن ندعي أن تدخالت البرامج النفسية تميل إلى التركيز بشكل أساسي على األطفال األصغر ًسنا، بينما تتجاهل إلى حد كبير المراهقين والتحديات التي تواجههم خصوصاً تلك المتعلقة بالسن والجنس.االستنتاج: بينت الدراسة بأنه يجب معالجة أوجه القصور المذكورة أعاله بشكل عاجل لدعم الرفاه النفسي واالجتماعي للفتيات المراهقات وقدرتهن على الصمود بشكل أفضل، مع التركيز بشكل أقوى على االحتياجات التطويرية المتزايدة لهن. إن من الضروري أن يتم مراعاة تأثير األعراف االجتماعية المتعلقة بالنوع االجتماعي على البرامج والتدخالت النفسية عند تصميمها للمناطق المتأثرة بالصراع .
Corresponding Author Dr Bassam Abu Hamad, Al Quds University, Faculty of Public Health, Al-Quds University, Tel El Hawa, Gaza - Palestine
E-mail: [email protected]
Authors Dr Bassam Abu Hamad, Al Quds University, Faculty of Public Health, Al-Quds University, Tel El Hawa, Gaza - Palestine
Dr Nicola Jones, Social Development Program, Overseas Development Institute, London - UK
Dr Fiona Samuel, Social Development Program, Overseas Development Institute, London - UK
180 The Arab Journal of Psychiatry (2020) Vol. 31 No.2 Page (181 – 190) (doi-10.12816/0056869)
Eating Disorder Symptoms among Medical Students at Suez Canal University
Sarah E. Bakr, Magda T. Fahmy, Khaled A. Mohamed, Haydy H. Said أعراض اضطرابات األكل بين طالب كلية الطب الغير ساعيين للمشورة الطبية في جامعة قناة السويس
سارة عصام بكر، ماجدة طه كمال الدين فهمي، خالد عبد المعز محمد، هايدي حسن سيد
Abstract
ackground: Eating disorders are characterized by a persistent disturbance of eating or eating-related behavior B that results in altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning. Medical students exposed to stress, who also express dissatisfaction about their body shape and weight could be at risk of developing eating disorders. Aim: Symptom prevalence rates associated with eating disorders were assessed in 122 medical students. Methods: A convenience sample of 122 undergraduates attending Suez Canal University were assessed using a demographics questionnaire, the eating attitude test (EAT- 26), the body shape questionnaire (BSQ) and self-reported BMI levels. Results: Results revealed 45.9% of participants had symptoms associated with eating disorders with the majority being women. There was a significant correlation between having symptoms of eating disorders and feeling dissatisfied about body shape. Dissatisfaction and concern about weight was related to higher BMI, especially among overweight or obese participants, and the presence of symptoms of eating disorders was higher in this group. Conclusion: Medical students are under high levels of stress, which is an important indicator when considering the development of eating disorders. A high percentage had symptoms of eating disorders together with low self-esteem and dissatisfaction about body shape found mainly among overweight or obese women.
Key words: Eating disorders, medical students, eating attitude test 26, body shape, body mass index
Declaration of interest: None
Introduction
Feeding and eating disorders are characterized by a In teenagers, poor eating habits can be related to persistent disturbance of eating or eating-related puberty development, overweight, and body behavior that results in altered consumption or satisfaction as well as family and peers effects, absorption of food and that significantly impairs adolescence is a stage in which individuals are more physical health or psychosocial functioning, these affected by fitness ideals hence more prone to disorders include pica, rumination disorder, developing eating disorders’ symptoms.3 avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa and binge-eating disorder.1 Social and cultural variables, economic status, westernized weight losing programs of the media and Adolescence is characterized by peak growth and peer pressure increase development of eating physical maturation. Having a healthy diet helps disorders' symptoms.4 teenagers reach complete growth potentials, increases health and wellbeing and decreases the risk of Moreover, the influence of a genetic contribution on chronic diseases in later life, studies have shown that the etiology of eating disorders comes from both adolescents are prone to a number of health family and twin studies. Relatives of pro-bands with problems, such as obesity and eating disorders, which eating disorders have a 10-fold lifetime risk of having 5 are attributed to their lifestyle that influences their the disorders than relatives of unaffected controls. 2 eating habits. Available data suggest that mothers with an eating disorder history are more likely to have infants with feeding difficulties, to restrict their child’s eating in
181 Eating Disorder Symptoms among Non-Consulting Medical Students at Suez Canal University early and middle childhood, and to use food for non- The prevalence of anorexia nervosa was 0.8%in a nutritive purposes (e.g., reward, distraction) when study by Stice et al. (2013) moreover, bulimia compared to mothers without an eating disorder nervosa was estimated to be 0.6 %, according to history.6 Machado et al. (2013).12,13 Regarding binge eating disorder prevalence estimates ranged from less than Maternal and/or familial emphasis on eating, weight 1% in several European countries to 2.6% in the and shape (e.g., parental dieting, comments about USA.14 weight and shape in the home environment) may also predict weight loss attempts, weight and shape According to the World Health Organization’s World concerns, binge eating and purging in children and Mental Health Survey the prevalence of binge eating adolescents.7 disorder is 0.8-1.9% compared to that of bulimia nervosa which is 0.4-1.0%.15 Considerable evidence suggests that eating disorder and obesity is growing throughout the world; A university is considered ‘a society’ or ‘community’ overweight teenagers are more exposed to keep or in which values regarding body shape and eating develop eating disorder symptoms.3Obesity has been behavior are shared, transmitted, and reinforced.16 found to be related to fast meals which many adolescents will consume during their day rather than Medical students are associated with high levels of homemade meals.8 stress that stand as a critically important causative factor in the development of eating disorders' A number of studies showed a correlation between symptoms. The stress they are exposed to is mainly the risks of increased symptoms of eating disorders, due to the academic pressure they may experience; overweight, body image concerns, and improper being unable to keep up with the academic workload; behaviors towards losing weight in teenagers.9 being worried almost all the time about their academic performance; and, not having spare or Girls show more frequent and severe symptoms and leisure time to enjoy their hobbies. Thus, it is quite behaviors that may progress to full-syndrome eating important to analyze all such instabilities in medical disorders, however, despite the fact that eating students who are an asset for the future of this disorders' symptoms are more prevalent in girls, boys country.17 are also vulnerable to developing eating disorders' symptoms.10 The findings from the present study may offer certain fundamental information about eating disorders and It has been reasoned that in non-western countries their symptoms and aid in any future exploration as where being overweight is not a disgrace, eating to their relation to individual and social factors. disorders are rare; however, there are studies that show considerable prevalence of eating disorders in developing and Arab countries.11, 2
Methods
Study Design where participants are recruit from a group of people easy to contact). There are no other criteria to the A cross-sectional descriptive study sampling method except that people are available and Study sample willing to participate accordingly. It does not necessitate a control group. From a cohort of 903 students attending the Faculty of Medicine at Suez Canal University in Egypt, 300 Study tools expressed an interest in participating in the study. In Socio-demographic data total, 122 students agreed to participate. Students were screened for history of medical or psychiatric Participant characteristics are described using a disorders to override factors leading to eating questionnaire concerned with age, gender, residence, problem. A convenience sampling method was taken marital status, and presence of psychiatric or medical (this is a type of non-probability sampling method disorder.
182 Bakr SE, Fahmy MT, Mohamed KA, Said HH
The Eating Attitude Test (EAT-26) 26-30 overweight (more body fat than is optimally healthy) This 26-item, self-report questionnaire assesses >30 obese (medical condition in which eating attitudes, feelings and behaviors related to excess body fat has accumulated such that it eating and eating disorder symptoms. No diagnosis is may have a negative effect on health provided, but screening assumes that early identification of an eating disorder can lead to earlier The Body Shape Questionnaire (BSQ) treatment thereby reducing serious physical and psychological complications or even death.18 This 34-item, self-report questionnaire assesses the body shape preoccupations typical of bulimia nervosa The EAT-26 is comprised of three subscales:(1) and anorexia nervosa.22 It measures feelings of low Dieting, (2) Bulimia and food preoccupation, (3) Oral self-esteem, the desire to lose weight and body control. The established cut-off point for caseness is dissatisfaction in both men and women. Scores are 20. Scores above 20 indicate need for further classified into four categories: scores lower than 80 assessment by a qualified professional to determine indicate no concern with shape, 80 to 110 indicates diagnostic criteria for an eating disorder although mild concern with shape, 111-140indicate moderate scores below 20 may also indicate a significant eating concern with shape, and scores higher than 140 problem.19 indicate a marked concern with shape.
Three criteria are used to establish the need for The discrepancy between a student’s current and further evaluation of risk of having an eating desired body weight indicates body weight disorder. These are: dissatisfaction.23
1. Score on EAT-26 test items Study procedure 2. Low body weight compared to age-matched norms The study protocol was reviewed by the ethics 3. Behavioral questions indicate possible committee of the Faculty of Medicine at Suez Canal eating disorder symptoms or recent University in December 2016. Eligible participants significant weight loss20 were informed about the purpose of the research and provided written consent prior to participating. The EAT-26 has been used to assess eating disorder risk among high school and college students. It has a Statistical analysis high degree of predictive validity and reliability, Data were analyzed using SPSS version 19 (SPSS including across cultures; and has been validated in Inc., Chicago, IL, USA). All 122 participants were 21 Egypt. from the Faculty of Medicine being a representative Body mass index (BMI) sample of the wider cohort. The BMI is a standard measure of body fat based on Quantitative data were expressed as means ± SD height and weight, which applies to adult men and while qualitative data were expressed as numbers and women. The index is estimated by the following percentages. Student t test was used to test equation: weight (KG)/Height2(M). significance of difference between two means while Chi square was used to test significance of difference Scores are estimated as follows: between qualitative data. Multiple logistical regressions were used to assess risk factors for eating <20 underweight disorders. A probability value (p-value) <0.05 was 20-25 average considered statistically significant.
183 Eating Disorder Symptoms among Non-Consulting Medical Students at Suez Canal University
Results
Questionnaire responses from all 122 participants Regarding the association between disordered eating indicated that symptoms of eating disorders were attitudes, body shape dissatisfaction and BMI, there found in 45.9% while 54.1% reported not having any was significant statistical difference with higher symptoms. prevalence among women (53.5%). We also found that women were more prone to body shape There was a significant statistical difference dissatisfaction and, therefore, more prone to (p=0.011) in attitudes based on gender with more expressing more disordered attitudes in relation to women reporting higher prevalence of disordered eating. thinking in relation to food (67.7%) than men (32.2%). Key demographic characteristics for all participants are described in Table 1. Most were 29 years of age In addition, there was high statistical difference (23%); 13% were 19 years of age with an overall between disordered eating attitudes and body mass M=19.4, SD=1.7. More than half (82%) lived with index (p=0.002) with higher prevalence among obese their families and 56% were women. and overweight participants. Further, there was high statistical difference between body shape Regarding BMI, most participants reported being dissatisfaction, low self-esteem, and disordered either obese (36%) or overweight (35%) with 15% eating attitudes, especially among women. and 13% either average or underweight, accordingly.
Table 1. Distribution of the studied cases according to demographic data (N=122)
No. % Age (years) 17 year 19 15.6 18 year 29 23.8 19 year 16 13.1 20 year 18 14.8 21 Year 22 18.0 22 year 18 14.8 Min. – Max. 17.0 – 22.0 Mean ± SD. 19.40 ± 1.71 Median 19.0 Gender Male 53 43.4 Female 69 56.6 Residence, living with family With family 100 82.0 Not living with family 22 18.0 BMI (kg/m2) <20 16 13.1 20-25 19 15.6 26-30 43 35.2 >30 44 36.1 Birth order within family 1st 49 40.2 2nd 33 27.0 3rd 25 20.5 4th 14 11.5 5th 1 0.8
184 Bakr SE, Fahmy MT, Mohamed KA, Said HH
Table 2. Participant scoring distribution according to EAT-26
EAT-26 scores No. %
<20 66 54.1
>20 56 45.9
Table 2 reports responses from the EAT-26 with considerable number of students (45.9%) did score 54.1% scoring<20, which suggests most students do >20suggesting symptoms associated with an eating not report having an eating disorder. Despite this, a disorder.
Table 3. Correlation between EAT-26 scores and gender
EAT-26 scores < 20 >20 Z2 P
(n= 60) (n= 62) No. % No. % Gender Male 33 55 20 32.5 6.418 0.011 Female 27 45 42 67.7 P values for Chi square test
*: Statistically significant at p ≤ 0.05
Table 3 shows the relationship between attitudes demonstrates a statistically significant difference towards eating and gender with a more women between both genders regarding eating attitudes (67.7%) reporting scores >20 than men (32.2%). This (p=0.011).
Table 4. Correlation between gender and BMI
BMI <20 20-25 26-30 >30 P value Gender Male 14 22 16 1 0.000 Female 10 8 15 36
Table 4 shows the relationship between gender and indicated a highly significant difference between BMI. The highest body mass index levels were genders(p=0.000). among women who reported scores of>30. This
185 Eating Disorder Symptoms among Non-Consulting Medical Students at Suez Canal University
Table 5. Correlation between EAT-26 and BSQ scores
BSQ <80 80-110 111-140 >140 P value EAT-26 <20 21 26 9 10 >20 4 11 14 27 0.011
Table 5 showsthe relationship between EAT-26 of low self-esteem, a desire to lose weight and body scores and the BSQ. This suggests a high pre- dissatisfaction. Scoressuggest a significant difference occupation with food and weight27among those between variables (p=0.011). reporting scores of >140as evidenced by experiences
Table 6. Correlation between EAT-26 scores and BMI
EAT-26 < 20 >20 χ2 P (n= 66) (n= 56) No. % No. % BMI (kg/m2) <20 13 21.6 1 1.6 20 – 25 8 13.3 11 17.7 14.6 0.002 26 – 30 22 36.6 20 32.2 >30 17 28.3 30 48.3 2, p: 2 and p values for Chi square test
*: Statistically significant at p ≤ 0.05
Table 6 demonstrates the correlation between EAT- associated with scores of >20 with this being 26 results and BMI showing the higher BMI statistically significant (p=0.002).
Table 7. Correlation between BSQ scores and BMI
BSQ < 80 80 – 110 111 – 140 >140 Z2 MCp (n= 16) (n= 22) (n= 52) (n= 32) BMI (kg/m2) <20 16 100.0 0 0.0 0 0.0 0 0.0 20 – 25 0 0.0 5 22.7 14 26.9 0 131.60* <0.001* 26 – 30 0 0.0 17 77.3 22 42.3 4 12.5 >30 0 0.0 0 0.0 16 30.8 28 87.5 2, p: 2 and p values for Chi square test
MCp: p value for Monte Carlo for Chi square *: Statistically significant at p ≤ 0.05
Table 7 highlights the correlation between BSQ scores and BMI levels. Worsening BMI levels are associated with a greater desire to lose weight, and also greater body shape dissatisfaction (p=<0.001).
186 Bakr SE, Fahmy MT, Mohamed KA, Said HH
Discussion
Drawing from a convenience sample of 122 was underweight rather than overweight or participants from a cohort of 903 students attending obese.28 the Faculty of Medicine at Suez Canal University, a range of views were obtained in relation to unhelpful Regarding the relationship between body shape attitudes (or disordered attitudes) towards eating, dissatisfaction, low self-esteem, and disordered reported symptoms associated with eating disorders eating attitudes, the current found statistical and their correlation with the participants’ self- differences that were also reported in a study from reported BMI levels. Disordered eating describes a Japan. Moreover, the previous study support findings variety of unconventional eating behaviors, such as in our study regarding women having higher concern constrained eating or compulsive eating. about their body shape when compared with men. This may be due to assumptions that men might be Our findings suggest that more women reported expected to have a stronger physique and possibly disordered attitudes towards eating compared with because there are fewer changes in their physique men, 67.7% and 32.2% respectively. This is than that of women. In addition, may also partly supported by Musaigeret al. (2013) who found that explain why eating disturbances are less likely to scores on the EAT-26 were twice as high as those occur in men.29 reported by men in Jordan, Libya, Palestine, and Syria with the difference being statistically However, a negative assessment of one’s body shape significant (p< 0.000).24 does not always correlate highly with body shape dissatisfaction and disordered eating Conversely, the proportion of women showing attitudes/preoccupation with food as another study disordered eating attitudes was higher in our study has found, which reported that 45.2% of participants compared to a study in Taiwan reporting a much with disordered eating attitudes did not have body lower number of women (10.4%) with these views.25 shape issues.30 Such difference may be explained by Studies from Algeria and Sharjah on disordered cultural factors or a less adverse influence by media eating attitudes between genders revealed non- on the population compared with the current study. statistical significance;26 while in Kuwait higher This contrasts with Bearman et al. (2006) which prevalence of disordered eating attitudes were found reported that parents play an influential role in in men (47.3%) than in women (42.8%). Studies in helping their children maintain positive attitudes Kuwait found more men than women were obese or about body shape and that those with good overweight than women, which may be one relationships with their family are less concerned explanation26,27.Apart from differing methodologies, with their body shape.31 the variances between the current findings and past studies may be due to different cultural backgrounds, The current results demonstrated statistical difference parental education, socioeconomic status, ethnicity between symptoms of eating disorders and gender and exposure to western media. with higher prevalence among women, which is supported by Eisenberg et al. (2011).32 Another study In the current study there was a high statistical supporting our results found that women are more difference between disordered eating attitude and prone to body shape dissatisfaction, therefore; they body mass index (p=0.002) with higher prevalence are more prone to developing disorders eating among obese and overweight subjects. This is attitudes.33 supported by Musaiger et al. (2013), which reported statistical difference between disordered eating Information on cultural factors that may contribute to attitudes and obesity in all countries except for disordered eating attitudes in Arab countries is Algeria and Palestine.24 Findings from a study in sparse. and further investigations are needed to find Vietnam, similarly, suggest there is a correlation the role of socio-cultural factors on the occurrence of between body mass index and disordered eating eating disorders in these countries. The lack of behavior; however, differed from our results in that knowledge and awareness regarding eating disorders the prevalence was higher in subjects whose BMI in Arab communities should be considered given there is limited research on the matter.
187 Eating Disorder Symptoms among Non-Consulting Medical Students at Suez Canal University
It is also important to understand how eating and unaccepted as a health professional by the society if body image problems present differently in different diagnosed as having an eating disorder. cultures and to identify potential risk factors for abnormal or unhelpful eating attitudes. For example, The current study has some limitations. Students a study conducted from Saudi Arabia showed that from the faculties of private universities could also low BMI, speaking a Western language, and having have been recruited because their students are likely lived in a Western country were the most significant from high socioeconomic backgrounds and their personal factors associated with dieting behavior. responses may have highlighted trends that could Small family size and higher parental education and have usefully informed the study. Further, participant better occupation were significant family factors attitudes toward eating disorder symptoms should associated with dieting. Results reflect some culture- have been assessed before the interview. The specific findings that are explained in cultural outcome measures used have not been standardized terms.34 for validity and reliability on Egyptian people and the use of their original scoring methods may be locally These disorders are rarely given attention in health inappropriate. education or in preventative and curative health programs. Therefore, adolescents with disordered Conclusion: Medical students are associated with eating attitudes may seek help from their family or high levels of stress that stands as a critically friends rather than from health professionals. The important causative factor of development of eating stigma of visiting a psychologist or counsellor is still disorders' symptoms. In addition, by interviewing apparent in the Arab world and can lead to self- or them a high percentage had symptoms of eating family treatment, especially among medical students disorders together with low self-esteem and who are more aware of stigma associated with dissatisfaction about body shape that was found seeking professional help and the idea of being mainly among women who are overweight or obese.
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MedGenMed [Internet]. WebMD/Medscape 23. Furnham A, Badmin N, Sneade I. Body Health Network; 2004 Sep 27 Image Dissatisfaction: Gender Differences 12. Stice E, Marti CN, Rohde P. Prevalence, in Eating Attitudes, Self-Esteem, and incidence, impairment, and course of the Reasons for Exercise. J Psychol [Internet]. proposed DSM-5 eating disorder diagnoses Taylor & Francis Group; 2002 Nov 2 in an 8-year prospective community study of 24. Musaiger AO, Al-Mannai M, Tayyem R, young women. J Abnorm Psychol [Internet]. Al-Lalla O, Ali EYA, Kalam F, et al. Risk 2013 May of disordered eating attitudes among 13. Machado PPP, Gonçalves S, Hoek HW. adolescents in seven Arab countries by DSM-5 reduces the proportion of ednos gender and obesity: A cross-cultural study. cases: Evidence from community samples. Appetite [Internet]. 2013 Jan Int J Eat Disord [Internet]. 2013 Jan 25. Tsai M-R, Chang Y-J, Lien P-J, Wong Y. 14. Hoek HW. Review of the worldwide Survey on eating disorders related thoughts, epidemiology of eating disorders. Curr Opin behaviors and dietary intake in female junior Psychiatry [Internet]. 2016 Nov high school students in Taiwan. Asia Pac J 15. Kessler RC, Berglund PA, Chiu WT, Deitz Clin Nutr [Internet]. 2011 AC, Hudson JI, Shahly V, et al. The 26. Musaiger AO, Al-Mannai M, Tayyem R, Prevalence and Correlates of Binge Eating Al-Lalla O, Ali EYH, Kalam F, et al. Disorder in the World Health Organization Prevalence of Overweight and Obesity World Mental Health Surveys. Biol among Adolescents in Seven Arab Psychiatry [Internet]. 2013 May Countries: A Cross-Cultural Study. J Obes 16. Agrawal P, Gupta K, Mishra V, Agrawal S. [Internet]. 2012 The Psychosocial Factors Related to 27. Al-Adawi S, Dorvlo ASS, Burke DT, Moosa Obesity: A Study Among Overweight, S, Al-Bahlani S. A survey of anorexia Obese, and Morbidly Obese Women in nervosa using the Arabic version of the India. Women Health [Internet]. Routledge; EAT-26 and “gold standard” interviews 2015 Aug 18 among Omani adolescents. Eat Weight 17. Dahlin M, Joneborg N, Runeson B. Stress Disord - Stud Anorexia, Bulim Obes and depression among medical students: a [Internet]. Springer International Publishing; cross-sectional study. Med Educ [Internet]. 2002 Dec 26 John Wiley & Sons, Ltd (10.1111); 2005 28. Ko N, Tam DM, Viet NK, Scheib P, Jun 1 Wirsching M, Zeeck A. Disordered eating 18. Garner DM, Rosen LW, Barry D. Eating behaviors in university students in Hanoi, disorders among athletes. Research and Vietnam. J Eat Disord [Internet]. BioMed recommendations. Child Adolesc Psychiatr Central; 2015 Clin N Am [Internet]. 1998 Oct 29. Nishizawa Y, Kida K, Nishizawa K, 19. Dotti A, Lazzari R. Validation and reliability Hashiba S, Saito K, Mita R. Perception of of the Italian EAT-26. Eat Weight Disord self-physique and eating behavior of high [Internet]. 1998 Dec school students in Japan. Psychiatry Clin 20. Garner DM, Garfinkel PE. The Eating Neurosci [Internet]. 2003 Apr Attitudes Test: an index of the symptoms of 30. Madanat HN, Lindsay R, Campbell T. anorexia nervosa. Psychol Med [Internet]. Young urban women and the nutrition 1979 May transition in Jordan. Public Health Nutr 21. Nasser M. Screening for abnormal eating [Internet]. 2011 Apr 12 attitudes in a population of Egyptian 31. Bearman SK, Presnell K, Martinez E, Stice secondary school girls. Soc Psychiatry E. The Skinny on Body Dissatisfaction: A Psychiatr Epidemiol [Internet]. 1994 Feb Longitudinal Study of Adolescent Girls and 22. Cooper PJ, Taylor MJ, Cooper Z, Fairbum Boys. J Youth Adolesc [Internet]. 2006 Apr CG. The development and validation of the 15 body shape questionnaire. Int J Eat Disord 32. Eisenberg D, Nicklett EJ, Roeder K, Kirz [Internet]. 1987 Jul NE. Eating Disorder Symptoms Among College Students: Prevalence, Persistence,
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الملخص
الخلفية :تتصف اضطرابات االكل باختالل مستمر لالكل او السلوك المنسوب لالكل والذي يودي تغيرات في اخذ او امتصاص الطعام والذي يودي اال اختالل الصحة الجسدية والنشاط النفسي االجتماعي . الغرض من تلك الدراسة استبيان انتشار أعراض اضطرابات األكل بين طالب كلية الطب الغير ساعين للمشورة الطبية لما تمثله تلك المجموعة من أهمية نظرا لتعرضهم للعديد من العوامل البيئية والنفسية المرتبطة بتلك المرحلة العمرية والضغوط النفسية المتعلقة بالدراسة. وقد قمنا بالدراسة على 211 طالب من طالب كلية الطب بجامعة قناة السويس من خالل استطالع قاموا باإلجابة عليه لتقييم مدى انتشار أعراض اضطراب األكل. وقد تم استبعاد كل من لديه تاريخ مرضى لمرض مزمن او مرض نفسي او الذين يتعاطون عقار ما للصرع او متعاطون المواد المخدرة. النتائج : تبين ان %45.9 لديهم اعراض اضطراب االكل ووجد فرق ذو دالالت احصائية واضحة بين الذكو واالناث في ر واال وجود أعراض اضطرابات األكل مع زيادة نسبة وجود تلك األعراض بين األناث، بين تقبل الطالب للشكل الجسدي وبين وجود أعراض اضطراب األكل مع زيادة نسبة عدم التقبل للشكل الجسدي واالنشغال بالتفكير باألكل والوزن بين االناث. كما وجد فرق ذو دالالت إحصائية واضحة بين الذكور واالناث في تقبل الشكل الجسدي وقلة الثقة بالنفس وخاصة بين االناث. وجد فرق ذو دالالت احصائية واضحة بين مقياس الوزن المثالي وتقبل الشكل الجسدي حيث تبين ان الطالب اصحاب الوزن الزائد يعانون من قله الثقة بالنفس وعدم تقبل للشكل الجسدي وخاصة بين االناث. كما وجد فرق ذو دالالت احصائية واضحة بين مقياس الوزن المثالي ووجود أعراض اضطراب األكل حيث وجدت بعض أعراض اضطرابات األكل مع أصحاب الوزن الزائد خاصة بين االناث ونوصى بزيادة العدد المقام عليه الدراسة مع تقديم جلسات توعية صحية داخل الكلية لنشر التوعية عن اضطرابات األكل واعراضها والمبادرة في العالج . .
Corresponding Author
Prof Khaled Abd El Moez, Professor of Psychiatry Faculty of Medicine, Suez Canal University, Ismailia - Egypt email: [email protected] [email protected]
Authors Professor Magda Fahmy, Professor of Psychiatry, Faculty of Medicine, Suez Canal University, Ismailia -Egypt
Prof Khaled Abd El Moez, Professor of Psychiatry Faculty of Medicine - Suez Canal University, Ismailia - Egypt
Dr Haydy Hassan, Assistant Professor of Psychiatry Faculty of Medicine, Suez Canal University, Ismailia -Egypt
Dr Sarah E. Bakr, Assistant Lecturer of Psychiatry, Faculty of Medicine, Suez Canal University, Ismail -Egypt
190 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (191 - 195) (doi-10.12816/0056870)
Bimaristan Arghun Al-Kamili in Aleppo, Syria: A Mental Hospital with Unique Architecture Designed to Meet Patient Need in Medieval Islam (1354 AD)
Mohammed T Abou-Saleh, Ihsan M Salloum
بيمارستان أرغون الكاملي في حلب، سوريا: مستشفى عقلي بهندسة معمارية فريدة في اإلسالم في العصور الوسطى ) 4531 م(
محمد طموح أبو صالح واحسان ّسلوم
Abstract
n this brief article, we report on Bimaristan Arghun Al-Kamili in Aleppo, Syria, the first mental hospital built on a site I that was a residential palace in medieval Islam (1354 AD). The bimaristan in Aleppo is a substantial stone building with quite complex plan standing on sound footings with a unique architecture. It is considered one of the most remarkable intact examples of Islamic bimaristans and the only one that was dedicated for the care of people with mental illness. It’s architectural and space design are harmonic to the needs of patients with courtyards, single rooms and gurgling fountains and is a testimony to the humane care that people with mental illness received in medieval Islam.
Key words: Architecture, Bimaristan, medieval Islam, mental illness
Declaration of interest: None
Introduction
The provision of bimaristans (derived from Persian or near, whether they are residents or foreigners, strong ‘bimar’ means "sick" and ‘stan’ means place) or or weak, low or high, rich or poor, employed or hospitals was a cardinal feature of the ‘Golden Age’ of unemployed, blind or signed, physically or mentally ill, medieval Islam, a period that witnessed remarkable learned or illiterate. There are no conditions of cultural and scientific renaissance traditionally dated consideration and payment; none is objected to or even from the 8th Century to the 14th Century. Moreover, the indirectly hinted at for non-payment. The entire service special provision for people with psychiatric conditions is through the magnificence of Allah, the generous one.’ is a remarkable aspect of the Islamic hospital. Unlike the 4 earlier Byzantine hospitals, the Islamic hospitals Naqvi described four medieval hospitals in Syria, two in invariably included wards for men and women who Damascus and two in Aleppo, including Bimaristan experienced mental illness. It is probable that the first Arghun Al-Kamili that is the most well preserved and the major hospitals established in Baghdad in the 9thCentury only one that was built for the care of people with mental AD treated those with mental illness. A bimaristan was illness. certainly founded by Ibn Tulun in Egypt in AD 872-73, The Bimaristan was built by Arghun Al-Kamili, the and it appears to have provided for people with mental Mamluk governor in Aleppo in 1354 AD on a site that 1 illnesses. was a residential palace. The hospital is a substantial The bimaristan was, in short, the cradle of Islamic stone building with a complex plan standing on sound medicine and the prototype for the modern hospital. footings and was dedicated for the care of people with They were not only critical to the dissemination of mental illness. medical learning, but formed the basis for hospitals and The Bimaristan is an example of Islamic architecture and medical schools, as we know them today. Sultan al- is remarkably intact covering 3900 square meters. The Mansur Qalawun had established the Cairo hospital that architectural plan (Fig. 1) unlike other bimaristans is carries his name in 1285 A.D. Their philosophy is best asymmetrical and complex as outlined by Gorini.5 The summarised by the policy statement of Cairo’s 8000 bed west side entrance opens into a vestibule with a large 2, 3 Mansuri Hospital: room for pharmacy and two rooms for outpatient clinic ‘The hospital shall keep all patients, men and women, and waiting area. The pharmacy was stocked with until they are completely recovered. All costs are to be medicines, herbs and opium. borne by the hospital whether the people come from afar
191 Bimaristan Arghun Al-Kamili in Aleppo, Syria: A Mental Hospital with Unique Architecture in Medieval Islam
Fountains were central to the architecture of the fountain, around which patient rooms were arranged. Bimaristan Arghun: Three courtyards each held a
Fig 1. Architectural design and space outline of Bimaristan Arghun Al-Kamili
The main central rectangular courtyard has a basin with rooms with one side open to the courtyard) in the north fountain bubbling outside with sides that support and south sides. The bigger south side iwan was used as flowerpots of basil (Fig 2). The quiet gurgling of the a stage for musicians, singers, and storytellers to fountains and scent of flowers calmed the nerves of the entertain the patients. patients. The courtyard has two iwans (outdoor vaulted
192 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (191 - 195) (doi-10.12816/0056870)
Fig 2. The main central courtyard of Bimaristan Arghun Al-Kamili https://www.google.co.uk/search?q=bimaristan+aleppo&tbm=isch&source=univ&sa=X&ved=2ahUKEwjalpXon8nnAhVL Q8AKHbwrB80QsAR6BAgJEAE&biw=1920&bih=962#imgrc=7dk7Vke379x_5MChromeHTML.OZAE5PEYRXKA5R LTHI7MTNHAVQ\Shell\Open\Command
The eastern part has three more secluded and disturbed patients; and a rectangular ward for the independent wards comprising a square ward with recovering patients. There were separate wards for windows equipped with strong iron bars for the very women and men, dining area and an exit for the well disturbed patients, including those affected by contagious patients on the southside. diseases; an octagonal ward with 12 single rooms (Fig 3) for the less
193 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (191 - 195) (doi-10.12816/0056870)
Fig 3. The octagonal ward with 12 single rooms with courtyard of Bimaristan Arghun Al-Kamili
The authors were involved with the architectural design The Bimaristan’s historical importance was highlighted of Naufar, considered one of the largest comprehensive in a delightful poem penned by Chris Ellery, Professor of addiction treatment and rehabilitation centers in the English at Angelo State University in Texas. Professor world that was established in Doha, Qatar in 2013. Ellery spent some time at Aleppo University teaching Naufar’s architectural design was modeled on historic English as Fulbright scholar. His visit to Bīmaristan Islamic hospitals and informed by modern functional Arghun inspired a long and moving poem that was design. Its name, ‘Naufar’, was found on a medical jar published in March 2006 in a collection titled All the unearthed at the site of Al-Nuri Hospital in Damascus Light We Live In. The poem is quite long. The first six founded in the 12th Century and remained functional for lines are reproduced below.4 seven centuries. The jar was used at the hospital to store herbal preparations of naufar lutea (waterlily) that were Bīmaristan Arghun used as a medicine. The wealth and benevolence of Arghun al Kāmilī
It is remarkable that the Bimaristan architectural design Provided here for the dangerous insane conforms to some features of modern psychiatric ward design that can reduce aggressive behaviors: single An asylum of darkness, water, bread, and stone. bedrooms, communal areas, gardens accessible to The walls have absorbed their wails, their stench, patients and higher daylight exposure.6 The therapeutic use of music, theater and storytelling and the exquisite Their outrageous laughter in a honeycomb of cells attention to environmental details, such as the gurgling fountains with their calming and serene sounds and the Like the chambered heart of Aleppo7 use of calming scents of plants provide a remarkable example for the humane treatment of people with mental illness in medieval Islam.
194 Abou-Saleh MT and Salloum IM
References
1. Dols MW. Insanity and its treatment in Islamic 5. Gorini R. Attention and care to the madness Society. Medical History. 1987; 31:1-14. during the Islamic middle age in Syria: the 2. Atiyeh M. Arab Hospitals in History. Annals of example of the Bimaristan Al-Arghun from Saudi Medicine. 1982; 2(2):121-126. princely palace to Bimaristan. JISHIM. 2002; 3. Tschanz DW. Bimaristans and the rise of 2:40-42. modern healthcare systems Aspetar Sports Med 6. Ulrich RS, Bogren L, Gardiner SK et al. J. 2017; 6:438-443. Psychiatric ward design can reduce aggressive 4. Naqvi NH. Four Medieval Hospitals in Syria. behaviour. J Environ Psychology 2018;57:53-66 Vesalius.2007;8(I):10-15. 7. Ellery C. All This Light We Live In. Panther www.MuslimHeritage.com Creek Press. 2006.
ّ الملخص الملخ
في هذا المقال الموجز، أوردنا ًتقريرا عن بيمارستان أرغون الكاملي في حلب،سوريا، أول مستشفى لألمراض العقلية تم بناؤه على موقع كان ًقصرا سكنيًا في العصر الذهبي لإلسالم في القرون الوسطى ) 4531 م(. البيمارستان هو مبنى حجري كبير مع خطة معمارية معقدة للغاية وتقف على أسس سليمة مع بنية فريدة نوعها.من يعتبر واحدا من أبرز األمثلة على تميّز هذه المشافي وهو البيمارستان المخصص لرعاية المرضى النفسيين. إن تصميمه المعماري متناسق مع احتياجات المرضى النفسيين مع األفنية والغرف المفردة ونوافير الماء شهادة على الرعاية اإلنسانية التي تلقاها المرضى النفسيين في العصور الوسطى.
Corresponding Author Mohammed T Abou-Saleh, Professor of Psychiatry, St George’s, University of London - UK
Email: [email protected]
Authors Prof Mohammed T Abou-Saleh, St George’s, University of London - UK
Prof Ihsan M Salloum, Department of Neuroscience, University of Texas Rio Grande Valley School of Medicine - USA
195 The Arab Journal of Psychiatry (0202) Vol. 31 No.2 Page (196) (doi-10.12816/0056871)
Book review I Lived Life
Unaiza Niaz
Starting with, as a young Muslim psychiatrist, reading Prof. Unaiza’s biography brought so much emotions, she is an inspiration for every woman who wants to outstand in her life and profession. The autobiography in 272 pages is different from autobiographies in general; it presents a scenery of photos and memories around the world, covering life in Pakistan, training abroad for one of the most active, passionate, and enthusiastic and achiever female Muslim psychiatrist
From her early life, Dr Unaiza lived a happy childhood, with rich brain empowering environment, her parents were extraordinary and that gave great predictions for the superiority and uniqueness of their children. Although she went through hard times losing close people to her heart, that never stopped her from giving and doing more effort to blossom. Looking at her professional life, she is a woman to look up-to. She definitely was born to become the psychiatrist she is now. She had many dreams and nothing stopped her reaching them. The photographs she added to her book gave it a special taste, I feel now as if I have met her and talked to her and it would be my pleasure to meet her in person one day.
Her book shows how humble she is, despite all what she has achieved and this reveals how a great “human” she is.
Reaching the part she talked about her marriage to her schoolmate and described it as “A fairy Tale” and the love you see in their eyes, just made it even more inspiring and sensational. Although Dr. Unaiza’s life may seem perfect to some, it had its ups and down; with achievements, love, friendships, losses and struggles. She was able to cope really well with faith and psychiatry helping her become resilient. Her blooming soul was able to look beyond lives’ challenges.
The book is a gallery from every corner around the world including the Middle East, she has been to many Arab countries and had visited Gaza strip in Palestine at bad times I thing this book should be read by all young psychiatrists, especially young female psychiatrists from the developing countries ,as it sets an example that everything is possible by hard work and dedication to the profession and humanities
In Sum, Dr. Unaiza is a Role Model.
Jana Zabalawi
Amman-Jordan
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