Hisham Ramy

Correlates of psychiatric co-morbidity in a sample of Egyptian patients with bipolar disorder

BACKGROUND AND OBJECTIVES Bipolar disorder (BD) is a complex, chronic mood disorder involving repeated episodes of depression and mania/hypomania. Two thirds of patients with bipolar disorder have a comorbid psychiatric condition. This study aims to assess the prevalence of Axis I diagnosis with its socio-demographic and clinical correlates among a sample of Egyptian patients with bipolar disorder. METHODS Out of the 400 patients who were enrolled in the study from number of governmental and private psychiatric hospitals in Cairo, Egypt, 350 patients diagnosed with bipolar affective disorders (157 females and 193 males) with age ranging from 18 to 55years were selected. Patients were assessed using the Structured Clinical Interview for DSM-IV Axis I disorder (Research Version) (SCID-I). RESULTS Prevalence of psychiatric comorbidity among BD patients was 20.3% (71 patients) among which 63 patients (18%) had comorbid substance abuse and 8 patients (2.3%) had comorbid anxiety disorders. LIMITATIONS The study was limited by its cross sectional design with some patients having florid symptoms during assessment, not having a well representative community sample. This might have decreased the reliability and prevalence of lifetime psychiatric comorbidity due to uncooperativeness or memory bias. The study group was composed of bipolar patients attending tertiary care service which limits the possibility of generalizing these results on different treatment settings. CONCLUSIONS Substance abuse followed by anxiety disorders was found to be the most common psychiatric comorbidity. Family history of psychiatric disorders and substance abuse as well as current psychotic features were highly correlated with comorbidity.

Impact of personality temperaments and characters on academic performance and specialty selection among a group of Egyptian medical graduates

Background: The relationship between personality temperaments, academic achievement and specialty interest is important because of its implications in career counseling. Aim: To assess the effect of personality on academic performance and career selection and to study the impact of some sociodemographic factors on academic achievement and career choice of medical graduates. Methodology: A total of 436 medical graduates of Ain Shams medical school were approached, out of which 331 participated. They were given a sociodemographic questionnaire, and the Temperament and Character Inventory–Revised (TCI-R; 240) for personality construct; they had to answer questions about academic achievement, ranking, scores and choice of medical specialty. Results: Novelty seeking (NS1, NS2 and NS3) and self-transcendence (ST1 and ST2) were correlated with graduation ranking, (r = .2, p = .00; r = .15, p = .009; r = .16, p = .005; r = .12, p = .003; r = .14, p = .02; r = .17, p = .004; r = .13, p = .03, respectively), that is, lower NS and ST had better academic outcome. Only high school score was associated with better achievement (p = .00). In specialty selection, females were significantly overrepresented in pediatrics and clinical pathology, whereas males were significantly predominating surgical specialties except for obstetrics and gynecology (p = .00). Students choosing patient-centered specialties had higher reward dependence (RD), persistence (PS) and cooperativeness (C); those choosing clinical pathology had highest harm avoidance (HA), whereas those choosing radiology had lowest HA and those choosing surgery had significantly higher self-directedness (SD3). Conclusion: Personality impacts academic achievement and specialty choice with other factors as gender and previous scholastic performance.

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

Background: A large number of mentally ill patients prefer to visit non-medical practitioners such as traditional healers because of the confidence in the system, affordability and accessibility of the service. This may lead to delay in seeking psychiatric services and has prognostic impact. Aim: To assess the rate of bipolar affective disorder (BAD) patients seeking traditional healers, the sociodemographic and clinical correlates of those patients. Methods: We assessed 350 patients with BAD after confirmation of diagnosis with Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I) research version and assessment of functioning with Global Assessment of Functioning scale. They were assessed for percent, rate and timing of seeking traditional healers. Results: In all, 40.8% sought traditional healers, with 34.9% more than four times. Of those, 62.2% were before seeking psychiatric services and 37.8% after. Lower educational level, less impairment of functioning and presence of hallucinations were significant correlates. Conclusion: This study shows that most of the patients suffering from mental illness prefer to approach faith healers first, which may delay entry to psychiatric care and thereby negatively impact the prognosis of BAD. This highlights the importance of mental health education and developing a positive collaborative relationship with traditional healers.

Screening for ADHD in a Sample of Egyptian Adolescent School Students.

Objective: To screen for ADHD in a sample of Egyptian adolescent students, and study the distribution of different subtypes of ADHD, associated comorbidities, and sociodemographic correlates. Method: A total of 925 adolescents were randomly selected and screened by the Conners-Wells’ Adolescent Self-Report Scale–Short form (CASS:S), and potential cases were further assessed by the Kiddie Schedule for Affective Disorders and Schizophrenia–Present and Lifetime versions (K-SADS-PL). Results: A total of 87 students (9.4%) had potential ADHD diagnosis with evident preponderance in boys (13.8%, n = 58) than in girls (5.8%, n = 29) with a ratio of 2:1 (p = .000, χ2 = 17.328). The hyperactive-impulsive subtype comprised the majority of cases (54.7%, n = 41). Psychiatric comorbidity was invariably present (85.1%, n = 74). Nearly half the cases had poor academic achievement (43.7%, n = 34). Positive correlates included family history of psychiatric disorders, the order of birth, and parental disharmony. Conclusion: ADHD is prevalent in Egyptian adolescents and is associated with high psychiatric comorbidity and a pronounced effect on academic performance.

Use of second-generation antipsychotics in the acute inpatient management of schizophrenia in the Middle East.

Background Management of acute psychotic episodes in schizophrenic patients remains a significant challenge for clinicians. Despite treatment guidelines recommending that second-generation antipsychotics (SGAs) should be used as monotherapy, first-generation antipsychotics, polypharmacy, and lower than recommended doses are frequently administered in clinical practice. Minimal data exist regarding the use of SGAs in the Middle East. The objective of this study was to examine the discrepancies between current clinical practice and guideline recommendations in the region. Methods RECONNECT-S Beta was a multicenter, noninterventional study conducted in Egypt, Kuwait, Saudi Arabia, and the United Arab Emirates to observe the management of schizophrenic patients who were hospitalized due to an acute psychotic episode. Patients underwent one visit on the day of discharge. Demographic and medical history, together with data on antipsychotic treatment and concomitant medication during the hospitalization period and medication recommendations at discharge were recorded. Results Of the 1,057 patients, 180 (17.0%) and 692 (65.5%) received SGAs as monotherapy and in combination therapy, respectively. Overall, the most frequently administered medications were given orally, and included risperidone (40.3%), olanzapine (32.5%), and quetiapine (24.6%); the doses administered varied between countries and deviated from the recommended guidelines. Upon discharge, 93.9% of patients were prescribed SGAs as maintenance therapy, and 84.8% were prescribed the same medication(s) as during hospitalization. Conclusion Current clinical practice in the Middle East differs from guideline recommendations. Patients frequently received antipsychotics in combination therapy, by various methods of administration, and at doses above and below the recommended guidelines for the management of their acute psychotic episodes.

Risk factors for attention deficit hyperactivity disorder in a sample of Egyptian adolescents: a case–control study

BackgroundAttention deficit hyperactivity disorder (ADHD) is a commonly diagnosed behavioral disorder of childhood and adolescence that represents a public health problem with long-term adverse effects on academic, vocational and social development. ObjectivesThe aim of this study was to assess some putative risk factors that may be associated with ADHD in Egyptian adolescents compared to matched healthy controls. Methods925 preparatory school students were randomly selected from private and public schools in Eastern Cairo. We used the Conners-Wells’ Adolescent Self report Scale Short form (CASS: S), as a screener for ADHD students. Those scoring >65 were considered potential ADHD cases, and were assessed by the kiddie Schedule for Affective Disorders and Schizophrenia present and lifetime version (K-SADS-PL) for establishing a diagnosis then were further evaluated by: Wechsler Intelligence Scale (WISC) to assess intellectual abilities. School performances prepared by teachers were recorded. Students were asked to complete a Designed Questionnaire fulfilling data including family background. A local scale for social class classification was administered. We finally compared the ADHD group with a matched healthy control group. Results9.4% (N=87) of the selected sample had ADHD. The diagnosis of ADHD was significantly associated with low socioeconomic state (8.0%), first sib order (42.5%), quarrelsome home atmosphere (21.8%). One third of the ADHD sample was exposed to cold family relations and criticism with a highly significant association (P<0.001); a similar percentage was exposed to parental aggression and abuse but displayed significant statistical association P<0.05. Students with ADHD were significantly exposed to postnatal complications (23%), and had more joint (20.7%) and chest (26.4%) diseases; their school performance and IQ scores displayed very highly significant lower values than the control group. Risk factors associated with ADHD were family history of psychiatric illness, history of head trauma, first sib order, delayed sphincter control, epilepsy and parental disharmony. ConclusionOur findings highlighted important differences between ADHD subjects and healthy students in several aspects as psychosocial adversities and physical health and delineated significant associations between ADHD and some putative risk factors. These findings would serve as a useful guidance tip for early management of ADHD adolescents and their families who display those risk factors.

Impact of a culturally adapted behavioural family psychoeducational programme in patients with schizophrenia in Egypt

Abstract Objective: To study the effect of a culturally adapted, structured family intervention on symptom severity, medication attitudes and knowledge, social functioning and quality of life in patients with schizophrenia. Methods: Thirty subjects with schizophrenia were selected to receive 14 sessions of a culturally adapted behavioural family psychoeducational programme (BFPEP). Another 30 subjects received standard treatment as usual (STU) for 6 months. Pre- and post-intervention outcomes were assessed using the Positive and Negative Syndrome Scale (PANSS), Drug Attitude Inventory 10-item scale (DAI-10), Quality of Life Scale (QLS) and Social Functioning Questionnaire (SFQ). Results: There was a no significant difference between BFPEP and STU at baseline on all measures. There was a significant difference (p < .05) between pre- and post-treatment scores for BFPEP on all measures, a significant difference (p < .05) between pre- and post-treatment scores for STU on all measures (favouring pre-treatment scores) and a significant difference (p < .05) favouring BFPEP over STU on all measures post-treatment. Conclusions: These results demonstrate the feasibility and effectiveness of implementing family therapy psychoeducational interventions in different cultural settings, with relatively minor modifications. This may have implications for mental health policy makers to make available such programmes for patients and mental health professionals.

Risk factors influencing severity of attention deficit hyperactivity disorder in a sample of preparatory school students in Cairo

Background: Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood psychiatric disorders. Severity of symptoms is associated with more behavioral problems, poor academic performance, and persistence of symptoms into adulthood. Methods: To examine the clinical and social correlates that may be identified as risk factors associated with ADHD severity in a sample of adolescent ADHD school students. A total of 925 students were recruited from two public and two private schools from eastern Cairo. They were interviewed using Conners-Wells Adolescent Self-Report—short version (CASS-S); students scoring more than 65 were further interviewed with Kiddie Schedule for Affective Disorders and Schizophrenia—present and lifetime version (K-SADS-PL) to confirm the diagnosis, then Conners-Wells Adolescent Self-Report—long version (CASS-L) to assess severity and Wechsler Intelligence Scale for Children (WISC) to ascertain intellectual ability. Results: About 10.3% of cases were severe, 5.7% were moderate, and 83.9% were mild. Severity was significantly associated with female gender, psychiatric comorbidity, family problems, conduct symptoms, and poor anger management. Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV) hyperactive–impulsive type was the only predictive factor of ADHD severity. Conclusions: The diagnosis of hyperactive–impulsive subtype may predict the severity of ADHD symptoms.

Pattern of Obsessive Compulsive Symptoms among Patients with Bipolar-I Disorder

Background: Clinicians have observed the occurrence of obsessive and/or compulsive symptoms within the course of bipolar disorder. However the pattern of their occurrence is not clearly delineated. This study aimed to explore this pattern. Method: A cross sectional study. All patients were assessed by the Structured Clinical Interview for DSM-IV (SCID I) to diagnose bipolar disorder (BD) and comorbid obsessive compulsive (OC) symptoms. The symptom severity was assessed by Young Mania Rating Scale (YMRS), Beck Depression Inventory II (BDI-II), Yale-Brown Obsessions and compulsions Scale (Y-BOCS). Results: Sixty two patients were classified into two groups: BD comorbid with OC symptoms (BD-OC) and BD with no comorbidity (BD). High rates of OC symptoms in BD patients (38.7%) with higher educational level in the BDOC group, and higher rates of unemployment were noticed among patients of BD–OC group. The smoking was more prevalent in BD group than BD-OC group. The most common among BD-OC subjects were contamination, religious and aggressive obsessions and cleaning/washing and counting compulsions. Limitations: The prevalence rates are not to be generalized because of the small size of the sample. Most of the history was taken from the patients and their relatives depending on their memory. More experimental study designs about the effectiveness of different types of management strategies would be beneficial to the patients. Conclusion: Bipolar Patients with comorbid Obsessive and/or Compulsive symptoms showed higher educational levels, unemployment, greater functional impairment, and less smoking. Most common obsessions were contamination, religious and aggressive obsessions, cleaning and counting compulsions.

The extent and correlates of same class versus multiclass polypharmacy among Egyptian psychiatric inpatients: a cross-sectional study

ObjectiveTo examine the frequency and patterns of polypharmacy use among Egyptian psychiatric inpatients and to assess the influence of patients’ characteristics on polypharmacy prescription. MethodsA cross-sectional study conducted in the Institute of Psychiatry, Ain Shams University, during a period of 6 months. Medical records of patients were reviewed upon discharge. Demographic data, diagnosis, the duration of the illness, the number of episodes, psychotropic medications prescribed on discharge, and the duration of hospital stay were obtained. Polypharmacy was operationally defined as the concurrent use of two or more psychotropic medications in the same patient for treating symptoms of his/her illness. ResultsA total of 187 patients were included in the study, and 78.1% were discharged on polypharmacy. Diagnosis was the only significant factor associated with polypharmacy (P=0.003). The number of drugs prescribed was positively correlated to the number of episodes (P=0.001), the duration of hospital stay (P=0.04), and the duration of the illness (P=0.05). Multiple antipsychotics were prescribed to younger patients (P=0.008) with psychotic disorders (P=0.001) and with a longer duration of hospitalization (P=0.05). Multiple antidepressants were prescribed more to patients with depressive disorders (P=0.03) with a longer duration of the illness (P=0.05) and a higher number of episodes (P=0.01). ConclusionPolypharmacy is a common clinical practice in psychiatric inpatients influenced by a complex interplay of several factors. Clinical diagnosis seems to be the most consistent factor influencing polypharmacy prescription. There is a need for more pragmatic approaches to improve clinical practice and reduce the use of polypharmacy.