Tarek Okasha

Mental health services in the Arab world

This paper summarizes the current situation of mental health services in the Arab world. Out of 20 countries for which information is available, six do not have a mental health legislation and two do not have a mental health policy. Three countries (Lebanon, Kuwait and Bahrain) had in 2007 more than 30 psychiatric beds per 100,000 population, while two (Sudan and Somalia) had less than 5 per 100,000. The highest number of psychiatrists is found in Qatar, Bahrain and Kuwait, while seven countries (Iraq, Libya, Morocco, Somalia, Sudan, Syria and Yemen) have less than 0.5 psychiatrists for 100,000 population. The budget allowed for mental health as a percentage from the total health budget, in the few countries where information is available, is far below the range to promote mental health services. Some improvement has occurred in the last decade, but the mental health human resources and the attention devoted to mental health issues are still insufficient.

A Psychiatric Study of Nonorganic Chronic Headache Patients

Nonorganic chronic headache is a common, challenging presentation in clinical practice. The aim of this study was to investigate the frequency of associated psychiatric psychopathology, personality disorders, or traits. In addition, the study attempted to investigate possible relationships of nonorganic chronic headache with alexithymia, locus of control, and pain perception. Psychiatric pathology, personality traits, and pain profiles were examined in 100 randomized patients with chronic headache lacking an obvious organic basis, and they were compared with 100 subjects, 50 with headache of a known organic cause and 50 seemingly healthy persons, by using structured clinical interviews. Somatoform pain disorder was diagnosed in 43% of the nonorganic and 20% of the organic headache group. Nine percent of the former group had major depression, 16% had dysthymia, and 8% had both. In the organic group, 56% had no psychiatric disorder and 20% had somatoform pain disorder. Seventy-seven percent of the patients in the nonorganic pain group had personality disorders, mostly of the mixed and multiple types, compared with 24% of the organic headache patients. The study sample was more alexithymic than the other groups (in 65% of subjects) and had a culturally influenced locus of control and a pain profile characterized by dramatization, vagueness, lower pain threshold, and lower pain tolerance. The nonorganic chronic headache patients showed a high prevalence of somatoform, depressive, and other forms of psychiatric disorders. The high frequency of personality disorders, mostly the mixed and multiple types, the high alexithymic pattern, and low pain threshold and tolerance in the study group should be taken into consideration in the evaluation and management of nonorganic headache patients.

Comorbidity of axis I and axis II diagnoses in a sample of Egyptian patients with neurotic disorders

Neurosis and personality disorder (PD) are two of the most used but least clarified and understood terms in psychiatry. The separation of PD by the American Psychiatric Association in DSM-III and -IV as a discrete axis of classification has been a major advance in psychiatric nosology. Also with the advent of DSM-III and its multiaxial system, it was recognized that both PD and clinical syndromes can coexist, and in some cases this coexistence may have implications on treatment response and prognosis. This study was performed on 200 neurotic patients in an attempt to investigate possible correlations between various neurotic subcategories and personality types. Our results confirm that PD and personality abnormality are significantly higher in neurotic patients than in controls and need to be considered in diagnostic assessment. Some comorbidity was shown between borderline PD and somatoform disorder; compulsive PD and obsessive-compulsive disorder (OCD), and generalized anxiety disorder (GAD); and avoidant PD and phobia. However, our data failed to show a correlation between the presence of an additional PD and particular neurotic symptomatology. It seems that the association between neurotic disorders and PD should not be taken to indicate a direct causative relationship. It is likely that personality is just one of the predisposing factors that influence the individual response to psychological trauma and determine the form of neurosis. The most prevalent PD was found to be PD NOS, followed by borderline, compulsive, avoidant, and finally histrionic PDs. The term, multiple PD, should be given substance to characterize the diagnosis as a disorder, rather than leaving it at its current status of what seems to be a nondistinct clinical picture. Extensive research has to be undertaken in an attempt to decide which specific PDs most deserve to be included in the official nomenclature.

Notes on mental disorders in Pharaonic Egypt

A few authorities have attempted to summarize our knowledge of ancient Egyptian medicine. A medical perspective was presented by Prof. Ghalioungui at the Faculty of Medicine of Ain Shams University in Cairo.~ He posed various questions: what was the nature of that medicine? Was it sorcery or rational practice? What was valid in it? What influence did it exert on the medicine of the Greeks who claimed to have borrowed from it? His book also

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.

Characterization of Substance Abuse Patients Presenting for Treatment at a University Psychiatric Hospital in Cairo, Egypt

ObjectivesThis study was designed to assess the patterns and severity of drug and alcohol problems of a group of patients presenting for treatment at a substance abuse treatment program in Egypt. MethodsA total of 268 patients with drug/alcohol problems were interviewed at the Ain Shams Institute of Psychiatry in Cairo over a period of 1 year (2005 to 2006) using the Arabic version of the Addiction Severity Index, 5th edition. One hundred sixty patients were interviewed during the intake session and the other 108 were interviewed within the first week of their admission to the treatment program. ResultsIn the past 30 days before admission to the treatment program, 30% of the patients reported medical problems, 38% reported employment problems, 9% reported illegal activities, 62% reported serious conflicts with their families, 37% reported serious conflicts with other people, and 64% reported one or more psychiatric symptoms. The major drug problem was heroin for 52% of the patients, other opiates for 23%, and other drugs, including alcohol, for the remaining 25% of the patients. ConclusionsOpiates were the major drug problem for most of our patients, representing 75% of cases, whereas barbiturates, stimulants, hallucinogens, and inhalants were rarely found to be the major drug problem for patients. Injection was a significant problem for heroin users that needs to be addressed in treatment programs.

Psychiatric disorders among a sample of internally displaced persons in South Darfur

Background: The violent armed conflict in Darfur has been ongoing for years getting the attention of human rights activists and mental health professionals. Aim: The aim of this study was to assess psychiatric disorders in a sample of internally displaced persons (IDPs) in South Darfur. Method: A cross-sectional observational study, as a part of the ‘Darfur Campaign’ organized by Arab Federation of Psychiatrists, assessing psychiatric disorders in a sample of internally displaced women using the Structured Clinical Interview for DSM-IV (SCID-I) (clinical version). Results: Up to 25.7% of participants had lost a close family member or more in the violent clashes. Psychiatric diagnoses were found in 62.2% of the participants. The most frequently reported was post-traumatic stress disorder (PTSD) reaching 14.9%, followed by depression 13.5% (among which 2.7% with psychotic features), while comorbid PTSD and depression reached 8.1% of participants. Patients with psychiatric diagnoses had an older age (36.6 years) (p = .024). Suffering from a psychiatric disorder was found to be associated with losing a family member in the conflict (p = .015), being 35.6% in patients with psychiatric diagnoses compared to 10.3% in those without losing a family member in the conflict (odds ratio (OR) = 4.7, 95% confidence interval (CI) = 1.25–18.28). Conclusions: This study used a standardized tool for diagnosing psychiatric morbidity among refugees in Darfur to give as much as possible an actual description of the problems and psychiatric morbidity caused by human-made disasters. This study can help to lead to a more detailed and specific mental health service program much needed by this population.

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 bipolar disorder among patients undergoing a major depressive episode: Report from the BRIDGE study in Egypt

BACKGROUND To estimate the frequency of bipolar disorder (BPD) among patients with a major depressive episode (MDE) and elucidate clinically-relevant factors predictive of bipolarity. METHODS We evaluated 306 patients undergoing a MDE at facilities throughout Egypt. Patients were given the HCL-32 R2 questionnaire to assess the presence of manic/hypomanic symptoms; those scoring >14 were considered bipolar. We also investigated how various clinical criteria for bipolarity changed the incidence of bipolar diagnosis. Finally, we examined if demographics, psychiatric history, clinical characteristics, and the incidence of co-morbid conditions differed significantly between bipolar and unipolar patients. RESULTS The positive screen rate for BPD based on HCL-32 R2 scores was 62.2% (188/302). However, only 26% (80/306) of patients had been diagnosed previously as bipolar. In contrast, when DSM-IV criteria were used, only 13.7% (42/306) of patients qualified as bipolar. A number of factors were highly predictive of bipolarity including: seasonality, number of past mood episodes, history of psychiatric hospitalization, mixed state, and mood reactivity. Of the comorbidities examined, only borderline personality disorder occurred at a higher rate in bipolar than in unipolar patients. LIMITATIONS Participating centers were not randomly selected and there could be a bias if only psychiatrists having specific interest in BPD were included. CONCLUSIONS The positive HCL-32-R2-based bipolar screen rate of 62% suggests that a substantial proportion of patients with a MDE may have BPD. Further, a number of factors in the patients psychiatric history as well as clinical aspects of the episode itself may signal an increased likelihood of bipolarity.

Overview of the family structure in Egypt and its relation to Psychiatry

Abstract The family is the basic unit of any society and culture. The concept, structure, and function of the family unit vary considerably across different cultures; however, its role continues to be imperative to the development of individuals and their psychological make-up. All societies have a concept of ‘family’, its relative importance, structure, and functions; however, this varies according to the particular culture. In the Arabic culture, as well as other collectivistic cultures, the extended family is often regarded as the basic unit. The family is the foundational and basic social unit that fosters the stability, well-being and sustainability of society. The quality of family relationships shapes and influences the social, psychological, and biological development and functioning of its members. This may be especially relevant to individuals with mental health problems. The people of ancient Egypt valued family life highly, and this is the case even now. They treasured children and regarded them as a great blessing. If a couple had no children, they would pray to the gods and goddesses for help. They would also place letters at the tombs of dead relatives asking them to use their influence with the gods. The importance of family has not changed dramatically even though the structures are beginning to. In this paper we highlight changes in family set-up and the state of family therapy in Egypt.