Psychiatric services in Bahrain: past, present and future.

The Kingdom of Bahrain is an archipelago of 33 islands, located in the Arabian Gulf, covering 2400 km2. The main island, Manama, is the nation's capital. The total population stands at 742 562, 62.3% of whom are local Bahrainis and the remaining 37.7% expatriates (Central Statistics Organisation Directorate, 1991). Bahrain first entered the historical stage around 3000 BC, and for almost 2000 years was the centre of the old Dilmun civilisation (Bibby, 1969). Dilmun was perceived as a sacred land by the Sumerians and Babylonians; it was a burial ground for their dead, and Bahrain has over 100 000 burial mounds each containing 200-250 bodies. In the old Babylonian epic of Gilgamesh, which antedates Homer's Iliad, Dilmun is described as a paradise where the worthy enjoy eternal life (Clarke, 1981).

Neurobiological correlates of panic disorder and agoraphobia.

Panic Disorder and agoraphobia offer considerable diagnostic and management challenges, particularly in general practice. We describe a typical case of panic disorder in a young adult. The recent advances in our understanding of brain functions can be used to explain to a certain extent the biologic basis of panic disorder. A hypothetical model integrating current views on panic disorder and agoraphobia has been proposed. The management principles including the role of cognitive therapy and pharmacotherapy have been discussed.

Factors associated with immediate relapse among Bahraini heroin abusers.

Demographic characteristics and factors associated with immediate relapse to heroin use among 40 male Bahraini heroin abusers were studied 1 week after discharge from the Drug and Alcohol Rehabilitation Unit in Bahrain. The mean age of the patients was 32.7 years, the age at which drug abuse began ranged from 12 years to 31 years, and the age range of regular use was 15-37 years. More than half the patients were single, unemployed, unskilled labourers with secondary-school education. The vast majority used heroin intravenously. Negative emotional states and drug-related cues were seen by the majority of the subjects as influential in their immediate relapse after discharge. Findings suggest that the treatment and rehabilitation unit in Bahrain should look into the issues of after-care.

Factors associated with immediate relapse among Bahraini heroin abusers

Demographic characteristics and factors associated with immediate relapse to heroin use among 40 male Bahraini heroin abusers were studied 1 week after discharge from the Drug and Alcohol Rehabilitation Unit in Bahrain. The mean age of the patients was 32.7 years, the age at which drug abuse began ranged from 12 years to 31 years, and the age range of regular use was 15-37 years. More than half the patients were single, unemployed, unskilled labourers with secondary-school education. The vast majority used heroin intravenously. Negative emotional states and drug-related cues were seen by the majority of the subjects as influential in their immediate relapse after discharge. Findings suggest that the treatment and rehabilitation unit in Bahrain should look into the issues of after-care

Psychiatric morbidity in primary care.

The prevalence of hidden psychiatric morbidity was assessed using the General Health Questionnaire (GHQ) and Hospital Anxiety Depression Scale (HAD). A total of 149 Bahraini patients aged > or = 16 years were selected randomly from those attending primary health care centres for problems other than psychiatric illness. The prevalence of psychiatric morbidity using GHQ was 45.1% (cut-off > or = 5) and 27.1% (cut-off > or = 9). Using the HAD scale, the prevalence was 44.4% (cut-off > or = 8) and 23.6% (cut-off > or = 11). Psychiatric morbidity was more common in women aged 50-55 years, in divorcees or widows and in lesser educated patients. Either instrument could be used to diagnose psychiatric illness.

Levels of disability among the elderly in institutionalized and home-based care in Bahrain.

We compared the levels of disability between the elderly admitted to an institution and those cared for at home. Of the 74 elderly people in this study, 56 were institutionalized and 18 were living at home. The Clifton Assessment Procedure for the Elderly (CAPE) was used to assess and compare the behavioural disabilities between the two groups. In addition to their younger age, the home-cared elderly were less incontinent, more social, better communicators and less confused than the institutionalized group, despite the fact that they had more physical disabilities with regard to bathing and walking.

Levels of disability among the elderly in institutionalized and home-based care in Bahrain

We compared the levels of disability between the elderly admitted to an institution and those cared for at home. Of the 74 elderly people in this study, 56 were institutionalized and 18 were living at home. The Clifton Assessment Procedure for the Elderly [CAPE] was used to assess and compare the behavioural disabilities between the two groups. In addition to their younger age, the home-cared elderly were less incontinent, more social, better communicators and less confused than the institutionalized group, despite the fact that they had more physical disabilities with regard to bathing and walking

Psychiatric morbidity in primary care

The prevalence of hidden psychiatric morbidity was assessed using the General Health Questionnaire [GHQ] and Hospital Anxiety Depression Scale [HAD]. A total of 149 Bahraini patients aged > or = 16 years were selected randomly from those attending primary health care centres for problems other than psychiatric illness. The prevalence of psychiatric morbidity using GHQ was 45.1% [cut-off > or = 5] and 27.1% [cut-off > or = 9]. Using the HAD scale, the prevalence was 44.4% [cut-off > or = 8] and 23.6% [cut-off > or = 11]. Psychiatric morbidity was more common in women aged 50-55 years, in divorcees or widows and in lesser educated patients. Either instrument could be used to diagnose psychiatric illness

OCD in Bahrain: a phenomenological profile.

Fifty patients with a primary diagnosis of Obsessive-Compulsive Disorder (OCD) were studied during the course of the year 1994 from a phenomenological point of view in order to delineate the various forms and contents of obsessions and compulsions. An attempt was made to highlight the frequency with which the different forms and contents occur. Six types of obsessions were identified: doubts, thoughts, fear (phobia), images, impulses and miscellaneous. Compulsive acts were classified into two types: yielding and controlling. The contents of obsessions could be classified into eight broad categories as relating to: dirt and contamination, germs, aggression, sex, religion, blasphemy, illness and indecisiveness. Thirty eight percent of the patients displayed obsessional thoughts related to dirt and contamination, while forty per cent showed religious and blasphemous obsessional thoughts and doubts. Fifty six percent of the patients had compulsions of which 36% were multiple, while 20% displayed only a single compulsion. The paper discusses these findings and emphasizes the role played by sociocultural and religious factors in shaping the character of an obsessional thought content.

Epidemiology of HIV and AIDS in Bahrain.

Between 1986 and 1996, 378 HIV cases were identified in Bahrain, of whom 51% were foreign nationals. Intravenous drug abuse was a major risk factor (38.8%) among Bahraini nationals, while transmission through sexual contact was more common (45.7%) among foreigners. Other well known risk factors were also represented in the two communities. The male to female ratio for the two communities were very different with 10:1 for nationals compared to 1:1.4 for foreigners. Among the AIDS defining manifestations, Pneumocystis carinii pneumonia was the commonest (50%), followed by tuberculosis (21%), oro-esophageal candidiasis, cryptosporidiosis and toxoplasmosis. Transmission through sex and maternal-foetus route could emerge as significant contributors in the spread of AIDS in Bahrain unless appropriate preventive steps are taken.

Heroin addiction in Bahrain: 15 years experience.

This study describes the development and outcome of a new treatment programme for the management of heroin addiction in Bahrain. The problem reached its peak in the early 1980s with several reported deaths and with the involvement of many disciplines in the overall response. In 1983, treatment of all addicts was restricted by law to the government psychiatric hospital. The newly established specialized drug unit was overwhelmed by the number of patients seeking treatment. The lack of sufficient resources and suitably trained staff forced the unit to adopt an outpatient maintenance therapy approach for most of its clients. In 1987, a new comprehensive treatment programme was introduced that relies on a clear philosophy, safe detoxification (using objective scales for withdrawal manifestations) rather than maintenance therapy, followed by psychological and social rehabilitation. A national committee for drug addiction was formed and an intensive programme of education was started at all levels. The results indicate an initial increase at inpatient level but a marked drop of outpatient attendance. The use of the Opioid Objective Withdrawal Manifestations Scale (OOWMS) revealed that only a small number of our patients developed moderate or severe signs of withdrawal that required detoxification, and the rate of dispensed controlled medication was reduced by 99%. The effect of this approach is discussed, with special reference to the need for a collaborative effort from all disciplines in planning, implementing, continuously evaluating and modifying the national programmes for handling the serious problem of addiction.

HIV antibodies among intravenous drug users in Bahrain.

A 12-month study was conducted to identify risk factors for human immunodeficiency virus (HIV) infections among intravenous drug users (IDU) attending drug rehabilitation clinic of the Psychiatric Hospital, Manama, Bahrain. Patients provided demographic and behavioural information based on a questionnaire. Two hundred and forty male IDUs participated in the study on voluntary basis. The seroprevalence of HIV was 21.1 per cent. The presence of HIV antibody was associated with educational status, frequency of injecting drugs and needle sharing.

PIP: During January 1st to December 31st, 1991, a total of 242 male intravenous drug users (IDUs) attending the drug rehabilitation clinic of the Psychiatric Hospital, Manama, Bahrain, for treatment were interviewed by trained interviewers using a structured questionnaire to gather information on age, sex, marital status, nationality, religion, income, educational status, history of drug use, sexual practices, and blood and blood product transfusions. The sera were tested for antibodies to HIV-1 and HIV-2 using a second generation enzyme linked immunoassay (ELISA) and confirmed by Western Blot. 51 (21.1%) IDUs were positive for anti-HIV-1 by ELISA as confirmed by Western blot. 5 of 62 (8.1%) cases with college education were positive for HIV compared with 35 of 138 (25.4%) with secondary level of education and 11 of 42 (26.2%) with primary or lower level of education (p 0.01). Among the behavioral characteristics, only needle sharing showed an association of borderline statistical significance (p = 0.06). Frequency of intravenous drug use and sexual practice showed 95% confidence limits close to 1.0 (the null value) and higher limits of 4.61 and 2.71, respectively. Only educational status showed a significantly lower risk of HIV positivity in persons with college education with an odds ratio of 0.25. Stepdown logistic regression analysis was performed on 219 IDUs using the five potential predictor variables: age, education, intravenous drug use, needle sharing, and sexual practice. This showed that sexual practice was not an independent predictor variable of HIV positivity. Hence a second logistic regression analysis was carried out using age as a continuous variable and education, intravenous drug use, and needle sharing as dichotomous variables. Data on all 242 drug users were available for this analysis. Only education and needle sharing emerged as significant predictor variables. The odds ratios were: education 0.250 and needle sharing 2.46.

Diagnostic agreement in psychiatry. A comparative study between ICD-9, ICD-10 and DSM-III-R.

A random sample of 100 new patients referred consecutively to the psychiatric hospital was assessed using the Arabic translation of the PSE. An abstract form was designed to include all PSE scores as well as the necessary extra data to make ICD-9, ICD-10, and DSM-III-R diagnoses. Kappa correlation was calculated for inter-rater and intra-rater reliability. Overall reliability and reliability of each major psychiatric diagnosis were compared between the three systems. The use of the PSE helped in achieving good agreement between Arab psychiatrists for all the three systems, but ICD-10 was found to have the highest reliability figures both for three-digit and four-digit psychiatric diagnoses.

Utilisation of psychotropic drugs in patients of the long stay ward.

A survey of the prescribing of psychotropic drugs was carried out at the Psychiatric Hospital of Bahrain. This retrospective study on 60 inpatients of the Long Stay Ward revealed a man:woman ratio of 2.7. 91% of the men and 88% of the women were over 40 years old. 44 of the 60 patients had a diagnosis of schizophrenia, the rest had dementia, depression, schizoaffective disorders, drug-induced psychosis, general paralysis or Huntington's chorea. 95% of patients received antipsychotic drugs. Thioridazine was the most common drug followed by chlorpromazine. The mean number of drugs/patient was 1.7, with 41.7% of patients receiving only 1 drug. Tardive dyskinesia was observed in 11 patients and 9 experienced varying degrees of tremor. The findings confirm that psychiatric illness treated by psychiatrists need not lead to polypharmacy. As a consequence, its treatment may be less likely to result in adverse reactions than when patients are treated by general practitioners.

Problem-based curriculum: outcome evaluation.

The College of Medicine and Medical Sciences of the Arabian Gulf University (CMMS-AGU) in Bahrain is, in its innovativeness, unique in the region in that a problem-based strategy is used in the planning and implementation of the curriculum. The first batch of graduates have completed their internship programme in the different countries of the region. This paper presents an evaluative study of the outcome of the programme in relation to the institutional goals. Assessment of the intern's performance in clinical competence, interpersonal relations, self-directed learning, and their relative standing vis-à-vis graduates from other schools was done by supervisors. The findings of the study confirm the relative merits of the problem-based curricular strategy in medical education.