Primary care psychiatry: pertinent Arabian perspectives.

There is substantive evidence of significant psychiatric morbidity among primary care patients, mainly in the form of anxiety and depressive disorders. A careful critical approach is essential for ensuring the cultural relevance, validity and reliability of the psychiatric screening instruments used to identify such morbidity. Most psychiatric morbidity among primary care patients passes undetected by the primary care practitioners. This will inevitably lead to unnecessary investigation and medication and the continuation of suffering for patients. Comorbidity and physical presentation in most instances contribute significantly to failure to detect psychiatric disorders. To deal with this problem of hidden psychiatric morbidity, carefully designed educational and training programmes need to be tailored to address the particular weaknesses and needs of primary care doctors.

Primary care psychiatry: pertinent Arabian perspectives

There is substantive evidence of significant psychiatric morbidity among primary care patients, mainly in the form of anxiety and depressive disorders. A careful critical approach is essential for ensuring the cultural relevance, validity and reliability of the psychiatric screening instruments used to identify such morbidity. Most psychiatric morbidity among primary care patients passes undetected by the primary care practitioners. This will inevitably lead to unnecessary investigation and medication and the continuation of suffering for patients. Comorbidity and physical presentation in most instances contribute significantly to failure to detect psychiatric disorders. To deal with this problem of hidden psychiatric morbidity, carefully designed educational and training programmes need to be tailored to address the particular weaknesses and needs of primary care doctors

Reliability, validity, and factor structure of the Arabic version of the 12-item General Health Questionnaire.

The aim was to examine the psychometric properties of the Arabic 12-item General Health Questionnaire in a sample of university students. A sample of 157 university students was screened using this questionnaire and the Hopkins Symptom Checklist-90. A standardized clinical interview using SCID was conducted on a subset of screened students. Reliability, validity, and factor analysis of the questionnaire were evaluated. Using factor score discrimination between cases and noncases was also evaluated. The Arabic version of the GHQ-12 proved to be reliable as indicated by Cronbach alpha of .86. The best balance between sensitivity and specificity was found at the General Health Questionnaire cut-off point of 15/16: at this threshold, sensitivity was .88 and was paired with a specificity of .84. Principal component analysis with varimax rotation identified three factors, namely, Factor A (general dysphoria), Factor B (lack of enjoyment), and Factor C (social dysfunction). Factors A and C discriminated between clinically distressed and clinically nondistressed subjects. The General Health Questionnaire-12 as a whole is a reliable and valid screening tool in university settings.

A comparison of the validity of two psychiatric screening questionnaires: the Arabic General Health Questionnaire (AGHQ) and Self-Reporting Questionnaire (SRQ-20) in UAE, using Receiver Operating Characteristic (ROC) analysis.

This study compared the ability of the Arabic General Health questionnaire (AGHQ) and Self-Reporting Questionnaire (SRQ-20) to screen ICD-10 psychiatric disorders in an Arab community in Al Ain, United Arab Emirates. Standardised psychiatric assessments of subjects using the Composite International Diagnostic Interview (CIDI) were carried out. The Receiver Operating Characteristic (ROC) analysis was used to determine validity indices for the AGHQ and SRQ-20. For the AGHQ, sensitivity, specificity and area under the curve (AUC) were 86, 85 and 93% respectively, while for the SRQ-20, validity indices were 83, 83 and 90% respectively. Overall performance of the AGHQ was significantly better than the SRQ-20, especially in males and those under the age of 30 years. We conclude that both questionnaires are valid screening instruments in an Arab community in the UAE.

Somatized mental disorder among primary care Arab patients: I. Prevalence and clinical and sociodemographic characteristics.

The aims of this study were to estimate the prevalence of somatized mental disorder (SMD) in comparison to psychologized mental disorder (PMD) among a sample of primary health care (PHC) Arab patients, and to investigate the clinical and sociodemographic characteristics of SMD. The first stage of study was conducted by general practitioners (GPs), using the 12-item General Health Questionnaire (GHQ-12). The second stage was carried out by a psychiatrist using the Clinical Interview Schedule (CIS) and an inquiry schedule. Specific operational criteria were used to identify SMD and PMD. The estimated prevalence rate of SMD among the total screened sample was 12%. SMD patients constituted 48% of the psychiatric patients identified, whereas, for the PMD group, this figure was 42%. Educational level was significantly lower in the SMD group. Headache, backache, and abdominal pain were the most commonly presented somatic symptoms. The symptoms pursued a chronic and persistent course and most patients experienced multiple symptoms. The most common ICD-10 psychiatric diagnoses among both SMD and PMD patients were mixed anxiety and depressive disorder, generalized anxiety disorder, and mood and adjustment disorders. Recurrent depressive disorder and dysthymia were significantly more prevalent in the PMD group. The severity of psychiatric illness identified was greater among psychologizers than the somatizers of mental disorder.

The rationale, development and reliability of a new screening psychiatric instrument.

BACKGROUND: This paper describes the rationale, development, reliability and validity of a new screening psychiatric instrument. METHOD: The instrument comprises 26 items that tap the cardinal features of main psychiatric categories as defined by ICD-10 and DSM-IV. These items were adapted from various structured and semi-structured diagnostic interviews that yield ICD-10 and DSM-IV psychiatric diagnoses. After a training course, 12 trainees and the trainer rated blindly the 26 items on 45 subjects (22 with psychopathology and 23 without). Inter-rater reliability coefficient (Kappa) was estimated between trainees and the trainer on each item of the instrument. The total score on the new instrument was then correlated with the total score on the Arabic Self Reporting Questionnaire (SRQ-20) and the Arabic version of the General Health Questionnaire (GHQ) in a random sample from the general population (n = 365). Logistic regression was utilised to estimate the power of the total score on the new instrument in discriminating between cases and non-cases as classified by the SRQ-20. RESULTS: Excellent levels of agreement (Kappa > 0.80) were found for all items except for obsession (Kappa = 0.65) and for depressed mood (Kappa = 0.70). Moderate correlations were found between the total score on the new instrument and total score on SRQ-20 (r = 0.69) and the total score on the Arabic GHQ (r = 0.7). The new instrument correctly classified 89% of subjects into cases and non-cases. CONCLUSIONS: The results of this study indicate that the new instrument is a highly reliable and valid screening instrument. The authors are now investigating its test-retest reliability and its procedural validity.

Psychiatric screening among Type II diabetic patients: Validity of the General Health Questionnaire-12.

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Pediatric injuries in an Arabian Gulf country.

OBJECTIVE: To determine the common types of injuries among children (0-14 years) in Al-Ain, United Arab Emirates (UAE). DESIGN: A retrospective descriptive hospital based study. SETTING: Al-Ain Medical District, Al-Ain Teaching Hospital, UAE. SUBJECTS: All patients aged 0-14 years seen at Al-Ain Teaching Hospital for injuries during 1994. RESULTS: The number of children with an injury who attended the emergency room was 16,518 (69.9% boys; 30.1% girls). Injury rates were higher among non-UAE nationals. The most frequent reason for hospital admission was poisoning (41%). In the age group < 5 years, the most common causes were falls, blunt trauma, and burns or scalds, while in the 5-9 year and in 10-14 year groups the most frequent cause was road traffic accidents (RTAs). Fights and sporting injuries were also seen frequently in children aged 10-14 years. CONCLUSION: Injury rates were higher in boys and RTAs mostly occurred in children over 10 years. The majority of cases (56%) occurred among non-UAE nationals, who are usually of lower socio-economic status. RECOMMENDATION: Injuries can be prevented by developing strategies to substantially increase the profile of health education to parents and children, by educating policy makers and health professionals, and by environmental modification, legislation, and enforcement. The UAE government can play an important part by establishing and supporting injury prevention programs with these goals.

The primary care anxiety and depression (PCAD) scale: a culture-oriented screening scale.

The construction of a screening scale for states of anxiety and depression among primary health care (PHC) patients is described. Most of the scale items were selected from a pool of items chosen from two international screening scales which were validated locally, namely the Self-Reporting Questionnaire (SRQ-20) and the Hospital Anxiety and Depression (HAD) Scale. A validity study of a new sample of PHC patients indicated that the scale provided a valid measure of anxiety and depressive states, and was closely correlated with the psychiatrist's clinical judgement. The scale correlated more strongly with the psychiatrist's clinical judgement than the general practitioners' assessments. Two cut-off points were established, one of which is more appropriate for clinical use and the other for prevalence estimation. The former threshold of the scale could be used to alert the busy general practitioner to the possibility that clinically significant anxiety or depression may be present.

The diagnostic stability of ICD-10 psychiatric diagnoses in clinical practice.

This study examines the stability of ICD-10 diagnoses of patients admitted to Al Ain (United Arab Emirates) inpatients psychiatric unit during the period from November 1993 to August 1995. Diagnostic stability is a measure of the degree to which diagnoses remained unchanged at a later hospital admission. One hundred and seven patients were admitted more than once during this period, accounting for 168 readmissions. High levels of diagnostic stability were found for ICD-10 Fl-psychiatric disorders (100%), F2-schizophrenia (87%), F3-bipolar disorders (87%) and F3-depressive disorders (73%). A poor level of stability was found for patients with neurotic, stress related and adjustment disorders (F4), ranging from zero for somatoform disorders to 50% for generalized anxiety and panic disorders. Poor levels of stability were also found for other psychoses (excluding schizophrenia and affective psychoses) and personality disorders. We conclude that the introduction of ICD-10 as a formal diagnostic system has greatly improved the temporal stability of the most commonly encountered psychiatric disorders (ICD-10 Fl to F3 disorders), confirming the construct validity of those psychiatric disorders. Further investigations are required to evaluate the diagnostic stability of neurotic and other psychotic disorders.

Sexual dysfunction among type II diabetic men: a controlled study.

This was a primary health care (PHC) study aiming at the investigation of the prevalence and nature of sexual dysfunction among a sample of type II diabetic men, in comparison with the control groups of hypertensive men and apparently healthy men with no chronic medical illness. Subjects were assessed by PHC physicians using a sexual dysfunction semistructured questionnaire and a questionnaire designed for medical history and sociodemographic data. Clinical assessments for peripheral vascular disease and peripheral neuropathy were carried out for the diabetic group only. The estimated high prevalence rate of sexual dysfunction among the diabetic group (89.2%) was significantly greater than the hypertensive group (43.6%), and the apparently healthy group (16.7%). The commonest clinical presentations of sexual dysfunction among the diabetic men were impaired morning and spontaneous erections, erectile weakness, and ejaculatory disturbances. Lesser common presentations were reduced sexual interest and complete erectile failure. There were no significant associations between the sexual dysfunction and clinically obvious physical complications of diabetes, or factors that might affect sexual functioning (i.e., alcohol or drug misuse or marital disharmony). However, the validity of these results is questioned due to the small numbers used for statistical analysis.

Validation of the Arabic versions of the thirty- and twelve-item General Health Questionnaires in primary care patients.

BACKGROUND: The aim of this study was to investigate the validity of the Arabic versions of the GHQ-30 and GHQ-12 in a sample of primary health care (PHC) patients in Al Ain, United Arab Emirates. METHOD: A randomly selected sample (n = 157) of patients attending a PHC centre in Al Ain was screened using the Arabic version of the GHQ-30, the first 12 items of which constitute the GHQ-12. Then a standardised clinical interview using the Clinical Interview Schedule (CIS) was conducted with all screened patients. The receiver operating characteristic analyses of the Arabic versions of both GHQ-30 and GHQ-12 were compared and their correlation coefficients with the weighted total score of the CIS and the overall severity rate were estimated. Discriminant functional analysis was also performed to assess the discriminatory powers of both the GHQ-30 and GHQ-12. RESULTS: Using the simple Likert scoring method, the best cut-off point of the GHQ-30, that balances between sensitivity and specificity, was 31/32 with a sensitivity of 0.83 and specificity of 0.83, and that of the GHQ-12 was 12/13 with a sensitivity of 0.83 and specificity 0.80. The total discriminatory powers of the GHQ-30 and GHQ-12 were approximately 93 and 86%, respectively. Both versions of the GHQ were found to have a significant concurrent validity. CONCLUSION: The Arabic versions of both GHQ-30 and GHQ-12 are valid psychiatric screening instruments, with almost similar performance, for Arabic-speaking PHC patients.

Retesting the validity of the Arabic version of the Hospital Anxiety and Depression (HAD) scale in primary health care.

The Arabic version of the Hospital Anxiety and Depression (HAD) scale was retested and cut-off points determined in a sample of 217 patients attending a primary health care centre in Al Ain, United Arab Emirates (U.A.E.). Subjects were screened using the HAD scale and all patients were then interviewed by a single consultant psychiatrist. The scale scores were assessed against the psychiatrist's clinical evaluations. The study furnished evidence that the Arabic version of the HAD scale is a valid instrument for detecting anxiety and depressive disorders in primary health care settings. Spearman rank correlations of all items of the scale were significantly above zero. The butterflies item of the anxiety subscale had the lowest correlation coefficients. The overall Cronbach alpha measures of internal consistency were 0.7836 and 0.8760 for anxiety and depression, respectively. The cut-off points that produced a balanced combination of sensitivity and specificity appropriate for referral to a psychiatric facility by the general practitioner were 6/7 for anxiety and 3/4 for depression. Almost all other similar studies have determined a single cut-off point for both subscales of the HAD. This study also indicated that the HAD depression subscale is more consistent and more predictive than the HAD anxiety subscale. Moreover some of the problems arising from applying psychiatric research instruments across cultures are highlighted by this study.

Minor psychiatric morbidity in primary health care: prevalence, nature and severity.

The Clinical Interview Schedule (CIS) (Goldberg et al. 1970) was applied in a study investigating the prevalence rate, nature and severity of minor psychiatric disorders among U.A.E. nationals attending a primary health care centre in Al Ain, United Arab Emirates (U.A.E.). The total prevalence rate of minor psychiatric morbidity, among the group of attenders who were interviewed, was 27.6%. The morbidity was higher among females (31.9%), than males (20.3%). The highest morbidity rate among the entire sample occurred among the 35-54 year age group. The commonest diagnoses encountered were neurotic depression (55%), anxiety-depressive states (13.3%) and anxiety states (11.7%). The distribution of diagnostic entities was similar among males and females except for anxiety-depressive states which were more common in females. The prevalence of neurotic depression and anxiety-depression states were highest in the middle age group, while anxiety states were highest among the young age group. The overall severity rate (OSR) among the identified cases was found to be ranging between mild and moderate severity.

Identifying anxiety and depressive disorders among primary care patients: a pilot study.

One stage case-identification method, using the Arabic Version of the Hospital Anxiety and Depression Scale (HAD) was applied in a pilot study for estimating the prevalence of depressive and anxiety disorders among a group of Saudi primary care attenders. The validity of the Arabic Version of the HAD scale was previously tested and found valid with high sensitivity and specificity. The total prevalence rate of depression was 17% and that of anxiety was 16%. Seven percent of the sample suffered both depression and anxiety i.e. the total percentage of patients with depression, anxiety or both was 26%. Higher morbidity of depression was recorded among females and a higher morbidity of anxiety among male patients.

Validity study of the Hospital Anxiety and Depression Scale among a group of Saudi patients.

The Arabic version of the HAD scale was validated in a sample of 50 Saudi patients. The scale scores were assessed against the principal author's clinical evaluations. Spearman correlations of all items of the scale, except for one, were statistically significant. The non-significance of one item was probably related to the way it was translated into Arabic. The study furnished evidence that the Arabic version was a reliable instrument for detecting states of anxiety and depression in Saudi patients in a primary health care setting.

Acute schizophrenic episode: is it a culture-related syndrome?

The patients in this study, from Abu Dhabi, United Arab Emirates, presented with an acute psychotic syndrome preceded by stressful life events. The patients represented only three nationalities, although many people from other nationalities labour under similar stressful conditions. It is suggested that cultural factors play a role in the aetiology of this particular syndrome.