Mental and physical comorbidity in an Arab primary health care setting.

BACKGROUND: There are no published studies on the comorbidity of common mental conditions (anxiety, depression, and somatization) and physical illnesses in the Arab world. Our aim was to estimate the prevalence of common mental conditions comorbid with physical illnesses among primary care attenders in Kuwait, and the sociodemographic characteristics associated with this comorbidity. METHODS: The Patient Health Questionnaires for somatization, anxiety and depression (PHQ-SAD) were administered to a representative sample of 1046 attenders (M: F = 429: 617; mean age 37.6, SD 12.7) seen in primary care clinics in Kuwait. Based on well-established cut-off scores, the presence and severity of three mental conditions -depression, anxiety, and somatization-was ascertained; physical diagnoses were ascertained by the attending physicians. RESULTS: Of 1046 respondents, 442 (42.3%) had at least one mental condition and 670 (64.1%) had a physical illness diagnosis, viz.: diabetes mellitus (248/670 = 37.0%), hypertension (229/670 = 34.2%), asthma (82/670 = 12.2%), non-chronic physical illnesses (63/670 = 9.4%), or heart disease (48/670 = 7.2%), with 34.4% (360/1046) having mental-physical comorbidity. Male: female ratio for the 670 subjects was 287: 383. The unadjusted odds ratio (OR) for having a mental condition in those with a physical illness vs. those without a physical illness was 4.16 (95% C.I. = 3.12, 5.55). Comorbidity was associated with older age, being divorced or widowed, a lower level of education, and poorer living conditions. Regardless of the physical illness, the most frequent comorbid mental disorder was somatization. The prevalence and severity of mental conditions were associated with the number of physical illnesses. CONCLUSION: As has been reported in other parts of the world, somatization, anxiety, and depression are highly prevalent among primary care attenders in Kuwait and they are typically comorbid with physical illness. Strategies for their prevention and treatment need to take into consideration their association with physical illness and social disadvantage.

Nurses' Attitude Towards Patients with Mental Illness in a General Hospital in Kuwait.

INTRODUCTION: Stigma and discrimination have been reported to cause unnecessary delay in mentally-ill patients seeking help, which adversely affects a patient's outcome. The attitude of health care professionals has been described as being, even more, negative than that of the general public, which worsens the prognosis for patients with a mental illness. AIMS: The aim of this study was to describe the attitude of nurses toward mentally-ill patients in a general hospital. METHODS: All the nurses in the hospital were administered a 40-item Community Attitudes Toward the Mentally-Ill (CAMI) questionnaire which determines whether the mentally-ill are viewed as "inferior;" deserve "sympathy;" perceived as a "threat" to society or "acceptable" if residing in community dwellings. The analysis of variance was performed to determine association of the four subscales with the individual characteristics, including age, gender, education, qualification type, position held, contact and contact type. RESULTS: Out of a total of 990 nurses, 308 (31%) completed the CAMI questionnaire. The mean scores for the authoritarian (2.85), benevolent (3.66), social restrictiveness (2.97) and community mental health ideology (3.48) subscales reflected a negative attitude of nurses toward mentally-ill patients. The direct or indirect utilization of the mental health facilities resulted in significantly higher authoritarian and lower benevolence scores, indicating a positive attitude change in this group of nurses. CONCLUSION: Despite the small size and selective nature of the sample, the nurses' negative attitude toward the mentally-ill patients provides useful baseline data for further large-scale studies and underscores the need for psychoeducation of different health care professionals, including nurses.

Prevalence of psychiatric morbidity in the primary health clinic attendees in Kuwait.

BACKGROUND: A substantial proportion of primary clinic attendees suffer from psychiatric disorders and many of them are neither recognized nor adequately treated by primary clinic physicians. OBJECTIVES: To determine the point prevalence of, and identify risk factors for, depression, anxiety, and somatisation disorder in the primary health clinics in the country. METHOD: The Physical Health Questionnaires (PHQ-SADs), were administered to a randomized sample of 1046 primary clinic attendees in all the five governorates of the country over a 5-month period. The descriptive data were computed with chi-square tests while the association of demographic characteristics with psychiatric disorders was determined with the logistic regression test. RESULTS: 42.7% of the our patients suffered from psychiatric disorders including depressive (22.9%), anxiety (17.7%), and somatization (33.4%) disorder. Comorbidity between the three disorders was found in 20.4% of the sample; 11% had two and 10.4% had all three disorders. The Kuwaiti nationals, female gender, older age group subjects and those with lower level of education were more likely to suffer from psychiatric disorder. LIMITATIONS: The inter-rater reliability may have affected the results as large number of physicians were responsible for administering the questionnaires. Moreover, the study did not include eating and substance-abuse disorders and the findings were limited to detection of somatization, depression, and anxiety disorders. CONCLUSIONS: In order to ensure timely provision of appropriate treatment, the primary care physicians need adequate information on different forms of presentation, and basic front line treatment, of the common mental disorders at the primary care level.

The mental health needs of immigrant workers in Gulf countries.

The oil-rich member states of the Gulf Cooperation Council (GCC) attract large numbers of migrant workers. The reported rates of psychiatric morbidity among these migrant workers are higher than among nationals, while the mental health services in the GCC countries remain inadequate in terms of both staff and service delivery. The multi-ethnic origin of migrants poses considerable challenges in this respect. The development of mental illness in migrants, especially when many of them remain untreated or inadequately treated, results in their premature repatriation, and the mentally ill migrant ends up facing the same economic hardships which led to migration in the first place. The availability of trained interpreters and transcultural psychiatrists, psychologists and social workers should make psychiatric diagnoses more accurate. Suitable rehabilitation services are also needed.

Introducing the Objective Structured Clinical Examination (OSCE) in the undergraduate psychiatric curriculum: evaluation after one year.

OBJECTIVE: The Objective Structured Clinical Examination (OSCE) was introduced in undergraduate psychiatry clerkship in 2008. The authors studied the effect of OSCE on the students' performance. METHODS: The ″short case″ (SC) and ″oral examination″ (OE), two of the five components of the previous assessment format, were replaced with the OSCE. Results were compared with those of the 2007 students. RESULTS: The introduction of the OSCE had little impact on the overall scores, but the 2007 students had significantly higher scores on the essay examination and long case, whereas the 2008 group had significantly higher scores on the OSCE (versus the OE for the 2007 group). In comparing the top 10 scoring students from the two classes, the 2007-year students had significantly higher overall scores, both on end-of-course tests and the annual examinations. In particular, the scores for the OSCE exams for the 2008 class were significantly lower than the scores for the OE in the 2007 class. CONCLUSION: The higher scores on OSCE in Year 2008 suggest that students performed better on clinical skills and professional development than recall on the factual-knowledge domains. Since the changes were introduced in the year 2008, the comparison can best be regarded as qualitative, and it is probably too early to judge the impact of the OSCE. Further studies to determine validity of the OSCE are needed.

Correlates of quality of life in an Arab schizophrenia sample.

OBJECTIVES: We focused on the subjective quality of life (QOL) indicators of the Lancashire quality of life profile, European version (LQoLP-EU) in a Kuwaiti schizophrenia sample. The objectives were: First, to assess the reliability and validity of the questionnaire. Second, to highlight the patients' QOL profile, in comparison with the results of the European five-nation study. Third, to examine the association of perceived needs for care, caregiver burden, service satisfaction, self-esteem and psychopathology, with three indices of global QOL: total life satisfaction or perceived QOL (PQOL) score; general wellbeing (GW) and Cantril's ladder (CL). METHOD: Consecutive outpatients in stable condition and their family caregivers were interviewed with the LQoLP, and measures of needs for care, service satisfaction, caregiver burden and psychopathology. RESULTS: There were 130 patients (66.1%m, mean age 36.8). Majority of the patients (56%) felt satisfied with the nine domains of life investigated, and 44.6% felt "averagely" happy. Their clinical severity was moderate (BPRS-18 = 44.4). In exploratory factor analysis (FA), the original domains were mostly replicated. Reliability indices were significant (>0.7). In stepwise regression analyses, the associations of PQOL were more in number and mostly different from those of GW and CL. The correlates of PQOL included, social unmet need (8.1% of variance), staff perception of unmet need (10.3%), general satisfaction with services (11.3%), burden of caregiver supervision (3.7%), self-esteem (2.9%) and positive symptoms (2.6%). Of the nine life domains, health was the most important correlate of GW and CL, indicating the centrality of health status in judgments of subjective QOL. In secondary FA, GW and CL loaded together, but separately from life domains, implying that these are separable parts of the subjective wellbeing construct. CONCLUSION: The profile of QOL scores was mostly similar to European data. The significant multivariate association with patients/staff perceptions of unmet need for care and service satisfaction indicate the usefulness of staff professional development and service improvement in outcome; and imply that promotion of QOL should be an institutional objective. Our finding about the relationship between the three global measures of QOL has added support to the emerging QOL theory.

Coping with infertility among Kuwaiti women: cultural perspectives.

BACKGROUND: Although previous studies conducted in western countries have reported that psychological factors are part of the experience of infertility, no study has assessed this relationship in Arab women. AIMS: To examine psychological distress among Kuwaiti women with infertility problems and explore the perceived causes of infertility. METHODS: An Arabic version of the Hospital Anxiety and Depression Scale (HADS) was used to examine the psychological status of 120 Kuwaiti infertile women and an age-matched sample of 125 healthy pregnant women as a control group. RESULTS: Compared with age-matched pregnant control sample. The infertile women exhibited a significant higher psychopathology in all HADS parameters in the form of tension, hostility, anxiety, depression, self-blame and suicidal ideation. The illiterate group attributed the causes of their infertility to supernatural causes such as evil spirits, witchcraft and God's retribution, while the educated group blamed nutritional, marital and psychosexual factors for their infertility. Faith and traditional healers were considered as the first treatment choice among illiterate women, while the educated women opted for an infertility clinic for treatment. Childlessness results in social stigmatization for infertile women and places them at risk of serious social and emotional consequences. CONCLUSIONS: The prevalence and severity of psychological distress in this sample of infertile Kuwaiti women indicates the appropriateness of referring these patients for psychological evaluation. Successful programmes in dealing with infertility in Kuwait need to include the establishment of a community based intervention strategy to educate people about infertility and to give guidelines for treatment options.

Psychiatric morbidity among housemaids in Kuwait. III: Vulnerability factors.

BACKGROUND: Housemaids are a relatively homogenous immigrant subgroup in terms of their gender; ethnic origin; and socio-cultural, educational and occupational background. Psychiatric morbidity among housemaids is two to five times higher than the native female population. AIMS: To determine the possible pre-immigration risk factors for prospective psychiatric breakdown among the housemaids. METHODS: The sample consisted of all the housemaids (N = 197) hospitalised during the two-year study period. The controls comprised all the newly arrived housemaids (N = 502). The measures obtained included demographic characteristics and previous history of physical illness, psychiatric illness, hospitalisation and family history of psychiatric disorder. RESULTS: More than a quarter of the hospitalised group broke down within one month of their arrival. The hospitalised group had a significant excess of Sri Lankan housemaids; non-Muslims; those with less than four years of education and those with a previous history of physical illness, psychiatric illness or hospitalisation. CONCLUSIONS: A number of potential risk factors results in premature repatriation of housemaids on mental health grounds. Preventive measures involving recruitment procedures and pre-departure orientation courses are needed to minimise the expatriate failure among the housemaids.