Co-Morbidity between Major Depression and Schizophrenia: Prevalence and Clinical Characteristics.

BACKGROUND: The aim of this study was to explore the co-morbidity between Major Depressive Disorder (MDD) and Schizophrenia (SZ) among a large number of patients describing their clinical characteristics and rate of prevalence. SUBJECTS AND METHODS: A cohort-study was carried out on 396 patients affected by MDD and SZ who consecutively attended the Department of Psychiatry, Rumeilah Hospital in Qatar. We employed the World Health Organization - Composite International Diagnostic Interview (WHO-CIDI) and the Structured Clinical Interview for DSM-5 (SCID-5) for diagnoses. Patients were also grouped in MDD patients with and without co-morbid SZ (MDD vs MDD/SZ) for comparisons. RESULTS: A total of 396 subjects were interviewed. MDD patients with comorbid SZ (146(36.8%)) were 42.69±14.33 years old whereas MDD without SZ patients (250 (63.2%)) aged 41.59±13.59. Statistically significant differences between MDD with SZ patients and MDD without SZ patients were: higher BMI (Body Mass Index) (p=0.025), lower family income (p=0.004), higher rate of cigarette smoking (p<0.001), and higher level of consanguinity (p=0.023). Also, statistically significant differences were found in General Health Score (p=0.017), Clinical Global Impression-BD Score (p=0.042), duration of illnesses (p=0.003), and Global Assessment of Functioning (p=0.012). Rates of anxiety dimensions (e.g.: general anxiety, agoraphobia, somatisation, etc.), mood dimensions (e.g.: major depression, mania, oppositional defiant behaviour, Bipolar disorder), Attention Deficit Hyperactivity Disorder, psychotic and personality dimensions were higher among MDD with SZ patients than MDD without SZ. CONCLUSION: This study confirms that MDD with SZ is a common comorbidity especially among patients reporting higher level of consanguinity. MDD/SZ comorbidity presents unfavourable clinical characteristics and higher levels of morbidity at rating scales.

Schizophrenia and co-morbid obsessive - compulsive disorder: Clinical characteristics.

BACKGROUND: Psychiatric co-morbidity is a common condition, partly due to the overlap of symptoms in the categorical diagnosis of mental disorders. The co-occurrence of schizophrenia (SZ) and obsessive compulsive disorder (OCD) is a common and challenging co-morbid condition. Also, the relationship between SZ and OCD remains unclear. AIM: The aim of this study was to describe the co-morbidity of obsessive-compulsive disorder (OCD) among schizophrenia (SZ) patients and compare clinical characteristics of schizophrenia patients with versus without comorbid OCD. SUBJECTS AND METHODS: A cohort-study was carried out on 396 patients enrolled between November 2011 to June 2014 at the Department of Psychiatry, Rumeilah Hospital in Qatar. We employed the WHO Composite International Diagnostic Interview (WHO-CIDI), and Structured clinical interview for DSM-5 (SCID-5) for diagnoses, the Yale-Brown Obsessive Compulsive Scale Symptom Checklist for scoring OCD. Patients were grouped in SZ patients with and without comorbid OCD (SZ-OCD vs SZ). RESULTS: 396 subjects were interviewed. Age of SZ-OCD patients was 42.69 ± 14.33 (years old) whereas SZ patients without OCD ranged 41.59 ± 13.59 years old. There were statistically significant differences in clinical characteristics between SZ with and without OCD : age (p = 0.010), BMI (body mass index; p = 0.011), education (p = 0.033), employment (p = 0.019), cigarette smoking (p = 0.039), sheesha smoking (p = 0.008), and prevalence of consanguinity (p = 0.043). In particular, the rate of consanguinity in the current generation was 31.8% [95% CI = 29.1-34.7]. Also, there were statistically significant differences at Hamilton Depression score, General Health Score, Clinical Global Impression- Score, duration of illnesses, and Global Assessment of Functioning (p < 0.001). The results show that anxious, mood and psychotic dimensions rated higher among SZ - OCD ones than SZ only patients. CONCLUSION: This study confirms that SZ-OCD is a common co-morbidity and prevalence of SZ OCD is higher among patients reporting a degree of consanguinity. Even if this condition is under-recognized in clinical practice, it may significantly change SZ presentation and outcome since psychopathological dimensions report higher scores in the co-morbidity sample.

Lithium in the episode and suicide prophylaxis and in augmenting strategies in patients with unipolar depression.

BACKGROUND: Depressive disorders are a leading cause of the global burden of disease and are associated with high recurrent often continuing morbidity and high excess mortality by suicide and cardiovascular disease. Whilst there are established, effective and cost-effective treatments for depression, their long-term management is often neglected: there is continuing controversy over the case of need for long-term treatment including lifelong treatment and safety issues. OBJECTIVE AND METHODS: In this narrative review, we critically examine the evidence for the effectiveness and safety of lithium salts in the long-term management of unipolar depression. We refer to existing recent international guidelines as well as the scientific literature selectively and against the background of our longstanding experience with patients suffering from unipolar depression who are often under treated or inappropriately treated. RESULTS AND DISCUSSION: According to many studies mostly dating back to the 1970/1980s, lithium is efficacious in the prophylaxis of unipolar depression particularly depression with melancholia and delusional depression and showing a clearly episodic course. Also the efficacy of lithium maintenance treatment following recovery by ECT has been clearly shown. Moreover, convincing evidence exists that lithium has added value and benefit for its unique anti-suicidal effects as well as reducing mortality by other causes. The anti-suicidal effect has been convincingly demonstrated in bipolar as well as in unipolar patients. Nevertheless its use in the management of patients with unipolar depression has not been properly recognized by a majority of textbooks and guidelines. Whilst it has been well considered as an effective treatment for depression that has not responded to antidepressants as an adjunct treatment, also called augmentation, it has been much less recommended for the prevention of recurrent episodes of unipolar depression. One of the reasons for this neglect is the blurring of the diagnosis "unipolar depression" by modern diagnostic tools. Lithium will hardly work in a patient with "unipolar depression spectrum disease". CONCLUSIONS: We conclude that lithium is an effective prophylactic treatment for carefully selected patients with unipolar depression and is safe when prescribed in recommended doses/plasma lithium levels and with regular, careful monitoring. We propose that lithium prophylaxis can be indicated in patients with unipolar depression and that the occurrence of 2 episodes of depression within 5 years is a practical criterion for starting lithium prophylaxis particularly in severe depression with psychotic features and high suicidal risk. Furthermore, an indication might be considered especially in unipolar patients in whom a bipolar background is suspected. In some cases, lithium prophylaxis may be recommended after a single episode of depression that is severe with high suicidal risk and continued life-long.

Mental health of refugees: global perspectives.

Refugees have high rates of mental health morbidity as a result of conflict. However, their needs for mental healthcare and psychosocial support are often unmet, despite the efforts of professional and humanitarian organisations. The war refugee crisis is a global challenge that needs a global solution. We call on all governments, regional and international organisations to take responsible humanitarian actions to intervene and support people affected by these disasters and for all humanity to unite against the forces of injustice and degradation. The thematic papers in this issue report on the Syrian crisis from a variety of perspectives.

Greece and the refugee crisis: mental health context.

The recent influx of refugees and immigrants to Greece has coincided with the ongoing and deteriorating financial crisis. This situation does not allow the Greek authorities to provide help to the desired extent. Yet, the church, local communities, medical societies and non-governmental organisations are offering good psychosocial support. In parallel with support for refugees it is important to provide support for the citizens of the host country. The rich countries of northern Europe should help the poorer countries of southern Europe cope with the refugees. A number of important declarations on refugee mental health and related issues have been produced recently, including the Anti-war Declaration of Athens.

The prevalence and burden of psychiatric disorders in primary health care visits in qatar: too little time?

BACKGROUND: Psychiatric disorders including anxiety, depression, somatization, obsessive compulsive, and bipolar disorders are recognized as causing the biggest burden of disease worldwide. AIM: In this study, we aimed to assess the prevalence and burden of common mental disorders at Primary Health Care Centers (PHCC) using the World Health Organization Composite International Diagnostic Interview (WHO-CIDI) in the Qatari population, aged 18-65 who attended Primary Health Care (PHC) settings. DESIGN: A prospective cross-sectional study conducted during November 2011 to October 2012. SETTING: Primary Health Care Centers of the Supreme Council of Health, Qatar. SUBJECTS: A total of 2,000 Qatari subjects aged 18-65 years were approached; 1475 (73.3%) agreed to participate. METHODS: Prevalence and severity of International Classification of Disease-10 disorders were assessed with the WHO-CIDI (Version 3.0). RESULTS: Of the 1475 participants, 830 (56.3%) were females and 645 (43.7%) was males. One-third were aged 35-49 years 558 (37.8%). The three most common disorders were major depression disorders (18.31%), any anxiety disorders (17.3%), any mood disorders (16.95%), followed by separation anxiety disorders (15.25%), personality disorder (14.1%). In the present study, prevalence in women was significantly higher than men for the most common psychiatric disorders, specifically generalized anxiety disorder, panic disorder, social phobia, specific phobias, obsessive compulsive disorders, posttraumatic disorder, somatization, major depressive disorder, bipolar disorder, dysthymia, and oppositional defiant disorder. Of the total 20% had only one psychiatric diagnosis and 12% had two disorders, 9.7% respondents with three diagnoses, and finally 4.3% of respondents had four or more diagnoses. CONCLUSION: One-fifth of all adults who attended the PHCC (20%) had at least one psychiatric diagnosis. The CIDI is a useful instrument for psychiatric diagnosis in community settings such as PHC clinics, clinical research and intervention studies. There is an urgent need to not only assess prevalence, but also risk factors, burden, treatment gaps and outcomes to obtain evidence for policy making.

Mental health in Syria.

This paper begins by outlining the nature of the present conflict in Syria. It goes on to describe the psychological consequences of this conflict and the present state of the mental health services in the country.

Prevalence, symptom patterns and comorbidity of anxiety and depressive disorders in primary care in Qatar.

AIM: The aim of this study was to assess the prevalence of anxiety and depressive disorders in a Qatari population who attend the primary health care settings and examine their symptom patterns and comorbidity. DESIGN: This is a prospective cross-sectional study conducted during the period from July 2009 to December 2009. SETTING: Primary Health Care Center and the Supreme Council of Health in the State of Qatar. SUBJECTS: A total of 2,080 Qatari subjects aged 18-65 years were approached and 1,660 (79.8%) patients participated in this study. METHODS: The study was based on a face-to-face interview with a designed diagnostic screening questionnaire, which consisted of 14 items for anxiety and depression disorders. Socio-demographic characteristics, comorbidity factors, and medical history of patients were collected. The Hospital Anxiety and Depression Rating Scale (HADS), which consisted of seven items for anxiety (HADS-A) and seven for depression (HADS-D), was used. The items are scored on a 4-point scale from zero (not present) to 3 (considerable). The HADS-A had an optimal cut-off ≥ 8 (sensitivity 0.87 and specificity 0.78), and the HADS-D had an optimal cut-off ≥ 8 (sensitivity 0.82 and specificity 0.86). The HADS scales generally used the cut-off score ≥ 8 to identify respondents with the possible presence of anxiety or depression. RESULTS: Of the studied Qatari subjects, 46.2% were males and 53.8% were females. The mean HADS-A anxiety symptom scores were 4.1 ± 3.6 for males and 4.9 ± 3.7 for females (p = 0.048) and with a prevalence of 18.7% among males and 24.6% among females (p = 0.017). The mean HADS-D depressive symptom scores were 8.0 ± 6.3 for males and 10.8 ± 7.5 for females (p = 0.041) and with a prevalence of 26.6% among males and 30.1% among females (p = 0.219). Qatari women were at higher risk for depression (53.1 vs. 46.9%) and anxiety disorder (56.7 vs. 43.3%) as compared to men. More than half of the sufferers with anxiety (56.7%) and depression (53.1%) were Qatari women with a higher frequency in the age group 18-34 years. There were significant differences between men and women with depression in terms of age group (p = 0.004), marital status (p = 0.04), occupation (p < 0.001), and household income (p = 0.002). Nervousness was the most common symptom in subjects with anxiety disorders (68.4%), whereas sleep difficulty was the most common symptom in subjects with depressive disorder (59.4%). Diabetes mellitus (23.4 vs. 19.2%), hypertension (25.7 vs. 25.0%), headache and migraine (21.6 vs. 25.4%), and low back pain (22.2 vs. 28.6%) were the frequent comorbidity conditions in both anxiety and depressive disorders, respectively, in the studied subjects. CONCLUSION: The findings of this study revealed that depression was more prevalent in the Qatari population than anxiety disorders. Women were likelier than men to have depression and anxiety disorders. The high-risk groups of depression and anxiety disorders were female gender, being married, middle aged, and highly educated.

Prevalence of mental disorders in adult population attending primary health care setting in Qatari population.

OBJECTIVE: To determine the prevalence of common mental disorders in Qatari population attending primary health care settings and identify the people at high risk. METHODS: A prospective cross sectional study was conducted from July 2009 to December 2009 at the primary health care centers of the Supreme Council of Health, State of Qatar. A total of 2080 Qatari subjects aged 18 to 65 years were approached and 1660 (79.8%) patients particiapted in this study. The study was based on a face to face interview with a designed diagnostic screening questionnaire which contained 79 questions on symptoms and signs of of various common mental disorders such as Anxiety disorder, Depression, Obsessive-compulsive disorder, Phobia, personality disorder, Bipolar disorder, Dementia, Schizophrenia, Alcohol abuse and other drug abuse. A standard forward-backward procedure was applied to translate the English version of the questionnaire to Arabic. Also, Socio-demographic charecteristics and medical history of patients were collected. The Diagnostic screening quetionnaire was reviewed and the final score, calculated which determined a provisional diagnosis. Physicians determined the definitive diagnosis by further checking and screening the symptoms. RESULTS: Of the studied Qatari subjects, 46.2% were males and 53.8% were females. The overall prevalence of mental disorders was 36.6%. Depression (13.5%) was the most common mental disorder, followed by anxiety disorders (10.3%). Qatari women (55.6%, p=0.005) were significantly at higher risk for common mental disorders compared to men (44.4%). Regarding their relationaships with age, Depression (42.9%), anxiety disorder (43.3%), obsessive compulsive disorder (56.9%), phobia (62%), personality disorder (51.6%) and bipolar disorder (47.9%) were found to be most common in the young population aged 18 - 34 years. The highest prevalence of Dementia was seen in the population above 50 years (52.6%), but schizophrenia was prevalent in the age group 35 - 49 years (52.5%). CONCLUSION: The study findings revealed that the almost one-quarter of all Qatari adults who attended the primary health care setting presented with atleast one type of mental disorder. The high risk groups were females, younger age and education. The highest prevalence of common mental disorders in Qatari population was depression and anxiety disorder.

The effectiveness of behavioural interventions in the primary prevention of hepatitis C amongst injecting drug users: a randomised controlled trial and lessons learned.

AIM: To develop and evaluate the comparative effectiveness of behavioural interventions of enhanced prevention counselling (EPC) and simple educational counselling (SEC) in reducing hepatitis C viral (HCV) infection in sero-negative injecting drug users (IDU). DESIGN: Randomised controlled trial (RCT) of EPC intervention in comparison with simple educational counselling (SEC). SETTING SPECIALISED: Drug services in London and Surrey, United Kingdom. PARTICIPANTS AND MEASUREMENTS: Ninety five IDUs were recruited and randomised to receive EPC (n = 43) or SEC (n = 52). Subjects were assessed at baseline using the Addiction Severity Index (ASI), the Injecting Risk Questionnaire (IRQ), and Drug Injecting Confidence Questionnaire (DICQ). The primary outcome was measured by the rate of sero-conversion at 6 months and 12 months from baseline and by the ASI, IRQ and DICQ at 6 months from baseline. Hepatitis C testing was undertaken by the innovative test of the dried blood spot (DBS) test which increased the rate of testing by 4 fold compared to routine blood testing. FINDINGS SEVENTY: Eighty two subjects (82%) out of the 95 recruited were followed up at 6 months and 62 (65%) were followed up at 12 months. On the primary outcome measure of the rate of seroconversion, 8 out of 62 patients followed-up at twelve months seroconverted, three in the EPC group and five in the SEC group, indicating incidence rates of 9.1 per 100 person years for the EPC group, 17.2 per 100 person years for the SEC group, and 12.9 per 100 person years for the cohort as a whole. Analysis of the secondary outcome measures on alcohol use, risk behaviour, psychological measures, quality of life, showed no significant differences between the EPC and the SEC groups. However, there were significant changes on a number of measures from baseline values indicating positive change for both groups. CONCLUSION: We were not able to prove the efficacy of EPC in comparison with SEC in the prevention of hepatitis C in IDUs. This was related to low recruitment and retention rates of the participants. Moreover there was a low adherence rate to EPC. The study provided the benefits of developing and introducing behavioural interventions of the EPC and SEC and the DBS screening for Hepatitis C. Moreover the main lessons learnt were that piloting of a new intervention is a crucial first step before conducting pragmatic RCTs of psychological interventions in the field of addiction; that an infrastructure and culture for psychosocial interventions is needed to enable applied research in the service environment, and research funding is needed for enabling the recruitment of dedicated trained therapists for the delivery of these interventions.

Diffusion tensor imaging of the corpus callosum in addiction.

Diffusion tensor imaging, a novel technique with an increased capability of detecting abnormalities in the white matter, has increasingly been employed in the study of the biology of addictions. A comprehensive search from a range of databases was conducted and publications on this topic were selected. Nine reports, eight published and one unpublished, met criteria for inclusion, five on alcoholism, three on cannabis and one on cocaine use. Findings of this review suggest focal disruption of commissural connectivity in the corpus callosum. In alcoholism, the genu and splenium were particularly affected with a different pattern in men and women, and an association with age and duration of substance use. In cocaine dependence, the genu and rostral body showed significant damage. Cannabis consumption may be associated with white matter disruption, but there is not sufficient evidence to support pathological changes in the corpus callosum. The improved detection of white matter pathology with diffusion tensor imaging supports the importance of future research in this field.

Folic acid and the treatment of depression.

Reduced plasma, serum, or red blood cell folate is commonly found in major depressive illnesses. Supplementing antidepressant medication with folic acid enhances the therapeutic effect. Although more work is required to confirm these beneficial results, it is suggested that, meanwhile, 2 mg of folic acid should be given during the acute, continuation, and maintenance treatment of depression.

Neuroimaging in psychiatry: An update.

The introduction of neuroimaging techniques in the 1960s has revolutionized the study of the biology of psychiatric disorders with implications for psychiatric practice. These comprise structural (computerized axial tomography, magnetic resonance imaging) and functional (including neurochemical/neuropharmacological techniques such as single-photon emission computerized tomography, positron emission tomography, functional magnetic resonance imaging, and magnetic resonance spectroscopy) techniques. As a result, we now have a better understanding of the morbid anatomy, pathophysiology, and chemical pathology of organic brain disease, schizophrenia, addictions, and affective disorders. This selective review will focus on recent advances in the use and application of neuroimaging techniques in the study of addictions, schizophrenia, and depression. Reference will be made to studies conducted in the United Arab Emirates on Arab patients with depression, schizophrenia, and alcohol dependence. The refinement of these techniques and their application in the study of psychiatric disorders will redefine these disorders, promising their deconstruction and the development of novel and more specific treatments.

Substance use disorders: Recent advances in treatment and models of care.

Drug and alcohol misuse is a global health problem with great health economic costs to substance misusers, their families, and their communities. It is associated with high physical and psychiatric morbidity, and with high mortality. There are serious obstacles to its treatment, including the stigma associated with it. Major advances in assessment and treatment have enabled health professionals to tackle drug and alcohol problems in a variety of settings, including primary care setting. This overview focuses on recent advances in the treatment of substance use disorders and on optimal models of care and services, with reference to studies conducted in the United Arab Emirates. Community surveys in Dubai and Al-Ain have shown a high prevalence of these disorders. It is proposed that these problems be dealt with in primary care settings, and it has been found that primary health care workers have a key role to play and are often in an ideal position to coordinate the community's response.