Attitudes and stigma toward seeking psychological help among Saudi Adults.

BACKGROUND: In the Kingdom of Saudi Arabia (KSA), public attitudes and stigma toward mental health illness seem to prevent people from seeking psychological help, which negatively impacts an individual's life. The primary objective of this study was to investigate people's attitudes toward seeking psychological help and identify the extent to which the associated stigma is responsible for preventing them from seeking psychological help. METHODS: Two hundred eighteen adults recruited from the community living in the Eastern Province of the KSA completed the questionnaires, customized to create the Arabic version of Attitudes Toward Seeking Professional Psychological Help Scale-Short Form (ATSPPH-SF-A), the Arabic version of Stigma Scale for Receiving Psychological Help (SSRPH-A), and the Arabic version of Hopkins Symptom Checklist-25 (HSCL-25-A). RESULTS: Both stigma and psychological distress significantly affected attitudes toward seeking professional help. Furthermore, it indicated that attitudes were negatively correlated with stigma while positively correlated with psychological distress. No significant difference in attitudes toward psychological help-seeking was identified between male and female participants. However, males displayed higher levels of stigma, while females showed greater psychological distress. Furthermore, the groups who received psychological treatment demonstrated more favorable attitudes toward seeking psychological help. CONCLUSION: Stigma and psychological stress influence attitudes toward treatment-seeking behavior for mental illness, making them two major predictors responsible for the underutilization of mental health services. More research is needed to assess specific sociodemographic disparities across more data sources and the factors that further contribute to stigma and psychological distress.

Characteristics of subjects with comorbidity of symptoms of generalized anxiety and major depressive disorders and the corresponding threshold and subthreshold conditions in an Arab general population sample.

BACKGROUND: There is controversy about differential meaningfulness between comorbid generalized anxiety disorder (GAD)/ major depressive disorder (MDD), the corresponding "pure" disorders and subthreshold conditions. We compared subjects who met DSM-IVTR criteria of symptoms and functional impairment for comorbid GAD/MDD, versus those with GAD, MDD, subthreshold conditions, and without significant symptoms. The comparison measures were socio-demographics, clinical severity, and quality of life (QOL). MATERIAL/METHOD: Participants (N=3155: 55.1% female, aged 16-87 yrs) were a general population sample of Kuwaitis who self-completed DSM-IVTR criteria-based questionnaires and the WHOQOL-BREF in 2006/7. We scrutinized the questionnaires and classified them into categories. RESULTS: Of the 273 GAD and 210 MDD cases, the prevalence of comorbidity among cases with GAD was 30.8%, and 40% among MDD. Of the 398 subthreshold GAD and 194 subthreshold MDD cases, 58 had subthreshold anxiety/depression comorbidity. Comorbid threshold GAD/MDD cases were significantly older, and more likely to be women, divorced and unemployed, compared with GAD and MDD. In all measures, the threshold GAD/MDD comorbidity was the severest condition. There was a monotonic decrease in QOL with increasing anxiety-depression symptoms. For the predictors of subjective QOL, the GAD/MDD comorbidity group differed markedly from the others. CONCLUSIONS: The high prevalence of comorbidity and subthreshold conditions supports the recommendation to assess them routinely, regardless of the primary reason for consultation. Our findings support a dimensional model with comorbid GAD/MDD at the higher end of a continuum, and differing from the "pure" conditions by a later onset and predictors of subjective wellbeing.

Relationship between symptoms of major depressive and generalized anxiety disorders in an Arab population using diagnostic criteria-based instruments.

BACKGROUND: The relationship between major depressive disorder (MDD) and generalized anxiety disorder (GAD) has been problematic in psychiatric nosology. We examined two research questions: First, using a data-driven approach, exploratory factor analysis (EFA), will symptoms that define MDD and GAD appear together in one factor, or are they separable into the hypothesized dimensions of the disorders? Second, using a theory-driven approach, confirmatory factor analysis (CFA), how will the structural integrity of the resulting factors compare with those of the various models that have been used to explain the relation between the symptoms? MATERIAL/METHODS: Participants (n=3303) were a general population sample of adult Kuwaitis who self-completed the DSM-IV-TR criteria-based questionnaires for MDD and GAD. Exploratory factor analysis was by principal axis factoring, with oblique rotation. Models were compared in CFA using 7 "fit" indices in AMOS-16 software. RESULTS: The questionnaires had adequate psychometrics. In the EFA, each questionnaire yielded 2 factors ("somatic-affective" and "cognitive"); but when the items were combined, 3 factors emerged ("somatic-affective"/"general distress: depressed"; "core anxiety"; and "cognitive-depression"). In CFA, only the (hierarchical) bifactor model and the (dimensional) model characterized by correlation of the 3 factors met the "fit" criteria. CONCLUSIONS: Our findings have widened the cross-cultural base of the evidence that while the symptoms of MDD and GAD form separate empiric clusters, there is an overlap of symptoms, which the disorders share. The relationship between the disorders' symptoms probably has hierarchical and dimensional elements.

Quality of life in people with epilepsy and their family caregivers. An Arab experience using the short version of the World Health Organization quality of life instrument.

OBJECTIVE: To assess the subjective quality of life (QOL) of Sudanese epilepsy patients with generalized tonic clonic seizures and their family caregivers, compared with the general population, and previous Sudanese data for chronic conditions, and to examine the predictors of QOL. METHODS: This cross-sectional study using the World Health Organization's 26-item QOL instrument, was carried out from December 2005 to December 2006, on consecutive government hospital Neurology Clinic attendees and their family caregivers, who fulfilled the study's inclusion criteria, in the cities of Khartoum, Wad Medani, and Atbara, Sudan. RESULTS: There were 276 patients (56.5% male; mean age 29.5 years). Patients' QOL scores were significantly lower (physical health domain [57.1%], psychological [60.1%], social relations [58.4%], environment [50.6%], and general facet [60.8%]), than the control group. They scored lower than the WHO 23-country patients for social relations and environment domains, and had lower environment domain scores than Sudanese diabetes patients. Caregivers had significantly higher scores (57.4 -73.7%) than patients and control group. Patients' higher QOL was associated with marriage, education, employment, no side effects and caregiver occupation. Caregivers had lower QOL if they were female, patients' own children, and less educated. The predictors of QOL included caregiver's proxy rating of the patient's QOL and drug side effects. CONCLUSION: Poor QOL in epilepsy reflects social underachievement, and calls for programs to remedy their psychosocial circumstance, and improve service provisions. Vulnerable caregivers need to be identified for assistance, to enhance their role.

The reliability and validity of the short version of the WHO Quality of Life Instrument in an Arab general population.

BACKGROUND AND OBJECTIVES: There is rising interest in quality of life (QOL) research in Arabian countries. The aim of this study was to assess in a nationwide sample of Kuwaiti subjects the reliability and validity of the World Health Organization Quality of Life (WHOQOL-BREF), a shorter version of the widely used QOL assessment instrument that comprises 26 items in the domains of physical health, psychological health, social relationships, and the environment. METHODS: A one-in-three systematic random proportionate sample of consenting Kuwaiti nationals attending large cooperative stores and municipal government offices in the six governorates completed the Arabic translation of the questionnaire. The indices assessed included test-retest reliability, internal consistency, item internal consistency (IIC), item discriminant validity (IDV), known-groups and construct validity. RESULTS: There were 3303 participants (44.8% males, 55.2% females, mean age 35.4 years, range 16 to 87 years). The intra-class correlation for the test-retest statistic and the internal consistency values for the full questionnaire and the domains had a Cronbach's alpha>/=0.7. Of the 24 items that constitute the domains, 21 met the IIC requirement of correlation > or =0.4 with the corresponding domain, while 16 met the IDV criterion of having a higher correlation with their corresponding domain than other domains. Domain scores discriminated significantly between well and sick groups. In the factor analysis, four strong factors emerged with the same construct as in the WHO report. CONCLUSION: The Arabic translation of the WHOQOL-BREF has impressive reliability and validity indices. The poor IDV findings are due to the multidimensional nature of the questionnaire. The highly significant validity indices should reassure researchers that the questionnaire represents the same constructs across cultures. Negatively worded items possibly need refinement.

Subjective quality of life in a nationwide sample of Kuwaiti subjects using the short version of the WHO quality of life instrument.

OBJECTIVES: The usefulness of quality of life (QOL) as an outcome measure in medicine has inspired general population studies to establish normative values. The objectives of the study were to: (1) highlight the pattern of satisfaction with aspects of life circumstances among a nationwide sample of Kuwaiti subjects, using the 26-item WHOQOL Instrument (WHOQOL-Bref); (2) establish the QOL domain normative values; (3) highlight the relationship of QOL with socio-demographic variables and scores on scales for anxiety and depression; and (4) assess the relationship between domains of QOL. METHOD: A one-in-three systematic random proportionate sample of consenting Kuwaiti nationals attending the large cooperative stores and municipal government offices in the six governorates, were requested to complete the questionnaires anonymously. RESULTS: There were 3,303 participants (44.8% m, 55.2% f, mean age 35.4, SD 11.9; range, 16-87). As a group, they were only moderately satisfied with their life circumstances. The domain scores for physical health (14.6 or 66.2%) and psychological health (14.2 or 63.9%) were at the middle of the range for the WHO 23-country report, while the social relations (15.0 or 68.8%) and environment (14.5 or 65.4%) domains were at the upper end of the WHO range. The general facet (GF) score (15.5 or 71.6%) was significantly higher than all domains. Diminished QOL was significantly associated with female gender, older age, social disadvantage, and high scores on anxiety/depression. Depression was the most important predictor of QOL, accounting for over 77% of total variance. CONCLUSION: QOL was sensitive to distressing and unfulfilled life circumstances. Hence, coupled with the difficulty of conducting house-to-house surveys in such a conservative society, a cost effective way of tracking societal distress is by including a brief and responsive measure of QOL during national census exercises. Clinicians need to be aware of QOL issues because QOL is associated with clinical and social variables. The differences between GF (representing subjective well-being) and the domains, has implications for QOL theory.

Family caregiver quality of life in multiple sclerosis among Kuwaitis: a controlled study.

BACKGROUND: Research interest in the quality of life (QOL) of persons with multiple sclerosis (MS) has been spurred by the need to broaden outcome measures. Far less of this interest has been directed at the family caregivers, who bear most of the burden of care. The objectives of the study were: First, to compare the subjective QOL of family caregivers of persons with relapsing remitting and progressive MS, with those of a matched general population sample and caregivers of diabetes and psychiatric patients. Second, to assess the relationship of QOL with caregiver attitudes to MS and patient's variables. METHODS: Consecutive MS clinic attendees were assessed with the 26 - item WHOQOL Instrument, and for depression and disability. Similarly, caregivers independently rated their own QOL as well as their impression of patients' QOL and attitudes to patients' illness. RESULTS: The 170 caregivers, mean age 35.7 years, had no significant diagnostic differences in QOL domain scores and attitudes to MS. Caregivers had significantly lower QOL than the general population control group for five out of six domains and the general facet (P < 0.01), but higher QOL than the patients. When the scores were corrected for patients' depression and disability, caregivers had similar QOL with the general population group for four domains. Using corrected scores, MS caregivers had lower scores than diabetic and psychiatric caregivers in the physical, psychological and social relations domains. Majority expressed negative attitudes to MS. Caregiver QOL was more affected by their fear of having MS than their feelings about the illness and caregiving role. Caregiver attitudes had mostly no significant impact on their proxy ratings of patients' QOL. The significant predictor of caregivers' overall QOL was their impression of patients' QOL. CONCLUSION: Caregivers need specific attention if they are less educated, unemployed, afraid of having MS and caring for patients with longer duration of illness and less education. In particular, attention to patients' depression and disability could improve caregivers' QOL. Caregivers need specific programs to address fear of having MS, negative attitudes to illness and their unmet needs.

Relationship of depression, disability, and family caregiver attitudes to the quality of life of Kuwaiti persons with multiple sclerosis: a controlled study.

BACKGROUND: Assessment of subjective quality of life (QOL) of persons with multiple sclerosis (MS) could facilitate the detection of psychosocial aspects of disease that may otherwise go unrecognized. The objectives of the study were to (i) compare the QOL ratings of relapsing remitting (RRMS) and progressive (PMS) types of MS with those of a general population group and the impression of their family caregivers; and (ii) assess the association of demographic, clinical, treatment, depression, and caregiver variables with patients' QOL. METHODS: Consecutive clinic attendees at the national neurology hospital were assessed with the 26 -item WHOQOL Instrument, Beck's Depression Inventory and Expanded Disability Scale. Caregivers rated their impression of patients' QOL and attitudes to patients' illness. RESULTS: The 170 patients (60 m, 109 f) consisted of 145(85.3%) with RRMS and 25 with PMS, aged 32.4(SD 8.8), age at onset 27.1(7.7), EDSS score 2.9 (1.8), and 76% were employed. The patients were predominantly dissatisfied with their life circumstances. The RRMS group had higher QOL domain scores (P < 0.001), and lower depression(P > 0.05) and disability (P < 0.0001) scores than the PMS group. Patients had significantly lower QOL scores than the control group (P < 0.001). Caregiver impression was significantly correlated with patients' ratings. Depression was the commonest significant covariate of QOL domains. When we controlled for depression and disability scores, differences between the two MS groups became significant for only one (out of 6) QOL domains. Patients who were younger, better educated, employed, felt less sick and with lesser side effects, had higher QOL. The predictors of patients' overall QOL were disability score, caregiver impression of patients' QOL, and caregiver fear of having MS. CONCLUSION: Our data indicate that MS patients in stable condition and with social support can hope to have better QOL, if clinicians pay attention to depression, disability, the impact of side effects of treatment and family caregiver anxieties about the illness. The findings call for a regular program of psychosocial intervention in the clinical setting, to address these issues and provide caregiver education and supports, in order to enhance the quality of care.

Confirmatory factor analytical study of the WHOQOL-Bref: experience with Sudanese general population and psychiatric samples.

BACKGROUND: The widespread international use of the 26-item WHO Quality of Life Instrument (WHOQOL-Bref) necessitates the assessment of its factor structure across cultures. For, alternative factor models may provide a better explanation of the data than the WHO 4- and 6-domain models. The objectives of the study were: to assess the factor structure of the WHOQOL-Bref in a Sudanese general population sample; and use confirmatory factor analysis (CFA) and path analysis (PA) to see how well the model thus generated fits into the WHOQOL-Bref data of Sudanese psychiatric patients and their family caregivers. METHOD: In exploratory factor analysis (FA) with all items, data from 623 general population subjects were used to generate a 5-domain model. In CFA and PA, the model was tested on the data of 300 psychiatric outpatients and their caregivers, using four goodness of fit (GOF) criteria in Analysis of Moment Structures (AMOS). In the path relationships for our model, the dependent variable was the item on overall QOL (OQOL). For the WHO 6-domain model, the general facet on health and QOL was the dependent variable. RESULTS: Two of the five factors ("personal relations" and "environment") from our FA were similar to the WHO's. In CFA, the four GOF criteria were met by our 5-domain model and WHO's 4-domain model on the psychiatric data. In PA, these two models met the GOF criteria on the general population data. The direct predictors of OQOL were our factors: "life satisfaction" and "sense of enjoyment". For the general facet, predictors were WHO domains: "environment", "physical health" and "independence'. CONCLUSION: The findings support the credentials of WHO's 4-domain model as a universal QOL construct; and the impression that analysis of WHOQOL-Bref could benefit from including all the items in FA and using OQOL as a dependent variable. The clinical significance is that by more of such studies, a combination of domains from the WHO models and the local models would be generated and used to develop rigorous definitions of QOL, from which primary targets for subjective QOL interventions could be delineated that would have cross-cultural relevance.

Factors associated with quality of life of outpatients with breast cancer and gynecologic cancers and their family caregivers: a controlled study.

BACKGROUND: Quality of life (QOL) issues are of interest in cancer because effective methods of treatment and detection have led to an increase in the number of long-term survivors. The objectives of the study were: to assess the subjective QOL of stable Sudanese women cancer outpatients and their family caregivers, using the WHO 26-item QOL Instrument; compare with matched general population groups, as well as diabetic and psychiatric patient groups; examine patient-caregiver concordance in ratings; and assess the variables associated with their QOL, with a view to identifying factors that can enhance quality of care. METHODS: Responses of oncology outpatients with breast cancer (117), cervical cancer (46) and ovarian cancer (18) (aged 44.6, SD 11.5) were compared with those of their family caregivers and matched general population groups. Data were analyzed by univariate and multivariate statistics. RESULTS: The cancer groups had similar QOL domain scores, which were significantly lower than those of their caregivers, but higher than the control group as well as those of psychiatric and diabetic patients studied previously. Patients who were married, with higher education, better employment, and with longer duration of illness had higher QOL. Patients on radiotherapy and their caregivers had higher QOL scores. Correlations between patient's ratings and caregiver impression of patient's QOL were high. Caregiver impression was a significant predictor of patient's and caregiver's QOL. Other predictors for the patient were: currently feeling sick and duration of illness; for the caregiver: feeling sick, relationship to patient, and age. CONCLUSION: Cancer patients in stable condition and with psychosocial support can hope to enjoy good QOL with treatment. The findings constitute an evidence base for the country's cancer care program, to boost national health education about prognosis in cancer. Families living with women cancer patients are vulnerable and need support if the patient is recently diagnosed, less educated, single, not formally employed; and the caregiver is female, parent, younger, less educated, unemployed and feels sick. Clinicians need to invest in the education and support of family caregivers. The patient-caregiver dyad should be regarded as a unit for treatment in cancer care.

Diabetes mellitus patients' family caregivers' subjective quality of life.

OBJECTIVES: To assess the subjective quality of life (QOL) of family caregivers of Sudanese type-1 and type-2 diabetic outpatients, using the WHO 26-item QOL instrument, compared with a general population sample; and to examine the factors associated with caregiver QOL. METHOD: Responses of caregivers of 105 outpatients with type-1 diabetes and 135 with type-2 diabetes were compared with 139 general population subjects. RESULTS: Caregivers were satisfied with the content of items related to general social supports. Type-1 caregivers had significantly lower QOL scores than type-2 caregivers and the general population. Parents and siblings had lowest scores compared with other family groups. Caregivers scored higher than patients. Patients' age and duration of illness, and caregivers' education, marital status and state of health were positively associated with caregiver QOL. Caregivers' QOL was predicted by their appraisal of patients' QOL. CONCLUSIONS: Caregivers who were sick, younger, single, less educated and caring for patients with more recent illness appeared relatively vulnerable. Clinicians should be interested in the dynamics of the family caregiving situation--as it impacts QOL--and in promoting caregiver awareness of diabetes in order to enhance the caregiving role, quality of care and QOL.

Subjective quality of life of outpatients with diabetes: comparison with family caregivers' impressions and control group.

BACKGROUND: There is a paucity of studies on comparison of quality of life (QOL) of type-1 and type-2 diabetes patients, and the impact of family caregivers' impressions on the QOL of patients. OBJECTIVES: To assess the subjective QOL of Sudanese diabetics using the WHOQOL-Bref, compared with a general population sample; examine caregiver-patient concordance; and assess the variables that impact on QOL. METHOD: The responses of 105 outpatients with type-1 diabetes and 136 with type-2 diabetes were compared with their family caregivers' impressions and 139 general population subjects. RESULTS: Patients were predominantly dissatisfied with their life circumstances. Type-1 diabetics had significantly lowest QOL scores, while the control group had highest scores. Having additional medical problems; having diminished sexual desire; and being young, unemployed and single were associated with poor QOL, but illness duration was not. Type-2 diabetics had lesser concordance with caregivers. The only predictor of patients' QOL was the caregivers' impression of patients' QOL. CONCLUSIONS: Caregivers' impression of patients' QOL impacted on outcome. Caregiver education is, therefore, important. The factors associated with QOL indicate a group that needs focused attention. The good QOL for type-2 and nonsignificance of illness duration encourage therapeutic optimism.

Subjective quality of life of family caregivers of community living Sudanese psychiatric patients.

BACKGROUND: Reports on the quality of life (QOL) of family caregivers of psychiatric patients are uncommon. OBJECTIVE: The objective of this study was to assess the subjective QOL of caregivers of stable Sudanese outpatients using the World Health Organization 26-item Quality of Life Instrument compared with a general population sample, and assess the factors associated with caregivers' QOL. METHOD: Responses of caregivers of outpatients with schizophrenia (99), major affective disorders (120), and neuroses (81) were compared with 211 general population subjects. RESULTS: Caregivers were satisfied with the items related to the strengths of the traditional society and dissatisfied with the items related to national economic indices. Schizophrenia caregivers had lower scores than the others (P > 0.05) who scored significantly higher than general population subjects and patients. Parents had the least scores. Patients' variables were not significantly associated with caregivers' QOL. Caregivers' sociodemographic variables were significantly associated with QOL. Caregivers' QOL was predicted by their impression of patients and state of health. Schizophrenics had the least correlations with caregivers' QOL. CONCLUSION: Caregivers who are women, parents, and sick seemed relatively vulnerable and need assistance. Their areas of dissatisfaction with material circumstances should be addressed in a social welfare program. Caregivers' inner strengths, extended family supports, and positive appreciation of the patients are resources for enhancing their caregiving role.

A critical review of the clinical effects of therapeutic irradiation damage to the brain: the roots of controversy.

We critically examined the damaging affects of therapeutic irradiation by comparing results from cross-disciplinary studies of early- and late-delayed radiotherapy effects. Focus is attained by concentrating on clinical treatment issues (volume of brain, dose, timing of effects, age, modality types, and stereotactic treatment techniques), rather than on methodological means or problems, which is necessary to understand the mechanisms and characteristics of radiotherapy-induced behavioral dysfunction including cognition. We make observations and hypotheses about the actual risks from radiotherapy that could be informative in the treatment decision process, and which may lessen the concerns of some patients and their families about the risks they take when receiving radiation. Conditions that predispose to radiation injury are reviewed: (1) higher doses even to part of the brain versus lower doses to the whole brain, (2) combined treatment modalities, (3) malignancy itself, (4) radiation early during postnatal brain development, and (5) late-delayed effects (more than 3 years posttreatment). Current neurocognitive frameworks for understanding cognitive change over time in children and adults are summarized, along with the literature on effects of brain tumors and treatment on depression. No studies have as yet identified candidate brain regions that are more sensitive to radiotherapy. Two studies have provided early, preliminary evidence for a specific vulnerability of visual attention/memory to the early stage of late radiation damage. Furthermore, radiation effects appear severe only in a minority of patients. Risk is related to direct and indirect effects of cancer type, concurrent clinical factors, and premorbid risk factors.