no - arab journal of psyciatry€¦ · journal of psychiatry (ajp). they are among the best papers...

No.1

The Arab Journal of Psychiatry

The Editorial Boarded

The Editor in chief

Walid Sarhan – Jordan

The Deputy Editor

Suhaila Ghuloum – Qatar

The Honorary Editors

Ahmad Okasha – Egypt

Adnan Takriti – Jordan

The International Editors

Dinesh Bhugra – UK

David Sheehan – USA

Norman Sartorius – Switzerland

Malek Badri –Malaysia

The Associate Editors

Abdul Manaf Aljadri – Jordan

Numan Ali – Iraq

Adib Essali – New Zealand

Elie Karam – Lebanon

M. Faker Eleslam – Egypt

Tarek Okasha– Egypt

The English Editor

Tori Snell – UK

Statistics Consultant

Kathy Sheehan – USA

Executive Secretary

Raja Nasrallah – Jordan

Treasures

Hussein Alawad – Jordan Website: http://arabjournalpsychiatry.com

The Editorial Board

Nasser Shuriquie – Jordan

Basil Alchalabi – Iraq

Wail Abohemdy – Egypt

George Karam – Lebanon

John Fayyad – Lebanon

Tarek – Al Habib – Saudi Arabia

Adel Zayed – Kuwait

Afaf Hamed – Egypt

Maha Yonis – Iraq

Issam Alansari – Kuwait

Marwan Dwairy – Palestine

Abdelaziz Thabet – Palestine

Elham Khatab – Iraq

Ghada Elkhouly – Egypt

Mohamad Abo Saleh – UK

Malek Bajbouj – Germany

Charlotte Kamel – Bahrain

Ahmad Alhadi – Saudi Arabia

Jamal Turkey – Tunisia

Tori Snell – UK

The Editorial Assistants – Jordan

Radwan Bani Mustafa Ali Alqam Nayel Aladwan Nabeel Alhmoud Tayseer Elias Bahjat Abderrahim

Mohamad Dabbas Basma Kilani

Ahmad Jaloudi Walid Shnaiqat Ahmad Alsalem Ayman Rabie

Alaa Albeshtawi Hashem Fakhouri

Ahid Husni Mohamad Shoqirat

Nasri Jasser Diana Qasas

The Arab Journal of Psychiatry (2017) Vol. 28 No.2

The Arab Journal of Psychiatry (2017) Vol. 28 No. 2

Instruction to Authors

The Arab Journal of Psychiatry (AJP) is published by the Arab Federation of Psychiatrists since 1989 in Jordan. The Journal is biannual published in May and November electronically and as hard copy. Original scientific reports, review articles, and articles describing the clinical practice of Psychiatry will be of interest for publication in AJP. The Articles should not be published before. The articles may be written in English or Arabic and should always be accompanied by an abstract in English and Arabic. All Papers are accepted upon the understanding that the work has been performed in accordance with national and International laws and ethical guidelines. Manuscripts submitted for publication in the Arab Journal of Psychiatry should be sent to:

The Chief Editor.

Papers are submitted in electronic form � Title, running head (Max: 40 letters), title of the article in English and Arabic, the names of

authors should be without their titles and addresses in both languages. � Abstract in English (max: 200 words). It should follow a structured format (objectives,

method, results and conclusion). It should be followed by key words (max. 5). � Declaration of interest after the key words. � Names of authors, titles, and full addresses and address for correspondence at the end of the

paper. � Acknowledgment of support and persons who have had major contribution to the study can

be included after the references. � Arabic abstract like the English abstract should follow a structured format. And it follows the

references section (last page). � All Pages should be numbered.

Tables Tables should be typed with double-spaced in separate pages. They should be numbered with Arabic (e.g1, 2, 3) numerals and have a short descriptive headings.

Illustrations All illustration should be submitted camera-ready; line drawings/diagrams should be approximately twice the size they will appear in print.

Reference List References should follow the ‘Van Couver style’ only the numbers appear in the text. List them consecutively in the order in which they appear in the text (not alphabetically).

Example of references: � Zeigler FJ, Imboden, JB, Meyer E. Contemporary conversion reactions: a clinical study. Am.

J. Psychiatry 1960: 116:901 – 10.� Mosey AC. Occupational therapy. Configuration of a profession. New York: Raven Press,

1981.

Mailing Address: Dr. Walid Sarhan - The Chief Editor -The Arab Journal of Psychiatry P.O. Box 541212 Postal Code 11937 Amman – Jordan Tel: 00962 – 6 – 5335446 Fax: 00962 – 6 – 5349763 Email: [email protected] Journal Website: http://arabjournalpsychiatry.com/


Editorial Letter

It is my pleasure to offer many excellent papers in Arabic for the current issue of the Arab Journal of Psychiatry (AJP). They are among the best papers I could have and cover a wide range of topics. One observation I would like to convey to young researchers who are trying to write papers is that you truly need to read good papers regularly. Be confident and knowledgeable about your topic. Get to know it well by reading thoroughly about it. Ask your colleagues and your mentors for their guidance and opinions so the chances of your paper being accepted for publication improve.

Please visit the AJP website and register yourself. Once you do, you will be able to read and download all previous issues since November 1989.

I would like to thank Dr Tori Snell who takes care of the final editing and spends so much time and effort in making the journal up to the standard.

I am also thankful to the referees who provide opinions and directions to the authors.

I hope Arab researchers will publish more good papers. The AJP prides itself in fostering and disseminating scientific research for the benefit of readers in the region and more widely.

Dr Walid Sarhan, FRCPsych, IDFAPA

Chief Editor of the Arab Journal of Psychiatry

Amman - Jordan


Guidelines

• Arab treatment guidelines for the management of major depressive disorderAhmed Okasha; Suliman Alkhadhari, Abdullah Al Sharqi,Tarek Al Sherif, Tarek Asaad, Dory G. Hachem, Adel Karrani; Suhail A. Khan, Sonia Laflamme, Ossama T. Osman; Hisham Ramy, Walid Sarhan, David V. Sheehan ………………………………………………………………………………………………………….………….…… 97

Editorial

• A Critical Review of the Literature: The Safety, Tolerability and Risks Associated with the Use of NewerGeneration Antidepressant Drugs Ahmed Okasha ………………………………………………………………………………………………… …….118

Short Editorial

• Person-centering of Psychiatric Medicine

M. Fakhr El-Islam …………………………………………………………………………………………..………….127

Psychiatric Audit

• Audit Report of an inpatient liaison psychiatry service at Baghdad Teaching Hospital.Numan Serhan Ali, Emad Aref Al-Kubaisy, Tori Snell ……………………………………………………………… 131

• Clinical auditAdib Essali ……………………………………………………………………………………………………………. 137

Liaison Psychiatry

• Rate of physical health monitoring for metabolic syndrome of patients prescribed olanzapine attending a tertiarycare hospital in Oman Abdullah Al-Jaradi, Mandhar Al-Maqbali, Idris Gaafar, Khalid Al-Khanbashi ………………………………………..141

• Prevalence of depression in a sample of hypertensive outpatients in Mosul city in IraqAdnan Yassin Mohammed ……………………………………………………………………………………………. 147

Trauma in Palestine

• The Trauma of Humiliation in the Occupied Palestinian TerritorySamah Jabr and Elizabeth Berger ………………………………………………………………………………………154

Psychiatric Epidemiology

• Prevalence of psychiatric disorders among Saudi female adolescents attending high school in Riyadh CityY. Alatiq, M. Alshalan and O. Almodayfer …………………………………………………………………………… 160

Arabic papers • Psychoses in DSM-5

Hassan Almaleh …………………………………………………………………………………………..…………... 169 • The Arab network of the psychological sciences …seventeen years achievements (Towards Arb cooperation for

scientific development of psychological sciences) Jamal Turky………………………………………………………………………………………...…………………. 171

• Psychoanalysis of Zionism in the context of history and circumstances.Federico Allodi - Ahmed Okasha, Adel Youssef …………………………………………...…………………………. 181

Table of contents

The Arab Journal of Psychiatry (2017) Vol. 28 No.2 Page (97 - 117) (doi: 10.12816/0041709)

Guidelines Arab Treatment Guidelines for the Management of Major Depressive Disorder

Ahmed Okasha, Suliman Alkhadhari, Abdullah Al Sharqi, Tarek Al Sherif, Tarek Asaad, Dory G. Hachem, Adel Karrani, Suhail A. Khan, Sonia Laflamme, Ossama T. Osman, Hisham Ramy, Walid Sarhan, David V. Sheehan,

دلیل العالج العربي في تدبیر اضطراب االكتئاب الجسیم احمد عكاشة، سلیمان الخضري، عبد هللا الشرقي، طارق الشریف، طارق اسعد، دوري ھاشم، عادل كراني، سھیل خان، سونیا الفالم، اسامھ عثمان، ھشام

رامي، ولید سرحان، دافید شیھان

Abstract ajor depressive disorder is currently the second leading cause of disability and is projected to be the leading cause of global burden of disease by 2030. Arab healthcare practitioners face region-specific challenges that the current set

of international guidelines do not address. Currently, most Middle Eastern countries are exposed to a multitude of stressors because of conflicts and wars. Consequently, there has been a rise in terrorism and fundamentalism, as well as stress-related mental health problems. A panel of experts from 22 Arab countries met to reach consensus and develop clear practice guidelines on the treatment of major depressive disorder in those countries. The guidelines are based on evaluations of evidence from the Food and Drug Administration (FDA) registration studies and regulatory approvals, as well as large, well-designed, double blind, placebo-controlled studies.

Given the regional specificity of these guidelines (addressing social determinants, religious beliefs, available resources and reaction to treatment modalities), psychiatrist compliance to guidelines might increase and lead to improved patient outcomes. Members of the working group recommend that collaborative projects be developed and initiated regionally to study clinical outcomes of treatment of major depressive disorder in the Middle East.

Key words: Treatment, Guidelines, Major Depressive Disorder, Depression, Arab

Declaration of interest: See below

Introduction Major depressive disorder (MDD) is currently the second leading cause of disability worldwide and a major contributor to the burden of suicide and ischemic heart disease.1 It is projected to be the leading cause of global burden of disease by 2030. Although national epidemiological studies on the prevalence of MDD showed some differences in Arab countries depending on the region of conflict2-6 the disease prevalence in Arab countries is like the rest of the world, with 5-6% of the population affected in a 12-month period.7

Arab healthcare practitioners face region-specific challenges. The perception and management of mental illness is heavily influenced by the local culture and political situation. Currently, most Arab countries are exposed to a multitude of stressors because of conflicts and wars. Consequently, there has been a rise in terrorism and fundamentalism, as well as stress-related mental health problems.8 Religion also plays an important role in symptom formation, attribution and management of

mental health problems. Religious and cultural beliefs are known to have a positive influence on the outcome of psychiatric disorders. At times, however, such beliefs may lead patients and family members to attribute depression to transcendent forces out of their control, such as God’s will, a weak personality or lack of faith. The locus of control in the Arab countries is often external. In addition, a study by Okasha showed that 71% of those attending outpatient counseling in a university hospital had tried traditional and religious therapy before consulting a psychiatrist.9

Availability of resources is also a determinant of clinical care for patients suffering from MDD in the region. Faced with a lack of human resources in the field of mental health, the WHO Regional Office for the Eastern Mediterranean (EMRO) recommended that the most essential antidepressants should be available to every local primary care unit to deal with the disease burden. Treatment cost is also a major challenge. In some

M

97

Arab treatment guidelines for the management of Major Depressive Disorder

countries medications are an out-of-pocket expense for patients, resulting in poor adherence and compliance with the prescribed treatment.9

This is the first time that treatment guidelines for MDD have been produced for the Arab region. The expert panel expressed concern with the international guidelines’ lack of specificity for the realities of the region. As regional experts write these guidelines, they take into consideration the cultural and religious landscape in which clinical care is provided. This is compounded by the rarity of systematic research that measures treatment outcomes in Arab populations.10 It is the consensus panel’s hope that this will facilitate the adoption of the guidelines by regional psychiatrists and authorities. Finally, the Arab treatment guidelines for MDD are held to a high standard of evidence and should serve as a reference for both junior and senior clinicians, as well as help to frame mental health service policies in the region to support better patient outcome.

Method Expert panel

A panel of experts met in Dubai on 29 September 2012 to agree and develop clear practice guidelines on the treatment of MDD in the Middle East region. The panel included psychiatrists with expertise in the treatment of MDD. Following the meeting, panel members deliberatedbefore finalizing the current document.

Evidence evaluation

In evaluating the evidence for these guidelines, primary consideration was given to reviews of the available efficacy and safety data in registration studies from the Food and Drug Administration (FDA) and the European Medicines Agency’s (EMA) Committee for Medicinal Products for Human Use (CHMP). In contrast to treatment guidelines by other bodies, meta-analyses were demoted to a lower level of evidence and double-blind placebo-

controlled registration studies were promoted to the highest level.

International guidelines for the treatment of MDD were reviewed by the expert panel as a base for the guidelines development discussion included The Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults (2009), The American Psychiatric Association (APA) practice guideline for the treatment of patients with major depressive disorder (2010), and The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorder (2002).11-19 Since the original meeting, panel members have reviewed more recent evidence and treatment options not available earlier, such as the CANMAT 2016 clinical guidelines for the management of major depressive disorder in adults.20

The recommendations in the APA, CANMAT, WFSBP guidelines reviewed by the expert panel were based on meta-analyses and systematic reviews of available evidence. However, the current Middle East guidelines are based primarily on evaluations of evidence from the FDA registration studies and regulatory approvals, as well as large, well-designed, double-blind, placebo-controlled studies, rather than on meta-analyses and systematic reviews. The expert panel chose to use FDA approval documents because they maintain the highest standard and threshold for safety concern.

After critical analysis of the above mentioned guidelines and discussions of the available evidence, the panel arrived at consensus recommendations for the treatment of MDD in the Middle East region.

Levels of evidence and recommendation

After discussing the levels of scientific confidence, the expert panel agreed that levels of evidence and lines of treatment for the regional recommendations would be assigned according to the criteria listed in Tables 1 and 2.

Table 1. Levels of evidence for efficacy

Level Definition

1 ≥2 RCTs with adequate sample sizes, double-blind, randomized, placebo-controlled

2 ≥1 RCT with adequate sample size, double-blind, randomized, placebo-controlled

3 1 meta-analysis with narrow confidence intervals or ≥2 consistent meta-analyses

4 Non-randomized, controlled prospective studies or case control study or cohort study or high-quality retrospective studies or case series or systematic reviews

5 Expert opinion/consensus

98

Okasha A, et al.

Table 2. Lines of treatment based on levels of evidence

Line of treatment Definition

First line Level 1 and exact wording of indication in FDA approval

Second line Level 1 or 2 evidence, plus solid clinical support* without FDA approval

Third line Level 3 evidence, plus solid clinical support

Fourth line Level 4 evidence, plus solid clinical support

Fifth line Level 5 evidence, plus solid clinical support *Solid clinical support is defined as the consensus agreement on best practices based on the experience of a group of practicing psychiatrists from

various representative communities in the Arab region and approval of the drug for the indication cited in Canada, Europe, or in other major countries.

Levels of evidence for safety were assigned according to FDA product information reports and are shown in Table 11. This source is the most reliable, comprehensive andconsistently updated source of pre- and post-marketing product safety data. In the United States, federal law mandates reporting of all safety data in all studies to the FDA. Post-marketing surveillance further strengthens this information. Consequently, the expert panel agreed to base its safety assessments on this source and recommends it as the best guide for clinicians.

Guidelines development

The discussions and consensus statements were recorded during the meeting and written up as a full manuscript draft by a professional medical writer. The panel reviewed, edited and provided comments on the outline and manuscript drafts until a final version was reached, which was approved by all members.

Recommendations for evaluation of major depressive disorder Therapeutic alliance

The collaborative aspect of the relationship between the psychiatrist/therapist and a patient is highly relevant to the treatment success. The traditional concept of this alliance includes 1) an agreement between psychiatrist/therapist and patient about the goals of treatment, 2) an agreement about the therapy tasks needed to accomplish those goals,

and 3) the emotional bond developed between psychiatrist/therapist and patient, which enables the patient to make therapeutic progress.21 To establish the working alliance, the psychiatrist must be sensitive to the patient’s concerns and perception of psychiatric treatment. Cultural and religious beliefs should be considered. In the Middle East region, for example, beliefs in possession by spirits and in the impact of sorcery or the evil eye may affect the patient’s interpretation of mental symptoms. In this context, the first resort for the families of mental patients might not even be to consult a medical doctor, but rather the traditional and religious healers who acquire a special importance because of their claim of dealing with the ‘mystical’ and the ’unknown’. The therapeutic alliance should also include considerations for the role of the patient’s family. Middle Eastern countries emphasize social integration more than individual autonomy. This means that the family, not the individual, is the unit of society. Dependence is more natural and infirmity less alien in these cultures. Some cultures value the collectivity of the community rather than the individuality of its member citizens. Decisions are often not taken on an individual, but rather on a familial level.

Psychiatric evaluation

A comprehensive psychiatric evaluation is necessary for the diagnosis of MDD or other psychiatric conditions. The elements of a complete psychiatric evaluation are listed in Table 3.

99


Table 3. Elements of a psychiatric evaluation

• Establishing a therapeutic alliance• Identifying information• Presenting problem(s) and description of current symptoms• Onset and course of presenting problem(s)• Past psychiatric history• Physical examination• Routine lab tests, including thyroid function test for all hospital admissions for MDD treatment. This

should also be considered, but not required, for those who have failed three consecutive courses of standard antidepressant treatments, especially if any clues to medical problems are noted on the medical history and medical review of systems

• Psychiatric medications, past and current• History of suicide, homicide or violence• Past medical history (major illnesses, surgeries, hospitalizations, injuries, accidents, physical or sexual

abuse, allergies and current review of medical systems) • Current health practices (current non-psychiatric prescription medications, current non-prescription and

over-the-counter medications, consultation with faith/traditional healers, history of or current substance abuse)

• Family psychiatric and medical history• Social history (home/family, occupational, financial, educational, interests, leisure activities, legal, support

systems – availability and quality and agencies etc. involved with patient and family) • Mental status examination (appearance, review of range of common psychiatric signs and symptoms,

sensorium and intellectual abilities). Note especially any past or current psychotic symptoms or symptoms of mania or hypomania

• Family or caregiver input when possible (including interpretation of symptoms)• Cultural Formulation Interview (CFI) based on DSM-5• List of diagnoses, list of ICD-9-CM (V codes) or alternatively ICD-10-CM (Z codes) for psychosocial

stressors and other conditions that may be a focus of clinical attention, and assess the degree of dysfunction using a disability scale

Adapted from APA 2010

Measurement-based evaluation and care

Careful and systematic assessment of the patient can be facilitated using measurement tools, such as a structured diagnostic interview, depression symptom scales, disability/functional impairment scales, global improvement scales and suicidality tracking scales. Benefits of using such tools in the initial and ongoing evaluation of the patient include monitoring of treatment progress, improved outcomes and accountability. Furthermore, rating scales allow for comparison over time, quality control and an exhaustive review of the patient’s psychopathological symptoms.

The expert panel recognizes that measurement tools are under-utilized in the Middle East region. This is due to a lack of training on the appropriate use of the scales and structured diagnostic interviews, as well as lack of time in the clinician’s practice. Several measurement scales were translated into Arabic (e.g. Montgomery Asberg Depression Rating Scale (MADRS), Hamilton Depression Rating Scale (HAMD), PHQ-9 Depression Scale, Sheehan Disability Scale (SDS)), but only the Mini

International Neuropsychiatric Interview (MINI) is available. Consequently, the expert panel recommends that healthcare practitioners in the region work at developing culturally appropriate tools in the future. In addition, the patients themselves, as well as the clinic staff, could be involved in the completion of the measurement tools.

Recommendations for the treatment of major depressive disorder Treatment modalities

Modalities for the treatment of acute phase major depressive disorder include active management, pharmacotherapy, psychotherapy, a combination of medications and psychotherapy, and other approaches such as electroconvulsive therapy (ECT), also known as (BST) Brain Synchronization Treatment. Treatment selection should be influenced by the patient’s clinical features and preferences for treatment, as well as prior response, the treatment cost and the presence of co-

100

Okasha A, et al.

morbidities. The expert panel agreed on the levels of efficacy of the key treatment modalities used to provide

remission in acute phase MDD listed in Table 4.

Table 4. Recommended treatment modalities for acute phase of MDD based on severity

Modality Severity Mild Moderate Severe

without psychotic features

Severe with psychotic features

Pharmacotherapy alone Yes (Level 1)

Yes (Level 1)

Yes (Level 1)

Yes (combination of antidepressant and antipsychotic medication) (Level 1)

Pharmacotherapy + psychotherapy

Useful for patients with psychosocial/ interpersonal or social problems, intra-psychic conflict (Level 2)

Useful for patients with psychosocial/ interpersonal problems, intra-psychic conflict (Level 2)

Yes (Level 2)

Yes (combination of antidepressant and antipsychotic medication) (Level 2)

Psychotherapy alone Yes (Level 3)

Yes (Level 3)

No (Level 4)

No (Level 4)

BST* ECT**

No evidence Should not be used

No evidence Yes (Level 1)

Yes (Level 1)

TMS No evidence No evidence No evidence No evidence Adapted from APA 2010

BST - brain synchronization treatment, ECT - electroconvulsive therapy, TMS - transcranial magnetic stimulation

*BST is now the preferred nomenclature for ECT; however, the term ECT remains commonly used for this treatment in many Arabcountries. ECT is a misnomer as there should be no convulsion during the treatment. This change in nomenclature should help to reduce the stigma of ECT with patients and families (Okasha A and Okasha T, 2014. A plea to change the misnomer ECT. World Psychiatry 13:327).

**According to the APA guidelines (APA, 2010), BST (ECT) is a treatment option for pregnant patients with moderate to severe depression who are unresponsive to or unsuitable for pharmacotherapy; for pregnant patients with MDD with psychotic features; and for pregnant patients who choose this modality as a matter of preference. Based on review studies and meta-analyses suggesting that the risk of hazardous side effects, although minimal, is not zero, the expert panel recommends that the optimal benefit-to-risk trade-off be determined and documented in each case.

Providing active support, advice on exercise, accurate education on and correcting popular misconceptions about the disorder, encouraging self-management and activation of social support networks (family, friends), and referral for counseling if available are often helpful adjunctive measures. However, they are not intended to replace or substitute for the standard, evidence-based treatments for MDD listed in Table 4.

Depression-focused psychotherapies such as Interpersonal Psychotherapy (IPT) and Cognitive Behavioral Therapy (CBT) should be considered in the

treatment plan in combination with medication, especially for those who have had a good response to a particular psychotherapy in the past or who strongly prefer to avoid medication. However, IPT, CBT or psychotherapy should not be mandatory adjuncts to medication for patients who prefer to avoid it.

Pharmacotherapy

The overall goals of treatment of MDD should focus on alleviating functional impairments and improving quality of life in addition to achieving symptom and episode remission.

101


Selection criteria for antidepressants

Antidepressants are classified as tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs) and other novel antidepressants. Overall efficacy between classes is similar, but safety and tolerability vary across and within classes of antidepressants as well as across individuals.

The selection of an appropriate antidepressant medication should take into consideration the patient’s preference, the nature of the prior response to a medication, the family history of response to a specific antidepressant, the safety and tolerability profile, the patient’s psychiatric and medical comorbidities, potential drug interactions, and cost.

Efficacy of antidepressants

• Serotonin norepinephrine reuptake inhibitorsThe ‘newer’ generation of antidepressants includes venlafaxine, desvenlafaxine, duloxetine, vortioxetine and milnacipran which all demonstrate superior efficacy when compared with placebo.22, 23 Several randomized controlled trials have shown similar efficacy between venlafaxine and duloxetine, and SSRIs.24, 25

• Selective serotonin reuptake inhibitorsThis class includes fluoxetine, sertraline, paroxetine, citalopram, escitalopram, fluvoxamine, and vilazodone. Several studies show no differences in efficacy within this class of antidepressants.23, 26-28 SSRIs are superior to placebo in the treatment of MDD and their efficacy matches that of TCAs.29, 30 Tricyclic antidepressants, these ‘older’ antidepressants, have a well-established efficacy in treating MDD when compared with SSRIs, SNRIs and MAOIs.31 They are effective in treating hospitalized patients with severe to moderate–severe major depressive disorder.32, 33 Based on the efficacy registration studies, the FDA did not approve fluvoxamine for the treatment of MDD.

• Monoamine oxidase inhibitors

These antidepressants are usually not considered first-line treatment, despite their comparable efficacy to other classes, given their safety issues.34, 35 In fact, MAOIs are now mostly prescribed to patients with MDD who have tried several other medications without adequate response.

• Other antidepressantsThe efficacy of bupropion is comparable to that of the SSRIs, but unlike most other antidepressants it is not effective in addressing any primary anxiety disorder.36 It might, however, be helpful in the treatment of MDD in overweight or obese patients given the minimal weight gain typically experienced. The noradrenergic/specific serotonergic agent (NaSSA) mirtazapine is comparable to SSRIs in terms of efficacy.37, 38 Trazodone, a serotonin modulator, is an effective antidepressant when compared with placebo,39,40 but is more frequently used in clinical practice for its sedative–hypnotic effect. It is used, but not approved for any insomnia indication. Trazodone can cause postural hypotension in elderly patients.17 Agomelatine has been shown to be superior to placebo in some double-blind placebo-controlled registration trials, but is not approved by the FDA for the treatment of major depressive disorder, because the risk benefit trade off was judged unacceptable.41

Safety of antidepressants

Given the comparable efficacy across the various antidepressant classes and agents, the selection of an antidepressant is generally based on its safety and tolerability. Safety differs across classes and may differ within a class. Polypharmacy is common in patients with MDD because of associated medical and psychiatric co-morbidities and limited response to antidepressant monotherapy. Safety within individuals may be based on the potential for drug–drug interactions given most antidepressants’ effect on cytochrome P450 enzymes (Tables 5 and 6, Figure 1).

102

Okasha A, et al.

Figure 1: How antidepressants are metabolized

Table 5. Cytochrome P450 enzyme inhibition by antidepressant agents

1A2 2A6 2B6 2C8 2C9 2C19 2D6 2E1 3A4 Amitriptyline † † † Bupropion ††† Citalopram † † † † Desipramine †† †† †† † †† Desvenlafaxine † Duloxetine †† Escitalopram †† Fluoxetine Norfluoxetine

†† †

†† ††

†† † †

†† ††† ††

† †

Imipramine † † † † Milnacipran Mirtazapine † † Nortriptyline †† † † †† Paroxetine † ††† † † ††† † Selegiline † † † † † † † Sertraline Desmethylsertraline

† †† †

† † †

†† †† †

†† †

Venlafaxine † † † Vilazodone †† †† †† Vortioxetine † Agomelatine

Adapted from APA 2010

Note: The antidepressants in the first column inhibit the CYP450 enzymes indicated in columns 2-10. For example, fluoxetine is a major inhibitor of CYP 2D6. By inhibiting 2D6, this will result in an increased blood level of medications metabolized by the 2D6 system including most tricyclic antidepressants and many neuroleptics, causing an increase in side effects and toxicity associated with these latter medications.

103


Table 6. Cytochrome P450 enzyme metabolism of antidepressant agents

1A2 2B6 2C9 2C19 2D6 3A4

Amitriptyline † † †† †† †† † Bupropion Hydroxybupropion

† †† † † ††

Citalopram †† † †† Desipramine † †† Desvenlafaxine † Duloxetine †† †† Escitalopram †† † † Fluoxetine Norfluoxetine

† † †† † †† †††

†

Imipramine †† † †† †† †† Maprotiline † †† Milnacipran †† Mirtazapine

8-Hydroxymirtazapine Mirtazapine-N-oxide

†† † †† ††

† †† ††

Nortriptyline † † †† † Paroxetine †† Protriptyline †† Selegiline † †† † † Sertraline †† † †† † † Venlafaxine O-Norvenlafaxine

† † †† ††

†

Vilazodone ††

Vortioxetine ††

Agomelatine ††† † † Adapted from APA 2010

Note: The antidepressants in the first column are metabolized by the CYP450 enzymes indicated in columns 2-7. For example, medications like fluvoxamine or ciprofloxacin that inhibit the 1A2 system will result in increased blood levels of all meds metabolized by the 1A2 system e.g. agomelatine, mirtazapine and imipramine, causing an increase in side effects and toxicity associated with these medications.

The relative risks and benefits of all medications must be considered when looking at treatment options (Table 7). Based on the FDA and EMA (CHMP) Product

Information reports, the expert panel agreed on the safety classification of treatment modalities for MDD listed in Table 8.

104

Okasha A, et al.

Table 7. Potential side effects of antidepressant classes

Antidepressant class Side effects SSRIs and SNRIs Nausea, vomiting, sexual side effects (delayed time to orgasm or

ejaculation or orgasmic or ejaculatory blockade), headaches, activation, abnormal bleeding, hypertension, hyponatremia, potential dose-dependent QT interval prolongation (citalopram), increased risk of suicidal ideation and behaviors in children and adolescents and those under 25*.

TCAs Cardiovascular: arrhythmia, tachycardia, orthostatic hypotension, QT interval prolongation Anticholinergic: constipation, dry mouth, urinary hesitancy, Increased risk of suicidal ideation and behaviors in adolescents and those under 25*. Hepatotoxicity, blood dyscrasias, delirium.

MAOIs* Hypertension (with high-tyramine foods or other vasoactive amines from medications)

Others Bupropion* Insomnia, activation, dry mouth, seizures Mirtazapine* Weight gain, sedation, dry mouth, agranulocytosis Trazodone* Sedation, priapism, postural hypotension in elderly Agomelatine* and ** Hepatotoxicity

MAOI, monoamine oxidase inhibitor; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant.

* All antidepressants have suicidality risk as a class warning in the labeling.

** It is important to monitor liver function when treating patients with agomelatine. As per product labeling, agomelatine is contraindicated in patients with liver impairment and in those taking any CYP 1A2 inhibitor (e.g. fluvoxamine and ciprofloxacin). Proceed with caution when prescribing agomelatine to patients with pre-treatment elevated transaminase levels or hepatic injury risk factors, e.g. obesity/overweight/non-alcoholic fatty liver disease, substantial alcohol intake or use of concomitant medicines associated with risk of hepatic injury, diabetes. Prescribers are also reminded that agomelatine is contraindicated in patients with hepatic impairment i.e. cirrhosis or active liver disease.

Table 8. Levels of safety based on FDA Product Information

Level Definition Treatment 1 Minimal safety concern* SSRIs, SNRIs, bupropion, mirtazapine, trazodone, TMS

(the Neuronetics and the Brainsway Ltd devices only), CBT, psychotherapy

2 Modest safety concern** TCAs, MAOIs, augmenting atypical neuroleptics

3 Of serious clinical concern*** BST (ECT), VNS, agomelatine

BST, brain synchronization treatment; CBT, cognitive behavioral therapy; ECT, electroconvulsive therapy; MAOI, monoamine oxidase inhibitor; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant; TMS, transcranial magnetic stimulation; VNS, vagus nerve stimulation

*No investigations, no dosing procedures or dietary/drug restrictions recommended by regulatory agencies.

**Good clinical practice suggests that certain investigations be done or dosing procedures or dietary/drug restrictions be followed for some patients under some circumstances, but FDA or EMA regulatory agencies do not routinely recommend or mandate such investigations.

***Mandatory investigations for all patients.

Implementation of pharmacological intervention

Based on the review of efficacy and safety data of the various treatment modalities for MDD, the expert panel

developed a treatment algorithm to guide clinicians who treat patients with MDD in the Middle East region, shown

105


in Table 9. The final assignment for each drug or drug class was based on risk-benefit tradeoffs that emerged

from the review of the efficacy and safety data.

Table 9. Treatment algorithm for major depressive disorder

Line of treatment Treatment modality First line SSRIs and SNRIs Second line Bupropion SR or XL, trazodone, mirtazapine Third line TCAs, agomelatine Fourth line MAOIs, tianeptine Fifth line BST (ECT), TMS

BST, brain synchronization treatment; ECT, electroconvulsive therapy; MAOI, monoamine oxidase inhibitor; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant; TMS, transcranial magnetic stimulation.

Note: All above medications have serious side effects. Please check the FDA Product Information prior to recommending to your patient. Nefazodone has been withdrawn from most countries and is not indicated for the treatment of MDD.

The consensus group also discussed the importance of basic investigations upon implementation of pharmacotherapy as well as necessary monitoring. They suggest obtaining a basic metabolic panel (including liver function and kidney function tests, glucose level, HbA1c) on all patients before starting any psychiatric medication, particularly in view of the high incidence of diabetes and diabetic renal complications in the Middle East region.42 This should be encouraged. In the final analysis, the need for such additional testing should be based on medical and family history and any associated physical findings. In addition, liver function tests should be assessed prior to

treatment and after dose stabilization and monitored regularly for patients on agomelatine.23 Blood pressure assessment and monitoring should be performed for patients on SNRIs and MAOIs. For treatment with TCAs43 the panel also recommended electrocardiograms (ECGs) at baseline, after initial dose stabilization, and after significant dose changes, with special attention to PR and QTc interval prolongation and arrhythmias. Caution is needed in children, in those over the age of 60 or with cardiovascular disease, and at higher doses. Recommended monitoring for antidepressants and adjuvants are shown in Table 10.

Table 10. Recommended monitoring of some medications and adjuvants used in the treatment of MDD

Agent Recommended monitoring Frequency Agomelatine* Liver function tests 1. At baseline initiation

2. At 3, 6, 12, 24 weeks after initiation or dosage increase, withfurther testing when clinically indicated and every 4 months after week 24

TCAs ECG Pre-treatment: o Patients with cardiovascular risk factorso Patients < 18 years or >50 years or

ECG monitoring is recommended twice yearly for patients prescribed a higher dose. When the dose is stabilized, a minimum of an annual ECG is recommended in the absence of CVD.

Lithium Lithium levels After each dose change from 900 mg per day and higher and thereafter every 2 months (due to hot and humid weather in the Middle East region, lithium monitoring might be needed more often).

Serum creatinine, free T4, free T3 and TSH

Every 4 months

106

Okasha A, et al.

Atypical anti-psychotic

Lipid panel Blood glucose

At the start of treatment and periodically during treatment

Thyroid hormone

Free T4, Free T3, TSH Every 6 months after stabilization

CVD, cardiovascular disease; ECG, electrocardiogram; T4, T3, thyroxine; TCA, tricyclic antidepressant; TSH, thyroid-stimulating hormone

* Source: EMA (CHMP) and Australian Regulatory Agency Product Information documents

Partial and non-response in major depressive disorder

Partial response is defined as less than 50% improvement of baseline level of severity. Partial and non-response should be first addressed by gradually increasing the medication dose and allowing sufficient time for response. The expert panel recommends allowing four to six weeks following the increase to the maximum tolerated dose before switching to another first line agent (SSRIs and SNRIs). The expert committee’s recommended strategy for further lack of adequate response is switching to an antidepressant from another class or augmenting with any of the following adjuvants:

• Aripiprazole or quetiapine XR (Level 1)• Lithium (Level 2)• Olanzapine (Level 2)• T3 (Level 2)• Risperidone (Level 4)

• Lamotrigine (Level 4)

The panel agreed that switching to another class of antidepressants is not any more effective than switching to an agent within the same class.44

Treatment-resistant major depressive disorder

While there is no consensus definition of treatment-resistant major depressive disorder, the one most commonly used is <20% reduction in depression scores after a trial of at least two different classes of antidepressants at the maximum tolerated dose, for an adequate duration (i.e. eight weeks). Treatment options include augmentation with an agent or modality that is not an antidepressant, combining with another antidepressant or switching to a different agent (Table 11). The expert panel developed an algorithm for the management of pharmacotherapy in the occurrence of partial or non-response, shown in Figure 2.

Table 11. Levels of evidence for treatment augmentation in treatment-resistant depression

Augment with: Level of evidence

Aripiprazole* or quetiapine XR* or Neuronetics TMS

Level 1

Lithium or lamotrigine or BST (ECT) or L-methyl folate

Level 2

None Level 3

Mood stabilizer or other antipsychotic or another antidepressant

Level 4

Psychotherapy (CBT, interpersonal, family-focused)

Level 5

BST, brain synchronization treatment; CBT, cognitive behavioral therapy; ECT, electroconvulsive therapy; TMS, transcranial magnetic stimulation.

*FDA-approved for treatment-resistant depression.

107


Figure 2. Medication strategy for major depressive disorder

SSRI, selective serotonin reuptake inhibitor; SNRI, serotonin-norepinephrine reuptake inhibitor; TCA, tricyclic antidepressant; MAOI, monoamine oxidase inhibitor.

Length of pharmacological treatment and recurrence risk for MDD

Pharmacotherapy duration should take into consideration the number of major depressive episodes the patient has experienced. A first MDD episode warrants a minimum of 6 months of pharmacological treatment following clinical and functional remission. This is associated with a 50% recurrence risk within a year of recovery from the index episode. Antidepressants should be continued for three to five years after remission is achieved in the event of a second episode, which carries a 70% recurrence risk within a year of recovery. Finally, the third MDD episode is associated with greater than 90% recurrence risk within a year of recovery and therefore medications should be implemented indefinitely unless there is compelling evidence to justify discontinuation.45, 46

Other treatment modalities

Psychotherapy

Cognitive behavioral therapy (CBT) is currently the most studied and efficiently used psychotherapy option. CBT aims to solve problems by identifying and tracking the patient’s dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure focused on the present.47 CBT should only be done by trained therapists and is considered an effective mode of management of MDD.

Brain synchronization therapy (BST), electroconvulsive therapy (ECT)

The use of BST (ECT) is more prevalent in certain regions of the world. Several studies showed that maintenance BST (ECT) is beneficial especially in drug-resistant major depressive disorder, intolerance or contraindication to antidepressants.48,49 It can be effective acutely, but is not effective in protecting from long-term relapse.

Transcranial magnetic stimulation (TMS)

The use of TMS for the treatment of MDD is still in its early stage. Neuronetics Neuro-Star and Brainsway Ltd

Medication Strategy

Major Depressive Disorder

SSRI/SNRI

Level of recovery Failure to respond

Remission

Another SSRI Another SNRI

TCA MAOI

Atypical antipsychotics Lithium

Lamotrigine Sodium valproate

1 Year of Medication followed by

Drug - free trial

108

Okasha A, et al.

are currently the only FDA-approved devices for MDD subjects who are either treatment-resistant (Brainsway Ltd) or have failed to achieve satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode (Neuronetics).50-60 The results from most studies conducted with devices other than the Neuronetics and Brainsway devices varied in efficacy and could not be clearly established due to the wide variability in the quality of the other TMS devices used.61,62 One study showed that a better acute response to TMS could result in less treatment resistance.63 The user manual for the Neuronetics device warns that effectiveness has not been established in patients with MDD who have failed to achieve satisfactory improvement from zero and from two or more antidepressant medications in the current episode and that, the device has not been studied in patients who have had no prior antidepressant medication.

Treatment not approved as monotherapy

The panel of experts agreed that the following treatment modalities should not be used as monotherapy in the treatment of major depressive disorder:

• Benzodiazepines are not antidepressants. Theyare effective only for anxiety symptoms. They have no specific effect on depressive symptoms or MDD overall. However, they can be helpful for anxiety co-occurring with MDD when used in conjunction with an antidepressant.64,65

• Atypical neuroleptics are a useful augmentationstrategy, but should not be used as monotherapy due to the substantial risk of metabolic syndrome and high rates of diabetes in the Middle East region.

• Typical neuroleptics• Anticonvulsants• Lithium is not an effective treatment for acute

depressive episodes, but it can be used to augment response. It is effective in protecting from future relapses and it has a better anti-suicidal effect than other antidepressants.66-68

• L-methyl folate• St. John’s Wort*, acupuncture, homeopathy

*The value of St. John’s Wort in the treatment of MDDhas been the subject of multiple studies leading to variable outcomes. However, the two largest and most rigorous placebo-controlled, multicenter trials conducted in the United States both found St. John’s Wort ineffective in the treatment of MDD.69,70 Furthermore, the potential for drug–drug interactions is a major consideration. Through its effect on CYP 3A4, St. John’s Wort induces

metabolism of various drugs such as antiretroviral medications, immunosuppressants (including cyclosporine), antineoplastic agents, anticoagulants (including warfarin), oral contraceptives, and hormone replacement therapy, resulting in a reduction of efficacy with those medications.71-73

Treatment compliance

To assess and promote patient compliance, clinicians should inquire about any history of previous non-compliance, family support and cultural or religious attitudes that might affect treatment adherence. Patient and family education is pivotal. It is particularly important to emphasize that antidepressants are not addictive. Patient education regarding time to response, time to remission and necessary duration of treatment with antidepressants plays an important role in setting expectations. Medication side effects should also be addressed as they often drive patient non-compliance. Enlisting the collaboration of family and of the patient’s support network in ensuring compliance with the treatment plan is even more important in Arab than in Western countries.

Suicidality

Suicide is difficult to predict and suicidal ideation and behavior should be assessed before starting treatment and then monitored repeatedly throughout the course of treatment for all patients with MDD. The expert panel agreed that any patient at significant suicidal risk should be admitted for treatment based on local laws. In the region, particular consideration should be given to “accidents and accidental overdoses”.

Recent studies report that the risk of treatment emergent suicidal ideation and behaviors on antidepressants is age-dependent.74 In a study by Stone, the risk of suicidal ideation and suicidal behavior in adults under 25 years of age was higher than placebo and this risk increased as the age decreased. In those between 25 and 65 antidepressants had the same effect as placebo on treatment emergent suicidal ideation and behavior.74 Only in those aged ≥65 do antidepressants decrease the risk compared to placebo. Recognizing the variety of antidepressants and treatment options currently available for the treatment of MDD, the panel of experts recommends advising patients of all age groups on the risks and benefits of treating their condition with an antidepressant or with other treatments, as well as the risks and benefits of not treating their condition. Major Depressive Disorder significantly increases the risk of suicidal ideation and behavior. This risk is higher if a family member has thought of or attempted suicide. The

109


patient’s condition, symptoms and personal and family medical history should be taken into consideration when deciding on the appropriate type of treatment.

Special populations

Children and adolescents

Antidepressants have all consistently failed to separate from placebo in children under the age of 18, except for fluoxetine and escitalopram, which are FDA-approved for the acute and maintenance treatment of major depressive disorder in pediatric patients aged 8 to 18 years (fluoxetine) and 12 to 17 years (escitalopram). This population should be monitored closely given the elevated risk of suicide.

Elderly

The presence of chronic illness is a risk factor for major depressive disorder in this patient population. The increased risk for completed suicide associated with males over the age of 65 years mandates that suicide risk assessment be part of the evaluation.75 Special consideration should be given to drug–drug interactions given the polypharmacy in this population. Treatment should not be initiated with the maximum dose of antidepressant and more time to response should be allowed due to slower drug metabolism in this age group.

Substance use disorder

The evidence for the treatment of MDD when it is co-morbid with substance abuse and dependence is limited (Level 5). MDD should be treated as usual with consideration for the substance use disorder. Clinical experience, but not compelling scientific evidence, suggests that proper treatment of the MDD enhances compliance in managing the substance use disorder and in adherence to the long-term abstinence from the abused substance (Level 5).

Pregnancy and breastfeeding

There are no controlled trials on the use of antidepressants during pregnancy. Most antidepressants are labeled as Category C. This means that there are animal data suggesting teratogenic effects and no compelling evidence supporting the safety of the medication for the human fetus. The FDA labels paroxetine as pregnancy Category D, which means that studies in pregnant women (controlled or observational) have demonstrated a risk to the human fetus (atrial and ventricular septal defects, persistent pulmonary hypertension of the newborn), but the benefits of therapy may still outweigh the potential risks to the fetus. A recent population-based cohort study from all Nordic countries (Denmark, Finland, Iceland, Norway and Sweden) showed no significant association

between the use of SSRI antidepressants during pregnancy and risk of stillbirth, neonatal death or postnatal death. Rates of stillbirth and postnatal death were higher in women who used SSRIs than those who did not, but statistical analyses showed that the increase was more likely to be due to other factors - such as severity of underlying psychiatric illness, smoking and older age - that were more common among SSRI users.76

The panel recommends tackling this issue on a case-by-case basis through conducting a simple risk analysis weighing the pros and cons and taking into consideration the cultural background of the family and their personal preferences.

Value of generics

Given the large number of generic medications available in the region, the expert panel offers a note of caution and warns that not all generics are equally good. Quality control is not carried out on all generic products in Arab countries. To obtain FDA approval, a generic in the USA must have bioavailability of between 80% and 125% of the approved brand.77 There are many generics not allowed into the USA for this reason. The panel recommends that people in Arab countries not be exposed to the hazards of flawed generics, as in Canada, Europe and the USA. Due to the variability in bioavailability, patients who are clinically stable on a specific generic should not be switched to a different one; if switched, patients need to be monitored for either an increase in side effects or loss of efficacy.

Conclusion The current report has summarized the consensus agreement of an expert panel for the treatment of MDD in the Middle East region based on evidence-based international guidelines and a review of the relevant literature. It is the opinion of the expert panel that the diagnosis and treatment of MDD should be done systematically using psychiatric measurement tools. The panel encourages the development of regional culturally appropriate depression scales and questionnaires. All classes of antidepressants are equal in terms of efficacy. However, safety and tolerability often differ and determine the selection of antidepressant. Consequently, the expert panel based its treatment recommendations on levels of evidence for efficacy AND safety developed according to the FDA Product Information reports. For drugs not approved by the FDA, the safety data is based on EMA regulatory documents. For all patients, and particularly those with partial or non-response to

110

Okasha A, et al.

pharmacological treatment, it is pivotal to ensure that the adequate dose of antidepressant is used for the appropriate treatment duration. Recurrence risk should be considered when deciding on pharmacological treatment duration. These guidelines provide clinicians with the appropriate evidence-based medication strategy for patients with partial or non-response to pharmacotherapy.

There is strong evidence that improvement in major depressive disorder also comes from non-pharmacological aspects of the intervention; a very important factor is the therapeutic alliance. The relationship between therapeutic alliance and outcome seems remarkably robust across treatment modalities and clinical presentations.78 What emerges from the evidence is that non-specific factors (client variables, extra-therapeutic events, relationship variables and expectancy and placebo effects) account for about 85% of the variance in therapeutic outcomes across the psychotherapy field.

The compliance of psychiatrists with practice guidelines is usually poor in the region. This could be due to the lack of culturally tailored recommendations. Given the regional specificity of these guidelines for the treatment of MDD (addressing social determinants, religious beliefs, available resources and reaction to treatment modalities), compliance might increase and lead to improved patient outcomes. Members of the working group acknowledged that these guidelines should be followed as closely as possible and used alongside clinical judgment. It is also recommended that collaborative projects be developed and initiated regionally to study clinical outcomes of treatment of MDD in the Middle East.

Author disclosures and acknowledgments Funding for the meetings to develop the Guidelines was provided by Pfizer. During the year when these guidelines were developed, no pharmaceutical company, with the exception of Servier, lobbied members of the Guidelines Board for a more favorable mention of their product in the guidelines.

Medical writing support for the development of this manuscript was provided by Sonia Laflamme (SL), who was an employee of Choice Healthcare Solutions (CHS) and was funded by Pfizer. During the development of this manuscript, SL left CHS and was a paid consultant to Pfizer for completion of this manuscript.

Dr. Okasha has received travel expenses from Pfizer for the submitted work; outside the submitted work, he has received consulting fees from Pfizer and other financial support from the Institute of Psychiatry, Ain Shams University in Cairo, Egypt. Dr. Alkhadhari has received

travel expenses from Pfizer for the submitted work; he also received consulting fees and travel expenses from Eli Lilly, GlaxoSmithKline, Servier, AstraZeneca, Janssen, Lundbeck, and Novartis. Dr. Al Sharqi has received travel expenses from Pfizer for the submitted work. Dr. Al Sherif has received travel expenses from Pfizer for the submitted work. Dr. Asaad has received travel expenses from Pfizer for the submitted work. Dr. Hachem has received travel expenses from Pfizer for the work submitted; he received honorariums from AstraZeneca, Lundbeck, and Pfizer for his participation in advisory boards; he received consulting fees from Janssen and Novartis; he received sponsorships from Eli Lilly and Servier to attend scientific conferences; he also received honorariums for speaking engagements with GlaxoSmithKline; he was paid honorariums by Bristol-Myers Squibb, Servier, and Roche for his participation in scientific activities. Dr. Karrani has received travel expenses from Pfizer for the submitted work; he also received consulting fees and travel expenses from Lundbeck, Janssen, Servier, Eli Lilly, GlaxoSmithKline, and Pfizer outside the submitted work. Dr. Khan has received travel expenses from Pfizer for the submitted work; he received travel expenses and an honorarium from AstraZeneca as scientific workshop chair; he also received honorariums from Eli Lilly and Bristol-Myers Squibb as scientific workshop chair. Sonia Laflamme was an employee of Choice Healthcare Solutions who was a paid consultant to Pfizer in connection with the development of this manuscript. She also received honorarium from Pfizer in connection with the development of this manuscript. During the course of the project, she met ICMJE (International Committee of Medical Journal Editors) criteria for authorship but received no additional compensation by Pfizer. Dr. Osman has received travel accommodations’ from Pfizer for the submitted work; he also received sponsorship or travel expenses from Lundbeck, AstraZeneca, and Servier for attending scientific conferences. Dr. Ramy has received travel expenses from Pfizer for the submitted work; he has received consulting fees for advisory boards and/or speaking engagements from Sanofi Aventis, Servier, AstraZeneca, GlaxoSmithKline, MSD, Eli Lilly, and Lundbeck; he also received honorarium from Abbott for the training of medical representatives. Dr. Sarhan has received consulting fees from Hikma Phamaceuticals, AstraZeneca, and Janssen outside the submitted work. Dr. Sheehan has received travel expenses from Pfizer for the submitted work; outside the submitted work, he has received grant funding support, or been affiliated or received honoraria and travel expenses related to lectures/presentations or consultant activities from the following organizations: Abbott Laboratories1,2,3, Ad Hoc Committee, Treatment Drug and Assessment Research Review1, Alexa1, Alza Pharmaceuticals, Palo Alto,

111


California1, American Medical Association2, American Psychiatric Association Task Force on Benzodiazepine Dependency1, American Psychiatric Association Task Force on Treatments of Psychiatric Disorders1, American Psychiatric Association Working Group to revise DSM III Anxiety Disorders Section1, Anclote Foundation2, Anxiety Disorders Resource Center1, Anxiety Drug Efficacy Case, U.S. Food and Drug Administration1, Applied health Outcomes/ xCenda1, Apsen Pharma3, AstraZeneca1,23, Avera Pharmaceuticals1, 2, BioMarin1, Bionomics1, Boehringer Ingelheim3, Boots Pharmaceuticals3, Bristol-Myers Squibb1,2,3, Burroughs Wellcome2,3, Cephalon1, Charter Hospitals3, Ciba Geigy3, Committee (RRC) of N.I.M.H. on Anxiety and Phobic Disorder Projects1, Connecticut and Ohio Academies of Family Physicians1, Cortex Pharmaceutical1, Council on Anxiety Disorders1, CPC Coliseum Medical Center1, Cypress Bioscience1, Daiichi Sumitomo2, Dista Products Company3, Division of Drugs and Technology, American Medical Association1, EISAI1, 2, Eli Lilly1,2,3, Excerpta Medica Asia3, Faxmed, Inc1, Forest Laboratories1,2, Glaxo Pharmaceuticals3, GlaxoSmithKline1,2,3, Glaxo-Wellcome2, Hikma Pharmaceuticals3, Hospital Corporation of America3, Humana3, ICI3, INC Research1,3, International Clinical Research (ICR)2, International Society for CNS Drug Development (ISCDD)1, Janssen Pharmaceutica1,2,3, Jazz Pharmaceuticals1,2, Kali-Duphar2,3, Labopharm-Angellini1,2,3, Layton Bioscience1, Lilly Research Laboratories1, Lundbeck1,2,3, Marion Merrill Dow3, McNeil Pharmaceuticals3, Mead Johnson2,3, Macmillan3, MAPI1, Medical Outcome Systems4, MediciNova1,2, Merck Sharp and Dohme2,3, National Anxiety Awareness Program1, National Anxiety Foundation1, National Depressive and Manic Depressive Association1, National Institute of Drug Abuse2, National Institute of Health (NIH)2, Neuronetics1, NovaDel1, Novartis Pharmaceuticals Corp.1,2, Novo Nordisk3, Organon1,3, Orion Pharma1, Parexel International Corporation1, Otsuka1, Parke-Davis2,3, Pfizer1,2,3, Pharmacia1, Pharmacia and Upjohn1,3, PharmaNeuroBoost1,3, Philadelphia College of Pharmacy and Science1, Pierre Fabre, France1, Quintiles2, ProPhase1, Rhone Laboratories3, Rhone-Poulenc Rorer Pharmaceuticals3, Roche1, Roerig3, Sagene Pharma1, Sandoz Pharmaceuticals2,3, Sanofi-Aventis1,2,3, Sanofi-Synthelabo Recherche/Sanofi Aventis1,2, Schering Corporation3, Sepracor1, Shire Laboratories, Inc1, Simon and Schuster3, SmithKlineBeecham1,2,3, Solvay Pharmaceuticals1,3, Sunovion2,3, Takeda Pharmaceuticals1,2,3, Tampa General Hosp.1, University of South Florida Psychiatry Center2, University of South Florida College of Medicine. TAP Pharmaceuticals2,3, Targacept1, TGH-University

Psychiatry Center3, Tikvah Therapeutics1, Titan Pharmaceuticals1, United Bioscience1,2,3, The Upjohn Company1,2,3, U.S. Congress-House of Representatives Committee1, USF Friends of Research in Psychiatry, Board of Trustees1, Warner Chilcott2, 3, World Health Organization1, Worldwide Clinical Trials2, Wyeth-Ayerst1,2,3, ZARS1, Zeneca Pharmaceuticals2, Neuronetics1.

1, Consultant; 2, Grant/Research Support; 3, Lectures/Presentations/Royalties; 4, Stock Holder

References

1. World Health Organization. Global status report onalcohol and health 2014. World Health Organization; 2014.

2. Alhasnawi S, Sadik S, Rasheed M, Baban A, Al-AlakMM, Othman AY, Othman Y, Ismet N, Shawani O, Murthy S, Aljadiry M. The prevalence and correlates of DSM-IV disorders in the Iraq Mental Health Survey (IMHS). World Psychiatry. 2009 Jun; 8(2):97.

3. Kadri N, Agoub M, Assouab F, Tazi MA, Didouh A,Stewart R, Moussaoui D. Moroccan national study on prevalence of mental disorders: a community‐based epidemiological study. Acta Psychiatr Scand. 2010 Jan 1; 121(1):71-4.

4. Ghanem M, Gadallah M, Meky FA, Mourad S, El-KholyG. National Survey of Prevalence of Mental Disorders in Egypt: preliminary survey/Enquete nationale sur la prevalence des troubles mentaux en Egypte: etude preliminaire. East Medit Health J. 2009 Jan 1; 15(1):65-76.

5. Okasha A, Karam E. Mental health services and researchin the Arab world. Acta Psychiatr Scand. 1998 Nov 1; 98(5):406-13.

6. Karam EG, Mneimneh ZN, Karam AN, Fayyad JA,Nasser SC, Chatterji S, Kessler RC. Prevalence and treatment of mental disorders in Lebanon: a national epidemiological survey. The Lancet. 2006 Mar 31;367(9515):1000-6.

7. Okasha A, Khalil AH, El Fiky MR, Ghanem M, Abdel-Hakeem R. Prevalence of depressive disorders in a sample of rural and urban Egyptian communities. Egypt J Psychiatry. 1988;11:167-81.

8. Okasha A, Karam E, Okasha T. Mental health services inthe Arab world. World Psychiatry. 2012 Feb 1;11(1):52-4.

9. Okasha A. Focus on psychiatry in Egypt. The BritishJournal of Psychiatry. 2004 Sep 1;185(3):266-72.

10. Osman OT, Afifi M. Troubled minds in the Gulf: mentalhealth research in the United Arab Emirates (1989-2008). Asia Pac J Public Health. 2010 Jul;22(3_suppl):48S-53S.

11. Kennedy SH, Lam RW, Parikh SV, Patten SB,Ravindran AV. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for

112

Okasha A, et al.

the management of major depressive disorder in adults. J Affect Disord. 2009 Oct 31;117:S1-2.

12. Parikh SV, Segal ZV, Grigoriadis S, Ravindran AV,Kennedy SH, Lam RW, Patten SB. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication. J Affect Disord. 2009 Oct 31;117:S15-25.

13. Patten SB, Kennedy SH, Lam RW, O'Donovan C, Filteau MJ, Parikh SV, Ravindran AV. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. I. Classification, burden and principles of management. J Affect Disord. 2009 Oct 31; 117:S5-14.

14. Lam RW, Kennedy SH, Grigoriadis S, McIntyre RS,Milev R, Ramasubbu R, Parikh SV, Patten SB, Ravindran AV. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. III. Pharmacotherapy. J Affect Disord. 2009 Oct 31;117:S26-43.

15. Ravindran AV, Lam RW, Filteau MJ, Lespérance F,Kennedy SH, Parikh SV, Patten SB. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. V. Complementary and alternative medicine treatments. J Affect Disord. 2009 Oct 31; 117:S54-64.

16. Kennedy SH, Milev R, Giacobbe P, Ramasubbu R, LamRW, Parikh SV, Patten SB, Ravindran AV. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults.: IV. Neurostimulation therapies. J Affect Disord. 2009 Oct 31; 117:S44-53.

17. Gelenberg AJ, Freeman MP, Markowitz JC, RosenbaumJF, Thase ME, Trivedi MH, Van Rhoads RS, Reus VI, J Raymond DePaulo Jr MD, Fawcett JA, Schneck CD. Practice guideline for the treatment of patients with major depressive disorder third edition. Am J Psychiatry. 2010 Oct 1;167(10):1.

18. Bauer M, Pfennig A, Severus E, Whybrow PC, Angst J,Möller HJ. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders, part 1: update 2013 on the acute and continuation treatment of unipolar depressive disorders. World J Biol Psychiatry. 2013 Jul 1; 14(5):334-85.

19. Bauer M, Bschor T, Pfennig A, Whybrow PC, Angst J,Versiani M, Möller HJ, WFSBP Task Force on Unipolar Depressive Disorders, Bauer M, Bschor T, Pfennig A. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders in primary care. World J Biol Psychiatry. 2007 Jan 1; 8(2):67-104.

20. Lam RW, McIntosh D, Wang J, Enns MW, Kolivakis T,Michalak EE, Sareen J, Song WY, Kennedy SH, MacQueen GM, Milev RV. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical

guidelines for the management of adults with major depressive disorder:

21. Bordin ES. The generalizability of the psychoanalyticconcept of the working alliance. Psychother: Theor, Res Pract. 1979; 16(3):252.

22. Thase ME, Kornstein SG, Germain JM, Jiang Q, Guico-Pabia C, Ninan PT. An integrated analysis of the efficacy of desvenlafaxine compared with placebo in patients with major depressive disorder. CNS Spectrums. 2009 Mar 1;14(03):144-54.

23. Gartlehner G, Gaynes BN, Hansen RA, Thieda P,DeVeaugh-Geiss A, Krebs EE, Moore CG, Morgan L, Lohr KN. Comparative benefits and harms of second-generation antidepressants: background paper for the American College of Physicians. Ann Intern Med. 2008 Nov 18; 149(10):734-50.

24. Nemeroff CB, Entsuah R, Benattia I, Demitrack M,Sloan DM, Thase ME. Comprehensive analysis of remission (COMPARE) with venlafaxine versus SSRIs. Biol Psychiatry. 2008 Feb 15;63(4):424-34.

25. Thase ME, Pritchett YL, Ossanna MJ, Swindle RW, XuJ, Detke MJ. Efficacy of duloxetine and selective serotonin reuptake inhibitors: comparisons as assessed by remission rates in patients with major depressive disorder. J Clin Psychopharm. 2007 Dec 1;27(6):672-6.

26. Cipriani A, Brambilla P, Furukawa TA, Geddes J, GregisM, Hotopf M, Malvini L, Barbui C. Fluoxetine versus other types of pharmacotherapy for depression. The Cochrane Library. 2005 Oct 19.

27. Kennedy SH, Andersen HF, Lam RW. Efficacy ofescitalopram in the treatment of major depressive disorder compared with conventional selective serotonin reuptake inhibitors and venlafaxine XR: a meta-analysis. J Psychiatry Neurosci. 2006 Mar 1; 31(2):122.

28. Murdoch D, Keam SJ. Escitalopram. Drugs. 2005 Nov 1;65(16):2379-404.

29. MacGillivray S, Arroll B, Hatcher S, Ogston S, Reid I,Sullivan F, Williams B, Crombie I. Efficacy and tolerability of selective serotonin reuptake inhibitors compared with tricyclic antidepressants in depression treated in primary care: systematic review and meta-analysis. BMJ. 2003 May 10;326(7397):1014.

30. Arroll B, Elley CR, Fishman T, Goodyear-Smith FA,Kenealy T, Blashki G, Kerse N, MacGillivray S. Antidepressants versus placebo for depression in primary care. Cochrane Database Syst Rev. 2009 Jul 8; 3.

31. Anderson IM. Selective serotonin reuptake inhibitorsversus tricyclic antidepressants: a meta-analysis of efficacy and tolerability. J Affective Disord. 2000 Apr 30; 58(1):19-36.

32. Anderson IM. SSRIs versus tricyclic antidepressants indepressed inpatients: A meta‐analysis of efficacy and tolerability. Depression and Anxiety. 1998 Jan 1;7(S1):11-7.

33. Barbui C, Hotopf M. Amitriptyline v. the rest: still theleading antidepressant after 40 years of randomised controlled trials. Brit J Psychiatry. 2001 Feb 1; 178(2):129-44.

113


34. Quitkin F, Rifkin A, Klein DF. Monoamine oxidaseinhibitors: a review of antidepressant effectiveness. Arch Gen Psychiatr. 1979 Jul 1; 36(7):749-60.

35. Thase ME, Trivedi MH, Rush AJ. MAOIs in thecontemporary treatment of depression. Neuropsychopharmacology. 1995 May 31;12(3):185-219.

36. Papakostas GI, Trivedi MH, Alpert JE, Seifert CA,Krishen A, Goodale EP, Tucker VL. Efficacy of bupropion and the selective serotonin reuptake inhibitors in the treatment of anxiety symptoms in major depressive disorder: a meta-analysis of individual patient data from 10 double-blind, randomized clinical trials. J Psychiatric Res. 2008 Jan 31; 42(2):134-40.

37. Papakostas GI, Fava M. A meta-analysis of clinical trialscomparing the serotonin (5HT)-2 receptor antagonists trazodone and nefazodone with selective serotonin reuptake inhibitors for the treatment of major depressive disorder. Eur Psychiatry. 2007 Oct 31;22(7):444-7.

38. Papakostas GI, Homberger CH, Fava M. A meta-analysisof clinical trials comparing mirtazapine with selective serotonin reuptake inhibitors for the treatment of major depressive disorder. Journal of psychopharmacology. 2008 Nov; 22(8):843-8.

39. Schatzberg AF. Trazodone: a 5-year review ofantidepressant efficacy. Psychopathology. 1987 Jul 1; 20(Suppl. 1):48-56.

40. Cunningham LA, Borison RL, Carman JS, Chouinard G,Crowder JE, Diamond BI, Fischer DE, Hearst E. A comparison of venlafaxine, trazodone, and placebo in major depression. J Clini Psychopharmacol. 1994; 14(2):99-106.

41. Howland RH. A benefit-risk assessment of agomelatinein the treatment of major depression. Drug safety. 2011 Sep 1; 34(9):709-31.

42. Badran M, Laher I. Type II diabetes mellitus in Arabic-speaking countries. Int J Endocrinol. 2012 Jul 18; 2012.

43. Pilling S, Anderson I, Goldberg D, Meader N, Taylor C,Two Guideline Development Groups. Depression in adults, including those with a chronic physical health problem: summary of NICE guidance. BMJ. 2009 Oct 27; 339(oct27 1):b4108-.

44. Gaynes BN, Warden D, Trivedi MH, Wisniewski SR,Fava M, Rush AJ. What did STAR* D teach us? Results from a large-scale, practical, clinical trial for patients with depression. Psychiatric Services. 2009 Nov; 60(11):1439-45.

45. Kupfer DJ. Long-term treatment of depression. J ClinPsychiatr. 1991 May; 52:28-34.

46. Geddes JR, Carney SM, Davies C, Furukawa TA, KupferDJ, Frank E, Goodwin GM. Relapse prevention with antidepressant drug treatment in depressive disorders: a systematic review. The Lancet. 2003 Feb 22; 361(9358):653-61.

47. Gersner R, Rosenberg O, Dannon PN. Major depressivedisorder: treatment and future perspective. Clin Pract. 2012 May; 9(3):269-78.

48. Andrade C, Kurinji S. Continuation and maintenanceECT: a review of recent research. J ECT. 2002 Sep 1; 18(3):149-58.

49. Procopio M. NICE guidelines and maintenance ECT.Brit J Psychiatr. 2003 Sep 1; 183(3):263-.

50. O’Reardon JP, Solvason HB, Janicak PG, Sampson S,Isenberg KE, Nahas Z, McDonald WM, Avery D, Fitzgerald PB, Loo C, Demitrack MA. Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial. Biol Psychiatr. 2007 Dec 1;62(11):1208-16.

51. Demitrack MA, Thase ME. Clinical significance oftranscranial magnetic stimulation (TMS) in the treatment of pharmacoresistant depression: synthesis of recent data. Psychopharmacol Bull. 2009 Jan 1; 42(2):5-38.

52. George MS, Lisanby SH, Avery D, McDonald WM,Durkalski V, Pavlicova M, Anderson B, Nahas Z, Bulow P, Zarkowski P, Holtzheimer PE. Daily left prefrontal transcranial magnetic stimulation therapy for major depressive disorder: a sham-controlled randomized trial. Arch Gen Psychiatr. 2010 May 1;67(5):507-16.

53. Avery DH, Isenberg KE, Sampson SM, Janicak PG,Lisanby SH, Maixner DF, Loo C, Thase ME, Demitrack MA, George MS. Transcranial magnetic stimulation in the acute treatment of major depressive disorder: clinical response in an open-label extension trial. J Clin Psychiatr. 2008 Mar 14; 69(3):441-51.

54. Carpenter LL, Janicak PG, Aaronson ST, Boyadjis T,Brock DG, Cook IA, Dunner DL, Lanocha K, Solvason HB, Demitrack MA. Transcranial magnetic stimulation (TMS) for major depression: a multisite, naturalistic, observational study of acute treatment outcomes in clinical practice. Depression and Anxiety. 2012 Jul 1; 29(7):587-96.

55. Janicak PG, Nahas Z, Lisanby SH, Solvason HB,Sampson SM, McDonald WM, Marangell LB, Rosenquist P, McCall WV, Kimball J, O’Reardon JP. Durability of clinical benefit with transcranial magnetic stimulation (TMS) in the treatment of pharmacoresistant major depression: assessment of relapse during a 6-month, multisite, open-label study. Brain Stimulation. 2010 Oct 31;3(4):187-99.

56. Simpson KN, Welch MJ, Kozel FA, Demitrack MA,Nahas Z. Cost-effectiveness of transcranial magnetic stimulation in the treatment of major depression: a health economics analysis. Advances in Therapy. 2009 Mar 1; 26(3):346-68.

57. Gaynes BN, Lux L, Lloyd S, Hansen RA, Gartlehner G,Thieda P, Brode S, Swinson Evans T, Jonas D, Crotty K, Viswanathan M, Lohr KN. Nonpharmacologic Interventions for Treatment-Resistant Depression in Adults. Comparative Effectiveness Review No. 33. (Prepared by RTI International-University of North Carolina (RTI-UNC) Evidence-based Practice Center under Contract No. 290-02-0016I.) AHRQ Publication No. 11-EHC056-EF. Rockville, MD: Agency for Healthcare Research and Quality. September 2011. www.effectivehealthcare.ahrq.gov/reports/final.cfm.

114

Okasha A, et al.

58. Schutter DJ. Antidepressant efficacy of high-frequencytranscranial magnetic stimulation over the left dorsolateral prefrontal cortex in double-blind sham-controlled designs: a meta-analysis. Psychological Medicine. 2009; 39(01):65-75.

59. Slotema CW, Dirk Blom J, Hoek HW, Sommer IE.Should we expand the toolbox of psychiatric treatment methods to include Repetitive Transcranial Magnetic Stimulation (rTMS)? A meta-analysis of the efficacy of rTMS in psychiatric disorders. J Clin Psychiatr. 2010 Jul 1; 71(7):873.

60. Allan CL, Herrmann LL, Ebmeier KP. Transcranialmagnetic stimulation in the management of mood disorders. Neuropsychobiol. 2011 Jul 29; 64(3):163-9.

61. Herwig U, Fallgatter AJ, HÖPPNER J, Eschweiler GW,Kron M, HAJAK G, Padberg F, Naderi-Heiden A, Abler B, Eichhammer P, Grossheinrich N. Antidepressant effects of augmentative transcranial magnetic stimulation. Brit J Psychiatr. 2007 Nov 1; 191(5):441-8.

62. Couturier JL. Efficacy of rapid-rate repetitivetranscranial magnetic stimulation in the treatment of depression: a systematic review and meta-analysis. J Psychiat Neurosci. 2005 Mar 1; 30(2):83.

63. Lisanby SH, Husain MM, Rosenquist PB, Maixner D,Gutierrez R, Krystal A, Gilmer W, Marangell LB, Aaronson S, Daskalakis ZJ, Canterbury R. Daily left prefrontal repetitive transcranial magnetic stimulation in the acute treatment of major depression: clinical predictors of outcome in a multisite, randomized controlled clinical trial. Neuropsychopharmacol. 2009 Jan 1; 34(2):522-34.

64. Valenstein M, Taylor KK, Austin K, Kales HC,McCarthy JF, Blow FC. Benzodiazepine use among depressed patients treated in mental health settings. Am Journal Psychiatr. 2004 Apr 1; 161(4):654-61.

65. American Psychiatric Association. Practice guideline forthe treatment of patients with panic disorder. American Psychiatric Association; 2009.

66. Baldessarini RJ, Tondo L, Hennen J. Lithium treatmentand suicide risk in major affective disorders: update and new findings. J Clin Psychiatr. 2003; 64:44.

67. Baldessarini RJ, Tondo L, Davis P, Pompili M, GoodwinFK, Hennen J. Decreased risk of suicides and attempts during long‐term lithium treatment: a meta‐analytic review. Bipolar Disorders. 2006 Oct 1; 8(5p2):625-39.

68. Cipriani A, Pretty H, Hawton K, Geddes JR. Lithium inthe prevention of suicidal behavior and all-cause mortality in patients with mood disorders: a systematic review of randomized trials. Am J Psychiatr. 2005 Oct 1; 162(10):1805-19.

69. Shelton RC, Keller MB, Gelenberg A, Dunner DL,Hirschfeld R, Thase ME, Russell J, Lydiard RB, Crits-Christoph P, Gallop R, Todd L. Effectiveness of St John's wort in major depression: a randomized controlled trial. JAMA. 2001 Apr 18; 285(15):1978-86.

70. Hypericum Depression Trial Study Group. Effect ofHypericum perforatum (St John's wort) in major depre

71. Hammerness P, Basch E, Ulbricht C, Barrette EP, FoppaI, Basch S, Bent S, Boon H, Ernst E, Natural Standard Research Collaboration. St. John’s wort: a systematic review of adverse effects and drug interactions for the consultation psychiatrist. Psychosomatics. 2003 Aug 31; 44(4):271-82.

72. Mannel M. Drug interactions with St John’s wort. DrugSafety. 2004 Sep 1; 27(11):773-97.

73. Mills E, Montori VM, Wu P, Gallicano K, Clarke M,Guyatt G. Interaction of St John's wort with conventional drugs: systematic review of clinical trials. BMJ. 2004 Jul 1; 329(7456):27-30.

74. Stone M, Laughren T, Jones ML, Levenson M, HollandPC, Hughes A, Hammad TA, Temple R, Rochester G. Risk of suicidality in clinical trials of antidepressants in adults: analysis of proprietary data submitted to US Food and Drug Administration. BMJ. 2009 Aug 11; 339:b2880.

75. Conwell Y, Thompson C. Suicidal behavior in elders.Psychiatric Clinics of North America. 2008 Jun 30; 31(2):333-56.

76. Stephansson O, Kieler H, Haglund B, Artama M,Engeland A, Furu K, Gissler M, Nørgaard M, Nielsen RB, Zoega H, Valdimarsdóttir U. Selective serotonin reuptake inhibitors during pregnancy and risk of stillbirth and infant mortality. JAMA. 2013 Jan 2; 309(1):48-54.

77. U.S. Department of Health and Human Services, F.D.A.,Center for Drug Evaluation and Research (CDER), Guidance for Industry Bioavailability and Bioequivalence Studies for Orally Administered Drug Products - General Considerations 2003.

78. Castonguay LG, Beutler LE. Principles of therapeuticchange that work. Oxford University Press, USA; 2006.

الملخص.یواجھ ممارسي الرعایة 2030في العبء الناتج عن األمراض عام كتئاب الجسیم ھو ثاني سبب إلعاقة البشر ومن المتوقع إن یكون األول عالمیا ضطراب اإلإإن

كتئاب العالمیة، تمر مختلف دول الشرق األوسط بضغوط مختلفة نتیجة الصراعات والحروب نتج عنھا إقلیمیھ ال تتعامل معھا دالئل اإلالصحیة العرب تحدیات م حول دلیل ھضطرابات النفسیة المتعلقة بالضغوط. التقى مجموعة من الخبراء العرب للوصول الى تفالتطرف وبالتالي ارتفاع معدالت اإلزیادة في اإلرھاب وا

.لكبیر في االثني وعشرین دولھ عربیھكتئاب اللممارسة في عالج اإل

ات الكبیرة ضافة إلى الدراسواعتمد ھذا الدلیل على تقییم الدالئل من إدارة الغذاء والدواء األمریكیة وشملت دراسات التسجیل وتنظیم تسجیل األدویة المختلفة، باإل .المقارنة العشوائیة التعمیھیھ المزدوجة ذات المستوى العالي

115


سوف یؤدي إلى ةھذا الدلیل للمنطقة العربیة والتي تأخذ في االعتبار المحددات االجتماعیة، وتوفر اإلمكانات باإلضافة إلى تقبل أشكال العالج المختلفإن خصوصیة .تحسن االلتزام بالعالج وبالتالي تحسن مخرجات العالج

.الجسیمكتئاب ول ألفضل نتائج معالجة اضطراب اإلوصیوصي أعضاء فریق العمل بالقیام بأبحاث مشتركھ في المنطقة العربیة لل

Corresponding author

Prof Ahmed Okasha, MD, PhD, FRCP, FRCPsych, FACP (Hon), DFAPA

Founder, Professor and Emeritus Chairman Institute of Psychiatry, Ain Shams University

President Egyptian Psychiatric Association

3, Shawarby Street, Kasr El Nil, Cairo - Egypt

Email: [email protected]

Authors

Prof Ahmed Okasha, MD, PhD, FRCP, FRCPsych, FACP (Hon), DFAPA

Founder, Professor and Emeritus Chairman Institute of Psychiatry, Ain Shams University

President Egyptian Psychiatric Association


Dr Suliman Alkhadhari, MB, BCh, FRCPsych Assistant Professor of Psychiatry, Faculty of Medicine, Kuwait University – Kuwait

Dr Abdullah Al Sharqi, MD, ASAM

Consultant of Psychiatry and Addiction Medicine

Psychcare Center, Riyadh, PO Parks 71077 Riyadh 11587- Saudi Arabia

Dr. Tarek Al Sherif, MB, BCh, MRCPsych Consultant Psychiatrist, National Guard Hospital, Jeddah - Saudi Arabia

Prof Tarek Asaad, MD, PhD Professor of Psychiatry, Ain Shams University, Cairo - Egypt

Dr Dory Hachem, MD,

Head of Department of Psychiatry, Psychiatric Hospital of the Cross, Jall-Eddddib, Beirut - Lebanon

Dr Adel Karrani, MRCPsych, MSc

Psychiatrist and Deputy CEO, American Center for Psychiatry and Neurology, Sharjah, Dubai, Al Ain - UAE

Dr Suhail AbdalHameed Khan MD

Consultant Psychiatrist, Ministry of Health, Assistant Professor

Ibn Sina College for Medical Studies, Jeddah, PO 387- Saudi Arabia

Ms Sonia Laflamme, RDN, Principal Medical Writer Vital MedCom, Dubai - UAE

116

Okasha A, et al.

Dr Ossama Tawakol Osman, MD, DABPN, LFAPA

Associate Professor, Department of Psychiatry and Behavioral Sciences

College of Medicine and Health Sciences, United Arab Emirates University. P.O. Box 17666, Al Ain - UAE

Prof Hisham Ahmed Ramy, MD, PhD

Professor of Psychiatry, Ain Shams University, Cairo, Secretary General of Mental Health MOH, Cairo - Egypt

Dr Walid Sarhan, MD, FRCPsych, DFAPA

Consultant Psychiatrist, 121 Yajouz Street, Aljubieha-Amman11942 - Jordan

Prof David V. Sheehan, MD, MBA, DLFAPA

Distinguished University Health Professor Emeritus

University of South Florida, College of Medicine, Tampa, Florida - USA

117

The Arab Journal of Psychiatry (2017) Vol. 28 No.2 Page (118 - 126) (doi:10.12816/0041710)

Editorial

A Critical Review of the Literature: Safety, Tolerability and Risks Associated with Newer Generation Antidepressant Drugs

Ahmed Okasha

تقییم نقدي شامل: السالمة والتحمل والمخاطرة المصاحبة الستعمال العقاقیر الحدیثة المضادة لالكتئاب

أحمد عكاشھ

Abstract

ewer generation antidepressant drugs (ADs) are widely used as the first line of treatment for major depressive disorders and are considered to be safer than tricyclic agents. Several side effects are transient and may disappear after a few

weeks following treatment initiation, but potentially serious adverse events may persist or ensue later. They encompass gastrointestinal symptoms (nausea, diarrhea, gastric bleeding, dyspepsia), hepatotoxicity, weight gain and metabolic abnormalities, cardiovascular disturbances (heart rate, QT interval prolongation, hypertension, orthostatic hypotension), genitourinary symptoms (urinary retention, incontinence), sexual dysfunction, hyponatremia, osteoporosis and risk of fractures, bleeding, central nervous system disturbances (lowering of seizure threshold, extrapyramidal side effects, cognitive disturbances), sweating, sleep disturbances, affective disturbances (apathy, switches, paradoxical effects), ophthalmic manifestations (glaucoma, cataract) and hyperprolactinemia. At times, such adverse events may persist after drug discontinuation, yielding iatrogenic comorbidity. Other areas of concern involve suicidality, safety in overdose, discontinuation syndromes, risks during pregnancy and breast feeding, as well as risk of malignancies. The rational selection of ADs should consider the potential benefits and risks, likelihood of responsiveness to the treatment option and vulnerability to adverse events.1

Keywords: Antidepressant drugs, SSRI, SNRI, TCA, iatrogenic comorbidity

Declaration of interest: None

Introduction

Studies have shown that up to 43% of patients with (Major Depressive Disorder) MDD may discontinue antidepressants due to treatment-emergent adverse effects.2 The introduction of tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors in the 1950s revolutionized the treatment of MDD. Since then, the search for more selective and possibly better tolerated ADs has continued. This movement of rational drug development gave birth to selective serotonin reuptake inhibitors (SSRIs). The ensuing years have witnessed SSRIs becoming the first line drugs for the treatment of MDD among several other indications.3 Following the marketing success of SSRIs, many newer generation antidepressants have gained approval as treatments for MDD, including but not limited to serotonin and noradrenaline reuptake inhibitors (e.g. venlafaxine, desvenlafaxine and duloxetine), bupropion (a noradrenaline and dopamine reuptake inhibitor), mirtazapine (noradrenaline and selective serotonin antagonist) and trazodone (serotonin antagonist and

reuptake inhibitor). With the exception of agomelatine (melatonin receptor agonist with 5-HT2C receptor antagonist properties), all other agents primarily act through the modulation of monoaminergic neurotransmission.4-5 Over the past four years, the US FDA has approved three additional antidepressants for the treatment of MDD, namely vilazodone, levomilnacipran and vortioxetine.6

Cardiovascular

Among the SSRIs, citalopram may cause a clinically significant increase in the QTc interval and has been associated with cases of torsades de pointes.7 A few case reports have suggested an association whereby the use of fluoxetine and sertraline may lead to QTc prolongation in individuals with preexisting risk factors for QTc prolongation. Paroxetine can be considered the least likely SSRI to cause QTc prolongation.7

N

118

Risks associated with newer generation antidepressant drugs

Venlafaxine use has been associated with clinically significant increases in diastolic blood pressure of up to 15 mm Hg from baseline. This risk was lower among individuals receiving doses of less than 200 mg daily.8-9 Duloxetine may also increase blood pressure and levomilnacipran may increase both systolic and diastolic blood pressure, although the magnitude of the effect seems to be small and its clinical significance is yet to be determined.10 It is well established that TCAs may cause orthostatic hypotension due to their well-known antagonistic α1-adrenergic receptor activity.11-12 The main mechanisms associated with SSRI-induced orthostatic hypotension remain unknown. Postural hypotension associated with the use of SSRIs is most commonly observed in elderly populations (Anticholinergic effects).11 Paroxetine seems to be the SSRI most frequently associated with orthostatic hypotension at least partly due to its anticholinergic effects.13 Similarly, fluoxetine use has also been associated with an increased incidence of orthostatic hypotension among the elderly.14 Some studies suggest that venlafaxine may cause orthostatic hypotension in more than 50% of patients aged over 60 years, most likely secondary to its strong noradrenergic action.15

Genitourinary

Urinary retention secondary to the use of SSRIs appears to be a rather rare event and is supported only by case reports.16 In most cases, SSRIs have been implicated only when used in combination with benzodiazepines and/or antipsychotics. These case reports have particularly concerned fluvoxamine, while fewer studies have implicated fluoxetine.16 There have also been a few reports to suggest that venlafaxine can also cause urinary incontinence. Even though the exact underlying mechanism is unknown, the action of venlafaxine on 5-HT4 receptors appears to cause incontinence.17 Likewise, duloxetine appears to be associated with both urinary retention and hesitancy.9

Sexual dysfunction

Loss of libido has been reported to affect 25-75% of patients with MDD, and its prevalence may correlate with the severity of depressive symptoms.18 A significant body of data shows that antidepressants may differentially affect sexual function in multiple aspects, leading to reductions in libido, arousal dysfunction (erection in males and vaginal lubrication in females) and orgasmic dysfunctions.19-20 Several mechanisms may contribute to antidepressant-induced sexual dysfunction, including but not limited to psychosocial factors and comorbid medical

diseases, as well as the use of other medications that may affect sexual function.19 The serotonergic action of SSRIs and SNRIs reduces dopaminergic transmission in the mesolimbic area, which in turn is known to regulate orgasm and sexual desire.21 These effects are reduced or absent among individuals taking medications with a predominant effect on dopamine or noradrenaline reuptake (e.g. bupropion). Mirtazapine and agomelatine have been associated with lower risks of sexual side effects.22

Preliminary data suggest that vortioxetine and vilazodone might have some advantage over SSRIs with regards to sexual side effects.23-25 TCA, e.g. Clomipramine, imipramine and amitryptiline, are particularly troublesome, whereas nortriptyline may be less so.26-27 Some antidotes (e.g. bupropion) have been proposed as effective strategies for a subgroup of patients.28 The use of type 5 phosphodiesterase inhibitors (e.g. sildenafil, tadalafil and vardenafil) may also alleviate antidepressant-induced erectile dysfunction.19 Finally, it is worth mentioning that for a small group of patients sexual dysfunction may either persist after treatment discontinuation or be a transitory phenomenon during AD treatment.29

Hyponatremia

SSRIs and venlafaxine appear to be the antidepressants most commonly associated with hyponatremia.30 The incidence could be slightly higher for fluoxetine, citalopram and escitalopram, whereas incidence rates may be lower for paroxetine and sertraline31-32 The risk of hyponatremia is significantly higher in elderly patients and among individuals using diuretics. The discontinuation of the antidepressant, fluid restriction and diuresis are possible measures that can be taken to treat antidepressant-induced hyponatremia.33

Osteoporosis and fractures

Multiple studies and a subsequent meta-analysis have associated depression with an increased risk of fractures and a reduction in bone density among patients.34 This reduction in bone density and a metabolic state which favors bone resorption has been attributed to a complex interplay between the hypothalamic-pituitary-adrenal (HPA) axis and inflammation.35 Patients with depression tend to have increased secretion of cortisol and also display elevation in markers of inflammation, especially, IL-1, IL-6 and TNF-α (which in turn can also increase cortisol secretion).36

119

Okasha A

Bleeding

SSRIs have been associated with an increased risk of bleeding during surgical procedures.108 The risk of bleeding appears to be higher with concomitant use of nonsteroidal anti-inflammatory drugs (NSAIDs) including aspirin, preexisting platelet dysfunction, or a concomitant use of heparin.37

Central nervous system

All kinds of EPS are seen in patients taking antidepressants, but akathisia appears to be the most common presentation followed by dystonic reactions, parkinsonian movements and tardive dyskinesia.38 Among antidepressants, SSRIs have the highest number of case reports of EPS.39-40 The incidence of EPS appears to be highest among patients taking duloxetine, followed by sertraline, escitalopram, paroxetine, fluoxetine, bupropion and citalopram in decreasing order of incidence.41 The elderly and individuals who carry the A1 allele of the dopamine D2 receptor (DRD2) gene Taq1A polymorphism were at increased risk of developing EPS with the use of SSRIs.42

The widespread use of SSRIs may result in the so-called serotonin syndrome, autonomic hyperactivity and neuromuscular abnormalities, but not all of these manifestations are universally present in patients presenting with this disorder.43 The concomitant use of SSRIs and monoamine oxidase inhibitors may pose a significant risk, while the serotonin syndrome may occur in up to 16% of individuals who overdose on SSRIs.44

Cognitive function

Antidepressants may have a small beneficial effect upon certain cognitive domains (e.g. delayed recall and psychomotor speed).45 However, the use of antidepressants may also lead to cognitive side effects.46 In addition, the use of antidepressants was associated with inattentiveness, forgetfulness, word-finding difficulty and mental slowing in depressed individuals reaching partial or full remission.47

Cerebrovascular

A meta-analysis of observational studies indicated that the use of SSRIs could be associated with a 40% increased risk of stroke.48 However, this association was significant only in older age groups. In addition, a recent cohort study conducted in UK primary care settings did not confirm this association.49

Sweating

The action of TCAs on muscarinic receptors may lead to excessive sweating in approximately 14% of the patients who take them.50 Among the newer antidepressants, bupropion and venlafaxine have been more frequently associated with excessive sweating, while fluvoxamine and trazodone may be associated with lower incidence rates.51 Most studies indicate that approximately 10% of patients on SSRIs may develop excessive sweating, although the incidence may be higher for paroxetine.51

Sleep disturbances

Studies have shown that patients suffering from depression have reduced rapid eye movement (REM) latency and a reduction in the non-REM phases in the first sleep cycle.52 The SSRIs and venlafaxine are associated with increased REM sleep latency and a reduction in the overall time spent in the REM phase while sleeping. These effects on REM sleep are mostly associated with the initial days/weeks of treatment, and may return to baseline levels after eight weeks of treatment. A rebound in REM sleep can be measured upon discontinuation of SSRIs. These effects on REM sleep could be due to an increase in synaptic serotonin levels. Mirtazapine can increase latency to REM sleep.1 Trazodone and mirtazapine have been associated with improving sleep continuity in patients with MDD.53 SSRIs and venlafaxine may cause and exacerbate restless leg syndrome. Among the newer antidepressants, mirtazapine followed by paroxetine and sertraline have been associated with the highest incidence of restless leg syndrome.54

Affective disturbances

Many patients taking SSRIs have reported experiencing emotional blunting. They often describe their emotions as being ‘damped down' or ‘toned down', while some patients refer to a feeling of being in ‘limbo' and just ‘not caring' about issues that were significant to them before.55 Evidence indicates that these adverse affective manifestations may persist even after the symptoms of depression have improved and can occur in patients of all ages.48,56 Some authors hypothesize that AD-induced emotional blunting occurs as a result of a downregulation of dopamine neurotransmission in neural circuits that regulate reward processing, secondary to an activation of 5-HT2C receptors in the nucleus accumbens.57 Thesechanges in emotional processing are not limited to SSRIs, and have also been reported for patients taking mirtazapine, agomelatine and reboxetine.56 In addition, cases of apathy, lack of motivation and frontal lobe

120


syndrome have been described in patients taking SSRIs in adults, adolescents and children.58

A meta-analysis indicates that the treatment of juvenile patients for both anxiety and depressive disorders may lead to excessive arousal activation and even hypomania, which calls for a proper clinical monitoring for the emergence of bipolar disorder.59 Furthermore, an activation syndrome in which patients taking antidepressants may experience anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness and impulsivity in the first three months of treatment may ensue.60

Suicidality

Since 2014, the US FDA issued a black box warning regarding the risk of suicidality related to the use of antidepressants in children and adolescents.61 Two recent meta-analyses have not identified a clear increased risk of treatment-emergent suicidality in adult individuals treated with antidepressants in RCTs.62-63 An expert statement issued by the European Psychiatric Association (EPA) mentions that antidepressants decrease suicidality, but there is no consistent evidence to support this statement.64

Safety in overdose

One study reviewed records in the UK and found that among antidepressants the case fatality rate (ratios of deaths to nonfatal overdose) was highest for TCAs (1.6) followed by venlafaxine (0.29) and mirtazapine (0.22), and was lowest for SSRIs (0.06). Among the SSRIs, citalopram was found to be associated with the highest case fatality rates in overdose.65 Another study investigated poison control data in the USA from 2000 to 2004. Likewise, TCAs were associated with the highest mortality rates due to overdose. In addition, among SSRIs, citalopram and fluvoxamine appeared to be related to higher mortality rates in overdose, whereas fluoxetine and sertraline were the safest.66

Discontinuation syndromes (withdrawal syndrome)

An often-underappreciated clinical problem associated with the use of almost all SSRIs and SNRIs is the emergence of withdrawal symptoms of varying degrees of severity upon treatment discontinuation and/or interruption.67-68 These symptoms include flu-like symptoms, tremors, tachycardia, shock-like sensations, paresthesia, myalgia, tinnitus, neuralgia, ataxia, vertigo, sexual dysfunction, sleep disturbances, vivid dreams, nausea vomiting, diarrhea, worsening anxiety and mood

instability.68 A recent review suggested that dependence and withdrawal symptoms associated with newer antidepressants were comparable, if not worse, to those experienced with benzodiazepines.68 These reactions have been defined as ‘discontinuation syndromes', with the aim of avoiding any hint to a potential for dependence that may affect marketing.69 Due to the severity and unpredictability of these manifestations, it has been recently suggested that the term ‘discontinuation syndrome' should be replaced by ‘withdrawal syndrome'.68 Symptoms typically appear within three to four days of stopping an antidepressant or initiating a medication taper. They may be mild and resolve spontaneously within one to three weeks; in other cases, they may persist for months or even years, leading to what has been defined as ‘persistent postwithdrawal disorder' .70 Withdrawal symptoms are most prominent in agents with shorter half-lives and high potency, such as venlafaxine and paroxetine.68,71 Interestingly, most studies show that although tapering the drug over a period of weeks to months may confer some advantages, it does not eliminate the probability of developing withdrawal symptoms.68 Alternative strategies for the management of antidepressant-related withdrawal syndrome are scarce, and the quality of the evidence is limited.67 A combination of cognitive behavior therapy and well-being therapy has been reported to be successful in a case series for managing persistent postwithdrawal disorders.72

Ophthalmic effects

A subsequent review indicates that the use of different SSRIs may increase intraocular pressure and lead to the emergence of angle-closure glaucoma, which case reports have also indicated may be caused by venlafaxine.73-75 While the use of SSRIs was associated with a substantial independent risk of acute angle-closure glaucoma (OR = 5.80; 95% CI = 1.89-17.9), there was no apparent risk of either primary angle-closure glaucoma or primary open-angle glaucoma in patients with depression on long-term SSRI use.76-77 A nested case-control study found a higher likelihood of cataracts after exposure to newer generation antidepressants, including fluvoxamine (RR = 1.39, 95% CI = 1.07-180), followed by venlafaxine (RR = 1.33, 95% CI = 1.14-1.55) and paroxetine (1.23, 95% CI = 1.05-1.45).78

Hyperprolactinemia

Tuberoinfundibular dopamine pathways primarily regulate prolactin release, but it is also modulated indirectly by serotonin via the activation of 5-HT1C and 5-HT2 receptors.79 Long-standing increases in peripheral prolactin levels are occasionally observed in patients using ADs, including SSRIs; hyperprolactinemia may have deleterious

121

Okasha A

health consequences (e.g. a decrease in BMD and hypogonadism).80-81 Where hyperprolactinemia is confirmed, a switch to mirtazapine may be a good therapeutic choice, although a switch to another SSRI may also stop this abnormality.82

Risks during pregnancy and breast feeding

Pregnant women have an increased risk of developing depressive illness by about 10-15%. The risk of depression appears to be highest in the second and third trimester and almost half of these women continue to have symptoms after the end of pregnancy.83 It is important to treat MDD during pregnancy, as it has been associated with an increased risk of complications during pregnancy, including increased risk of preeclampsia, preterm birth, abnormal bleeding, miscarriages and even fetal death.84 After controlling confounding factors, SSRIs have not been unequivocally associated with an increased risk of major birth defects.85 The clinical significance of these data is questionable. SSRIs have been associated with a modest increase in risk of congenital cardiac malformations, with a relative risk of about 1.4, as well as with an increased risk of postpartum hemorrhage.86-87 In addition, paroxetine has been associated with an increased risk of congenital cardiac defects and should not be used during pregnancy.88 A recent meta-analysis indicated that exposure to SSRIs in late pregnancy may confer an increased risk of persistent pulmonary hypertension.89 However, the absolute risk was small, and thus the clinical significance of this finding seems rather limited. Exposure to SNRIs (e.g. duloxetine and venlafaxine) during pregnancy does not seem to be consistently associated with an increased risk of birth defects, but use of these medications has been associated with an increased risk of postpartum hemorrhage, and venlafaxine in particular has been associated with an increased risk of hypertension during pregnancy. 90-92 Similarly, most data suggest that the risk associated with the use of bupropion, mirtazapine and trazodone during pregnancy is low, while some studies have shown equivocal results regarding the potential risk cardiac malformation related to bupropion use.93-96 The use of SSRIs and SNRIs during late pregnancy has been associated with withdrawal reactions characterized by irritability, excessive crying, tremor and even seizures.97 The benefits of treating depression during pregnancy and lactation should be balanced against the risks associated with the treatment itself. Depending on the severity and degree of recurrence of the underlying illness, if the patient is already stabilized on a specific antidepressant, a recent expert panel advises that the patient should be maintained on the same medication, except in the case of paroxetine.98 Whenever the patient is drug-naïve, sertraline and citalopram appear to be the best therapeutic option.98 The

use of TCAs (with the exception of doxepin) is also a relatively safe option during breast feeding.99

Risk of malignancies

Preclinical studies have found that antidepressants can increase the growth of fibrosarcomas and melanomas, and may also promote mammary carcinogenesis.100 However, other animal studies have reported the opposite trend (i.e. antidepressant use has been shown to have protective effects in tumor models).101-103 It should be mentioned that the concomitant use of SSRIs, which inhibit the CYP450 2D6 isoenzyme (e.g. paroxetine), and tamoxifen may increase breast cancer-related mortality.104 In summary, limitations in the overall quality of available evidence do not allow the establishment of causal inferences linking exposure to antidepressants and carcinogenesis.105

Conclusions

Patients with multiple major depressive episodes may experience significantly less benefit from long-term AD treatment compared to patients with single episodes.106 This finding indicates that in patients with chronic recurring MDD, recurrences are difficult to prevent with AD use only. It has been suggested that the use of ADs should be limited to those patients with the more severe and chronic forms of MDD, for the shortest possible period of time. The findings of the current review suggest that long-term treatment with new generation ADs should be avoided if alternative treatments are available. The sequential use of pharmacotherapy in the acute phase of depression and of psychotherapy in its residual stage may allow the tapering and discontinuation of ADs, with significant clinical advantages.107

References

1. Carvalho AF, Sharma MS, Brunoni AR, Vieta E. TheSafety, Tolerability and Risks Associated with the Use of Newer Generation Antidepressant Drugs: A Critical Review of the Literature, Psychother Psychosom 2016;85:270–288.

2. Bull SA, Hunkeler EM, Lee JY, Rowland CR, WilliamsonTE, Schwab JR, Hurt SW. Discontinuing or switching selective serotoninreuptake inhibitors. Ann Pharmacother 2002;36: 578–584.

3. Anderson IM. Selective serotonin reuptake inhibitorsversus tricyclic antidepressants: a meta-analysis of efficacy and tolerability. J Affect Disord 2000; 58: 19–36.

4. Machado-Vieira R, Henter ID, Zarate CA. New targets forrapid antidepressant action. Prog Neurobiol 2015, Epub ahead of print.

122


5. Rosenblat JD, McIntyre RS, Alves GS, Fountoulakis KN,Carvalho AF. Beyond monoamines- novel targets for treatment-resistant depression: a comprehensive review. Curr Neuropharmacol 2015; 13: 636–655.

6. Elmaadawi A, Singh N, Reddy J. Prescriber’s guide tousing 3 new antidepressants. Curr Psychiatry 2016; 14: 32–36.

7. Beach SR, Celano CM, Noseworthy PA, Januzzi JL,Huffman JC. QTc prolongation, torsades de pointes, and psychotropic medications. Psychosomatics 2013; 54: 1-13.

8. Feighner JP. Cardiovascular safety in depressed patients:focus on venlafaxine. J Clin Psychiatr 1995; 56: 574-579.

9. Whiskey E, Taylor D. A review of the adverse effects andsafety of noradrenergic antidepressants. J Psychopharmacol 2013; 27: 732–739.

10. Asnis GM, Henderson MA. Levomilnacipran for thetreatment of major depressive disorder: a review. Neuropsychiatr Dis Treat 2015; 11: 125-135.

11. Pollock BG. Adverse reactions of antidepressants in elderly patients. J Clin Psychiatry 1999; 60(suppl 2):4-8.

12. Rodriguez de la Torre B, Dreher J, Malevany I, Bagli M,Kolbinger M, Omran H, Lüderitz B, Rao ML. Serum levels and cardiovascular effects of tricyclic antidepressants and selective serotonin reuptake inhibitors in depressed patients. Ther Drug Monit 2001; 23: 435-440.

13. Darowski A, Chambers SA, Chambers DJ. Antidepressantsand falls in the elderly. Drugs Aging 2009; 26: 381-394.

14. Cherin P, Colvez A, Deville de Periere G, Sereni D. Riskof syncope in the elderly and consumption of drugs: a case-control study. J Clin Epidemiol 1997; 50: 313-320.

15. Johnson EM, Whyte E, Mulsant BH, Pollock BG, WeberE, Begley AE, Reynolds CF. Cardiovascular changes associated with venlafaxine in the treatment of late-life depression. Am J Geriatr Psychiatr 2006; 14: 796-802.

16. Verhamme KMC, Sturkenboom MC, Stricker BHC, Bosch R. Drug-induced urinary retention: Incidence, managementand prevention. Drug Saf 2008; 31: 373-388.

17. Votolato NA, Stern S, Caputo RM. Serotonergicantidepressants and urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2000; 11: 386-388.

18. Williams K, Reynolds MF. Sexual dysfunction in majordepression. CNS Spectr 2006; 11: 19-23.

19. Clayton AH, Croft HA, Handiwala L. Antidepressants andsexual dysfunction: mechanisms and clinical implications. Postgrad Med 2014; 126: 91-99.

20. Serretti A, Chiesa A. Treatment-emergent sexualdysfunction related to antidepressants: a meta-analysis. J Clin Psychopharmacol 2009; 29:259-266.

21. Bella AJ, Shamloul R. Psychotropics and sexualdysfunction. Cent Eur J Urol 2013; 66: 466-471.

22. Angst J. Sexual problems in healthy and depressed persons. Int Clin Psychopharmacol 1998; 13(suppl 6):S1-S4.

23. Citrome L. Vortioxetine for major depressive disorder: anindirect comparison with duloxetine, escitalopram, levomilnacipran, sertraline, venlafaxine, and vilazodone, using number needed to treat, number needed to harm, and likelihood to be helped or harmed. J Affect Disord 2016; 196:225-233.

24. Citrome L. Vilazodone for major depressive disorder: asystematic review of the efficacy and safety profile for this newly approved antidepressant – what is the number

needed to treat, number needed to harm and likelihood to be helped or harmed? Int J Clin Pract 2012; 66:356-368.

25. Montejo AL, Montejo L, Navarro-Cremades F. Sexualside-effects of antidepressant and antipsychotic drugs. Curr Opin Psychiatr 2015; 28:418-423.

26. Montgomery SA, Baldwin DS, Riley A. Antidepressantmedications: a review of the evidence for drug-induced sexual dysfunction. J Affect Disord 2002; 69:119-140.

27. Segraves RT, Balon R. Antidepressant-induced sexualdysfunction in men. Pharmacol Biochem Behav 2014; 121:132-137.

28. Pereira VM, Arias-Carrión O, Machado S, Nardi AE, SilvaAC. Bupropion in the depression- related sexual dysfunction: a systematic review. CNS Neurol Disord Drug Targets 2014; 13:1079-1088.

29. Csoka AB, Shipko S. Persistent sexual side effects afterSSRI discontinuation. Psychother Psychosom 2006; 75: 187-188.

30. De Picker L, van Den Eede F, Dumont G, Moorkens G,Sabbe BGC. Antidepressants and the risk of hyponatremia: a class-by class review of literature. Psychosomatics 2014; 55:53-547.

31. Degner D, Grohmann R, Kropp S, Rüther E, Bender S,Engel RR, Schmidt LG. Severe adverse drug reactions of antidepressants: results of the German multicenter drug surveillance program AMSP. Pharmacopsychiatr 2004; 37(suppl 1):S39–S45

32. Letmaier M, Painold A, Holl AK, Vergin H, Engel R,Konstantinidis A, Kasper S, Grohmann R. Hyponatraemia during psychopharmacological treatment: results of a drug surveillance programme. Int J Neuropsychopharmacol 2012; 15:739-748.

33. Jacob S. Hyponatremia associated with selective serotonin-reuptake inhibitors in older adults. Ann Pharmacother 2006; 40:1618-1622.

34. Eom CS, Lee HK, Ye S, Park SM, Cho KH. Use ofselective serotonin reuptake inhibitors and risk of fracture: a systematic review and meta-analysis. J Bone Miner Res 2012; 27: 1186-1195.

35. Rosenblat JD, Gregory JM, Carvalho AF, McIntyre RS.Depression and disturbed bone metabolism: a narrative review of the epidemiological findings and postulated mechanisms. Curr Mol Med 2016; 16:165-178.

36. Cizza G, Primma S, Csako G. Depression as a risk factorfor osteoporosis. Trends Endocrinol Metab 2009; 20:367-373.

37. De Abajo FJ. Effects of selective serotonin reuptakeinhibitors on platelet function: mechanisms, clinical outcomes and implications for use in elderly patients. Drugs Aging 2011; 28:345-367.

38. Hawthorne JM, Caley CF. Extrapyramidal reactionsassociated with serotonergic antidepressants. Ann Pharmacother 2015; 49:1136-1152.

39. Schillevoort I, van Puijenbroek EP, de Boer A, Roos RAC,Jansen PAF, Leufkens HGM. Extrapyramidal syndromes associated with selective serotonin reuptake inhibitors: a case-control study using spontaneous reports. Int Clin Psychopharmacol 2002; 17:75-79.

40. Gill HS, DeVane CL, Risch SC. Extrapyramidal symptomsassociated with cyclic antidepressant treatment: a review of the literature and consolidating hypotheses. J Clin Psychopharmacol 1997; 17:377-389.

123

Okasha A

41. Madhusoodanan S, Alexeenko L, Sanders R, Brenner R.Extrapyramidal symptoms associated with antidepressants – a review of the literature and an analysis of spontaneousreports. Ann Clin Psychiatry 2010; 22:148-156

42. Hedenmalm K, Güzey C, Dahl M-L, Yue Q-Y, Spigset O.Risk factors for extrapyramidal symptoms during treatment with selective serotonin reuptake inhibitors, including cytochrome P-450 enzyme, and serotonin and dopamine transporter and receptor polymorphisms. J Clin Psychopharmacol 2006; 26:192-197.

43. Boyer EW, Shannon M. The serotonin syndrome. N Engl JMed 2005; 352:1112-1120.

44. Iqbal MM, Basil MJ, Kaplan J, Iqbal MT. Overview ofserotonin syndrome. Ann Clin Psychiatry 2012; 24:310-318.

45. Rosenblat JD, Kakar R, McIntyre RS. The cognitive effectsof antidepressants in major depressive disorder: a systematic review and meta-analysis of randomized clinical trials. Int J Neuropsychopharmacol 2015; 19:pyv082.

46. Bortolato B, Carvalho AF, McIntyre RS. Cognitivedysfunction in major depressive disorder: a state-of-the-art clinical review. CNS Neurol Disord Drug Targets 2014; 13:1804-1818.

47. Fava M, Graves LM, Benazzi F, Scalia MJ, Iosifescu DV,Alpert JE, Papakostas GI. A cross-sectional study of the prevalence of cognitive and physical symptoms during long-term antidepressant treatment. J Clin Psychiatry 2006; 67:1754-1759.

48. Shin D, Oh YH, Eom C-S, Park SM. Use of selectiveserotonin reuptake inhibitors and risk of stroke: a systematic review and metaanalysis. J Neurol 2014; 261: 686-695.

49. Coupland C, Hill T, Morriss R, Moore M, Arthur A,Hippisley-Cox J. Antidepressant use and risk of cardiovascular outcomes in people aged 20-64: cohort study using primary care database. BMJ 2016; 352:i1350.

50. Trindade E, Menon D, Topfer LA, Coloma C. Adverseeffects associated with selective serotonin reuptake inhibitors and tricyclic antidepressants: a meta-analysis. CMAJ 1998; 159:1245-1252.

51. Marcy TR, Britton ML. Antidepressant-induced sweating.Ann Pharmacother 2005; 39:748-752.

52. Lauer CJ, Schreiber W, Holsboer F, Krieg JC. In quest ofidentifying vulnerability markers for psychiatric disorders by all-night polysomnography. Arch Gen Psychiatr 1995; 52:145-153.

53. Wilson S, Argyropoulos S. Antidepressants and sleep: aqualitative review of the literature. Drugs 2005; 65:927-947.

54. Rottach KG, Schaner BM, Kirch MH, Zivotofsky AZ,Teufel LM, Gallwitz T, Messer T. Restless legs syndrome as side effect of second-generation antidepressants. J Psychiatr Res 2008; 43:70-75.

55. Price J, Cole V, Goodwin GM. Emotional side-effects ofselective serotonin reuptake inhibitors: qualitative study. Br J Psychiatry 2009; 195:211-217.

56. Szmulewicz A, Samame C, Caravotta P, Martino DJ, IgoaA, Hidalgo-Mazzei D, Colom F, Strejilevich SA. Behavioral and emotional adverse events of drugs frequently used in the treatment of bipolar disorders:

clinical and theoretical implications. Int J Bipolar Disord 2016;4:6.

57. Levy R, Dubois B. Apathy and the functional anatomy ofthe prefrontal cortex-basal ganglia circuits. Cereb Cortex 2006; 16:916-928.

58. Moret C, Isaac M, Briley M. Problems associated withlong-term treatment with selective serotonin reuptake inhibitors. J Psychopharmacol 2009; 23:967-974.

59. Offidani E, Fava GA, Tomba E, Baldessarini RJ. Excessivemood elevation and behavioral activation with antidepressant treatment of juvenile depressive and anxiety disorders: a systematic review. Psychother Psychosom 2013; 82:132-141.

60. Harada T, Sakamoto K, Ishigooka J. Incidence andpredictors of activation syndrome induced by antidepressants. Depress Anxiety 2008; 25:1014-1019.

61. Stone MB. The FDA warning on antidepressants andsuicidality - why the controversy? N Engl J Med 2014; 371:1668-1671.

62. Braun C, Bschor T, Franklin J, Baethge C. Suicides andsuicide attempts during long-term treatment with antidepressants: a meta-analysis of 29 placebo-controlled studies including 6,934 patients with major depressive disorder. Psychother Psychosom 2016; 85:171-179.

63. Sharma T, Guski LS, Freund N, Gøtzsche PC. Suicidalityand aggression during antidepressant treatment: systematic review and meta-analyses based on clinical study reports.BMJ 2016;352:i65.

64. Wasserman D, Rihmer Z, Rujescu D, Sarchiapone M,Sokolowski M, Titelman D, Zalsman G, Zemishlany Z, Carli V, Association EP. The European Psychiatric Association (EPA) guidance on suicide treatment and prevention. Eur Psychiatry 2012; 27:129-141.

65. Hawton K, Bergen H, Simkin S, Cooper J, Waters K,Gunnell D, Kapur N. Toxicity of antidepressants: rates of suicide relative to prescribing and non-fatal overdose. Br J Psychiatry 2010; 196:354-358.

66. White NC, Litovitz T, Clancy C. Suicidal antidepressantoverdoses: a comparative analysis by antidepressant type. J Med Toxicol 2008; 4:238-250.

67. Wilson E, Lader M. A review of the management ofantidepressant discontinuation symptoms. Ther Adv Psychopharmacol 2015; 5:357-368.

68. Fava GA, Gatti A, Belaise C, Guidi J, Offidani E.Withdrawal symptoms after selective serotonin reuptake inhibitor discontinuation: a systematic review. Psychother Psychosom 2015; 84:72-81.

69. Starcevic V, Brakoulias V, Viswasam K, Berle D.Inconsistent portrayal of medication dependence, withdrawal and discontinuation symptoms in treatment guidelines for anxiety disorders. Psychother Psychosom 2015; 84:379-380.

70. Chouinard G, Chouinard VA. New classification ofselective serotonin reuptake inhibitor withdrawal. Psychother Psychosom 2015; 84:63-71.

71. Harvey BH, Slabbert FN. New insights on theantidepressant discontinuation syndrome. Hum Psychopharmacol 2014; 29:503-516.

72. Belaise C, Gatti A, Chouinard VA, Chouinard G. Persistentpost-withdrawal disorders induced by paroxetine, a selective serotonin reuptake inhibitor, and treated with

124


specific cognitive behavioral therapy. Psychother Psychosom 2014; 83:247-248.

73. Costagliola C, Parmeggiani F, Sebastiani A. SSRIs andintraocular pressure modifications: evidence, therapeutic implications and possible mechanisms. CNS Drugs 2004; 18:475-484.

74. Ezra DG, Storoni M, Whitefield LA. Simultaneousbilateral acute angle closure glaucoma following venlafaxine treatment. Eye (Lond) 2006; 20:128-129.

75. Ng B, Sanbrook GM, Malouf AJ, Agarwal SA. Venlafaxineand bilateral acute angle closure glaucoma. Med J Aust 2002; 176:241.

76. Chen HY, Lin CL, Kao CH. Long-term use of selectiveserotonin reuptake inhibitors and risk of glaucoma in depression patients. Medicine (Baltimore) 2015; 94:e2041.

77. Chen HY, Lin CL, Lai SW, Kao CH. Association ofselective serotonin reuptake inhibitor use and acute angle-closure glaucoma. J Clin Psychiatr 2016, Epub ahead of print.

78. Etminan M, Mikelberg FS, Brophy JM. Selective serotonin reuptake inhibitors and the risk of cataracts: a nested case-control study.Ophthalmology 2010; 117: 1251-1255.

79. Rittenhouse PA, Levy AD, Li Q, Bethea CL,Van de KarLD. Neurons in the hypothalamic paraventricular nucleus mediate the serotonergic stimulation of prolactin secretion via 5-HT1c/2 receptors. Endocrinology 1993; 133:661-667.

80. Trenque T, Herlem E, Auriche P, Drame M. Serotoninreuptake inhibitors and hyperprolactinaemia: a case/non-case study in the French pharmacovigilance database. Drug Saf 2011; 34:1161-1166.

81. Ajmal A, Joffe H, Nachtigall LB. Psychotropic-inducedhyperprolactinemia: a clinical review. Psychosomatics 2014; 55:29-36.

82. Mondal S, Saha I, Das S, Ganguly A, Das D, Tripathi SK.A new logical insight and putative mechanism behind fluoxetine-induced amenorrhea, hyperprolactinemia and galactorrhea in a case series. Ther Adv Psychopharmacol 2013; 3:322-334.

83. Bennett HA, Einarson A, Taddio A, Koren G, Einarson TR.Prevalence of depression during pregnancy: systematic review. Obstet Gynecol 2004; 103:698-709.

84. Grigoriadis S, VonderPorten EH, Mamisashvili L,Tomlinson G, Dennis C-L, Koren G, Steiner M, Mousmanis P, Cheung A, Radford K, Martinovic J, Ross LE. The impact of maternal depression during pregnancy on perinatal outcomes: a systematic review and meta-analysis. J Clin Psychiatr 2013;74:e321-e341.

85. Reis M, Källén B. Combined use of selective serotoninreuptake inhibitors and sedatives/ hypnotics during pregnancy: risk of relatively severe congenital malformations or cardiac defects: a register study. BMJ Open 2013; 3:e002166.

86. Grigoriadis S, VonderPorten EH, Mamisashvili L,Roerecke M, Rehm J, Dennis CL, Koren G, Steiner M, Mousmanis P, Cheung A, Ross LE. Antidepressant exposure during pregnancy and congenital malformations: is there an association? A systematic review and meta-analysis of the best evidence. J Clin Psychiatr 2013; 74:e293-e308.

87. Palmsten K, Hernández-Díaz S, Huybrechts KF, WilliamsPL, Michels KB, Achtyes ED, Mogun H, Setoguchi S. Use

of antidepressants near delivery and risk of postpartum hemorrhage: cohort study of low income women in the United States. BMJ 2013; 347:f4877.

88. Reefhuis J, Devine O, Friedman JM, Louik C, Honein MA.Study NBDP: Specific SSRIs and birth defects: Bayesian analysis to interpret new data in the context of previous reports. BMJ 2015; 351:h3190.

89. Grigoriadis S, Vonderporten EH, Mamisashvili L,Tomlinson G, Dennis CL, Koren G, Steiner M, Mousmanis P, Cheung A, Ross LE. Prenatal exposure to antidepressants and persistent pulmonary hypertension of the newborn: systematic review and meta-analysis. BMJ 2014; 348:f6932.

90. Hudson JI, Wohlreich MM, Kajdasz DK, Mallinckrodt CH, Watkin JG, Martynov OV. Safety and tolerability of duloxetine in the treatment of major depressive disorder: analysis of pooled data from eight placebo controlled clinical trials. Hum Psychopharmacol 2005; 20:327-341.

91. Bellantuono C, Vargas M, Mandarelli G, Nardi B, MartiniMG. The safety of serotonin- noradrenaline reuptake inhibitors (SNRIs) in pregnancy and breastfeeding: a comprehensive review. Hum Psychopharmacol 2015; 30: 143-151.

92. Furu K, Kieler H, Haglund B, Engeland A, Selmer R,Stephansson O, Valdimarsdottir UA, Zoega H, Artama M, Gissler M, Malm H, Nørgaard M. Selective serotonin reuptake inhibitors and venlafaxine in early pregnancy and risk of birth defects: population based cohort study and sibling design. BMJ 2015; 350:h1798.

93. Chun-Fai-Chan B, Koren G, Fayez I, Kalra S, Voyer-Lavigne S, Boshier A, Shakir S, Einarson A. Pregnancy outcome of women exposed to bupropion during pregnancy: a prospective comparative study. Am J Obstet Gynecol 2005; 192:932-936.

94. Alwan S, Reefhuis J, Botto LD, Rasmussen SA, Correa A,Friedman JM. National Birth Defects Prevention Study: Maternal use of bupropion and risk for congenital heart defects. Am J Obstet Gynecol 2010; 203: 52.e1-6.

95. Djulus J, Koren G, Einarson TR, Wilton L, Shakir S, Diav-Citrin O, Kennedy D, Voyer Lavigne S, De Santis M, Einarson A. Exposure to mirtazapine during pregnancy: a prospective, comparative study of birth outcomes. J Clin Psychiatr 2006; 67:1280-1284.

96. Einarson A, Bonari L, Voyer-Lavigne S, Addis A, MatsuiD, Johnson Y, Koren G. A multicentre prospective controlled study to determine the safety of trazodone and nefazodone use during pregnancy. Can J Psychiatr 2003; 48:106-110.

97. Sanz EJ, De-las-Cuevas C, Kiuru A, Bate A, Edwards R.Selective serotonin reuptake inhibitors in pregnant women and neonatal withdrawal syndrome: a database analysis. Lancet (London) 2005; 365:482-487.

98. Larsen ER, Damkier P, Pedersen LH, Fenger- Gron J,Mikkelsen RL, Nielsen RE, Linde VJ, Knudsen HED, Skaarup L, Videbech P. Use of psychotropic drugs during pregnancy and breast-feeding. Acta Psychiatr Scand 2015; 132:1-28.

99. Eberhard-Gran M, Eskild A, Opjordsmoen S. Use ofpsychotropic medications in treating mood disorders during lactation: practical recommendations. CNS Drugs 2006; 20:187-198.

125

Okasha A

100. Brandes LJ, Arron RJ, Bogdanovic RP, Tong J, ZaborniakCL, Hogg GR, Warrington RC, Fang W, LaBella FS. Stimulation of malignant growth in rodents by antidepressant drugs at clinically relevant doses. Cancer Res 1992; 52:3796-3800.

101. Bendele RA, Adams ER, Hoffman WP, Gries CL, MortonDM. Carcinogenicity studies of fluoxetine hydrochloride in rats and mice. Cancer Res 1992; 52:6931-6935.

102. Gil-Ad I, Zolokov A, Lomnitski L, Taler M, Bar M, LuriaD, Ram E, Weizman A. Evaluation of the potential anti-cancer activity of the antidepressant sertraline in human colon cancer cell lines and in colorectal cancer xeno grafted mice. Int J Oncol 2008; 33:277-286.

103. Abdul M, Logothetis CJ, Hoosein NM. Growth-inhibitoryeffects of serotonin uptake inhibitors on human prostate carcinoma cell lines. J Urol 1995; 154:247-250.

104. Carvalho AF, Hyphantis T, Sales PMG, Soeiro-de-SouzaMG, Macêdo DS, Cha DS, McIntyre RS, Pavlidis N. Major depressive disorder in breast cancer: a critical systematic

review of pharmacological and psychotherapeutic clinical trials. Cancer Treat Rev 2014; 40:349-355.

105. Ghaemi NS, Vohringer PA, Whitham EA. Antidepressantsfrom a public health perspective: Re-examining effectiveness, suicide, and carcinogenicity. Acta Psychiatr Scand 2013; 127:89-93.

106. Kaymaz N, van Os J, Loonen AJ, Nolen WA. Evidence thatpatients with single versus recurrent depressive episodes are differentially sensitive to treatment discontinuation: a meta-analysis of placebo-controlled randomized trials. J Clin Psychiatr 2008; 69:1423-1436.

107. Guidi J, Tomba E, Fava GA. The sequential integration ofpharmacotherapy and psychotherapy in the treatment of major depressive disorder: a meta-analysis of the sequential model and a critical review of the literature. Am J Psychiatry 2016; 173:128-137.

108. Halperin D, Reber G. Influence of antidepressants onhemostasis. Dialogues Clin Neurosci 2007;9:47-59.

الملخص

كتئاب الجسیم وھي أكثر سالمة من العقاقیر ثالثیة الحلقات. وعادة ما تكون األعراض كتئاب ھو الخط األول في عالج اإلمال العقاقیر الحدیثة المضادة لإلیعتبر استعبدء العالج ولكن األعراض الخطیرة قد تستمر أو تظھر في فترة الحقة، ویشمل ذلك أعراض الجھاز الھضمي (الغثیان، الجانبیة عارضة وتختفي بعد أسابیع قلیلھ من

سرعة ضربات القلب، وإطالة ) واإلسھال نزیف المعدة، وسوء الھضم، والتسمم الكبدي، وزیادة الوزن، وخلل في األیض) واضطرابات في الجھاز القلبي الوعائيQT و أعراض اضطراب الجھاز البولي التناسلي ( احتباس البول، والسلس البولي) واضطرابات (لقلب، و ارتفاع ضغط الدم، خفض ضغط الدم الوضعيي رسم اف

جانبیة لراض اجنسیة، ونقص الصودیوم في الدم، وھشاشة العظام وكذلك احتمال الكسور، والنزیف. اضطرابات الجھاز العصبي (انخفاض عتبة التشنجات، واألع، دیة (المیاه الزرقاءخارج الھرمیة، واالضطرابات المعرفیة) والعرق، واالضطرابات الوجدانیة (الجمود العاطفي، والتحول للھوس، وتأثیرات متناقضة) وظواھر رم

.والمیاه البیضاء) وزیادة ھرمون إدرار اللبن (بروالكتین)

العالج مما یؤدى إلى أعراض مصاحبة. ویجدر اإلشارة إلى احتماالت االنتحار، وسالمة الجرعة الزائدة، ما تستمر ھذه اإلعراض بعد التوقف عن اخذ أحیانا .ومتالزمة االنسحاب، والخطر أثناء الحمل والرضاعة وكذلك خطر األورام الخبیثة

.ورة، واحتمال االستجابة للعالج واالستعداد لإلعراض الجانبیةكتئاب یجب أن یأخذ في االعتبار التوازن بین الفوائد والخطالعقالني لمضادات اإلإن االختیار

Prof Ahmed Okasha

MD, PhD, FRCP, FRCPsych, FACP (Hon)

Founder, Professor and Director of WHO collaborating Center for Training and Researches

Institute of Psychiatry, Ain Shams University

Hon President Egyptian Psychiatric Association and Arab Federation of Psychiatrists

Past President of WPA

Advisor to the Egyptian President (Mental Health and Community Compatibility)


E-mail: [email protected]

[email protected]

126


Short report Person Centered Psychiatric Medicine

M. Fakhr El-Islam

شخصنة الطب النفسي محمد فخر اإلسالم

Abstract

ore than any other branch of medicine, psychiatric medicine is keenly focused on the individual. No two cases are exactly alike in psychiatric practice. This not only involves the differential appraisal of mental health for various

individuals, but also for the differential delivery of management of their ill health including both pharmacotherapy and psychotherapy. The family also acquires a pivotal position in person-centered psychiatric practice in the Arab world.

In addition, psychiatric research especially in social psychiatry recognized the social person-centered correlates of mental ill health at the levels of psychogenesis and interpersonal consequences. Training in mental health needs also to consider the personal qualities of the trainees and their trainers. In the Arab world, the personal dimension in psychiatry has been observed long before the term “person-centered” was introduced to describe personalized clinical care in medical practice.

Key words: person-centered care, person-centered research, person centered training


Introduction

Personalized clinical care has been part of holistic medicine since the inception of Hippocratic, Chinese and aryuvedic medicines.1 The person-centered approach permeates psychiatric practice in its clinical, educational and research domains. The client in all these domains has both ill and positive aspects. The latter are used as a resource to manage the former in the “partnership” among clinicians, patients and families in the form of an alliance in therapy, education and research.1,2

Person-centered clinical psychiatric practice

Although psychiatric medicine is the same all over the world, globalized psychiatry has to be adapted in various communities in order to take into account sick persons’ systems of beliefs, attitudes and codes of conduct.3 The beliefs shared by patients and their families are psychic realities for them. Although they cannot be objectively proved these beliefs form the yardstick that helps the clinical psychiatrist in deciding whether patients’ thought contents are pathologically beyond or outside what is culturally shared. This has been used to distinguish shared beliefs about supernatural agents from Schneiderian first-rank symptoms suggesting schizophrenic disorder.4,5

That emotional problems may underlie somatic symptoms is not part of the belief systems of many Arabs. Therefore, patients with somatization believe they have somatic disorder. Person-centered clinical psychiatrists explain the psychophysiological relations involved to patients before offering them psychiatric treatment.6 The involved person of the patient is brought to the foreground of clinical work.1 In an Arab community where a woman is socially defined as a child-producer, women who do not get married or are infertile develop a recalcitrant multi-somatic syndrome.7

The introduction of a person-centered psychiatric service in the 1970s has elicited the psychogenesis of this culture-bound syndrome in women who reversed the sequence of events by attributing their lack of marriage and childlessness to their physical ill health. None of these women was assured by the multitude of negative physical investigations of their somatic symptoms. The syndrome was introduced to primary care health services and was associated with the introduction of socially accepted multi-roles for women during the 1970s and 1980s. In the 1990s, the culture-bound syndrome eclipsed8 although the community remained pro-natalist. Women in polygamous marriage were also found to experience a significant excess of somatic symptoms when compared to women in monogamous marriages.9

In traditional societies patients and families who attribute illness or suffering to supernatural agents question the

M

127

Person-Centered Psychiatric Medicine

value of Western-type treatment. Person-centered psychiatrists recognize this only too well. Traditional psychic realities which act as stresses, like other life stresses, set into action the same biochemical mechanisms that generate symptoms and impair mental functioning. With this understanding the majority of patients accept Western-type psychiatric management of their illness.10

Person-centered psychotherapy was initially introduced as client-centered psychotherapy.11 Logotherapy was introduced later as a search for meaning of mental experiences according to patients’ belief systems.12 In both forms of psychological treatment, person-centered psychiatrists study patients’ personal cognitive, affective and spiritual systems to render their distress and suffering meaningful in the patients’ here-and-now. Patients learn how to use their own psychological systems for self-regulation. Person-centered psychiatry fosters partnership for shared understanding and shared decision making in order to deepen understanding and healing through personalized clinical care.1 Moreover, studies of ethnicity and psychopharmacology13 provided more reason for the person-centered approach to treatment using psychotropic medication. Patients who have ethnic differences in the cytochrome P450 enzymes (CYP), e.g. white and Southeast Asians in the USA, metabolize psychoactive drugs in different ways and therefore show differences in therapeutic and unwanted effects attributable to these agents. They have to receive person-centered instructions in pharmacotherapy.

Since many patients, needed psychiatric help after conflict between members of young and older generations in the family14 it was hypothesized that conflict precipitated a state of mental ill health. The question to answer through further investigation was whether intergenerational conflict was different in these patients from its analogue in the community. A person-centered community study failed to elicit any correlation between symptoms on the scaled version of a general health questionnaire15 and a scale of measurement of intergenerational conflict in Kuwait.16 It was concluded that withdrawal of family support in families with intergenerational conflict was instrumental in professional help seeking for problems that family support would have solved within the family bounds.

Person-centered psychiatric practice makes use of resources of individual patients and resources of their families in the care, after-care and rehabilitation of the mentally ill.17 All family members seek integration into the family unit irrespective of the individuals’ physical, mental and socioeconomic shortcomings. This accounts for the better outcome of severe mental disorder in collective developing than individualistic developed societies.18 All forms of psychiatric treatment (medicinal,

psychological and supportive) empower individual persons to achieve their full potential after understanding the illness experience that underlies the illness behavior.2,19

In group psychotherapy, person centering is highlighted. The whole group is treated as one person with different feelings and attitudes expressed by different individuals sharing a common dynamic structure or reinforcing a common tension. Each group member receives therapy as a person in a group medium. Various group members offer person-to-person help to each other.20 Therefore, group psychotherapy combines treatment of group with treatment in a group and treatment by a group with pervasive person-centeredness.

The involvement of religion in helping patients is a person-centered approach taken by psychiatrists as well as traditional healers both of whom know about or share patients’ religion. Psychiatrists take a religious history from their patients in order to ascertain the presence of religious slots where religious material could be utilized. However, traditional healers are not person-centered as they consider that religious advice and practice are universally helpful and equally helpful to the mentally ill and the mentally healthy. Religious self-help involves self-regulation using the belief system in the face of stress. e.g. they regard stress as a test where believers showresilience and expect reward in their after-life for patient endurance of stress.21

Social distance between relatives is smaller in Arabian families and among friends. Social support is a dutiful part of filial piety. In studies of relatives’ expressed emotions towards family members with serious mental disorder22 all relatives would be overinvolved by Western measures if the person-centered approaches were neglected. Moreover, warmth and positive comments were found to mitigate the effects of criticism of patients from relatives who endeavor to prevent social withdrawal of patients by continuous unreciprocated support. Most young people take pride in looking after their elderly and maintain respect for their parents and grandparents as sources of advice and as participants in decision taking on family issues, e.g. arranging marriages, housing or business partnership.

Person-centered clinical psychiatric training

The vulnerability of medical students to develop symptoms like their patients’ was recognized by Hippocrates as “morbus medicorum”. This is particularly likely to develop when students deal with mentally ill persons. Trainers recognize the personal needs of trainees. Medical students were instructed in clinical psychiatry by

128

El-Islam FM

two methods: one centering on clinical material and the other on students’ subjective feelings and impressions about it. The second method led to ventilation of many students’ anxieties about their possible psychiatric disorder through talking about the patients’ symptoms they identified with. The number of students presenting with fears of being mentally ill was significantly lower in the groups trained by the student-centered method than the groups trained according to the case-taking sheet. 23

Person-centered research in mental health

Psychometric research in mental health yields reliable valid results only if it is appropriate to the persons tested. Translated questionnaires may have to be rephrased in order to convey the same meaning to those who speak a different language from the original language of the questionnaire. Scaled answers may have to be replaced by yes/no answers for persons who are not used to quantify description of feelings as severe, moderate, mild, minimal in everyday life.

Situations tested in projective tests should be common in the environment of the persons tested. Fantasy is not distinguished from memory by many Arab patients.24 Person-centered psychometry would be the most appropriate approach.

Participants in research can only give “informed” consent if they receive person-centered information that could be comprehended by each person according to his /her cultural and educational background. Written consent forms are not welcome by the majority of persons participating in research. Most IRBs (Institution Review Boards) accept verbal consent in the presence of a witness as good enough evidence of personal consent to participate in research in Arab communities.

Conclusion

In no branch of medicine is a person-centered approach as necessary and appropriate as it is in psychiatry. In the Arab world, clinical psychiatry is not only person-centered, but it is also family-centered. Psychiatric education and psychiatric research can only gain from a person-centered approach. Before the introduction of the term “person-centered” to describe the discipline of medical practice, Arab psychiatrists have had a person-centered psychiatric medicine for several decades.

References

1. Mezzic JE, Salloum IM, Cloninger CR et al (2010).Person-centred integrative diagnosis: conceptual bases and structural model. Can J Psychiatry 55, 701-708

2. El-Islam MF (2005). Some cultural aspects of the Arabpatient-doctor relationship. Int Psychiatry 7, 18-20.

3. El-Islam MF (1998). Clinical applications of culturalpsychiatry in Arabian Gulf communities. In: Clinical methods in transcultural psychiatry, Ed Okpaku SO. Washington DC. American Psychiatric Press Inc p. 155-170.

4. Al-Ansari EA, Emara MM, Mirza IA and El-Islam MF(1989). Schizophrenia in ICD-10: A field trial of suggested diagnostic guidelines. Comprehensive Psychiatry 30, 416-419.

5. Botros M, Atalla SF and El-Islam MF (2006).Schneiderian First-rank symptoms in a sample of schizophrenic patients in Egypt. Int J Soc Psychiatry 52, 424-431.

6. El-Islam MF (2001). The woman with one foot in thepast. In: Culture and Psychotherapy. Ed Tseng WS and Streltzer J. Washington DC. American Psychiatric Press Inc p. 27-41.

7. El-Islam MF (1975). Culture bound neurosis in Qatariwomen. Soc Psychiatry 10, 25-29.

8. El-Islam MF (2006). The eclipse of a culture boundsyndrome. World Cultural Psychiatry Research Review 1, 34-36

9. Chaleby K (1985). Women of polygamous marriages inan outpatient psychiatric service in Kuwait. J Nerv Ment Disord 173, 56-58.

10. El-Islam MF (2010). Cultural adaptation of globalizedpsychiatry. Arab J Psychiatry 21, 1-8.

11. Rogers C (1961). Becoming a Person. Boston. Houghton Mifflin.

12. Frankl V (1964). Man’s Search for Meaning. AnIntroduction to Logotherapy. London. Hodder and Stoughton.

13. Kinzie JD and Edeki T (1998). Ethnicity andpsychopharmacology. In: Clinical Methods in Transcultural Psychiatry Ed OK paku, vid sup Ref 3 p 171-190.

14. El-Islam MF (1976). Intergenerational conflict and theyoung Qatari neurotic. Ethos 4, 45-56.

15. Goldberg DP and Hillier VF (1979). A scaled version ofthe general health questionnaire. Psychological Medicine 9, 139-145.

16. El –Islam MF (1988). Interparental differences inattitudes to cultural changes in Kuwait. Soc Psychiatry Psychiatric Epidemiol 23, 109-113.

17. El-Islam MF (1989). Collaboration with families for therehabilitation of schizophrenic patients and the concept of expressed emotion. Acta Psychiatr Scand 79, 303-307.

18. Jablensky A, Schwarz R and Tomor (1980). WHOcollaborative study on impairments and disabilities associated with schizophrenic disorders. Acta Psychiatr Scand 62, (suppl 285), 152-163.

19. El-Islam MF and Abu-Dagga SI (1990). Illness behaviorin mental ill-health in Kuwait. Scand J Soc Med 18, 195-201.

129

Person-Centered Psychiatric Medicine

20. Bion WR (1961). Experiences in Groups: London.Tavistock Publications Limited.

21. El-Islam MF (2015). Religion and mental health. Arab JPsycliatry 25, 1-3

22. El-Islam MF (1989). Collaboration with families for therehabilitstion of schizophrenic patients and the concept of expressed emotion. Acta Psychiatr Scand 79, 303-309.

23. El-Islam MF (1968). Mental health of students receivingclinical psychiatric training. The Lancet, November 30, p 1184-1185.

24. El-Islam MF (2015). Culture and mental health.Margaret Mead memorial lecture presented at the WFMH Congress, Cairo 2015.

الملخص

تعتبر شخصنة الممارسة في الطب النفسي ھي األھم في ھذا الفرع من سیة. في الممارسة الطبیة النف الممارسة الطبیة. لیس ھناك مریضان تتطابق حالتھما تماماسرة في العالم العربي وتكتسب األ وینطبق ھذا على الفردیة في تقییم الحالة النفسیة وتقدیم الرعایة لمختلف األفراد سواء كانت ھذه الرعایة بالدواء أو بالعالج النفسي.

.أھمیة خاصة في ھذا المضمار

خاصة من الشخصنة وخاصة في میادین الطب النفسي اإلجتماعي الذي یبحث في أسباب وتداعیات إضطراب كما أن البحوث في الصحة النفسیة تكتسب أھمیة .ترات طویلةبف الصحة النفسیة. وقد كانت ممارسة الطب النفسي في العالم العربي سباقة في إتباع المدخل الشخصي قبل أن تدخل بھ باقي فروع الطب األخرى


Prof M. Fakhr El-Islam FRCP, FRCPsych


Behman Hospital, Helwan, Cairo - Egypt

130


Psychiatric audit

Audit Report of an Inpatient Liaison Psychiatry Service within Baghdad Teaching Hospital

Numan Serhan Ali, Emad Aref Al-Kubaisy, Tori Snell

تقریر تدقیقي للطب النفسي التشاوري في مستشفى بغداد التعلیمي

توري سنل، الكبیسي عماد عارف، مان سرحان علينع

Abstract

ntroduction: Liaison psychiatry is a sub-specialty of medicine concerned with the management of mental disorder in general medical settings. It deals with conditions where the problem is the co-existence of physical and psychological

symptoms regardless of causation. Aims: The current audit involved screening all patients referred over a three month period to the Liaison Psychiatry Consultation Service, Baghdad Teaching Hospital. Cases were from all departments of Baghdad Medical City. The purpose was to establish an initial audit cycle for referral pathways, patient demographics, and clinical presentation in order to develop the service. Methods: Patients (N=72) were referred to the service between March and June 2016 (N=72). In the current audit, no specific standards were set. A questionnaire was used to record patient information. Results: Take up of the service was 9.37%. This was on the basis of there being 2305 hospital beds in use during the audit period. All departments within Baghdad Medical City made at least one referral with the majority being from the Department of Medicine (29.1%) and the Emergency Department (23.6%). The most common presentations were delirium (31.9%) and depression (19.4%). The majority of patients were aged 18-29 years (23.6%) followed by those over 60 years (19.4%). Conclusions: Qualitative feedback from resident doctors was that a majority of patients with physical complaints benefitted from having psychiatric input for what appeared to be co-morbid mental health conditions. Future audits should be conducted to examine the initial reason for hospital admission against mental health presentation and patient feedback should be sought.

Key words: Audit, liaison psychiatry, Baghdad Teaching Hospital, psychiatric consultation


Introduction

Liaison psychiatry is a sub-specialty of medicine concerned with the management of mental disorder in general medical settings. It deals with conditions where the problem is the co-existence of physical and psychological symptoms regardless of causation.1

The main objective of liaison psychiatry is to maintain a bridge between psychiatry and medicine and other specialties to ensure a biopsychosocial approach to health care.

This kind of service may not be available in some hospitals. It is often available in psychiatric units within general hospitals where a consultation liaison service for all age groups, including inpatient services, might be appropriate. Some teams could provide service to specific age groups, e.g. children or the elderly.

Liaison psychiatry services provide a wide range of different activities, including diagnosis and treatment of mental health conditions as well as consultation and

liaison with other health professionals. Risk assessments, advice on mental capacity assessments, the management of challenging or disturbed behavior, and advice on medication, participation in discharge planning for hospital inpatients and the education and training of acute hospital staff are also on offer.2

The prevalence of mental illness among people with physical health conditions is two to three times higher than in the rest of the population.3 Prevalence is particularly high in the hospital setting, where around half of all inpatients experience a mental health condition such as depression, dementia or delirium. Many of these co-morbid mental health problems go undiagnosed and untreated. In the absence of effective intervention, they lead to poorer health outcomes, including increased rates of mortality and morbidity.

Hospital patients with any psychiatric co-morbidity are more likely to utilize health care resources than those with only medical conditions. Levenson and colleagues found that patients with psychopathology or pain had longer

I

131

Liaison psychiatry within Baghdad Teaching Hospital

stays, more procedures performed and incurred more hospital charges.4,13

International recommendations:5

1. 24-hour services are preferable. However, if it isnot possible, then it is important to ensure that out of hours services are of the same quality as daytime services. Also, that the links between out-of-hours services and other services are as good as those with the liaison psychiatry team.

2. A very important feature of a liaison psychiatryteam is that they spend time listening. It is important to include staff who have the time to listen. This does not have to involve expensive senior staff.

3. The role of liaison psychiatry teams in trainingother hospital staff is of vital importance and will help reduce stigma as well as improve outcomes for people with mental health problems.

4. Good communication between teams is veryimportant, especially in terms of making sure that everyone has read the same notes and is reporting back to the same set of notes.

5. Services should be delivered seven days a week,and beyond office hours, but this will depend on local conditions.

In a recent systematic review, Chen et al. found that patients who are more likely to be referred to consultation liaison psychiatry tend to be young, have a psychiatric history, live in an urban setting or have functional psychosis.14

A study by Sherda et al. on consultation-liaison psychiatric services in Dubai, UAE over a six months period found that the total number of referrals was sixty and that suicidal behavior was the highest among the reasons for referrals. The most common diagnosis was depression.15

Aims

The current audit aimed to screen all patients referred to a liaison psychiatry inpatient consultation service to the psychiatric unit at Baghdad teaching hospital so as to establish a baseline for socio-demographics, type of referral, and management of referrals, with a view of improving this kind of service.

Participants and methods

Seventy two patients were enrolled into the current audit, whose consultations were sent to the psychiatry unit at

Baghdad Teaching Hospital during the period from 15 March to 15 June 2016. A questionnaire was used to record patient information needed for the current study.

The psychiatry unit at Baghdad Teaching Hospital has six consultants and eight SHO/Registrars, the unit offers a 24/7 liaison psychiatry consultation service to all specialties at the Medical City Campus including the causality departments

The Medical City is the largest medical campus in Iraq. It was established in 1972 and consists of:

1. Baghdad Teaching hospital with a bed capacityof 1000 beds and two emergency rooms (medical and surgical). The psychiatric unit is situated in this hospital.

2. Ghazi Al-Hariri Specialist surgical hospital of530 beds.

3. Children's Hospital with a 320 beds capacity.4. Oncology Hospital (30 beds).5. Burns and plastic surgery hospital (25 beds).6. GIT surgical hospital (90 beds).7. Nursing home (250 beds).8. Cardiac Surgery center (60 beds).

All those hospitals are situated within the Medical City campus, and the total number of beds in the campus included in this audit was (2305) beds.

Results

Results are summarized in Figures 1-4.

Seventy two consultations were made from all departments of Baghdad Medical city during the study period, the referral rate was 9.37% per bed per year.

Consultations originated mostly from the general medical wards comprising 29.1%, followed by the emergency department comprising 23.6%. The hematology wards made the fewest referrals amounting to 1.3% only.

Delirium was the most common presentation (31.9%), followed by depression (19.4%) and suicide attempts (11.1%). Pseudo-seizures and Autism Spectrum Disorder were less common (2% and 1%, respectively).

Approximately one quarter of the consultations were for patients aged 18-29 years (23.6%), followed by those ≥ 60 years (19.4%), then 30-39 years with 13 (18.0%), while there were 11 patients, aged 40-49 years, (15.2%) and eight patients, aged 50-59 years, (11.1%). There were nine patients ranging in ages <18 years.

132

Ali NS, Al-Kubaisy AE, Snell T

Eight cases had attempted suicide - six women and two men. Four of the women were below 20 years of age and described having family problems; one had

Been diagnosed with Major Depressive Disorder and

presented with pseudo-seizures. Another woman was a known case of epilepsy. Both men had a diagnosis of chronic schizophrenia.

Figure 1. Demonstrated the distribution of sample according to age group

Figure 2. Demonstrated the distribution of sample according to diagnosis

0

2

4

6

8

10

12

14

16

18

< 18 18 - 29 30 - 39 40 - 49 50 - 59 > 60

Age Groups

0 5 10 15 20 25

Suicide

Pseudosiezure

Postpartum blue

Further Ix

Depression

Delerium

Conversion syndrome

Autism

Alcoholic enchephalopathy

ADHD

Acute psychotic disorder

Number of Cases

133


Figure 3. The relationship between age groups and diagnosis

Figure 4. The relationship between gender and diagnosis

Discussion

The current audit was conducted in the largest hospital in Baghdad. The referral rate was 9.37% per bed per year. This is considered to be low, but it was similar to rates reported in other developing countries, for example

India.5,10 While in developed countries it is much higher, as seen in Guy’s Hospital, London in which it was 37.5% per bed per year (150 inpatient referrals per year for total 400 beds).6 This might be due to the low index of suspicions and the lack of non-psychiatric staff training, also reported by Prince M, et al. who reported low mental

62 3 2

811

6

23

6

12

1 25 3

NUMBER OF CASESFemale Male

0

5

10

15

20

<18 18 - 29 30 - 39 40 - 49 50 - 59 >60

1 3 2 1 11 132

31

6

14 2

3

1

62

11

1

5

1

25

3

Age groups

Suicide Pseudoseizure Postpartum blue

Further Ix Depression Delerim

Conversional Autism Alcoholic enchephalopathy

ADHD Acute psychotic disorder

134

Ali NS, Al-Kubaisy AE, Snell T

health training as one of the causes for low referral rates.7 Also, referral rates should be calculated regarding number of consultations made rather than number of beds or inpatients.11,12

Average response time in the current study was 21 minutes, and this might be explained on the basis that there was a good number of consultants in the department of psychiatry during the office hours and that resident doctors were available 24h a day and seven days a week, also they were in the same center in which all hospitals could be reached on foot in no more than 15 minutes. In the UK, a report on the second annual survey of liaison psychiatry had shown the response time was in 63.1% less than one hour,2 while at Guy’s Hospital only 25% were seen within one hour.6

The most common presentation in the current audit was delirium23 (31.9%%), but other studies have indicated that the most common was either somatic symptoms5, 8 or the presence of psychiatric symptoms,9 while in other studies had psychosis as the commonest cause of referral.10 This might be because some of the psychiatric presentations could be explained medically and more could not, also Ndetei et al. have suggested that psychosis is too broad to be diagnosed and more measures considered in referred cases for accurate diagnosis.9

Consultations from obstetrics/gynecology were very low, with only four out of 72 all with postpartum depression. One study suggested that obstetrics/gynecology patients are much less likely to be referred unless they manifest acute or exaggerated psychotic symptoms.9

Referrals due to self-harm were the third most common cause (11.1%). In some developed countries (like England) this remains much higher, frequently cited as the principal reason for referral,4 but it was lower in some African developing countries and India This might relate to the stigma associated with suicide in most developing countries.5,9,10

A study on the pattern of psychiatric referrals in a tertiary care hospital found that out of 400 referrals to the psychiatry unit over a period of one year, the majority were from the medicine department and that substance use disorder was the most common diagnosis followed by depressive disorders.16

Conclusion

Although there is no proper psychiatric training to resident doctors of other specialties yet the consultations were made properly and those colleagues are more aware of the mental health of their patients.

Recommendations

1. Adopt a psychiatry referral form to includeurgency field, age, gender, medications, physical symptoms, previous psychiatric history, detailed reason for consultation, origin of referral, reason for admission.

2. Storing all the consultations for follow up andmore importantly the results and benefits that came out of it.

3. Improve a protocol to recommend a psychiatricopinion to be taken in all cases of alcohol and drug misuse and suicide attempts.

Limitations

1. The study period was short (three months) andwe recommend a longer period of study in the future projects (six months or more) which might give a better idea about CLP at this hospital.

2. We missed a few consults which were made overthe phone, mainly from the ER because they were urgent and unfortunately their details were not recorded.

References

1. Aitken P, Robens S, Emmens T. Liaison PsychiatryServices - Guidance. 1st edition. Pp5; Devon Partnership NHS Trust .February 2014.

2. Fossey M, Parsonage M. Outcomes and performancein liaison psychiatry: Developing a measurement framework. Centre for Mental Health. June 2014.

3. Parsonage M, Fossey M, Tutty C. Liaison psychiatryin the modern NHS © Centre for Mental Health 2012.

4. Levenson JL, Hamer RM, Rositter LF. Relation ofpsychopathology in general medical inpatients to use and cost of services. Am J Psychiatr 1990;147(11):1498-503.

5. Keertish N, Sathyanarayana MT, Hemanth Kumar BG et al. Pattern of psychiatric referrals in a tertiary care teaching hospital in southern India. J Clin Diagn Res 2013; 7:1689-91.

6. Hotopf M, Rayner L, Valsraj K. Improving ‘WholePerson Care’ 2012.http://www.kcl.ac.uk/ioppn/depts/pm/research/imparts/Quick-links/Mapping-Report.pdf

7. Prince M, Patel V, Saxena S et al. No health withoutmental health. The Lancet 2007; 370:859-877.

8. Akhtar J, Farooq S, Ali A. Psychiatric referrals in amultidisciplinary hospital. J Med Pharm Innov. 2011; 18:626-630.

9. Ajiboye PO, Adelekan ML. A prospective analysis ofin-patient consultation liaison psychiatry in a Nigerian teaching hospital. East Afr Med J. 2004; 81:620-625.

135

http://www.kcl.ac.uk/ioppn/depts/pm/research/imparts/Quick-links/Mapping-Report.pdf

http://www.kcl.ac.uk/ioppn/depts/pm/research/imparts/Quick-links/Mapping-Report.pdf


10. Dave T, Dr. Paul R. A study of liaison psychiatryreferrals in a Zambian teaching hospital. J Med Sci Tech. 2016; 5(1):18-22.

11. Ndetei DM, Khasakhala LI, Ongecha FA et al.Outcome of a working diagnosis of “psychosis” in relation to DSM-IV diagnostic criteria in a Kenyan in-patient cohort at Mathari hospital, Nairobi. Afr Health Sci 2007; 7:197-201.

12. Tadros G, Salama RA, Kingston P et al. Impact of anintegrated rapid response psychiatric liaison team on quality improvement and cost savings: the Birmingham RAID model. The Psychiatrist. 2013; 37:4-10.

13. Roland MO, Bartholomew J, Morrell DC, et al.Understanding hospital referral rates: a user’s guide. Brit Med J. 1990; 301(6743):98-102.

14. Chen et al. Why hospital doctors are not referring toconsultation liason psychiatry? A systematic review BMC Psychiatry (2016) 16:390.

15. Sherda M, Sherra K, Mahmood E, Elsaid O.Consultation-liaison psychiatric services in Dubai, UAE: a descriptive analysis study. Egyptian J Psychiatry (2016),37 ,111-116.

16. Desai et al. Pattern of psychiatric referrals in a tertiarycare hospital: an overview of consultation-liaison psychiatry, Nat J Integr Res Med. (2016):7(2)56-60.

الملخص:

یتزامن قسام الطبیة المختلفة ویتعامل مع الحاالت التيى بمعالجة االمراض النفسیة في األعنالطب النفسي التشاوري ھو التخصص الدقیق في الطب الذي ی المقدمة: فیاتشملت الدراسة الحالیة مسح لكافة المرضى المحالین من كافة المستش الدراسة:اھداف .من االعراض الجسدیة والنفسیة بغض النظر عن المسببات فیھا تواجد كال

.أشھرلى الشعبة النفسیة في مستشفى بغداد التعلیمي خالل مدة الدراسة التي كانت ثالثة إوالشعب في مجمع مدینة الطب

یة رض وخصائصھم الدیموغرافالغرض من الدراسة ھو تدقیق مسار احاالت الم نتعلیمیة، وكابغداد من عدة مستشفیات - نة الطب في باب المعظممجمع مدی یتألف .لى حاالتھم السریریة لغرض تطویر ھذه الخدمةإاضافة

72وكان عددھم 2016 حزیران -اذاربین فترة الدراسة مالى شعبة الطب النفسي خالل إنة البحث من كل المرضى المحالین تألفت عی البحث:طریقة وقد . مریضاوقد %9.37سریر وكان معدل االحالة 2305كان عدد االسرة الكلي في مجمع مدینة الطب ھو النتائج: .تم استخدام استبیان خاص لتثبیت كافة معلومات المریض

حیث الطوارئعیادة وتلتھا % 29,1القل ولكن أغلب االحاالت كانت من الطب الباطني حیث شكلت احالة واحدة على ا بإرسالقامت كل شعبة من شعب المجمع أكثركانت . %23,6كانت 29-18اغلب المرضى كانوا من الفئة العمریة . % 19,4 الكآبة ثم % 31,9بین المحالین ھي الھذیان وبنسبة الحاالت المرضیة شیوعا

وتلیھم % 23,6حیث شكلوا اوضحت ردود الفعل النوعیة من قبل االطباء االستنتاجات:. %19,4نسبتھم حیث بلغت المجموعة التي تجاوزت اعمارھم الستین عاما .الة نفسیةالمقیمین بأن اغلبیة المرضى الذین كانت لدیھم اعراض جسدیة قد استفادوا من التداخل النفسي لما تبین انھ كان بسبب تزامنھا مع وجود ح

ي سماع من عرض حاالتھم كحاالت نفسیة ومن الضرور لى المستشفى بدال إدخول المرضى بد من أن تقوم البحوث التدقیقیة مستقبال بالبحث عن االسباب االولیة ل ال .اراء المرضى وتقییمھم لالستشارة النفسیة


Dr Numan Serhan Ali FRCPsych, DPM, DCN

Consultant Psychiatrist, Baghdad Teaching Hospital, Baghdad - Iraq


Authors

Dr Numan Serhan Ali, FRCPsych DPM, DCN

Consultant Psychiatrist, Baghdad Teaching Hospital, Baghdad - Iraq


Dr Aref Al-Kubaisy, FICMS-Psych

Specialist Psychiatrist, Baghdad Teaching Hospital, Baghdad - Iraq

Dr Tori Snell, DClinPsy CPsychol AFBPsS

Clinical Psychologist

University of Leicester, Department of Psychology, Leicester - UK

136

Psychiatric audit


Clinical Audit

Adib Essali

التدقیق السریري

ادیب العسالي

Abstract

linical audit is the process used by health professionals to assess if they are actually doing the right thing in the right way in their clinical practice. A clinical audit might be undertaken to ensure that best practice is being followed and

that patient outcomes are the desired ones. The quality of care is measured using accepted standards. The failure to meet these standards means that there is a room to improve an individual, a team, or an organization’s clinical work. The ultimate goal of an audit process is improved clinical practice, leading to better patient outcomes.

Key words: audit, psychiatry, research


Introduction

It is intuitive for clinicians to critically analyze the quality of their practice in order to assess whether patients are receiving the best quality of care. This is the essence of audit, which may be dated back to as early as 1750 BC when King Hammurabi of Babylon instigated audit for clinicians with regard to outcome. The concept has been developed greatly since then. Most recently, clinical audit has been defined as ‘a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria… Where indicated, changes are implemented…and further monitoring is used to confirm improvement in healthcare delivery.’ 1

Audit and research

Audit is different from research. Research uses strict methodology to addresses clearly defined questions and hypotheses in order to generate new evidence. Clinical audit aims to improve the quality of patient care and clinical outcomes through reviewing practice against evidence-based standards and implementing change where necessary. Thus, ‘Research is concerned with discovering the right thing to do; audit with ensuring that it is done right.’2 While research asks the question ‘what is the right thing to do?’, clinical audit asks ‘are we doing the right thing in the right way?’

Audit should be transparent and non-judgmental rather than confrontational - it is not an opportunity to name, shame, and blame. The aim is to find out how the present provision compares with the desired standard. This information can then be used to plan improvements in the service.

The audit cycle

The term 'audit cycle' is usually used to describe the clinical audit process. A commonly quoted definition states that ‘Clinical audit is a quality improvement cycle that involves measurement of the effectiveness of healthcare against agreed and proven standards for high quality, and taking action to bring practice in line with these standards so as to improve the quality of care and outcomes’.3 This cycle is then repeated to determine whether the actions taken have been effective, or whether further improvements are needed. As the process continues, each audit cycle aspires to a higher level of quality; hence the term 'audit spiral'.4

Each audit cycle is made up of four steps (Figure 1):

1. Selecting a topic for the audit.2. Selecting criteria and standards.3. Conducting the audit.4. Making improvements.

C

137

Clinical audit

Figure 1. The audit cycle

Selecting a topic for the audit

The first step in the audit cycle is to select a topic for audit. Priority healthcare audit topics are chosen usually because they are associated with high risk or cost, or because they are widely used. Audit topics may also be derived from concerns such as adverse incidents or patient complaints. Patients’ priorities can differ markedly from those of clinicians. Practical approaches have been developed for involving patients in all stages of audit, including design, data collection, and implementing change.5,6

The objective of clinical audit is to measure adherence to healthcare standards that have been shown to produce best outcomes for patients.

Selecting criteria and standards

The second step in the audit cycle is to identify the criteria of the audited topic, and the standards against which current practice will be measured.

Audit criteria are explicit statements defining an outcome to be measured. They should relate to important aspects of care and be derived from the best available evidence, e.g., ‘All patients who take antipsychotic medication should be…’. The standards for achieving the criteria are then defined.

A standard is the level of care to be achieved for any particular criterion, and is usually a target expressed as a percentage.7 It may be a minimum standard or an optimal one, depending on the clinical scenario. ‘A minimum standard describes the lowest acceptable standard of performance. Minimum standards are often used to distinguish between acceptable and unacceptable practice. An ideal standard describes the care that should be possible under ideal conditions. Such a standard by definition cannot usually be attained. An optimum standard lies between the minimum and the ideal. Setting an optimum standard requires judgment, discussion and consensus with other members of the team. Optimum standards represent the standard of care most likely to be achieved under normal conditions of practice.’8

Standards are usually adopted from published evidence-based guidelines or systematic reviews. For instance, the criteria set by recent clinical practice guidelines for the management of schizophrenia and related disorders9 include that psychiatrists should prescribe only one antipsychotic agent at a time. However, antipsychotic polypharmacy is not uncommon in routine clinical practice. A meta-analysis of 147 studies reported that the use of antipsychotic polypharmacy varies considerably, ranging from 6-90%, with a median global prevalence of 19.6%.10 A local audit of the prevalence of antipsychotic polypharmacy may use this median global prevalence as an optimum standard against which local clinical practice may be measured.

Selecting a topic

Selecting criteria and standards

Conducting the audit

Making improvements

138

Essali A

Once a standard to measure current performance is agreed, a written plan is devised to include explicit selection criteria and ensure that the collected data are precise and essential for the audit. The plan should define the patients to be included or excluded, the audit criteria, what data to be collected and over what time period, the source of data, and who will collect the data. The data may be available in a computerized information system, or may be collected manually depending on the outcome being measured.

Conducting the audit

The third step in the audit cycle involves measuring the level of performance through collecting data manually and/or from computerized records. Data for an audit are generally collected retrospectively. However, prospective data collection can give immediate feedback on current performance and act as positive reinforcement to improve or maintain practice. Prospective audit usually requires good information technology resources.1

At the end of this step, the collected data is analyzed in order to compare actual performance with the standards that were set for the audit. If the standards were not met, then there is room for improvement.

Making improvements

The fourth step in the audit cycle aims at improving patient care through using the audit results to develop an action plan, specifying what needs to be done, how it will be done, who is going to do it and by when.

The action plan is developed in order to increase compliance with the set standards thus maximizing the benefit of the process to patient outcomes. This is possible, in theory at least, if the set standard was not fully met. However, in practice, if the results were close to 100% further improvement may be difficult to achieve.

Re-auditing

Subsequent audit cycles are planned so that the audit is part of a spiral process of continuous quality improvement. This step is critical to the successful outcome of an audit: it verifies whether the changes implemented have had an effect and determines whether further improvements are needed to achieve the identified standards.

Re-auditing aims at checking whether the practice has improved. If it has improved, re-auditing may aim to measure the service against a new set of standards. Every time an audit cycle is completed, there should be further improvement in patient care.

References

1. National Institute for Health and Clinical Excellence.Principles of best practice in clinical audit. London: NICE, 2002. Available at: https://www.nice.org.uk/ media/ default/About/what-we-do/Into-practice/principles-for-best-practice-in-clinical-audit.pdf. Accessed 2 August 2017.

2. Smith R. Audit & Research. BMJ 1992:305:905-6.3. HQIP UK. New Principles of Best Practice in Clinical

Audit. Healthcare Quality Improvement Partnership 2011. 4. Benjamin A. Audit: how to do it in practice. BMJ.

2008:336:1241-5. 5. Kelson M. Promoting patient involvement in clinical audit.

Practical guidance on achieving effective involvement. London: College of Health and the Clinical Outcomes Group, 1998.

6. Balogh R, Simpson A, Bond S. Involving clients in clinicalaudits of mental health services. Int J Qual Health Care.1995:7:343-53.

7. Irvine D, Irvine S. Making sense of audit. Oxford: RadcliffeMedical Press, 1991.

8. Anderson DG. ABC of audit. http://www.gp-training.net/training/tutorials/management/audit/audabc.htm. Accessed on 2 August 2017.

9. Galletly et al. Royal Australian and New Zealand Collegeof Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Australian and New Zealand Journal of Psychiatry 2016:50(5):410-472.

10. Gallego et al. Prevalence and correlates ofantipsychotic polypharmacy: A systematic review and meta-regression of global and regional trends from the 1970s to 2009. Schizophr Res 2012:138:18-28.

Further reading in Arabic

Essali MA. Chapter 9: Clinical Audit. In: Essali MA. Designing, conducting and publishing health research studies. Damascus, Tinawi Press, 2010. pp. 94-116. Available at: https://www.researchgate.net/ publication/ 262006523_Health_Research_Made_Easy_tbsyt_tsmym_wtnfydh_wnshr_albhwth_alshyt_allmyt Accessed 2 August 2017.

139

https://www.nice.org.uk/

https://www.researchgate.net/

Clinical audit

الملخص

د یستخدم الصحیة الصحیحة بطریقة سلیمة. فقالتدقیق السریري (أو العیادي) ھو إجراء یقوم بھ العاملون في الرعایة الصحیة بغیة تقییم ما إذا كانوا یقدمون الرعایة تخدام معاییر لمقدمة باسالتدقیق السریري للتأكد من أنھ یتم اتباع الممارسة المثلى ومن أن المرضى یحصلون على النتائج المرجوة، حیث یتم قیاس جودة الرعایة ا

حیة المقدمة من قبل فرد أو فریق أو منظمة صحیة. فالغایة النھائیة للتدقیق السریري مقبولة، ویدل عدم تحقیق تلك المعاییر على وجود مجال لتحسین الرعایة الص .ھي تحسین الممارسة السریریة بشكل یؤدي لتحسین النتائج التي یحصل علیھا المرضى

Author

Dr Adib Essali, MD, PhD, MRCPsych, Affiliate RANZCP

Consultant Psychiatrist, Waikato DHB and Honorary Senior Lecturer, University of Auckland

Manaaki Centre, Mary Street, Thames - New Zealand

E-mail: [email protected] or [email protected]

140

mailto:[email protected]


Abstract

ackground: Clozapine and olanzapine are highly associated with the risk of metabolic syndrome resulting in lower functional outcomes, poorer quality of life and non-compliance to treatment. Objective: The current study examined

the rate of assessment of metabolic syndrome parameters in patients on olanzapine attending Almasarrah Hospital in Muscat. Methods: Patients starting olanzapine between January 2014 and May 2015 were recruited to the study, which is based on the retrospective revision of cases gathered from medical records over a period of 18 months. Patients aged 18 years or above, who were prescribed olanzapine and had five or more hospital visits were included. Demographics included physical health parameters with regards to metabolic syndrome, namely blood pressure, weight, fasting blood sugar level and lipid profile. Results were compared to the ADA-APA monitoring protocol for patients on second generation antipsychotics. Results: N=46 patients met study inclusion criteria. No gender difference was identified. Most (74%) were between 21 and 40 years of age with 50% diagnosed with schizophrenia; 50% did not have a baseline lipid profile and 30% had blood sugar levels checked prior to olanzapine therapy. The majority (97%) had blood pressure and weight measured at baseline and follow-up. Overall, none of the patients matched the full standards of the ADA-APA protocol. Conclusion: Screening for metabolic syndrome among patient prescribed olanzapine in Almasarrah Hospital is behind international standards. This is especially true for lipid profile and fasting blood sugar level parameters. Findings are consistent with similar studies. Further studies should assess factors contributing to suboptimal monitoring of olanzapine-induced metabolic syndrome.

Key words: Metabolic syndrome, atypical antipsychotics, olanzapine, schizophrenia, Oman


Introduction

Second generation antipsychotics have been consistently linked with an increased risk of metabolic abnormalities.1 Metabolic syndrome encompasses a cluster of clinical features, including obesity, hypertension, dyslipidemia and impaired fasting glucose levels or overt diabetes mellitus (Expert Panel on Detection, 2001).2 The presence of these features in patients with schizophrenia increases the incidence of cardiovascular diseases and the mortality rate.3

A literature review on this subject revealed a high prevalence of metabolic syndrome among patients with schizophrenia.4,5 Alison et al. (1999) found that the rate of metabolic syndrome among patients with schizophrenia was 46% compared with a rate of 27% in the general population.6 Even before the introduction of antipsychotic medications, metabolic abnormalities have been identified as side effects of schizophrenic illnesses.7 Several reasons have been put forward to explain the higher incidence of metabolic syndrome among patients with schizophrenia,

including poor dietary habits, high rates of smoking and consuming alcohol.8

Among all antipsychotic medications, clozapine and olanzapine are the most highly associated with the risk for metabolic syndrome.8,9 Hert et al. (2004) estimated that the occurrence of metabolic syndrome in a three-year follow-up of patients treated with olanzapine to be as high as 47%, second only to clozapine (58%). Underlying reasons for this increase in second generation induced metabolic syndrome are still under debate. However, several studies have proposed that an increase in adiposity due to the effects of second generation antipsychotics can lead to a decrease in insulin sensitivity, and thus change plasma glucose and lipid levels.10

In addition to its effects on physical health, metabolic syndrome can result in lower functional outcomes, poor quality of life and non-compliance to treatment.11-13 Thus, metabolic syndrome and its associated cardiovascular diseases and premature death have become a major clinical

B

141

The Arab Journal of Psychiatry (2017) Vol. 28 No.2 Page (141 - 146) (doi: 10.12816/0041714)

Liaison psychiatry

Physical Health Monitoring for Metabolic Syndrome in Patients Prescribed Olanzapine in Oman Abdullah

Al-Jaradi, Mandhar Al-Maqbali, Idris Gaafar, Khalid Al-Khanbashi

معدل تقییم األطباء لمتالزمة األیض للمرضى المتعالجین بدواء األوالنزابین والذین یراجعون في مستشفى للرعایة النفسیة الثالثیة بسلطنة

عمان عبد هللا الجرادي، منذر المقبالي، إدریس جعفر، خالد الخنبشي

Physical health monitoring for metabolic syndrome in patients prescribed olanzapine in Oman

concern. Moreover, close monitoring of physical health and metabolic abnormalities among psychiatric patients is highly recommended.

Almasarrah Hospital is the biggest mental health center in the Sultanate of Oman. It receives referrals from all around the country and provides in-patient, as well as outpatient, services. Olanzapine is widely used as a first line treatment for various indications, such as schizophrenia and bipolar disorder. There is a paucity of studies investigating the effects of olanzapine on physical health among patients with mental health disorders in Oman. The current study aims to assess the rate of screening for metabolic syndrome among patients who have been prescribed olanzapine.

Methods

Study design and sampling

The current study involves a cross-sectional design based on retrospective data collected via case series from a medical records database from January 2014 to May 2015. All records of newly registered patients, both inpatients and outpatients, visiting Almasarrah Hospital, a tertiary care hospital in Oman, were reviewed for recruitment to the current study.

Patients who were aged 18 years or above, who were placed on olanzapine and had five or more documented hospital visits were included. In order to obtain a clearer view on the rate of patient monitoring, a minimum of five visits to the hospital were selected for inclusion. Patients with insufficient data (excluding metabolic syndrome parameters) were excluded. A data collection sheet was designed to record the patients’ age, gender and the given diagnosis during their final visit. In addition, the data collection sheet included a checklist for the physical health parameters of metabolic syndrome, namely blood pressure, weight, fasting blood sugar levels and lipid profile. These parameters were chosen based on the definition of the Expert Panel on Detection (2001) for metabolic syndrome2. The present study also took into account the recommendations in the existing guidelines for monitoring patients who are on second-generation

Antipsychotic-induced metabolic syndrome, such as the ADA-APA guideline.14 this guideline recommends a baseline monitoring of the patient’s weight, blood pressure, lipid profile and fasting glucose level prior to commencing the patient on second-generation antipsychotics. Their weight should be monitored after four weeks for a period

of three months, and then annually. The ADA-APA guidelines also recommend the monitoring of blood pressure, fasting glucose levels and lipid profile after three months following the start of treatment and then annually.

Medical records of patients fulfilling the inclusion criteria were reviewed to trace the frequency that the metabolic syndrome parameters were monitored. The rate of monitoring blood pressure, weight, lipid profile and fasting glucose levels at baseline and subsequent visits were analyzed using the patients’ medical records.

Data analysis

The Statistical Package for the Social Sciences (SPSS) version 20 (IBM Corp., Armonk, NY, USA) was used to analyze the results. For descriptive purposes, categorized variables were described as percentages with confidence intervals. Continuous variables were presented as means with standard deviations or medians with an inter-quartile range.

Ethical approval

Ethical approval for the study was obtained from the hospital administration of Almasarrah Hospital.

Results

A total of 381 visits among 46 patients were included in this cross-sectional retrospective study after eliminating 883 visits due to the inclusion criteria.

The mean patients’ age and the average number of visits during the study period is illustrated in Table 1. The patients’ characteristics are provided in Table 2.

Table 1. Mean participant age and average number of visits

Mean (± SD)

Participant age (in years) 33.4 (± 13) Number of visits 7.4 (± 2.4)

SD = standard deviation

142

Al-Jaradi A, et al.

Table 2. Participant characteristics

Percentage

Age (in years) ≤20 21-40>40

6 74 20

Sex Female Male

50 50

Number of visits 5 6–8 >8

21.7 45.7 32.6

Diagnosis Schizophrenia Bipolar Disorder Others

50 17 33

The gender among the sample was evenly distributed, with 50% being men. With regard to age distribution, 74% of the patients fell within the 21 to 40 year old age range, followed by 20% of the sample being above the age of 40 years with 6% who were 20 years or younger. In terms of number of visits, 45.7% of the sample had six to eight, 32.6% had more than eight visits and 21.7% had five visits.

The majority of the patients who were included in the present study were diagnosed with schizophrenia (50%), followed by bipolar disorder (19%). The rest of the sample had different diagnoses, such as depression with psychotic features, schizoaffective disorders, and intellectual disability among others.

In respect to lipid monitoring, results found that 54.3% of the patients had no lipid monitoring during their visits, while the rest of the patients had their lipid profile

monitored one to two times (30.4%) and three to four times (15.2%). Fasting plasma glucose testing was not carried out in 92.2% of the visits, and only in 8.6% of the visits was fasting glucose checked, though on an irregular basis.

The non-invasive interventional parameters, blood pressure and weight measurements, were noted to be highly monitored, both noted in about 91% of visits. Blood pressure monitoring was noted to occur variably, with around 37% of patients having their blood pressure checked five times or more, 30.4% checked one to two times and 23.9% checked three to four times, over their visits. Blood pressure was not monitored in 8.7% of the patients. Weight monitoring was noted to occur with variable frequencies in this study, ranging from one to four times (26.1%) to five times and more (39.1%). Table 3 summarizes the results of the blood pressure, weight, fasting plasma glucose levels and lipid profile monitoring.

Table 3. The overall frequency of monitoring parameters of metabolic syndrome for all participants

Not done one to two times three or more times

Lipid profile 54.3% 30.4% 15.2% Blood pressure 8.7% 30.4% 60.9% Weight 8.7% 26.1% 65.2% Fasting plasma glucose 69.6% 30.4% 0%

In comparison to the APA-ADA protocol for monitoring patients on second generation antipsychotics, none of the patients in the current study matched all of the requirements. Only 52% of the patients had a baseline lipid profile and only one patient had repeated lipid profile taken after three months and one year. Fasting blood sugar levels

were checked in 21% of the patients at baseline. As previously, only one patient had repeated blood fasting sugar level testing after three months and one year.

Baseline weight and blood pressure measurements were documented in 89% and 69% of the patients, respectively.

143


Patients’ weight was taken after four weeks for 60% of the patients, after eight weeks for 48% of the patients and after three months for 41% of the patients. Blood pressure was monitored after three months in 45% of patients and only five patients had an annual blood pressure measurement in their records.

Among the whole cohort, 10.8% discontinued olanzapine before they had been taking it for one year. Side effects such as weight gain and excessive sedation were the main contributing factors for this discontinuation.

Discussion

The current study is the first to examine the rate of assessment of metabolic syndrome parameters among patients who were commenced on olanzapine in Oman. The findings from this study demonstrated that the rate of assessing blood pressure and weight as screening measures for metabolic syndrome were undertaken at a frequency that matched international standards.15 The reasons for this are likely due to the routine practice among nursing staff to measure blood pressure and weight prior to the patients seeing the doctor and due to the ease of taking these measurements.

Lack of cooperation, agitation or a busy nursing staff might explain the small percentage of missed blood pressure and weight measurements.

On the other hand, interventional parameters such as lipid profile and blood glucose level monitoring lags behind international standards. In Almasarrah Hospital, doctors are expected to collect blood from their patients. Therefore, busy clinics and a lack of doctors’ clinical awareness to check for these measures could attribute to the low frequency of monitoring fasting glucose levels and lipid profile. In addition, some patients may refuse to have their blood collected.

The results from this study are parallel to those of similar studies investigating the frequency of assessment of metabolic syndrome parameters. A UK audit screening for the metabolic side effects of antipsychotics among 1966 patients under the care of 48 multidisciplinary assertive outreach clinical teams (AOTs) found that the rate of blood pressure screening was 26%, obesity was noted in 17% of patients, blood glucose or HbA1c in 28% of patients, and plasma lipid in 22%. All four measures were only documented in 11% of the patients.16 Notably, the frequency of screening patients prescribed second generation antipsychotics was even lower in the centers included in the AOTs study as compared to the current

study in Almasarrah Hospital, particularly with regards to weight and blood pressure measurements.

There are a series of obstacles to routine screening practices in AOTs, including uncertainty as to whether physical health screening is the responsibility of the psychiatric team or primary care providers, as reported by about a third of the participating teams in the UK audit. Less than half of the teams were confident enough to interpret abnormal screening results. In addition, limited access to basic equipment, such as tape measures and weighing scales was a relatively common problem.16

An Australian study conducted in 2009 assessed the rate of metabolic syndrome screening among patients who were prescribed antipsychotic drugs in Australia concluded that routine screening was inadequate due to some practical barriers, such as busy clinicians, lack of basic measurement tools and a lack of local monitoring protocols.17

Screening for metabolic syndrome among patients prescribed olanzapine in Almasarrah Hospital currently lags behind international standards. This is especially true for the lipid profile and fasting blood sugar parameters. Nevertheless, the results from the current study are comparable to similar studies carried out in the field. Further studies are required to assess the factors contributing to the suboptimal monitoring of olanzapine-related metabolic syndrome in Almasarrah Hospital. The present study reflects the need to improve the clinical practices of regular monitoring for metabolic syndrome parameters. Increasing awareness among health workers about the side effects of antipsychotic medications, developing local protocols with easy follow-up algorithms, building special blood collection rooms with blood collectors may result in an improved monitoring frequency rate.

Finally, the current study has highlighted an important aspect of metabolic syndrome in Oman. The prevalence rate of metabolic syndrome in Oman in a community based study was found to be 23%, compared to 37% in Saudi Arabia and 21% in the USA.18,19 In most developing countries, the annual rate of metabolic syndrome is substantially high. There are several factors, which could explain this high rate of metabolic syndrome in developing countries, such as demographic and epidemiologic transitions, rapid urbanization and changes in nutritional patterns. Though it is a controversial subject, a thrifty genotype, which increases survival during famines, can increase the tendency to develop metabolic syndrome during abundant food availability.20

Concerning olanzapine-induced metabolic syndrome, Ellingrod et al. (2005) demonstrated that patients with a T allele of the 5HT2C receptors -759 C/T polymorphism may have a lower incidence of weight gain from olanzapine

144

Al-Jaradi A, et al.

over a 6 week period of treatment compared to those with the C allele.21

Therefore, screening for metabolic syndrome and implementing effective interventions to lower the risk of metabolic syndrome in patients taking olanzapine is of paramount importance in order to prevent the risk of cardiovascular disease and decrease mortality rates.

Limitations

Larger sample sizes and longer study duration may yield more results that are generalizable. In addition, the current study did not include self-reported blood pressure or weight for the patients on olanzapine. It is not uncommon for patients to check their weight and blood pressure in local health centers and to attend clinic with the measurement report. This is applicable to the fasting glucose level and lipid profile too.

Conclusion

Screening for metabolic syndrome among patients who have been prescribed olanzapine in Almasarrah Hospital lags behind the international standards. This is especially true for lipid profile and fasting blood sugar-testing parameters. Findings in the current study are consistent with similar studies conducted in other mental health centers. Further studies are required to assess the factors contributing to suboptimal monitoring of olanzapine-related metabolic syndrome.

Acknowledgment

The authors would like to thank the department of information technology at Almasarrah Hospital for their generous and active corporation in collecting the data for the present study.

References

1. Allison DB, Casey DE. Antipsychotic-induced weightgain: a review of the literature. J Clin Psychiatry. 2001; 62(Suppl 7):22-31.

2. American Diabetes Association. Consensus developmentconference on antipsychotic drugs and obesity and diabetes. Diabetes care. 2004 Feb 1;27(2):596-601.

3. Cohn T, Prud'homme D, Streiner D, Kameh H,Remington G. Characterizing coronary heart disease risk in chronic schizophrenia: high prevalence of the

metabolic syndrome. Can J Psychiatry. 2004 Nov;49(11):753-60.

4. Bobes J, Arango C, Aranda P, Carmena R, Garcia-GarciaM, Rejas J. Cardiovascular and metabolic risk in outpatients with schizophrenia treated with antipsychotics: results of the CLAMORS Study. Schizophrenia Research. 2007 Feb 28;90(1):162-73.

5. Correll CU, Frederickson AM, Kane JM, Manu P.Metabolic syndrome and the risk of coronary heart disease in 367 patients treated with second-generation antipsychotic drugs. J Clin Psychiatry. 2006 Apr 15;67(4):575-83.

6. Allison DB, Fontaine KR, Heo M, Mentore JL, Cappelleri JC, Chandler LP, Weiden PJ, Cheskin LJ: The distribution of body mass index among individuals with and without schizophrenia. J Clin Psychiatry. 1999; 60:215–220

7. Meduna LJ, Gerty FJ, Urse VG. Biochemical disturbancesin mental disorders. J Nerv Ment Dis. 1942 Dec 1;96(6):719.

8. Marder, Stephen R., et al. Physical health monitoring ofpatients with schizophrenia. Am J Psychiatry. 161.8 (2004): 1334-1349.

9. De Hert, Marc, et al. Typical and atypical antipsychoticsdifferentially affect long-term incidence rates of the metabolic syndrome in first-episode patients with schizophrenia: a retrospective chart review. Schizophrenia Research. 101.1 (2008): 295-303.

10. Newcomer, John W. Second-generation (atypical)antipsychotics and metabolic effects. CNS Drugs. 19.1 (2005): 1-93.

11. Lyketsos CG, Dunn G, Kaminsky MJ, Breakey WR.Medical comorbidity in psychiatric inpatients: relation to clinical outcomes and hospital length of stay. Psychosomatics. 2002 Feb 28;43(1):24-30.

12. Awad AG. Antipsychotic medications: compliance andattitudes towards treatment. Current Opinion in Psychiatry. 2004 Mar 1;17(2):75-80.

13. Weiden PJ, Mackell JA, McDonnell DD. Obesity as a riskfactor for antipsychotic noncompliance. Schizophrenia Research. 2004 Jan 1;66(1):51-7.

14. American Diabetes Association, American PsychiatricAssociation; American Association of Clinical Endocrinologists; North American Association for the Study of Obesity; North American Association for the Study of Obesity, Consensus development conference on antipsychotic drugs and obesity and diabetes. J Clin Psychiatry. 2004;65 (2) 267- 272

15. American Diabetes Association. Consensus developmentconference on antipsychotic drugs and obesity and diabetes. Diabetes Care 27.2 (2004): 596-601.

16. Barnes, Thomas RE, et al. A UK audit of screening for the metabolic side effects of antipsychotics in community patients. Schizophrenia Bull. 33.6 (2007): 1397-1403.

17. Waterreus, AJ, Laugharne, JD. Screening for themetabolic syndrome in patients receiving antipsychotic treatment: a proposed algorithm. Med J Aust 190.4 (2009): 185-9.

18. Al-Lawati JA, Mohammed AJ, Al-Hinai HQ, Jousilahti P. Prevalence of the metabolic syndrome among Omani adults. Diabetes Care. 2003 Jun 1;26(6):1781-5.

145


19. Al-Nozha M, Al-Khadra A, Arafah MR, Al-Maatouq MA,Khalil MZ, Khan NB, Al-Mazrou YY, Al-Marzouki K, Al-Harthi SS, Abdullah M, Al-Shahid MS. Metabolic syndrome in Saudi Arabia. Saudi Medical Journal. 2005;26(12):1918-25.

20. Misra A, Khurana L. Obesity and the metabolic syndrome in developing countries. J Clin Endocrinol Metab. 2008 Nov 1;93(11_supplement_1):s9-30.

21. Ellingrod VL, Perry PJ, Ringold JC, Lund BC, Bever‐Stille K, Fleming F, Holman TL, Miller D. Weight gain associated with the - 759C/T polymorphism of the 5HT2C receptor and olanzapine. Am J Med Genet. Part B: Neuropsychiatric Genetics. 2005 Apr 5;134(1):76-8.

الملخص

سلطنة عمان. ب قیاس معدل تقییم األطباء لمتالزمة األیض للمرضى المتعالجین بدواء األوالنزابین والذین یراجعون في مستشفى للرعایة النفسیة الثالثیةاالھداف: تشفى ج بمسمستشفى المسرة بمسقط/ سلطنة عمان. المنھج / الطریقة: ھذه الدراسة المقطعیة اعتمدت على مراجعة جمیع بیانات المرضى الذین تلقوا العال المكان:

الى المستشفى وخضوعھم وتم استخالص المرضى الذین تعالجوا بدواء األوالنزابین ومن ثم حساب عدد زیاراتھم 2015الى شھر مایو 2014المسرة من شھر ینایر استخلصت الدراسة أن تقییم متالزمة األیض للمرضى النتائج:للفحص الدوري المعتمد لمتالزمة األیض وھي قیاس ضغط الدم والوزن والدھون ونسبة السكر.

منھم لم % 70ل أن یصرف لھم دواء أألوالنزابین والمتعالجین بدواء أألوالنزابین دون المستوى المطلوب إذ أن نصف المرضى المشاركین لم یتم فحص الدھون قبیجب أن یحرص األطباء على تقییم المرضى الخاتمة: یتم فحص السكر. ھذا ولقد تم فحص الضغط والوزن بمعدل جید یفوق معدالت استخلصت من دراسات أخرى.

على المریض ال سیما وأن المریض النفسي یكون عرضة أكثر من غیره لآلثار لمؤشرات متالزمة األیض ومتابعتھا بشكل دوري لتجنب مضاعفاتھا النفسیة والجسدیة .المترتبة على متالزمة األیض

Corresponding Author

Dr Munther Al Muqbali

Resident in Psychiatrist, Al Mascara Hospital, Muscat - Sultanate of Oman


Authors

Dr Abdullah Al Jaradi

Consultant Psychiatrist, Psychiatry Department, Armed Forced Hospital, Muscat - Sultanate of Oman

Dr Munther Al Muqbali

Psychiatry Resident, Oman Medical Specialty Board, Muscat - Sultanate of Oman

Dr Idris Gaafar

General Practioner, Family Medicine Department, Armed Forced Hospital, Muscat - Sultanate of Oman

Mr Khalid Al Khanbashi

Medical Simulation Specialist, Oman Medical Specialty Board, Muscat - Sultanate of Oman

146


Liaison psychiatry

Prevalence of Depression in a Sample of Hypertensive Outpatients in Mosul

Adnan Yassin Mohammed

انتشار االكتئاب في عینة من مرضى العیادات الخارجیة في مدینة الموصل في العراق الذین یعانون من ارتفاع الضغط الشریاني

عدنان یاسین محمد

Abstract

ypertension is a common chronic cardiovascular disease that affects all ethnic groups throughout the world. It leads to chronic disability and excess mortality. Depression is common sequelae of hypertension and contributes

significantly to poor health in hypertensive patients. Objective: The current study assessed the prevalence of major depression in patients with hypertension. The effect of sociodemographic and hypertension related factors on its development were also assessed. Method: Hypertensive patients were selected randomly from a medical outpatient unit in Mosul. Patients were diagnosed by a specialist physician, denied any past history of psychological illnesses or psychiatric consultations prior to having hypertension. N=300 (n=140 men, n=160 women) received the International Ne Questionnaire -version 5.0.0- (major depression module) by direct interview. Antihypertensive drugs used by the patients were also take in consideration. Data was collected in a period between the 1st Jan and the 5th June 2014.severity of the depression was assessed by Beck depression inventory. Results: Current prevalence of major depression in hypertensive patients was 27.3%. Statistically significant difference was found between employed and unemployed, the income of the patient, age groups (>40 years was found to be risky) and marital status groups (being widow, divorced or single risky).while being employed was a protective factor against the development of major depression in some patients. Conclusions: Current prevalence of major depression in hypertensive patients was 27.3%, which is higher than other studies (5-26.5%). Also, it was found that having the grade II hypertension, being a widow, divorced or single, or age >40 years old are risk factors to develop major depression in hypertensive patients, while being employed was a protective factor.

Key word: Depression, hypertension, employed, widow, single, age


Introduction

Systemic hypertension

Systemic hypertension is diagnosed when an individual’s blood pressure is found to be higher than what is considered normal for age and gender.1 Past studies have viewed it as a predominantly psychophysiological condition.2 The association between the physical and psychiatric disorder is evident in many cases, where the emotional impact of illness is sufficiently profound to precipitate psychiatric disorder. Several factors influence this development, including the patient's personality, social circumstances, the type of treatment required and the nature of the physical illness3. Diagnosis of hypertension in adults is decided when the average of two or more diastolic BP measurements on at least two subsequent visits is 90 mm Hg or more or when the average multiple systolic BP readings on two or more subsequent visits is consistently greater than 140 mm Hg.4

Depressive disorder

Depressive disorders are common, with a prevalence of 5-10% in primary care settings. These currently rank as a fourth cause of disability worldwide, but projected to rank second by the year 2020. The prevalence of depressive symptoms may be as high as 30% in the general population with women being twice as likely to be affected as men.5

Relationship between depression and hypertension

Depression and hypertension are frequently occurring disorders although their association could be a chance coincidence. Many patients with recurrent depression or chronic depression (dysthymia) may develop hypertensive disease as part of their distress.

The prevalence of depression among people with hypertension is variously reported to range from 30% to

H

147

Prevalence of depression in a sample of hypertensive outpatients in Mosul city

37% in many studies using differing methods of case finding and differing operational definitions of depression and hypertension.6 This is appreciably higher than the 2% to 9% prevalence, both in DSM-III affective disorders reported for several general populations7,8 and depression among normotensives.9,10 The association between hypertension and depression can be understood from three positions: 1) a common physiological factor underlies both disorders;11 2) depression results from side effects of some antihypertensive medications, e.g., impotence or drowsiness;17,25,26 Depression is secondary to experiencing a chronic illness and hypertension is one of them.6,12 Depression results from treatment that lowers the blood pressure such that it causes cerebral insufficiency in the elderly;13 and, 3) the association is coincidental.14 A number of studies have examined the association between hypertension and depression. While most have found support for the existence of an association,15 there are also a number of negative reports.16 Several review papers have concluded that the findings remain inconsistent.13,15,16 Undetected psychiatric morbidity among PHC patients commonly leads to unnecessary investigation, medication and possibly hospitalization, as well as the continued suffering of the patient. This will inevitably lead to impaired family, occupational and social functioning.17,18 Bridges and Goldberg demonstrated that psychiatric illness occurs in a quarter to a third of all new episodes of illness seen in primary care settings. Most of these illnesses occur either in conjunction with a known physical disease or as a “somatized” presentation of a psychiatric disorder.19

Method

Design

The present study is a descriptive observational cross sectional study. It was conducted in the medical outpatient department of Ibn Sina Teaching Hospital in Mosul from 1 Jan to 5 June 2014. A total of 300 attendees in the medical outpatient clinic (n=140 men, n=160 women) were randomly selected by choosing every fifth patient. Inclusion criteria were 1) diagnosis by a specialized physician, 2) no past history of psychological illnesses or psychiatric consultations prior to having hypertension. Patient interviews were completed in a confidential space. After completing the interview, the researcher returned to the examining room and identified subsequent participants via the randomization procedure.

Drugs used by the patients

Participants reported using a range of medications, including:

Atenolol, captopril,amlodipine,valsartan,candisartan,metoprolol,nifedipine,aprisoline and deltiazem.

Ethics

Ethical approval was obtained from a senior panel at the Ibn Sina Teaching Hospital, which included the chairman of the hospital’s medical unit. All participants provided their verbal consent prior to interview.

Statistical analysis

Results were subjected to statistical analysis using Chi-square test, OR, 95% CI and p value. The computerized statistical program used was STATISTICA version 5.

Measures

All participants were interviewed on their own after providing socio-demographic information and data relating to their experience of hypertension. The Mini International Neuropsychiatric Interview was used (MI.N.I.). Arabic Version 5.0.0 (Module A) concerned in the diagnosis of major depressive episodes currently in respect. The MINI is a brief structured interview that assesses the major Axis I psychiatric disorders in DSM-IV and ICD-10. Validation and reliability studies comparing the MINI to the SCID-P for DSM-III-R and the CIDI showed that it has acceptably high validation and reliability scores.20 Response options were either ‘Yes’ or ‘No’. Clinical judgment by the rater should be used when coding the responses.20 Diagnosis of major depression is established if all of the followings are met:21

• ‘Yes’ response for either A1 or A2 questions or both.

• ‘Yes’ response for three or more questions of A3 group(or 4 if either A1 or A2 question is answered ‘No’).

• Severity of the patient who is depressed would beassessed via the Beck Depression Inventory (BDI) on four levels of severity (Likert scale).

• Severity of hypertension is assessed as either Grade Iwhen systolic BP 140-159mmHG or diastolic BP is 90-99HG, Grade II when systolic BP more than or equal to 160HG or diastolic BP is more than or equal to 100mmHG.22

Inclusion criteria

Inclusion criteria were patients of either genders ranging in age from 20 to 70 years with a confirmed diagnosis of

148

Mohammed AY

hypertension clinically and without history of depression prior to hypertension.

Discussion and conclusions

The current study found that prevalence of major depression in hypertensive patients was 27.3%, which is higher than prevalence of depression in the general, population (4-6%).23 The prevalence of depressive symptoms may be as high as 30% in the general population with women being twice as likely to be affected as men.5 In a previous study, greater psychiatric morbidity was associated with chronic illnesses.24 Also it is more than that in hypertensive patients in studies done elsewhere (5-26.5%),25, 26, 27, 28, 29,30 and this may be due to the difficult situation in Mosul. However, the figure is approximate to a study done by Dr. Reem AlBedawy in A.R.E, which was 26.5%30.

Analyzing the effect of gender showed no statistical significant difference between prevalence of major depression in men (39%) and women (61%) with hypertension in accordance with a study conducted in Hong Kong that found depression, as measured using the HADS-D, correlated with increasing age (p=0.003) and hypertension severity (p=0.039), see Tables 3 and 8 respectively, but not with gender (r=0.02, p=0.68).31

Analyzing the effect of ethnicity showed no statistically significant difference between ethnic groups (p=0.105). This is in contrast to an earlier study, which found that the risk factors in black participants were significantly higher than those of the white cohort.32 Analysis of the effect of age showed differences between a group of 40-59 year olds and a group of 60-70 year olds were statistically significant (p=0.031) as a risk factor as compared to the younger age group (20-39 yr.).31

Analysis of the effect of marital status showed that being a widow, divorced or single had a very highly statistically significant difference (<0.000) as compared to the married group as a strong association in development of major depression in hypertension patients. The relationship between the development of major depression in hypertensive patients and association with financial satisfaction has shown statistically significant difference.

Study had shown that having a low income is a risk factor for development of depression in hypertensive patients. The relationship between the development of major depression in hypertensive patients and association with employment has shown statistically significant difference (p-value 0.029). Another study found that being unemployed is a risk factor for development of depression in hypertensive patients when compared to those who were retired, employed in government or private sector. The relationship between the development of major depression in hypertensive patients and the effect of duration of illness has shown a statistically significant difference (see Table 5). Those whose duration of illness was less than one year due to the psychological impact of the illness on them and those whose illness was more than five years due to added complications seemed to be at greater risk of developing depression than those whose illness was between one to five years only.

The clinical relevance of this theme is clear, since depressive symptomatology is associated with poor BP control in hypertensive patients and with the development of complications of hypertension.33 Analysis of the effect of severity of the illness showed that, having the more severe form of hypertension (Grade II) had a very highly statistically significant difference (<0.025) as compared to the (Grade I) is a risk factor for the development of major depression in hypertension patients. This supports a study that found depression reflects more severe hypertension.34 Analyzing the effect of the level of education showed no statistically significant difference (p=0.735) between all levels of educations studied in this research, although those with primary education appeared risky group than others on OR. This might be due to sharing the same stressful life events. Connecting the severity of the depression with the severity of hypertension showed that the most significant relationship was between mild and moderate depression and Grade I hypertension with p-value being 0.001, which is highly significant. Severe depression and severe hypertension were not correlated, which supports a study that found no correlation between elevated scores on the Zung SDS and elevated BP. Data were reanalyzed in terms of subscales of the Zung SDS, especially the Depressed Mood Index, and again there was no significant association between depression and hypertension severity.35

149


Table 1. Distribution according to gender

Gender Cases Non-Cases OR 95% Confidence Interval

χ2 p value no. % no. %

Male 32 39 108 49.5 0.65(*) (1.092,0.387) 2.648 0.104

Female 50 61 110 50.5 1.53(**) (0.917,2.554)

(*)Protective (**)Risk No statistical difference is seen between genders

Table 2. Distribution according to age

Age Cases Non-Cases OR 95% Confidence

Interval

χ2 p value no. % no. %

20 - 39 15 18.3 73 33.5 0.54(*) (0.810,0.239) 6.942* 0.031

40 - 59 50 61 113 51.8 1.4(**) (1.099,1.798)

60 - 70 17 20.7 32 14.7 1.5(**) (1.109,2.028)

* Significant at the 0.05 level (*) Protective (**) Risk Increasing age is highly associated with depression

Table 3. Distribution according to marital status

Marital status Cases Non-Cases OR 95% Confidence

Interval

χ2 p-value no. % no. %

Single 10 12.2 16 7.3 1.75(**) (1.373,2.231) 20.381** 0.000

Married 47 57.3 178 81.7 0.30(*) (0.506,0.178)

Widow 15 18.3 13 5.9 3.5(**) (2.032,6.029)

Divorced 10 12.2 11 5.1 2.6(**) (1.717,3.937)

** Significant at the 0.01 level (*)Protective (**)Risk Marital status is less likely associated with depression than widow, divorced and single

150

Mohammed AY

Table 4. Distribution according to employment

Employment Cases Non-Cases OR 95% Confidence

Interval


Unemployed 53 64.6 99 45.4 2.1(**) (1.295,3.406) 9.042* 0.029

Retired 4 4.9 13 5.9 0.8(1*) (0.925,0.692)

Privates sector 12 14.6 47 21.6 0.6(*) (0.837,0.430)

Gov. employed 13 15.9 59 27.1 0.5(*) (0.786,0.318)

* Significant at the 0.05 level (*)Protective (**)Risk Being unemployed is highly associated with depression

Table 5. Distribution according to duration of hypertension

Hypertension related factors

Cases Non-Cases OR 95% Confidence

Interval


Dur

atio

n

< one year 20 24.4 26 11.9 2.3(**) (1.572,3.365) 18.401** 0.000

(1-5) year 30 36.6 139 63.8 0.30(*) (0.520,0.173)

≥ 5 year 32 39.0 53 24.3 1.9(**) (1.417,2.548)

** Significant at the 0.01 level (*)Protective (**)Risk Duration of hypertension less than one year and more than five years is highly associated with depression

Table 6. Distribution according to severity of hypertension and severity of depression

Severity of depression

Severity of Hypertension n=82 95% Confidence

Interval

p-value*Grade I (140-90)

(mmHg.)-(159-99) (mmHg)

Grade II ≥ 160 mmHg

no. % no. % Mild 38 16.8 6 8 44 (0.010;0.167) 0.027

Moderate 10 4.4 18 28 28 (0.095;0.296) 0.001

Severe 6 2.7 4 10 10 (-0.082;0.028) 0.342

* Significant at the 0.01 level.(Z-Two proportion test) Most association is seen between mild and moderate depression with Grade I hypertension

151


Conclusions

The current study identified the following:

1. The prevalence of major depression inhypertensive patients attending the medical outpatients unit at Ibn Sinā Teaching Hospital was 27.3%and this is more than the prevalence of depression in general population (4-6 %).33 but somewhat equal to studies done elsewhere (5-26.5%).

2. Age groups (>40 yr.) have a higher association todevelop major depression in hypertensive patients.

3. Being single, widow or divorced are having highassociation for developing major depression in hypertensive patients.

4. Having a severe form of hypertension is aassociated with developing major depression in hypertensive patients.

5. Being employed is a protective factor against thedevelopment of major depression in hypertensive patients.

6. Depression was found to be more prevalent inthose whose illness were less than one year and those more five years.

7. A strong association was found between the mildand moderate form of depression with Grade I hypertension.

8. The most significant relationship was betweenmild depressions and Grade I hypertension.

Limitations

1. For estimation of socioeconomic status level, arough estimation approach of the author is conducted rather than relying on a specific standardized tool.

2. The tools used in the study have not beenstandardized on Iraqi individuals; the use of their original scoring system was one of the limitations in the current study.

References

1. Masha JPM, Baingana S, Odiit A, Jene K. Guidelines fornon-communicable diseases at district level. 1998. 29.

2. Rubio-Guerra AF, Rodriguez-Lopez L, Vergas-Ayala G,Huerta-Ramirez S, Castro Serna D, Lozano-Nuevo JJ. Depression increases the risk for uncontrolled hypertension, Exp Clin Cardiol. 2013.18(1):10-12.

3. Haslett C, Chilvers ER, Hunter JA, Davidson. Principleand Practice of Medicine. Eighteenth Edition. Churchill Livingstone, London. 1999, 471-542.

4. Goldman L, Bennett JC. Cecil Textbook of Medicine, 21st Edition. Philadelphia: W B Saunders, Co. October 1999.

5. Smith MV, Rosenheck RA, Cavaleri MA, Howell HB,Poschman K, Yonkers KA. Screening for Detection of Depression, Panic Disorder, and PTSD in Public-Sector Obstetric Clinics. Psychiatr Serv. 2004 55:407-414.

6. Li Z, Li Y, Chen L, Hu Y. Prevalence of depression inpatient with hypertension. Medicine (Baltimore). 2015 Aug; 94(31): e1317.

7. Kessler LG, Burns BJ, Shapiro S, Tischler GL, GeorgeLK. Psychiatric diagnoses of medical service users: evidence from the epidemiological catchment area program. Am J Public Health. 1987 77:18-24.

8. Myers JK, Weissman MM, Tischler GL, Holzer CE, LeafPJ. Six-month prevalence of psychiatric disorders in three communities. Arch Gen Psychiatry. 1984 41:959-967.

9. Liu Z, Bing X, Zhi XZ. A case-control study on depression and anxiety in hypertensive patients, US National library of Medicine. 2008 Feb; 29(2):125-7.

10. Bonger HR, de Vries HF. Integration of depression andhypertension treatment: a pilot randomized, controlled trial, Ann Fam Med. 2008,6(4):297.

11. Cheung BM, Au T, Chan S, Lam C, Lau Sh, Lee R, et al.The relationship between hypertension and anxiety or depression in Hong Kong Chinese., Exp Clin Cardiol. 2005 Spring; 10(1):22-4.

12. Paykel E, Fleminger R, Watson J. Psychiatric side effectsof antihypertensive drugs other than reserpine. J Clin Psychopharmacol. 1982 Feb;2(1):14-39.

13. Nutt DJ, Baldwin DS, Clayton AH, Elgie R, Lecrubier Y,Montejo AL et al. Consensus statement and research needs: the role of dopamine and norepinephrine in depression and antidepressant treatment. J Clin Psychiatry. 2006;67 Suppl. 6:46-9.

14. Lampe IK, Hulshoff Pol HE, Janssen J. Association ofdepression duration with reduction of global cerebral gray matter volume in female patients with recurrent major depressive disorder. Am J Psychiatry. 2003 November 160:11, 2052-2054.

15. Stein DJ, Seedat S, Herman A, Moomal H, Heeringa SGet al. Life time prevalence of psychiatric disorders in South Africa. Brit J Psychiatry. 2008 192:112-117.

16. Paterniti S, Verdier-Taillefer MH, et al. Low bloodpressure and risk of depression in the elderly. Brit J Psychiatr. 2000,176(5)464-467.

17. Gillespie CF, Nemeroff CB. Hypercortisolemia anddepression. Psychosom Med., 2006 67 Suppl 1:26.

18. O’Neill E. The Inside Story,effect of depression on dailylife. Psychiatric Alliance. 2008, 1.

19. Ruzanna Zam Zam, Maniam Thambu and Pervesh Kaur.-(2009).Psychiatric morbidity among adult patients in a semi urban primary care setting in Malaysia, International Journal of mental health systems.,8.

20. Sheehan, D.V., Licrubier, Y. and Sheehan. (2006). TheMini-International Neuropsychiatric interview: The

152

Mohammed AY

development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 59: 22-33.

21. Pettersson, Agenta. The use of a structured interview tosupport diagnosis of depression and anxiety disorders in primary care. (2017) Karolinska Institute.

22. Thomas, E. A. (2010). Cecil Essentials of Medicines, 8thedn. Philadelphia, USA.,:175

23. David Semple and Roger Smith.-(2013).OxfordHanabook of Psychiatry, Oxford University, Third edition. 242.

24. Dean, C. (1988). Psychiatry in general practice. InKendell and Zeally (eds). Companion to psychiatric studies, 4th edition. Churchill Livingstone. 634-645.

25. Nasrawi, M.M. (2007). Prevalence of psychiatricmorbidity in hypertensive patients in primary health care centers in Erbil city. 12: In Press

26. Behnam Sadeghirad. (2010). Epidemiology of majordepressive disorder in Iran: a Systematic Review and Meta-Analysis Int J Prevent Med. 2:81.

27. Jaime Miranda, J. (2009). The association betweenhypertension and depression and anxiety disorders: result from nationally representative sample of South African adults. http://www.hcp.havard.edu/wmh/may,14.

28. Kearney et al. (2004). Worldwide prevalence ofhypertension: a systematic review. J Hypertension., 1: 11-190-922.

29. Mustafa, Cankurtaran et al. (2005). Depression andconcomitant diseases in a Turkish geriatric outpatient setting. Archives of Gerontology and Geriatrics. 3: 307-315.

30. Reem, S. and El Bedewy, M.D. et al. (2011). Comparativestudy of depressive symptoms among hypertensive Egyptian patients without co-morbid diseases. Middle East J Depression. 4.

31. Bernard, M.Y. and Cheung (2005). The relationshipbetween hypertension and anxiety or depression in Hong Kong Exp Clin Cardiol. 1: 21-24.

32. Karina, Davidson et al. (2000) Do Depression SymptomsPredict Early Hypertension Incidence in young Adults in the CARDIA Study. Arch Int Med. 160.

33. Stress M. (2003). Blood pressure regulation, cognition,arid depression in response to orthostatic challenge in African American children: an initial investigation. Behav Med. 29:27-32.

34. Kenneth, B., and Wells, M.D. (1995). MPHPsychosomatic Medicine. 57:436-438.

35. Bernhard T. Baunce.-(2016).Cardiovascular Diseases andDepression. Phillip J. Tully. 86.

الملخص

الدمویة والتي تصیب كل األعراق في العالم وتؤدي الى إعاقة مزمنة وزیادة في نسبة یعتبر ارتفاع ضغط الدم من األمراض الشائعة والمزمنة للقلب واألوعیة ئاب ھو مساھم كتاإل و فقدان االھتمامأاط و/و االحبأبالشعور العمیق والمستمر للحزن كتئاب ھو نتیجة شائعة الرتفاع ضغط الدم وھو مرض عقلي یتمیزاإل الوفیات

اع رتفإكتئاب في المرضى المصابین بي لإلالھدف من ھذه الدراسة ھو لتقییم االنتشار الحال المصابین بارتفاع ضغط الدممھم لحصیلة صحیة ضعیفة في المرضى .كتئاببارتفاع ضغط الدم في تطور مرض اإلضغط الدم وتحلیل نتائج العوامل الدیموغرافیة واالجتماعیة والعوامل المتعلقة

دة حكتئاب في المرضى المصابین بارتفاع ضغط الدم والمراجعین الى ونسبة انتشار اإل :أظھرت ھذه الدراسة النتائج التالیة :ةالنتائج واالستنتاجات في ھذه الدراس ا) ولكنھ٪٦-٤على من تلك في عدد السكان العام (أوھي نسبة ٪۲۷،۳ي في الموصل ھو بن سینا التعلیمأالعیادة الخارجیة في مستشفى ما مساویة لدراسات نوعا

لقات لدیھن رامل او المطاأل اإلناث غیر المتزوجات،. كتئاب وارتفاع ضغط الدمعالي بین اإل ارتباطنة أظھرت س ٤۰من لفئات العمریة األكبر .)٪۲٦،٥-٥(أخرى أظھرت الدراسة .كتئابدید یشكل عامل خطورة لإلصابة باإلاإلصابة بارتفاع ضغط الدم الش ضغط الدم رتفاعباكتئاب لدى المصابات منھن ارتباط عالي لتطور اإل

ر ن سنة وأكثقل مأ(الدم ارتباط عالي وجد بین فترة اإلصابة بارتفاع ضغط . من غیره ضد اإلصابة بارتفاع ضغط الدم أكثر ان الشخص الذي لدیھ عمل یكون محمیا .ول من ارتفاع ضغط الدمع األكتئاب البسیط والمتوسط من جھة مع النووجدت بین اإلعالقة قویة االرتباط . كتئابمن خمسة سنوات) مع اإلصابة باإل

Author Dr. Adnan Yassin Mohammed, Specialist Psychiatrist Baghdad Ibn Rushid Training Hospital

Baghdad - Iraq


153


Trauma in Palestine

The Trauma of Humiliation in the Occupied Palestinian Territory

Samah Jabr and Elizabeth Berger

صدمة اإلذالل في األراضي الفلسطینیة المحتلة

سماح جبر وإلیزابیث بیرغر

Abstract

umiliation has been described as the pervasive and fundamental experience of the Palestinian people under occupation, underlying the varied military, social, economic, and human rights violations that have been imposed over generations.

We review the current social science research literature regarding humiliation in Palestine. We then present clinical vignettes from psychiatric practice in the occupied territory and our observations of the Palestinian community, material which illustrates various aspects of humiliation in this context. We argue that a multidisciplinary conceptualization of humiliation is necessary to account for its phenomena as an individual and collective trauma; sociopolitical, experiential, and psychoanalytic models must be integrated to understand the dynamics of humiliation and how these dynamics drive the experience for both victim and perpetrator. Based on an integrated model, we describe several clinical tools for therapists to use that may be helpful interventions in the treatment of victims of humiliation in Palestine.

Key words: Palestine, trauma, humiliation, human rights, mental health Declaration of interest: None

Part One: The Context

Traumatic violence has formed the core of the Palestinian experience since the Nakba or catastrophe of 1948, when eight hundred thousand Palestinians were expelled from their villages to permit the establishment of Israel as a Jewish state.1 These refugees and their descendants reside today as over five million displaced persons within the Occupied Palestinian Territory, composed of the West Bank, Gaza,2 and East Jerusalem.3 Citizens nowhere, these Palestinians survive in stateless insecurity with all elements of life - their economy, judicial system, education, healthcare, human movement, water, roadways, and natural resources - entirely under the external control of the occupying power.4 These conditions impose losses and injuries upon every Palestinian.

Traumatic incursions continue to harm the Palestinian community through wars and bombings, shootings, house demolitions and dispossession, destruction of agricultural land, checkpoints and closures, fragmentation of neighborhoods, extrajudicial assassinations, states of siege, and particularly through mass detention - it is

estimated that over one third of all Palestinian men have been detained in Israeli prisons, often without charges brought against them and sometimes for decades.5 Here men, women, and children are very often mistreated to a degree constituting torture; over a period of six months in 2014, for example, there were over six hundred children arrested in Jerusalem alone - of which nearly 40% reported sexual abuse.6 Members of the Palestinian leadership such as academics and human rights activists have been especially targeted. Israeli policy has thus led to a downward spiral of increasing poverty and social disintegration.4

Material losses are accompanied by harassment of the Palestinian public by Israeli forces in their inevitable daily contact, reinforced by a global propaganda campaign justifying its abuses through a debased image of Palestinian identity as dangerously irrational and dishonest. A mixture of both weakness and violence, this is the classic portrait of the colonized Oriental as viewed through the eyes of Western power.7 In this way, the cultural heritage of the Palestinian people suffers a further degradation.

H

154

The trauma of humiliation in Palestine

Part Two: A Literature of Injury

Social science has developed a robust literature of Palestine studies exploring the themes of assault and resilience. Early measurements reported high rates of stress-related disorders such as post-traumatic stress, depression, and anxiety induced by the hazards of life under occupation, but these results were later challenged as forcing the Palestinian experience onto a Procrustean bed of medical diagnostic categories.8

Bringing the social context into focus, researchers at the Gaza Community Mental Health Program under the Psychiatrist Dr Eyad El Sarraj observed an association between improved levels of resilience among adolescents and their level of personal engagement in local political action.9 Likewise examining the larger context, the public health researcher Dr Rita Giacoman at Birzeit University identified humiliation as an especially salient element of injury in Palestine, predicting negative health outcomes regardless of exposure to other traumatic events; importantly, her work emphasizes a relational perspective, viewing humiliation as the instrument of disconnection within human relationships necessary for psychological well-being.10

These findings were broadened by Dr Brian Barber’s recent paper demonstrating that over a 25-year period, persistent humiliation in Palestine was associated with widespread poor outcomes in not only physical health but economic, political, and psychological functioning. He concludes that persistent humiliation is “a neglected form of political violence that is best represented as a direct…, acute…, macro…, and high-grade…. stressor whose particular injury is due to the violation of individual and collective identity, rights, justice and dignity.”11

Research focused on humiliation in Palestine acknowledges a broader literature regarding the construct of humiliation and its consequences.11 Relevant domains of inquiry are varied and far-reaching, including group phenomena such as war and the discrimination faced by minorities as well as intimate contexts such as the abuse of children by their parents.12-17

Part Three: A view from the office (details have been altered to protect confidentiality)

One night a patient, Mr A, was walking home when Israeli soldiers stopped him, demanded his papers, pushed him

against a wall, kicked him, and stripped him of his clothing. The soldiers then coerced Mr A to divulge the names of his mother, his wife, and his sisters and insulted these women with obscenities, which they forced him to repeat. Eventually Mr A was reduced to tears, at which the soldiers burst out laughing.

Another man, Mr B, was employed as a vehicle driver for a medical organization. He had dropped off a group of health workers, when he was approached by Israeli soldiers demanding his papers. He produced the papers and explained that he was awaiting the medical team to return. One of the soldiers began to shout, “You’re here to treat dogs! Come treat my sick dog!” Mr B replied, “I don’t treat anyone. I just drive the car.” In response, the soldier stuck him in the face.

In 2006, the Israeli army attacked the prison in the Palestinian town of Jericho and forced both the prisoners and the correction officers to undress. The soldiers took photos of the prisoners and the officers, which were widely reproduced in the media.18 The internet, by the way, has provided a broad platform for public exposure - as practiced for example by an Israeli woman ex-soldier who took selfies with elderly blindfolded Palestinian men and displayed these trophies on Facebook.19

The abuse of Palestinians in detention is a domain in which humiliation appears to play a particularly central role. Ms C, an activist tortured by the Israelis, described among her experiences being hung suspended from shackles, causing permanent damage to both hands. But the aspect of her interrogation which was the most difficult for her to reveal involved the Israeli interrogator stroking her thighs and making sexual suggestions, experiences associated with an extreme degree of revulsion and shame.

Mr D, an adolescent of 14, was asleep in his bed when Israeli soldiers burst into his home and detained him for several months. Although previously an excellent student, he dropped out of school following his release and withdrew from his friends. He reported beatings and other mistreatment leaving physical evidence of scarring on his body. He was taken to a mental health clinician and described being repeatedly interrogated by the Israeli forces, who laughed at him while making obscene references to his female relatives. He stated that one male interrogator took him blindfolded to the toilet area and

155

Jabr S & Berger E

shouted, “I am going to fuck you right now!” At this point in the interview, Mr D was unable to continue speaking and ended the clinical interview. As a result, further clarification of what had occurred in detention was not possible. He has refused all treatment.

Part Four: An Anatomy of Humiliation

Listening to trauma is not easy, and listening to the trauma of humiliation may be even more painful than reports of physical violence. A professional response involving moral outrage as well as intellectual analysis complicates the issue of our responsibilities. Moreover, the analysis of the humiliation of the Palestinian people is made difficult by the fact that our theory-building lacks adequate integration of social identity, collective history, and political action with an understanding of individual psychology.

On a clinical level, we observe the legacy of humiliation in Palestine working damage through multiple channels and in a variety of guises. Prominent among these is a withdrawal from intimacy within family and social relationships, a loss of the capacity for trust, growth, and joy. How can a man who has been publicly humiliated resume his role as a protective husband and father? We see the consequences of humiliation likewise behind many presentations of anxiety and depression in Palestine, although the patient may not at first see an immediate connection between them. Humiliation is deeply pathogenic because it provokes intense feelings of shame and impotent rage, and a powerful resistance to their re-emergence in conscious memory and narrative.

There are those in Palestine who may identify with the perpetrators, discrediting the experiences of fellow victims and reinforcing the victim’s isolation. The experience thus becomes inaccessible to reworking through a counter-narrative in which the humiliated is recast as a protagonist, further denying an opportunity to reconnect the victim to a network of supportive relationships.

Then too, humiliation can lead to conscious experiences of intense anger which may be misdirected. Individual and group activation of displaced rage can lead to a vicious cycle of revenge aimed at targets close to home - within the family, tribe, or political party. Humiliation stimulates community polarization, weakening the fabric of society.

The impulse for revenge may drive impulsive acts of retribution or identification with violent extremist groups, fulfilling the cycle of destruction by appearing to provide justification for further policies of humiliation.

A theory of the psychological trauma of humiliation must account for damage inflicted at many levels, involving harm to deep psychic structures,20 as well as the individual’s subsequent capacity for participation in interpersonal roles which ultimately depend upon the integrity of these psychic structures.

Humiliation can be conceptualized from a psychoanalytic perspective as a traumatic reconfiguration of self and object images, in which the effect of shame plays a cardinal role. The goal of humiliation - to annihilate through shame - reflects the downward flow of agency from the powerful to the powerless, reinforcing the discrepancy between them. One might say that the humiliator assumes the omnipotent capacities of a primitive destructive bad object; the humiliated then experiences a catastrophic loss of self-regard associated with helplessness and fear at the hands of this archaic and dangerous introject. The humiliator boasts of his total control over the humiliated, including control over the contents of his body and his mind. The archetypal acting out of this power dynamic in rape symbolizes the humiliator’s claim that he possesses the entirety of the humiliated from the inside out. Through a sadistic perversion of sexual intimacy, the humilator experiences what Klein termed “the manic triad” of contempt, triumph, and control - defenses against envy, depression, and anxiety.21

But the victim contains the depression and anxiety that the perpetrator has denied and projected onto him. Since self-esteem is related to the effectiveness of the ego to defend itself, there is a corresponding loss of self-esteem when this defense fails. Shame confirms the humiliated as complicit in his own violation in the identification with the aggressor that is characteristic of submissive acquiescence. The humiliated and the humiliator can at last agree - that the humiliated deserves nothing but contempt. With the loss of human dignity, there is nothing left to envy. The acquiescence, the point in which the humiliated “breaks,” is a kind of climax in which the degradation is complete, eradicating through the victor’s omnipotence the reality of the victim’s status as a human being. Despite the fact that women in Palestine are often said to be especially victimized, we believe that it is men and particularly younger men who are most likely to be humiliated and are most vulnerable to its devastation.

156


It is not our assertion that soldiers performing humiliation rituals themselves suffer from sadistic perversion or manic phenomena - or even that they are especially wicked people. Rather, we view the abuse of a captive civilian population by an occupying military force as the inevitable result of political hate propaganda and regressive group dynamics. Unlike the sexual abuser of children or the domestic batterer, the political humiliator appears to be an ordinary personality in a special social context that legitimizes enactment of primitive destructive impulses which are otherwise taboo. As agents of a politicized humiliation ritual, the humiliator is only temporarily insane - the entire experience takes place in a split-off psychic space. We are encouraged by movements within Israel that seek to recapture these split-off domains through protesting the mistreatment of Palestinians, such as the organization Breaking the Silence that permits ex-soldiers to explore their guilt and shame in regard to what they have seen and what they have done. 22

Part Five: Recovery and Restitution

Therapeutic approaches to Palestinian individuals who have suffered humiliation by Israeli forces include conventional psychiatric interventions such as medication for target symptoms of depression, anxiety, and PTSD as well as psychotherapy. These techniques may need modification in view of special challenges posed by humiliation). It appears, for example, that while Cognitive Behavior Therapy (CBT) techniques are effective in reducing PTSD symptoms of hyperarousal, the shame generated by humiliation appears relatively resistant to CBT.23 We focus here on some of these challenging aspects and suggest principles for management that could be examined in future research; it is beyond the scope of the current paper to propose how future research should be conducted, but we would expect that a full exploration of these issues would require both qualitative and quantitative clinical studies.

1. Not everyone is a patient. One adolescentbrought to a psychiatrist by his family following detention refused to cooperate at all with the interview, exclaiming “I’m not crazy!” A discussion group made up of similar youngsters led by an older man who has himself experienced the humiliations of detention may be more appropriate. Groups such as the Prisoner’s Club in Palestine offer self-help based on this model.24

2. The construction of a trauma narrative undergoesa process of many revisions. Initially, a therapist can offer a holding environment for the patient’s viewpoint, which is difficult enough to articulate because of the dysregulating effects of shame

and rage. Later, proposing cognitive shifts can open the possibility of reframing the narrative: for example, what initially seemed as the patient’s shameful acquiescence might be re-conceptualized as the path of wisdom in precluding even further violence, given his available choices.

3. A powerful tool in reframing humiliationthrough counter-narrative is to ask, “What motivated the perpetrator in the act of humiliation?” Inquiry about the perpetrator’s frame of mind can stimulate empathic insight into the infantile needs behind the humiliation ritual. Mr A, the man stripped of his clothes and forced to repeat obscenities about his wife, was initially unable to look his wife in the eye following this experience. It was helpful to him to speculate that the soldiers were perhaps themselves anxious about their own masculine dignity and that they viewed him in contrast as somehow more adequate as a man - thus needing to humiliate him so that he would no longer be an object of their painful envy. Utilizing the interpersonal perspective in this way may be a useful intervention specific to addressing the shame of humiliation.

4. Humiliation attacks identity, especially in itsexpression through social roles. Sensitive exploration of sources of connection may help the patient re-situate himself in roles from which he has been alienated. Couples counseling and family-oriented treatment may help as well as re-involvement in cultural and community groups and political action.

5. There can be no genuine validation of thePalestinian historical narrative without the restoration of justice to the Palestinian people, and no containment of fantasies of revenge without a mature moral and cultural transformation within Israel and the occupied territory. Working towards the goal of equitable liberation is an ethical mandate but it is also the sole therapeutic modality for each and all of its participants. Only an end to politicized humiliation can open the door to reconciliation on an international as well as a personal level - in which it is possible for injury to be counted, acknowledged, and worked through.25

157

Jabr S & Berger E

Acknowledgment

A version of the current paper was presented at a panel at the conference, “Listening to Trauma” held in Washington D.C. during October 2016.

References

1. Palestinian Central Bureau of Statistics (PCBS) 2013, May14. Special statistical bulletin on the 65th anniversary of the Palestinian Nakba. [Online] Available from: http://www.pcbs.gov.ps/site/512/default.aspx?tabID=512&lang=en&ItemID=788&mid=3171&wversion=Staging [Accessed 11 June 2017].

2. Palestinian Central Bureau of Statistics (PCBS.)Population. [Online] Availablefrom:http://www.pcbs.gov.ps/site/lang__ar/881/default.aspx#PopulationA [Accessed 11 June 2017].

3. United Nations Conference on Trade and Development(UNCTAD). The Palestinian Economy in East Jerusalem: Enduring annexation, isolation and disintegration 2013. [Online] Available from: http://www.un.org/depts/dpa/qpal/docs/2014Ankara/P2%20MAHMOUD%20ELKHAFIF%20gdsapp2012d1_en.pdf [Accesssed 11 June 2017].

4. United Nations Development Programme (UNDP).Palestinian Human Development Report, 2009/10: Investing in human security for a future state 2010. [Online] Available from:http://hdr.undp.org/sites/default/files/Country-Profiles/PSE.pdf [Accessed 11 June 2017].

5. Palestinian Central Bureau of Statistics (PCBS). Currentstatus of Palestinian detainees in Israeli prisons 2014. Press release, Ramallah, Palestine. [Online] Available from: http://www.pcbs.gov.ps/Portals/_pcbs/PressRelease/Detainees_in_Israeli.pdf [Accessed 11 June 2017].

6. International Middle East Media Center (IMEMC). Newsreport. Sexual abuse against Palestinian child detainees reported 2014. [Online] Available from: http://imemc.org/article/69791 [Accessed 11 June 2017].

7. Said, E. Orientalism. New York: Vintage Books; 1978.8. Jabr S, Morse M, El Sarraj W, Awidi B. Mental health in

Palestine: Country report. Arab J Psychiatr Nov 2013; 24 (2): 174-178.

9. Punamaki R, Qouta S, El Sarraj E. Resiliency factorspredicting psychological adjustment after political violence among Palestinian children. Int J Behav Dev 2001; 25 (3): 256-267.

10. Giacaman R, Abu-Rmeileh NM, Husseini A, Saab H,Boyce W. Humiliation: the invisible trauma of war for Palestinian youth. Public Health Aug 2007; 121 (8): 563-71.

11. Barber BK, McNeely C, Olsen J, Belli RF, Doty SB. Long-term exposure to political violence: the particular injury of persistent humiliation. Soc Sci Med 2016; 156 (C):154-166.

12. Hartling L, Luchetta T. Humiliation: assessing the impactof derision, degradation and debasement. J Prim Prev. 19 (4) (1999), pp. 259-278.

13. Klein DC. The humiliation dynamic: an overview. J PrimPrev. 12 (2) (1991), pp. 93-121.

14. Leask P. Losing trust in the world: humiliation and itsconsequences. Psychodyn Pract. 19 (2) (2013), pp. 129-142, 10.1080/14753634.2013.778485

15. Leidner B, Sheikh H, Ginges J. Affective dimensions ofintergroup humiliation PLoS One, 7 (9) (2012), p. e46375, 10.1371/journal.pone.0046375

16. Pascoe EA, Smart Richman L. Perceived discriminationand health: a meta-analytic review, Psychol Bull. 135 (4) (2009), pp. 531-554, 10.1037/a0016059

17. Spinazzola J, Hodgdon H, Liang LJ, Ford JD, Layne CM,Pynoos R, Briggs EC, Stolbach B, Kisiel C. Unseen wounds: the contribution of psychological maltreatment to child and adolescent mental health and risk outcomes. Psychol Trauma: Theory, Res Pract Policy, 6 (Suppl. 1) (2014), pp. S18-S28, http://dx.doi.org.proxygw.wrlc.org/ 10. 1037/a0037766.

18. Democracy Now! News Story. Israeli raid on Palestinianprison ignites crisis in Occupied Territories March 2006. [Online] Available from: https://www.democracynow.org/2006/3/16/israeli_raid_on_palestinian_prison_ignites [Accessed 11 June 2017].

19. Haaretz. IDF soldier posts images of blindfoldedPalestinians on Facebook, from ‘Best time of my life.’ [Online] Available from: http://www.haaretz.com/ israel-news/idf-soldier-posts-images-of-blindfolded-palestinians-on-facebook-from-best-time-of-my-life-1.308402.

20. Freud S. New Introductory Lectures on Psycho-Analysis(The Standard Edition of the Complete Psychological Works of Sigmund Freud, edited and translated by James Strachey). New York: Norton Press; 1933 (1994).

21. Klein, M. Mourning and its relation to manic-depressivestates. Int J Psychoanal 1940; 21:125-53.

22. Breaking the Silence. [Online] Available from:http://www.breakingthesilence.org.il/ [Accessed 11 June 2017].

23. Covert M, Tangney JP, Maddux JE, Heleno MN. Shame-proneness, guilt-proneness and interpersonal problem solving: A social cognitive analysis. Journal of Social and Clinical Psychology 2003; 22, 1-12.

24. Palestinian Prisoners Club. [Online] Available from:https://www.facebook.com/ppc1993/ [Accessed 11 June 2017].

25. Jabr S, Berger E. (2016). The Survival and Well-Being ofthe Palestinian People under Occupation. In H. Tilouine and R. Estes (Eds.) The State of Social Progress in Islamic Societies: Social, Economic, Political, and Ideological Challenges (pp. 529-543). Cham, Switzerland: Springer.

158

http://dx.doi.org.proxygw.wrlc.org/%2010.%201037/a0037766

http://dx.doi.org.proxygw.wrlc.org/%2010.%201037/a0037766

http://www.haaretz.com/%20israel-news/idf-soldier-posts-images-of-blindfolded-palestinians-on-facebook-from-best-time-of-my-life-1.308402




الملخص

ة وحقوق اإلنسان ادیتم توصیف اإلذالل كتجربة واسعة االنتشار وأساسیة للشعب الفلسطیني تحت االحتالل، وھي أساس االنتھاكات العسكریة واالجتماعیة واالقتصاالجتماعیة الحالیة حول اإلذالل في فلسطین. ثم نسرد المقاالت الطبیة السریریة من الممارسة المختلفة التي فرضت على مر األجیال. نستعرض أدب أبحاث العلوم

صوریة متعددة اغة تالنفسیة في األراضي المحتلة ومالحظاتنا للمجتمع الفلسطیني، وھي مادة توضح الجوانب المختلفة لإلذالل في ھذا السیاق. نناقش ضرورة صیل السیاسیة والتجریبیة والنفسیة التحلیلیة لفھم دینامیات اإلذال –اھره باعتباره صدمة فردیة وجماعیة؛ ویجب دمج النماذج االجتماعیة المجاالت لإلذالل لتفسیر ظو

ي قد تكون لجین والتالمعا وكیف أن ھذه الدینامیات تقود التجربة لكل من الضحیة والجاني. استنادا إلى نموذج متكامل، نشرح عدة أدوات سریریة الستخدامھا من قبل .عبارة عن تدخالت مفیدة في عالج ضحایا اإلذالل في فلسطین


Dr Elizabeth Berger MD, MPhil

Email: elizabethbergermd @gmail.com

Authors

Dr Samah Jabr MD

Psychiatrist

Director of the Mental Health Unit, Palestinian MoH

George Washington University, Washington DC - USA

Dr. Elizabeth Berger MD, MPhil

Child Psychiatrist

George Washington University, Washington DC - USA

159


Psychiatric epidemiology

Prevalence of Psychiatric Disorders among Saudi Adolescent Girls in a Riyadh City High School

Yousra Alatiq, Meshael Alshalan, Omar Almodayfer

بمدینة الریاضنسبة انتشار االضطرابات النفسیة بین المراھقات السعودیات من طالبات المرحلة الثانویة

عمر المدیفر الشعالن،مشاعل العتیق،یسرى

Abstract

bjective: Studies have shown that mental health problems at an early age can lead to greater impairment in adult life. Epidemiological evidence on the prevalence and incidence of mental health disorders is fundamental for planning

mental health services. However, such data are lacking in Saudi Arabia. Method: This two-stage epidemiological study used the Strengths and Difficulties Questionnaire (SDQ) to screen all eligible participants for the presence of a possible psychiatric disorder. A structured psychiatric interview (MINI-Kid) was administered to a subsample to confirm the presence or absence of psychiatric disorders. Results: A total of 4745 participants were screened in the first stage, and 692 participants underwent follow-up interviews. Results revealed the most common disorders were agoraphobia, with a prevalence of 30.6%; major depression, with a prevalence of 30.0%; and separation anxiety, with a prevalence of 27.1%. Although many factors were expected to predict the diagnosis of a psychiatric disorder, having a private teacher was the only significant factor (OR=1.87, p=.013). Conclusion: Agoraphobia, major depression and separation anxiety are the most common psychiatric disorders among Saudi adolescent girls. The only factor that predicted a psychiatric disorder was having a private teacher.

Keywords: Psychiatric disorders, prevalence, adolescent girls, Saudi Arabia


Introduction

The study of adolescent mental health disorders is increasingly important, as these disorders involve significant impairments in general functioning, marked deterioration among different domains of quality of life and increased health care utilization1. There is substantial agreement among epidemiologists that mental health problems at an early age can lead to greater impairment in adult life. A 2003 World Health Organisation report noted that the ‘Lack of attention to the mental health of children and adolescents may lead to mental disorders with lifelong consequences, undermines compliance with health regimens, and reduces the capacity of societies to be safe and productive’.2

Epidemiological evidence on the prevalence and incidence of mental health disorders is fundamental for planning mental health services.3 While psychopathology in children and adolescents is not uncommon (the mean prevalence estimate is between 15.0% and 17.5%),4 many conditions are commonly unrecognised. A Western study found that only 27% of children with a psychiatric

disorder had been in contact with a health care specialist.5 In an Arab community sample, 1 in 7 children had a psychiatric disorder that involved significant functional impairment, but none of them had received professional health care.6 Epidemiology studies of child and adolescent mental health problems shape the rational planning of service delivery, improve early detection and allow professionals to develop prevention programmes for this vulnerable group.

In the past decade, large-scale child and adolescent psychiatric epidemiology studies have become increasingly common in developed countries, especially in the United States and the United Kingdom.3,7 In comparison, such studies are much less common in the Arab world and the Gulf countries, with the exception of a limited number of studies from the United Arab Emirates.6,8,9 Using data from studies in other countries allows for estimates of mental health problems in general. However, the planning of local health service delivery should be based on results from local communities;

O

160

Psychiatric disorders in adolescent girls in Riyadh City

therefore, research into mental health problems in Saudi Arabia is warranted.

The current study is a school-based study from Saudi Arabia that examines the prevalence rates of mental health problems in Saudi adolescent girls attending high school in Riyadh City. This is a much needed study that is believed to be an important step toward expanding epidemiological research that can have important clinical implications.

Method

The current study involved a two-stage epidemiological method that investigated the rates of psychiatric disorders in a school-based sample of adolescent girls in Saudi Arabia. Saudi education is delivered to girls and boys separately. The current study was conducted with students on an all girls’ campus and thus required women researchers. Initially, a study with boys was designed to be conducted in parallel, but due to funding difficulties, only the study with girls was completed.

The first stage involved use of a self-report questionnaire, the Strengths and Difficulties Questionnaire (SDQ), to screen eligible participants for the presence of a possible psychiatric disorder. Participants with higher scores than the cut-off on the screening measures were identified as the high-risk (screen-positive) sample. Participants who scored below the cut-off scores were identified as the low-risk (screen-negative) sample. To confirm the presence of a psychiatric disorder among a subsample of both groups, both the high- and low-risk participants were invited to participate in a detailed diagnostic structured interview.

Sample

The study sample included Saudi girls attending high schools in Riyadh City. Based on the statistics provided by the Ministry of Education, the original sample population included approximately 87,000 students from 177 schools (private and public) distributed over eight geographical areas. To ensure a representative sample, participating schools were randomly selected from 16 categories (eight geographical areas x two public vs. private); this random selection was proportionate to the size of each category area. The number of schools selected was proportionate to the total number of schools in each category. The total number of schools included in the study was 48, and all Saudi students attending these

schools in grades 10 through 12 were considered eligible for participation.

We included only Saudi students in the study sample for two reasons. First, the majority of students in the public schools are Saudis. Including other nationalities would have added a small subgroup that would have been difficult to analyse or compare to the total sample. Second, including non-Saudis would require paying attention to other factors that may affect mental health, such as reasons for moving away from the country of origin, adjustment to living in Saudi Arabia and the availability of a social support system. All these factors warrant a separate study design and focus beyond the scope of the present study.

Procedures

Ethical approval was obtained from King Abdulla International Medical Research Center and from the Ministry of Education. The research team was comprised of trained psychologists who visited the selected schools, introduced themselves and described the study rationale and procedures to the head teacher to facilitate recruitment. The study was conducted in the 2012/2013 academic year.

Stage one

All high school students in these schools were informed about the study and asked to participate by providing demographic data and completing the screening measure (SDQ) in a group setting. Students who did not wish to participate were asked to return the forms without completing them. In addition, each student was given a folder for their parents that included the same screening measure (SDQ-parent form) and consent for their daughter to be included in the study.

Stage two

Only students who completed the screening measures and whose parents granted permission for them to participate in the study were eligible for this stage. The sample consisted of students who were identified as high risk based on the screening questionnaire and an equal number of low-risk students. Both groups were randomly selected.

161

Alatiq Y, Alshalan M, Almodayfer O

Instruments

The demographic questionnaire

The demographic questionnaire was a structured questionnaire that covered age, years of education, number of family members, family status and socioeconomic status.

Possible predicting variables

Based on the literature of psychiatric disorders, a list of possible social and educational variables was assessed as possible predicting factors. These included a loss of one parent, a chronic medical illness, an experience of a traumatic accident, and a history of physical or sexual abuse. Educational risk factors included: being absent from school, failing a school year, and having a private teacher. With a multiple choice question, we also assessed perceived stress based on participants’ reports of stability in the family, the quality of their parents’ marital relationship and the current level of stress in the family. Finally, we assessed participants’ use of time, including how much time they spent watching TV, browsing the internet and using social media, as a possible risk factor. The list of variables is included in Table 1.

Strengths and Difficulties Questionnaire (SDQ)

The SDQ10 is a brief, friendly and nonintrusive self-reported questionnaire that covers common areas of emotional and behavioral difficulties. The questionnaire consists of 25 items that are divided into five scales: conduct, hyperactivity, emotional problems, peer problems and prosocial scales. It has been proven to be a valid and reliable screening measure for mental health difficulties in young people. The Arabic version has also displayed good psychometric properties11 and is available in both parent and teacher versions. In this study, we used the self-report (S-14-17) and parent-report versions (P 11-17).

The MINI International Neuropsychiatric Interview for children and adolescents (MINI-Kid)

The MINI-Kid12 is an abbreviated structured psychiatric interview that takes approximately 15-20 minutes to administer. The MINI-Kid uses decision-tree logic to

identify all of the symptoms that are listed for major Axis I diagnostic categories and for suicidality. The MINI has been validated against other structured interviews, including the English version of the Structured Clinical Interview (SCID-P) and the English and Arabic versions of the Composite International Diagnostic Interview (CIDI). There is no validation on the Saudi sample; therefore, we are using only the Arabic version validated on an Egyptian sample.13 The MINI-Kid-Parent interview was used to interview parents about the symptoms of their children.

Teacher involvement

In the initial design for this study, the primary teacher for each class was asked to complete the SDQ teacher form about the students. During the pilot for the current study, teachers consistently refused to complete the questionnaire, as they were not fully aware of the students’ emotional aspects as indicated in the SDQ. Therefore, we substituted the SDQ with one question: ‘Do you think the student has an emotional or behavioral problem?’ with the possible answers of (Yes\No\ I do not know). The question was followed by the following open question: ‘If yes, please specify your main concern.’ Again, almost all teachers in the pilot study reported ‘I don’t know’ as an answer, making their input not useful for the study. Therefore, the teacher screening measure was removed from the current study.

Results

Demographic characteristics of the screened and interviewed samples

At stage one, the total number of students who were screened was (N=4745). At stage two, the total number of students who were interviewed was (N=692). The demographic data are presented in Table 1 as the mean and standard deviation for continuous variables or as the proportion and percentage for categorical variables. A comprehensive analysis comparing the two groups (screened vs. interviewed) revealed no significant differences between the subsamples from the second stage and the overall sample form stage one. There were also no significant differences between the students who agreed to take part in the second stage and those who did not.

162


Table 1. Demographic and psychosocial characteristics of sample* Sample Characteristics Screened

(N=4745) Interviewed

(N=692) p Value

Bas

ic d

emog

raph

ic

Age: Mean (SD) 16.9 (.02) 16.9 (.05) 0.031

Marital status (single) 3951 (98.7) 650 (99.0) 1.000

Number of family member M(SD) 8.60 (0.06) 8.66 (0.14) 0.214

Father has more than one wife 637 (17.9) 106 (16.67) .394

Mother is not Saudi 668 (19.27) 122 (20.78) .089

Mother is working 782 (20.49) 126 (20.19) 0.511

Property independency Independent home Shared with extended family Shared with other wives

1265 (32.70) 2485 (64.23)

119 (3.08)

198 (31.03) 418 (65.52)

22 (3.45)

0.550

Socioeconomic status: < 4000 4000 – 7000 7000 -10000 10000-13000

476 (15.4) 549 (17.8)

469 (15.23) 442 (14.35)

77 (14.31) 106 (19.7) 68 (12.64) 71 (13.20)

0.089

13000- 16000 > 16000

373 (12.11) 771 (25.03)

62 (11.52) 154 (28.62)

Has a home maid 1562 (38.88) 265 (40.46) 0.368

Has a driver 921 (23.43) 154 (23.99) 0.496

Educ

atio

n Have failed a class before 481 (12.30) 77 (12.18) 0.127

Frequent absence from school (> 1/week) 281 (7.71) 45 (7.36) 0.158

Have ever had private teachers 1475 (38.95) 253 (40.54) 0.116

Use

of t

ime

Time spent on watching TV (>3hr) 576 (17.6) 96 (17.5) 0.938

Time spent on the internet (>3hr) 1149 (36.98) 202 (39.22) 0.452

Time spent on social network (>3hr) 953 (33.45) 169 (36.11) 0.649

Time spent with friends (<1hr) 558 (19.6) 100 (21.01) 0.219

Kno

wn

risk

fact

ors

Lost father 222 (5.6) 31 (4.78) 0.663

Lost mother 80 (2.04) 9 (1.39) .616

Has a chronic medical condition 977 (24.57) 178 (27.18) 0.153

History of head injury 169 (3.56) 30 (4.44) 1.000

Witnessed traumatic accident 624 (13.15) 111 (16.42) 0.055

History of physical abuse 123 (2.59) 27 (3.99) 0.159

History of sexual harassment/abuse 95 (2.00) 25 (3.70) 0.566

Had a visit to psychiatrist last year 94 (2.80) 20 (3.59) 0.755

Family psychiatric illness (yes) 104 (2.88) 18 (3.04) 0.496

Perc

eive

d

stre

ss Family is stable (no) 260 (6.61) 47 (7.26) 0.395

Parental marital compatibility (bad) 203 (5.39) 53 (8.38) 0.424

Family stressor (yes) 1020 (26.38) 192 (30.38) 0.250 *Data are given as percentage unless otherwise indicated.

163


Prevalence of psychiatric disorders

Table 2 displays the prevalence estimates and 95% CIs for DSM-IV diagnoses in the sample from stage two (N=692). (DSM-IV was used because it is the one applied in the Arabic version of the MINI-Kid.) Agoraphobia was the most common disorder with a prevalence of 30.6%. This was followed by major depressive episodes with a prevalence of 30.0%, followed by separation anxiety with a prevalence of 27.1%. The fourth in the list was oppositional defiant disorder with a prevalence of 23.9%.

Hypomania, specific phobias, obsessive compulsive disorder, generalized anxiety disorder, social phobia and mania were each rated between 18% and 12%. Panic and posttraumatic stress disorders were 8-9% each. This was followed by conduct disorder with a rate of 5.7% and dysthymia with 4.4%. There was an approximate 3% rate for bulimia and ADHD-combined. Psychotic disorder was rated at approximately 2.1%. Finally, adjustment, anorexia, and substance dependency were below 1%.

Table 2. Prevalence of major psychiatric disorder*

Major Psychiatric Disorder Prevalence n (%)

95% Confident Interval

Agoraphobia 211 (30.58) 0.271 - 0.341

Major Depressive Episode 207 (29.96) 0.265 - 0.335

Separation Anxiety 187 (27.10) 0.238 - 0.305

Oppositional Defiant Disorder 165 (23.91) 0.207 - 0.272

Hypomania 125 (18.22) 0.154 - 0.213

Specific Phobia 99 (14.35) 0.118 - 0.171

Obsessive Compulsive Disorder 95 (13.77) 0.112 - 0.165

Generalized Anxiety Disorder 94 (13.64) 0.111 - 0.164

Social Phobia 90 (13.02) 0.106 – 0.157

Mania 84 (12.17) 0.098 - 0.148

Panic 61 (8.85) 0.068 – 0.112

Posttraumatic Stress Disorder 57 (8.28) 0.063 – 0.106

Conduct Disorder 39 (5.66) 0.040 – 0.076

Dysthymia 30 (4.37) 0.029 – 0.061

Bulimia Nervosa 23 (3.34) 0.021 – 0.049

ADHD - Combined 21 (3.05) 0.019 – 0.046

ADHD - Inattentive 19 (2.75) 0.06 – 0.042

Psychotic Disorder 15 (2.17) 0.012 – 0.035

ADHD - Hyperactivity-Impulsivity 11 (1.59) 0.008 – 0.028

Adjustment Disorder 5 (0.72) 0.002 – 0.016

Anorexia Nervosa 4 (0.58) 0.001 – 0.014

Substance Dependency/Abuse 1 (0.14) 0.000 – 0.008

Alcohol Dependency/Abuse 0 0

*Results from the Interview Phase (N=692)

164


Sensitivity and specificity of the SDQ in predicting psychiatric disorder

The SDQ screening measure was reported by two informers, which included the students and the parents (primarily the mother) during stage one. The predictive power of the SDQ in determining psychiatric disorders as identified by the interview in stage two were assessed by the sensitivity and specificity as follows: students SDQ vs.

MINI results, parents SDQ vs. MINI results. These results are presented in Table 3.

The results showed a poor sensitivity for the SDQ of the two informers (18.5 for students and 11.0 for parents as screening tools. However, the specificity was much stronger (96.0 for students and 98.2 for parents). This suggests that the SDQ was not a good screening measure for identifying true positive cases, but it is highly specific in excluding true negative cases.

Table 3. Sensitivity and specificity of SDQ in predicting psychiatric disorders

SDQ Value 95% Confident Interval

SDQ Parent

Sensitivity 32 (11.00) 0.076 – 0.151

Specificity 108 (98.18) 0.935 – 0.997

SDQ Self

Sensitivity 89 (18.50) 0.151 – 0.222

Specificity 168 (96.00) 0.919 – 0.983

Predictors of psychiatric disorders

Most of the independent variables included in the current study were not a statistically significant predictor of

psychiatric disorders among our sample (See Table 4). However, the only variable with a p value of 0.013 was ‘Ever had a private teacher’ (OR 1.868).

Table 4. Possible predictors of psychiatric disorders

Variables OR 95 % Confident Interval p Value

Have ever had private teachers 1.868 1.137 – 3.070 0.013*

Have failed a class before 2.228 0.811 – 6.122 0.120

Family stressor (yes) 1.526 0.851 – 2.738 0.156

Parental marital compatibility

(bad)

0.573 0.197 – 1.671 0.308

Discussion

This was a two-stage epidemiology study examining the prevalence rate of psychiatric disorders among Saudi adolescent girls attending high school in Riyadh City. The first stage was the screening phase, which used the self-reported SDQ measure in a group setting and the SDQ-

parent form for the parents. The second stage was the interview stage and was conducted by trained psychologists using the MINI structured interview.

Prevalence of psychiatric disorder

165


Agoraphobia, depression and separation anxiety were among the most common psychiatric disorders in the current sample with rates of 30.6%, 30%, and 27%, respectively. This is in line with other international studies that found anxiety disorder to be the most common condition with a prevalence rate of 31% among a representative sample of adolescents in the US.14 Another study measured the lifetime prevalence of psychiatric disorders among adolescents and found a rate of 33%.15 Moreover, a rate of 31% was found at follow-up among girls who were between the ages of 9 to 16 years.6

In comparison with an Arab study, Alyahri and Goodman11,16 found anxiety disorder to be the most common diagnosis, which is in line with the current finding, but with a rate of 9.3%. Our rates were much higher than those reported in the study, which reflects differences in the informers and methodology. Our study was based on the diagnosis and adolescent self-report, whereas in the previous study, the parents were the primary source of information.17 It has been reported that the parents are better informers of behavioral problems, whereas adolescents are better informers of their emotional difficulties.

In a comparison of the present results with findings from Saudi Arabia, we again found similar patterns. In a study using a self-report measure with 545 adolescent girls in a secondary school in Abha City, anxiety disorder was found to be the most common condition in approximately 16% of the sample.18 Another study using the self-reported Beck Depression Inventory with secondary school boys and girls in Taif city found a rate of 22% for depressive symptoms.19 Another study using the self-reported Depression, Anxiety and Stress Scale with 1723 high school boys indicated that approximately 59.4% had reported at least one disorder, with depression being the most common condition.20

Although anxiety disorder has shown a similar rate in international studies, as reported above, other disorders, such as eating disorders, are considered to have a stronger cultural influence, and therefore, might not be globally similar. In our study, we found a rate of only 3.3% for bulimia and less than 1% for anorexia. In comparison to an international study of 934 adolescent girls, a rate of 17% was found for any eating disorder.21

Regarding the rate of hypomania and mania, which is higher than expected, it is important to remember that this is a study of adolescents girls who are asked to self-report specific mood symptoms (such as “feeling full of energy, grouchy or annoyed”). It is possible, therefore, that mood fluctuation, which is a major characteristic of this age group, could result in the over-reporting of such symptoms. One way of overcoming this potential bias is to include more informants in the study design, such as

parents or teachers, which is a major limitation of the present study to be discussed later.

It is important to note that a comparison with an epidemiological study is not easily performed due to a large variation among study methodologies, designs and sample selections. Therefore, it is crucial that these results be interpreted with caution in reference to its methodological process.

Predictor factors

Previous studies and surveys have found psychiatric disorders to be associated with specific factors, such as family socioeconomic status and the parents’ education level and occupations.7 Our study found only one educational factor that predicted the presence of a psychiatric disorder, which was ‘having a private teacher’.

Previous international studies have noted that lower educational achievement was strongly related to poor mental health.22 Another study found that anxiety disorder significantly increased the risk of premature withdrawal from school.23

Although we have not assessed academic performance, we only ask whether private teaching is a possible proximal indication of school difficulties. Therefore, the result might reflect the fact that school performance and difficulties in school that require extra help (such as private teaching) might be an indication of psychological difficulties in adolescents. However, it is possible that the use of private teachers for supervised studies is not necessary an indication of difficulties. Therefore, the question remains for future research to confirm and to add onto these findings. We encourage future research into look into this possible link.

Teacher involvement

It is unfortunate that the present study was unable to include input from teachers via the same screening measure (SDQ teacher version). However, almost all of the teachers initially included in the pilot study declined to complete the screening measure stating that they did not feel fully aware of their students’ psychological wellbeing. This gap of knowledge raises concern about the lack of early identification of a student’s psychological difficulties, which might go unnoticed by the school. It was reported by Ford et al.24 in a large epidemiology study that some disorders, such as ADHD, may be missed if information from the teacher is not sought out. This is also important in light of the current findings, which indicate that having a private teacher might predict a psychiatric disorder.

166


Limitations

The limitations of the current study need to be addressed. First, the results were based on information obtained from one informant group – the adolescents. Other sources of information, such as information from the mother or father should also be explored. Second, not being able to assess the teacher input is a major limitation to this study and those with a similar design. Researchers should therefore think carefully when designing a similar study. It might be advisable to use a follow-up study design in which teachers are asked to evaluate their students over a longer period of time. Finally, our study did not identify social predictors of psychiatric disorders, which is likely attributable to having only one informer for each subject. Psychiatric disorders are complex conditions in which no single cause can fully explain the variation observed among patients; therefore, one informer is not enough to explain this complex dynamic with social factors.

Having acknowledged these limitations, the current findings have important clinical implications for adolescent mental health research and service planning. This is especially important because information on this topic is very limited in Saudi Arabia.

Conclusion

The current study was a two-stage epidemiological survey that examined the prevalence of mental health problems in Saudi adolescent girls attending high school in Riyadh City. The most common psychiatric disorders were agoraphobia and depression with prevalence of 30.6% and 30%, respectively. The differences in methodology affect the comparability with other studies; the use of a school-based sample and reliance on information from the adolescent only may have contributed to a relatively higher rate compared with other Arab studies. Having a private teacher was the only predictor of a psychiatric illness in the sample.

Acknowledgement

We would like to thank all participants for giving their time to participate in the study. Also we thank the research assistants who collected the data.

References

1. Philbrick JT, Connelly JE, Wofford AB. The prevalence ofmental disorders in rural office practice. J. Gen. Intern. Med. 1996; 11:9–15. doi: 10.1007/BF02603478.

2. World Health Organization. Caring for children andadolescents with mental disorders: Setting WHO directions. Geneva: World Health Organization 2003.

3. Costello EJ, Egger H, Angold A. 10-year research updatereview: the epidemiology of child and adolescent psychiatric disorders: I. Methods and public health burden. J Am Acad Child Adolesc Psychiatry 2005; 44:972–86. doi: 10.1097/01.chi.0000172552.41596.6f.

4. Roberts RE, Attkisson CC, Rosenblatt A. Prevalence ofpsychopathology among children and adolescents. Am J Psychiatr 1998; 155:715–25. doi: 10.1176/ajp.155.6.715.

5. Meltzer H, Gatward R, Goodman R, Ford T. Mental healthof children and adolescents in Great Britain. London: Stationery Office 2000.

6. Eapen V, Jakka ME, Abou-Saleh MT. Children withpsychiatric disorders: the A1 Ain community psychiatric survey. Can. J. Psychiatry Rev. Canadienne Psychiatrie. 2003; 48:402–7. doi: 10.1177/070674370304800607.

7. Roberts RE, Roberts CR, Xing Y. Rates of DSM-IVpsychiatric disorders among adolescents in a large metropolitan area. J. Psychiatr. Res. 2007; 41:959–67. doi: 10.1016/j.jpsychires.2006.09.006.

8. Eapen V, Al-Gazali L, Bin-Othman S, Abou-Saleh M.Mental health problems among schoolchildren in United Arab Emirates: prevalence and risk factors. J Am Acad Child Adolesc Psychiatr 1998; 37:880–6. doi: 10.1097/00004583-199808000-00019.

9. Eapen V, Al-Sabosy M, Saeed M, Sabri S. Child psychiatric disorders in a primary care Arab population. Int. J. Psychiatr Med. 2004; 34:51–60. doi: 10.2190/JW8N-PW2D-P63A-F5YV.

10. Goodman R, Ford T, Simmons H, Gatward R, Meltzer H.Using the strengths and difficulties questionnaire (SDQ) to screen for child psychiatric disorders in a community sample. Br J Psychiatr 2000; 177:534–9. doi: 10.1192/bjp.177.6.534.

11. Alyahri A, Goodman R. Validation of the Arabic strengthsand difficulties questionnaire and the development and well-being assessment. East Mediterr Health J. 2006; 12 (Suppl 2):S138–46.

12. Sheehan D, Lecrubier Y, Harnett Sheehan K, Janavs J,Weiller E, Keskiner A, et al. The validity of the mini international neuropsychiatric interview (MINI) according to the SCID-P and its reliability. Eur. Psychiatr 1997; 12:232–41. doi: 10.1016/S0924-9338(97)83297-X.

13. Ibrahim M, Bishry Z, Hamed A. Comparison of miniinternational neuropsychiatric interview for children (mini-kid) with the schedules for affective disorders and schizophrenia for school-aged children, present and lifetime version (KSADS-PL): in Egyptian sample presenting with childhood disorders. (MD Thesis). Egypt: Ain Shams University 2002.

14. Merikangas KR, He JP, Burstein M, Swanson SA,Avenevoli S, Cui L, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the national comorbidity survey replication–adolescent supplement (NCS-A). J. Am. Acad. Child Adolesc Psychiatr 2010; 49:980–9. doi: 10.1016/j.jaac.2010.05.017.

15. Lewinsohn PM, Hops H, Roberts RE, Seeley JR, AndrewsJA. Adolescent psychopathology: I. Prevalence and incidence of depression and other DSM-III-R disorders in high school students. J Abnorm Psychol 1993; 102:133–44. doi: 10.1037/0021-843x.102.1.133.

167


16. Matsuura M, Okubo Y, Kojima T, Takahashi R, Wang YF,Shen YC, et al. A cross-national prevalence study of children with emotional and behavioural problems - A WHO collaborative study in the western Pacific region. J Child Psychol Psychiatr 1993; 34:307–15. doi: 10.1111/j.1469–7610.1993.tb00994.x.

17. Kolko DJ, Kazdin AE. Emotional/behavioral problems inclinic and nonclinic children: correspondence among child, parent and teacher reports. J Child Psychol Psychiatr 1993; 34:991–1006. doi: 10.1111/j.1469-7610.1993.tb01103.x.

18. Al Gelban KS. Prevalence of psychological symptoms inSaudi secondary school girls in Abha, Saudi Arabia. Ann. Saudi Med 2009; 29:275–9. doi: 10.4103/0256-4947.55308.

19. Abdel-Fattah MM, Asal A-RA. Prevalence,symptomatology, and risk factors for depression among high school students in Saudi Arabia. Euro J Psychol 2006; 2. Available at: <http://ejop. psychopen. eu/article/view/335>.

20. Al-Gelban KS. Depression, anxiety and stress among Saudiadolescent school boys. J R Soc Promot Health 2007; 127:33–7. doi: 10.1177/1466424007070492.

21. Kjelsås E, Bjørnstrøm C, Götestam KG. Prevalence ofeating disorders in female and male adolescents (14-15 years). Eat Behav 2004; 5:13–25. doi: 10.1016/S1471-0153(03)00057-6.

22. Patel V, Flisher AJ, Hetrick S, McGorry P. Mental healthof young people: a global public-health challenge. Lancet 2007; 369:1302–13. doi: 10.1016/S0140-6736(07)60368-7.

23. Van Ameringen M, Mancini C, Farvolden P. The impact ofanxiety disorders on educational achievement. J Anxiety Disord 2003; 17:561–71. doi: 10.1016/S0887-6185(02)00228-1.

24. Ford T, Goodman R, Meltzer H. The British child andadolescent mental health survey 1999: the prevalence of DSM-IV disorders. J Am Acad Child Adolesc Psychiatr 2003; 42:1203–11. doi: 10.1097/00004583-200310000-00011.

ملخص

عد األبحاث شد. ولذلك تأظھرت الدراسات العالمیة أن المشاكل النفسیة التي یتعرض لھا الفرد في سن مبكرة یمكن أن تؤدي إلى تدھور كبیر في أدائھ في مرحلة الر لمملكة العربیة في ا لكن ھذا النوع من الدراسات محدود جدا مجتمع،في التخطیط للخدمات النفسیة في أي التي تعنى بمدى انتشار االضطرابات النفسیة أمرا أساسیا

لطرق:اضطرابات النفسیة لدى المراھقات السعودیات من طالبات المرحلة الثانویة في مدینة الریاض. اسة إلى البحث في نسبة انتشار اإلالسعودیة. ولھذا سعت الدري لفحص مدى احتمال وجود اضطراب نفس والضعف،طبقت ھذه الدراسة على مرحلتین: اعتمدت المرحلة األولى على مسح العینة المختارة باستخدام استبیان القوة

فسیة. وجود أو عدم وجود اضطرابات ن والتي أجریت على عینة فرعیة لتأكید المقننة،باستخدام المقابلة المقابلة،مرحلة الثانیة،ویتبع ذلك المرحلة العینة،لدى حلة الثانیة. وجدت النتائج أن اإلمشاركة للمقابلة في المر 692من المشاركین في المرحلة األولى، وخضع 4745تم فحص النتائج: ھي ضطرابات األكثر شیوعا

ل في القدرة فشل العدید من العوام . وأظھرت النتائج ایضا ٪27.1ة ل بنسب، وقلق االنفصا٪30.0كتئاب الشدید بنسبة ، اإل٪30.6ألماكن المفتوحة بنسبة الخوف من ا . (OR=1.87, p=.013) "ضطراب نفسي باستثناء عامل واحد فقط وھو " االستعانة بمعلم خاصإعلى التنبؤ بوجود


Dr Yousra Alatiq, DPhil

Consultant Clinical Psychologist

Mental Health Division, King Abdulaziz Medical City - Riyadh

PO Box 22490, Riyadh 11426, Saudi Arabia


Authors

Dr Yousra Alatiq, DPhil

Consultant Clinical Psychologist

Mental Health Division, King Abdulaziz Medical City - Riyadh

Ms Meshael Alshalan, MSc

Clinical Psychologist

Mental Health Division, King Abdulaziz Medical City – Riyadh

Dr Omar Almodayfer, MD

Consultant Psychiatrist & Family Therapist

Head of Mental Health Division

Mental Health Division, King Abdulaziz Medical City – Riyadh

168

التشخیصي واإلحصائي الخامس لالضطرابات النفسیةالذھان في الدلیل األمریكي

Disorganized thinkingط تفكیر (كالم) غیر متراب •(speech)

Grossly disorganizedسلوك مضطرب بشدة أو جمودي •or catatonic behavior

Negative symptoms أعراض سلبیة •

وسابقا في الدلیل الرابع كان یكفي وجود عرض واحد إذا كان من أعراض المرتبة األولى لشنایدر (ھذیانات السیطرة وصدى األفكار وغیرھا وأھالس سمعیة تعلق على الشخص وسلوكھ أو تتحدث بینھا عنھ). وھذا یعني فقدان

ھي ال تكفي ف الفصام.لى لشنایدر أھمیتھا التشخیصیة في أعراض المرتبة األووحدھا أبدا، ویمكن لھا أن تظھر في حاالت اضطراب المزاج المختلفة كما إال إذا ترافق الھذیان مع ھلوسة وھنا یصبح في االكتئاب أو الھوس. طبعا

.لدینا عرضان معا وھو یكفي للتشخیص

یجب أن یكون أحد العرضین .2 الذھانیین من األعراض وأیضااإلیجابیة الثالثة األولى. وھذا یساعد على التفریق بین الفصام

.وبین االضطرابات المزاجیة وغیرھا

) یساعد على تحسین وتشدید معاییر 2( ) و1وما سبق ذكره من تغییرات في ( .Reliability تشخیص الفصام مما یؤدي إلى زیادة ثبات التشخیص

وحدود المرض الواضحة، فإن ذلك ال یزال Validity واما صحة التشخیص ویسعى الدلیل الجدید أخرى.غیر واضح تماما بسبب تداخلھ مع اضطرابات

.إلى مزید من الوضوح في ھذه الموضوع

الشبابي مثل الفصام الفصام.تمت إزالة التصنیفات الفرعیة لشكل .3والزوري والجمودي وغیرھا، وذلك بسبب عدم ثبات ھذه

ألشكال عبر تطور المرض، وندرة استعمالھا في األبحاث اوالدراسات خالل العشرین سنة الماضیة، وأیضا لضعف

.صحتھا، وغیر ذلك من األسباب

وبدال عن ھذه األشكال الفرعیة تمت إضافة بعد جدید یقیس شدة األعراض ، حیث تتدرج شدة 4إلى 0الذھانیة الخمسة مؤلف من خمس درجات، من

عراض الذھانیة من: غیر موجودة إلى غیر أكیدة، موجودة لكن خفیفة، األ .1متوسطة، شدیدة

وأعتقد أن ھذه اإلضافة مفیدة من الناحیة العیادیة وفي الدراسات، ألن مرضى الفصام مختلفون في حالتھم وشدة أعراضھم، وتمییز ذلك ضروري من

، تجاوبھ مع العالجات الناحیة العیادیة في التعامل مع المریض وفي متابعة التمییز في شدة وكذلك یفید في الدراسات المتنوعة ألنھ أصبح ممكنا لھذا الدلیل، وما یرتبط بذلك من عوامل متنوعة األعراض الذھانیة وفقا

.تخضع للدراسة والبحث

:تغییرات في تشخیص اضطرابات طیف الفصام

أشھر من األعراض 6تشخیص الفصام المزاجي یتطلب .1المرضیة، وفیھا أعراض مزاجیة غالبة، ولكن األعراض الفصامیة مستمرة لمدة أسبوعین على األقل دون أیة أعراض مزاجیة. وھذا یساعد على التفریق بین الفصام والفصام المزاجي. وال یكفي وجود أعراض اكتئابیة لمدة قصیرة لیصبح التشخیص

ة غالبة لفترةفصام مزاجي، بل یجب أن تكون األعراض المزاجیطویلة، أي أن تشخیص الفصام المزاجي أصبح یعتمد على مقطع

.طولي زمني في األعراض ولیس مقطعا عرضیا في االضطراب الذھاني یمكن أن یكون الھذیان غریبا. وغرابة .2

.الھذیان التجعل الحالة فصاما، بل اضطراب ذھانياألخرى، الذھان التشاركي یصنف ضمن االضطرابات الذھانیة .3

.ولیس ضمن االضطراب الذھاني كما كان یصنف سابقا –إضافة تخصیص الجمودي لعدة اضطرابات: االكتئاب .4

حالة –االضطرابات الذھانیة –اضطراب المزاج ثنائي القطب .طبیة

ویتطلب تخصیص جمودي وجود ثالثة أعراض من اثنتي عشرة جود اثنین من خمسة عرضا جمودیا. اما سابقا فكان ذلك یتطلب و

.أعراض، وفي حاالت الجمود الطبیة عرض واحد فقط Attenuated اقتراح للمزید من الدراسة: تناذر الذھان المخفف .5

Psychotic Syndrome

وھذا االضطراب طرحھ الدلیل للمزید من الدراسة، وھو شائع ولھ صفات التفكیر، اضطراب –ھلوسة –محددة وھي: أعراض ذھانیة خفیفة ھذیان

مرة باألسبوع خالل الشھر الماضي، مع بقاء التبصر والحس الواقعي، مع .معاناة وتدھور في األداء الوظیفي

من السكان، حیث یعاني المصابون بھ من %13-8شائع وانتشاره حوالي .تجارب أھالسیة وأفكار ھذیانیة قصیرة، وھو أكثر قلیال عند الذكور

شخاص یصابون بأحد االضطرابات الذھانیة من ھؤالء األ %30وحوالي .1سنوات 3خالل

یشبھ االضطراب الذھاني واضحة. تعلیق: اضطراب غامض وحدوده غیر -قصیر األمد ولكنھ أخف أعراضا، وربما تكمن أھمیتھ في التدخل العالجي

.المبكر

:المراجع

1. DSM-5, American Psychiatric Association Press,2013.

2. https://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disorders

د. حسان المالح

استشاري الطب النفسي

الجمھوریة العربیة السوریة–دمشق


170

Short Report الذھان في الدلیل األمریكي التشخیصي واإلحصائي الخامس لالضطرابات النفسیة

حسان المالح

Psychoses in DSM-5 Hassan Almaleh

مقدمة

، وقد قصد بھ عدة اضطرابات نفسیة ذھانیة 1911الطبیب النفسي بلویلر في ألمانیا عام أطلقھھو مصطلح حدیث نسبیا، وقد Schizophrenia إن مصطلح الفصام .حیث استعمل التشخیص بلغة الجمع (فصامات) محددة.تجمعھا صفات

عدة شخیصاألولى تیھ للمرة وقد ساھمت الحرب العالمیة الثانیة بتطورات ھامة في میدان الطب النفسي حیث ظھر التصنیف العالمي لألمراض بطبعتھ السادسة وف .1949، عام ICD-6 م أمراض نفسیة ومنھا الفصا

من االضطرابات النفسیة 106وكان یضم .DSM-I 1952كما ظھر في الوالیات المتحدة األمریكیة الدلیل التشخیصي واإلحصائي األول لألمراض النفسیة عام .یھا مصطلح الفصام االرتكاسي ویعني الفصام الناتج عن ضغوط وأزمات معینةولكل منھا أوصافھا ومعاییر تشخیصھا المحددة. وظھر ف

.وقد ظھرت خالل السنوات التالیة إلى الوقت الحالي عدة تعدیالت على تشخیص األمراض النفسیة

الدلیل األمریكي التشخیصي واإلحصائي الخامس لالضطرابات النفسیة

ظھر الدلیل التشخیصي واإلحصائي الخامس، وفیھ أكثر من 2013عام وفي مالحظة: تم استعمال األرقام العربیة في تسمیة الدلیل ( تشخیص 350

ألنھا أكثر سھولة في برمجیات vبدال عن األرقام الرومانیة 5الخامس 2.) الكومبیوتر

اضطرابات طیف الفصام وغیرھا من االضطرابات الذھانیة في Schizophrenia spectrum and:الدلیل الخامس

other psychotic disorders

یضم الدلیل التشخیصي واإلحصائي الخامس لالضطرابات النفسیة ستة اضطرابات تحت عنوان اضطرابات طیف الفصام وغیرھا من االضطرابات

:الذھانیة وھي على الشكل التالي

:Schizophrenia الفصام .1وھو أكثر االضطرابات الذھانیة شیوعا، ونسبة انتشاره في

.من األشخاص %1المجتمع حوالي Delusional التوھمي) –االضطراب الھذیاني (الزوري .2

Disorder: من األشخاص، وھو ینتشر أكثر 1/500ونسبة انتشاره حوالي

عند الرجل، ویرتبط وراثیا بالفصام وأیضا بالشخصیة ذات النمط .الفصامي

Schizophreniform االضطراب ذو الشكل الفصامي .3Disorder:

من األشخاص، ومن الناحیة 1/500ره حوالي ونسبة انتشا في الوراثیة ھناك زیادة في حاالت الفصام، وھو أكثر شیوعادول العالم الثالث، وثلث الحاالت تشفى خالل ستة أشھر من ظھورھا، وباقي الحاالت تتحول إلى الفصام أو إلى الفصام

.المزاجي:Schizoaffective Disorder الفصام المزاجي .4

من األشخاص، وھو أكثر عند 1/300ة انتشاره حوالي ونسبالمرأة، ونسبة االنتحار فیھ مشابھة لنسبة االنتحار في الفصام

.%5وھي حوالي :Brief psychotic disorder الذھان قصیر األمد .5

وھو وجود أعراض ذھانیة لمدة أكثر من یوم واحد ولكن لمدة لعالم الثالث، وأكثر أقل من شھر، وھو أكثر انتشارا في دول ا

.انتشارا عند المرأة Schizotypal personality الشخصیة ذات النمط الفصامي .6

disorder: وھذه الشخصیة لدیھا أفكار اإلشارة المرضیة، وأفكار غریبة وسحریة، واوھام جسمیة وغیرھا. وتتمیز بالغرابة في التفكیر

عاني من القلقوالكالم والسلوك، وعدم وجود أصدقاء مقربین، وت .االجتماعي وغیر ذلك

من السكان، وھي ثابتة في تطورھا %4ونسبة انتشارھا حوالي عبر الزمن، ونسبة قلیلة منھا فقط تتطور إلى الفصام أو إلى أحد االضطرابات الذھانیة األخرى، وھي أكثر قلیال عند الذكور،

بالفصام، وتصاب باالكتئاب بنسبة ن م %50وترتبط وراثیا .الحاالت

:التغییرات في تشخیص الفصام في الدلیل الخامس

:وجود عرضین من األعراض الذھانیة التالیة .1 Delusions ھذیانات (أوھام) • Hallucinationsھالوس •

169

(The Arab Journal of Psychiatry (2017) Vol. 28 No.2 Page (169 - 170) (doi:10.12816/0041718

شبكة العلوم النفسیة العربیة ... منجزات سبعة عشرة عاما

Abstract

The 20th Century was characterized by significant advances in science and information which were greatly supported through improved methods of communication. In light of IT technology and the internet age, psychological science began to be seen differently.

The ever-evolving field of communication continues to bring with it the promise of change because of the speed at which information can be delivered. Thus inarguably, the widespread dissemination of information enhances the value of science.

:ذات صلة بالموضوع على شبكة االنترنت طرواب

الموقع العلمي -شبكة العلوم النفسیة العربیة -http://www.arabpsynet.com

المتجر االلكتروني -العربیة مؤسسة العلوم النفسیة -http://www.arabpsyfound.com

" نشرة " الرسالة اإلخباریة األسبوعیة -http://arabpsynet.com/menu.asp?link_c2=/Weekly/IndexNewsLetter.htm&current_c2=3

)المجلة العربیة: " نفسانیـات " (مجلة محكمة في علوم وطب النفس -http://arabpsynet.com/menu.asp?link_c2=apn.journal/index-apn.htm&current_c2=3

)مجلة "بصائر نفسانیة " (مجلة مستجدات العلوم النفسیة العربیة -http://arabpsynet.com/menu.asp?link_c2=apn.journal/index-eJbs.htm&current_c2=3

السلسلة المكتبیة " نفساني " (اصدارات مكتبیة محكمة في علوم وطب النفس -http://arabpsynet.com/menu.asp?link_c2=/apneBooks/index.eBooks.htm&current_c2=4

)السلسلة المكتبیة "وفي أنفسكم" (نحو لیاقة نفسیة أفضل لحیاة طیب -http://arabpsynet.com/menu.asp?link_c2=/apneBooks/index.eBFiAnfosikom.htm&current_c2=4

") السلسلة المكتبیة " الراسخون ( اصدار لجنة التراث النفسي العرباسالمي -http://arabpsynet.com/menu.asp?link_c2=/TourathPsy/index.TourathPsy.htm&current_c2=4

)السلسلة المكتبیة "الكتاب االبیض" (واقع الصحة النفسیة في الوطن العربي -http://arabpsynet.com/menu.asp?link_c2=/WhiteBooks/eWBIndex.htm&current_c2=4

اور)(النشرة الیومیة حسب المح " السلسلة المكتبیة: "اإلنسان والتطور -http://arabpsynet.com/menu.asp?link_c2=/Rakhawy/IndexeBRak.htm&current_c2=4

)وماسواھا" (أفكار نفسیة لحیاة“السلسلة المكتبیة: -http://arabpsynet.com/menu.asp?link_c2=/Samarrai/Index.eBSamarrai.htm&current_c2=4

)مقاربات" (الرؤیة من منظور مختلف“السلسلة المكتبیة: -http://arabpsynet.com/menu.asp?link_c2=/Muqarabet/Index.eBMuqarabet.htm&current_c2=4

) اصدار انكلیزي -اصدار فرنسي -المعجم "الموسع" في علوم وطب النفس ( اصدار عربي -http://www.arabpsyfound.com/index.php?id_category=28&controller=category&id_lang=3

) اصدار انكلیزي -اصدار فرنسي -المعجم "النفساني" في العلوم و الطب ( اصدار عربي -http://www.arabpsyfound.com/index.php?id_category=46&controller=category&id_lang=3

) اصدار انكلیزي -اصدار فرنسي -المعجم "الوجیز" في علوم وطب النفس ( اصدار عربي -http://www.arabpsyfound.com/index.php?id_category=31&controller=category&id_lang=3

) اصدار انكلیزي -اصدار فرنسي -المعجم "المختص" في علم النفس الجنسي ( اصدار عربي -http://www.arabpsyfound.com/index.php?id_category=30&controller=category&id_lang=3

) المعجم "المختص" في االضطرابات الوجدانیة ( اصدار انكلیزي -http://www.arabpsyfound.com/index.php?id_product=237&controller=product&id_lang=3

تونس-جمال التركي العلوم النفسیة العربیة رئیس مؤسسة

[email protected]

180

http://www.arabpsynet.com/

http://www.arabpsyfound.com/

http://arabpsynet.com/menu.asp?link_c2=/Weekly/IndexNewsLetter.htm&current_c2=3

http://arabpsynet.com/menu.asp?link_c2=apn.journal/index-apn.htm&current_c2=3

http://arabpsynet.com/menu.asp?link_c2=apn.journal/index-eJbs.htm&current_c2=3

http://arabpsynet.com/menu.asp?link_c2=/apneBooks/index.eBooks.htm&current_c2=4

http://arabpsynet.com/menu.asp?link_c2=/apneBooks/index.eBFiAnfosikom.htm&current_c2=4

http://arabpsynet.com/menu.asp?link_c2=/TourathPsy/index.TourathPsy.htm&current_c2=4

http://arabpsynet.com/menu.asp?link_c2=/WhiteBooks/eWBIndex.htm&current_c2=4

http://arabpsynet.com/menu.asp?link_c2=/Rakhawy/IndexeBRak.htm&current_c2=4

http://arabpsynet.com/menu.asp?link_c2=/Samarrai/Index.eBSamarrai.htm&current_c2=4

http://arabpsynet.com/menu.asp?link_c2=/Muqarabet/Index.eBMuqarabet.htm&current_c2=4

http://www.arabpsyfound.com/index.php?id_category=28&controller=category&id_lang=3




http://www.arabpsyfound.com/index.php?id_product=237&controller=product&id_lang=3


جمال التركي

النفــــس)(فـــي علـــم 2012جائزة العام. محمد الفائز: د: العلوم النفسیة العربیة لشبكة بدريجائزة مالك.

.ایمن عرقسوسي السعودیة / سوریا (فـــي الطـــب النفسانـــي) 2013جائزة العام. 2013جـائزة یحیى الرخاوي لشبكة العلـوم النفسیـة العربیـة 2013.تم حجب جائزة الشبكة لعام. (فـــي علـــم النفــــس) 2014جائزة العام. 2014العربیة جائزة عمر خلیفة الھارونلشبكة العلوم النفسیة

.لفائز: د. صـالح الدیــن فـرح عطـا اللـھا (فـــي الطـــب النفسانـــي) 2015جائزة العام. الفائز: 2015 :جائزة أحمد عكاشة لشبكة العلوم النفسیة العربیة

.سمیر كوتھ .د النفــــس)(فـــي علـــم 2016جائزة العام. جائزة البشیر معمریھ لشبكة العلوم النفسیة العربیة للعام:

.مصر-الفائزة: أ.د. سامیة بكري عبد العاطي2016

المفلحـــــون في العلـــوم النفسانیــة

النفــــس)(فـــي علـــم 2010تكریم بلقب " المفلحون " للعام o (مصر)علم النفس –عبد الستار ابراھیم

شبكة العلوم على جائزةاسمھ الكریم بمناسبةإطالق بھا عمروالتي فاز 2010النفسیة العربیة للعام

.ھارون الخلیفة (فـــي الطـــب النفسانـــي) 2011تكریم بلقب " المفلحون " للعام

o لبنانالطب النفساني –الراحل محمداحمد النابلسي)(شبكة العلوم على جائزةاسمھ الكریم إطالقبمناسبة

لطفي بھا احمدوالتي فاز 2010فسیة العربیة للعام الن .الشربیني

النفــــس)(فـــي علـــم 2012تكریم بلقب " المفلحون " للعام o على جائزةاسمھ الكریم إطالقمالك بدري بمناسبة

والتي فاز 2012شبكة العلوم النفسیة العربیة للعام .ایمن عرقسوسي بھا محمد

(فـــي الطـــب النفسانـــي) 2013" للعام تكریم بلقب " المفلحون o بمناسبة(مصرالطب النفساني –یحیـى الرخـاوي (

شبكة العلوم النفسیة على جائزةاسمھ الكریم إطالق .2013العربیة للعام

النفــــس)(فـــي علـــم 2014تكریم بلقب " المفلحون " للعام o علمالنفس (السودان)-عمـر خلیفـة الھــارون

اسمھ الكریم على جائزة شبكة العلوم إطالقناسبة بم بھا صالحوالتي فاز 2014النفسیة العربیة للعام

.الدین فرح عطا هللا (فـــي الطـــب النفسانـــي) 2015تكریم بلقب " المفلحون " للعام

o بمناسبة(مصرالطب النفساني –أحمــد عكاشــة (شبكة العلوم النفسیة على جائزةاسمھ الكریم إطالق

.كوتھ بھا سمیروالتي فاز 2015العربیة للعام النفــــس)(فـــي علـــم 2016تكریم بلقب " المفلحون " للعام

o بمناسبة(الجزائرعلم النفس –البشیــر معمریــة (شبكة العلوم النفسیة على جائزةاسمھ الكریم إطالق

بكري عبد ةبھا سامیوالتي فاز 2016العربیة للعام .العاطي

(فـــي الطـــب النفسانـــي) 2017تكریم بلقب " المفلحون " للعام

o الطب النفساني بمناسبة –محمــد أدیــب العسالــيشبكة العلوم النفسیة على جائزةاسمھ الكریم إطالق

.2017العربیة للعام

الراسخــون فـــي العلــوم النفسیــــة

العلماء أبرزشخصیـات من 10كرمنا لتأسیسھابمناسبة الذكرى العاشرة " بلقب الراسخون":العـرب بلقواالطباء النفسانیین

.)14لیتواصل التكریم بعد ھذا التاریخ سنویا (مجموع الشخصیات المكرمة:

واالطباء المكرمـــــــوناالساتذة

" الطــب (فـــي2004للعام التكریم بلقب " الراسخون .النفسانـــي)

.مصر)(النفساني الطب –یحیــى الرخــاوي • " النفــس)علــم (فـــي2005للعام التكریم بلقب " الراسخون.

.(مصر)علــم النفــس –عبــد الستــار ابراھیــم • " الطــب (فـــي2006للعام التكریم بلقب " الراسخون

.النفسانـــي) .(مصر)الطب النفساني –احمــد عكاشــة •

" النفــس)علــم (فـــي2007للعام التكریم بلقب " الراسخون. .(لبنان)علــم النفــس –مصطفــى حجـازي •

" الطــب (فـــي2008للعام التكریم بلقب " الراسخون .النفسانـــي)o الطب النفساني (لبنان) –محمـد أ. النابلســي.

" النفــس)علــم (فـــي2009للعام التكریم بلقب " الراسخون. oعلــم النفــس (لبنان)–علــي زیعـــور.

" الطــب (فـــي2010للعام التكریم بلقب " الراسخون .النفسانـــي)oالطب النفساني (أمریكا /العراق)-صـادق السامـرائي

النفــس)(فـــي علــم 2011التكریم بلقب " الراسخون " للعام. oعلــم النفــس (مصر)-قــدري حفنــــي.

" الطــب (فـــي2012للعام التكریم بلقب " الراسخون .النفسانـــي)o الطب النفساني (األردن) –عدنـان التكریتــي.

" النفــس)علــم (فـــي2013للعام التكریم بلقب " الراسخون. o علــم النفــس (مصر) –أحمـد عبـد الخالـق.

فـــي الطــب 2014التكریم بلقب " الراسخون " للعام) .النفسانـــي)oالطب النفساني (األردن)-ولیـــد سرحــان.

(فـــي علــم النفــس) 2015التكریم بلقب " الراسخون " للعام. oعلــم النفــس (مصر)–مصطفـــى صفــوان.

" الطــب (فـــي2016للعام التكریم بلقب " الراسخون .ـــي)النفسانo (لبنان)الطب النفساني –إیلــي كـــرم.

179


لیزيانج-اإلصدار العربي (عربي -والطـب فــي العلـوم “ـم "النفساني المعج فرنسي) –

عربي)-فرنسي –النفسانــي اإلنكلیــــزي (انجلیزي

–اإلنكلیزي (انجلیزي اإلصدار-والطـب العلـوم النفساني" فــيالمعجـم " عربي)-فرنسي

عربي) –انجلیزي -النفسانــي الفرنســــي (فرنسي

-اإلصدار الفرنسي (فرنسي -والطـب في العلـوم “المعجـم "النفساني عربي)-إنكلیزي

اعداد جمال التركي –علوم وطب النفس يالمختـــص " ف” المعجــم

فـي علـم النفـــس الجنســـي" المختــص” المعجــم

اسخ رتفتقر المكتبة النفسانیة العربیة الى المصطلح النفساني العربي الثابت والفي جمیع حقول علوم النفس وھي أشد منھ افتقارا للمصطلح النفساني المختصفي ھذا اإلطار یدخل سعینا تأسیس سلسلة "المعجم المختص في العلوم النفسانیة والذي نستھلھ بھذا " المعجم المختص في علوم الجنس" الذي

الى: و نعرض فیھ لترجمة مصطلحات علم النفس الجنسي باللغات الثالث من واإلنكلیزیة.العربیة، الفرنسیة

–انجلیزي-المختــص العربــــي فـي علـم النفـــس الجنســـي: (عربي .فرنسي)

– انجلیزي-فرنسيالمختــص الفرنســــي فـي علـم النفـــس الجنســـي ( .عربي)

-يفرنس –المختــص اإلنكلیــــزي فـي علـم النفـــس الجنســـي (انجلیزي .عربي)

دلیل المعجــــم "المختــــص" فـي علـم النفـــس الجنســـي

إضطرابـــات الوجــدان فـي“ المختــص” لمعجــما

–انجلیزي-عربيإضطرابـــات الوجــدان: ( العربــــي فـيالمختــص .فرنسي)

-فرنسي –المختــص اإلنكلیــــزي فـي إضطرابـــات الوجــدان (انجلیزي .عربي)

)دي سي(“ المبرمج للعلــوم النفسیــة المعجــم

–انجلیزي-عربيالعربـــي المبرمج للعلــوم النفسیــة: ( "المبرمج" .فرنسي)

یتم البحث في ھذا المعجم باللغة العربیة و تعرض نتائج ،مصطلح-36646 .اإلنكلیزیة والفرنسیة المصطلح باللغتینترجمة

-يفرنس –" اإلنكلیـــزي المبرمج للعلــوم النفسیــة (انجلیزيالمبرمج " .عربي)

البحث فیھ باللغة اإلنكلیزیة وتعرض مصطلحا، یتم 44132یحتوي على .نتائج ترجمة المصطلح النفسي باللغتین الفرنسیة والعربیة

–انجلیزي -المبرمج للعلــوم النفسیــة (فرنسي " الفرنسيالمبرمج" عربي)

مصطلحا، یتم البحث فیھ باللغة الفرنسیة وتعرض نتائج 32163یحتوي على .فسي باللغتین اإلنكلیزیة والعربيترجمة المصطلح الن

الجزء الثالث جوائز مؤسسة العلوم النفسیة العربیة

جائـزة شبكـة العلــوم النفسیــة العربیــة

2010سنة “جائزة شبكة العلوم النفسیة العربیة ” أسست • جائزة 6مجموع الجوائز: •یطلق سنویا على الجائزة شخصیة علمیة ممیزة، وفي ذلك تكریم •

رمزي لعلم من اعالم العلوم النفسیة العربیةسنویــــا" وبالتناوب" بین علم النفس والطب “تسند الجائزة •

النفسي عمــــــل جماعـــي او فـــردي لعملتمنح الجائزة •

o في تطور العلوم النفسیة قدم خدمات ممیزة ساھمت العربیة

o شكل إضافة ھامة في رقي العلوم النفسیة العربیة للعشر سنوات األخیرة (من تاریخ الجائزة)

.یرسل المترشح للجائزة سیرة علمیة مفصلة •الجائزة سنویة وتسند بالتناوب بین علم النفس (السنوات الزوجیة) •

والطب النفسي (السنوات الفردیة)الجائزة للفائز على ھامش أحد مؤتمرات علم النفس أو الطب تسلم •

النفسي 1000درع للشبكة" مع "مكافأة مالیة قدرھا ” تتكون الجائزة من •

.دوالر" (تحذف ان لم تسمح موارد الشبكة)

دیسمبر) 31یعلن عن الفائز آخر یوم من كل سنة (

یة الذي العلمتتكون من الرئیس (الشخصیة “لجنة تحكیم الجائزة " •تشرفت الجائزة حمل اسمھ الكریم)، أعضاء الھیئة العلمیة اإلستشاریة للشبكة حسب االختصاص، إضافة إلى الرؤساء األربع للشبكة (الرئیس الفخري، الرئیس الشرفي، الرئیس، نائب

.الرئیس)

النفــــس)(فـــي علـــم 2010جائزة العام

العلوم النفسیة العربیة جائزة عبد الستار ابراھیم لشبكة: السودان–الفائز:أ.د. عمر خلیفة الھارون

(فـــي الطـــب النفسانـــي) 2011جائزة العام الفائز: :العربیةجائزة محمد احمد النابلسي لشبكة العلوم النفسیة

مصر –د. احمد لطفي الشربیني

178


یة د. اإلنسانالنفسانیة ضد رسول االفتراءات: اإلصـدار الثالـــث - .خالد عبد الحمید ولید

شاھدي الیقین د. إدریس: صراع من أجل الرابـــعاإلصــدار - .الوزاني

والعالمیةدلیل المؤتمرات النفسیة العربیة

م 335مجموع المؤتمرات:

م/س 26المعدل السنوي:

:التوزیع السنوي

م 21: 2007م / 21: 2006م 16: 2005م / 12: 2004م / 16 :2003م 33: 2012م 39: 2011م / 37: 2010م / 34: 2009م 28: 2008/ م 4: 2016م /7 :2015 م 23: 2014م / 44: 2013/

م15: 2017إلى 2007ماجیستر & ملتقیات تكوینیة من

معاجــم وموسوعات فــي علـــوم وطــب النفـس

على الموقع العلمي للشبكة” المعجـم التفاعلـي فـي علـوم وطب النفـس

حیث بإمكان المتصفح النفـسوطب نعرض المعجـم التفاعلـي فـي علـوم االطالع على ترجمة المصطلح النفسي من وإلى العربیة، الفرنسیة

.ألف كلمة 113. تحتوي قاعدة بیانات المعجم أكثر من واإلنكلیزیة

یمتاز المعجم التفاعلـي على خالف المعجم الورقي بالتفاعلیة حیث یتطور رى ت جدیدة وتختفي أخمع استعمال المتصفحین لھ. فقد تضاف لھ مصطلحا

وقد تتغیر ترجمة كلمة ما وتضاف ترجمات جدیدة إلى أخرى قدیمة وبإمكان كل مشترك بالشبكة سواء من األطباء النفسانیین أو أساتذة علم النفس إبداء الرأي في ترجمة مصطلح ما وعرض ترجمة أخرى یرونھا مناسبة لمصطلح

عدیل ترجمة المصطلح أو إلضافتھ آخر وإرسالھا من خالل النماذج المرفقة لت .بعد المشاورة والدراسة

32163فرنسي/ -انجلیزي -(عربي“: التفاعلـــي العربــي ” - مصطلحا)

44142عربي /-فرنسي –(انجلیزي “: التفاعلـــي االنكلیــزي ” - مصطلحا)

36646عربي/-انجلیزي –فرنسي“: “(التفاعلـــي الفرنســي ” - مصطلحا)

اعداد جمال التركي –الموســع في علــوم وطــــب النفــس المعجــــم

المعجم الشامل لمصطلحات علوم النفس والطب

:ثالثجاء في ثالثة اصدارات الذي

إنكلیزي): محتویا على أكثر من -فرنسي -اصدار عربي (عربي •36 ألف مصطلحا نفسانیا .عربیا

ر محتویا على أكثعربي): –فرنسي -اصدار" انكلیزي (إنكلیزي • 44من ألف مصطلحا نفسانیا .انكلیزیا

عربي): محتویا على أكثر –إنكلیزي -اصدار فرنسي (فرنسي • 32من ألف مصطلحا نفسانیا .فرنسیا

فرنسي) – انجلیزي-عربيالموســع العربي (

36646العربي ( اإلصدار-وطـب النفـسعلـوم الموســع" فــيالمعجـم " .)مصطلحا

عربي)-فرنسي –الموســع اإلنكلیزي (انجلیزي

44142اإلنكلیزي ( اإلصدار-وطـب النفـسعلـوم يالموســع" فــالمعجـم " .)مصطلحا

عربي) – انجلیزي-فرنسيالموســع الفرنسي (

36646الفرنسي ( اإلصدار-وطـب النفـسفــي علـوم "المعجـم "الموســع .)مصطلحا

المعجــم " الموســع" في علــوم وطــب النفــسدلیــل

نمــاذج الحروف االولى من االصدارات الثالث للمعجم الموســع

اعداد جمال التركي –المعجــــم الوجیز في علــوم وطـــب النفــس

نسخة مختصرة من المعجم الموسع في العلوم النفسانیة، موجھھ باألساس الى ة النفسانیة وبشكل خاص لطلبة الطب النفساني وعلوم النفس، كل مھتم بالثقاف

.الذین یضعون اولى خطواتھم وھم یلجون ھذا الحقل من العلوم

فرنسي) –انجلیزي-الوجیز العربي: (عربي

اإلصدار العربي-فــي علـوم وطـب النفـس " المعجـم "الوجیــز

عربي)-فرنسي –الوجیـز اإلنكلیزي (انجلیزي

اإلصدار اإلنكلیزي-في علـوم وطـب النفـس “"الوجیز المعجـم

عربي) –فرنسي -إصدار أول: ثالثي اللغة (إنكلیزي • فرنسي)-إصدار ثان: ثنائي اللغة (إنكلیزي •

عربي) –انجلیزي -الوجیز الفرنسي (فرنسي

اإلصدار الفرنسي-في علـوم وطـب النفـس “المعجـم "الوجیز

عربي)-إنكلیزي –(فرنسي إصدار أول: ثالثي اللغة • إنكلیزي)-إصدار ثان: ثنائي اللغة (فرنسي •

في علــوم وطــب النفــس“دلیل المعجــم " " الوجیـــز"

نمـــاذج الحروف االولى من المعاجم الثالث

لمعجــــم "النفسانــي" فــي العلــوم والطـــبا

فرنسي) –انجلیزي-النفسانــي العربــــي: (عربي

177


o جمالعثمـان-: دلیــل اإلسعـاف النفسـي األولـي 10اإلصـدار- .قصیعـة میـس

o محمـد كمـال الشریـف د.-: سكینــة اإلیمــان 11اإلصـدار.o السعیـد عبـد الجـواد محمد-: حالـــة التوبـــة 12اإلصـدار

.أبوحـالوةo لمعاني ما بین اللغویین والتحلیل: سلسلة الدوالي وا13اإلصـدار

.مرسلینا شعبان حسن د.-النفسي o عبد الرحمان د.-1النفس العرب في علوم : أعالم14اإلصـدار

.إبراھیم

"دلیــل السلسلة المكتبیة الكتــاب العربــي " وفي أنفسكــــم

) الى 2013(شتاء 1من العدد ومقدمات األعدادالجزء األول: كامل فھارس )2016(ربیع 14العدد

سلسلـة إصدارات: "الراسخـون" (إصدارات لجنة البحث والدراسات في "التراث العربإسالمي)

االصدارات السابقة

تحلیل ومدرستھ فيالترمذي الحكیم 2013مـاي / 1اإلصـدار - .عبد السالم شاھدي الوزاني إدریس-اإلنسانیةالنفس

و جون دیوي نظرتھما الغزالي 2013/جوان 2اإلصـدار - .د.كفاح یحیى صالح العسكري -للطبیعة اإلنسانیة

بن اسحاق-الطب اإلسالمي منتراث 2013/أوت 4اإلصـدار - .د .بن احمد قویدر -عمران و مقالة فیالمالیخولیاأنموذجا

اإلنسانیة لدى علماء النفس النفس 2013أكتوبر / 5اإلصـدار - .د. صالح بن إبراھیم الصنیع أ.-الغربین وعلماء النفس المسلمین

النفسیة عند ابن عطاء االشارات 2014فیفري / 6اإلصـدار - .أ.د. حمدي فؤاد مصیلحي-السكندري هللا

المراحل العمریة بین"ابن تصنیف 2014فیفري / 7اإلصـدار - .يأ.د.عبد هللا الطارق-النفسیة المدارس فارس واألصفھاني"وبین

االضطرابات النفسیة بین 2014أوت / 8اإلصـدار - .أسمــاء بوعــود أ.-السیكولوجیا الحدیثة والمنظور االسالمي

-النفسيوتطور الفكر نشوء 2014أكتوبر / 10اإلصـدار - .السـود أ.نـزارعیـون-العرب عند االجتماعي

والنفس اإلنسانیة اإلنسان 2014مبر دیسعشر / 11اإلصـدار - .صالـح بـن إبراھیـم الصنیـع د.-التراث لدى علماء

فـي فكـر ابـن قیــم اإلنسـان 2014دیسمبر / 12اإلصـدار - .عشــوي د.مصطفــى-الجوزیــة

مسكویھ والكمـال في فكـر اإلنســان 2015مارس / 13اإلصـدار - .عشـوي د.مصطفـى-

.2015ن جوا/ 14اإلصـدار --.Psychologie Socio-politique&éthiquedans La

penséegréco-arabe&latine -. (AmeSociété, Etat et Universalisme chez

Avicenne) -AlyY. ZAYOUR . محمـد-من منظور نفسي اسالمي الغضب 2015-15اإلصـدار -

.عثمـان المحیسـي أبو-مصالح األبدان واألنفس 2016جانفــي / 16اإلصـدار -

قرون) تقدیمودراسة:زید البلخي (نفساني سبق عصره بعشرة .عشوي مصطفى-مالكبدري

االستئـذان والمشھــد األصلـي آیــة 2016مارس / 17اإلصـدار - .أحمــد المطیلــي-

ـع الصحـة النفسیـة فـي الوطـن (واق: "الكتاب األبیض" إصداراتسلسلـة ي)العربـ

د.معن عبد الباري –النفس في الیمن علم 2012االصـــدار االول - قصالح

–الصحة النفسیة في دولة فلسطین 2013االصـــدار الثانــي - د. عبد العزیز موسى ثابت

-الجزائـرالعلـوم النفسیــة فـي واقـع 2015الثالـــث االصـــدار - زبیـر بـن مبـارك د.

"تـاب األبیـضة"الكیدلیــل السلسلة المكتب

2016 (ربیــع 3) الـى العـــدد2013شتـــاء ( 1من العــدد

یحیى الرخاوي "(النشـرة الیومیـة حسـب –والتطـور سلسلـة: اإلنسـان اور)المحـ


.في علم السیكوباثولجي دراسة-2010شتاء االصـــدار االول - .)1الجزء ( اإلدمان ملف-2011خریف -الثانــياالصـــدار -(الجزء ملفالعالج النفسي-2011صیــف -الثالـــثاالصـــدار -

).1األول العالج النفسي ملف -2012خریــف –االصـــدار الرابـــع -

.)2ء(الجز .یتعرى اإلنسان عندما-2012شتــاء -الخامـــساالصـــدار - الفصام.-2012وصیــف ربیــع –االصـــدار الســـادس -تجلیات ماھو في-2013شتــاء –خریــف –ــدار السابـــعاالصـ -

.موت .اإلدراك-2014شتــاء –خریــف –االصـــدار الثامـــن --2015شتــاء –خریــف –االصـــدار التاســـع -

الوجـدانوإضطرابـات العواطـف. .اإلرادة إظطرابات-2016ربیــع -العاشـــراالصـــدار - .الوعي اضطرابات-2016صیـــف –االصـــدار الحـادي عشـر -

أفكــار نفسیــة السامرائي (صادق د.-ومــاسواھـــا"“ة المكتبیة:السلسلــ لحیـــاة)

.الجزء األول)وما سواھا (نفسیة لحیاة. . . اإلصـدار األول أفكار -الجزء وما سواھا (أفكار نفسیة لحیاة. . . اإلصـدار الثانـــي -

.ثاني)الالجزء وما سواھا (أفكار نفسیة لحیاة. . . اإلصـدار الثالـــث -

.الثالث)الجزء وما سواھا (أفكار نفسیة لحیاة. . . اإلصـدار الرابــــع -

.الرابــع)الجزء وما سواھا (أفكار نفسیة لحیاة. . . اإلصـدار الخامــس -

.الخامس)

مختلف)یة من منظور الرؤ" (مقاربـــات“السلسلـــة المكتبیــــة:


صادق د.-العربي: ضفاف الطب النفسي اإلصـدار األول - .السامرائي

صادق د.-: من وحي الثورة التونسیة اإلصـدار الثانـــي - .السامرائي

176


) الدلیــل العلمــي إلـى مناھــج 2016شتــــاء ( 42اإلصــدار -ــــر بشی د.-ني) الثاالبحـث والقیـاس فـي علــم النفــس (الجزء

.(الجزائر)معمریـــــة-الطفلالكفاءات المعرفیة لدى )2014(شتاء 41العدد -

.(المغرب)أحرشاوالغالیالدین فرح صالح-األطفال الموھبون )2015(خریف 40العدد -

.)(السودانبخیت السعید أبو محمد-الحسـرة الوجودیـة )2015(صیف 39العدد -

(مصر).حالوة أحمد محمد-جنون اإلسالموفوبیا )2015بیع (ر 38العدد -

(لبنان).النابلسي سرحان ولیـد-)6(الجزءسلوكیـات )2015(ربیع 37العدد -

.(األردن)أحمد عبد ریھام-ابنـي یدفعني للجنون )2015(شتاء 36العدد -

.)(مصر المحسنالجزء الثاني -الذھانات -) جاك الكان2014 (خریف 35العدد -

.الفقیر (المغرب/فرنسا)عبد الھادي -علم النفس اإلیجابي ... ماھیتھ ومنطلقاتھ )2014( 34العدد -

.(مصر)السعید أبو حالوة محمد-النظریة وآفاقھ المستقبلیة د. -المدرسة العربیة في التحلیل النفسي )2014(ربیع 33العدد -

.زكریا علي زیعور ( لبنان )نسانیة ... مقاربة المعرفة والتنمیة اإل )2014( 32العدد -

.(المغرب)أحرشاوالغالی-سیكولوجیة الصحة العاطفیة وضرورات التكیف في )2014(شتاء 31العدد -

.د. مرسیلینا شعبان حسن ( سوریا ) -الحیاة المعاصرة -سیكولوجیة الدافـع إلى اإلنجـاز )2013(صیف 30العدد -

.معمریـة ( الجزائر )بشیـر -للصدمة االضطرابات التالیة عالجة) م2013(صیف 29العدد -

.د. ولید خالد عبد الحمید ( األردن )د. محمد السعید عبد -الھزیمـة النفسیـة )2013(ربیع 28العدد -

.(مصر)الجواد أبو حالوة الناصر عبد-الثقافـي علـم النفس عبـر )2013(شتاء 27العدد -

.(المغرب)السباعي د. -دلیل الدعم النفسي في الكوارث )2012(خریف 26العدد -

مصطفـى شكیـب ( المغرب )االستقرار الزواجي: دراسة في )2012(صیف 24العدد -

د. كلثوم بلمیھـوب ( الجزائر ) -الـزواج سیكولوجیة لطفي د.-وعالج االكتئابلدلیل إلى فھم )2012(ربیع 23العدد -

.(مصر)الشربیني د.-الطب النفسي القضائي 9سلوكیات )2012(شتاء 22العدد -

.(األردن)ولید سرحان اإلسالميعلم النفس في التراث العربي )2011(خریف 21العدد -

.أ.د. الزبیر بشیر طھ ( السودان )-آفاق توطین علم النفس في العالم )2011صیف -(ربیع 20العدد -

.(السودان). د. عمر ھارون الخلیفة -العربـي الوفاة.كیف نفھم... )2011-2010شتاء -خریف( 19العدد -

.(سوریا)أ. د. عبد الرحمن إبراھیـم -ومرارة الفقـد واألسـى؟ أ. د. -والمدرسـة الطفل بین األسرة )2010(صیف 18العدد -

.(المغرب)الغالي أحرشـاوأزمة علماء النفس )2010-2009ربیع -(شتاء 17العدد -

.ن)(السوداأ.د. مالك بدري -المسلمین اضطراب النفس في.المرجع الوجیز )2009(صیف 16العدد -

.(العراق)أ.د. قحسین صالح -والعقل وسیكولوجیا الشواذ

مستقبل العالج النفسي: معالم عالج نفسي )2009(ربیع 15العدد - .(سوریا)د. سامر جمیل رضوان -عام

العالج النفسي الحواري: آفاقھ وشروطھ )2008(شتاء 14العدد - .(لبنان)أ.د نعیم عطیة -على طریق االحتراف

أساسیات... حمایة األطفال من )2008خاص (اصدار 13العدد -أ.د. محمد أدیب العسالي -في سوریة واإلھمال.سوء المعاملة

.(سوریا)أ.د. فارس كمال -الحب الرومانسي )2008(صیف 12العدد -

.عراق)(النظمي أ.د. الغالي -العلم والثقافة والتربیة )2008(ربیع 11العدد -

.أحرشاو ( المغرب )د. ولید -أحادیث في السلوك اإلنساني )2008 2 (شتاء 10العدد -

.(األردن)سرحان د. لطفي -االكتئاب ... المرض والعالج )2007 1 (شتاء 9العدد -

.(مصر)الشربیني الطب المسند في تطویر األبحاث )2007(خرف 8العدد -

.(سوریا)أ.د. محمد أدیب العسالي -والرعایة الصحیة حسین صالح أ.د. -االبداع وتذوق الجمال )2007(صیف 7العدد -

.(العراق)أ.د. سوسن شاكر الجلبي -التوحد الطفولـي )2007(ربیع 6العدد -

.(العراق). الزین عمارة أ.د-مدخل الى الطب النفسي )2006(شتاء 5العدد -

.(السودان)-اضطراب الشخصیة، فكرة وجیزة )2006(خریف 4العدد -

.(سوریا)أ.د. عبد الرحمن ابراھیم مان د. سلی -التفكیـر مدخل إلى سیبرنطیقا )2006(صیف 3العدد -

جار اللـھ ( الجزائر )د. -العالج النفسي الدینامیكي قصیر األمد )2006(ربیع 2العدد -

.رضوان ( سوریا ) سامر جمیلأ.د. عادل صادق -في بیتنا مریض نفسي )2006(شتاء 1العدد -

.( مصر )

سلسلـة "الكتـاب العربي: "وفي أنفسكم" (نحـو لیاقـة نفسیـة أفضـل لحیـاة )ھطیب


o أ.د. عمر ھارون الخلیفة -أمـة في خطر! : دمـاغ1اإلصــدار. o محمد السعید عبد الجواد أبو د.-المرونةالنفسیـة: 2اإلصــدار

.حالوةo محمد السعید عبد الجواد أبو د.-التدفـق: حالـة 3اإلصــدار

.حالوةo محمد السعید عبد الجواد د.-وإدانتھ: تخوین اآلخـر 4اإلصــدار

.أبو حالوةo مرسلینا شعبان د.-مجتمعیة : الدعم النفسـي ضرورة 5اإلصـدار

.حسـنoألف جلسة وجلسة لحظات مع فروید في التحلیل 6ـدار اإلص :

.عبد الھادیالفقیر د.-النفسيo یى یح أ.د.-: اللغـة العربیـة وتشكیـل الوعـي القومــي 7اإلصـدار

.الرخاويo یحیى الرخاوي أ.د.-وعلــوم النفــس: "العربیــة" 8اإلصـدار. o صادق أ.د.-العربیـة: تأمـالت نفسیــة في الثـورات 9اإلصـدار

.السامرائي

175


الملف: قـراءة-) 2005مارس -فیفري-(جانغي5العدد - .)(تونسالتركي جمال-سیكولوجیة العنف اآلخـر

: قراءة الملف-) 2004دیسمبر -نوفمبر-(أكتوبر4العدد - جمال-الذات العربیة تالنجرا حاسیكولوجیة العنف ... تجاوزا

.)(تونسالتركي على العدد: جمال التركي الشرف-)2004(صیف 3العدد -

.(تونس)على العدد: جمال الشرف-) 2004جوان -ماي-(أفریل2العدد -

.التركي (تونس)على العدد: جمال الشرف-) 2004مارس -فیفري-(جانفي1العدد -

.التركي (تونس)

مجلة مستجدات العلوم النفسیة العربیة)" (مجلة "بصائــــر نفسانیــــة

و ملخصات كامل األعدادالدلیـــــل" فھارس "

العـــدد الثالث عشر / االخیر ) الـى2010(شتاءوربیع من العــدد االول )2016-2015(شتاء

محاور ملفات االعداد السابقة

ترامب... الملف: ظاھرة-) 2017صیف-(ربیع 17-16العــدد - .قراءة نفسانیة في الحدث

ر الراسـخ ـوزی :الملف-) 2016شتاء – (خریف 15-14العــدد - .خاص)... أمـة فـي عالـم (عدد والنفسانیـاتفـي الفلسفـات

ي ف افتقد... بدر الملف: النابلسي-) 2016صیف-(ربیع 13العدد - .خاص) (عددظلمة لیل عربي

العنف في الملف: ظاھرة-) 2015شتاء –(خریف 12العدد - .المجتمع العربي... مقاربة نفسیة اجتماعیة

"العربیة" الملف: أسبوع-) 2015صیف-ربیع( 11العدد - .والعلوم النفسیة

: مقاربات في الملف-) 2014صیف – (ربیع 10العدد - .4 –السیكولوجیا العربیة

: مقاربات في الملف-) 2013خریف – (صیف 9العدد - .3 –السیكولوجیا العربیة

: مقاربات في السیكولوجیا الملف-) 2013ربیع – (شتاء 8العدد - .2 –یة العرب

: مقاربات في السیكولوجیا الملف-) 2012(خریف 07العدد - .1 –العربیة

: السیكولوجیا العربیة ... الملف-) 2012(ربیعوصیف 06العدد - .نحو إبراز الخصائص الممیزة

النفس الملف: سیكولوجیة-) 2012(خریف وشتاء 05العدد - .– 3-الثائرةالعربیة

سیكولوجیة النفس العربیة :الملف-) 2011(صیف 04العدد - .-2 –الثائرة

: سیكولوجیة النفس العربیة الملف-) 2011ربیع –(شتاء 3العدد - .-1 –الثائرة

: مستجدات العلوم الملف-) 2010خریف – (صیف 2العدد - .2-العربیةالنفسیة

: مستجدات العلوم النفسیة الملف-) 2010وربیع (شتاء 1العدد - .1-العربیة

مكتبیة في العلوم النفسانیةاصدارات

دلیل المكتبة النفسانیة

یأتي تأسیس ھذا الدلیل لیسد فراغا كبیرا في المكتبة العربیة، فالكتاب النفسي العربي رغم ندرتھ یبقى مھمشا مقارنة باإلصدارات األدبیة والتراثیة والدینیة

ي ال یكادوغیرھا، كما أنھ یشكو من سوء التعریف بھ واإلشھار المحدود الذیتجاوز المدینة أو البلد الصادر فیھ ولتجاوز ھذه النقائص سنعمل في إطار ھذه الصفحة التعریف باإلصدارات النفسیة العربیة القیمة سواء العربیة أو

دور والفرنسیة أو اإلنكلیزیة، حیث نعرض لملخصاتھا مع تعریف بالمؤلفین . النشر

اصــدارات مكتبیــة محكمــة في علــوم ("نفسانـــي” الكتــاب العربــي" وطــب النفــس)

2006تاریخ التأسیس: شتاء - إصدار فصلي: اربعة عناوین في السنة -

سلسلة اصدارات مكتبیة الكترونیة طبنفسیة وعلمنفسیة تصدرھا، فصلیا بدءا شبكة العلوم النفسیة العربیة ثم مؤسسة العلوم النفسیة العربیة بدایة من شتاء

.عنوانا52، 2017، صدر منھا لغایة صیف2006


إلى االستطالع وقیاسھ الدافع) “2017خریف ( 54اإلصــدار - (الجزائر).البشیر معمریة د.-“لفظیا وشكلیا

في علـــم ) األطروحــات2017صیف ( 53اإلصــدار -البشیر د.-والتقییـــمدلیــل مصغـــر لإلشــراف النفـــس. (الجزائر).معمریة

) االغتراب الدیني: ماھیتھ 2017صیف ( 52اإلصــدار - .محمد السعید أبو حالوة د.-ومحدداتھ

) الخصـال اإلیجابیـة في 2017صیف ( 51اإلصــدار -د. البشیر - 2الجزائـري. جالشخصیـة وقیاسھـا في المجتمـع

(الجزائر).معمریة) الخصـال اإلیجابیـة في 2017ربیع ( 50اإلصــدار -

البشیر د.- 1الجزائـري. جالشخصیـة وقیاسھـا في المجتمـع (الجزائر).معمریة

الخطاب العلمي والخطاب الدیني )2017(شتاء 49اإلصــدار -د. مرسلینــا شعبــان -وانعكاس ذلك على الصحة النفسیة؟؟

(سوریا).حســن. د. -) البحوث العلمیة الصحیة 2016 (خریـــف 48اإلصــدار -

(سوریا).محمد ادیب العسالي ) التمكیـــــــن األخالقــــــي 2016 (صیـــف 47اإلصــدار -

(مصر).محمــد السعیــد أبــو حـــالوة د.-للمعلــــــــم -) سیكولوجیــــا السعــــادة 2016صیـــف ( 46اإلصــدار -

(الجزائر).بشیــــر معمریـــــة د.) سیكولوجیا الذاكرة الجمعیة 2016 (صیـــف 45اإلصــدار -

د. كامل حسن كتلو -حیة ومعاناة التنتھي الفلسطینیة، ذاكرة فلسطین).(

الطـــب العـــالج فـي) 2016صیـــف ( 44اإلصــدار - ).سوریاد. محمـــد أدیـــب العسالــــي (-النفســـي

) الدلیــل العلمــي إلـى مناھــج 2016ربیـــع ( 43اإلصــدار - بشیــــر د.-األول) البحـث والقیـاس فـي علــم النفــس (الجزء

.(الجزائر)معمریـــــة

174


(لبنان) / علم النفس ( مصر ) / مجلة الطفولة المطمئنة (مصر) / العربیة (الكویت) / النفس

الجمعیة العالمیة اإلسالمیة للصحة النفسیة / اإلنسان و التطور (مصر ) / المجلة التونسیة للطب النفسي (تونس) / الحولیات التونسیة للطب النفسي / الطب النفسي المعاصر (مصر) / المجلة العربیة للطب

/ سيالنفسي (األردن) / المجلة المصریة للطب النفاألخصائي النفسي (مصر) / نشرة الجمعیة العالمیة اإلسالمیة للصحة النفسیة (مصر) / مجلة الطب

/نشرة الجمعیة العراقیة النفسیة أبو ظبي / -النفسي المجلة العربیة للموھبة والذكاء

المجلـة العربیـة: " نفسانیـات " (مجلة محكمة في علوم وطب النفس)

یة أكادیمیة تصدرھا فصلیا شبكة العلوم النفسیة العربیة (بدایة من مجلة علم )2004شتاء

عددا53، 2017صدر منھا لغایة شتاء ربیع -“ فھارس وملخصات-االعداد السابقة: " الدلیـــل -

o الـى 2004(ربیع 1الجزء االول من العــدد ( )2006خریف (12العـــدد

o ربیع-(شتاء 26-25الجزء الثاني من العــدد )2012 (خریف36) الـى العـــدد 2010

o ربیع-(شتاء 26-25الجزء الثالث من العــدد )2012 (خریف36) الـى العـــدد 2010

o ربیع -(شتاء 38-37الجزء الرابع من العــدد )2015(خریف 47الـى العـــدد) 2013

محاور ملفات االعداد السابقة

الملف: المعرفة-) 2017(شتاء & ربیع 53-52العـــدد -خالـد عبـد السـالم -النفسانیة: إنسانیة واحدة أم دینیة متعددة

.(الجزائر) لقیاس“الملف: -) 2016(صیف & خریف 51-50العـــدد -

بنت عزیز نادیة-“ 2ج –النفسي وبناء االختبارات .(الجزائر)بعیبن

لقیاس“الملف: -) 2016& ربیع شتاء 49( 49- 48العـــدد - زیز بعیبنبنت ع نادیة-“ 1ج-النفسي وبناء االختبارات

.(الجزائر)العالج النفسي األسري “الملف: -) 2015خریف ( 47العـــدد -

عمارجیةالدین نصر-“بمجتمع عربي یشھد تحوالت كبري .(الجزائر)

المثلیــة ... مــن الملف: الجنوسیـــة-) 2015(صیف 46العدد - .(سوریا)مبیــــض مأمـــون-الالسواء الــى االضطراب

النفسیة الملف: التداعیات-) 2015صیف -(ربیع 45العدد - .أبو بكر (عكا) خولة-واللجوءللصدمة

العنف في المجتمع الملف: ظاھرة-) 2015(شتاء 44العدد - .لمغرب)بودیس (ا محمد-اجتماعیةالعربي ... مقاربة نفسیة

البروفسور عمر ھارون عددخاص:-) 2014(خریف 43العدد -التركي جمال-لإلختفاء األعمال الكاملة 2الخلیفة الذكرى

.(تونس)اإلرشاد النفسي في الملف: ا-) 2014ربیع -(شتاء 42-41العدد -

.العزیز المطوع عبد-والتحدیاتالمجتمع العربي...المعوقات

السیاسي الملف: المشھد-) 2013خریف -(صیف 40-39العدد - (مصر)سعید أبو حالوة محمد-العربي المعاصر

النفسیة الملف: االختبارات-) 2013ربیع -(شتاء38-37العدد - (السعودیة)مروة خلدون-"في الممارسة العربیة

في المجتمع العربي... الملف: اإلدمان-) 2012(خریف36العدد - (مصر)حسین حسن اصطفى-الرعایةمن الوصمة إلى

العربیة الملف: السیكولوجیا-) 2012صیف -(ربیع35-34العدد - محمد-التواصلوالتراث النفسي اإلسالمي ... نحو مد جسور

توفیق الجندي الملف: السیكولوجیة-) 2012شتاء -(خریف33-32العدد -

نیعصالح ابراھیم الص-وتحدیات التأصیلمأزق التقلید …العربیةالنفسي... رؤیة مستقبلیة الملف: العالج-) 2011(صیف31العدد -

ابراھیم الفخراني خالد-متعددةمن خالل تخصصات نفسیة (مصر)

النفس االجتماعي الملف: علم-) 2011ربیع -(شتاء29-30العدد -یم الكر عبد-وواقع اإلنسانالعربيبین حاضر المعرفة العلمیة

بلحاج: الطفل العربي . . الملف-) 2010خریف -(صیف28-27العدد -

محمود النجار یحیى-الذات.نحو سیكولوجیة متوافقة مع (فلسطین)

التطرف الملف: سیكولوجیة-) 2013ربیع -(شتاء26-25العدد - (سوریا)جمیل رضوان سامر-العقائدي

. . . التداعیات الملف: غزة-) 2009(خریف24العدد - ن)طی(فلسالعزیز ثابت عبد-والحصارالسیكولوجیة للحرب

المصطلح النفسي الملف: أزمة-) 2009(صیف23العدد - شقیب (المغرب)مصطفى-العربي

الوظیفة الملف: اضطراب-) 2009ربیع -(شتاء22-21العدد - بلمھوب (الجزائر)كلثوم-األسریة

-الشرعيالنفسي الملف: الطب-) 2008(خریف 20العدد - .غرایبةنعمان

النفسي تحلیلالملف: ال-) 2008صیف -(ربیع19-18العدد - الھادي الفقیر (المغرب) عبد-العربیةوالذات

:من منظور عربي : السیكولوجیاف): المل2008(شتاء 17العدد - .المغرب)أحرشاو (الغالي

االكتئاب الملف: مظاھر-) 2007خریف -(صیف16-15العدد - .أحرشاو (المغرب) الغالي-العربيفي المجتمع

لخلی-والذھنیة العربیة الجنسانیةالملف: -) 2007(ربیع14العدد - .فاضل (مصر)

الشدة التالیة الملف: اضطرابات-) 2007(ربیع 13العدد - .العزیز ثابت (فلسطین) عبد-2للصدمة من منظور عربي

الشدة التالیة الملف: اضطرابات-) 2006(خریف 12العدد - .)النابلسي(لبنانأحمد محمد-1للصدمة من منظور عربي

المرأة الملف: سیكولوجیة-) 2006صیف -(ربیع11-10العدد - .التركي (تونس) جمال-صراع األصالةوالحداثةالعربیة...

النفسي الملف: العالج-) 2006مارس -فیفري-(جانغي9العدد - .التركي (تونس) جمال-العربیة في البیئة

الملف: أبحاث من -) 2005دیسمبر -نوفمبر-(أكتوبر8العدد -التركي جمال-العالمي الثالث عشر للطب النفسي المؤتمر .(تونس)

العربي... الملف: الطفل-) 2005سبتمبر -اوت-(جویلیة7العدد - .التركي (تونس) جمال-والتحدیات المستقبلیةالسیكولوجیا

العربیة الملف: الشخصیة-) 2005جوان -ماي-(أفریل6العدد - .)(تونسلتركي ا جمال-... قراءة سیكولوجیة وإعصار العولمة

173


قائمـــات للمراســــالت

قائمة المراسالت الشاملة

[email protected]عنوان 5287قائمة الشبكة:

[email protected]عنوان 3361قائمة الیاھو:

الكتروني) (عنوانالعربیة: حسب البالدقائمات مراسالت

.744السعودیة: -1 . 429الجزائر: -2 .421مصر -3 .263العراق: -4 .167السودان -5 .166تونس: -6 .158المغرب: -7 .155اإلمارات: -8 .139فلسطین: -9

.133سوریا: -10 .108األردن: -11 .80لبنان: -12 .63الیمن: -13 .28لیبیا: -14 .8 الكویت: -15

دلیل األطباء وأساتذة علم النفس

“العلمیة السیر” بیاناتقاعد -1 1335مجموع السیر العلمیة المدرجة : • 459السیر العلمیة لألطباء النفسانیین: مجموع •مجموع السیر العلمیة ألساتذة وأخصائیو العلوم •

876النفسانیة: واإلنكلیزیة العربیة، الفرنسیةالبحث: •

التوزیع حسب البلد -2: مصر- 36:تونس- 179: الجزائر- 43المغرب: •

- 102: العراق- 22: لبنان- 24:الیمن- 267- 49:سوریا- 28: اإلمارات- 144: السعودیة

376محددة: غیر- 64:األردن

بنك األبحاث الطبنفسیة والعلمنفسیة العربیة

تم تأسیس قاعدة بیانات األبحاث العلمنفسیة والطبنفسیة العربیة • كنواة جامعة لكل األبحاث والدراسات في ھذا المیدان

ثالثیة اللغة (عربیة، إنكلیزیة، الفرنسیة) •

تم فیھا ادراج عناوین األبحاث، أسماء الباحثین، الملخصات • .والكلمات المفتاحیة، المصدر

م 6717ي قاعدة بیانات األبحاث على تحو • .لخصا

دلیل الجمعیات الطبنفسیة والعلمنفسیة العربیة

:الجمعیات الطبنفسیة العربیة •اتحاد األطباء النفسیین العرب / الجمعیة اللبنانیة للدراسات

الجمعیة التونسیة / الطب النفسي التطوري النفسیة / جمعیةیة الدراسات النفس / مركزلألطباء النفسانیین بالممارسة الخاصة

جنة/ لالمصریة للصحة النفسیة / الجمعیةوالنفسیة الجسدیة طب المصریة لل / الجمعیةتجاه الفصام مكافحة الوصمة و التفرقة

الجمعیة /األخصائیین النفسیین المصریة رانم النفسي / رابطةالعالمیة اإلسالمیة للصحة المراھقة / الجمعیةالمصریة لعلم

لطب ل النفسیة / الجمعیة التونسیةغزة للصحة / برنامجالنفسیة دمان / االتحاد العالميالعربي للوقایة من اإل / االتحادالنفسي

الجمعیة التونسیة للطب النفسي / ).للصحة النفسیة( م. إ.ش. مالجامعي / جمعیة شرق المتوسط للصحة النفسیة لألطفال والمراھقین / معھد تطور األبحاث النفسیة وتطبیقاتھا على الرعایة الصحیة / المنتدى التونسي لالضطراب الثناقطبي / نادي

.ظبي للطب النفسيأبو /الجمعیات العلمنفسیة العربیة •

االتحاد العربي للعلوم النفسیة / الجمعیة الكویتیة لتقدم الطفولة العربیة / مركز معوقات الطفولة / جمعیة أحباء الطفولة / مركز اإلرشاد النفسي / الجمعیة المصریة للدراسات النفسیة

ة الیمنیة ن الیمنیین / الجمعیة النفسی/ فریق الباحثین النفسانیی/ الجمعیة الدولیة الختصاصي علم النفس المسلمین / الجمعیة األردنیة لعلم النفس / المركز األوروبي للتثقیف والرعایة

النفسیة للمھاجرین / مركز فلسطین للصحة النفسیة المجتمعیة /الجمعیات النفستحلیلیة العربیة •

بي لألبحاث النفسیة والتحلیلیة /جمعیة التحلیل المركز العر .المغربیةالنفسي

مجالت ودوریات العلوم النفسانیة

نسعى من خالل ھذه الصفحة للتعریف بالمجالت العربیة سواء المختصة في الطب النفسي أو علم النفس، ساعین إلى عرض فھارس أعدادھا مع ملخصات أبحاثھا والكلمات المفاتیح الخاصة بھا، آملین تحقیق تواصل علمي بینعربي

ة بیانات األبحاث النفسعربی وتأسیسا لقاعدةبین األطباء واالختصاصین .وتطویرھانعمل على إنشائھا والطبعربیة التي

دلیل الدوریات والمجالت

:مجالت ودوریات بكامل نصوصھا •o المجلـــة العربیـــة للطــــب النفســــي (اتحاد االطباء

من 2األردن): بدایة من العدد –النفسیین العرب .21المجلد

o للطـــب النفســـي (الجمعیةالمجلـــة العالمیـــةسویسرا): بدایة من العدد –العالمیة للطب النفسي

األول.o المجلــة السودانیــة للطــب النفســي (الجمعیة

.السودانیة للطب النفسي)

:فھارس وملخصات مجالت ودوریات العلوم النفسانیة •o / (الیمن) نشرة اإلدمان (مصر) / الصحة النفسیة

ة (الیمن) / دراسات نفسیة (مصر) / الصحة العقلیالمجلة المصریة للدراسات النفسیة / نشرة الجمعیة المصریة للطب النفسي / النشرة اإلخباریة للوقایة

الثقافة النفسیة المتخصصة / من اإلدمان (مصر)

172

The Arab Journal of Psychiatry (2017) Vol. 28 No.2 Page (171 -180 ) (doi: 10.12816/0041719)


( نحـو تعـاون عربـي رقیـا بعلوم وطب النفس)

The Arab Network of the Psychological Sciences: Seventeen Years of Arab Cooperation and Achievement


Jamal Turky

الملخص

مات في دمجتمعنا في الربع األخیر من القرن العشرین مقدمة خدمات في غایة األھمیة مجددة النظرة للعلوم محدثة تغیرا في العقلیات مقدمة خاقتحمت المعلوماتیة ة الالعودة الثورة حیث وصلنا إلى نقطغایة األھمیة مجددة النظرة للعلوم والتعامل مع المعلومة محدثة تغیرا في العقلیات لم یكن حقل العلوم النفسیة بمعزل عن ھذه

معلومة ات، من ذلك ان الیكون فیھا موقع الرافض لخدمات اإلعالمیة في وضعیة متخلفة. تحمل ثورة االتصاالت وعود التغییر المرتكزة على سرعة نقل المعلوم .تكتسب قیمة مضاعفة بمضاعفة سرعة انتقالھا

الجزء االول: الشبكـة ... المشــروع

بطاقـــة التعریـــف

العلوم النفسیة العربیة: مشروع علمي أكادیمي طبنفسي وعلمنفسي على شبكة الطب النفساني، –المؤسس: د. جمال التركي Arabpsynet :الویب النطاق

تاریخ االطالق على الویب: 01/01/2000تونس تاریخ التأسیس: الشبكة: نحـو تعـاون بینعربـي رقیـا بعلوم وطب النفس شعار 13/06/2003

تھما الجھة الراعیة: الشبكة مشروع مستقل، یتولى رعایتھ وتمویلھ وخدما الیوم).إلى 2000الرئیس المؤسس (منذ العام

األھـــداف، الطــرق، والوسائــل

االھداف تأسیس

دلیل األطباء النفسانیین وأساتذة علم النفس / بنك األبحاث •نفسیة الطب الطبنفسیة والعلمنفسیة العربیة / دلیل الجمعیات

والعلمنفسیة / دلیل المكتبة النفسیة العربیة / دلیل الروائز واالختبارات النفسیة العربیة / دلیل المؤتمرات النفسیة العربیة والعالمیة / دلیل المواقع النفسیة العربیة والعالمیة والنشر

.اإللكتروني / منتدى الحوار لألطباء وعلماء النفس /معجم علوم الطب والنفس / "دلیل الوظائف النفسیة العربیة •

ة العلوم جائزة شبك/ “دلیل مراكز االستشفاء الطبنفسیة العربیة “سالمي العرب إالنفسانیة العربیة / اصدارات في التراث النفسي

/االساتذة الرواد بلقب الراسخون في العلوم النفسیة / تكریم .النفسیةاألبیض لواقع العلوم الكتاب

الطرق والوسائل

:في ظل االنشغال بھموم اإلختصاص

.اكتسحت المعلوماتیة جمیع میادین المعرفة • .تحكمت البرمجیات في كافة األجھزة المسیرة لحیاتنا •التفكیر إلعداد ھذه الشبكة یعود إلى منتصف التسعینات •

.(بدایة عھد انتشار اإلنترنت)

.حلم بعید المنال... الترف الفكري الفكرة... •

الجزء الثاني: الشبكــة... المنجـزات

الھیئــة العلمیــة االستشاریــة

الرئیس الفخري: أحمد عكاشة (مصر) الرئیس الشرفي: یحیى الرخاوي (مصر) الرئیس: جمال التركي (تونس) مستشار الرئیس: محمد أبو صالح

ك بدري (السودان) المستشار الفخري: عبدالشرفي: مال بریطانیا) المستشار( .الستار إبراھیم (مصر)

الھیئـة اإلستشاریـة الفخریـة

أدیب العسالي (سوریا)، بشیر معمریھ (الجزائر)، شارل بدورة (لبنان)، (المغرب)، حسین صالح (العراق)، صادق السامرائي أحرشاو الغالي

مھدي أبو مدین الكویت)، –مصطفى عشوي (الجزائر العراق)،(أمریكا / األردن).(سرحان ، ولید (سوریا)نزار عیون السود (السعودیة)،

الھیئـة العلمیــة المحكمــــة

إخالص حسن عشریة (السودان) ، خالد الفخراني( مصر ) ، خالد عبد السالم (الجزائر) ، خولة أبو بكر (عكا) ، زبیر بن مبارك (الجزائر) ،

عمان) ، سداد جواد التمیمي ( -رضوان (سوریا سامر جمیل العراق،بریطانیا ) ، شاھدي عبد السالم الوزاني (المغرب) ، عبد الھادي

) ، صالح مصر -محمد فضل بشر (لیبیا فرنسا) ، شعبان -قیر (المغرب الفبن إبراھیم الصنیع (السعودیة) ، عبد الحافظ الخامري (الیمن) ، عبد

ان إبراھیم (سوریا/ لبنان) ، عبد العزیز موسى ثابت ( غزة/فلسطین الرحم) ، عبد الفتاح دویدا (مصر ) ، عبد الكریم بالحاج (المغرب) ، عبد الناصر

بد ، علي إسماعیل عبد الھادي الفقیر (المغرب/فرنسا)السباعي (المغرب) ، عو كتلكامل حسن أمریكا) ، –الرحمان (مصر ) ، قتیبة الجلبي ( العراق

إنكلترا ) ، محمد سعید أبو حالوة –(العراق ي، ماجد الیاسر(فلسطین)السعودیة) ، مرعي سالمة –(مصر ) ، محمد كمال الشریف (سوریا

السعودیة) ، وائل أبو - فرنسا) ، معن عبد الباري (الیمن -یونس(مصر .األردن )، ولید خالد عبد الحمید ( أمریكا/ مصر )ھندي (

171

Psychoanalysis of Zionism

ABSTRACT

The new historians of Zionism, both Israeli and Arab, have lifted the narrative of this controversial subject to new levels of scholarship and trust. At the same time, the concepts and insights of individual and family centered psychoanalysis have been applied to this complex social and political phenomenon. Under an integrated paradigm, the self or reflective individual is redefined essentially as linked to its history and environment. Such a model facilitates the analysis and explanations of the evolving movement of Zionism from its origins in the last decades of the 19th Century in Europe to its manifestations in Israel in the present time. Parting from the fear and latent anxiety experienced by individual Jews and collectively by the Jewish persecution and suffering in Eastern Europe in the last one hundred years, most prominently by the Holocaust under the regime of Nazi Germany, the psychological defenses against this anxiety most commonly listed have been paranoia, denial and the divided self. They have been common components and are manifest in the classic and neo Zionist narratives. Paranoia is not meant in a clinical sense, but as a discursive political ploy, which is also noted in other social and political instances in the United States’ history. The paper concludes with the hope that truth in history, like in any personal or national narrative, will become the basis for justice in the resolution of the Israel and Palestine conflict.

ف:المؤل

كندا-اونتاریو-تورنتو جامعھ-فیدیریكو اللودى د.

المترجم

جمھوریة مصر العربیة –القاھرة -. أحمد عكاشةأ.د

جمھوریة مصر العربیة –القاھرة – د. عادل یوسف

Author

Dr Federico Allodi MD, FRCPsych (UK), DPM, FRCP(C)

Associate Professor of Psychiatry, University of Toronto (Retired)

Toronto, Ontario - Canada

Email: Federico Allodi: [email protected]

Translation

Prof Ahmed Okasha,

MD, PhD, FRCP, FRCPsych, FACP (Hon)

Founder, Professor and Director of WHO collaborating Center for Training and Researches

Institute of Psychiatry, Ain Shams University

3, Shawarby Street, Kasr El Nil, Cairo – Egypt


Dr Adel Youssef, PhD Psychiatry

Consultant Psychiatrist, Cairo-Egypt


186

Allodi F, Okasha A, Youssef A

وتنتشر بشكل كبیر في إسرائیل حتى عند والتعبیر البارانویدياالتھامات م أي درجة یصدقھ إلىالتأكید ومن الصعب، والمستقیمین أخالقیا األذكیاء

والمقاومة الناس أو یقومون باستغاللھم في خضم المناقشات الساخنة، المتكررة مع الجیران العرب والصراعات العسكریةستمرة الم الفلسطینیة

الناجح من المجتمع الدولي عن طریق حركة المقاطعة والرفض النشط .االحتالل اإلسرائیلي والعقوبات ضد

التحلیل النفسي، یصعب تعریفھ ھنا، حیث أن وھو محورإن دور الالوعي، الصھاینة متغیرة إنوغیر محددة والوعي ذاتھحدوده مع طلیعة الوعي،

ل فائدة االحتال ویدركون تماما التقلیدیین یعبرون بوضوح عن دوافعھم، األكبر:" ایریتز" أو إسرائیل الكبرى. كما أن أي معارضة وعالقتھ بالھدف

اء مع اآلر للمجاھدین الصھاینة سوف ترفض حیث إنھا لن تتناغم معرفیافة والتكلالموازنة بین المزایا ن أالشك، ف وفي حالةالصھیونیة الجذریة.

یجب اتخاذ القرار وفي النھایةلھذه األوضاع تكون محمل المقامرة المحتملة الغیر طبیعي) أي –بوضع الشخص ذاتھ أو المجموعة على طیف (الطبیعي

أو عند حد البارانویا كأسلوب أو ضطراب الضالليواإلعند طرف الذھان ي الوقتوف. والدولي واالتفاق االجتماعيطبیعة كما یملیھا التفكیر المنطقي

تھم في صو وحكمھم یتمثلالحالي، فإن الذي یقوم بھذا الحكم ھم المواطنین، االنتخابي ىولیس عل واالھتمام الشخصيعلى أساس الثقة ویكون مبنیا

.ائدأساس عقل أو جنون الق

م الخاصة الدین أو القی وبالتالي فأنإن العالم الحدیث یحتاج إلى قیم لیبرالیة، خصوصیة البیوت وحصرھا علىقد تم سحبھا من مجال العامة،

والمواطنة على. إن دولة إسرائیل قد تعرف الجنسیة والمجتمعات المغلقةولة إسرائیل د وھكذا فأنواقع األمر مجتمع مدني. ولكنھا فيأساس دیني،

ھا أیضا ولكنتستخدم تشریعھا المدني الخاص بھا للحكم على سلوك مواطنیھا، توقیع بروتوكوالت حقوق اإلنسان ومسئولة عنعضو في األمم المتحدة،

قوانینھا الخاصة ال یمكن أن ولذلك فإنملزمة، وبروتوكوالت أخرىذا ون الدولي إال إتتبع القان ویجب أنتتعارض مع تشریعات األمم المتحدة

أرادت أن تكون منبوذة خارج المجتمع الدولي. إن السلطات التشریعیة لألمم ) لھا .اإلنسان، .....العمومیة، مجلس األمن، لجنة حقوق (الجمعیةالمتحدة

ن ع والبت فیھاالحقائق في الدعاوي، والبحث عنحق مناقشة المقترحات الدولیة قد أصدرتا ومحكمة العدلتحدة األمم الم فأن وأیضا طریق االقتراع.

توجد ھناك قوة قھریة إلجبارھا على ولكن العدة قرارات ضد إسرائیل، التنفیذ. إن شعوب العالم تطمح في وجود حكومة تقوم بحل الصراعات الدولیة

ب الواج وانھ منغیر متواجد حتى یومنا ھذا. والسالم ولكن ذلكباسم العدالة من خالل حكوماتھا أو من ظھرھا، والمنظمات األھلیةعلى شعوب العالم،

ابع ن وأي قرارأي قرار وطني قانوني، والتأكد أنالقیام بتمریر ھذه األحكام اكوفلسطین ھنمن األمم المتحدة یتم تنفیذه. أما عن الصراع بین إسرائیل

كتابات المؤرخین على وسالم قائمان ویتمنون عدالةیھود یتقبلون اإلسرائیلیین المتسامحین الجدد. إن الحقیقة في التاریخ ھي قاعدة الحكم العادل

سوف یؤدي إلى القضاء على وإن ذلكفي حالة الصراع. والعالج المالئموفقدان والھویة والبارانویا والخوف الخیالي والذات المشطورةاألفكار

نصل إلى مثل وإلى أنالجیران. جاهوالكراھیة والشیطنة والعنف ت األمانیجب أن نتبع ضمیرنا، وأن نتحدث عن والمحكمة الفعالةھذه العدالة الدولیة،

.ذكرھمأخالقیات المعاملة كما أشار الكتاب السالف

المراجع

1. Dan Bar-On. The Psychoanalysis of Zionism. Israel Studies Forum, vol.21, issue 1, Summer

2006:99-114. 2. Jacqueline Rose. The Question of Zionism.

Princeton University Press, 2005. 3. Mira Sucharov. The International Self.

Psychoanalysis and the Search for Israeli Palestinian Peace. Albany: SUNY Press, 2005.

4. Ruchama Marton. Forced Existence. Mondoweiss, 28 December, 2016.

http://mondoweiss.net/2016/12/forced-existence/ 5. SimhaFlapan. Birth of Israel – Myths and realities.

Pantheon Books. 1987. 6. IlanPappé. The Idea of Israel. A History of Power

and Knowledge. Verso. 2014. 7. Eugene L. Rogan and AviShlaim (Edward W.

Said). Introduction in The War for Palestine. Rewriting the history of 1948. Cambridge

University Press. 2001. 8. AviShlaim. Israel and the Arab Coalition in 1948.

Ibid. Rogan and Shlaim, page 81-83. 9. Richard Hofstadter. The Paranoid Style in

American Politics. Vintage Books, Random House. 1963.

10. Norman Fleckenstein. The Holocaust Industry: Reflections on the Exploitation of Jewis Suffering.

Verso. 2000. 11. Rashid Khalidi. The Palestinians and 1948. Ibid.

Rogan and Shlaim. Page 19. 12. Physicians for Human Rights-Israel (PHR-I) and

Public Committee Against Torture in Israel (PCATI). Doctoring the Evidence: Abandoning the

Victim. November 3, 2011. 13. Stanley Milgram. Obedience to Authority. An

experimental view. 1974. 14. Federico Allodi. Somoza’s National Guard: A

Study in Human Rights Abuses, Psychological Health and Moral Development. In: Ronald D. Crelinsten and Alex P. Schmid. The Politics of

Pain. The Torturers and their Masters. 1993. 15. David Riesman, Nathan Glazer, Reuel Denney.

The Lonely Crowd. A Study of the Changing American Character. Doubleday Anchor Books,

1950. 16. Christopher Lasch. The Culture of Narcissism.

American Life in an Age of Diminishing Expectations. 1979.

185


ة وخاصلیس صعبا حیث إن ھذا السلوك قد سبق اإلفشاء عنھ عند األطباء ة من في إنحاء مختلف وقوات اآلمن والمخابرات العسكریةبالشرطة الملتحقین

ن مة العفو الدولیة فأمناطق الحكم الشمولي. و طبقا لمنظ وخاصة في العالم،دولھ في العالم تقوم بتعذیب مواطنیھا. تقول نتائج 80حكومات أكثر من

األبحاث المتكررة في الوالیات المتحدة و غیرھا أن الكثیر من المواطنین العادیین یستجیبون بالطاعة لألمر المباشر وإلى ضغوط مصادر السلطات

درجة التسبب في األلم الشدید أو ىلأو األمن الوطني ) حتى إ،باسم العلم (اإلصابة أو الوفاة أو كبح حریة الضحایا المجھولین لھم و الذین تم اختیارھم

13.14 عشوائیا ةفي جمیع دول العالم و أن مشارك و برغم أن التعذیب متوطنا" لألطباء فأن ذلك ال یقدم عذرا ىاألطباء فیھ تحدث في أماكن أخر

تون مار د.المنظمة الطبیة اإلسرائیلیة موجودات نكرتوقد أاإلسرائیلیین. ، ورفضت االلتزام بتطبیق أي من اإلجراءات الوقائیة التي أوصت وزمالءھا

.تقاریرھمبھا

األنا المنقسمة للصھیونیة

عن اإلدراك األولي ناوتتطور األ الشخص.إن األنا ھي الجزء المنعكس من مید ج. وللمتابعة باستعارة أمھ.وجھ إلى –مثل المرآة –للطفل عندما ینظر

لألخریین ذوي األھمیة" تذوب “وإدراكھ فأن ھذه الصورة للطفل عبر حیاتھ ر كل منا یمتلك أكث وھویتھ. إنالشخص وتصبح نواةداخل الشخص الناضج

یة أو أسرة أو مھنة أو اھتمام. من ھویة كأعضاء في وطن أو مجموعھ دین .بدون صراعات والحیاة بھم وحملھم بداخلناخلطھم على وتساعدنا ثقافتنا

ر لتوتفأن ا األسباب،من ومتنافرة للعدیدعندما تكون صورة األنا مضادة وزوخاروف ضطراب أو كسر الذات. إن روز إالناتج یمكنھ أن یتسبب في

ا المشطورة" من ر.د.لینج الطبیب النفساني قد استعاروا لفظ "األن وبار أون شكوى المریض أنھا تجارب والذي اخذ والغیر تقلیديالمعارض األسكتلندي

مجرد مجموعھ من األمراض الطبیة التي تحتاج وأنھا لیستعاشھا المریض المرض النفسي أو أھمیة ىیمیائي، دون أن یھمل أو ینكر معنعالج ك إلى

أن ذلك ف واإلنسانیة للصھاینة،تطبیق ھذه المقاربة التحلیلیة وإذا تم العالج.سوف یجعل ھذه الظاھرة مفھومة بشكل أكبر. إن ھؤالء الباحثین یذكرونا

وسیجموند وھانا ارینتبأن الكثیر من الوجوه المشھورة مثل مارتن بور بني موریس الذین قاموا بنقد الصھیونیة كانوا من والمؤرخ المعاصر فروید

البعض منھم بالدفاع عن منظومة وقد قامناحیة أخري یمتلكون مشاعر وطنیة حفظ ھذا التناقض داخل أنفسھم. إن الذات ولكنھم استطاعواالید القویة

الصھیونیة تواجھ خطرا النشطار القوي بسبب ضعف الشخصیات أو تضاد وشاتیال ا رعن صاب والتقاریر الدولیةلبنان علىالمواقف العنیفة مثل الحرب

لجأ أو ت المواقف.مناورات دبلوماسیة للتكیف مع ھذه إلى أتلج ولذلك فأنھا .والبارانویابیأس شدید إلي آلیات غیر تكیفیھ مثل اإلنكار

یس ل ولكن االضطرابالفصام علىدالنج قد قام بتطبیق ھذه النظریة . إن ر تشخیصا یستخدمھ موالذي ل الصھیونیة، علىمستعارا یمكن تطبیقھ أو تشابھا

في كثیر من األحیان في الكتابات ونحن نجد ذكرھم.أي من الباحثین السالف دواج(ازحاالت وصفت بأنھا أفالم عنبما فیھا من والطب نفسیھ،الشعبیة

داخل في وكفاءةحیث یكون ھنا شخصین مختلفین بشكل منفصل الشخصیة)ضطرابات و اأصنیف اإلضراب التفككي الفئة تحت ت وتقع ھذه-الشخصنفس

یة في الدلیل التشخیصي للجمعیة األمریك اللھستیریالحدیث وھو االسمالھویة ین ھو انھ یوجد صراع ب وتفسیر ذلكالعالمیة. ومنظمة الصحةللطب النفسي

وبینمبكرة ومرتبط بصدمةأمنیھ مكبوتة أو خوف مكبوت في الالوعي ح سط علىلھ بالظھور وغیر مصرحرد مكبوت بین س الخارجي، أي الواقع

خارجي یغذي صورة الذات العامة كحقیقة واضحة. وسرد أخرالوعي الكامل یكون الحل عن طریق آلیة كبت غیر ةو في الحاالت التي نعتبرھا مرضی

واعي للحدث المثیر للخوف أو للسرد التاریخي الكامل .إن ألیھ الكبت ھذه ھو أن المكبوت یكون في الالوعي بالكامل و تفصل بین طرفین : األول

الثاني ھو إخفاء إرادي و معقول للسرد الممنوع و یسمي ھذا الطرف األخیر إكلینیكیا ( التمارض ) و باللغة العامیة ( الكذب ) و في حالة شخصیات عامة المحترمة تعرف باالحترام أو مواطنین ملتزمین بالقانون إذا شاركوا في

فھ للقانون أو أنشطة إجرامیة ,تكون ألیھ التكییف عندھم أمام ھذا أنشطة مخالأي وضع كل دور أو شق (doubling) الصراع ما نسمیھ ( المضاعفة )

في غرفھ منفصلة و االحتفاظ بالسرد الممنوع مخبأ غیر مصرح لھ بمواجھھ الشق أو السرد األخالقي و ذلك لحمایة الذات من التجزئة. إن مصطلح

1986ضاعفة قد أدخل بواسطة الطبیب النفساني روبرت جي لیفتون في المالذي حاول تفسیر آلیات التكییف لدي األشخاص الذین شاركوا في جرائم

الثانیة. عظمي إثناء المحرقة أو في كوارث جماعیة أثناء الحرب العالمیة فرانز ستانجل القائد النمساوي في معسكرات سوبیور قضیةاألمثلة ومن ھذه

و الذي لم یقر أبدا انھ كان مسئوال 1942الجماعیة في وتربلیمیكا لإلبادةمن الذین قاموا بالتعذیب في أمریكا وقضایا العدیدھذا المعسكر. وعلى رأس

یا االالتینیة في عھد الدكتاتوریات العسكریة في السبعینیات ففي كل ھذه القضام منزلھ لتناول الطع إلىكان القائم بالتعذیب بعد یوم من العمل الجاد یعود

ة معانا ىإسرائیل قد قامت عل ةو نستنتج من ذلك إن دول محبھ.وسط أسرة یقوم كیف سؤال: ىیكون الھدف من ھذا البحث الرد علو الفلسطیني،الشعب

.الصھاینة بالتعامل مع ھذه الحقیقة ؟

والمسئولیةالمسائلة

النفس المذكورین وأعمال علماءكتابات علىالتعلیق یمكن وأخیرا أن العلم یجد قیمتھ االجتماعیة الحقیقیة للصھیونیة، والمؤرخین الجددفسي إن التحلیل الن واألخالقیة.من خالل المسئولیة القانونیة واالندماج الكامل

ات التي تحدث في شخص أو مجتمع یحاول تفسیر التغیر –مثل التاریخ –كماأن الكتاب المذكورین حاولوا شرح شخصیھ المجتمع 0في وقت معین

اإلسرائیلي في نصف القرن األخیر مثلما فعل ریتشارد ھوفستاتر و دافید في كریزمان و كریستوفر التي في الوالیات المتحدة األمریكیة.

،ألسنھ قواد العالم السالف ذكرھم ىھل تكون التصریحات عل 16.159.الستینیات كبیرا تشیر إلي شخص أو مجموعھ أشخاص فقدوا و التي یساندھا قطاعا

ىتقدیم واقع خیالي أقیم عل ىھي بالغھ السیاسیین التي ترمي إلأم عقولھم، ة؟السیاسیأساس ترجمھ مغلوطة للحقائق ھدفھا الواضح ھو أن تالءم أجندتھ

عاني الضالل أو البارانویا بصرف النظر عن افتقاده أن ھذیان الشخص الذي یمع الظروف المحیطة ال تھدف وعدم توافقھ واضطراب تفكیرهالمنطق إلىتروج وأو للمجموعة التي تتبنى أفكاره وسیاسیة لھتحقیق أي فائدة مادیة إلى إلى. إن تشوھات السیاسي أو الداعیة تقع ضمن أسلوب تآمري یھدف لھا

واجتماعیا عارضة اقتصادیا أضعاف الم در ق أكبر والحصول على وسیاسیامن الفائدة من ذلك كلھ. إن الجمھور أو الجمع الساذج المتحمس بالوعود التي تشمل تعدیل اقتصادي أو سیاسي أو اجتماعي أو مزایا نفسیة سوف یتبع ھذا

فأة كاومیلتزم الشخص بھذه المعتقدات، فإن ضغط المجموعة وما أنالقائد، لمقدم الصھیونیة فإلى جانب التحفیز ا وفي سیاقتثبتان ھذه المعتقدات. الھویة

(الجزرة) توجد عصا تصیب أي انتقاد لھذه المعتقدات أو الممارسات في " المعادي ویحمل بوصفالمدافع عن الصھیونیة ولفظ منصورة تأنیب

."للسامیة" أو "الیھودي الكاره لذاتھ

متالكھا با االحتالل اإلسرائیلي تكون واضحة أوال علىإن الفائدة التي تعود میاه مواردھا بما فیھا من والتحكم فيالقطعة الغنیة من األراضي الفلسطینیة،

وإقلیمیةجوفیة ة وعسكری، فإن االحتالل یحضر معھ مساعده مالیة . ثانیا 1947ي ائیل منذ نشأتھا فمن القوى الغربیة التي تعتبر إسر وسیاسیة وفیرة والخط األماميالشرطي الیقظ لحمایة اھتماماتھا اإلمبریالیة المسلح نوویا

في الشرق األوسط. انھ من الواضح تعمد علماء النفس واالستعماریة التقلیدیةم یكن ل وكأن ذلكالذین قاموا بتحلیل الصھیونیة عدم استخدام لفظ استعمار

. أن المعتقدات التآمریة تعكساینة التقلیدیینوالصھفي لغة جابوتنسكي

184

Allodi F, Okasha A, Youssef A

النفسي في األطفال أما المؤرخ ریتشارد ھوفستادتر فقد استخدم لفظ البارانویدي لوصف األسلوب التآمري لمؤسسة جون بیرش األمریكیة،

ري جولدواتر الذي نعت الرئیس ایزنھاور بالشیوعي، ووصف السناتور باجوزیف مكارثیا الذي قال إن رئیس الوزراء الجنرال جورج وأیضا السناتور

. كما 9مارشال عبارة عن خائن، یخدم سیاسات السیطرة العالمیة للكرملین. ینطبق ذلك أیضا على رئیس الوزراء بنیامین نتنیاھو عندما اتھم إدارة

راك أوباما بالتآمر مع " الفخ المغري ضد إسرائیل" الذي ورد في الرئیس باالتوسع االستیطاني والذي یدین 2016دیسمبر 23قرار مجلس األمن في

، یمكننا أن نرى التیار الشعبوي،ھذا المنطلق ومن نفسفي األراضي المحتلة ینایر ياللذان قد أتیا بالرئیس دونالد ترامب في السلطة ف والمحافظ الزائف

. أنھا تعتبر ردود فعل ضد التھدید بفقدان االستقرار االقتصادي 2017بسبب تأثیر التكنولوجیا على سوق الموارد والذي أتى والھویة الوطنیة

یة والدینیة واإلثنللمجموعات العرقیة والھجرات الضخمةالبشریة، العولمة، . توقف عن الغلیانصورة " نقطة االنصھار" األمریكیة بعد أن ت والشك في

تاریخیا، أن ھذا النوع من التھدید الحقیقي او الزائف تنتج عنھ درجة من اد االستعد والمستغل والذي یجلدالتوتر یثیرھا عندئذ "القائد العظیم"

نفسھ یعد بحل كل ھذه المخاوف بواسطة العالج وفي الوقتالبارانویدي !طوريالماضي الذھبي األس إلى وھو العودةالمعروف

ب في الحر وأراضیھا المحتلةإن صدمة المحرقة النازیة للیھود في ألمانیا، ثقافة ویمكن التقلیل من شأنھا، قد توغلت في نفسیة والتي الالعالمیة الثانیة

، فأن الصدمة سوف تتسبب وعموماالیھودي عبر األجیال المتتالیة الشعباألحوال كل ولكنھا في، والتكیفيفي حالة من التوتر النفسي التحضیري

وتحدیدھا أودائما فرص سواء للتوائم معھا وكانت ھناكلیست بمصیر، معالجتھا لمصلحة اقتصادیة أو سیاسیة أو وضعیة كما استخدمتھا الصھیونیة

التي نشأت كرد فعل الضطھاد الیھود في العالمیة. ان الحركة الصھیونیة،، و التي تشكلت بواسطة األیدیولوجیة روسیا القیصریة و شرق أوروبا

القومیة السائدة في نھایات القرن التاسع عشر منذ المؤتمر الصھیوني العالمي ظلت نائمة لمدة نصف قرن، و لم تبدأ فاعلیات 1897األول في بازل عام

باالحتالل 1967الحركة إال بعد الحرب العالمیة الثانیة، و بشكل واضح بعد ئیلي لباقي" فلسطین"، أوال مع البریطانیین بواسطة میثاق العسكري اإلسرا

1947ثم مع الحكومة البریطانیة بواسطة تقسیم فلسطین في 1917بلفور في و بواسطة تكنیك متعمد إلضفاء الشرعیة على ھذا االحتالل، فإن الصدمة المدفونة للمحرقة، و التي كانت دوما محملة بالتوتر النفسي قد استخرجت،

تمت معالجتھا بحیث أنھا اكتسبت قوة رسمیة و دور محوري في المنظومة و .(Hasbara) 10 المدعومة للدعایة الصھیونیة

اإلنكار كآلیة دفاع نفسي

لعنفواعتناق اوكراھیة األخر وتسمم القوة ونقص البصیرةان إنكار الحقیقة ي كتابات جاء ف كما والمتغیرات التحلیلیةتعد من ضمن آلیات الدفاع النفسي

واستعماریة أخرىأیضا في مجموعات وطنیة وھي تتواجدالصھاینة. والعملیات العسكریةقامت بمھاجمة جیرانھا في الحروب ومجتمعات قد

. إن المؤرخین الصھاینة الجدد قد كشفوا النقاب عن والبعثات االستعماریةإن وھي: 1948األساطیر السبعة التي شجعتھا الصھیونیة التقلیدیة منذ

سرائیل رفضوه! أن إ ولكن الفلسطینیینالسالم إلىإسرائیل كانت تدعو دائما كانت تنكر قوتھا، بما فیھا من قوة نوویة متشبھة بداود النبي الغیر قادر على الدفاع عن نفسھ أمام جلیات! إنكار إسرائیل لوضعھا كمحتل الذي یمتلك قوة

! تتحمل مسئولیة متساویة مع الضحایا إنھاوادعائھا غاشمة ضد الفلسطینیین، ھجوم وخوف منإن أعمال إسرائیل قد أكرھت علیھا بسبب ظروف البقاء

! أن مفھوم" خیال الخوف" مفضل 5،6وتدمیرھا علیھا وباقي العالمالعرب ھ بالدعایة ل ویقوم الساسةلدى خبراء العالقات الدولیة لتفسیر الحرب،

! إن آلیة الدعایة الصھیونیة تستمر في استخدام ھذا النوع من واستخدامھ

اع عنوالدففلسطین، والھجوم علىالتھدید ضد إسرائیل لتبریر االحتالل .السبل وانتصاراتھا بكلأمنھا

إن اإلنكار في جمیع احتماالتھ یعد أكثر آلیات الدفاع النفسي تدمیرا، انھ یتعدى ن . إوممنھجمنظم وقد أصبح، والجمعي معاي حدود العقل اإلسرائیلي الفرد

میثاق بلفور قد دعم فكرة خلق وطن للیھود في فلسطین. إن نصھ الذي ال یتعدى الثماني سطور في عمود ضیق في صحیفة بریطانیة، قد ذكر" الشعب

والعربیة بلأي ذكر للشعوب الفلسطینیة وال یوجدالیھودي" فقط، ینكر تماما االعتراف وھكذا فانھدیة)، األخرى الغیر یھو (المجتمعات

مجتمع ال إلىبالشعب الفلسطیني، أو أي حق لھ في ھیكل دستوري للوصول إن ھذا اإلنكار لوضع وجود 11الدولي أو مشاركتھ في لندن أو جنیف

الفلسطینیین قد أستمر لعدة عقود تحت الصھیونیة. وأعلنت رئیسة الوزراء ھ ال یوجد شيء اسمھ" فلسطیني" حتى توغل ھذا اإلسرائیلیة جولدا مائیر ان

المظلوم،اإلنكار عند اإلسرائیلیة. إناالعتقاد في عقول أطفال المدارس عامل مشترك في كل والشیطنة ھوالممزوج بجرعة قویة من العنصریة

البعض منا كیف كان األفارقة في أفالم " وقد یتذكرالحاالت االستعماریة م وللفیة الصورة ككتلة سوداء غیر محدده المعالم، طرزان" یظھرون في خ

أبدا في صورة أسماء أو شخصیات! إن اإلنكار یذھب إلي ما وراء تتمیزالنفس الیھودیة الفردیة و الجماعیة، فقد لوحظ في سجالت المستشفیات انھ منذ لحظة الوالدة و مرورا بالبیروقراطیة اإلسرائیلیة، فأن ھذا اإلنكار یمر

مة تكفل المواطنة الكاملة و االنتماء ألبناء الطائفة الیھودیة، و حقوق بمنظومحدودة للغایة " للمقیم" أو الغائب" للفلسطینیین في إسرائیل، و الذین یحصلون الحقا على مواطنة محدودة و نرى في جوازات السفر اإلسرائیلیة

متعون ین یتأن النص باللغة اإلنجلیزیة یشیر إلى أن الیھود و الفلسطینیبالمواطنة، و لكن النص العبري یؤكد أن اإلسرائیلیین فقط یتمتعون بالجنسیة

بذلك أن الدیانة الیھودیة ھي التي والرسالة المقصودةأي بجمیع الحقوق. .تحدد" دولة" إسرائیل

إن اإلنكار یصل أیضا إلى إنكار مسئولیة التطھیر العرقي للفلسطینیین أثناء لتي تسمیھا إسرائیل حرب االستقالل و یسمیھا ، و ا1948حرب

الفلسطینیین" النكبة" إن إنكار المسئولیة قد أمتد أیضا لیشمل الحروب العنیفة و 1978، و الحروب ضد لبنان في 1973و 1967، 1956ضد مصر في

و 2009و 2008و الھجوم و اجتیاح غزه في 2006و 1993و 1982عاما من 50لكافة االتفاقیات خالل و الخرق المستمر 2014و 2012

االحتالل مثل اإلعدام الغیر قانوني و ھدم المنازل و الترحیل و التحكم القاسي في انتقال األفراد و المواد الغذائیة و التوسع المستمر في االستیطان

ن كل ذلك د. مارتون أ وتقول لنااإلسرائیلي في األراضي الفلسطینیة المحتلة. وتضیف رة الصھاینة من خالل المنشور الزجاجي للمحرقة، عبارة عن نظ

مارتون قائلة: عندما یواجھ شعب یھودي ذكي بھذه الحقیقة، فإن رده یكون د.ا: أیض واإلیمان والعدالة وسوف یقولوندائما أن المحرقة قد قتلت المشاعر

ھنا و بمبادئھ عندما كنا نساق إلى غرف الغاز؟ والمجتمع الدوليأین كان هللا الموازي سوف ولكن السؤالصعوبة اإلجابة، إذا كانت ھناك إجابة ما، تكمن

یاتھم وحیكون: ما ذنب الفلسطینیین في ذلك كلھ؟ لماذا تغتصب أراضیھم ؟وحریتھم

بتسالم" األھلیة اإلسرائیلیة قد كررتا “ومنظمة إن منظمة العفو الدولیة قد أدانت مشاركة األطباء اإلسرائیلیین في فحص ودكتور مارتونالرفض،

وقد ات األمن. قو والتعذیب بواسطةالسجناء الفلسطینیین الخاضعین للتحقیق منظمة حقوق اإلنسان الفلسطیني في إسرائیل بأدلة وزمالءھا فيھي تقدمت

حالة مسجلة لشھادات السجناء الفلسطینیین الذین تم 100ھامة على أكثر من بواسطة أطباء إسرائیلیین قاموا بدورھم بتزویر أو إھمال كتابة فحصھم

یر إن التقر والتعذیب وینتھي ھذاسوء المعاملة ورفضوا فضح الفحوصات،، مخالفین بذلك الغطاء المانع والتعذیباألطباء قد شاركوا في التحقیقات

وكیومیثاق طوللتعذیب في میثاق األخالق بالجمعیة الطبیة اإلسرائیلیة إن تفسیر ذلك السلوك من األطباء اإلسرائیلیین .12للمنظمة الطبیة العالمیة

183


والفلسطینیین والھجوم علىإسرائیل ترى نفسھا كالضحیة مبررة بذلك الكراھیة نوبالتالي فإ، والبصیرةإدراك الواقع دعاء إسرائیل إنھا ا وبالرغم من. العرب جمیعان الواقع الداخلي یشیر إلى انھ ال توجد أیھ أصوات معارضة على اإلطالق كما تصرح إسرائیل بان الوضع القائم تؤیده إاطیة الوحیدة في الشرق األوسط، فالدیمقر

قد جعل احتالل األراضي الفلسطینیة ظاھرة معقدة للغایة، 1967وبعد 1947إسرائیل منذ وتواجد دولةخلق وبالفعل فان. وتشریعاتھاالوالیات المتحدة بسیاستھا الوطنیة وصعوبة دمج التحلیل النفسي مع الشئون السیاسیة إلىأون وأشار بارأھم الدفاعات النفسیة لھا واإلنكار منالتأكید على أن ضاللة االضطھاد إلىأدت

.والتاریخیة المعقدة

آلیات ومنھجیة التحلیل، عنف الصھیونیة، الصراعات الداخلیة للصھیونیة :كاالتيكتابات ھؤالء الكتاب والبارزة فيالتالي یعالج المواضیع المشتركة إن البحث .واإلنكارالنفسي فیھا مثل األنا المنقسمة، ضاللة االضطھاد الدفاع

النفسيمنھج التحلیل

النفسي ال تعد الوحیدة أو األقوى في تفسیر وقوى الخللإن الدوافع الداخلیة السلوك اإلنساني، خاصة إذا كان توجھ مفھوم الباحث نحو الظروف المحیطة

مج األسلوب د ولكي یمكننامثل علم النفس االجتماعي أو المیتافیزیقا الوجودیة فرد"، لالتحلیلي مع آلیات المؤرخین في نموذج موحد، علینا أن نعید تعریف "ا

إن الفیلسوف االسباني خوزیھ اورتجا جاسیھ قد قام بتعریف "األنا" على إنھا اعتبر أن "األنا" المنفصلة الفردیة وھكذا فقدبي" والظروف المحیطة –" أنا

.عبارة عن تجرید بدون قاعدة واقعیة ملموسة

إن أفكار جورج ھیربرت میر عن أھمیة "األخر" في تطور ووظیفة الشخص فإننا المنطلق ومن ھذاؤید أیضا دور المحیط االجتماعي في علم نفس الفرد. ت

إذا أردنا فھم شخصیة الصھاینة أو الصھیونیة ذاتھا یجب علینا أن نضع في یروا أن القوى –كأي عالم نفس –االعتبار أن المؤلفین السابق ذكرھم

ار الكیان ى دمالداخلیة التي تدفع الصھیونیة فد تتسبب في اضطراب أو حتؤدي ت والصراعات التيبرمتھ إذا لم یتم السیطرة علیھا. خاصة التناقضات

.الدفاع النفسیة ضد ھذا القلق ویثیر خطوطقلق نفسي یصعب تحملھ، إلى

قعوھنا یأیضا ضروریات خارجیة تشرح السلوك اإلسرائیلي، وتوجد ھناك: إن إسرائیل تماعوعلماء االجالمؤرخین وصیاغتھا علىعبء إیضاحھا

الثمائة ث ویحیط بھاصغیرة یبلغ تعداد سكانھا ثمانیة مالیین نسمة وھي دولة میتوالتي سملیون عربي، ھي قطعة جدیدة في اللعبة القدیمة التي وضعت

" المباراة الكبرى". إن رقعھ الشطرنج قد تغیرت إلي حد ما في القرنین قال اكم- لكنھیخ لن یكرر نفسھ، و التار نالعشرون. واالعشرون و الواحد و

. لذلك فعلى أي شخص یرید أن یفھم عقلیة الصھاینة یتناغم- توینمارك لحالیةوالظروف االیھود أن یفھم أوال تاریخ الصراع اإلسرائیلي الفلسطیني

للمریض المستلقي على أریكة والوضع االجتماعيبنفس فھمھ للتاریخ مھا قد تم تقسی وسكانھا العربالتحلیل النفسي. إن منطقة الشرق األوسط

، 1917حسب اتفاقیة سایكس بیكو بعد نھایة الحرب العالمیة األولى في عام ذلك إلى خلق دول وقد أدى، وفرنساطبقا لالتفاق بین بریطانیا العظمى المھمة االستعماریة لھذه الدول. أما في صغیرة مستقلة، یسھل تحریكھا في ي للشرق األوسط كموقع ف االستراتیجیةباقي القرن العشرین، فإن األھمیة

بحت األحسن بل أص إلىتتغیر والبضائع واألفكار لمطریق مرور األشخاص 1947في خلقت التي-إسرائیلأكثر تعقیدا" بسبب اكتشاف البترول. إن دولة

الغربیة، لكي تكون مقاطعة تستقبل ومساندة القوىدة بواسطة األمم المتح –یة استعمار ودین وأیدیولوجیة والمرتبطین بقومیةیھود أوروبا المھاجرین

، ایةومنذ البدمواردھا. وتمكنت منقد احتلت عسكریا األراضي الفلسطینیة ، أن االحتالل قد القى مقاومة مستمرة، ضعیفة 1897كما توقع صھاینة

ي كانت العربیة والت وتفكك البالدالدبلوماسیة الصھیونیة، بسببومشوشة إن رد الفعل السیكولوجي .8االستعماریة 1917مھیأة لذلك بواسطة قوى

وما یتلوهیومیا ھذا، والمستمر حتىالجمعي للصھیوني ضد ھذه المقاومة .ومارتون النفسیة اون-بارمن صراعات تمثل جوھر الموضوع في تحالیل

النفس االجتماعي قد قاموا بالتركیز وباحثي علمإن القلیل من المؤرخین تأثیر انوكیف كاإلسرائیلي منذ تأسیسھ، وتركیبة المجتمععلى التغییرات

تمع ھذا المج واالنتماء ووضععلى مشاعر الھویة واالختالف الثقافيالتنوع لمون لكثیرین یا وبالطبع فانالداخلي ووضعھ بالنسبة للمجتمع العالمي.

ال أن الیھود منذ تأسیس الدولة اإلسرائیلیة إ والقیم لدىبالتغییر في الشخصیة اج واالحتیمؤرخي الصھیونیة التقلیدیة یفسرون ذلك بضرورة الظروف

للبقاء. إن المؤرخ بني موریس یتقبل أن فكرة طرد الفلسطینیین من األولىیذھا بواسطة الجیش قد سبق التخطیط لھا وتنف 1948أراضیھم في

أیضا، أن ذلك كان للضرورة، " للتحریر" ولكنھ یكتباإلسرائیلي، ان قد دی موشى-الكاریزما ذو-وأن الجنرالالصھیوني لفلسطین العھد القدیم،

قد وبرر للتجاوزات العسكریة إلسرائیل بمقولتھ الشھیرة " إما ھم أم نحن". تم وحق بواسطة المؤرخین الجدد التحلیل النقدي لھذه المقولة في وقت ال تم

ب "األساطیر السبعة" للصھیونیة. كما قام ھؤالء المؤرخون بنقد تسمیتھاالعنصریة داخل إسرائیل نفسھا حیث كان الضحایا من الیھود السفردیم من

كانت اواإلثیوبیین بینم والیھود المزراحي، وفلسطینیةأصول شمال افریقیة لیھود االشكنازي المھاجرین من أوروبا الشرقیة في ا والقوة تتمثلالصفوة

أیضا ازدراء إسرائیل للقوانین ومن المعروف وروسیا وأمریكا الشمالیةھا حلیف المتحدة،عالقتھا بممثلي حكومة الوالیات والتوتر فيالدولیة،

الدولي المتزاید في الحق الشرعي للفلسطینیین واعتراف المجتمعاألساسي، مستقل لھم تحت حمایة القانون الدولي. یوجد القلیل من الشك للعیش في وطن

في أن أي من النقاط السابق ذكرھا قد دفعت شعب إسرائیل الیھودي للتساؤل أو كأفراد والخارجي سواء، وأمنھ الداخلي وقانونیة انتمائھعن حقیقة ھویتھ

ید، إحساس الخوف المتزا إلىإن ھذا الشعور كثیرا" ما یترجم مجموعات! .اللذان یحفزان بدورھما آلیات الدفاع النفسي والتوتر النفسي

البارانویا –ضاللة الشك

ود نفسیة تس وآلة دفاعلقد عرف مارتون البارانویا على إنھا ظاھرة جماعیة، أخرى ھناك جزء من السجل ومن ناحیةالثقافة الیھودیة في إسرائیل،

التاریخي یؤكد أنھ في العدید من المرات قد سادت في عدة دول معتقدات وصف الضالالت البارانویدیة المشتركة نجماعیة. إبارانویدیة شعبیة

إكلینیكیا قد ظھر في الكتابات الطبیة بدءا من القرن التاسع عشر في فرنسا لجنون العائلي" و " جنون العدید من تحت أسماء: " الجنون الثنائي" و " ا

األشخاص". و في أیامنا ھذه، تقع التشخیصات تحت تصنیف الذھان المشترك و الذھان الضاللي المسبب في الدلیل التشخیصي و اإلحصائي

التابع (ICD-10 ) و التصنیف الدولي لألمراض (DSM-IV)األمریكي (ICD-11) األخیرة المراجعة ولكنلمنظمة الصحة العالمیة باألمم المتحدة.

قد لفظا ھذه الفئة 2013في (DSM-5) لھا والتصنیف المكافئ 2016في بالكامل على أساس انھ ال یمكن تحدید النقطة التي یتحول عندھا معتقد خاطئ

جبولكننا ی مرضى.اضطراب إلىمشترك بین عدد كبیر من أفراد المجتمع أن ندرك انھ عندما یستخدم طبیب نفسي مثل د. مارتون لفظ البارانویا، فأنھ

أدبي یحاكي أسالیب علماء ولكن بأسلوبال یستخدمھ كوصف إكلینیكي .الماضي والمؤرخین فياالجتماع

میل إنساني بدائي والتعاسة ھو وفقدان األمانإن لوم األخر على المخالفات ینشأ –االكتئاب إلىالمضاد للمیل كالقطب-بارانویاال إلى. أن المیل وعالمي

شھرا طبقا لكتابات میالني كالین رائدة التحلیل 18في نفسیة الطفل من سن

182

The Arab Journal of Psychiatry (2017) Vol. 28 No.2 Page (181 - 186 ) (doi:10.12816/0041720)

Translated paper

التحلیل النفسي للصھیونیة في سیاق التاریخ والظروف

فیدیریكو اللودى

عادل یوسفأحمد عكاشة، الترجمة العربیة:

Psychoanalysis of Zionism in the Context of History and Circumstances

Federico Allodi, Ahmed Okasha, Adel Youssef

ملخص

سرد ھذا الموضوع المثیر للجدل إلى مستویات جدیدة من التخصص ةعلى حد السواء قد قاموا برفع درجإن المؤرخین الجدد للصھیونیة، اإلسرائیلیین والعرب المتمركز حول الفرد واألسرة على ھذه الظاھرة االجتماعیة والسیاسیة المركبة. كما تم إعادة النفسيوالثقة، وفى الوقت نفسھ فقد تم تطبیق مفاھیم وبصائر التحلیل

صھیونیة الحركة ال تعریف " الذات" أو " الفرد المنعكس" بواسطة نموذج متكامل بشكل یرتبط بتاریخھ والبیئة المحیطة بھ. إن ھذا النموذج یسھل تحلیل وشرح قود األخیرة من القرن التاسع عشر في أوروبا وحتى مظاھرھا في إسرائیل الیوم، وانطالقا من الخوف والقلق الكامن في نفس الفرد الیھوديالناشئة منذ بدایتھا في الع

اعات ة، فإن الدفلنازیأو الجماعة نتیجة اضطھاد ومعاناة الیھود في أوروبا الشرقیة في السنوات المائة األخیرة، وخاصة بسبب محرقة الیھود تحت حكم ألمانیا اابات ونات مشتركة في الكتالنفسیة التي تم ذكرھا مرارا ضد ھذا القلق ھي البارانویا (الضاللة اإلضطھادیة) واإلنكار والنفس المنقسمة. وظھرت ھذه الدفاعات كمك

رى في سیاسیة استطرادیھ لوحظت في مواقع اجتماعیة وسیاسیة أخالتقلیدیة والصھیونیة الحدیثة. إن الضاللة اإلضطھادیة ال تحمل المعنى اإلكلینیكي بل تكون حیلة العدل في تصبح أساس تاریخ الوالیات المتحدة األمریكیة. ونأمل أن ھذا المقال یضع في االعتبار أن الحقیقة في التاریخ، مثلما في أي سرد شخصي أو قومي سوف

.حل الصراع اإلسرائیلي الفلسطیني

" و من جدا " ت الشعبیة و المتخصصة عن الصھیونیة، إال أن ما تم نشره باللغة اإلنجلیزیة الخاص بالبعد و التحلیل النفسي یعتبر محدودا توجد العدید من الكتاباروز، األكادیمیة ینابرز ھذه الكتابات أعمال دان بار أون، الطفل الصابرا الناجي من المحرقة، و ھو أخصائي في علم النفس و لھ العدید من الكتابات و جاكل

تون الطبیبة روخاما مار البریطانیة و التي تتبع مدرسة الكان للتحلیل النفسي و األكادیمیة األمریكیة میرا زوخاروف، التي تعمل في التدریس في اوتاوا و أخیراأما باقي 1،2،3،4ق اإلنسان اإلسرائیلیة و الناشطة الحقوقیة النفسانیة من أصل الیھود الصابرا و التي تعتنق المنھج التحلیلي و مؤسسة جمعیة أطباء من اجل حقو

صھیونیة، والصراع فھم طبیعة الالكتابات األوروبیة النفسیة فتنوه إلى الفاشیة و العنصریة و معاداة السامیة و لیس الصھیونیة. إن المراجع التي تم ذكرھا تساعد على یم، والطریقة التي كانت في األصل قد جمعت لدراسة األشخاص والعائالت لكنھا لألسف استخدمت في التطبیق اإلسرائیلي الفلسطیني ضمن محددات تطبیق المفاھ

ل ھامة دد" بأعماعلى ظاھرة سكانیة ذات بعد تاریخي وسیاسي. إن مقالة مارتون الحدیثة عن المجتمع اإلسرائیلي قد نشرت في وقت یشارك فیھ " المؤرخون الج، فواز لديورشید خاالجانب اإلسرائیلي الیھودي، وآخرون منھیونیة من أھمھا أعمال أیالن بابي، أفي شلیم، إسرائیل شاحاق، سیمحافالبان تاریخ الص إلىأضیفت .5،6،7والعربي الجانب الفلسطیني وآخرون من وادوارد سعیدجرجس

نتجا عن سنوات طویلة من االضطھاد والغضب اللذانالقلق المكبوت وأرجعوھا إلىإلسرائیل، والسیطرة العدوانیةالحظوا العنف وروز وزوخاروف قدإن بار أون . والعرب خاصةعلى الفلسطینیین 1948ومن ھذا القلق عن المجتمعات اإلسالمیة، وقد أزیح، 1904روسیا القیصریة في والمذابح فيالمسیحي للیھود في أوروبا

كتابات من قبل في السلبي من عصر التیھ. إال أن ھذا العنف كان ظاھرا ولیس الیھوديید القویة" للیھودي الحدیث، إن االعتقاد الحالي في العنف یوصف بأنھ "الحین نادي" بالجدار الحدیدي" في إسرائیل لحمایة الیھود من العرب الغاضبین. إن ھذان الوجھان للیھود واللذان أطلق علیھما " 1923فالدیمیر جابوتنسكي في

1967لمنقسمة للصھیونیة ودفاعاتھا المكتسبة بقیت حتى عام الذات ا ن م عندما تمدد االحتالل العسكري لفلسطین وتطھیر األرض من الفلسطینیین والذي خلق نوعایادات. كبوتة بواسطة المجتمع والقالتوتر الذي لم یھدأ إال بنظریة " المحارب البطل" النابعة من المشاعر الوطنیة وحتى ذلك الوقت ظلت الصدمة العمیقة للمحرقة م

رة المحرقة أما ھذا وقد بدأ إنقاذ ذاكرة المحرقة، وتم تشجیع سردھا في اإلعالم والجیش والمدارس والجامعات. وبالرغم من ذلك فلم تقترب روز قط من ذاك 1982ظاھرة الذات المنقسمة استمر حتى والذي خلقعن ھذا الكبت من معتقد داوود النبي وجلیات. وھكذا فأن االطمئنان الناتج نابعا زوخاروف فسلكت سلوكا

ما أدى إلى م الدولي،تحت العیون الضریرة لقیادات المجتمع وشاتیال والتي تمتمذابح صابرا وخاصة صدمةضد لبنان اإلسرائیلیة الحربعندما بدأت القوات ومقبولة لإلسرائیلیینبناء على الطلب العام كمحاولة لبناء ھویة جدیدة 1993لى اتفاقیة أوسلو عام إ وأدى ذلكالسیكولوجي. وتحطیم االتزانطفح الوعي الجماعي

.والمجتمع الدولي

وكان أكثرتحلیل روز وزوخاروف، والتاریخي فيإن بار اون قد الحظ غیاب المحتوى االجتماعي لوبوتغییر أسعن دور المقاومة الفلسطینیة لالحتالل وعیاتغییر الخلفیة السابقة لنظریة المحرقة إلى مفھوم جدید: إن الفلسطینیین إلىذلك وقد أدى 2011سبتمبر 11د في التشتت، خاصة بعد مذبحة نیویورك في الیھو

موضع العنف الموجھ من الذات المنقسمة المستمرة للصھیونیة. كما أشار بار اون أن تلك الذات المنقسمة إلى وھكذا تحولواأصبحوا "األخر" والعرب واإلسالم قدي تنویھ أ وزوخاروف تمامافقد حذفت روز ،وأیضا كقطر أوروبي ذو اتجاه غربي. وتري نفسھاللصھیونیة تتجاھل الموقع الجغرافي إلسرائیل في الشرق األوسط

.آلخرینااإلسرائیلیین وعالقتھم بالیھودعلما بأن ھؤالء یتساءلون عن ھویتھم العربیة،نتیجة النظرة العنصریة الیھودیة ضد أصولھم عن الیھود السفاردیم

لفلسطیني ا والنصف األخرتقول نظریة مارتون األساسیة إن إسرائیل في الواقع عبارة عن أمتین داخل قطر واحد، النصف الیھودي الذي یستمتع بجمیع الحقوق طمس إلىبسبب المحرقة مما یؤدي (PTSD) إال بالقلیل من الحقوق ویتبع ذلك إن إسرائیل تعاني من اضطراب كرب ما بعد الصدمة وال یستمتعتحت االحتالل

181

إتحاد األطباء النفسانیین العرب

للطب النفسي العربیةالمجلة

األسم: ____________________________________________________________

___ ___________________________________________________ :البریديالعنوان

ھاتف: ____________________________اإللكتروني: البرید

التخرج: ____________________ مكان وسنة _الجنسیة: ____________________ _

الحالي: _________________________ العمل _

:التوقیع: _______________________التاریخ___________ ___________________

_______________________________

.دوالرا أمریكیا في السنة 25: اشتراك المجلة لألطباء النفسیین

دوالرا أمریكیا في السنة. 50االشتراك السنوي للمجلة لباقي األفراد والمؤسسات

.فرع جبل عمان /األردن –األردني األھليالبنك 166055-10 :رقمترسل القیمة بحوالة بنكیة فقط على حساب

IBAN/JO40JONB0120000230101455066101

.األردن – 111937عمان 541212ب ص.یعاد طلب االشتراك على عنوان المجلة

_____________التبرع _____________________ االشتراك__________________________ المجموع__

____________________________________________________________وتاریخھا الحوالةمالحظة رقم

The Arab Journal of Psychiatry

Subscription of Institutions and Individuals

Name:_________________________________________________________________________________ Address:_______________________________________________________________________________

Signature: ________________________________________Date:_________________________________

Annual Subscription fee 50 U.S. $.

Money should be sent only by bank transfer to the account of the Journal No. 550661-01

National Jordan Bank, Jabal Amman Br. Amman-Jordan

IBAN/ JO40JONB0120000230101455066101

This form should be sent back to the journal P.O. Box (541212) Amman 11937 – Jordan.

Donatin______________________Subscription_________________________Total__________________

Note: Number and date of the bank transfer: _________________________________________________

Tel: 0096265335446 Fax: 0096265349763 E- mail:[email protected]

Website: http://arabjournalpsychiatry.com/

اك قس�مة االش��

vǳŜǘƛŀǇƛƴŜ нрΣ рлΣ мллΣ нллΣ олл ϧ пллƳƎ олΣсл ¢ŀōƭŜǘǎ

Quzal

*

'6J/ JOSWEÈ I Ŝ ŀ ƭ ǘ Ƙ C ƻ Ǌ [ ƛ Ŧ Ŝ

È *

!ǊƛǇƛǇǊŀȊƻƭŜ рΣ млΣ мр ϧ ол ƳƎ ол CƛƭƳ /ƻŀǘŜŘ ¢ŀōƭŜǘǎ

JOSWECNS WƻǊŘŀƴ {ǿŜŘŜƴ aŜŘƛŎŀƭ ŀƴŘ {ǘŜǊƛƭƛȊŀǘƛƻƴ /ƻΦ ǿǿǿΦƧƻǎǿŜΦŎƻƳ

no - arab journal of psyciatry€¦ · journal of psychiatry (ajp). they are among the best papers...

Documents