Taurine Levels in Human Aqueous Humour MEDICAL SCIENCES (2000), 2, 43−47 © 2000 SULTAN QABOOS UNIVERSITY 1Department of Behavioural Medicine, College of Medicine, Sultan Qaboos University, P.O.Box: 35, Postal Code: 123, Muscat, Sultanate of Oman. 2Ministry of Health, Al-Ain, UAE. 3Ministry of Health, Irbid, Jordan *To whom correspondence should be addressed. 43 Psychiatric morbidity in Northern Jordan: a ten-year review * Zaidan Z1, Alwash R2, Al-Hussaini A1, Al-Jarrah M3. :الحاالت المرضية النفسية في شمال األردن جاعيةعشر سنوات دراسة إستر ، مز الجارحالحسيني. علوش ، ع. زيدان ، د. ز مريضًا 2335 تم دراسة سجالت :الطريقة . الحاالت النفسية في شمال األردن لمعرفة نسبة هذه الحاالت لغرض التخطيط للخدمات النفسية المطلوبة هو دراسة : الهدف: الملخص آان التشخيص حسب الجدول . كمبيوتردراسة تفصيلية وقد حللت النتائج بال ) 1984�1993(نوات ـنفسيًا والذين راجعوا العيادة النفسية الوحيدة في شـمال األردن لمـدة عشر س إناثًا ، وآانت نسبة المراجعة أآثر للفئة % 45منهم ذآورًا و % 55 مريضًا خالل فترة الدراسة وآان 2335 راجع العيادة :النتائج والخالصة . العالمي التاسع لتصنيف األمراض وآان أآثر المرضى زيارة للعيادة هم مرضى الفصام يليهم . ذآور والذهان العاطفي أآبر نسبة عند اإلناثشكل مرض الفصام العقلي أآبر نسبة تشخيص عند ال. سنة44-22العمرية شكل مرض القلق النفسي أآبر نسبة تشخيص يليه مرض الفصام ثم مرض الذهان ) 1993سنة (في السنة األخيرة من البحث . مرضى الذهان العاطفي ثم مرضى القلق النفسي .العاطفي ABSTRACT: ��������� – To study the psychiatric morbidity in the northern part of Jordan and to determine the frequency distribution of various psychiatric disorders, for planning services. ���� – All records of 2,335 psychiatric patients attending the only psychiatric clinic in Northern part of Jordan during a ten-year period from 1984 to 1993 were extensively reviewed and subjected to computerized analysis. Diagnosis was made as per ICD-9. ������� – Out of the 2335 patients who attended the clinic, 55% were males and 45% were females. Those in the age group 25–44 recorded the maximum attendance. Among the male attendees of the clinic, schizophrenia was the commonest diagnosis(19.9%), while among females, affective disorders were the commonest(15.9%). ���������� – Schizophrenia was found to be the commonest diagnosis in general among attendance of the clinic for the ten-year research period, while anxiety disorders were the commonest diagnosis among attendance of the clinic for the year 1993. KEY WORDS: attendance rate, schizophrenia, anxiety, affective psychosis. sychiatric disorders are the problem of the cent- ury. It has been estimated that as many as 500 million people in the world may be suffering some kind of mental disorder1, a prevalence which is expected to rise with the growth of population.2 World Health Organisation has declared mental well being to be an integral part of health. WHO and psychiatric epidemiologists are in a position now to confidently answer questions about changes of psychiatric morbidity over time.3 Estimation of the prevalence of psychiatric disorders in the community and the variations of the rates of their prevalence4 are essential in planning health programs and in evaluating the results of com- munity treatment programs.5 Epidemiological research in psychiatry could also help in providing clues to aetiology and therefore, to prevention strategies.6 In developed countries, such statistics are readily avail- able. In U.S.A., 15% of the population is estimated to be in need of mental health care at any given time.7 Such essential information is scarce for the devel- oping countries due to lack of research.8 Further, among the medical profession of these countries,9 knowledge and recognition of the extent of psychiatric morbidity is poor in spite of an increase in interest lately. The patients themselves are much more likely to seek traditional help than avail of psychiatric services.10 Jordan is a typical case of such information- scarcity. This study attempts to help fill this gap to the extent possible, by giving an indication of psychiatric morbidity in the population of Northern Jordan, attendance rate, socio-demographic characteristics, and diagnostic categories of patients who attended the mental health clinic in Irbid during the period 1984– 1993. P Z A I D A N E T A L METHOD The study was carried out at the mental hea clinic of Princess Basma Hospital, Irbid, Jordan. It in uded all psychiatric attendances recorded during period of ten years from January 1984 to Decem 1993. The clinic was (and still is) the only governm mental health facility in Irbid City, and opera through open door policy. It was also the referral cl for psychiatric patients coming from primary hea centres in Irbid and its peripheries, the health centre Jordan University of Science & Technology, priv practitioners and other health care facilities in the r ion such as United Nations Refugees Welfare Age (UNRWA). The clinic was run daily by a rotation te of four psychiatrists. Each psychiatric patient w required to have a file containing information his/her case history, clinical examination, diagno management and notes of follow up. The clinic ser as the only referral clinic for Irbid Governorate, wh had a population of 1.02 million in 1993, represent about 24.2% of the whole Jordanian populati During 1984-1993, a total of 1,285 males & 1,0 females attended the clinic at different times, a constituted the population of this study. Data w collected from their record files, which w extensively reviewed and analysed. The follow variables were included: age, sex, residen occupation, employment status, education, mar status, frequency of attendance and final diagnosis. Attendance rate of psychiatric patien Male Diagnosis No Attendance Rate/100,000 Anxiety Disorders 169 9.2 Schizophrenia 363 19.9 Affective Psychosis 218 11.9 Other non-organic Psychosis 44 2.4 Dementia 21 1.1 Epilepsy 209 11.4 Mental Retardation 99 5.4 Personality Disorders 70 3.8 Alcohol & Drug Dependence 26 1.4 Others 66 3.6 Total 1285 70.3 * Denominator population is 1988 population (mid-term). TABLE 1 ts for both sexes for the period from 1984-1993 Female Both No Attendance Rate/100,000 No Attendance Rate/100,000 216 13.0 385 11.0 194 11.7 557 15.9 264 15.9 482 13.8 52 3.1 96 2.7 18 1.1 39 1.1 149 9.0 358 10.3 62 3.7 161 4.6 27 1.6 97 2.8 2 0.1 28 0.8 66 4.0 132 3.8 1050 63.1 2335 66.9 44 lth cl- a ber ent ted inic lth of ate eg- ncy am as on sis, ved ich ing on. 50 nd ere ere ing ce, ital Prior to the beginning of data collection, a pilot study was conducted to ascertain the availability of the required information, with the aim to determine the variables to be finally included in the study. It revealed that all the variables were well recorded in the patients’ files. The final diagnosis of each case was made by the attending senior psychiatrist and was classified into major diagnostic categories based on International Classification of Diseases – 9th revision (ICD-9)11: (a) Age of patients by years at the attendant time, which were grouped into five categories. (1) child: 0–14, (2) adolescent: 15–24, (3) young adult: 25– 44. (4) middle-aged: 45–64, and (5) elderly: 65+. (b) Sex. (c) Residence: whether the patient lived in Irbid City or was from the peripheries (d) Marital status: whether single, married, divorced or widowed. (e) Occupation. (f) Education:(1)child, (2) illiterate & primary, (3) inter- mediate & secondary, (4) college and university. (g) Frequency of attendance at the clinic. The study consisted of two parts (Part I and Part II). In Part I, the variables of age, sex, years, residence and final diagnosis of all the 2335 patients who attend- ed the clinic from 1984 to 1993 were studied. Part II, which studied only 500 patients who attended the clinic during the year 1993, considered the following additional variables: level of education, occupation, employment status, marital status and frequency of attendance in the clinic. Part II also coded all diag- P S Y C H I A T R I C M O R B I D I T Y I N N O R T H E R N J O R D A N 45 nostic categories according to ICD-9. Data from both Part I and II were analysed by a computer using SPSS programme to produce frequency distribution and cross tabulation of the various variables. TABLE 2 Characteristics of psychiatric patients who attended the mental health clinic in 1993 Variables Characteristics No % Anxiety Disorders 118 23.6 Schizophrenia 103 20.6 Affective Psychosis 92 18.4 Other non organic psychosis 23 4.6 Dementia 12 2.4 Epilepsy 45 9.0 Mental Retardation 33 6.6 Personality Disorders 20 4.0 Alcohol/Drug Dependence 10 2.0 Others 44 8.8 Diagnosis Total 500 100.0 Professional 52 11.7 Skilled / skilled worker student 51 11.5 Others* 49 11 Housewife 127 28.5 Occupation Unemployed . 162 37.3 Employed 116 44.4 Employment Status Unemployed 162 55.6 Child (0–14 year) 37 10 Illiterate & Primary 111 29.9 Intermediate & Secondary 151 40.7 Education College & University 72 19.4 Single (including 40 children) 207 46 Married 222 49.3 Widowed/Divorced 21 4.7 Marital Status Once 202 40.4 Twice 91 18.2 Three times 54 10.8 Frequency of attendance Four times and more 153 30.6 Irbid City 244 50.7 Place of Residence Irbid Peripheries 237 49.3 * ‘Others’ include students, retired and military. RESULTS: In both Part I and II, the majority (55% and 58% respectively) were male; higher rates were found among the 25–44 age group in both males and females. The attendance rates were relatively higher in males 164(I)-113(II) per 100,000 population) com- pared with 147(I)–87(II)/100,000 for females (the latter mostly aged 45 and above). For Part I, schizophrenia was the overall major diagnosis (15.9/100,000), and this was also the major diagnosis for the males (19.9/100,000), with the maximum attendance rates, while dementia figured the lowest (1.1/100,000). For females, the highest was affective psychosis (15.9/100,000) and the lowest, alcohol and drug dependence (0.1/100,000). Anxiety disorders, which were common in females than in males, occupied the third place in general frequency (11/100000). The fourth place went to epilepsy (10.3/100000), which was more common in males (table 1). Attendance rates were slightly higher from Irbid city than from the peripheries, and in both, there was a gradual increase in the attendance rates from 26.2/100,000 in 1984 to 106.4/100,000 in 1993. In Part II (1993), anxiety disorders, at 23.6%, accounted for the highest attendance followed by schizophrenia (20.6%) and affective disorders (18.4%). 55.6% of the subjects were unemployed. While 29.9% of the subjects were illiterate or had primary education, 40.7% had intermediate or secondary School educa- tion, and 19.4% had college or university education. About half the patients (49.3%) were married, 46% were single (including 40 children), while 4.7% were divorced or widowed. As regards attendance rates in the clinic, 40.4% of the patients attended only once, while 30.6% did four times or more (table 2). DISCUSSION For Part I (1989–1993), in contrast with the uni- versal excess of females among psychiatric patients as reported in most western studies,4,12-14 this study found overall attendance rates to be higher in males (70.3/100,000) than in females (63.1/100,000). Similar findings have been reported from other Arab count- ries, mainly Saudi Arabia.10,15-18 The reason for this could be that females in this region tend to seek help from the local support system for longer period than males do before availing of specialized services. Women are more encouraged to seek traditional healers than men and, culturally speaking, they are great believers in these. It could also be that families tend to have greater tolerance for mental illnesses in females. The stigma attached to mental illnesses might Z A I D A N E T A L 46 affect the girls’ chances of getting married, due to which, they might try to hide their problems. Significantly, we found more married female patients than married males. The 25–44 age group had the highest attendance rates throughout. This agrees with findings from other studies in developed & developing countries.19-22 The reasons for this are, the largest number of population falls in this age group; they are more educated and hence seek psychiatric help more than others; they are also more prone to stress from marital and family con- flicts and work pressures. Attendance rates were higher in females above 45 years of age possibly due to the increase frequency of affective disorders at that age group. Attendance rates increased through the years from 1984 to1993 in respect of both the sexes (24.6/100000 in 1984 to 100.7/100000 in 1993). This is in line with other studies in U.K. and USA,23,24 and is so possibly because of increased popular awareness and improvement of services. The study also showed higher attendance rates in male schizophrenics while in females it was among those with affective psychosis. Overall, schizophrenic patients had the highest atten- dance rate (15.9/100,000). These results agree with other studies in the Arab world and in the west.10,15,20,25 The data also showed that proportionately more patients from Irbid city attended the clinic (71.5/100,000) compared to those from the peri- pheries (64.4/100,000). This again, is in line with many studies in developed and developing countries15,20,26,27 which showed that psychiatric morbidity is more common in urban than in rural areas. The easy access for city patients to the clinic, could be another factor. Parts I and II of the study agreed with each other regarding attendance rates (higher in males compared with females). In Part II (1993), most attendees had anxiety disorder (23.6%), a finding that is in agreement with other studies28,29 including one in USA.7 Most of the attendees to the clinic were un- employed. This seems to be in agreement with findings in Kuwait,17 in Saudi Arabia30 and Egypt.19 The majority of patients who attended the clinic in 1993 had intermediate or secondary education. This finding does not agree with several studies13,14,31 which showed that the higher the education level, the lower the psychiatric morbidity. Most of the patients attend- ed the clinic in 1993 were married and this is in agreement with other studies in Arab countries.3,5,25,26,30 Studies in the Western World show that psychiatric morbidity is more common in those who are widowed, divorced or single.22,32 CONCLUSION Most of the attendees were males, majority of whom were of 25–44 years of age. Most of the patients were unemployed, married, and there was an increase in attendance over the years. Schizophrenia had the highest attendance rates followed by affective psychosis & anxiety disorders. The lowest rates were for alcohol & drug abuse. The commonest diagnoses among attendees to the clinic in 1993 were anxiety disorders, schizophrenia and affective psychosis, in that order. Further epidemiological studies on psychiatric morbidity are recommended. ACKNOWLEDGEMENT We would like to thank Dr. Mohammed Shaban and all the staff of the psychiatric outpatient clinic, Basma Hospital for help in collecting data. We are grateful to Mr. K. Ravindran for secretarial assistance. REFERENCES 1. World Health Organization. Intercountry Meeting on National Programes of Mental Health, Demascus, Syrian Arab Republic, WHO Geneva 1986, 2–6. 2. Henderson AS. Epidemiology of Mental Disorders and Psychosocial Problems: Dementia, WHO, Geneva 1994, 1–5. 3. Sartorius N, Nielsen JA, Stromgren E. Changes in frequency of mental disorder over time (Results of re- peated surveys of mental disorders in the general popu- lation). Acta Psychiatr Scand 1989, 79 (suppl.348), 5–10. 4. 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A psychiatric emergency clinic: a study of attendances over six months. Brit J Psychiatry 1983, 143, 460–6. 30. Qureshi NA, Al-Quraishi NY, Hegazy IS. Some characteristics of mental patients admitted to a psych- iatric hospital. Arab Journal of Psychiatry 1991, 2,146–58. 31. Filho NDA. Social epidemiology of mental disorders: a review of Latin-American studies. Acta Psychiatr Scand 1987, 75, 1–10. 32. Surtees PG. Dean C, Ingham JG, Kreitman NB, Miller PM, Sashidharan SP. Psychiatric disorders in women from an Edinburgh community: associations with demographic factors. BrJ Psychiatry 1983, 142, 238–4. Psychiatric morbidity in Northern Jordan:�a ten-year review Intro METHOD Table 2 Characteristics of psychiatric patients who attended the mental health clinic in 1993 Diagnosis Occupation RESULTS: DISCUSSION CONCLUSION ACKNOWLEDGEMENT REFERENCES