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International Journal of Clinical Psychiatry and Mental Health, 2014, 2, 000-000 1
E-ISSN: 2310-8231/14 © 2014 Synergy Publishe rs
Lifetime Prevalence of Common Mental Disorders in Qatar: Using
WHO Composite International Diagnostic Interview (WHO-CIDI)
Suhaila Ghuloum1, Abdulbari Bener2,3,* and Elnour E. Dafeeah1, Tariq Al-Yazidi1,
Ahmed ElAmin Mustapha1 and Ahmed E. Zakareia1
1Department of Psychiatry, Hamad Medical Corporation, & Weill Cornell Dept. of Psychiatry, Qatar
2Department of Medical Statistics & Epidemiology, Hamad Medical Corporation, Dept. of Public Health, Weill
Cornell Medical College, Doha, Qatar
3Department of Evidence for Population Health Unit, School of Epidemiology and Health Sciences, The
University of Manchester, Manchester, UK
Abstract: Background: Mental Disorders, particularly Depr ession, are rec ognise d as one of the biggest burden of
disease worldwide. Two of the top three burdens of disease in Qatar are mental health related. Yet, this is s carcity of
lifetime prevalence data available to understand the impact in th is country.
Aim: This study uses the WHO Composite International Diagnostic Interview (WHO-CIDI ), to measure the lif etime
prevalence of the most presenting mental disor ders in the adult Qatari pop ulation, aged 18-65, and examine their
symptom patterns and co-morbidity.
Design: This is a cross sectional study conducted dur ing the period from Apr il 2010 t o October 2011.
Setting: Five Primary Health Care (PHC) Ce ntres distribut ed arou nd the c ountry.
Subjects: A total of 1,500 Q atari su bjects aged 18 to 65 years w ere appr oached; 1,063 (70.8%) gave c onsent and
participated in this study.
Methods: Four field su pervisors from Qatar w ere trained and certified as trainers by IDRAAC, the education a nd training
centre responsib le for the Arabic translation and validation of CIDI. Variations i n Arabic dialect were reported to IDRAA C
for verification and approval. In line with the World Health Organization (WHO) World Mental H ealth (WMH) Surv ey
Initiative, a nationally representative psychiatric epidemiological survey was carried out in Qatar. Prevalence and severity
of ICD-10 disorders were assessed with the WHO Composite International Diagnostic I nterview (CIDI, Versio n 3.0).
Results: Of the studied 1063 subjects, 50.1% were males an d 49.9% were females. Mos t of the respon dents were in th e
age group 18-34 years ( 46.1%), followed by 35-49 years (34.1%), then 50-65 years (19.8%). The most common ICD-1 0
disorders were specific generalized anxiety disor ders (20.4)%, and major depr ession (19.1%), with a higher prevalence
in women. 20.6% of the s ample had chronic physical conditions. There were high levels of statistically significant
differences between age groups and gender regarding Generalized Anxiety D isorders, Soci al phobia, spec ific phobia,
major depressio n, and personality disorders scree n. Women performed significantly w orse as assessed by the 30 day
functioning screen (p < 0.001).
Conclusion: The findings of this study in lifetime prevalence of mental d isorders in Qatar are comparable with
international figures. Women were more likely than men to have mental illness. Overall, Gener alized Anxiety Disord ers;
Social phobia, specific phobia, major depression, and personality disorders were the commo nest dis orders.
Keywords: Prevalence, community, mental disorders, CIDI, Qatar.
INTRODUCTION
Mental disorders are widely recognized as a major
contributor (14%) to the global burden of disease
worldwide [1]. Patients often present to their Family
Physician as their first contact with health services,
Depression and Anxiety disorders being the most
common in such setups. Yet, symptoms are commonly
undetected [2]. Although potentially treatable, lack of
early detection and the subsequent non-treatment
results in substantial morbidity and contributes to the
*Address correspondenc e to this author at the Department of Medical Statistics
and Epidemiology, Hamad Medical Corporation & Department of Public Health ,
Weill Cornell Medical College, P.O. Box 3050, Doha, Qatar; Tel: + 974- 4439
3765, + 974- 4439 3766; Fax: + 974-4439 3769; E-mails: abener@hmc.org.qa;
abb2007@qatar-med.corne ll.edu
higher social burden of disease [3-5]. Psychiatrists in
the Middle East are well accustomed to patients
presenting late to professional services, often under
pressure from family as opposed to self-referral.
Generally, epidemiological data regarding lifetime
prevalence of mental illness, sociodemographic
variables, and disease burden are relatively scarce in
the Arab world [3, 4].
Internationally, the public health burden of
Depression is well recognised, ranking fourth among
global burden of diseases. By 2020, its impact is
estimated to rise to second [6, 7]. In previously
published data regarding lifetime prevalence of mental
illness in Qatar, depression was the most common;
second only to heart diseases as a cause of disability
2 International Journal of Clinical Psychiatry and M ental Health, 2014, Vol. 2, No. 1 Ghuloum et al.
in this country [3, 4]. Depression is the most common
mental health presentation at Primary Care (PHC)
level, often presenting with multiple somatic complaints
and comorbid with anxiety disorders [3, 4]. Lack of
awareness and high levels of stigma related to mental
health are a barrier to accessing mental health services
at an early stage, resulting in impairments in social
functioning, employment, and quality of life.
In the United States [8], the lifetime prevalence of
Anxiety disorders among adults aged 18 to 54 is
13.3%. Prevalence rates are higher in women in most
countries [9]. In primary care setting, the high
prevalence of anxiety and depressive disorders
increases use of health services, and delays response
to physical treatments [3, 4].
In the early 1980s, the Diagnostic Interview
Schedule (DIS) was the first structured instrument for
use by non-clinicians utilising computerized algorithms
to diagnose based on DSM-III criteria. It was used in
the Epidemiologic Catchment Area (ECA) study,
replicated in other countries. Other structured
diagnostic tools followed, most notably the World
Health Organization Composite International
Diagnostic Interview (CIDI), currently used worldwide
[10]. In fact, the Composite International Diagnostic
Interview (CIDI) is a fully standardized, structured
interview that provides a psychiatric diagnosis through
computerized algorithms according to the International
Classification of Diseases, 10th edition (ICD-10), and
the Diagnostic and Statistical Manual of the American
Psychiatric Association, 4th edition (DSM-IV) [11]. The
CIDI ascertains diagnoses based on WHO International
Classification of Disease (ICD) criteria. With ICD being
the most widely used international classification
system, CIDI facilitates cross-national comparative
research of epidemiological studies of mental illnesses
[8, 12, 13].
The aim of this study was to assess the lifetime
prevalence of common mental disorders at Primary
Health Care (PHC) Centres using the WHO Composite
International Diagnostic Interview (WHO-CIDI) in the
Qatari population who attended PHC settings and
examine their co-morbidity.
SUBJECTS AND METHODS
This is a cross sectional study that included Qatari
patients aged 18 to 65 years who attended the PHC,
during the period from April 2010 to October 2011,
using WHO Composite International Diagnostic
Interview. Primary health care centres are frequented
by all levels of the general population as a gateway to
specialist care.
A multistage stratified random sampling design was
developed using an administrative division of Qatar into
21 primary health care centers in terms of number of
inhabitants. Of these health centres, 13 were visited
primarily by Qatari people; the remainder were
excluded. We selected 5 centers to cover 5 geographic
catchment areas in and around the capital city of Doha,
three of which are urban health centres and 2 are semi-
rural (Figure 1). Equal proportion of subjects from each
health center was chosen.
With similarities in culture and social composition,
prevalence rates of depression and anxiety disorders in
Qatar were assumed similar to rates found in other
Arabian Gulf countries and the Eastern Mediterranean
[3, 4], with reported prevalence ranging from 20 to
25%. Assuming the lifetime prevalence of depression
and anxiety disorders to be 22.5%, with the 99%
confidence interval for an error of 3% at the level of
significance, a sample size of 1,500 subjects would be
required to meet the objectives of the study. A random
sample of Qatari nationals aged 18 – 65 years old was
drawn from the primary care registry. A total of 1,500
Qatari subjects were approached; 1.063 (70.8%)
participated and were interviewed with the Arabic
World Mental Health Composite International
Diagnostic Interview (WMH- CIDI) during the period
from April 2010 to October 2011.
The data was collected through a validated self-
administered questionnaire with the help of physicians
and qualified nurses. The questionnaire had three
parts. The first part included the socio-demographic
details of the patients, the second part with the medical
and family history of the patients, and the third part was
the diagnostic screening questionnaire.
IRB approval was obtained from Hamad Medical
Corporation for conducting this research in Qatar.
Interviewer Training
Four field supervisors, three psychiatrists and one
clinical psychologist, were formally trained and certified
at IDRAAC research centre in Beirut, Lebanon.
IDRAAC is the educational and research training centre
that translated and validated the WMH-CIDI instrument
to Arabic language. These trainers subsequently
trained 11 interviewers to administer the instrument.
Prevalence of Common Mental Disorders International Journal of Clinical Psychiatry and Mental Hea lth, 2014, Vol. 2, No. 1 3
The interviewers were all nurses working at the
psychiatry department of Hamad Medical Corporation.
Each centre was given an identification number. In
addition every 20 questionnaires were grouped
together into Replicate numbers. These conventions
were of paramount importance in organizing the editing
process of the data and generation of field reports. The
field supervisors edited all the returned questionnaires
and produced field reports to monitor and guide the
interviewers.
The psychiatric diagnoses reported were based on
ICD-10 criteria and generated with the Arabic WMH-
CIDI version 3.0. Paper and pencil Personal Interview
(PAPI) version 6 was utilized to bridge the data into
BLAISE software, a third party computer program
Figure 1: Flow chart of the cultural and linguistics adaptation of the Arabic WHO-CIDI version for use in Qatar.
4 International Journal of Clinical Psychiatry and M ental Health, 2014, Vol. 2, No. 1 Ghuloum et al.
customized to capture ICD-10 diagnoses and generate
statistical data into SPSS version 20, statistical
analysis software.
The Arabic version of WMH-CIDI was validated by
the IDRAAC centre in Lebanon. However, due to
linguistic variations of the Arabic dialect, a few words
were replaced during the pilot phase of the study in
Qatar to be in line with the common dialect in the gulf
region. The wording of the reviewed questions were
then back-translated and reported to IDRAAC centre to
ascertain their relevance to the original wording used in
the validated questionnaire.
The ICD-10 diagnoses generated in this study
included Generalised Anxiety Disorders, Major
Depressive Disorder, Social Phobia, Obsessive
Compulsive disorder, Psychosis and Personality
disorder. Chronic conditions sections section was also
included. Functional disability section was randomized
to every 10th interview. The original WMH-CIDI includes
41 sections and takes an average of 2 hours to
administer. The WHO field trials of the CIDI have
documented good inter-rater reliability, test-retest
reliability and validity for almost all diagnostic
categories.
Analysis Methods
Prevalence and severity were estimated by
calculating means, percentages and standard error.
Odds Ratio (OR) and their 95% confidence intervals
(CI) were calculated by using Mantel-Haenszel test.
One Way Analysis of variance (ANOVA) was employed
for comparison of several group means and to
determine the presence of significant differences
between group means. Student-t test was used to
ascertain the significance of differences between mean
values of two continuous variables and confirmed by
non-parametric Mann-Whitney test. Chi-square and
Fisher’s exac t test were performed to test for
differences in proportions of categorical variables
between two or more groups. The level p<0.05 was
considered as the cut-off value for significance.
RESULTS
Of the studied 1063 subjects, 50.1% were males
and 49.9% were females. Most of the respondents
were in the age group 18-34 years (46.1%). Majority of
them were married (75.1%).
Table 1 gives the prevalence and severity of ICD-10
disorders by severe, moderate and mild condition. The
three most common disorders were generalized anxiety
disorders (20.4%), major depression (19.1%), followed
by social phobia (17.03%). Of the studied population,
chronic physical conditions were prevalent in 20.6%.
The majority of subjects were in the mild to moderate
range of symptom severity.
Table 2 shows the prevalence and severity of
disorders by gender. In the present study, prevalence
Table 1: Prevalence and Severity of Disorders in Studied Subjects (N=1063)
Total Sever Moderate Mild
n(%)
SE*
n(%)
SE
n(%)
SE
n(%)
SE
Anxiety Disorder
Generalized Anxiety
Disorders 217(20.41) (1.2) 23(10.6) (2.1) 87(40.09) (3.3) 107(49. 31) (11.1)
Specific Phobia 154(14.49) (1.1) 21(13.6 4) (2.8) 67(43.51) (4) 66(42.86) (13)
Social Phobia 181(17.03) (1.2) 22(12.15) (2.4) 53(29.28) (3.4) 106(58.56) (11.9)
Obsessive Compulsive
Disorders 142(13.36) (1.0) 29(20.4 2) (3.4) 51(35.92) (4) 62(43.66) (13.6)
Mood Disorder
Major De pression
Disorders 203(19.1) (1.2) 17(8.37) (1.9) 61(30.0 5) (3.2) 125(61.58) (11.1)
Bipolar Disorders I and II
176(16.56) (1.1) 10(5. 68) (1.7) 71(40.34) (3.7) 95( 53.98) (12.2)
Psychosis 63(5.9) (1.0) 11(17.46) (0.4) 20(31.74) (4) 36(50.80) (13.5)
Personality Disorders
Screen 165(15.52) (1.1) 23(13.9 4) (2.7) 62(37.58) (3.8) 80(48.48) (12.7)
30 Day Functioning 124(11.67) (1.0) 13(10.48) (2.8) 38( 30.65) (4.1) 73(58.87) (14.4)
*Standard Error = SE.
Prevalence of Common Mental Disorders International Journal of Clinical Psychiatry and Mental Hea lth, 2014, Vol. 2, No. 1 5
in women was significantly higher than men for the
most common mental disorders, specifically
generalised anxiety disorder, social phobia, specific
phobias, and major depressive disorder. More women
had psychotic illness, and personality disorders, and
more women had comorbid chronic physical conditions.
The impact of the disease in women was worse, as
reflected by the 30-day functioning screen.
Table 3 presents the prevalence and severity of
ICD-10 disorders by age group. Most of the
respondents were in the age group 18-34 years
(46.1%) followed by 35-49 years (34.1%), then 50-65
years (19.8%). Across the diagnostic categories
covered in this study, the most affected were the 18-34
years age group with a high statistical significance
(p<0.001). This was also the age group most impaired
as assessed by the 30-day functioning.
Table 4 describes the most common co-morbid
chronic physical conditions. The highest co-morbidity
Table 2: Prevalence of ICD-10 Disorders of Studied Subjects by Gender (N=1063)
Gender
Male Female
Variable
n=533
n(%)
n=530
n(%)
OR( 95% CI) P-Value*
Anxiety Disorder
Generalized Anxiety Disorders 85(15.9) 132(24.9) 1.75 (1.29 – 2.37) <0.01
Social Phobia 62(11.6) 119(22. 5) 1.76 (1. 24 – 2.49) <0.01
Specific Phobia 59(11.1) 95(17.9) 2.2 (1.56 – 3.07) <0.01
Obsessive Compu lsive Disorders 62(11.6) 80(15.1) 1.35 (0.95 – 1.93) 0.09
Mood Disorder
Major De pression Disorders 80(15 .0) 123(23.2) 1.71 (1.25 – 2.34) <0.01
Bipolar Disorders I and II 77(14.4) 99(18.7) 1.36 (0.98 – 1.88) 0.06
Psychosis 21(3.9) 43(8.1.0) 2.15 (1.22 – 3.81) <0.01
Personality Disorders Screen 64(12 .0) 101(19.1) 1.73 (1.73 – 2.42) <0.01
30 Day Functioning 45(8.4) 79(14.9) 1.9 (1.29 – 2.80) <0.01
*Reference
(
Male
)
.
Table 3: Prevalence of ICD-10 Disorders of Studied Subjects by Age Group (N=1063)
Age Group
18-34 35-49 50-65
Variables
n=490
n(%)
n=362
n(%)
n=211
n(%)
OR( 95% CI) P-Value
Anxiety Disorder
Generalized Anxiety Disorders 133(27.1) 66(18.2) 18(8.5) 1.89(1.51 – 2.35) <0.01
Social Phobia 109(22.2) 60(16.6) 12(5.7) 1.6(1.25– 2.04) <0.01
Specific Phobia 88(18.0) 52(14.4) 14(6.6) 1.87(1.47 – 2.37) <0.01
Obsessive Compulsive Disorders 83(16.9) 44(12.2) 15(7.1) 1.59(1.23 – 2.04) <0.01
Mood Disorder
Major De pression Disorders 118(24.1) 68(18.8) 17(8.1) 1.7 1(1.37 – 2.14) <0.01
Bipolar Disorders I and II 103(21. 0) 60( 16.6) 13( 6.2) 1.75( 1.38 – 2 .22) <0.01
Psychosis 35(7.1) 25( 6.9) 3(0.2) 1.67( 1.29 – 2.16) <0.01
Personality Disorders Screen 101(20.6) 54(14.9) 10(4.7) 1.93(1.50 – 2.48) <0.01
30 Day Functioning 72(14.7) 42(11.6) 10(4.7) 1.65(1.26 – 2.17) <0.01
6 International Journal of Clinical Psychiatry and M ental Health, 2014, Vol. 2, No. 1 Ghuloum et al.
was for Ischaemic heart disease, followed by Diabetes
then hypertension.
Table 4: Morbidity (Chronic Conditions) Associated
with Mental Illnesses (219 / 1063 = 20.6)
Morbidity n (%)
Ischeamic Heart Disease 48(4.52)
Diabetes 30(2.82)
Generalised Abdominal Pain 16(1.50)
Low Back Pain 17(1.60)
Asthma 15(1.40)
Muscle P ain 14(1.32)
Trauma 17(1.60)
Lower Respiratory Infections 13(1.22)
Hypertensive Disease 21(2.00)
Endocrine 19(1.78)
Cancer 9(0.84)
Total 20.60
DISCUSSION
The impact of mental illness on burden of disease
data worldwide is well established [6-8]. In Qatar, three
of the top five causes of disability are mental disorders.
Yet, very few studies have been conducted to provide
strong data. In this study, we used the WHO-CIDI for
the first time to study the lifetime prevalence of mental
illness among the Qatari population. Like most
countries in this region, a culture of public participation
in research does not exist and our researchers faced
considerable challenge attempting to seek consent to
participate. Stigma is particularly high in this part of the
world and denial of symptoms very common. It is worth
noting that screening for substance misuse and
suicidality was in fact conducted. However, almost
unanimously, all subjects denied either. The data was
thus excluded. The subject of suicide is a religious
taboo and people are more likely to deny an attempt
reporting it is accidental. The overall lifetime
prevalence of mental disorders in the Qatari general
population was over 20%, which is consistent with
other epidemiological surveys [9]; this places mental
disorders among the most prevalent classes of chronic
diseases. Almost one quarter of respondents typically
met the criteria for at least one type of mental disorder.
According to previous studies conducted in various
countries, the prevalence of mental disorders range
from 3 to 52%. According to WHO estimates [7, 14],
nearly 25% of individuals develop one or more mental
disorders at some stage in their life, in both developed
and developing countries. In the U.S [14], mental
disorders are common and an estimated 22.1% of
Americans aged 18 year and older – about 1 in 5 adults
- suffer from a diagnostic mental disorder. Meanwhile, it
is worth to note that the high rates of psychosis and
mania Bipolar Disorders I and II were observed in
current survey.
In the present study, prevalence of General Anxiety
Disorders in women was significantly higher than men
(24.9%). Other studies reported that women are more
likely than men to be adversely affected by mental
disorders [14]. Prince et al. [1] revealed that women are
at higher risk for common mental disorders with a
higher female to male sex ratio of 1.5:1. Culturally, the
role of women in this society is changing. The level of
education for Qatari women is higher than men. More
women are now working in leadership positions, while
the cultural expectation of them as wives and mothers
remains unchanged. The extent of stress this imposes
on women, and its reflection on their mental health
needs further exploring. The study finding that 30-day
functioning was more impaired in women is an area for
future research. Qatar’s recently approved mental
health strategy recognises women’s mental health as
one of the national priorities.
The highest prevalence of common mental
disorders in Qatari population was anxiety disorders
(24.9%) followed by major depression (23.2%). The
result matches previous studies [15-17] conducted in
various countries, where depression and anxiety
disorders were the most frequent mental disorders.
Probably, it should be acknowledged that use of
primary care centers may be associated with
higher rates of mental illness than the general
community, as there is a long-standing clinical
literature in the West reporting increased rates of
mental illness in general practice settings
(particularly depression and anxiety) A lower
prevalence of depression was reported by Wright [18],
with figures of depression occurring in around 10% of
general practice attendees. A Canadian study
determined that 12.2% of the Canadian population [19]
were affected with anxiety disorders, which is higher
than the rate in the Qatari population. In the U.S
population, it’s been reported that nearly twice as many
women (12%) as men (6.6%) are affected by a
depressive disorder each year [11]. Anxiety disorder
was more prevalent among Qatari women (10.9%) than
in men (9.6%) which is consistent with other
Prevalence of Common Mental Disorders International Journal of Clinical Psychiatry and Mental Hea lth, 2014, Vol. 2, No. 1 7
researches [20, 21]. Dementia (1.7%), Schizophrenia
(4.0%) and Obsessive-compulsive disorders (4.9%)
were not very common in Qatari population as
compared to other disorders.
The study findings showed that young Qatari
population in the age group 18 – 34 years were the
most affected with mental disorders (45.6%). The
prevalence of Anxiety and Depressive disorders was
highest in the age group 18 to 34 years (43% & 42%),
followed by 35-49 years (40% & 42%). Our finding of a
peak age for depression and anxiety disorders during
midlife is in keeping with other epidemiological findings
in the State of Qatar [22] and other Western countries
[18-28].
The relationship between physical and mental
illness is a complex one with close cause-effect factors.
Diabetes, hypertension, and ischaemic heart disease
are among the most prevalent physical condition in this
society, with a sedentary lifestyle and eating habits that
contribute to the risk. Co-morbidity with mental illness
raises concerns about the management options, quality
of life and burden of disease for these disorders [29-
33].
The present study estimates are high enough to
place mental disorders among the most commonly
occurring health problems in Qatar. This research shed
light on the prevalence of mental disorders and the
high risk groups for having mental illness in Qatar.
Mental disorders are among the most burdensome of
all classes of disease because of their high prevalence
and chronicity, early age of onset and resulting serious
impairment. The study findings highlight the urgent
need for systematic development of community-based
mental health services for the screening, early
identification, and treatment of people with Mental
disorders. This study is timely as the national mental
health strategy is launched and the Qatar mental health
implementation plan is shaped, with a focus on
prevention, early recognition and intervention. These
data will ensure our plans are better informed of the
unique needs for this country and services are
targeting the right population.
CONCLUSION
The study findings revealed that almost one-fifth of
all adults who attended the primary health care setting
presented with at least one type of mental disorders.
This study identified people at higher risk for having
mental illness. Women’s mental health is a significant
public health issue. The highest lifetime prevalence of
common mental disorders in Qatari population was
depression and anxiety disorder. The young Qatari
population in the age group 18 – 34 years were the
most affected with mental disorders. There is an urgent
need to not only assess prevalence, but also risk
factors, burden, treatment gaps and outcomes to obtain
evidence for policy making.
The format of the WHO-CIDI has been successfully
adapted and its correct functioning has been pilot-
tested for its use in Qatar. This version will facilitate the
use of an international diagnostic instrument allowing
cross-national comparative research in epidemiological
studies of mental illness in Qatar.
LIMITATIONS
As explained earlier, public research participation is
a relatively recent approach in this country and mental
health stigma is considerably high. The interview lasted
an average of 50 minutes, which was difficult to
maintain with many patients. We therefore selected to
focus our study on primarily the diagnoses reported to
aim for shorter interview duration. Although suicide and
substance misuse were among the categories
selected, denial was almost unanimous among the
studied subjects because of legal, cultural, and
religious factors. The CIDI indirectly requires some
knowledge or judgment capacity to identify organic
disorders and mental symptoms. The most common
difficulties were: 1) the interviewer should understand
the interviewees' answers and decide in which
category they fit and 2) at some moments, the
questionnaire has rules through which the interviewer
should judge and codify a symptom mentioned by the
interviewee. Questions such as: "has the interviewee
felt worthless/guilty only due to depression?," require a
minimum level of clinical experience to decide about
the presence of the symptom. Other complication
generated by the lack of clinical expertise is the
information provided by the interviewees about their
clinical diseases, which are unknown to the
interviewers. In these cases, in addition to the
interviewer's clinical judgment, the patient should
understand the diagnosis he/she had received.
ACKNOWLEDGEMENTS
This study was generously supported and funded by
the Qatar National Research Fund- QNRF NPRP 30-6-
7-38. The authors would like to thank the Hamad
Medical Corporation for their support and ethical
8 International Journal of Clinical Psychiatry and M ental Health, 2014, Vol. 2, No. 1 Ghuloum et al.
approval. We also extend special thanks to IDRAAC
centre in Lebanon for their support through the project.
COMPETING INTERESTS
The authors have no conflict of interest to declare.
AUTHORS' CONTRIBUTIONS
AB and SG organised the study, collected and
analysed data and wrote the article.
AB, SG, EEA, AEA and TEY all contributed to the
analysis and the interpretation of the data. Also, AB
made contributions to conception and design and
revised the manuscript critically.
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