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R E S E A R C H Open Access
Opiate agonist treatment to improve health
of individuals with opioid use disorder in
Lebanon
Ali Ghaddar
1,2*
, Zeinab Abbas
3,4
and Ramzi Haddad
5,6
Abstract
Background: Opioid agonist therapy has been widely used to reduce harms among individuals with opioid use
disorder but its effectiveness has not been evaluated in the Middle East North African (MENA) region. This study aims
to evaluate the effectiveness of a program using opioid agonist therapy in combination with psychosocial support on
improving psychological and social well-being, reducing arrest, and reducing risky behavior in individuals with opioid
use disorder in Lebanon.
Methods: A one-group pre-test post-test design study was performed at SKOUN Lebanese Addiction Centre between
January 2013 and December 2014. Eighty-six out of 181 patients agreed to participate and completed the 3-month
assessment and 38 concluded the 12-month assessment. Psychological (depression and anxiety, quality of life), substance
dependence/abuse, behavioral (injecting behavior, sharing needles and paraphernalia), and social outcomes were
evaluated at baseline, 3, and 12 months post-treatment.
Results: Remarkable statistical significance improvements were observed 3 months after treatment in most outcome
variables including quality of life, anxiety, substance dependence, overdose, employment, and injecting behavior.
Improvements were sustained 12 months after treatment.
Conclusion: Results support expanding the access to opioid agonist therapy in other MENA countries to treat substance
dependence and reduce harms among individuals with opioid use disorder.
Keywords: Buprenorphine, Harm reduction, Opiate-related disorders, Lebanon
Background
Opioid agonist treatment (OAT) has become the main
treatment approach for people with opioid dependency
and a fundamental component of the evidence-based
harm reduction approach to HIV prevention in many
developed countries [1]. Its implementation has resulted
in a marked reduction in HIV-related risky behavior
including injecting needles and sharing syringes leading
to a decline in HIV transmission, HIV incidence, and
mortality associated with unsafe injection [2, 3] and in
preventing the spread of hepatitis C virus among inject-
ing drug users (IDUs) [4]. OAT has been increasingly
used in order to decrease the health, economic, and
social consequences of substance abuse and to improve
quality of life (QoL) of opioid-dependent users [5–8].
OAT involves the provision of opioid agonist such as
methadone and buprenorphine. The choice of the drug
and of the modality of its provision (observed vs. take-
home) influences treatment outcomes, yet there is little
consensus about the most effective treatment regime [9].
A synthesis of evidence obtained from placebo-controlled
trials revealed that buprenorphine is effective in suppress-
ing illicit opioid use [9] and in (at higher doses) retaining
patients in treatment although to a lesser extent than
methadone [10, 11]. On the other hand, buprenorphine
has longer duration and limited withdrawal syndrome,
and patients who receive buprenorphine were more likely
to test negative for opioid use compared to those receiving
methadone [12]. It also has a safer profile over methadone
in terms of reducing mortality [11] and reducing
* Correspondence: ali.ghaddar@liu.edu.lb
1
Department of Biomedical Sciences, Lebanese International University,
Beirut, Lebanon
2
Observatory of Public Policies and Health, Beirut, Lebanon
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Ghaddar et al. Harm Reduction Journal (2017) 14:78
DOI 10.1186/s12954-017-0204-8
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
diversion-related death [13]. In general, international
guidelines emphasize direct observational induction of
buprenorphine followed by multiple in-clinic visits [14].
However, with less strict supervision, unobserved take-
home induction supposes fewer logistic barriers and thus
results in better treatment outcomes including prolonged
abstinence from opioids and reduced drug use [15, 16].
Despite its proven effectiveness and affordability, OAT is
still unavailable in many low- and middle-income countries
where it is desperately needed [1]. In such countries, evi-
dence from a WHO collaborative study suggested that
OAT reduced illegal opioid use, HIV-associated risk behav-
iors, and criminality, and substantially improved physical
and mental health among opioid-dependent patients [17].
OAT also resulted in substantial improvements in QoL and
in several domains of Addiction Severity Index including
drug use, psychological well-being, criminality, and family
relations [18]. OAT also demonstrated positive impact on
QoL and physical, psychological, and social well-being
among opioid users in Malaysia, Lithuania [19, 20], and
Ukraine [21] and on reducing injecting behavior, criminal-
ity, HIV infections, and improving QoL in China [22–24].
Similarly, in Taiwan, OAT showed significant improve-
ments in health-related QoL, psychological, and social well-
being, and HIV-related risky behavior [25]. Indeed, there is
increasing evidence suggesting that OAT could attain con-
sistent outcomes in a culturally diverse range of settings in
both low- and middle-income and high-income countries.
In another study, OAT significantly reduced arrest inci-
dences, risky behavior, and improved QoL [26]. Likewise,
other studies encouraged to scale up OAT in low- and
middle-income countries to save lives and resources [2].
This issue is of particular importance as the epidemic of
dependence on prescription opioids is predicted to spread
to low- and middle-income countries [27].
So far, OAT has been provided in at least five Middle
East and North African (MENA) countries. Morocco
developed a national plan that enabled the introduction
of methadone substation treatment pilot programs in
2010. Bahrain, United Arab Emirates, and Palestine have
also recently started providing OAT. Iran adopted OAT
in its national policy and is the pioneer and leader in
outpatient programs with estimated 4275 dispensing
centers. In MENA countries, OAT program outcomes
have been evaluated only in Iran where evidence support
its effectiveness in reducing drug use, injection behavior,
and syringe sharing and in improving health, QoL [28],
and social well-being among IDUs [29].
In 2011, Lebanon adopted an OAT take-home bupre-
norphine pilot program only provided by authorized
psychiatrists working within pre-registered treatment
settings. One particularity of the treatment modality in
Lebanon is the provision of psychosocial support as a
basic component of the treatment. After being assessed
for eligibility to treatment (diagnosis with opioid use dis-
order according to DSM5 criteria), patients are followed
on weekly basis by a multidisciplinary team consisting of
a psychiatrist, psychologist, social worker, and registered
nurse. During follow-up, patients are monitored through
regular urine tests for opiates, buprenorphine, and other
drugs and are assessed for possible misuse, diversion,
stability, and response to treatment. Furthermore, it is
worth to mention that in Lebanon, a national study con-
ducted in 2010 showed that heroin use accounted for
50% of patients treated for addiction and described a
high rate of relapse among heroin users. It also revealed
a high rate of arrest related to heroin use, with half of
the treated patients having been already arrested at least
once by the police [30]. Another particularity of OAT in
Lebanon is that it could be a way out of arrest related to
drug use, as drug use is criminalized in Lebanon except
for users registered in treatment programs.
Almost 6 years has passed since the program initiation
in Lebanon in 2011, yet, there exist no published reports
about its effectiveness. Furthermore, the effectiveness of
an OAT approach combining the component of psycho-
social support provided by multidisciplinary team has not
been well explored in previous research. The current
study aims to evaluate the effectiveness of the pilot OAT
program in Lebanon implemented by multidisciplinary
teams on treating substance use disorders, improving the
mental health and social functioning, and in reducing
risky behavior among individuals with opioid use disorder.
It also aims to explore the program outcome on reducing
arrest related to drug use among registered users.
Methods
Assessment
The Lebanese Public Health Ministry (MOPH) imple-
mented buprenorphine for treating opioid use disorder as
evidence documents its feasibility, comparable safety pro-
file, and fewer logistic barriers than observed induction
[14]. The national guidelines specify that patients receive
weekly take-home buprenorphine prescribed by authorized
psychiatrists working within pre-registered treatment
settings. Eligible patients diagnosed with opioid use
disorder according to DSM5 or ICD10 (WHO) criteria are
followed up on weekly basis by multidisciplinary teams
consisting of a psychiatrist, psychologist, social worker, and
registered nurse. Patients are monitored through regular
urine tests for opioids and buprenorphine and are assessed
for possible misuse, stability, and response to treatment
during regular visits to treatment center.
Upon admission, participants completed a self-
administered questionnaire that included variables on
socio-demographic characteristics, medical history, and
substance use. Participants were interviewed by trained
psychologists that were part of the treatment team and
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were trained for the purpose of the project. For each
patient, questionnaires were filled systematically at three
time intervals: upon admission (baseline), 3, and
12 months post-treatment.
The research protocol was approved by the institutional
review boards at SKOUN and at the Lebanese
International University. A one-group pre-test post-test
design was adopted in order to measure the effect of OAT
by examining the difference in the outcomes at baseline,
3, and 12 months post-treatment.
Participants
SKOUN Lebanese Addiction Center is the first and
largest outpatient community-based treatment center to
implement OAT in Lebanon and currently enrolls
around 40% of the OAT patients in Lebanon. Partici-
pants in the study were opioid-dependent patients who
sought treatment at SKOUN. During the study period
(January 2013–December 2014), patients diagnosed with
opioid use disorder according to the Diagnostic and
Statistical Manual of Mental Disorders (DSM5) who
were prescribed OAT at SKOUN were approached for
participation (181 male patients). Women were not
included as there is a very low prevalence of women
seeking treatment, especially for heroin dependence.
Participants were clearly explained that refusal to
participate will not affect their treatment process.
Eighty-six patients agreed to participate and concluded
the 3-month follow-up assessment, out of which 38 con-
cluded the 12-month follow-up assessment. Participants
were briefed by the team members about the objectives
of the research and signed a written informed consent
prior to participation. Patients were explained that
refusal to participate will not affect positively or
negatively their treatment. Ethical approval was obtained
from the Institutional Review Board of the Lebanese
International University.
Measures
Participants were asked about their age, educational
level, average household income, marital status, employ-
ment criminal activity, number of arrests, and number
of days in prison. Several participants had along with
heroin dependence other substance dependence (cocaine
and cannabis). We monitored the outcome of OAT on
reducing heroin dependence along with cocaine and
cannabis dependence. Substance use disorder (i.e.,
heroin, cocaine, and cannabis) was assessed according to
DSM5 criteria (American Psychiatric Association, 2000).
Self-reports concerning participants’general health in
the last 2 weeks were measured using EUROHIS QoL
Scale (WHO QOL-8) validated questionnaire [31]. The
scales were composed of eight questions with Likert-
type scale with five response options (1 = very poor, 5 =
very good). The utilized scales were translated and
blindly back translated in Arabic by two separate
professional translators. An expert panel helped solve
discrepancies between both translations and the final
version was used.
The Hospital Anxiety and Depression Scale (HADS)
was used to assess psychological well-being [32]. Each of
anxiety and depression was measured by seven items with
Likert-type scale with four response options (0 = not at
all, 3 = most of the times). Anxiety was assessed by asking
whether participants experienced tense or frightened
feelings, worrying thoughts, or whether they felt restless.
Depression was assessed through questions such as “I
have lost interest in my appearance.”The score of each
dimension is established by the summation of the individ-
ual questions. Cronbach’s alpha reliability coefficients of
the scales in the sample were 0.77, 0.84, and 0.81 for QoL,
anxiety, and depression, respectively.
Injecting behavior was measured through a scale from
1 to 4 (1 = during last 3 months and 4 = never) and
sharing needles was measured through a scale from 1 to
6 (1 = more than 10 times and 6 = never) based on a
questionnaire that measures risk for transmission of
blood-borne viruses [33]. Overdose was measured
through a simple question about overdose during last
3 months.
Statistical analysis
We displayed in the results only the pretreatment
variables that explained at least 1% of the variance in
our health outcomes (Table 1). The other pre-treatment
variables that could not account for variance in the out-
come variables (eta-square less than 0.01) are not men-
tioned in the table. Shapiro-Wilk test was used to check
the normality of distribution of the outcome variables.
For continuous variables that showed normal distribution
(QoL, anxiety, and depression), within-group changes were
analyzed using paired, one-tailed ttest (for the 3-month
assessment) and one-way repeated measure ANOVA (for
the 12-month assessment). For the other variables that
were not normally distributed, changes in nominal
categorical variables (previous arrest, work) were analyzed
using the McNemar non-parametric tests with effect sizes
calculated in accordance with Cohen’sd. Differences in
ordinal variables (injecting behavior and sharing needles)
were analyzed by z-Wilcoxon rank non-parametric
tests with calculating r-correlation coefficient for effect
size. α-level of 5% was considered statistically significant.
Results
Sample characteristics
The baseline characteristics of participants who com-
pleted the 3- and the 12-month assessment are displayed
in Table 1. Participants age ranged between 18 and
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66 years with median = 28 years (standard deviation = 7.61).
Around 73% of participants had history of arrest. The num-
ber of previous arrests ranged between 0 and 18 times with
median = 2 times (standard deviation = 2.86). Participants
stayed in prison between 0 and 6330 days with median =
20 days (standard deviation = 716.27 days). Around half of
the participants had school education and had low average
household income, and the majority were never married.
Results indicated that the treatment had positive
effects on the quality of life, anxiety, and depression that
were sustained over the two post-treatment time inter-
vals. QoL scores significantly increased while anxiety
scores significantly decreased 3 and 12 months after the
treatment. Likewise, depression scores dropped after the
treatment, although the difference in scores compared to
baseline was statistically significant at the 3-month
interval but lost significance at the 12-month interval.
However, although reductions in anxiety scores were
maintained 12 months after the treatment, the difference
between baseline scores of anxiety lost statistical signifi-
cance (Table 2).
The treatment had positive effects on reducing arrest
and improving employment over time. McNemar’s test
determined that there was a statistically significant
reduction in the proportion of persons arrested, at the
two time intervals (3 and 12 months) post-treatment
compared to baseline. However, the % of employed
patients increased 3 months after treatment (statistically
significant difference) and 12 months after treatment
(non-significant difference). Similarly, the McNemar test
showed statistically significant reductions in the % of
patients who reported overdosing and the % of patients
who met heroin, cocaine, and cannabis dependence
criteria, at both the 3 and 12 months’time intervals after
the treatment (Table 3).
Results of the Wilcoxon z-non-parametric test
indicated a slight, statistically non-significant reduction in
injecting behavior scores at the 3-month interval (z=−1.23;
pvalue = 0.15; effect size r= 0.09) and the 12-month
intervals (z=−0.56; pvalue = 0.21; effect size r= 0.07). Simi-
larly, the Wilcoxon ztest showed significant reduction in
the score of sharing needles 3 months (z=−1.67; p
value = 0.001; effect size r= 0.12) and non-significant
reduction in the scores 12 months after the treatment
(z=−0.22; pvalue = 0.82; effect size r= 0.03). Fewer
patients reported overdosing after 3 and 12 months
compared to baseline. Significant reductions were
noted in the % of patients who met opioid use
disorder, cocaine use disorder, and cannabis use dis-
order 3 and 12 months after treatment.
Discussion
The primary outcome evaluation of OAT pilot program in
Lebanon supports its implementation for treating substance
use disorder and reducing harms among individuals with
opioid use disorder. Remarkable statistically significant
improvements were observed over time (3 and 12 months)
among patients under buprenorphine in most outcome
variables including QoL, anxiety, substance dependence,
overdose, and employment. Congruent findings have been
observed in low- and middle-income countries about the
effectiveness of buprenorphine in improving mental health
and in reducing risky behaviors [17].
The most impressive finding was improvement in em-
ployment, not something usually noted in evaluations
performed in high-income countries. Statistically signifi-
cant improvements in QoL were documented after
treatment, in consistence with previous findings in low-
and middle-income countries [18]. Contrary to findings
obtained in other countries, the percentage of arrest
Table 1 Pre-treatment individual characteristics of participants who
completed the 3-month assessment (n= 86) and the 12-month
assessment (n=38)
3 months 12 months
Age, years n=86 n= 38
18–25 32 (37.2%) 15 (39.5%)
26–30 25 (29.1%) 11 (28.9%)
31–35 20 (23.3%) 9 (23.7%)
36+ 9 (10.5%) 3 (7.9%)
Educational level n=84 n= 37
Illiterate 19 (22.6%) 5 (13.5%)
School 44 (52.4%) 19 (51.4%)
University 21 (25.0%) 13 (35.1%)
Average household income, $ n=77 n= 34
Low (< 1000) 43 (50.0%) 20 (52.6%)
Middle (1000–2500) 25 (29.1%) 11 (28.9%)
High (2500+) 9 (10.5%) 3 (7.9%)
Marital status n=86 n= 38
Never married 60 (69.8%) 24 (63.2%)
Ever married 26 (30.2%) 14 (36.8%)
Number of times arrested n=86 n= 38
None 24 (27.9%) 10 (26.3%)
1 20 (23.3%) 11 (28.9%)
≥2 42 (48.8%) 17 (44.7%)
Longest duration of detainment, days n=86 n= 38
0 23 (26.7%) 10 (26.3%)
1–30 21 (24.4%) 12 (31.6%)
≥1 month 42 (48.8%) 16 (42.1%)
Substance concern n=86 n= 38
Heroine 76 (89.4%) 36 (94.7%)
Cocaine 10 (11.6%) 6 (15.8%)
Cannabis 15 (17.4%) 7 (18.4%)
Ghaddar et al. Harm Reduction Journal (2017) 14:78 Page 4 of 7
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among patients receiving OST significantly decreased
after the treatment [34]. A possible explanation of this
discrepancy in the results is that participants were
arrested due to drug use, which is considered a criminal
act in Lebanon. Registering in the OAT program is a
way out of penalizing persons using drugs. This probably
explains the high number of arrest reported before en-
gaging in the program and the dramatic drop 3 months
after treatment.
Limitations
The current study has some limitations related to the
study population and design. The absence of a control
group and of randomization poses limitations to internal
validity related to the difficulty to exclude confounders.
The sample size was not calculated a priori, was
relatively small, and represented exclusively male heroin-
dependent users. Finally, results are prone to
information bias related to self-reporting as reported
improvement could have been possibility overestimated.
Actually, it could be argued that patients usually enter
treatment at a time of crisis, when social functioning is
poor and self-report is prone to overstate poor health.
On the other hand, there is a selection bias related to
non-response and loss to follow-up, as one could argue
that those followed up are the ones who were successful
and that only 47.5% concluded the 3-month assessment.
A possible explanation for patient non-participation and
dropout could be the transfer of patients to other
centers or due to patients’own will to stop treatment. A
more comprehensive evaluation is needed to monitor
the benefits of the treatment on a longer term.
Conclusion
Results have important implications to guide policy
makers in making informed decisions about treatment
options of individuals with opioid use disorder. The
challenges related to the difficult socio-political context
that faced the implementation of OAT program in
Lebanon since its launching in December 2011 should
be taken into consideration [35]. Other MENA countries
implementing OAT should also take into consideration
the specificities of the treatment protocol adopted by the
Table 3 Changes in frequency and % in outcomes 3 and
12 months post-treatment
n(%) pvalue
Arrested last 3 months—3-month assessment (n= 86)
Baseline 62 (72.1%)
3 months 7 (8.1%) 0.001
Arrested last 3 months—12-month assessment (n= 38)
Baseline 24 (70.6%)
12 months 1 (2.6%) 0.001
Working—3-month assessment (n= 86)
Baseline 24 (27.9%)
3 months 52 (60.5%) 0.02
Working—12-month assessment (n= 38)
Baseline 12 (31.6%) 0.07
12 months 30 (78.9%)
Ntimes overdose—3-month assessment (n= 86)
Baseline 12 (14.0%)
3 months 3 (3.5%)* 0.02
Ntimes overdose—12-month assessment (n= 38)
Baseline 8 (21.1%)
12 months 1 (2.6%) 0.03
Heroin use disorder—3-month assessment (n= 86)
Baseline 72 (100%)
3 months 5 (6.9%) ≤0.001
Heroin use disorder—12-month assessment (n= 38)
Baseline 38 (100%)
12 months 1 (2.6%) ≤0.001
Cocaine use disorder—3-month assessment (n= 86)
Baseline 13 (18%)
3 months 1 (1.3%) p= 0.04
Cocaine use disorder—12-month assessment (n= 38)
Baseline 6 (15.8%)
12 months 1 (2.6%) p= 0.01
Marijuana use disorder—3-month assessment (n= 86)
Baseline 18 (25%)
3 months 6 (9.7%) p= 0.01
Marijuana use disorder—12-month assessment (n= 38)
Baseline 8 (21%)
12 months 3 (7.8%) 0.04
Table 2 Changes in mean (s.d.) in outcomes 3 and 12 months post-treatment
3-month assessment (n= 75) 12-month assessment (n= 36)
Variable and group Baseline Post 3 months pvalue Effect size Baseline Post 3 months Post 12 months pvalue Effect size
EUROHIS Quality of Life
Scale (8–40) mean (s.d.)
21.82 (6.59) 24.93 (6.32) p≤0.001 Cohen’s d = 0.37 22.37 (6.22) 24.16 (5.82) 24.84 (6.92) p= 0.05 η2 = 0.14
Anxiety (HADS) (0–21)
mean (s.d.)
9.62 (4.09) 7.29 (4.55) p= 0.001 Cohen’s d = 0.34 9.27 (3.84) 7.18 (4.19) 6.91 (3.91) p= 0.006 η2 = 0.24
Depression (HADS)
(0–21) mean (s.d.)
8.97 (3.56) 7.66 (3.69) p= 0.03 Cohen’s d =0.21 8.94 (3.58) 8.01 (3.54) 7.65 (3.82) p= 0.19 η2 = 0.17
HADS Hospital Anxiety Depression, s.d. standard deviation, dCohen’sdeffect size, η2eta-squared effect size
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Lebanese pilot program and should address adopting
alternative treatment provision protocols. For instance,
in the Lebanese example, a positive evaluation of reten-
tion in the program was given to patients who tested
negative in the weekly urine test. Following the latest
evidence about using more frequent urine testing would
allow for a more objective evaluation of the retention in
the program and provide better outcomes on sustaining
opioid-free urinalysis [36]. Further evaluations of the
effectiveness of OAT countries are warranted to monitor
the potential adverse effects associated with buprenor-
phine misuse in MENA [1, 37]. The encouraging results
of the evaluation of the first pilot OAT program in
Lebanon support expanding the access to buprenorphine
in Lebanon and other MENA countries in order to treat
individuals with opioid use disorder.
Abbreviations
HIV: Human immunodeficiency virus; IDUs: Injecting drug users;
MENA: Middle East North Africa; MoH: Ministry of Public Health; OAT: Opioid
agonist therapy; QoL: Quality of life
Acknowledgements
The authors acknowledge the support of the SKOUN Lebanese Addiction
Center during the phases of study design and data collection. The authors
also acknowledge Dr. Alaa Fawaz for revising the paper.
Funding
This study was funded by the National Council of Scientific Research
(CNRS)—Lebanon.
Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated
or analyzed during the current study.
Authors’contributions
AG carried out the study design, evaluation, and data analysis and drafted the
manuscript. ZA drafted parts of the manuscript and provided guidance as a
consultant in the implementation of opioid substitution treatment programs.
RH revised and adjusted the study design and coordinated the psychiatric
follow-up and evaluation of the study participants. All authors read and ap-
proved the final manuscript.
Ethics approval and consent to participate
All procedures performed in studies involving human participants were in
accordance with the ethical standards of the institutional and national
research committee and with the 1964 Helsinki declaration and its later
amendments or comparable ethical standards. Informed consent was
obtained from all individual participants included in the study.
Consent for publication
Not applicable
Competing interests
The authors declare that they have no competing interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Department of Biomedical Sciences, Lebanese International University,
Beirut, Lebanon.
2
Observatory of Public Policies and Health, Beirut, Lebanon.
3
School of Pharmacy, Lebanese International University, Beirut, Lebanon.
4
Department of Narcotics, Ministry of Public Health, Beirut, Lebanon.
5
Department of Psychiatry, Lebanese University, Beirut, Lebanon.
6
Department of Psychiatry, Saint Joseph University, Beirut, Lebanon.
Received: 15 September 2017 Accepted: 29 November 2017
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