Epidemiological Profile of Common Mental Health Disorders in Outpatient Psychiatry Clinics of Two Military Hospitals in Riyadh

Introduction:

The life of military personnel is different from the one of civilians in many aspects given their exceptional nature of work [1]. These include living in isolated environment, endurance of life-threatening conditions, losing friends in battlefields, and being separated from their families for long periods of time [1]. Although these stressors can have a major impact on mental health, it is still questionable whether military personnel are a high-risk group for mental disorders compared to other populations [2]. A study in the United Kingdom aimed to assess the prevalence of common mental health disorders in military personnel compared to the general population with a sample size of approximately 14090 military personnel and 15623 civilians found that military soldiers have double the chance of having symptoms of mental disorders [3]. In contrast, a study on the United States military personnel with a large sample size (77,047) found that the prevalence of mental disorders in those personnel is similar to the general population as 18.3% of the participants met the criteria for a mental disorder [4]. However, some military subgroups including single, females, younger, less educated, shorter service were found to have higher chances for some mental disorders in that study [4]. Similarly, a German study that compared the prevalence of mental disorders between 1023 civilians, 1439 deployed soldiers, and 779 non-deployed soldiers found that the prevalence of a 12-month mental illness did not differ in deployed soldiers compared to civilians, and, surprisingly, it was lower in non-deployed soldiers [2]. Nevertheless, deployed soldiers with high warfare exposure had elevated rates of agoraphobia and posttraumatic stress disorder [2].

Due to recurrent relocations, prolonged separations, the potential injury or death of the family member, and the burden of managing civilian life as a single parent, military work also has a stressful impact on soldiers’ families [5-7]. A study on 642,397 children found that there is an increase of 19% in behavioural disorders, 18% in stress disorders, and 11% in outpatient psychiatric visits when a military parent is deployed [5]. A study on the effects of deployments on the utilization of mental-health outpatient services among US army personnel’ partners found that wives of deployed personnel had more diagnoses of depressive disorders (27.4 more cases per 1000 spouses), anxiety (15.7 more cases per 1000 spouses), and sleep disorders (11.6 more cases per 1000 spouses) [6]. Even before being deployed, military soldiers and their families might endure anxiety while waiting for expected deployment [7].

Despite growing in psychiatric literature, there is scarce data addressing the mental health of Saudi Arabia or other Middle Eastern countries’ military personnel or their families. This could be attributed to security reasons and/or the negative stigma associated with psychiatric disorders in the Middle East [8]; this stigma could be more exaggerated in sensitive groups such as army forces [9]. However, data about the mental health profile of military personnel and their families are needed to establish evidence-based intervention programs to ensure good mental health among our soldiers. Thus, the aim of this study is to determine the profile of mental disorders and the characteristics of patients attending psychiatric clinics in two military hospitals that provide care for military personnel and their families in Riyadh, Saudi Arabia.

Materials and Methods:

Study design and settings:

This is across-sectional study of psychiatric patients attending clinics at two tertiary care military hospitals in Riyadh, Saudi Arabia. The two hospitals provide healthcare for military soldiers and their families.

Study Participants and sample size

All patients attending the psychiatric outpatient clinics in the study period at the two military hospitals were included in this study after their approval. Using Raosoft with margin of error 5%, confidence level 95%, and an estimated population size of 20000, the minimum recommended sample size for this study was 377.

Data collection method:

The study was approved by the Institutional Review Board and Ethical Committee of the King Abdullah International Medical Research Center (KAIMRC). All participants signed an informed consent and were informed in advance of the objectives of the study. Data were collected from the 1st of January until the 1st of December 2018. All psychiatric patients attending the outpatient clinics at two main military hospitals in the study period and who were willing to participate were included. For a sampling method, the data were collected 5 days a week (from Sunday to Thursday); every other patient attending the psychiatry clinics in these days was included in this study after his/her permission. Demographic information was collected from the patients and their electronic health records by trained physicians. Participants aged 18 years and above were included. Aggressive or severely mentally ill patients, who were unable to give consent, were excluded as well as patients with unclear/ uncertain diagnosis.

The diagnosis of participants was based on Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). Patients were divided into 6 categories according to their diagnosis: depression, anxiety, psychosis, bipolar, other disorders, and two or more disorders. Disorders included under the depression category were major depressive disorder, dysthymia, and depression due to medical illness. Moreover, disorders under the anxiety category include generalized anxiety disorder (GAD), obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), social phobia, panic disorders, and phobias. Also, the diagnosis of psychosis includes schizophrenia, brief psychotic episode, schizophreniform, substances induced psychosis, and psychotic disorder not otherwise specified (NOS), while the diagnosis of bipolar disorder includes bipolar I disorder, bipolar II disorder, bipolar disorder not otherwise specified, cyclothymia, substance induced mania, and manic episode. Other disorders include mental retardation, dementia, Alzheimer, conduct disorder, attention deficit hyperactivity disorder (ADHD), autism, neuropathic pain, intellectual disability and substance dependent.

Data management and analysis:

Data were analysed using Statistical Package for the Social Sciences (SPSS) version 21. Categorical variables were described using frequency and percentages. For evaluating the association between the study variables and four psychiatric disorders (depression, anxiety, psychosis, and bipolar), a Pearson’s Chi-square test was used and odds ratios (specific disorder vs. other disorders) were calculated. For observing the independent association of the prevalence of the diagnostic categories with the study variables, multivariate binary logistic regression was used. To test the goodness of fit of the models, the Hosmer and Lemeshow test was used. A P-value of less than .05 and 95% confidence intervals were considered statistically significant.

Results:

Demographics:

Of the 439 participants, 202 (46.5%) were male, 259 (64.6%) were in the 26 to 50-year-old age group and 270 (63.7%) were married. The educational status of the participants was evenly distributed and more than 50% were unemployed. Almost 75% of the participants were either overweight (29.8%) or obese (43.5%) (Table1). The prevalence of psychiatric disorders (depression, anxiety, psychosis and bipolar disorder) among the psychiatric outpatient clinics’ attendees in the two military hospitals is available in Table 2.

Associated factors with the common psychiatric disorders:

Psychosis:

The bivariate analysis shows a statistically significant association between psychosis and gender, age group, marital status, educational level, and occupation. Compared to the other groups, the odds of suffering from psychosis were higher among males (OR: 2.54), ≤ 25-year-old age group (OR: 11.47), single (OR: 28.44), secondary education (OR: 4.43), and students (OR: 3.92). BMI level was not significantly associated with having psychosis. (Table 3 and Table 4).

Depression:

Depression was significantly associated with gender, age group, marital status, educational level, and BMI. Odds of suffering from depression were higher among females (OR: 1.97), > 50-year-old age group (OR: 3.97), widowed (OR: 5.19), illiterate (OR: 2.30), underweight and obese people (OR: 2.90 and 2.10) than the other groups. In contrast, occupation was not significantly associated with depression (Table 3 and Table 4).

Anxiety disorder:

Anxiety disorders did not show an association with gender or occupation but was significantly associated with age (26-50 years-old, OR: 2.86), marital status (married, OR: 3.62), and education (University and higher, OR: 2.20). Also, people with normal and overweight BMI had slightly higher odds of having anxiety than the other groups (OR: 5.67 and 5.47) (Table 3 and Table 4).

Bipolar disorder:

Bipolar disorder was not statistically and significantly associated with any of the study variables.

Other disorders and two or more disorders:

Due to the low prevalence of “other disorders” and “two or more disorders”, there was no evidence of a significant association with the study variables.

Discussion:

In this study, we found that the most frequent diagnosis among the subjects in psychiatric outpatient clinics in military hospitals was depression (44.4%), followed by anxiety (35.1%), psychosis (25.7%), and bipolar disorder (7.1%) (table 3). This finding is contradictory to a recent study by Alosaimi et al [10] that looked into the pattern of psychiatric disorders in six different civilian hospitals; authors in that study reported that the most frequent psychiatric diagnoses in outpatients following in public hospitals were depression (29.3%), psychosis (28.9%), anxiety (15.6%) and bipolar (11.5%) [10]. The Percentage of mood disorders and anxiety are much higher in this study (86.6%) compared to (56.4%) in Alosaimi’s et al [10]. Another public-hospital based study that assessed the prevalence of depressive disorders among psychiatric outpatients in eastern Saudi Arabia found that the prevalence of depression was 19.3% [11], which is lower than the percentage that was found in the present study in military hospitals (44.4%), and more similar to the percentage that was found by Alosaimi et al in other public hospitals (29.3) [10].

When comparing the prevalence of mental disorders in male subjects in military hospitals to male subjects in public hospitals, men in military hospitals had a higher prevalence of depression and anxiety compared to men in public hospitals. The most common mental disorder in male outpatients in public hospitals was psychosis (40.4%), followed by depression and anxiety which had the same percentage (14.8%) [10]. However, the most common disorder among men in military hospitals was depression (35.6%), followed by psychosis (34.7%), and anxiety (33.2%) (table 3). The higher levels of depression and anxiety in male outpatients in military hospitals could be attributed to them being military personnel or members of military families, which makes them face special stressors such as deployment and the potential injury or death of oneself or a family member.

In this study, when mental disorders were investigated only in people who work as military soldiers (n=104, 24.5%) (table 1), it was found that the most common mental disorders in military soldiers were anxiety (42.3%) and depression (37.5%) (table 3). However, this finding cannot be generalized to all military personnel and the true prevalence of mental disorder among military personnel might be higher as only outpatients were investigated. Military personal is a sensitive group and some of them might prefer to be followed outside their own institution for different reasons which were addressed previously in the literature such as stigma, fear of being perceived weak or incompetent by colleagues, and fear of being medically downgraded [9].

Regarding similarities between military and civilian hospitals, depression was found to be the most common disorder among female outpatients in both types of hospitals (military: 52.2%, public: 30.3% [10]). This similarity could be due to the fact that all military personnel in Saudi Arabia are men, so women in both studies had similar demographics although women in military hospital usually are spouses or first-degree related to military personnel. Also, unemployment was common (military: 52.0%, public: (68.1% [10] and 70% [11]) among the outpatients in both types of hospitals. This finding suggests that poor mental health could influence the employment status of an individual or vice versa.

Another similarity between the psychiatric outpatients in military and public hospitals was the high rates of overweight and obesity (military:73.3%, public: 69.9% [10]). Strikingly, three-quarters of subjects in this study fit into overweight and obesity categories which is much higher prevalent than other local studies on Saudi population (table 1) [12]. Although previous evidence found that obesity is linked to an increased in anxiety and mood disorders [13], the use of medications in management of mood and anxiety disorders might contribute to this finding, and a directional causality cannot be indicated. This finding could also be due to the lack of physical activity among psychiatric patients, which could be supported by a previous study that was conducted on 796 psychiatric outpatients and 389 psychiatric inpatients in five different regions across Saudi Arabia and found that approximately 87% of these patients were physically inactive with higher levels of physical activity among men compared to women (15.9% versus 9.6%, p<0.001) [14].

There was a remarkable age-specific mental illness prevalence among psychiatric outpatients in this study, among younger age group (≤25), psychosis was most prevalent. Anxiety disorders were highly prevalent in middle age group (26-50), while in older age group (>50) depression was the commonest (table 3,4). The results share similar conclusions with the ones of other previous studies [15-17]. The wide variation of the age specific mental illness prevalence imposes a great challenge on mental health services and healthcare system in Saudi Arabia where there is a lack in specialized clinic for specific population like adolescence and geriatric.

The findings also showed that there is a significant association between higher education and anxiety; it is assumed that higher education could introduce stress by itself which might be a confounding factor. Although there is inconclusive data about true association of education with anxiety, some of the studies linked low education to anxiety which contradicts the finding of this study [18].

This study showed that widowed status was the highest risk factor among all other marital status for depression (table 3). Widowhood is an overwhelming state that needs support in many aspects like the spiritual, social, and medical ones. While this finding is not surprising, emphasis is still put on the importance of addressing widowhood as a significant risk for depression in primary care and psychiatric settings.

Psychosis in this study was associated with unemployment, younger age, and being single. This finding is alarming as these are crucial stages in life and social support is needed the most, especially, in the presence of mental illness, although family support in Saudi Arabia anticipated to have a positive effect [19].

Limitations

The current research study can be summarized as follows: No available data on mental disorders in Saudi or Middle Eastern military personnel was found. Consequently, there are no other findings to compare with the ones of the present study. Not all the participants in this study were military personnel; thus, further studies are needed to establish a more precise profile of mental disorders among military soldiers, and the outpatient followers, even if they were all military, it does not provide an accurate representation of military personnel mental health due to some barriers to mental health treatment in military population. Thus, exploring private clinics is essential as private mental health services are growing in Saudi Arabia, and a significant percentage of patients might prefer private clinics over public ones for several reasons like fear of stigmatization and fast service.

Conclusions

the majority of patients attending psychiatric clinics have depression, then anxiety, psychosis, and bipolar disorder respectively. More data is needed to develop effective measures for military personnel and their families to ensure good mental health for them. The high rates of obesity and overweight warrant further studies to identify the possible reasons. Also, weight reduction and physical exercise programs, if added to the treatment plan, could be beneficial. A national wide survey is needed including private and governmental sectors as empowering primary mental health is a national priority along with establishing specialized clinics for special population.

Acknowledgment

The authors declare that they have no conflicts of interest. This study was funded by the King Abdullah International Medical Research Center (KAIMRC).

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