Reviewing the US Select Agents and Toxins List with More Efficient Assessment of the Potential Applicability of Microbes in Bioterrorism: The Fungal Agent

Maha S Younis^1# and Riyadh K Lafta^2#*

¹Department of Psychiatry, Baghdad University, Iraq

²Department of Community Medicine, Mustansiriya University, Iraq

*Corresponding author: Riyadh Lafta, Department of Community Medicine, College of Medicine, Mustansiriya University, Iraq

Received: August 20, 2014; Accepted: September 18, 2014; Published: September 20, 2014

Abstract

Background: Iraq is an exemplar of the challenging mental health needs in underdeveloped, conflict-affected countries as it has been exposed to the large share of traumatic events since 1980 including the economic sanction, sustainable acts of violence, and terrorism. Iraq lacks to link primary health care and mental health needs, supervised by specialized psychiatric department.

Objective: To explore the workload on the Neuropsychiatric clinic in Baghdad (as a conflict region) at a critical period of economic, social and security instability.

Methods: This is a cross-sectional; outpatient based record study that investigated patients of the main Neuropsychiatric consultation clinic in Baghdad. All the files of the patients for the studied year (1993) were studied, computed, and tabulated to extract data and profile of the patients that attend this clinic during an entire year. Identification of mental illnesses was based on clinical diagnosis by the senior psychiatrist.

Results: The total studied sample was 10101patients. The highest percentage of attendees was in the age group 21-40 (40.6%). Males showed a higher percentage (55.3%) than females (44.7%) with a female to male ratio of about 1:1.2. Headache forms 22.2% of the total mental disorders reported at that year, anxiety disorders form 18.9%, mood disorders 16%, epilepsy 15.7%, neurotic disorders 9.7% and psychotic disorders 7.3%.

Conclusion: The outpatient workload in Iraq as a conflict region at that time was higher than the accepted rate of patient/ doctor visits per day. Most of the attendees were young adults, males more than females, and the most prevalent mental disorders were headache then anxiety and mood disorders.

Keywords: Workload; Conflict region; Neuropsychiatric clinic

Introduction

The mental health services in Baghdad began to develop at the early fifties when a number of European qualified psychiatrists and neurologist joined the growing national health system in Iraq mainly in Baghdad [1,2]. During the 1970s and 1980s, Iraqi health care and medical education were considered to be the best in the region. At 1970; the (Medical City Teaching Hospital) was established with a new well equipped Neuropsychiatric clinic that functions under a referral protocol [3]. Implementing a proper referral and appointment protocol in this clinic was put in action at the mid-eighties. At the time of the cease-fire of the first Gulf War, the economic sanction imposed on Iraq led to a diminution of financial, social and medical resources in the country [4,5].

The workload and attendance rate of the psychiatric clinic was not fully explored in Iraq, nor by the Arab authors apart from some studies that mainly focused on referral systems [6,7]. Iraq lacks data on how the primary health care and mental health facilities should be linked to a specialized psychiatric department [8]. The studied clinic was established to be the station of first contact for patients with psychiatric or neurological complaints regardless of referral appointments which eventually increased the workload on the clinic, Iraq is an example of the challenging mental health needs in low-income, conflict-affected countries as it has been exposed to large-scale traumatic events since 1980, in addition to the comprehensive economic sanction and continuous acts of violence, this insecure situation negatively impacts on the psychosocial status of the Iraqi community, especially women and children [9,10].

The studied clinic is reputable, serves patients from Baghdad as well as from remote provinces, it is centrally located, accessible and run by highly qualified doctors [3]. To the best of the author's knowledge, this is the first comprehensive report that describes the work load in such a clinic during the era of sanction. The rationale behind conducting this study is to explore the workload on the Neuropsychiatric clinic in a conflict region at a critical period and to study patient's distribution according to some demographic characteristics and types of their neuropsychiatric disorders.

Methods

This is a cross sectional outpatient based record study of the patients of the Neuropsychiatric Consultation Clinic in the campus of the Medical City (the main teaching hospital in Baghdad). The clinic is comprised of a consultant psychiatrist, a specialist registrar, two clinical psychologists and two social workers. The clinic opens six days a week and is known to be accessible to the general public. Every attendee is registered by the clinic clerk and pays a minimal fee for registration. The registration paper includes some demographic characteristics of the patients: name, age, sex, occupation, residence and the eventual diagnosis. Drugs provided free from the hospital pharmacy. The consultation file includes demographic data and clinical details, archived alphabetically into the clinic box files. We have collected and studied the files of the entire calendar year (from January through December 1993). The Medical City is the main Medical campus that comprises almost all medical, surgical and gynecological specialties in Baghdad. It drains the patients from almost all the districts and sectors of Baghdad in addition to the attendees from vicinity and remote governorates, so, we are relatively confident that the sample included in this study was representative -at least- for Baghdad and nearby governorates, it also represents -accordingly- different socio- economic strata (elite, public and urban). All the patients' files for the studied year (1993) were collected, revised, computed, organized and tabulated to list out the bulk and profile of the patients that attend this clinic during an entire year.

A structured form was used to extract the following data from these files: name, sex, age, date of attendance, occupation, residence, a short history of the illness and provisional diagnosis. Identification of mental illnesses was based on clinical diagnosis by the senior psychiatrist and neurologist.

Results

The total number of patients attended the Neuropsychiatric clinic during the whole year was 10200; 99 files were deficient in their information and were discarded, the total studied sample was 10101.

Table 1 show that children less than ten years of age from 6.8% of the total attendees, and people age more than 60 years from 8% of the total. The highest percentage was in the age group 21-40 (40.6%) while the age groups (11-20 and 41-60) showed percentages of (19.4% and 25.2%) respectively. Males showed a higher percentage (55.3%) than females (44.7%) with a female to male ratio of about 1:1.2. In respect to the occupation; the results revealed that 26.5% were housewives, 20.5% students and 19.4% were governmental employees. Table 2 shows the distribution of the patients according to their illnesses; headache forms 22.2% of the total mental disorders, anxiety disorders form 18.9%, mood disorders 16%, epilepsy 15.7%, neurotic disorders 9.7% and psychotic disorders 7.3%.

Table 1: Distribution of the studied sample according to age, sex, and occupation.



  
     
    Number 
    % 
  
  
    Age (years) 
      1-10
      11-20
      21-40
      41-60
      >    60
       
     
      689
      1958
      4101
      2544
      809
     
      6.8
      19.4
      40.6
      25.2
      8.0
  
  
    Sex 
      Male
      Female
     
      5591
      4510
     
      55.3
      44.7
  
  
    Occupation 
      Governmental    employees
      Work    in private sector
      Housewife    (female)
      Unemployed    adults
      Students
      Non-schooled children
      Retired 
     
      1961
      1178
      2673
      1016
      2074
      486
      713
     
      19.4
      11.7
      26.5
      10.1
      20.5
      4.8
      7.0
  
  
    Total 
    10101
    100



Table 1:   Distribution of the studied sample according to age, sex, and occupation.

Table 2: Distribution according to the provisional diagnosis of the neuropsychiatric problem.



  
    Clinical diagnosis 
    Number 
    % 
  
  
    Mood disorders
    1615
    16.0
  
  
    Psychotic disorders
    739
    7.3
  
  
    Anxiety disorders
    1910
    18.9
  
  
    Somatoform disorders
    401
    4.0
  
  
    Neurological disorders
    983
    9.7
  
  
    Headache/ Migraine
    2240
    22.2
  
  
    Epilepsy
    1590
    15.7
  
  
    Brain disorders
    505
    5.0
  
  
    Seeking sick leaves
    118
    1.2
  
  
    Total 
    10101
    100



Table 2:  Distribution according to the provisional diagnosis of the neuropsychiatric problem.

Discussion

Mental illness affects people regardless of education, socio-economic conditions, and cultures [11]. According to estimates given in WHO's World Health Report 2001 "about 450 million people alive today suffer from mental disorders, one person in every four will be affected by a mental disorder at some stage of his or her life" Neuropsychiatric disorders account for 12.3 % of the Disability- Adjusted Life Years (DALYs) out of the total DALYs for all disorders [12]. In the current study; the most prevalent age group attending the Neuropsychiatric clinic was the group of young adults (21-40) years, which was expected being involved in the situation of conflict, those were either men that are exposed to an extraordinary stress or women who endure worries about their families. It is well known that psychiatric disorders most often affect young adults who are on the midst of their most productive years of life [3,6,13,14]. Children and adolescents showed collectively a percentage of 26.2%of the total attendees. Child and Adolescent Mental Health Services (CAMHS) in Iraq are almost non-existent, child and adolescent psychiatrists are few in number, and the stigma associated with adults' mental disorders extends to enroll children and adolescents [8,10,13,14] although this study demonstrates a sizable ratio of children and adolescents affected with neurological and psychiatric disorders, its association with age and sex was not discussed in details. Males seem to suffer from mental illness more than females. Nevertheless, women report relatively high frequencies (44.7% of the total) a finding that matches the WHO Aims Report [13]. Many studies have pointed out a strong relationship between gender and mental illness, with female gender being more vulnerable and more likely to admit having mental illness specially anxiety and depression, yet more reluctant to seek help from mental health professionals [15,16]. Regarding the occupation; housewives registered the highest frequency, this might be attributed to the fact that a high quota of women in Iraq is housewives, other occupations showed no important difference. In the current study; the most prevalent complaint was headache that may be because this psychiatric clinic was working as an outpatient clinic rather than a tertiary referee, most of the patients visiting the clinic were self-referred or brought by their relatives. The second most prevalent disorder was anxiety followed by mood disorders. This trend makes sense as those two groups of disorders usually exchange their orders in prevalence of mental disorders in many communities [17-20].Epilepsy occupied the third order followed by neurological and psychotic disorders.The Iraqi Mental Health Survey (IMHS) estimated the lifetime prevalence of any DSM-IV disorder as 18.8%, [14] the most prevalent class of disorders is anxiety disorders (13.8%) followed by mood disorders (7.5%), and behavioral disorders (1.8%),the most prevalent individual lifetime disorders are major depressive (7.2%), obsessive-compulsive (4.6%), specific phobia (4.2%), generalized anxiety (3.7%) and posttraumatic stress disorder (2.5%) [14].

The results of our study are also comparable to a study conducted in Lesotho, Africa which revealed that 23% of the outpatient psychiatric clinic attendees have DEP, 24% with PD, and 29% with GAD, 36% had either DEP or PD, with 45% having concurrent illness [17].

Anxiety is increasing in Iraq as a consequence of the successive wars, this is an expected response to such violent circumstances [21- 23]. On the other hand; depression is starting to become a serious health problem in Iraq. Depression can cause the affected person to suffer greatly and function poorly at work, at school and in the family, and at its worst, it can lead to suicide [21,24].

The health services in Iraq is deteriorating, partially because of insecurity, failure of applying a referral system and a shortage in human resources [7,8,10]. Knowing that the average of patients seen by two doctors (a consultant and a senior registrar) was about 40 patient/ day in the usual six hours working day, the work load will negatively reflect on the quality of the provided care, it is too difficult and exhausting for any doctor to see such a big number of patients which is clinically impractical especially for psychiatric patients keeping in mind that the ratio of psychiatrist/100,000 population in Iraq is less than (0.5) [7,25]. There are many reasons behind that; first, failure of applying the referral system so that the patients attend the psychiatric clinic usually as outpatient visitors by their wish. Referral to consultation liaison psychiatry appears to be low as noted in many countries [25-28]. Lower referrals may not only be a result of a lack of awareness of non-psychiatric physicians; it depends on a variety of factors that may be patient-related, disease-related, and/or physician-related [29-31]. The traditional norms in Iraq considered mental illness as a social stigma [2,10,13,14], which is responsible for unreported or missed data about epidemiology of mental disorders. The extent of psychological trauma in the population has led the Iraqi Ministry of Health to include mental health in the basic health service package [8,10,13,14]. Although some pilot community psychosocial services have been implemented, how these services will be linked to the basic health service package is unclear. Research about services provided in conflict areas can assist policy makers and stakeholders to understand the most effective approach under these conditions [32,33].

It can be concluded from this study that the outpatient workload in Iraq as a conflict region at that time is higher than the accepted rate of patient/ doctor visits per day. Most of the attendees were young adults, males more than females, and the most prevalent mental disorders were headache, anxiety and mood disorders. The authors call for activation of mental health policy designed by the WHO [10,13], focusing on integration of mental health into primary health care and implementation of proper referral system [33].

References

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Citation: Younis MS and Lafta RK. Working in a Conflict Region: A Total Year Work Load of a Psychiatry-Neurology Outpatient Clinic in Baghdad. American J Bioterror Biosecur Biodefens. 2014;1(1): 4.

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Clinical diagnosis	Number	%
Mood disorders	1615	16.0
Psychotic disorders	739	7.3
Anxiety disorders	1910	18.9
Somatoform disorders	401	4.0
Neurological disorders	983	9.7
Headache/ Migraine	2240	22.2
Epilepsy	1590	15.7
Brain disorders	505	5.0
Seeking sick leaves	118	1.2
Total	10101	100