The following sections will be divided into two theme categories an overview of schizophrenia in the Arabic and the surrounding countries and Overview of Schizophrenia in Palestine.
An overview of schizophrenia in the Arabic and the surrounding countries
Mental health conditions are a major cause of disability in the Arab World [18]. In Islam, "no responsibility was attributed to a child, a psychotic adult or a sleeping or stuporous person." The care of people with mental illness under Islam is considered a family responsibility [19-23]. In Arabic culture, such an illness is viewed as a family issue. Whether the person is hospitalized or not or kept in or discharged from the hospital depends not on the individual needs but on the desire of the family. Therefore, in Arab culture, the issues of patient consent, autonomy, and decision making are considered family-centered [23].In the Arab world, families of patients with schizophrenia suffer from stigmatization [24]. Actually, it's a common belief in the Arab society that mental illnesses have a devilish and sinful component [25]. Along with stigma, it acts as a barrier to seeking treatment.
The Saudi Arabian Ministry of Health reported that 22.4% of the outpatient mental health services suffer from mental and behavioral disorders caused either by schizophrenia, schizotypal, or delusional disorder [26]. According to Foldemo et al., "Quality of life is a complex and multidimensional construct. The majority of definitions include several broad concepts such as well-being, happiness/ satisfaction, and achievement of personal goals, social relations, and natural capacity." [27]. Recently, quality of life is considered an indicator of the impact of diseases on patients who suffer from mental disorders [28]. A descriptive qualitative study was conducted at a psychiatric outpatient department in Saudi Arabia in 2010 among 159 people with schizophrenia to investigate how do people with schizophrenia perceive their quality of life. Forty-four of the participants from the total sample reported that the shame of schizophrenia affected their lives negatively. Thirty-nine of the participants from the total sample reported that the shame of having schizophrenia had affected their lives. Participants indicated that they would prefer to keep their illness secret for two main reasons: the family shame of having a family member with schizophrenia and the public shame of having schizophrenia. On the other hand, 110 out of 159 participants reported that the positive role of religion, such as praying and using the Quran, was positively linked with improving their quality of life [26]. An additional descriptive study was carried out on 160 Jordanian outpatients diagnosed with schizophrenia. The results revealed that the participants had a poor quality of life. Age, marital status, education level, stigma against mental illness, and severity of depression were significantly associated with quality of life among Jordanian patients with schizophrenia [29]. Stigma related to mental illness refers to "the view that persons with mental illness are marked, have undesirable characteristics, or deserve reproach because of their mental illness" [30]. Stigmatizing attitudes toward people with mental illness are common. The stigma associated with mental illness brings shame to the family and affect the marriage potential for other siblings, so families keep the illness private and are often reluctant to seek professional help [31]. A comparative study aimed to explore the internalized stigma of mental health illness among 200 patients with schizophrenia and their families during the follow-up visit in two settings. The 1st clinic was the outpatient clinic for psychiatric patients affiliated to Abbasia hospital, and the 2nd clinic was the outpatients' clinic for psychiatric patients affiliated to Abha psychiatric hospital using the stigma Impact Scale. Results revealed that both groups of people with schizophrenia and their family caregivers have a high level of the internalizing stigma of mental illness. Results also showed that 80% of family members at Abha hospital agreed that "My life security has been affected by the illness in my family member" and 66% of the family members were strongly agreed and agreed that "I feel I have been treated with less respect than usual by others" and "I feel a need to keep my family members illness a secret" respectively [30].
Overview of Schizophrenia in Palestine
Meeting the need for mental health care for the Palestinian population is still an ongoing struggle [3]. Palestinians are especially at a higher risk for developing mental health illnesses due to their chronic exposure to political violence, prolonged displacement, and insecurity. Additionally, limited professional, educational, and financial opportunities that are linked to the protracted conflicts and instability in the region [32]. These vulnerabilities were compounded by the limited availability of the quality of mental health providers, inconsistent mental health services, and the stigma associated with seeking mental health care [7]. Focusing on only one aspect of the Palestinian reality and gaining more insight into its mental health challenges, especially among schizophrenia patients. According to the Palestinian Health Information Center (PHIC, 2016), the incidence rates for newly reported cases in the West Bank showed that schizophrenia is the third-highest incidence in mental disorders, with it being the highest -Number one- in the treatment with 30,008 cases.
The life and characteristics of schizophrenic patients seem to be vouge. Studies have investigated the lifestyle and clinical features of schizophrenic patients in Palestine. A cross-sectional study design conducted at the governmental primary psychiatric health care centers in Northern West Bank and used a survey to investigate the different lifestyle parameters, diet, body mass index, smoking, and unemployment among 250 schizophrenic clients in Palestine. Results showed that 43.6% had completed their elementary level of education, 41.6% with a high school level, 14.8% with a two-year diploma, and None of the clients had a bachelor’s degree. One hundred and ninety-seven (78.80%) participants were without a job, and the number of working participants was only 53 (21.2%). Results also showed that only 82 clients (32.8% of the total number of clients) had an average BMI values most of them are males (60 male and 13 female), the number of schizophrenic clients suffering from overweight and obesity was high (67.2%), and the average of waist circumference for most of the clients was abnormal (97.8±13.4). In addition to the previous, over half of the participants were smokers representing (61.20%) [33].
A similar study to the previously investigated the clinical characteristics of schizophrenia among three different group category (Negev Bedouin, Galilee Palestinians, and Palestinian Authority) results reported regarding the category of Palestinian Authority patients, from the 50 patients in this category, (78%) were males, (66%) were single/divorced, (70%) were unemployed and (70%) have low-medium education level. Somatic delusions were the highest delusions in this category (86%) followed by Persecution delusions (82%), and Jealousy delusions were the lowest among Palestinian Authority patients (4%). Among all of the different categories, Palestinian authority patients had the most moderate disability insurance coverage compared with the other two groups [34].
Moreover, a cross-sectional study design was carried out at four governmental primary psychiatric health centers using patients’ medical files to investigated Schizophrenia treatment guidelines in care centers located in Nablus, Tukaram, Jenin, and Qalqilya. Both newly diagnosed patients and patients who were not on antipsychotic therapy were excluded. The characteristics of the 250 participants in the study were 182 (73.8%) male patients, 145(58%) live in village/camp, 213 (85.2%) have completed school education or less, 112 (44.8%) were single/divorced, 153(61.2%) were smokers, 219(87.6%) without a job and 161(64.4%) reported having a duration of illness for more than ten years [35].
According to Sweileh et al., several major well-known algorithms were used for the treatment of schizophrenia [35]. Antipsychotic drug therapy is considered to be one of the treatment regimens for schizophrenia and has been reported to successfully minimize the frequency of acute schizophrenic episodes and hospitalization [36]. Schizophrenia treatment guidelines in Palestine were investigated, and results showed that there was a 406 prescription of antipsychotic drugs for the study sample. The antipsychotics were mainly from First-generation type (FGT) (85.7%), the most common antipsychotic medication was used by the patients were: Chlorpromazine tablet (31.5%), followed by Fluphenazine IM depot injection (30.8%), Haloperidol tablet (18.2%), Clozapine (8.6%), Olanzapine (3.7%), Haloperidol Decanoate (2.7%), Risperidone (2%), Trifluoperazine (1.7%), Thioridazine (0.2%) and Zuclopentchixol (0.5%). This study also indicated that antipsychotic prescribing was not in the conformance with the international guidelines with respect to maintenance dose and combination therapy; categorization of Chlorpromazine dose equivalencies (CPZeq) showed that 88 (35.2%) clients were using sub-therapeutic treatments (< 300 mg CPZeq), 105 (42%) were using the optimum dose (300-600 mg CPZeq), 57 (22.8%) were using supratherapeutic treatments ( > 600 mg CPZeq) and 7 (2.8%) were using supra-maximal dose (CPZeq>1000 mg) [35].
Antipsychotic medication adherence and satisfaction were also assessed in schizophrenic patients. For example, a cross-sectional study was conducted in 2010 at Al-Makhfya psychiatric health center in Nablus. Medication adherence was assessed using the 8-item Morisky Medication Adherence Scale (MMAS-8), treatment satisfaction was assessed using the Treatment Satisfaction Questionnaire for Medication (TSQM 1.4), and psychiatric symptoms were evaluated using the expanded Brief Psychiatric Rating Scale (BPRS-E). Results showed that medication nonadherence was common and was associated with low treatment satisfaction scores and poor psychiatric scores; the majority of patients with schizophrenia were nonadherent, and the younger people had significantly lower adherence scores than the elderly (P=0.028) [25].
Antipsychotic medication has serious side effects, including metabolic syndrome (MS) [37]. Metabolic syndrome is defined as a cluster of conditions that occur together, which increases the risk of developing heart diseases, stroke, and type 2 diabetes. These conditions included elevated blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels (Adult Treatment Panel III, 2004). A cross-sectional study conducted from August 2011 until February 2012 at governmental primary healthcare psychiatric centers in Northern West-Bank, investigated the prevalence of metabolic syndrome (MS) among 250 patients with schizophrenia above the age of 16 and were diagnosed according to DSM IV. Using the Adult Treatment Panel III (ATP III) criteria, results showed that 109 (43.6%) patients met the criteria for the syndrome, with 39% in males and 55.9% in female patients. Among males, high levels of triglyceride were the most common metabolic component compared to females who have abdominal obesity as a common metabolic component, and elevated fasting blood sugar was the least common metabolic dysregulation in both genders. This study also showed by using the univariate analysis that MS was significantly higher with older age, female gender, longer duration of illness, abdominal obesity, smoking, higher systolic and diastolic blood pressure , high triglycerides, low HDL-C, and fasting plasma glucose compared to the multiple logistic regression analysis which showed that only systolic blood pressure, high triglycerides, high fasting plasma glucose and low HDL-C were significant predictors of MS in schizophrenic patients. This study also supported the previous studies in patients’ characteristics. 213(85.2%) had only school education or less, 122 (44.8%) were single or divorced, 153( 61.2%) were smokers, and 219 (87.6%) without a job [13].
Metabolic syndrome is not the only complication that affects this category of patients. Diabetes, anemia, cardiovascular diseases, and more were also studied in these patients. A cross-sectional study was carried out in 4 governmental primary psychiatric healthcare centers in Northern West-Bank from August 2011 until February 2012 and used a survey to examine the prevalence of Diabetes Mellitus among 250 schizophrenic patients. The criteria for the patient was age above 16 years old, diagnosed with schizophrenia as defined by DSM IV, didn’t suffer from an acute attack of illness during the past year, and their drug regimen had not been changed in the last six months. Results showed that among the study sample, 189 (75.6%) were considered to have euglycemia, and 61 (24.4%) have dysglycemia (defined as FBG ≥ 110 mg/dl). Based on the WHO criteria, 27 patients (10.8%) had Diabetes, and 34 (13.6%) had prediabetes. Results of multiple logistic regressions showed that only advancing age and abnormal waist circumference were significant predicators of dysglycemia among schizophrenia clients with a significant (P= 0.003) and (P=0.013), respectively [12].
Inadequate or inappropriate dietary habits increase the risk of anemia in schizophrenic patients [38]. Many studies have demonstrated that people with schizophrenia make poor nutritional choices [39]. A cross-sectional study was conducted between August 2011 and February 2012, covering four governmental primary psychiatric health care centers located throughout the Northern West Bank, reported the prevalence of anemia among 250 patients. Results showed the number of anemic females was 38 (55.9%) out of 68 female patients, while the number of anemic males was 25 (13.7%) out of 182 male patients (P-value <0.01). About 6.1% of male and 11.8% of female patients had leucopenia, while 7.7% of male and 7.3% of female patients had leukocytosis and 5.5% of males and 4.4% of females had thrombocytopenia, while 1.1% of male patients and 5.9% of female had thrombocytosis. Results suggested that an unhealthy lifestyle and poor dietary choices are the primary cause of anemia among these patients [38]. Besides, a cross-sectional study design was carried at four governmental primary psychiatric health care centers in northern West-Bank estimated Ten years’ risk of coronary heart diseases (CHD) among 112 schizophrenic patients. Results showed that one-fifth of the patients had a CHD risk of 10% [40].
Globally, approximately 3% of the total burden of human disease is attributable to schizophrenia [41]. The WHO has estimated that around 40-90% of patients having schizophrenia live with their families [42]. A cross-sectional study conducted at the Gaza governmental community mental health centers aimed to investigate the burden of care experienced by 120 caregivers of schizophrenic patients. Results showed that the sociodemographic characteristics of schizophrenic patients were the following: The majority of male patients were 62.5%. About half of the sample were married 53.3%, 28.3% were single, 16.7% divorced, and 1.7% widowed. The educational level showed that 10% were illiterate, 40.9% completed their primary education, 29.2% completed secondary school, 5.8% had a diploma,13.3% had a bachelor’s degree, and 0.8% had a master’s degree or higher. The rate of unemployment was 87.5%. Regarding the medical income, 81.7% had less than 1000 NIS, 13.3% had 1000 to 2500 NIS, while only 5% had a monthly salary of 2500 NIS or more. The burden on caregivers of schizophrenic patients was measured using the Burden assessment scale. Results revealed that caregivers suffered from a high level of total burden 74.5%, and the distribution was as the following: physical 81%, financial 79.3%, psychological 72.4%, and social burden 68.3%. Results also revealed that there were significant differences in the level of responsibility, and education, occupation, and monthly income of both caregivers and patients [43].
Stigma among psychiatric patients is dangerous as it interferes with understanding, gaining support from friends and family, delays getting help, and self-blame [44]. A descriptive study was conducted at the outpatient clinics of the only psychiatric hospital in the Gaza Strip and used a questionnaire to assess the impact of stigma on the daily life of 106 psychiatric patients. Results revealed that the majority of the participants were males 61.3%, 50% of participants were single, and stigma had a significant effect on the daily life of mental illness patients. The participants highest reports were as the following: “I fell shy because of my psychiatric illness, and this prevents me from expressing my point of view easily” (p=0.004), “I prefer giving a pen name and change my look and clothes when I go to the psychiatrist to avoid an embarrassment” (p=0.007), and then “My request was rejected for several jobs because of my psychiatric illness” (p<0.001) [45].