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Aim: The work wasto study polymorphisms in the LEP gene in type 2 diabetics in Minia, Egypt and determined the relationship between the leptin and c - peptide levels in different genotypes and insulin resistance in obese patients. The study also has evaluated the role of leptin gene polymorphism in prediction of diabetes mellitus prognosis and its prevention. Study Design: Investigative.

IGF-1 has a pivotal role in regulating glucose homeostasis and sensitivity to insulin. The present study aimed at evaluating the association of three SNPs of IGF-1, rs35767, rs5742612, and rs2288377 with gestational diabetes mellitus (GDM) and type-2 diabetes mellitus (T2DM) risk. A total of 505 pregnant women (180 with T2DM, 160 GDM patients and 165 controls) were recruited. The SNPs of IGF-1 gene (rs35767, rs5742612 and rs2288377) were genotyped by real time polymerase chain reaction using Taqman® allelic discrimination assays. The TT genotype of rs35767and rs5742612 was associated with an elevated risk of T2DM and GDM compared to controls. In the dominant model, the CT + TT genotype of rs35767 and rs5742612 had an increased risk of developing GDM and T2DM in comparison to the CC genotype. In the recessive model, the TT genotype revealed a higher risk of developing T2DM and GDM than the CT + CC genotype. Moreover, IGF-1 rs2288377 was not found to be significantly associated. In addition, the individuals carrying TT genotype of rs35767 exhibited an elevated BMI in T2DM and GDM patients. However, carriers of the TT genotype in rs5742612 had an elevated BMI in pregnant women with T2DM. Conclusions Human IGF-1 gene may be a candidate gene for GDM and T2DM risk, as our study suggests a significant association between the IGF-I rs35767 and rs5742612 polymorphisms and the risk of T2DM and GDM in pregnant women, whereas there was no association for rs2288377.

To assess the progression of mental health research over four decades in the Arab world. Publications on mental health in 21 Arab countries from 1966 to 2006 were screened using PubMed and Psychinfo. Data were collected and analyzed for Arab authors and affiliations, publication year, topic and type of journal. In 40 years (1966–2005), the Arab world published 2,213 articles on a vast variety of topics, most common being mood, anxiety and substance use disorders, and mostly in international journals. By the last decade, the total yearly publications increased about eightfold since the first two decades, and nearly doubled from the third one. The disparity of output was high across countries. The highest yearly output was from Egypt, Saudi Arabia, Kuwait and Lebanon. Per million population, the top four producing countries were Kuwait, Bahrain, Lebanon and United Arab Emirates. Over a decade, the Arab world produced approximately 17% of the global output of mental health publications/million population and was comparative to Latin American and Caribbean countries. There is a wide gap in comparison with the industrialized world, with a fertile ground for cross-cultural and genetic studies.

Objectives This study was designed to assess the quality of life in a group of Egyptian substance dependence patients by comparing it with World Health Organization (WHO) standards and to assess the correlation between their quality of life and personality dimensions. Methods A total of 54 patients with substance dependence (after detoxification) were diagnosed by the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders IV over a period of 6 months at the Okasha Institute of Psychiatry in Ain Shams University and at the Psychiatric Health Resort in Cairo. Their quality of life and personality profiles were assessed using the WHO Quality of Life-100 instrument and Temperament and Character Inventory. Results Substance dependence patients had a significantly worse overall quality of life than the WHO standards. This deterioration was evident in physical, psychological, level of independence, social, and spiritual domains of the WHO Quality of Life-100 instrument. Overall quality of life had a significant negative correlation with novelty seeking, whereas it had a significant positive correlation with self directedness. Conclusions All treatment programs should pay more attention to improve defective aspects and overall quality of life in substance dependence patients. Higher novelty seeking and lower self directedness were linked to poorer overall quality of life in those patients. This finding reflects the importance of addressing these personality dimensions in the treatment plan of such patients.

Bipolar disorder is underdiagnosed, misdiagnosed and undertreated. The emphasis now is on the bipolar spectrum and its management is under continuous revision, for example, the controversial use of antidepressants. The recent change in the conceptualization of bipolar disorder has changed the lifeti

In the past few years several papers have reported critically on the risk of suicidal thoughts and behaviour associated with antidepressants, primarily SSRIs. The risk-benefit ratio of antidepressant (AD) treatment has been questioned especially in children and adolescents. The critical publications led to warnings being issued by regulatory authorities such as the FDA, MHRA and EMEA and stimulated new research activity in this field. However, potential harmful effects of antidepressants on suicidality are difficult to investigate in empirical studies because these have several methodological limitations. Randomised controlled trials (RCTs) are the most reliable way to test the hypothesis that AD have such side effects. In addition to meta-analyses of RCTs, complementary research methods should be applied to obtain the most comprehensive information. We undertook a comprehensive review of publications related to the topics ADs, suicide, suicidality, suicidal behaviour and aggression. Based on this comprehensive review we conclude that ADs, including SSRIs, carry a small risk of inducing suicidal thoughts and suicide attempts, in age groups below 25 years, the risk reducing further at the age of about 30-40 years. This risk has to be balanced against the well-known beneficial effects of ADs on depressive and other symptoms (anxiety, panic, obsessive-compulsive symptoms), including suicidality and suicidal behaviour. According to the principles of good clinical practice, decision making should consider carefully the beneficial effects of AD treatment as well as potentially harmful effects and attempt to keep the potential risks of AD treatment to a minimum. It is the major problem facing efforts to identify the possible 'suicidal effects' of antidepressants.

Data from two major government-funded studies of comparative antipsychotic effectiveness in schizophrenia contradict the widely prevalent belief that the newer second-generation medications are vastly superior to the older first-generation drugs. This has caused uncertainty among patients, clinicians and policy-makers about the relative utility of first- and second- generation antipsychotic agents in its treatment. To reduce confusion and provide a contextual understanding of the new data, the World Psychiatry Association Section on Pharmacopsychiatry comprehensively reviewed the literature on the comparative effectiveness of different antipsychotic treatments for schizophrenia and developed this update. Utilizing data from the approximately 1,600 randomized controlled trials of antipsychotic treatment in schizophrenia, we applied the two indirect and one direct method to comparing the effectiveness of 62 currently-available antipsychotic agents. The subclasses of 51 first-generation and 11 second-generation antipsychotics were both found to be very heterogeneous, with substantial differences in side-effect profiles among members. Second-generation antipsychotic agents were found to be inconsistently more effective than first-generation agents in alleviating negative, cognitive, and depressive symptoms and had a lower liability to cause tardive dyskinesia; these modest benefits were principally driven by the ability of second-generation antipsychotics to provide equivalent improvement in positive symptoms along with a lower risk of causing extrapyramidal side-effects. Clozapine was found to be more efficacious than other agents in treatment-refractory schizophrenia. There were no consistent differences in efficacy among other second-generation antipsychotic agents; if such differences exist, they are likely small in magnitude. Dosing was found to be a key variable in optimizing effectiveness of both first- and second- generation antipsychotic agents. There was enormous individual variability in antipsychotic response and vulnerability to various adverse effects. In contrast to their relatively similar efficacy in treating positive symptoms, there were substantial differences among both first- and second- generation antipsychotic agents with regard to their propensity to cause extrapyramidal, metabolic and other adverse effects; second-generation agents have a lower liability to cause acute extrapyramidal symptoms and tardive dyskinesia along with a tendency to cause greater metabolic side-effects than first-generation agents. Based on these data about the comparative effectiveness of different antipsychotic treatment options, we summarize elements of current best antipsychotic practice for the treatment of schizophrenia and discuss the role of government and the pharmaceutical industry in obtaining and disseminating information which can facilitate best practice.

This article consists of two sections. In the first section, the author presents a comprehensive review which highlights the psychological consequences suffered by populations living in war zones, revealing the worrying prevalence of fear, panic, depressions, behavioral disturbances and PTSD. Especially vulnerable groups include women, children, the disabled and the elderly. Loss and destruction of homes, loss of male heads of households to death or captivity, displacement and exposure to the dangers of sexual abuse and rape, almost always associated with war crimes leaves women, especially mothers at high risk of hopelessness and depression. The level of depressive symptomatology in the mother was found to be the best predictor of her child's reported morbidity. The devastation of families and the breakdown of the home structure deprive the elderly and the handicapped of the family care, which usually constitutes their primary resource of support. In the second section of the article, the author summarizes the efforts done by the World Psychiatric Association, in addressing the consequences of war and collective violence in the different regions of the world. The author suggests a comprehensive professional intervention program, involving several world organizations involved in health and education. Also, of special importance in that regard is the role of key religious institutions, to highlight the peaceful values carried by all religions and to replace the currently dominant messages of conflict and rejection of the "other".

Mental disorders have been recognised in Egypt for millennia; 5000 years ago, they were considered to be physical ailments of the heart or uterus, as described in the Ebers and Kahun papyri (Okasha, 2001). These disorders carried no stigma, as there was no demarcation then between psyche and soma. In the 14th century – 600 years before similar institutions were founded in Europe – the first psychiatric unit was established, in Kalaoon Hospital in Cairo.

What are the current recommendations for the long-term treatment of generalized anxiety disorder (GAD)? GAD is a common disorder with a lifetime prevalence of 4% to 7% in the general population. GAD is characterized by excessive, uncontrollable worry or anxiety about a number of events or activities that the individual experiences on more days than not over a 6-month period. Onset of GAD symptoms usually occurs during an individual's early twenties; however, high rates of GAD have also been seen in children and adolescents. The clinical course of GAD is often chronic, with 40% of patients reporting illness lasting >5 years. GAD is associated with pronounced functional impairment, resulting in decreased vocational function and reduced quality of life. Patients with GAD tend to be high users of outpatient medical care, which contributes significantly to healtcare costs. Currently, benzodiazepines and buspirone are prescribed frequently to treat GAD. Although both show efficacy in acute treatment trials, few long-term studies have been perform Benzodiazepines are not recommended for long-term treatment of GAD, due to associated development of tolerance, psychomotor impairment, cognitive and memory changes, physical dependence, and a withdrawal reaction on discontinuation. The antidepressant venlafaxine extended-release (XR) has received approval for the treatment of GAD in the United States and many other countries. Venlafaxine XR has demonstrated efficacy over placebo in two randomized treatment trials of 6 months' duration as well as in other acute trials. Paroxetine is the first of the selective serotonin reuptake inhibitors (SSRIs) to receive US approval for the treatment of GAD. Paroxetine demonstrated superiority to placebo in short-term trials, and investigations into the use of other SSRIs are ongoing. This suggests that other SSRIs, and serotonin and noradrenaline reuptake inhibitors, are likely to be effective in the treatment of GAD. Of the psychological therapies, cognitive-behavioral therapy (CBT) shows the greatest benefit in treating GAD patients. Treatment gains after a 12-week course of CBT may be maintained for up to 1 year. Currently, no guidelines exist for the long-term treatment of GAD.

What are the latest psychotherapeutic and pharmacotherapeutic treatment recommendations for obsessive-compulsive disorder (OCD)? OCD is a relatively common disorder with a lifetime prevalence of ~2% in the general population. It often has an early onset, usually in childhood or adolescence, and frequently becomes chronic and disabling if left untreated. High associated healthcare utilization and costs, and reduced productivity resulting in loss of earning, pose a huge economic burden to OCD patients and their families, employers, and society. OCD is characterized by the presence of obsessions and compulsions that are time-consuming, cause marked distress, or significantly interfere with a person's functioning. Most patients with OCD experience symptoms throughout their lives and benefit from long-term treatment. Both psychotherapy and pharmacotherapy are recommended, either alone or in combination, for the treatment of OCD. Cognitive-behavioral therapy is the psychotherapy of choice. Pharmacologic treatment options include the tricyclic antidepressant clomipramine and the selective serotonin reuptake inhibitors (SSRIs) citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline. These have all shown benefit in acute treatment trials; clomipramine, fluvoxamine, fluoxetine, and sertraline have also demonstrated benefit in long-term treatment trials (at least 24 weeks), and clomipramine, sertraline, and fluvoxamine have United States Food and Drug Administration approvals for use in children and adolescents. Available treatment guidelines recommend first-line use of an SSR1 (ie, fluoxetine, fluvoxamine, paroxetine, sertraline, or citalopram) in preference to clomipramine, due to the latter's less favorable adverse-event profile. Further, pharmacotherapy for a minimum of 1–2 years is recommended before very gradual withdrawal may be considered.

Posttraumatic stress disorder (PTSD) is a common and disabling condition. In addition to combat-related PTSD, the disorder occurs in civilians exposed to severe traumatic events, with the community prevalence rate for the combined populations reaching as high as 12%. If left untreated, PTSD may continue for years after the stressor event, resulting in severe functional and emotional impairment and a dramatic reduction in quality of life, with negative economic consequences for both the sufferer and society as a whole. Although PTSD is often overlooked, diagnosis is relatively straight-forward once a triggering stressor event and the triad of persistent symptoms—reexperiencing the traumatic event, avoiding stimuli associated with the trauma, and hyperarousal—have been identified. However, comorbid conditions of anxiety and depression frequently hamper accurate diagnosis. Treatment for PTSD includes psychotherapy and pharmacotherapy. The latter includes selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, and monoamine oxidase inhibitors. Only SSRls have been proven effective and safe in long-term randomized controlled trials. Current guidelines from the Expert Consensus Panel for PTSD recommend treatment of chronic PTSD for a minimum of 12–24 months.

What is the best approach for treating patients with social phobia (social anxiety disorder) over the long term? Social phobia is the most common anxiety disorder, with reported prevalence rates of up to 18.7%. Social phobia is characterized by a marked and persistent fear of being observed or evaluated by others in social performance or interaction situations and is associated with physical, cognitive, and behavioral (ie, avoidance) symptoms. The onset of social phobia typically occurs in childhood or adolescence and the clinical course, if left untreated, is usually chronic, unremitting, and associated with significant functional impairment. Social phobia exhibits a high degree of comorbidity with other psychiatric disorders, including mood disorders, anxiety disorders, and substance abuse/dependence. Few people with social phobia seek professional help despite the existence of beneficial treatment approaches. The efficacy, tolerability, and safety of the selective serotonin reuptake inhibitors (SSRIs), evidenced in randomized clinical trials, support these agents as first-line treatment. The benzodiazepine clonazepam and certain monoamine oxidase inhibitors (representing both reversible and nonreversible inhibitors) may also be of benefit. Treatment of social phobia may need to be continued for several months to consolidate response and achieve full remission. The SSRIs have shown benefit in longterm treatment trials, while long-term treatment data from clinical studies of clonazepam are limited but support the drug's efficacy. There is also evidence for the effectiveness of exposure-based strategies of cognitive-behavioral therapy, and controlled studies suggest that the effects of treatment are generally maintained at long-term follow-up. In light of the chronicity and disability associated with social phobia, as well as the high relapse rate after short-term therapy, it is recommended that effective treatment be continued for at least 12 months.

Are we in need of including in our diagnostic systems a new category of subthreshold psychiatry? Studies have shown that we are faced in our daily clinical practice with many patients who do not fulfil the criteria of either ICD-10 or DSM-IV (at best they may be included under ‘atypical’, ‘unspecified’ or ‘not elsewhere classified’). Subthreshold cases or prodromal psychotic or non-psychotic clinical cases are encountered frequently in clinical practice, especially primary care (Knappe et al, 2008), but because of some ethical and nosological issues their needs are unmet. Pharmacological interventions for such conditions are denied in some countries, especially with managed care, where maximisation of profit and minimisation of cost are often the main objectives. It has been reported that the early treatment of many disorders ensures a better outcome and better assimilation in society and reduces residual manifestations of disease. Recent data suggest that the impairment and disability caused by subsyndromal disorders are almost equal to those caused by syndromal ones. We need more scientific data and research studies to evaluate the course, outcome and value of treating such disorders.

Convulsive therapy was introduced by Meduna in 1933 (1), using intravenous camphor, then cardiazol. In 1938, Cerletti and Bini (2) initiated convulsive therapy using electricity, which was named electric shock treatment, then electroconvulsive therapy (ECT). The portrayal of ECT in the media, especially the movies showing that it was used as a punitive intervention, in an inhumane way and violating the human rights of patients, has perpetuated its negative image and increased the stigma related to this therapy. It has been rarely emphasized that ECT may be a life saving measure, especially in the treatment of melancholic, psychotic and suicidal depression. Furthermore, the term ECT is now a misnomer, since there are no convulsions with the use of anesthesia and muscle relaxants (modified ECT). The procedure just produces blinking of the eyes rather than a full body convulsion. C. Kellner already criticized the name ECT in 1990 (3). In Egypt, we changed the name into brain synchronization therapy (BST). This has made a shift to the positive in the family awareness and patient's acceptance of the treatment. Explaining to the patient and family the procedure without referring to convulsions has been of great help (4). In the new Mental Health Act in Egypt (2009), the term BST (of course in Arabic) replaced ECT, and it was specified that “under no circumstances should BST be given without anesthesia and muscle relaxant” and that the treating psychiatrist will be accountable if this regulation is not followed. A group of eminent Arab psychiatrists have just finalized the preparation of “guidelines for the treatment of depression in the Arab World” and have also replaced the term ECT by BST in order to reduce the stigma and change the wrong perception of families and patients. This letter is a plea to psychiatrists worldwide to follow us in changing the name of ECT to BST, in order to decrease the stigma associated to this therapy and to allow more patients receiving a treatment that has become unpopular also because of its name, but that, if applied in the correct manner, can be life saving.

Background: Schizophrenic patients and family members often retrospectively report having observed a number of nonpsychotic symptoms and/or certain alterations in behavior that they believe preceded any psychotic symptoms and behavior. The identification of possible relapse before its actual occurrence and the timely intervention in management are expected to spare both patient and family the suffering and pain of a full schizophrenic episode. The aim of this study was to determine if prodromal symptoms could be used as valid predictors of relapse in schizophrenic disorders and the relative diagnostic values of these symptoms in a sample of Egyptian schizophrenic patients. Method: One hundred Egyptian patients with schizophrenic disorders (DSM-III-R criteria) that had recently relapsed were retrospectively assessed for prodromal symptoms in the month preceding relapse. They were compared with 2 control groups, 50 Egyptian nonrelapsing schizophrenic patients and 50 healthy Egyptian individuals. Results: Nonpsychotic symptoms were the most common prodromal symptoms occurring in relapsing patients. A significant difference in frequency of prodromal symptoms was found for relapsing patients versus nonrelapsing patients (p

Okasha A, Rafaat M, Mahallawy N, El Nahas G, Seif El Dawla A, Sayed M, El Kholi S. Cognitive dysfunction in obsessive-compulsive disorder. Acta Psychiatr Scand 2000: 101: 281–285. © Munksgaard 2000. Objective: Assessment of cognitive functions among obsessive-compulsive disorder (OCD) patients would help in understanding the neurobiology and brain areas involved in that disorder. The objective of this work was to study the cognitive dysfunction in OCD patients and to identify its correlation with both the clinical picture and the severity of the disorder. Method: Neuropsychological and electrophysiological event-related potentials were tested in 30 OCD patients and compared with 30 normal volunteers of a matched gender, age and education. Results: Results showed a defective visuospatial recognition, which worsens with chronicity, deteriorated set-shifting abilities, overfocused attention to irrelevant stimuli and delayed selective attention to relevant tasks. Mild cases showed better selective attention than severe cases. Obsessive cases had a defective visual memory, while compulsive cases had delayed perception of task relevant stimuli. Mixed cases showed disturbed information-processing both early and late. Conclusion: OCD patients have a characteristic pattern of cognitive dysfunction that differs among patients of varied severity, chronicity and symptom type. We suggest a striatofrontoparietal neural pathophysiol-ogy. OCD seems to be a heterogeneous disorder, both clinically and pathophysiologically.

The Declaration of Hawaii, adopted by the World Psychiatric Association (WPA) in 1977, was a significant event. But the needs and new ethical dilemmas of the 1990s led WPA to develop new recommendations on the duties of psychiatrists resulting in the Declaration of Madrid, adopted by WPA in 1996. It outlines the framework of ethical conduct of psychiatrists, formulates seven general guidelines with an increased emphasis on research and resource allocation, and gives five specific guidelines on euthanasia, torture, the death penalty, selection of sex, and organ transplantation.

Egypt was created by the Nile, determined by the desert, and shaped by its people. To think of Egypt is to summon up images of pyramids, temples, and tombs. The inner eye feasts on images of unparalleled artistry : the timeless diorite statue of Khafre, elegant wall paintings in the tomb of Nefertari, the funerary mask of Tutankhamun. Perhaps the palm-fringed Nile springs to mind, or the exquisite Islamic monuments of medieval Cairo, or even the overgrown mega city of today's Cairo. Yet Egypt is, before all else, desert. Were it not for the Nile, this immense territory in the east of the Sahara would be perhaps the hottest and driest wasteland in the world.

Nonorganic chronic headache is a common, challenging presentation in clinical practice. The aim of this study was to investigate the frequency of associated psychiatric psychopathology, personality disorders, or traits. In addition, the study attempted to investigate possible relationships of nonorganic chronic headache with alexithymia, locus of control, and pain perception. Psychiatric pathology, personality traits, and pain profiles were examined in 100 randomized patients with chronic headache lacking an obvious organic basis, and they were compared with 100 subjects, 50 with headache of a known organic cause and 50 seemingly healthy persons, by using structured clinical interviews. Somatoform pain disorder was diagnosed in 43% of the nonorganic and 20% of the organic headache group. Nine percent of the former group had major depression, 16% had dysthymia, and 8% had both. In the organic group, 56% had no psychiatric disorder and 20% had somatoform pain disorder. Seventy-seven percent of the patients in the nonorganic pain group had personality disorders, mostly of the mixed and multiple types, compared with 24% of the organic headache patients. The study sample was more alexithymic than the other groups (in 65% of subjects) and had a culturally influenced locus of control and a pain profile characterized by dramatization, vagueness, lower pain threshold, and lower pain tolerance. The nonorganic chronic headache patients showed a high prevalence of somatoform, depressive, and other forms of psychiatric disorders. The high frequency of personality disorders, mostly the mixed and multiple types, the high alexithymic pattern, and low pain threshold and tolerance in the study group should be taken into consideration in the evaluation and management of nonorganic headache patients.

Although there are 22 Arab countries in the Arab League, the mental health services provided in those countries show several forms of variation. Economic, political, social and cultural factors seem to play a major role in determining the state of the psychiatric profession and the access of the service to citizens. The different needs expressed by Arab colleagues at times seem incompatible with the available allocated resources. Some Arab countries enjoy the highest income per capita, yet this is inconsistent with the quality of mental health services available there. The per capita mental health services, the availability of a Mental Health Act, and the space allocated for mental health in medical curricula are but a few of the concerns that have been expressed by colleagues from the different countries of the Arab region. The following review will attempt to draw up a profile of the situation for mental health services and research in the region, and to suggest some measures for intervention.

The current statement is a systematic review of the available data concerning the efficacy of medication treatment of bipolar disorder (BP). A systematic MEDLINE search was made concerning the treatment of BP (RCTs) with the names of treatment options as keywords. The search was updated on 10 March 2012. The literature suggests that lithium, first and second generation antipsychotics and valproate and carbamazepine are efficacious in the treatment of acute mania. Quetiapine and the olanzapine–fluoxetine combination are also efficacious for treating bipolar depression. Antidepressants should only be used in combination with an antimanic agent, because they can induce switching to mania/hypomania/mixed states/rapid cycling when utilized as monotherapy. Lithium, olanzapine, quetiapine and aripiprazole are efficacious during the maintenance phase. Lamotrigine is efficacious in the prevention of depression, and it remains to be clarified whether it is also efficacious for mania. There is some evidence on the efficacy of psychosocial interventions as an adjunctive treatment to medication. Electroconvulsive therapy is an option for refractory patients. In acute manic patients who are partial responders to lithium/valproate/carbamazepine, adding an antipsychotic is a reasonable choice. The combination with best data in acute bipolar depression is lithium plus lamotrigine. Patients stabilized on combination treatment might do worse if shifted to monotherapy during maintenance, and patients could benefit with add-on treatment with olanzapine, valproate, an antidepressant, or lamotrigine, depending on the index acute phase. A variety of treatment options for BP are available today, but still unmet needs are huge. Combination therapy may improve the treatment outcome but it also carries more side-effect burden. Further research is necessary as well as the development of better guidelines and algorithms for the step-by-step rational treatment.

This paper summarizes the current situation of mental health services in the Arab world. Out of 20 countries for which information is available, six do not have a mental health legislation and two do not have a mental health policy. Three countries (Lebanon, Kuwait and Bahrain) had in 2007 more than 30 psychiatric beds per 100,000 population, while two (Sudan and Somalia) had less than 5 per 100,000. The highest number of psychiatrists is found in Qatar, Bahrain and Kuwait, while seven countries (Iraq, Libya, Morocco, Somalia, Sudan, Syria and Yemen) have less than 0.5 psychiatrists for 100,000 population. The budget allowed for mental health as a percentage from the total health budget, in the few countries where information is available, is far below the range to promote mental health services. Some improvement has occurred in the last decade, but the mental health human resources and the attention devoted to mental health issues are still insufficient.

We compared three groups of patients with panic disorder, generalised anxiety disorder and major depressive episode with a control group. Methods of comparison included a clinical profile of the patients, assessed by the Arabic version of the Present State Examination (PSE), a psychological battery of tests measuring personality traits and depressive and anxiety states, and the dexamethasone suppression test (DST) as a biological marker. Our data showed that psychological assessment and DST did not significantly differentiate between the three disorders. Despite a symptom overlap between the disorders, however, some symptoms were associated significantly more often with one disorder than another. Patients with panic disorder differed from patients with major depressive episode in showing more situational, avoidance and free floating anxiety, and more anxious foreboding. They showed less self-negligence, ideas of guilt, early awakening and social withdrawal. Compared with patients with generalised anxiety disorder, patients with panic disorder showed more loss of interest and muscle tension and less anxious foreboding, restlessness, inefficient thinking, social withdrawal and delayed sleep. Our conclusion is that the clinical course and the symptom profile of panic disorder justifies its existence as an independent diagnostic category.

Ninety patients suffering from obsessive-compulsive disorder (OCD) and diagnosed according to International Classification of Diseases (10th edition [ICD-10]) criteria attending the outpatient clinic of the Institute of Psychiatry in Cairo in 1991–1992 were assessed by the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) for symptomatology and severity of symptoms. Sixty-nine percent of the patients were males, and 32% were females. The mean age of the sample was 23.7 years, with a mean duration of OCD of 3.2 years. Twenty percent of patients had a positive family history for OCD. Forty percent of patients presented with a mixture of obsessions and compulsions, whereas 29% presented with obsessions and 31% with compulsions. The most commonly occurring obsessions were religious and contamination obsessions (60%) and somatic obsessions (49%), and the most commonly occurring compulsions were repeating rituals (68%), cleaning and washing compulsions (63%), and checking compulsions (58%). Seventy-one percent of patients were rated severe on the Y-BOCS, and all of them had impaired insight; 9% were insightless. The age of patients was found to correlate positively with the total compulsive score and the total Yale BOCS score, but it correlated negatively with the total obsessive score. One third of patients had a comorbid depressive disorder. Regarding premorbid personality disorders, 14% had obsessive personality disorder, 34% had paranoid, anxious, or emotionally labile personality disorder, and 52% had no premorbid personality disorder. The role of religious upbringing has been evident in the phenomenology of OCD in Egypt, which is similar to the outcomes of studies in Jerusalem and different from results in India and Britain. The psychosociocultural factors are so varied that they can affect the onset, phenomenology, and outcome of OCD and even the response to treatment.

A random sample of 100 new patients referred consecutively to the psychiatric hospital was assessed using the Arabic translation of the PSE. An abstract form was designed to include all PSE scores as well as the necessary extra data to make ICD-9, ICD-10, and DSM-III-R diagnoses. Kappa correlation was calculated for inter-rater and intra-rater reliability. Overall reliability and reliability of each major psychiatric diagnosis were compared between the three systems. The use of the PSE helped in achieving good agreement between Arab psychiatrists for all the three systems, but ICD-10 was found to have the highest reliability figures both for three-digit and four-digit psychiatric diagnoses.

Scientific progress fostered in DSM and ICD over the past quarter of century has significantly increased awareness of the limitation of categorical definitions of mental illness. Disorders highly merge into another with no natural boundary in between. The addition of continuous, “dimensional” measures into the various diagnostic domains might help resolve some of the critical taxonomic issues currently facing the field of mental health. It was overtly recognized that both categorical and dimensional approaches to diagnosis are important both for clinical work and for research, and that the ideal taxonomy would offer both. Within each diagnostic entity, there are multiple options for creating a dimensional scale based on a categorical definition. The ICD 10 and DSM IV have no place for subthreshold disorders except in atypical, not otherwise specified or to marginalize its existence with subsequent suffering and impairment of the patients. The chapter will discuss how the subthreshold affective, psychotic, anxiety, cognitive and substance abuse and other psychiatric disorders contribute to psychiatric morbidity and impairment. The chapter discusses the impairment and suffering of patients with subthreshold various psychiatric disorders and how its inclusion in a dimensional approach may result in ameliorating the suffering of that group as their current status may initiate some ethical considerations for their management.

Coercion, compulsory admission, and the involuntary treatment of the mentally ill are among the most controversial issues in mental health care and are the subject of ongoing debate among patients, mental health care professionals, and a wider public. Physical restraint, seclusion, the involuntary application of neuroleptic drugs, and numerous other forms of compulsorily applied treatments are an essential part of mental health care all over the world. The practices of applying coercive measures also vary internationally according to cultural and legal traditions. Certain human problems are psychiatric diseases which, like other medical illnesses, are biological but, unlike other medical illnesses, can be treated with confinement and coercion! Religious beliefs have a strong influence on ethics, morals, and deontological mistakes. Although there are diverse cultures, only one human conscience, one human sense of responsibility, and one human moral obligation exist. Individual autonomy is valued in Scandinavian, European, and American cultures but is not empowering for the traditional, family-centered societies in Arab, sub-Saharan African, Indian, and Japanese cultures. This difference may affect the use of involuntary admission, informed consent, among other practices, in traditional versus Western Societies. The paper will discuss the transcultural ethical aspects of implementing coercive management of psychiatric disorders.

Sixty years ago at the Nuremberg Trials, 23 Nazi leaders were tried as war criminals, in what was known as "The Doctors' Trial". This trial exposed a perverse system of the criminal use of medicine in the fields of public health and human research. These practices, in which racial hygiene constituted one of the fundamental principles and euthanasia programmes were the most obvious consequence, violated the majority of known bioethical principles. Psychiatry played a central role in these programmes, and the mentally ill were the principal victims. The aim of the present work is to review, from the historical perspective, the antecedents of the shameful euthanasia programmes for the mentally ill, the procedures involved in their implementation and the use of mentally ill people as research material. The Nuremberg Code, a direct consequence of the Doctors' Trial, is considered to be the first international code of ethics for research with human beings, and represented an attempt to prevent any repeat of the tragedy that occurred under Nazism. Nevertheless, the last 60 years have seen continued government-endorsed psychiatric abuse and illegitimate use of psychoactive drugs in countries such as the Soviet Union or China, and even in some with a long democratic tradition, such as the United States. Even today, the improper use of psychiatry on behalf of governments is seen to be occurring in numerous parts of the globe: religious repression in China, enforced hospitalization in Russia, administration of psychoactive drugs in immigrant detention centres in Australia, and the application of the death penalty by lethal injection and psychiatric participation in coercive interrogation at military prisons, in relation to the USA. The Declaration of Madrid in 1996 constituted the most recent attempt to eradicate, from the ethical point of view, these horrendous practices. Various strategies can be used to combat such abuses, though it is uncertain how effective they are in preventing them.