Overview of Schizophrenia in Palestine
Meeting the need for mental health care for the Palestinian population remains an ongoing struggle [3]. Palestinians are notably at a higher risk for developing mental disorders due to their chronic exposure to political violence, prolonged displacement and insecurity. In addition, the 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 only on one aspect of the Palestinian reality and gaining more insight into its mental health challenges, especially among patients with schizophrenia. According to the Palestinian Health Information Center (PHIC, 2016), the incidence rates for newly reported cases in the West Bank showed that schizophrenia was 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 patients with schizophrenia seem to be vouge. Studies have investigated the lifestyle and clinical features of patients with schizophrenia in Palestine. A cross-sectional study design conducted at the governmental primary psychiatric health care centers in Northern West Bank and implemented a survey to investigate the different lifestyle parameters, diet, body mass index, smoking, and unemployment among 250 patients with schizophrenia 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 obtained a bachelor’s degree. One hundred and ninety-seven (78.80%) participants were without a job, and the number of working patients was only 53 (21.2%). Moreover, only 82 clients (32.8% from the total number of patients) had an average BMI values most of them were males (60 males and 13 females), and the number of patients with schizophrenia 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].
Another study investigated the clinical characteristics of schizophrenia among three different group categories (Negev Bedouin, Galilee Palestinians and Palestinian Authority). The results revealed that from the total 50 patients in the Palestinian category; (78%) of the patients were males (66%) were single/divorced (70%) were unemployed and (70%) had low to medium education level. Moreover, somatic delusions were the highest delusions in this category representing (86%), followed by Persecution delusions representing (82%), and Jealousy delusions were the lowest among Palestinian Authority patients (4%). Among all of the three 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 investigate schizophrenia treatment guidelines in the 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].
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 episodes for schizophrenia and hospitalization [36]. According to Sweileh et al., several major well-known algorithms were used for the treatment of schizophrenia [35]. Schizophrenia treatment guidelines in Palestine were investigated, and results revealed there were 406 prescriptions of antipsychotic drugs used by the 250 patients. The antipsychotics were primarily from First-generation type (FGT) (85.7%), and the most common antipsychotic medications that were consumed by the patients: 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 Zuclopenthixol (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 the supra-maximal dose (CPZeq > 1000 mg) [35].
Antipsychotic medication adherence and satisfaction were also assessed in patients with schizophrenia. 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 revealed medication nonadherence was common and was associated with low treatment satisfaction scores and poor psychiatric scores. In addition, 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 medications cause serious side effects, including metabolic syndrome (MS) [37]. Metabolic syndrome is defined as a cluster of conditions that occur simultaneously, 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 revealed that 109 (43.6%) of patients met the criteria for the syndrome; 39% in males and 55.9% in female patients. Among males, elevated levels of triglyceride were the most common metabolic component compared to females who have abdominal obesity as a common metabolic component. Elevated fasting blood sugar was the least common metabolic dysregulation in both genders. This study also revealed 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 these patients. This study also supported the previous studies in the characteristics of patients with schizophrenia; 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 four 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 patients with schizophrenia. The criteria for the patients were: 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 been unchanged in the last six months. Results revealed 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 patients with schizophrenia with a significant (P= 0.003) and (P=0.013) respectively [12].
Inadequate or inappropriate dietary habits increase the risk of anemia in patients with schizophrenia [38]. Many studies have demonstrated that patients 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 to report the prevalence of anemia among 250 patients with schizophrenia. Results revealed the number of anemic females was 38 (55.9%) out of 68 patients, while the number of anemic males was 25 (13.7%) out of 182 patients (P-value <0.01). In comparison, 6.1% of males and 11.8% of female patients had leucopenia, 7.7% of males and 7.3% of females had leukocytosis, 5.5% of males and 4.4% of females had thrombocytopenia and 1.1% of males and 5.9% of females had thrombocytosis. Results revealed an unhealthy lifestyle and poor dietary choices represent the primary cause of anemia among these patients [38].
Coronary heart diseases and mental illness are one of the leading causes of morbidity and mortality worldwide. Research has revealed several, and sometimes surprising links between both CHD and mental illness and has even suggested that both may actually cause one another [40]. A cross-sectional study design was carried at four governmental primary psychiatric health care centers in northern West-Bank to estimate the ten years’ risk of coronary heart diseases (CHD) among 112 patients with schizophrenia. Results revealed one-fifth of the patients had a CHD risk of 10% [41].
Globally, approximately 3% of the total burden of human diseases is attributable to schizophrenia [42]. The WHO has estimated that around 40-90% of patients having schizophrenia live with their families [43]. 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 patients with schizophrenia. Results revealed the sociodemographic characteristics of patients were the following: the majority of the sample were male patients representing 62.5%, and 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, and 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%, and 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 for patients with schizophrenia was measured using the burden assessment scale. Results revealed that caregivers suffered from a high level of a total burden representing 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, education, occupation, and monthly income for both caregivers and patients [44].
Stigma among psychiatric patients is dangerous as it interferes with the understanding, gaining support from friends and family, delays getting help, and self-blame [45]. 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 the majority of the patients were males representing 61.3%, 50% of patients were single, and stigma had a significant effect on the daily life of patients with mental illness. The patients 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) [46].