Moroccan national study on prevalence of mental disorders: a community-based epidemiological study

Adaption and validation of the Rwandese version of the Mood Disorder Questionnaire for the screening of bipolar disorder

BACKGROUND

Bipolar disorder is challenging to diagnose. In Rwanda, a sub-Saharan country with a limited number of psychiatrists, the number of people with an undetected diagnosis of bipolar disorder could be high. Still, no screening tool for the disorder is available in the country. This study aimed to adapt and validate the Mood Disorder Questionnaire in the Rwandan population.

METHODS

The Mood Disorder Questionnaire was translated into Kinyarwanda. The process involved back-translation, cross-cultural adaptation, field testing of the pre-final version, and final adjustments. A total of 331 patients with either bipolar disorder or unipolar major depression from two psychiatric outpatient hospitals were included. The statistical analysis included reliability and validity analyses and receiver operating characteristic curve (ROC) analysis. The optimal cut-off was chosen by maximizing Younden's index.

RESULTS

The Rwandese version of The Mood Disorder Questionnaire had adequate internal consistency (Cronbach's alpha =0.91). The optimal threshold value was at least six positive items, which yielded excellent sensitivity (94.7%), and specificity (97.3%). The ROC area under the curve (AUC) was 0.99.

CONCLUSION

The adapted tool showed good psychometric properties in terms of reliability and validity for the screening of bipolar disorder, with a recommended cutoff value of six items on the symptom checklist for a positive score and an exclusion of items 14 and 15. The tool has the potential to be a crucial instrument to identify otherwise undetected cases of bipolar disorder in Rwanda, improving access to mental health treatment, thus enhancing the living conditions of people with bipolar disorder.

Phone addiction, cyberbullying, and mental health amongst young adults in the United Arab Emirates: a cross-sectional study

BACKGROUND

Smartphone addiction is a common phenomenon worldwide and within the UAE. It is related to many factors, including gender and ethnicity, and can lead to mental health disorders, such as anxiety and depression. This study investigates these factors concerning smartphone addiction among young adults in the UAE.

METHODS

421 participants answered a questionnaire of validated and reliable scales measuring smartphone addiction, cyberbullying experiences, mental health, and demographic information. The average age of the participants was 21 years, and the age groups were divided into two groups. Group 1 consists of participants who are 20 years or younger, and group 2 consists of participants aged 21 or older.

RESULTS

There was a positive correlation between smartphone addiction with both anxiety and depression. A positive correlation was also found between cyberbullying victims, anxiety, and depression. Females were found to have higher levels of anxiety and smartphone addiction in comparison to males.

CONCLUSION

Smartphone addiction is a problem that connects to disorders like anxiety and depression. Conversely, cyberbullying is not directly related to smartphone addiction but is also strongly related to anxiety and depression.

Depression among Turkish and Moroccan immigrant populations in Northwestern Europe: a systematic review of prevalence and correlates

BACKGROUND

This systematic review aimed to synthesize the prevalence and correlates of depressive disorders and symptoms of Turkish and Moroccan immigrant populations in Northwestern Europe, formulating evidence-informed recommendations for clinical practice.

METHODS

We conducted a systematic search in PsycINFO, MEDLINE, Science Direct, Web of Knowledge, and Cochrane databases for records up to March 2021. Peer-reviewed studies on adult populations that included instruments assessing prevalence and/or correlates of depression in Turkish and Moroccan immigrant populations met inclusion criteria and were assessed in terms of methodological quality. The review followed the relevant sections of the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting (PRISMA) guideline.

RESULTS

We identified 51 relevant studies of observational design. Prevalence of depression was consistently higher among people who had an immigrant background, compared to those who did not. This difference seemed to be more pronounced for Turkish immigrants (especially older adults, women, and outpatients with psychosomatic complaints). Ethnicity and ethnic discrimination were identified as salient, positive, independent correlates of depressive psychopathology. Acculturation strategy (high maintenance) was related to higher depressive psychopathology in Turkish groups, while religiousness appeared protective in Moroccan groups. Current research gaps concern psychological correlates, second- and third-generation populations, and sexual and gender minorities.

CONCLUSION

Compared to native-born populations, Turkish immigrants consistently showed the highest prevalence of depressive disorder, while Moroccan immigrants showed similar to rather moderately elevated rates. Ethnic discrimination and acculturation were more often related to depressive symptomatology than socio-demographic correlates. Ethnicity seems to be a salient, independent correlate of depression among Turkish and Moroccan immigrant populations in Northwestern Europe.

Prevalence of depression and anxiety in older people in low- and middle- income countries in Africa, Asia and South America: A systematic review and meta-analysis

BACKGROUND

There is rapid growth of older people in Low- and Middle- Income Countries (LMICs). The aim of this review was to assess the literature on prevalence of anxiety and depression in this demographic, which to our knowledge, has not yet been conducted.

METHODS

Databases including Medline, PsychInfo, Embase, Scielo and African Journals Online were searched for terms including "mental disorders", "neurotic disorders", "mood disorders" and "anxiety disorders". Studies published between 1990 and 2020 providing data on older people (≥50 years) in LMICs (defined by World Bank Criteria) were included and quality-assessed. Meta-analysis was conducted on a subset of higher-quality studies to derive pooled prevalence estimates of depression.

RESULTS

One hundred and forty relevant studies were identified, of which thirty-two were included in meta-analysis. One hundred and fifteen studies reported depression prevalence only, 19 reported both depression and anxiety, and six reported anxiety only. In all studies identified, depression prevalence ranged from 0.5 % to 62.7 %, and Generalised Anxiety Disorder prevalence ranged from 0.2 % to 32.2 %. The pooled prevalence of depression on meta-analysis was 10.5 % (95 % CI, 8.9 % - 11.2 %). Reported prevalence rates of depression were significantly different in studies using ICD-10 compared with DSM criteria, and between community and clinical settings.

LIMITATIONS

The search strategy contained bias towards English language papers and high income country (HIC) publications. There is significant heterogeneity within the meta-analysis.

DISCUSSION

A wide range of methodologies and clinical criteria are used in prevalence studies of depression and anxiety in older people. Studies using screening tools found higher prevalence rates; clinicians and researchers should ensure diagnosis is made with gold-standard clinical criteria. Meta-analysis data suggest that rates of depression are similar in older people in LMICs compared to HICs but mental healthcare resources are limited, suggesting a large potential treatment gap.

Epigenome-wide DNA methylation analysis of whole blood cells derived from patients with GAD and OCD in the Chinese Han population

Generalized anxiety disorder (GAD) and obsessive-compulsive disorder (OCD) had high comorbidity and affected more than 44 million people around the world leading to a huge burden on health and economy. Here, we conducted an epigenome-wide DNA methylation study employing 93 patients with GAD, 65 patients with OCD, and 302 health controls, to explore epigenetic alterations associated with the onset and differences of GAD and OCD. We identified multiple differentially methylated positions (DMPs) and regions (DMRs): three DMP genes included RIOK3 (cg21515243, p = 8.00 × 10^-10), DNASE2 (cg09379601, p = 1.10 × 10^-9), and PSMB4 (cg01334186, p = 3.70 × 10^-7) and two DMR genes USP6NL (p = 4.50 × 10^-4) and CPLX1 (p = 6.95 × 10^-4) were associated with the onset of GAD and OCD; three DMPs genes included LDLRAP1 (cg21400344, p = 4.40 × 10^-12), ACIN1 (cg23712970, p = 2.98×10^-11), and SCRT1 (cg25472897, p = 5.60 × 10^-11) and three DMR genes WDR19 (p = 3.39 × 10^-3), SYCP1 (p = 6.41 × 10^-3), and FAM172A (p = 5.74 × 10^-3) were associated with the differences between GAD and OCD. Investigation of epigenetic age and chronological age revealed a different epigenetic development trajectory of GAD and OCD. Conclusively, our findings which yielded robust models may aid in distinguishing patients from healthy controls (AUC = 0.90-0.99) or classifying patients with GAD and OCD (AUC = 0.89-0.99), and may power the precision medicine for them.

Psychological distress in a sample of Moroccan prisoners with drug-dependence

Research regarding mental illness and drug addiction among inmates in Morocco requires increased knowledge; previous literature reported that prisoners suffer from severe psychological distress. The present study aimed to provide information about Moroccan prisoners' psychological distress and define the differences in psychological distress levels among inmates with and without drug-dependence. A sample of 177 male inmates completed a set of surveys, including the Drug Use Disorders Identification Test (DUDIT) and the Brief Symptom Inventory (BSI). The "Drug dependence" group scored significantly higher psychological distress levels in each of the BSI domains. The strongest differences were measured in the General Severity Index (GSI), hostility, and depression scales. Moroccan prison inmates have high psychological distress, and those with drug-dependence have even higher. There is a need of psychiatric assessment, selection, and care possibilities in prison inmate populations.

Understanding the role and importance of occupational therapy in mental health services in Morocco: Perspectives from mental health professionals

BACKGROUND: Across the global landscape, mental health care still exhibits challenges because of the lack of human and professional resources to face its consequences. In Morocco, mental health problems affect mainly adolescents and young adults, with a clear impact on functional engagement in their daily lives. Occupational therapy, as a holistic and person-centered practice, may be an ideal mental health strategy to promote health and well-being through occupation, thereby enabling individuals to participate in regular daily activities. OBJECTIVE: To understand, from an intercultural perspective, the point of view of mental health professionals regarding the role and importance of occupation-based practices in Errazi Mental Health Hospital in Salé(Rabat) Morocco. METHOD: A qualitative research design was used for this study. Data collection consisted of semi-structured interviews with 12 mental health care professionals (non-occupational therapists). These results were used to gain an understanding of their perspectives regarding the main role of human occupation in mental health services in Morocco, and to incorporate an intercultural outlook in terms of occupational therapy. Data analysis was conducted in three phases, by following the grounded theory methodology. RESULTS: Two categories, “dimensions of occupation in Moroccan mental health” and “the interplay between traditional and western perspectives involving mental health” emerged from this research. Both categories included five subcategories. CONCLUSION: This study identifies how occupation-based services in Moroccan mental health care require considering not only the cultural perspective of mental health, and the sociocultural meaning rooted in occupations, but also the relevance of incorporating a community-centered approach. Moreover, it discusses how occupational therapy education in Morocco must incorporate an intercultural perspective of the therapy’s theory and practice.

Cannabis and schizophrenia: characterisation of a risk factor in a sample of Moroccan patients hospitalised for psychosis

Background

In addition to the biological plausibility widely described through a very large number of studies, the causal link between cannabis uses and schizophrenia disorders has become illicit internationally and given the scarcity of similar studies in Morocco. Our study consists of a prospective descriptive study in the psychiatric department of the Moulay ben Abdallah Hospital in Essaouira. The sample consisted of 95 patients diagnosed with schizophrenia according to the DSM5 criteria. The diagnostic assessment included the Positive and Negative Syndrome Scale to assess the severity of positive and negative symptoms of schizophrenia as well as the patient’s general psychopathology, the Clinician-Rated Dimensions of Psychosis Symptom Severity to assess the symptom severity of the psychotic dimensions according, and the Cannabis Abuse Screening Test to assess the extent of cannabis use.

Results

The mean age of the patients recruited in the study was 33.7 ± 9.37 years with a clear male predominance (p < 0.0001). Cannabis users compared to non-users were younger and comprised only men. Cannabis users also have a lower educational and economic level than non-users. Furthermore, a clear dose effect of cannabis uses on the onset of positive and negative symptoms of schizophrenia. The temporality criterion is clear in our study, since the predictivity of the parameter: “age of onset of cannabis use” is highly significant (p = 0.000). These results suggest that cannabis use can be considered as the most illicit risk factor for the development and/or onset of schizophrenia.

Conclusions

These results suggest that there is a causal relationship between cannabis use and/or dependence (problematic use) and the onset and/or worsening of schizophrenic disorder. This means that problematic cannabis use can be considered as a real risk factor for the emergence and development of schizophrenic disorder.

Mental Health during the COVID-19 Crisis in Africa: A Systematic Review and Meta-Analysis

We aim to provide a systematic review and meta-analysis of the prevalence rates of mental health symptoms among major African populations during the COVID-19 pandemic. We include articles from PubMed, Embase, Web of Science, PsycINFO, and medRxiv between 1 February 2020 and 6 February 2021, and pooled data using random-effects meta-analyses. We identify 28 studies and 32 independent samples from 12 African countries with a total of 15,071 participants. The pooled prevalence of anxiety was 37% in 27 studies, of depression was 45% in 24 studies, and of insomnia was 28% in 9 studies. The pooled prevalence rates of anxiety, depression, and insomnia in North Africa (44%, 55%, and 31%, respectively) are higher than those in Sub-Saharan Africa (31%, 30%, and 24%, respectively). We find (a) a scarcity of studies in several African countries with a high number of COVID-19 cases; (b) high heterogeneity among the studies; (c) the extent and pattern of prevalence of mental health symptoms in Africa is high and differs from elsewhere-more African adults suffer from depression rather than anxiety and insomnia during COVID 19 compared to adult populations in other countries/regions. Hence, our findings carry crucial implications and impact future research to enable evidence-based medicine in Africa.

Mental Health during the COVID-19 Crisis in Africa: A Systematic Review and Meta-Analysis

We aim to provide a systematic review and meta-analysis of the prevalence rates of mental health symptoms among major African populations during the COVID-19 pandemic. We include articles from PubMed, Embase, Web of Science, PsycINFO, and medRxiv between 1 February 2020 and 6 February 2021, and pooled data using random-effects meta-analyses. We identify 28 studies and 32 independent samples from 12 African countries with a total of 15,071 participants. The pooled prevalence of anxiety was 37% in 27 studies, of depression was 45% in 24 studies, and of insomnia was 28% in 9 studies. The pooled prevalence rates of anxiety, depression, and insomnia in North Africa (44%, 55%, and 31%, respectively) are higher than those in Sub-Saharan Africa (31%, 30%, and 24%, respectively). We find (a) a scarcity of studies in several African countries with a high number of COVID-19 cases; (b) high heterogeneity among the studies; (c) the extent and pattern of prevalence of mental health symptoms in Africa is high and differs from elsewhere-more African adults suffer from depression rather than anxiety and insomnia during COVID 19 compared to adult populations in other countries/regions. Hence, our findings carry crucial implications and impact future research to enable evidence-based medicine in Africa.

The epidemiology of psychiatric disorders in Africa: a scoping review

This scoping review of population-based epidemiological studies was done to provide background information on the prevalences and distribution of psychiatric disorders in Africa for calls to broaden diversity in psychiatric genetic studies. We searched PubMed, EMBASE, and Web of Science to retrieve relevant literature in English, French, and Portuguese from Jan 1, 1984, to Aug 18, 2020. In 36 studies from 12 African countries, the lifetime prevalence ranged from 3·3% to 9·8% for mood disorders, from 5·7% to 15·8% for anxiety disorders, from 3·7% to 13·3% for substance use disorders, and from 1·0% to 4·4% for psychotic disorders. Although the prevalence of mood and anxiety disorders appears to be lower than that observed in research outside the continent, we identified similar distributions by gender, although not by age or urbanicity. This review reveals gaps in epidemiological research on psychiatric disorders and opportunities to leverage existing epidemiological and genetic research within Africa to advance our understanding of psychiatric disorders. Studies that are methodologically comparable but diverse in geographical context are needed to advance psychiatric epidemiology and provide a foundation for understanding environmental risk in genetic studies of diverse populations globally.

Prevalence of Mental Disorders in the WHO Eastern Mediterranean Region: A Systematic Review and Meta-Analysis

Objectives: To synthesize the prevalence of mental and substance use disorders in countries of the Eastern Mediterranean Region (EMR) of the World Health Organization. Methods: The literature search was conducted across several databases in two phases. First, we searched for systematic reviews and/or meta-analyses published before 2014, reporting prevalence estimates for mental disorders in the EMR. Then, we identified new primary cross-sectional or longitudinal studies published between 2014 and 2020. Studies were included if they had a sample size of ≥ 450 and were conducted among the general adult population. Current, period and lifetime prevalence estimates for each disorder were pooled using random-effects meta-analyses, and subgroup analyses and meta-regressions were conducted. Findings: Prevalence estimates were extracted from 54 cross-sectional studies across 15 countries within the EMR. Pooled analyses of current, period and lifetime prevalence showed the highest prevalence for depression (14.8%, 95% confidence interval, CI: 10.7-20.1%), followed by generalized anxiety disorder (GAD) (10.4%, 95% CI: 7.1-14.7%), post-traumatic stress disorder (7.2%, 95% CI: 2.9-16.6%), substance use (4.0%, 95% CI: 3.1-5.2%), obsessive compulsive disorder (2.8%, 95% CI: 1.6-4.9%), phobic disorders (1.8%, 95% CI: 1.1-2.8%), panic disorders (1.1%, 95% CI: 0.6-2.2%), bipolar disorders (0.7%, 95% CI: 0.3-1.6%), and psychosis (0.5%, 95% CI: 0.3-0.9%). Populations exposed to adverse events had higher prevalence of mental disorders than the general population. Period and lifetime prevalence showed little difference across mental disorders. More pronounced differences in prevalence were seen for depression and GAD, specifically between current and lifetime prevalence (depression: current prevalence 20.5% (95% CI: 14.9-27.4%), vs. lifetime prevalence: 4.2% (95%CI: 1.8-9.6%); GAD: current prevalence 10.3% (95% CI: 6.1-17.0), vs. lifetime prevalence: 4.5% (95% CI: 2.4-8.3%). Differences between current and lifetime prevalence of mental disorders may be due to the use of different screening instruments and thresholds being applied. Conclusion: The prevalence of mental and substance use disorders in the EMR is high. Despite substantial inter-survey heterogeneity, our estimates align with previous global and regional data on mental disorders. Our meta-review provides new evidence on the burden of mental health problems in the EMR. Systematic Review Registration: PROSPERO, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020187388.

Epidemiological profile of psychiatric illnesses in the province of Taza, Morocco: case of a study on a schizophrenic sub-population in the Ibn Baja Hospital

Aim

The objective of this study is to assess the prevalence of major psychiatric disorders and to plot some characteristics of the schizophrenic sub-population in the study area.

Methods

We present the results of a retrospective study on psychiatric illnesses listed at the level of the psychiatric department at the Ibn Baja Hospital in the province of Taza (Morocco), involving a sample of 3803 patients aged 18 years and over between 2006 and 2016.

Results

The results obtained show that the average age of our sample is 33 ± 10.5 years and that schizophrenia is the most pronounced psychiatric disorder with a prevalence of 69.9%, followed by bipolar disorder (8.4%), manic state (8.3%), major depression (5.8%), epilepsy (3.7%), dementia (2.5%), and drug addiction (1.5%). The predominance of the workforce for all psychiatric disorders was significantly in favor of males (P = 0 .000) with an M/F sex ratio of 4.9. Most patients were from urban areas 77.1%, compared with 22.9% from rural areas, with a predominance of males (P<0.001). Schizophrenia disease is the most predominant in the region with a prevalence of 1.6% and affects 83% of men versus 17% of women with a M/F sex ratio value of 5.6 in favor of men (P = 0.000).

Conclusion

In our region of study, as everywhere else in the world, the prevalence of psychiatric diseases on the one hand, and schizophrenia on the other hand, seems to be worrying, thus requiring more vigilance on the part of public health workers in general and mental health workers.

Suicide Prevention in the Eastern Mediterranean Region

Abstract. The WHO Eastern Mediterranean Region (EMR) consists of 22 countries including Afghanistan, Bahrain, Djibouti, Egypt, Iraq, Islamic Republic of Iran, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates (UAE), and Yemen. According to Global Burden of Disease (GBD) data, death from self-harm has increased by 100% between 1990 and 2015 in this region. Although this increase is substantial, it appears trivial in comparison to the 1027% increase in deaths due to war and legal interventions. This might partly explain why suicide prevention does not have a high priority in these countries and why there are currently no suicide prevention strategies in place. Despite the above, some important activities in the area of suicide prevention have been carried out in the region. And while peace and stability may take time to come to the region, it should not prevent suicide prevention programs from being developed and implemented.

Frequency of use of the International Classification of Diseases ICD-10 diagnostic categories for mental and behavioural disorders across world regions

AIMS

The study aimed to examine variations in the use of International Classification of Diseases, Tenth Edition (ICD-10) diagnostic categories for mental and behavioural disorders across countries, regions and income levels using data from the online World Psychiatric Association (WPA)-World Health Organization (WHO) Global Survey that examined the attitudes of psychiatrists towards the classification of mental disorders.

METHODS

A survey was sent to 46 psychiatric societies which are members of WPA. A total of 4887 psychiatrists participated in the survey, which asked about their use of classification, their preferred system and the categories that were used most frequently.

RESULTS

The majority (70.1%) of participating psychiatrists (out of 4887 psychiatrists) reported using the ICD-10 the most and using at least one diagnostic category once a week. Nine out of 44 diagnostic categories were considerably variable in terms of frequency of use across countries. These were: emotionally unstable personality disorder, borderline type; dissociative (conversion) disorder; somatoform disorders; obsessive-compulsive disorder (OCD); mental and behavioural disorders due to the use of alcohol; adjustment disorder; mental and behavioural disorders due to the use of cannabinoids; dementia in Alzheimer's disease; and acute and transient psychotic disorder. The frequency of use for these nine categories was examined across WHO regions and income levels. The most striking differences across WHO regions were found for five out of these nine categories. For dissociative (conversion) disorder, use was highest for the WHO Eastern Mediterranean Region (EMRO) and non-existent for the WHO African Region. For mental and behavioural disorders due to the use of alcohol, use was lowest for EMRO. For mental and behavioural disorders due to the use of cannabinoids, use was lowest for the WHO European Region and the WHO Western Pacific Region. For OCD and somatoform disorders, use was lowest for EMRO and the WHO Southeast Asian Region. Differences in the frequency of use across income levels were statistically significant for all categories except for mental and behavioural disorders due to the use of alcohol. The most striking variations were found for acute and transient psychotic disorder, which was reported to be more commonly used among psychiatrists from countries with lower income levels.

CONCLUSIONS

The differences in frequency of use reported in the current study show that cross-cultural variations in psychiatric practice exist. However, whether these differences are due to the variations in prevalence, treatment-seeking behaviour and other factors, such as psychiatrist and patient characteristics as a result of culture, cannot be determined based on the findings of the study. Further research is needed to examine whether these variations are culturally determined and how that would affect the cross-cultural applicability of ICD-10 diagnostic categories.

Risk and protective factors for drug dependence in two Moroccan high-risk male populations

BACKGROUND

Substance use is linked to biological, environmental, and social factors. This study provides insights on protective and risk factors for drug dependence in two Moroccan, high-risk, male samples.

METHODS

Data from the "Mental and Somatic Health without borders" (MeSHe) survey were utilized in the present study. The MeSHe survey assesses somatic and mental health parameters by self-report from prison inmates (n = 177) and outpatients from an addiction institution (n = 54). The "Drug dependence" and the "No drug dependence" groups were identified based on the Arabic version of the Drug Use Disorder Identification Test's (DUDIT) validated cutoff for identifying individuals with drug dependence, specifically in Morocco.

RESULTS

The majority of participants who had at least high school competence (67.6%), were living in a partnership (53.7%), were a parent (43.1%), and/or had a job (86.8%) belonged to the "No drug dependence" group, while the presence of mental health problems was typical among the "Drug dependence" group (47.4%). A multivariable regression model (χ2 (df = 5, N = 156) = 63.90, p < 0.001) revealed that the presence of depression diagnosis remains a significant risk factor, while a higher level of education, having a child, and being employed are protective factors from drug dependence.

DISCUSSION

Findings support the importance of increasing academic competence and treating depression as prevention from the persistence of drug addiction in male high-risk populations.

The CZEch Mental health Study (CZEMS): Study rationale, design, and methods

OBJECTIVES

The CZEch Mental health Study (CZEMS) was launched to inform the ongoing mental health care reform. This paper describes rationale, methods, and the plan for the future analyses of this project.

METHODS

A cross-sectional survey on a representative sample of the general adult noninstitutionalized population of the Czech Republic was conducted. Two-stage sampling was utilized and respondents were interviewed by centrally trained staff using a paper and pencil interviewing. The presence of mental disorders was assessed by The Mini-International Neuropsychiatric Interview. The study also collected information about disability, self-identification of having a mental illness, medical history, and help-seeking behaviour.

RESULTS

This survey had a 75% response rate, and the final sample consisted of 3,306 persons aged from 18 to 96 years (mean age 49 years old, 54% women) that were interviewed in their homes. The final sample is representative for the Czech Republic in terms of age, gender, education, and region.

CONCLUSIONS

CZEMS will provide up-to-date evidence about a prevalence of mental disorders in the Czech Republic, associated disability, and treatment gap. This will help informed decision-making about the current mental health care reform and future mental health care development in the Czech Republic.

Acceptability of Mental Health Services for Anxiety and Depression in an Arab Sample

The aim of this paper was to examine the acceptability and use of mental health services in an Arab sample. An Internet survey was made available to Arab people worldwide and enquired about the acceptability of traditional face-to-face and internet-delivered mental health services. Five hundred and three participants were recruited via media and Facebook promotions. Of those surveyed, 36% (183/503), 46% (233/503), and 73% (365/503) reported that they would be willing to consult a mental health professional, take prescription medication and try an internet-delivered psychological treatment, respectively. Moderate to high acceptability rates for mental health services were found in this sample of Arab people. High acceptability of internet-delivered treatments among the current Arab sample, provides the opportunity for directing resources to the development of internet-delivered interventions to help reduce the stigma and burden of mental disease in the Arab world.

Psychometric Properties of the Arabic Version of the Drug Use Disorders Identification Test (DUDIT) in Clinical, Prison Inmate, and Student Samples

Purpose

The study aimed to validate the Arabic version of the Drug Use Disorders Identification Test (DUDIT) by (1) assessing its factor structure, (2) determining structural validity, (3) evaluating item-total and inter-item correlation, and (4) assessing its predictive validity.

Method

The study population included 169 prison inmates, 51 patients with clinical diagnosis of substance used disorder, and 53 students (N = 273). All participants completed the self-report version of the Arabic DUDIT. After exploratory factor analysis, internal consistency of the Arabic DUDIT was determined and external validation was performed.

Results

Principal factor analysis showed that Arabic DUDIT exhibited only one factor, which explained 66.9% of the variance. Reliability based on Cronbach’s alpha was .95. When compared to the DSM-IV substance use disorder diagnosis in a clinical sample, DUDIT had an area under the curve (AUC) of .98, with a sensitivity of .98 and a specificity of .90.

Conclusion

The Arabic version of DUDIT is a valid and reliable tool for screening for drug use in Arabic-speaking countries.

Empowering patients of a mental rehabilitation center in a low-resource context: a Moroccan experience as a case study

Mental, neurological and substance use (MNS) disorders represent a major source of disability and premature mortality worldwide. However, in developing countries patients with MNS disorders are often poorly managed and treated, particularly in marginalized, impoverished areas where the mental health gap and the treatment gap can reach 90%. Efforts should be made in promoting help by making mental health care more accessible. In this article, we address the challenges that psychological and psychiatric services have to face in a low-resource context, taking our experience at a Moroccan rehabilitation center as a case study. A sample of 60 patients were interviewed using a semi-structured questionnaire during the period of 2014-2015. The questionnaire investigated the reactions and feelings of the patients to the rehabilitation program, and their perceived psychological status and mental improvement, if any. Interviews were then transcribed and processed using ATLAS.ti V.7.0 qualitative analysis software. Frequencies and co-occurrence analyses were carried out. Despite approximately 30 million inhabitants within the working age group, Morocco suffers from a shortage of specialized health workers. Our ethnographic observations show that psychiatric treatment can be ensured, notwithstanding these hurdles, if a public health perspective is assumed. In resource-limited settings, working in the field of mental health means putting oneself on the line, exposing oneself to new experiences, and reorganizing one's own skills and expertise. In the present article, we have used our clinical experience at a rehabilitation center in Fes as a case study and we have shown how to use peer therapy to overcome the drawbacks that we are encountered daily in a setting of limited resources.

The Burden of Mental Disorders in the Eastern Mediterranean Region, 1990-2013

The Eastern Mediterranean Region (EMR) is witnessing an increase in chronic disorders, including mental illness. With ongoing unrest, this is expected to rise. This is the first study to quantify the burden of mental disorders in the EMR. We used data from the Global Burden of Disease study (GBD) 2013. DALYs (disability-adjusted life years) allow assessment of both premature mortality (years of life lost–YLLs) and nonfatal outcomes (years lived with disability–YLDs). DALYs are computed by adding YLLs and YLDs for each age-sex-country group. In 2013, mental disorders contributed to 5.6% of the total disease burden in the EMR (1894 DALYS/100,000 population): 2519 DALYS/100,000 (2590/100,000 males, 2426/100,000 females) in high-income countries, 1884 DALYS/100,000 (1618/100,000 males, 2157/100,000 females) in middle-income countries, 1607 DALYS/100,000 (1500/100,000 males, 1717/100,000 females) in low-income countries. Females had a greater proportion of burden due to mental disorders than did males of equivalent ages, except for those under 15 years of age. The highest proportion of DALYs occurred in the 25–49 age group, with a peak in the 35–39 years age group (5344 DALYs/100,000). The burden of mental disorders in EMR increased from 1726 DALYs/100,000 in 1990 to 1912 DALYs/100,000 in 2013 (10.8% increase). Within the mental disorders group in EMR, depressive disorders accounted for most DALYs, followed by anxiety disorders. Among EMR countries, Palestine had the largest burden of mental disorders. Nearly all EMR countries had a higher mental disorder burden compared to the global level. Our findings call for EMR ministries of health to increase provision of mental health services and to address the stigma of mental illness. Moreover, our results showing the accelerating burden of mental health are alarming as the region is seeing an increased level of instability. Indeed, mental health problems, if not properly addressed, will lead to an increased burden of diseases in the region.

The effects of the gender-culture interaction on self-reports of depressive symptoms: cross-cultural study among Egyptians and Canadians

PURPOSE

Research in depression has revealed differences in the way depressed individuals across cultures report their symptoms. This literature also points to possible differences in symptom reporting patterns between men and women. Using data from a larger dataset (Beshai et al. 2016), the current study examined whether non-depressed and depressed Egyptian and Canadian men and women differed in their self-report of the various domains of the Beck Depression Inventory -II (BDI-II).

METHOD

We recruited a total of 131 depressed and non-depressed participants from both Egypt (n = 29 depressed; n = 29 non-depressed) and Canada (n = 35 depressed; n = 38 non-depressed). Depression status was ascertained using a structured interview. All participants were asked to complete the BDI-II along with other self-report measures of depression. BDI-II items were divided into two subscales in accordance with Dozois, Dobson & Ahnberg (1998) factor analysis: cognitive-affective and somatic-vegetative subscales.

RESULTS

We found a significant three-way interaction effect on the cognitive-affective (F(1,121) = 9.51, p = .003) and main effect of depression status on somatic-vegetative subscales (F(1,121) = 42.80, p < .001). Post hoc analyses revealed that depressed Egyptian men reported lower scores on the cognitive-affective subscale of the BDI-II compared to their depressed Canadian male counterparts.

CONCLUSIONS

These results suggest that males across cultures may differentially report cognitive symptoms of depression. These results also suggest that clinicians and clinical scientists need to further examine the interaction effect of culture and gender when investigating self-reported symptoms of depression.

A pilot study of self-guided internet-delivered cognitive behavioural therapy for anxiety and depression among Arabs

This pilot study examined the efficacy and acceptability of a self-guided and culturally modified internet-delivered Cognitive Behaviour Therapy (iCBT) treatment for Arab people, aged 18 and over, with symptoms of depression and anxiety. Thirty-six participants from seven countries, with at least mild symptoms of depression (Patient Health Questionnaire 9-item; PHQ-9; total scores ≥ 5) or anxiety (Generalised Anxiety Disorder 7-item; GAD-7; total scores ≥ 5) accessed the online Arabic Wellbeing Course, which consisted of five online lessons delivered over eight weeks and presented in the English language. Standard measures of depression, anxiety, distress and disability were administered at pre-treatment, post-treatment and 3-month follow-up. Thirty-six percent of participants completed the five lessons over eight weeks, with 61% and 36% providing post-treatment and 3-month follow-up data respectively. Participants reported significant improvements (within-group Cohen's d; avg. reduction) in depression (ds ≥ 1.20; avg. reduction ≥ 46%), anxiety (ds ≥ 1.15; avg. reduction ≥ 45%), disability (ds ≥ 0.81; avg. reduction ≥ 35%) and psychological distress (ds ≥ 0.91; avg. reduction ≥ 24%) immediately post-treatment, which were sustained at or further improved to 3-month follow-up. Participants rated the Arabic Wellbeing Course as acceptable. Notwithstanding the absence of a control group, low follow-up questionnaire completion rates and the Course not being translated in Arabic, these results are encouraging and contribute to a growing body of literature indicating that, with minor modifications, internet-delivered interventions have the potential of increasing access to treatment for immigrant groups.

Prevalence of substance use among moroccan adolescents and association with academic achievement

AIM: To investigate rates of drug and alcohol use and their association with academic performance in Moroccan youth.

METHODS: An adapted version of the European School Project on Alcohol and Other Drugs survey was administered to 2139 10^th-12^th graders in 36 Moroccan public high schools. Two multiple logistic regressions were completed, one for male and one for female subjects. Grade average was used as a two-part outcome variable, and drug use was used as a four-level categorical independent variable. Parents’ education levels and socioeconomic status were included as covariates.

RESULTS: Of the subjects, 181 girls (16%) and 390 boys (40%) reported ever having used alcohol, hashish, or psychotropic drugs. Girls who had used any of those substances in the past 30 d demonstrated an adjusted odds ratio (AOR) of 2.62 (95%CI: 1.31-5.22) of having average or below-average grades, and those with any lifetime use showed an AOR of 1.72 (95%CI: 1.07-2.77). Among the boys, use in the past 30 d was associated with an AOR of 2.08 (95%CI: 1.33-3.24) of average or below average grades, and use in the last 12 mo with an AOR of 1.74 (95%CI: 1.00-3.05). Any lifetime use among male and previous 12 mo use among female subjects were not significantly associated with academic achievement.

CONCLUSION: Among Moroccan adolescents, drug use is substantially different between boys and girls. In both genders, lower academic achievement was associated with alcohol, hashish, or psychotropic drug use in the last 30 d.

Psychological Distress in the Hospital Setting: A Comparison between Native Dutch and Immigrant Patients

Background

Prevalence of psychological distress (i.e. depressive and anxiety symptoms) in medically ill patients is high. Research in the general population shows a higher prevalence of psychological distress among immigrants compared to natives. Our aim was to examine the prevalence of psychological distress in the hospital setting comparing immigrant and native Dutch patients and first and second generation immigrant patients.

Methods

Prevalence of psychological distress was assessed using the extended Kessler-10 (EK-10) in 904 patients in a Dutch general teaching hospital. Logistic regression was used to calculate odds ratios to determine differences between native and immigrant patients and first and second generation immigrants in the prevalence of psychological distress. We adjusted for demographic and social variables, socio-economic status, physical quality of life, history of psychiatric disease and health care use.

Results

Of 904 patients, 585 were native Dutch patients and 319 were immigrant patients. The prevalence of psychological distress in native compared to immigrant patients was 54% and 66% respectively, with especially high prevalences among Turkish and Moroccan immigrant patients. The crude OR for prevalence of psychological distress for immigrant patients versus native patients was 1.7 (95% CI 1.2–2.2) and for first versus second generation immigrant patients 2.1 (95% CI 1.2–3.5). After full adjustment ORs were 1.7 (95% CI 1.2–2.3) and 2.2 (95% CI 1.2–4.1) respectively.

Conclusion

Immigrant patients and first generation immigrant patients were more likely to have psychological distress compared to native patients and second generation immigrant patients respectively. We found a particularly high prevalence of psychological distress in Turkish and Moroccan immigrants.

Population level mental distress in rural Ethiopia

BACKGROUND

As part of a situational analysis for a research programme on the integration of mental health care into primary care (Programme for Improving Mental Health Care-PRIME), we conducted a baseline study aimed at determining the broad indicators of the population level of psychosocial distress in a predominantly rural community in Ethiopia.

METHODS

The study was a population-based cross-sectional survey of 1497 adults selected through a multi-stage random sampling process. Population level psychosocial distress was evaluated by estimating the magnitude of common mental disorder symptoms (CMD; depressive, anxiety and somatic symptoms reaching the level of probable clinical significance), harmful use of alcohol, suicidality and psychosocial stressors experienced by the population.

RESULTS

The one-month prevalence of CMD at the mild, moderate and severe threshold levels was 13.8%, 9.0% and 5.1% respectively. The respective one-month prevalence of any suicidal ideation, persistent suicidal ideation and suicide attempt was 13.5%, 3.8% and 1.8%. Hazardous use of alcohol was identified in 22.4%, significantly higher among men (33.4%) compared to women (11.3%). Stressful life events were widespread, with 41.4% reporting at least one threatening life event in the preceding six months. A similar proportion reported poor social support (40.8%). Stressful life events, increasing age, marital loss and hazardous use of alcohol were associated with CMD while stressful life events, marital loss and lower educational status, and CMD were associated with suicidality. CMD was the strongest factor associated with suicidality [e.g., OR (95% CI) for severe CMD = 60.91 (28.01, 132.48)] and the strength of association increased with increase in the severity of the CMD.

CONCLUSION

Indicators of psychosocial distress are prevalent in this rural community. Contrary to former assumptions in the literature, social support systems seem relatively weak and stressful life events common. Interventions geared towards modifying general risk factors and broader strategies to promote mental wellbeing are required.

Major depressive disorder in Africa and the Middle East: a systematic literature review

With major depressive disorder (MDD) associated with significant clinical, economic and health-related quality of life impact, we sought to systematically review and synthesize information relevant to the burden of MDD in Africa and the Middle East, from which published evidence is slim. Our literature search identified 54 publications assessing epidemiological (43), humanistic (5), clinical/treatment (7) or economic outcomes (2). General population MDD prevalence and that among chronic disease populations were similar in Africa and the Middle East. No MDD-related economic literature specific to Africa or the Middle East was identified. Five studies of humanistic outcomes were identified; four African studies documented significant reduction of health-related quality of life related to MDD. The frequency of certain risk factors for MDD, such as disease, trauma and associated stress, as well as patterns of MDD treatment, suggest the potential for a higher burden of disease in Africa and the Middle East than in western countries.

Responsiveness of the EuroQol EQ-5D and Hospital Anxiety and Depression Scale (HADS) in rheumatoid arthritis patients receiving tocilizumab

The aim of this study was to assess the responsiveness to change of the quality of life evaluated by the EuroQol Five Dimensions Questionnaire (EQ-5D) and Hospital Anxiety and Depression Scale (HADS) after biological treatment in a population of rheumatoid arthritis patients. A cohort of patients with RA (n = 29) treated with tocilizumab (TCZ) were analyzed in the study. The inclusion criteria were patients aged between 18 and 65 years, fulfilling American College of Rheumatology 1987 criteria for RA. All patients had inadequate response to methotrexate and with no prior biologic exposure. They were evaluated clinically including Disease Activity Score 28 (DAS28), and the European Quality of Life 5 Dimensions (EQ-5D) to measure the quality of life, and HAD assessed the anxiety and depression status at the initiation of treatment with anti-IL 6 receptor antibody agent and after 6 months. Sensitivity to change was quantified by the effect size (ES) before and after the treatment with TCZ. Among 29 patients with RA included in the study, 25 were females and 4 males. The mean age was 42 years ± 13.4 (SD). Three patients were excluded from the study before 24 weeks because of serious side effects, and five have missing data. The study population exhibited significant decreases in all measures of disease activity at 24 weeks. Physical activity expressed by the Health Assessment Questionnaire (HAQ) score increased through the observation period (for all p < 0.001). Sensitivity to change was high for the VAS and EQ-5D (ES 1.58 and 1.36, respectively) but only moderate for the HAD anxiety component (ES = 0.70) and small for the HAD depression component (ES = 0.4). The EQ-5D and VAS were more responsive than HADS to evaluate the quality of life on patient with RA treated with TCZ.

Mental health research in the Arab world

PURPOSE

To assess the progression of mental health research over four decades in the Arab world.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

[Depressive disorders in diabetic patients]

INTRODUCTION

Diabetes is a public health problem. Its global prevalence was 2.8% in 2000 and it will reach 4.4% in 2030 to be 366 million diabetics. In Morocco, this true "epidemic" affects 6.6% of the population. Many epidemiologic studies have shown that patients with diabetes are more susceptible to depression. Diabetes and depression align in a non-accidental way and complicate one another.

PATIENTS AND METHODS

We report a cross-sectional study conducted in association with the endocrinology department of the Mohammed VI university hospital during the period spread between April and September 2006. The aim was to evaluate the prevalence of depressive disorders in patients with diabetes and to describe their sociodemographic and clinical profile. The study included 187 patients. The scales used were the Mini International Neuropsychiatric Interview (MINI) and Hamilton's depression. Sociodemographics and diabetic characteristics were evaluated by self-questionnaire.

RESULTS

The average age of our patients was 53±14 years and the percentage of females was high: 71.2%. Diabetes type 2 was the most representative (85.6%), diabetes type 1 (11.8%) and gestational diabetes (2.7%). Half of diabetics were treated with an association of healthy dietary measures (MHD) and oral anti-diabetics; 31.6% were under MHD and insulin therapy; 33.2% of patients had acute complications and 43.5% had degenerative complications. Only 11 patients (5.9%) had antecedents of depression. The prevalence of major depressive episode was 41.2%; 27.8% of patients suffered from dysthymia and 21.9% from double depression. Hamilton's depression scale indicates that all depressed patients had mild depression (total of 17 items from 8 to 17). Major depressive episode and dysthymia were frequent in out patients. Dysthymia was predominant in diabetic patients in the 46 to 55 years age group, never been schooled and without any comorbidity. The vast majority of patients with EDM had type 2 diabetes with 89.6%, 7.8% type 1 diabetes and 2.6% gestational diabetes. Most of dysthymic patients had type 2 diabetes with 94.2% against 5.8% type 1 diabetes.

DISCUSSION

The association of depression and diabetes was noted in the literature for the first time more than 300 years ago by the English doctor Willis. Compared to the population of non-depressed subjects, patients with depression may be more likely to develop type 2 diabetes. There would be an increase in the release of hyperglycemic hormones in depression, as in the stress response. In addition, patients with depression have insulin resistance during testing tolerance to insulin, and during testing tolerance to glucose. Other hypotheses explain that the depression/diabetes link included biological and genetic resources.

CONCLUSION

Diabetes and depressive disorders are public health problems due to their prevalence and their cost. The prevalence of major depressive disorders found among our population of diabetics justifies their research by doctors. The literature promotes appropriate care that would improve the prognosis of diabetes, as well as depression-increased mortality among diabetics.

Risk of psychiatric treatment for mood disorders and psychotic disorders among migrants and Dutch nationals in Utrecht, The Netherlands

PURPOSE

While there are consistent reports of a high psychosis rate among certain groups of migrants in Europe, there is little information on their risk for mood disorders. The aim of this study was to investigate the risk of receiving psychiatric treatment for mood disorders or psychotic disorders, comparing migrants and Dutch nationals in an ethnically mixed catchment area. A second aim was to calculate the 1-year prevalence rates of psychotic disorders in first-generation migrants.

METHOD

A psychiatric registry provided information on treatments at all in- and outpatient facilities. Statistics Netherlands provided annual population figures.

RESULTS

The risk of receiving treatment for unipolar depressive disorder was increased for the Turkish-Dutch (first and second generation combined; age- and sex-adjusted relative risk 4.9; 95% CI: 4.4-5.5), Moroccan-Dutch (RR = 3.6; 3.3-4.0) and Surinamese-Dutch (RR=1.8; 1.5-2.2). The risk of being treated for bipolar disorder was not significantly increased for any group, except for the Turkish-Dutch of the second generation. The risk of treatment for non-affective psychotic disorder was very high for the Turkish-Dutch, Moroccan-Dutch and Surinamese-Dutch of the second generation. There was a large difference in the relative risk of this disorder between the Turkish-Dutch of the first (RR = 1.3; 1.0-1.8) and the second generation (RR = 8.7; 5.5-13.9). The 1-year prevalence rates of treated psychotic disorders were highest for Surinamese-Dutch (2.1%) and Moroccan-Dutch males (1.2%) of the first generation. Migrants from western-European countries were not at increased risk for any of these disorders.

CONCLUSIONS

The stressful position of non-Western migrants in Dutch society has negative consequences on their mental health.

Mental health services in the Arab world

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.

A systematic review of the global distribution and availability of prevalence data for bipolar disorder

BACKGROUND

The multiple factors likely to influence estimates of the prevalence of bipolar spectrum disorders (BSD) make it difficult to determine its actual prevalence. A systematic review was undertaken to explore the availability and quality of epidemiological data for BSD. This will inform the Global Burden of Disease 2010 study.

METHODS

Electronic databases searched were Medline, PsycInfo and EMBASE using search terms generated in consultation with a research librarian. Reference lists were searched and experts contacted to obtain articles not identified through the database search. Prevalence data pertaining to point, 6 month or 12 month prevalence of BSD were sought.

RESULTS

The mean pooled prevalence was 0.741% (point) and 0.843% (6/12 months). The study region, response rate and diagnostic tool had a significant impact on prevalence estimates but there were no significant differences in prevalence across prevalence types, gender, sample coverage, economic status and bipolar subtype. Little or no prevalence data was apparent for many regions of the world. Also, the entire bipolar spectrum was rarely assessed.

LIMITATIONS

Although stringent quality assurance methodology was used, controlling for all sources of variability around the pooled prevalence was not possible.

CONCLUSIONS

This systematic review has made significant contributions to the epidemiological profile of BSD. Prevalence estimates will be used to generate estimates of burden for BSD in the global burden of disease 2010 study.

First multicenter study for risk factors for hepatocellular carcinoma development in North Africa

AIM

To assess the role of the major risk factors for hepatocellular carcinoma (HCC) development in the western part of North Africa.

METHODS

A multicenter case control study was conducted in Tunisia, Morocco and Algeria in collaboration with Pasteur Institutes in these countries. A total of 164 patients with HCC and 250 control subjects without hepatic diseases were included. Prevalences of HBsAg, anti-hepatitis C virus (HCV) and diabetes were assessed. HCV and HBV genotyping were performed for anti-HCV and HBsAg positive patients.

RESULTS

The mean age of patients was 62 ± 10 years old for a 1.5 M:F sex ratio. Sixty percent of HCC patients were positive for anti-HCV and 17.9% for HBsAg. Diabetes was detected in 18% of cases. Odd ratio (OR) and 95% confidence intervals (CI) were 32.0 (15.8 - 65.0), 7.2 (3.2 - 16.1) and 8.0 (3.1 - 20.0) for anti-HCV, HBsAg and diabetes respectively. Multivariate analysis indicated that the three studied factors were independent. 1b HCV genotype and D HBV genotype were predominant in HCC patients. HCV was the only risk factor significantly associated with an excess of cirrhosis (90% vs 68% for all other risk factors collectively, P = 0.00168). Excessive alcohol consumption was reliably established for 19 (17.6%) cases among the 108 HCC patients for whom data is available.

CONCLUSION

HCV and HBV infections and diabetes are the main determinants of HCC development in North Africa. An active surveillance and secondary prevention programs for patients with chronic hepatitis and nutrition-associated metabolic liver diseases are the most important steps to reduce the risk of HCC in the region.