Abstract: Background and Objectives: Few studies have assessed the prevalence of mental illness and the utilization of formal mental health services in the United Arab Emirates (UAE). The objectives of this study were to estimate the prevalence of mental disorders, assess the use of formal mental health services and identify the reason for not accessing formal mental health services among adults in Sharjah city in the UAE. Materials and Methods: A cross-sectional survey was distributed among participants in public places in Sharjah city using convenience sampling methods. Results: Overall, 57.2% of participants suffered from at least one mental disorder, with higher prevalence rates in women than in men (62% vs. 52.6%, p = 0.029). Anxiety (56.4%), depression (31.5%), post-traumatic stress disorder (15.1%) and phobic disorder (10.8%) were the most prevalent mental disorders among participants. Over 80% of participants sought help for their mental problems, with 57.7% of them consulting a health professional and 42.3% consulting a non-health professional. Participants who consulted a health professional were more satisfied with their treatment (66.2%) compared to those who consulted a non-health professional (48.1%). Conclusion: The prevalence of anxiety and depression is higher in UAE compared with other disorders. Overall, women have a higher prevalence than men do, except for substance abuse. Formal mental health services were used more than non-formal services were. These findings indicate that interventions are required in the UAE to improve mental health outcomes. Further research at the national level is needed.
INTRODUCTION
Mental health is as essential as physical health for the general well-being of individuals, societies and nations1,2. The global mental health challenge is profound3. Better mental health contributes to the promotion of healthy development and to the achievement of educational, social and economic goals, as well as to the avoidance of both communicable and non-communicable health problems and the consequent premature mortality3. Adams4 mentioned in his article that the World Health Organization (WHO) revealed that 1 in 4 adults suffer from a mental or neurological disorder, with approximately two-thirds not seeking treatment. Globally, prevalence rates are estimated to be around 5-15% for common mental disorders and 0.5% for psychosis5,6. Some disorders are short-lived while others pursue a chronic course. By 2030, depression alone is expected to rise from the fourth-to the second-leading cause of the global disease burden as measured by disability-adjusted life years3,7. Adams4 found that around 4% of the population of the United Arab Emirates (UAE) was clinically depressed and that mild depression could be affecting approximately 15% of the population. However, many aspects of the epidemiology of mental illness are still poorly understood in the UAE.
The use of formal health care services including mental health causing great concern worldwide8,9. There are several factors restricting access to mental health care services. Multiple studies have found that mental illness and stigma are considered to as major barriers for individuals accessing mental health services10,11. Worldwide, being male, married, less educated and being older were associated with not seeking mental health treatment12. Moreover, other factors might contribute significantly such as a limited awareness of mental disorders, the limited availability and afford ability of mental health care services, a lack of appropriate professional responses and inappropriate referral patterns13.
In the UAE, only a few studies have assessed the availability of mental health services and attitudes toward these services14,15. In the Kingdom of Saudi Arabia (KSA), for example, the cost of treatment, the stigma attached to receiving mental health treatments and seeking faith-healing treatments were identified as reasons for not seeking professional mental treatment16. However, comprehensive information about access and patterns of use for the mental health services in the UAE is lacking.
In general, studies on mental health issues such as access, delivery, barriers, knowledge and attitudes are essential to improve policies and programs to address the multiple needs and enhance interventions required to encourage access and treatment initiation. Based on past research, the aims of this study were to estimate the prevalence of mental disorders among adults in Sharjah city in the UAE, to identify the gender differences in the prevalence of mental disorders, to assess the associations between demographic characteristics and the use of mental health services and to identify the reasons behind not accessing formal mental health services.
MATERIALS AND METHODS
Study design and setting: A cross-sectional survey was conducted among Sharjah city’s adult residents. Sharjah city is the 3rd biggest city in the UAE. The target population was the non-institutionalized expatriate and UAE national adult aged 18 years and above from Sharjah city.
Data collection: The data collection was conducted over a 3-month period from 27 May, to 28 August, 2018.The data was collected through a self-administered questionnaire that was professionally translated into the Arabic language and piloted. The few items of the questionnaire was based on the latest version of the Composite International Diagnostic Interview (CIDI)17. The CIDI is a research instrument designed to assess the presence of mental disorders. The questionnaire was available in both languages: Arabic and English. The inter-rater reliability18 for the CIDI was >0.94. The questionnaires were distributed to participants by research assistants in public places in Sharjah city using convenience sampling methods. All participants provided their written informed consent before participating in filling in the questionnaire.
The participants were asked to report on their sociodemographic characteristics, lifetime use of formal or informal mental services, level of satisfaction with the provided services and barriers to them not seeking help for any mental disorders.
Ethical considerations: The ethics and research Committee of the University of Sharjah and the Ministry of Health and Prevention approved this study.
Statistical analysis: To describe the demographic, lifestyle and clinical characteristics of the study population, we reported the frequencies with proportions and means with standard deviations (SDs) for the participants. Bivariate analysis (Chi-squared test) were conducted to identify the prevalence of mental disorders by gender and factors associated with the usage of formal mental health services. The statistical significance level was set at p<0.05.
The data analysis were performed using19 IBM SPSS Statistics for Windows, Version 25.0. The reporting followed the Strengthening the Reporting of Observational Studies in Epidemiology statement for cross-sectional studies.
RESULTS
Of the 530 subjects, 51.3% (272/530) were males, with a mean age f or the entire population of 30.7 years (SD±11.7 years). Table 1 shows the demographic and socioeconomic characteristics of the study participants.
Anxiety (56.4%), depression (31.5%), post-traumatic stress disorder (15.1%) and phobic disorder (10.8%) were the most prevalent mental disorders among Sharjah residents (Table 2).
| Table 1: Characteristics of the participants (n = 530) | ||
| Characteristics | Number |
Percentage |
| Gender | ||
| Male | 272 |
51.3 |
| Female | 258 |
48.7 |
| Nationality | ||
| Local Emirati | 46 |
8.7 |
| Expatriate | 484 |
91.3 |
| Age, years | ||
| Mean (SD) | 30.7 |
11.7 |
| Age groups, years | ||
| <25 | 213 |
40.2 |
| >25 | 317 |
59.8 |
| Education level | ||
| Secondary and below | 121 |
22.8 |
| Tertiary | 404 |
77.2 |
| Marital status | ||
| Married | 231 |
56.4 |
| Not married | 299 |
43.6 |
| Employment | ||
| Employed | 282 |
53.4 |
| Unemployed | 246 |
46.6 |
| Household income/month (AED) | ||
| <10,000 | 252 |
62.5 |
| >10,000 | 151 |
37.5 |
| SD: Standard deviation, AED: United Arab Emirates Dirham | ||
Overall, 57.2% (303/530) of the participants suffered from at least one mental disorder, with higher prevalence rates in women than in men (62 vs. 52.6%, p = 0.029, Table 2). In addition, Table 2 reveals that women had higher prevalence rates than men for depression (36 vs. 27.2%, p = 0 .029), post-traumatic disorders (20.5 vs. 9.9%, p = 0.001), phobic disorders (14.7 vs. 7%, p = 0.004) and somatoform disorders (6.2 vs. 1.8%, p = 0.010).
From the total number of people with emotional or mental disorders, 81.2% (246/303) sought help for their problem, with 57.7% (142/246) of them consulting a health professional and 42.3% (104/246) consulting a non-health professional (Table 3). Participants who consulted a health professional were more satisfied with their treatment (66.2%) compared to those who consulted a non-health professional (48.1%, Table 3).
Figure 1 lists the various reasons for the participants not seeking help for their emotional or mental problems, with the main reasons reported being that they “wanted to handle the problem on their own” (32%), having “no health insurance” (30%) and that they “thought the problem would get better by itself” (29%).
Table 4 shows the characteristics of participants who consulted a health professional for an emotional or mental problem. Being female, over 25 years old, not married and with a high education level were significantly (p<0.05) associated with seeking help from formal services (Table 4).
DISCUSSION
The present study investigated the prevalence of mental health disorders, reasons for not seeking help for mental health issues, the preferred methods for treatment and the demographic variables associated with the use of mental health services among adults from the UAE residing in Sharjah city.
| Table 2: Prevalence of mental disorders by gender | |||||||
| Total | Female | Male | |||||
| Mental disorders | Number |
Percentage |
Number |
Percentage |
Number |
Percentage |
p-value |
| Anxiety | 299 |
56.4 |
147 |
57.0 |
152 |
55.9 |
0.8 |
| Depression | 167 |
31.5 |
93 |
36.0 |
74 |
27.2 |
0.029* |
| Post-traumatic stress | 80 |
15.1 |
51 |
20.5 |
29 |
9.9 |
0.001* |
| Phobia | 57 |
10.8 |
38 |
14.7 |
19 |
7.0 |
0.004* |
| Personality | 34 |
6.4 |
20 |
7.8 |
14 |
5.1 |
0.221 |
| Mania | 26 |
4.9 |
14 |
5.4 |
12 |
4.4 |
0.589 |
| Somatoform | 21 |
4.0 |
16 |
6.2 |
5 |
1.8 |
0.010* |
| Substance abuse | 11 |
2.1 |
2 |
0.8 |
9 |
3.3 |
0.041* |
| Schizophrenia | 5 |
0.09 |
3 |
1.2 |
2 |
0.7 |
0.611 |
| *Significant at <0.05 level | |||||||
| Fig. 1: | Participants' reported reasons for not seeking help for emotions or mental problems |
| Table 3: Description of usage of formal and non-formal mental health services (n = 246) | ||
| Parameters | Number |
Percentage |
| Consulted a health professional | 142 |
57.7 |
| Psychological counselling >15 min | 37 |
26.1 |
| Received a medicine | 35 |
24.6 |
| Satisfaction | 98 |
66.2 |
| Consulted a non-health professional | 104 |
42.3 |
| Received treatment | 52 |
50.0 |
| Satisfaction | 50 |
48.1 |
| Table 4: Characteristics of participants who consulted a health professional for an emotional or mental problem, (n = 142) | |||
| Characteristic | Number |
Percentage |
p-value |
| Gender | |||
| Male | 67 |
25.0 |
0.012* |
| Female | 75 |
35.6 |
|
| Nationality | |||
| Local Emirati | 8 |
22.2 |
0.288 |
| Expatriate | 134 |
30.7 |
|
| Age, years | |||
| <25 | 40 |
21.7 |
0.002* |
| >25 | 102 |
35.3 |
|
| Education level | |||
| Secondary and below | 23 |
20.7 |
0.013* |
| Tertiary | 119 |
33.1 |
|
| Marital status | |||
| Married | 63 |
23.8 |
0.001* |
| Not married | 79 |
38.0 |
|
| Employment | |||
| Employed | 73 |
28.7 |
0.492 |
| Unemployed | 69 |
31.7 |
|
| Household income/month (AED) | |||
| <10,000 | 64 |
28.2 |
0.526 |
| > 10,000 | 42 |
31.3 |
|
| *Significant at <0.05 level, AED: United Arab Emirates Dirham | |||
In this study, the prevalence rate for anxiety was the highest at 56%, followed by depression, post-traumatic disorders, phobias, personality issues, mania, somatoforms, substance use disorder and schizophrenia. Comparing this study’s findings with other countries, the prevalence rate for anxiety in the UAE is almost similar to that of Qatar (56%)20, is higher in Oman (82.5%)21 but is less in Egypt (4.75%)22, Iraq (13.8%)23, Iran (15.6%)24, the USA (33.7%)25 and the KSA (45.6%)26. The second highest prevalence rate was 32% for depression and this prevalence rate was higher than for mood disorders in Egypt (6.43%)22, Iran (7.2%)23,but was less than that in the KSA (37.4%)26. Anxiety and depression are considered common mental disorders. According to the WHO27, 4.4% of the world’s population experiences depression. In this study, most of the participants were expatriates, which might be one of the reasons for finding such high rates of anxiety and depression in our mixed cohort. Research has shown that expatriates are prone to mental illness more than native people are28,29.
In the present study, approximately 2% were accepted that they abuse any one of the substances and 1% was suffering from schizophrenia. The prevalence of substance abuse is slightly higher in KSA (2.5%)30 and lesser than Egypt (0.13%)22 and Iran (0.2%)23. The UAE is an Islamic state and drugs are prohibited by law but people might become addicted to some of the licit drugs prescribed by their doctor such as tramadol or tramal and benzodiazepines31. Furthermore, people can be addicted to other nicotine-based substances such as dokha, cigarettes, shisha, etc.32. One percent of this study’s participants was either currently experiencing or had a past history of schizophrenia. This prevalence rate was slightly higher than for psychotic disorders in Egypt (0.19%)22. However, the prevalence rate in our study was approximately consistent with the global prevalence of schizophrenia, which was estimated to be33 0.28% in 2016.
In the present study, there was a significant difference between males and females in their prevalence rates for depression, post-traumatic disorders, phobias, somatoforms and substance abuse. This result is consistent with another study conducted in the UAE34 and with studies from other Middle Eastern countries in that females tend to experience more mental disorders compared with males22,24,27,35. Females experience higher levels of depression, post-traumatic disorders, phobias and somatic symptom disorders than males do. The major reasons identified for women experiencing higher levels of mental disorders in the Gulf Region were age-related (being under 55 years old), being divorced with four or more children and those who reported a higher exposure to recent adverse life events36. Moreover, ill mental health is also linked to employment stress, poor physical health, social isolation and gender inequality. Physicians working in primary health care centers and hospitals should be made aware of the high prevalence of depression and somatic symptom disorders among the female population in the UAE. A lack of screening for these disorders may lead to detrimental effects such as marital discord, suicidal behavior and poor self- and family care.
In this present study, the majority of participants who suffered from mental disorders indicated that they preferred to handle their problems on their own as the main reason for not consulting mental health professionals. The other reasons were no health insurance, that they thought the problem would go away automatically, that they were not sure who they should consult, they believed the treatment might not work, that the cost of treatment would be expensive, that there was stigma attached to consulting mental health professionals, that they were scared about being admitted to hospital against their will and that they could not get an appointment. A previous study also found that mentally ill people prefer to handle their problems on their own rather than consulting mental health professionals37. This could be due to stigma, a lack of insight about the illness, low perceived need and the severity of the illness37,38. Residents of the UAE have mandatory health insurance but this insurance may not cover mental health treatment39. Thus, mentally ill people either consult another physician for their mental illness or pay money for their consultation, which increases the financial burden. The results from this study are consistent with other studies conducted in the UAE and overseas, indicating that self- and public stigma, cultural barriers, the financial burden, a lack of knowledge and negative attitudes and beliefs about mental health treatments mean that many mentally ill people do not seek treatment38,40. There is a need for the Ministry of Health to promote mental health awareness among the public, as many mentally ill people do prefer to handle their problems on their own, which, in the long run, may increase the burden on their doctors and caregivers.
Although the various reasons mentioned in the above paragraph delineate the key reasons behind not seeking mental health treatment, in this present study, out of 246 mentally ill participants, 142 (57.7%) of them received formal treatment and 104 (42.3%) received informal treatment. The prevalence rate for seeking mental health treatments in this study is almost similar to that of the UK41. More satisfaction was reported by the participants who received formal treatments than by those who accessed non-formal treatments. This finding is consistent with a previous study conducted in the UAE where 47% of the participants reported no improvement after seeing a faith healer and 7% reported a worsened condition42. Globally, more than 70% of people with a mental illness receive no treatment from health care professionals43. People sometimes prefer to seek non-mental health treatments such as Ayurvedic treatments, religious preaching and so on, rather than formal mental health treatments, due to a lack of knowledge and a fear of addiction and side effects from mental health drugs. In addition, many people believe that supernatural powers are a major reason for their mental illness44. Thus, they prefer seeking treatment from faith healers rather than accessing formal treatments. Therefore, there is a need to enhance public knowledge and attitudes toward mental illness.
In our cohort, females over 25 years old who have studied at the tertiary level of education and who are unmarried are most likely to seek formal mental health treatments when they experience any mental health issues. Salaheddin and Mason41 found similar results as females sought more mental health treatments than males did. This may be due to the high prevalence of common mental disorders such as depression and anxiety among the female population. However, a study conducted in Qatar found that men were more willing to visit mental health professionals for their emotional problems than females were45. A previous study conducted in Egypt also found that divorced women and widows were more prone to mental disorders than married and unmarried women were but this study has found that unmarried women actually sought more mental health treatments22. Educated people consult mental health professionals more so than uneducated people do45. This may be due to them having more insight into mental illness and thus it could be one of the reasons for educated people to consult mental health professionals more. This study showed that people are willing to consult mental health professionals and receive formal mental health treatments for their emotional and mental illness but a considerable number of people are still unwilling to seek consultations and prefer receiving informal treatments for their mental illness.
Limitations: This study used standardized tools to measure the prevalence of mental disorders but the participants were not clinically interviewed to confirm their diagnosis. Moreover, due to stigma, some participants may have under-reported the true extent of their mental illness or they may have refused to accept that they had a mental illness. In addition, the study was based on residents in Sharjah city, which might not be representative of the overall UAE population.
CONCLUSION
The prevalence rates for anxiety and depression in the UAE are higher compared with other disorders. People’s intention to seek mental health treatments is not adequate. Female participants are more willing to access formal mental health services than males are, however, the prevalence of mental disorders among the female population is higher and this needs to be seriously addressed. Formal mental health services were used more than non-formal services were. The present study findings indicate that interventions are required to improve mental health outcomes. Further research at the national level is needed to explore the true magnitude of mental disorders in the UAE.
SIGNIFICANCE STATEMENT
Mental health is one of the major health problems in UAE. This study screens the prevalence of mental health problems, access to mental health services and awareness about formal and informal mental health treatment as these are the important areas need to be studied. The result of this study will be useful for the Ministry of Health (MOH) to understand the prevalence of mental disorder and people usage of formal and informal mental health services. Based on this study result, MOH will enhance insight about the mental illness and its related treatment.
ACKNOWLEDGMENT
We like to say thank you for University of Sharjah to provided fund (1701090318-P) for conduct this research. We like to say thank you for the participants who participated in this study.