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The coronavirus disease 2019 (COVID-19) pandemic created a situation of general distress. Although the focus has been initially more on the physical health during the pandemic, mental health concerns linked to the lockdown have quickly risen. This study aims to assess the effect of the COVID-19-related lockdown on Tunisian women’s mental health and gender-based violence. An online survey was conducted, using the Depression Anxiety and Stress Scales (DASS-21) and the Facebook Bergen Addiction Scale (FBAS). We chose a female-exclusive social group on Facebook and used the snowball sampling method. A total of 751 participants originating from all the Tunisian regions completed the questionnaire. More than half of the participants (57.3%) reported extremely severe distress symptoms, as per the DASS-21. Those who had a history of mental illness and who were allegedly abused during lockdown were found to have more severe symptoms of depression, anxiety, and stress. Around 40% of women reported problematic social media use. Violence against women also reportedly increased significantly during the lockdown (from 4.4 to 14.8%; p < 0.001). Psychological abuse was the most frequent type of violence (96%). Women who had experienced abuse before the lockdown were at an increased risk of violence during lockdown (p < 0.001; OR = 19.34 [8.71–43.00]). To our knowledge, this is the first study that evaluates the acute impact of COVID-19 on mental health and violence against women in Tunisia, Africa, and the Arab world. It may be a sound basis for developing a more effective psychological intervention aimed at women in these regions.

Treatment resistant schizophrenia (TRS), affecting approximately one-third of patients with schizophrenia, is associated with a serious impairment in global psychosocial functioning. Clozapine is the only licensed drug for TRS. However its prescription remains limited by its side effects requiring mandatory monitoring. The need to identify clinical factors associated with good response to clozapine in TRS has been established. The presence of ethnic differences in these factors and the scarcity of data on the Tunisian or more generally the North-African population warrants the conduct of a clinical study on the subject. The aim of this study was to investigate demographic, clinical, and biochemical patient characteristics as potential predictors of response to clozapine. This is a cross-sectional and retrospective study, at the “F and A psychiatry departments” of Razi Hospital in Manouba, Tunisia. All patients, with DSM 5 diagnosis of schizophrenia in its resistant form, on clozapine for at least 12 months and who consulted from June 1, 2018 to November 30, 2018 were included. We investigated premorbid functioning by the premorbid adjusment scale, demographic and clinical characteristics, and clozapine plasma level as potential clozapine response predictors. The response to clozapine was defined by a total BPRS score of 35 or less. Sixty-three patients were included in the study. The mean age at clozapine introduction was 30,84 ±9,25 years. The mean duration of clozapine treatment was 7,22 ± 4,02 years. There were 16 clozapine responders (25%) who had BPRS total scores below or equal to 35 and 47 non-responders (75%). A higher premorbid social functioning in childhood (p = 0,018) and early adolescence (p = 0,024) was associated with better response to clozapine. A delay clozapine initiation shorter than 7 years(p = 0,036), one atypical antipsychotic trial (p = 0,029) and schizophrenia paranoid subtype (p< 0.01) were found to be significantly predictive of good clozapine response. None of the demographic factors or biochemical characteristics were associated with clozapine response. Our work is consistent with previous studies suggesting the need for clinicians to be aware of the clinical predictors of a good response to clozapine to overcome their reluctance to prescribe it. It also highlighted the major prognostic role of premorbid adjustment in the clinical response to treatment. However, prospective studies including therapeutic drug monitoring would be very useful to better delineate the sub-group of patients to whom clozapine would benefit the most and to improve prescription modalities. •Investigation of factors predicting response to clozapine in a Tunisian or more generally the North-African population where data are scarce.•This study highlithed the major prognostic role of premorbid adjustment in the clinical response to treatment•Responders to clozapine had plasma clozapine levels similar to Caucasians population

Stigma among healthcare providers is a barrier to the effective delivery of mental health services in primary care. Few studies have been conducted in primary care settings comparing the attitudes of healthcare providers and experiences of people with mental illness who are service users in those facilities. Such research is necessary across diverse global settings to characterize stigma and inform effective stigma reduction. Qualitative research was conducted on mental illness stigma in primary care settings in one low-income country (Nepal), two lower-middle income countries (India, Tunisia), one upper-middle-income country (Lebanon), and three high-income countries (Czech Republic, Hungary, Italy). Qualitative interviews were conducted with 248 participants: 64 primary care providers, 11 primary care facility managers, 111 people with mental illness, and 60 family members of people with mental illness. Data were analyzed using framework analysis. Primary care providers endorsed some willingness to help persons with mental illness but reported not having appropriate training and supervision to deliver mental healthcare. They expressed that people with mental illness are aggressive and unpredictable. Some reported that mental illness is incurable, and mental healthcare is burdensome and leads to burnout. They preferred mental healthcare to be delivered by specialists. Service users did not report high levels of discrimination from primary care providers; however, they had limited expectations of support from primary care providers. Service users reported internalized stigma and discrimination from family and community members. Providers and service users reported unreliable psychiatric medication supply and lack of facilities for confidential consultations. Limitations of the study include conducting qualitative interviews in clinical settings and reliance on clinician-researchers in some sites to conduct interviews, which potentially biases respondents to present attitudes and experiences about primary care services in a positive manner. Primary care providers' willingness to interact with people with mental illness and receive more training presents an opportunity to address stigmatizing beliefs and stereotypes. This study also raises important methodological questions about the most appropriate strategies to accurately understand attitudes and experiences of people with mental illness. Recommendations are provided for future qualitative research about stigma, such as qualitative interviewing by non-clinical personnel, involving non-clinical staff for recruitment of participants, conducting interviews in non-clinical settings, and partnering with people with mental illness to facilitate qualitative data collection and analysis.

Schizophrenia, bipolar disorder and schizoaffective disorders are severe mental illnesses (SMI) associated with high levels of co-morbid psychopathology and premature mortality. Reducing delays in accessing services and providing early intervention are key strategies in preventing morbidity and mortality associated with these diseases. The pathways to psychiatric care have been studied in many countries worldwide. To the best of our knowledge, no study on this subject has so far been conducted in Tunisia. The purpose of the present study was to understand the pathways of care adopted by patients, to determine the care delay and to explore the relationship between delayed consultation and socio-demographic and clinical variables. This is a cross-sectional descriptive study conducted at the Department Psychiatry A of Razi Hospital including patients with SMI consulting the outpatient clinic between January and March 2018. Data was collected by one medical investigator who conducted face-to-face interviews with patients using a questionnaire based on the World Health Organization's \"Pathway Questionnaire\". Data analysis was done using the SPSS software version 17. A multivariate analysis was performed to study the relation between delayed consultation and socio-demographic and clinical variables. A total of 232 patients responded to the questionnaire. The average age was 41.3 years ± 10.1 and the gender ratio was 1.2. More than the third of the study population consulted a traditional healer in the first place and sixty percent of the patients had recourse to a medical doctor. The average consultation delay was 15 months (±23.0) with a median of 6 months. The delay was more than 6 months in around half of the cases. The symptoms that motivated the first consultation were hallucinations, sleep disorders and aggressive behavior. The main reason of delayed consultation was lack of knowledge about psychiatric symptoms followed by illness beliefs and insidious onset of the illness. The multivariate analysis showed a significant relationship between aggressive behavior and non-delayed consultation. The principal recommendations are to strengthen public education and awareness about SMI in the Tunisian population and to implement an early detection program of these disorders.

Background Studies about the two most used and validated instruments for the early detection of Bipolar Disorder (BD), the 32 - item Hypomania Checklist (HCL - 32) and the Mood Disorder Questionnaire (MDQ), are scarce in non-Western countries. This study aimed to explore the reliability, factor structure, and criterion validity of their Arabic versions in a sample of Tunisian patients diagnosed with mood disorders. Methods The sample included 59 patients with BD, 86 with unipolar Major Depressive Disorder (MDD) and 281 controls. Confirmatory factor analysis was applied to show that a single global score was an appropriate summary measure of the screeners in the sample. Receiver Operating Characteristic analysis was used to assess the capacity of the translated screeners to distinguish patients with BD from those with MDD and controls. Results Reliability was good for both tools in all samples. The bifactor implementation of the most reported two-factor model had the best fit for both screeners. Both were able to distinguish patients diagnosed with BD from putatively healthy controls, and equally able to distinguish patients diagnosed with BD from patients with MDD. Conclusion Both screeners work best in excluding the presence of BD in patients with MDD, which is an advantage in deciding whether or not to prescribe an antidepressant.

Neuropsychiatric manifestations in Sjögren’s syndrome are common and can occur not only during its course, but also at the onset of the disease. Depression and anxiety were the most frequently described symptoms. However, the association with bipolar disorder seems to be rare and not well documented. This case report presents a patient with bipolar disorder as comorbidity with Sjögren’s syndrome, suggesting that bipolar disorder could be associated with this autoimmune disease, which could lead to delaying diagnosis and treatment. A better analysis of the clinical background should be done by psychiatrists so to help early diagnosis and adapting prescription. Corticosteroids indicated in Sjögren’s syndrome should be prescribed with caution in bipolar disorder.

Le suicide est un problème de santé publique retrouvé dans la plupart des maladies psychiatriques notamment dans le trouble bipolaire (TB). Le but de ce travail était d´estimer la prévalence des tentatives de suicide (TS) et de déterminer les différents facteurs qui lui sont associés au sein d´une population de patients atteints de trouble bipolaire type I (TB I). Etude transversale et descriptive auprès de 150 patients. Nous avons eu recours à une fiche de renseignements, aux questionnaires d´évaluation des tempéraments affectifs, de l´addiction à l´alcool et des addictions aux drogues. La comparaison entre suicidants (23,3%, n = 35) et non-suicidants (76,7%, n = 115) a permis de dégager, les facteurs de risque de suicide suivants: l´addiction au cannabis, l´addiction aux psychotropes, un âge avancé, un antécédent familial de TB, de dépression, de TS et de décès par suicide, des antécédents personnels somatiques, un trouble de la personnalité associé en particulier la personnalité histrionique, un tempérament dépressif, un premier épisode thymique de nature dépressive, la récurrence des épisodes thymiques et une longue durée d´évolution de la maladie. On a également identifié deux facteurs protecteurs: l´acide valproïque et un nombre plus élevé de frères et sœurs. En étude multivariée les facteurs de risque étaient: l´âge, un antécédent familial de TB, un antécédent familial de TS et l´addiction au cannabis. Une attention particulière se doit d'être portée aux déterminants associés aux comportements suicidaires chez les patients atteints de TB I afin d'adopter des stratégies préventives et thérapeutiques efficaces.

PurposeStudies of mental illness stigma reduction interventions have been criticised for failing to evaluate behavioural outcomes and mechanisms of action. This project evaluates training for medical students entitled ‘Responding to Experienced and Anticipated Discrimination’ (READ), developed to focus on skills in addition to attitudes and knowledge. We aimed to (i) evaluate the effectiveness of READ with respect to knowledge, attitudes, and clinical communication skills in responding to mental illness-related discrimination, and (ii) investigate whether its potential effectiveness was mediated via empathy or/and intergroup anxiety.MethodsThis is an international multisite non-randomised pre- vs post-controlled study. Eligible medical students were currently undertaking their rotational training in psychiatry. Thirteen sites across ten countries (n = 570) were included in the final analysis.ResultsREAD was associated with positive changes in knowledge (mean difference 1.35; 95% CI 0.87 to 1.82), attitudes (mean difference − 2.50; 95% CI − 3.54 to − 1.46), skills (odds ratio 2.98; 95% CI 1.90 to 4.67), and simulated patient perceived empathy (mean difference 3.05; 95% CI 1.90 to 4.21). The associations of READ with knowledge, attitudes, and communication skills but not with simulated patient perceived empathy were partly mediated through student reported empathy and intergroup anxiety.ConclusionThis is the first study to identify mediating effects of reduced intergroup anxiety and increased empathy in an evaluation of anti-stigma training that includes behavioural measures in the form of communication skills and perceived empathy. It shows the importance of both mediators for all of knowledge, skills, and attitudes, and hence of targeting both in future interventions.

Vaginismus in one of the most frequent causes of non-consummation of marriage, and of infertility, in Arab-Muslim societies. Cognitive behavioural therapy (CBT) proved to be effective, but it is important to consider the cultural context of the patient attending CBT for vaginismus. The aim of our study was therefore to draw attention to the belief systems and behaviours linked to female sexuality and couple relationship in the Arab-Muslim culture. We present a series of four patients representative of the local culture and show how treatment strategies were adapted to fit these behaviours and belief systems, as well as environmental factors. We found that excessive closeness of family members, allowing the family to be intrusive and exercising pressure on the couple, a strict education which highly values virginity, transmits fear of ‘the male’ and fear of sex, and which links sex with pain, were the common denominator of all patients of our case series. We adapted the classical CBT strategies for vaginismus to our cultural context. The educational component was enlarged. Cognitive techniques were used to modify specific traditional beliefs. The integration of the family, and not only of the partner, into the treatment process proved uniquely beneficial for the patients.