The results of the LEBANON have to be interpreted in light of three limitations. First, a tradition of public opinion research does not exist in Lebanon. Declarations of anonymity and confidentiality consequently might have had less persuasive power in motivating complete reporting than in more developed countries. Second, CIDI 3.0 has not yet been validated in Lebanon, although the earlier CIDI 1.1, 23
was validated in a clinical sample. Third, the response rate (70.0%) could have introduced downward bias, as methodological studies find that lower response rates are often associated with systematic under-representation mental illness. 24
Based on these considerations, prevalence estimates are likely to be on lower bounds on true prevalence.
Within the context of these limitations, the prevalence estimates reported here are similar to those in Western European WMH surveys.25
These estimates are high enough to place mental disorders among the most commonly occurring health problems in the population of Lebanon. It is noteworthy that the commonly occurring anxiety, mood, and substance use disorders with the lowest proportions classified serious are all consistent with clinical experience – specific phobia being the least severe anxiety disorder, dysthymia the least severe mood disorder, and alcohol abuse the least severe substance use disorder. Other patterns, though, are more difficult to understand, such as the low proportion of OCD cases classified serious and the high proportion of social phobia cases classified serious. While it is beyond the scope of a first report to investigate these specifications, this needs to be done in future analyses.
The only previous comparable community survey in the Arab World 12
was based on a single city in the United Arab Emirates and reported only lifetime prevalence estimates using ICD-10 criteria. Inferring from a small (n = 245) follow up of that survey using SCID diagnoses, 12-month prevalence of any DSM-III-R/SCID disorder was 5.9%. A prospective wartime study in four Lebanese communities found a lifetime prevalence of 27.8% for major depression10
with subsequent extremely high 12-month prevalence of major depression (41.5%) in two Beirut neighbourhoods (after an intense conflict), but this fell to a period prevalence of 14.4% in the first four years following cessation of armed conflict. No other psychiatric epidemiological studies from the Arab World lend themselves to comparisons. Given that Lebanon has enjoyed peace in most parts of the country since the early 1990's, it is not surprising that our prevalence estimates are lower than in the previous Lebanese surveys, which were carried out during and shortly after the war. However, it is striking that we found significant residual associations between retrospectively reported war-related trauma and 12-month mental disorders even after more than a decade of peace.
The finding that anxiety and mood disorders are more prevalent among women than men is consistent with much previous research, 17,25
but failure to find gender differences in impulse-control or substance disorders is quite atypical. 17
The comparatively low prevalence estimates of both impulse-control and substance disorders raise the question whether males might have had a high rate of under-reporting these disorders. Follow-up clinical reappraisal interviews are planned to investigate this possibility. Another notable non-finding is the absence of the typically found inverse association between socio-economic status (SES) and the mental disorders. 26
The absence of this association might mean that advantaged socio-economic position was incapable of protecting people from exposure to the enormous stresses visited on the Lebanese population due to war and internal sectarian strife At the same time, we replicated the commonly found inverse relationship between age and mental disorder and the widely documented finding that never married people have a higher prevalence of mental disorders than the married 27, 28
While SES is unrelated to prevalence, it is importantly related to treatment, a finding consistent with research in other countries 29
The proportion of cases in treatment was found to be much lower than in industrialized countries.29,30
This is not due, though, to lack of physician resources, as the 274 physicians per 100,000 population in Lebanon is both the highest in the Arab World and comparable to some European countries. This presumably accounts for the majority of treatment being in the healthcare sector. Although we have not yet examined survey information on reasons for failing to seek treatment, financial constraints are likely important, as no private insurance exists for mental disorders in Lebanon. Expansion of insurance is likely to be needed to address the problem of unmet need for treatment. Although the extended family plays an important role in supporting patients, we suspect that taboos as well as lack of awareness are additional barriers against seeking treatment. An encouraging finding is that over 80% of health care treatment of mental disorders was classified as at least minimally adequate using Western guidelines. This compares quite favourably with developed countries. Although questions could be raised whether the same guidelines are appropriate for the Arab world, no body of empirical research exists on the relationship between treatment intensity and clinical outcome among Arab patients.
Future research is needed to make evidence-based assessments of treatment response to develop treatment standards for the Arab world. Future research is also needed to replicate the LEBANON in other Arab countries both to shed light on the problems of mental disorders and to facilitate exchange of expert opinion. Results will facilitate increased awareness about mental disorders and their impact and will allow policy-makers to make valid inferences about the societal burden of mental disorders and unmet need for treatment.