This study presents data on national lifetime prevalence of a wide array of psychiatric disorders in an Arab country, to our knowledge for the first time. One-fourth of the Lebanese adult population met criteria for any of the DSM-IV disorders, and one-third were estimated to do so by age 75 y. Females are at higher risk of developing anxiety and mood disorders than are males. Being separated, divorced, or widowed increased the likelihood of developing a mood disorder. The effect of sex and marital status on the first onset of mental disorders was independent of war exposure.
The high prevalence of mental disorders and the early age of onset during the young, formative, and productive years create a considerable national burden. This burden is compounded by long delays in seeking care for these often chronic and recurrent conditions. Seeking treatment in the first year of onset of disorder and shortly after was very low. The extremely long delay for treatment of anxiety disorders was due to onset of many anxiety disorders occurring in childhood and treatment not occurring until adulthood. Whereas barriers to seeking care could include factors such as financial difficulties, stigma, and lack of awareness; shortage of health care professionals in Lebanon is not expected to be one of the reasons. It is estimated that there are 325 physicians per 100,000 population in Lebanon [29
], the highest ratio in the Arab World and equivalent to many industrialized countries. Therefore, increasing awareness about mental health conditions and reducing possible taboos rather than increasing human resources becomes imperative, not only among the general public and health policy makers, but also and most importantly among health care professionals.
In addition, the study examines on a national level the effect of war on developing first-time mental disorders. In our sample, only 31.2% of the Lebanese were not exposed to any war events, whereas 11.1% were exposed to at least four war events. Males were exposed to more war events and to those events that reflect greater mobility in war time, whereas females reported more often being civilians in war regions or refugees. Those who were children at the start of war reported being less exposed to war events, possibly reflecting their lower mobility and lower recall of the war events at that time.
War, analyzed as both individual events and cumulative exposure, increased the risk of developing, for the first time, mental disorders in the life of the Lebanese. This increased risk was shown for all anxiety disorders that had enough participants to be analyzed (separation anxiety disorder [SAD], PTSD, and GAD), for mood disorders (major depressive disorder [MDD] and dysthymia, but not for bipolar disorder), and for impulse control disorder (intermittent explosive disorder). This increased risk was highest for impulse control disorders followed by PTSD and dysthymia. It is important to note here that the age cohort effect we report could be explained by either having been exposed to these events during this specific age or being in this age group per se [17
Three main limitations of this study have to be considered. First, adults reporting on past psychiatric disorders, age of onset, treatment, and exposure to war may be subject to differential recall bias. A number of factors, including current psychiatric status, time to first onset of disorders, older age, and severity of episode, might have contributed to this differential recall bias. Second, the survey population excluded institutionalized respondents. Third, given the taboos surrounding mental illness, respondents in a face-to-face interview may have under-reported relevant symptoms. Taking these limitations into consideration, the results are probably an underestimate of the true lifetime prevalence of psychiatric disorders in Lebanon since all these factors are likely to bias the estimates downwards. Moreover, with regard to war exposure, although we looked at specific war events, exposure to the general war environment and its impact on the respondent's mental health was difficult to assess. Also many of the CIs are very wide; consequently, results may not be reliably extrapolated to the whole population.
In conclusion, there is an urgent need to assess not only the prevalence, but also the determinants, of treatment failure and delays in treatment in a comparative manner to obtain robust evidence for policy making with regard to the burden of mental disorders in the Arab World. Furthermore, in the Middle East, where armed conflicts have been commonplace for decades, it is important to recognize that these conflicts result in mental disorders that are not limited to PTSD but also include mood and impulse control disorders that are likely to have long-term implications for the war-exposed populations.