Challenges associated with mental health management: Barriers and consequences.

INTRODUCTION: Mental illness has become a global public health issue and according to WHO report in 2015, United Arab Emirates (UAE) recorded the highest level of depression among all countries at Eastern Mediterranean Region. Many people frequently suffer from mental health diseases but tend not to obtain help. Treatment delay can become life-threatening.
OBJECTIVES: This study aimed to identify the barriers to seeking professional help for mental illness and the consequences of untreated mental health disorders. The study also aimed to examine outcomes in patients when help was provided by health care providers.
METHODS: A self-administrated survey was distributed among 377 people randomly selected from general population of three different cities at United Arab Emirates (UAE): Abu Dhabi, Dubai and Sharjah. Their perception of the barriers, consequences and outcomes was analyzed to achieve the objectives of the study.
RESULTS: Overall, 341 participants completed the survey. Wrong thought regarding mental disorders (60.1%) and being ashamed (58.9%) were identified to be the most common and significant barriers (P < 0.001) that prevent people from obtaining healthcare providers' assistance. The majority of responders reported building confidence (78.9%) and improvement in relationships (73.0%) as outcomes for taking professional help in mental illness. Moreover, many individuals believed that untreated mental illness could lead to problems with family and friends (69.2%) as well as to suicidal thoughts (56.3%).
CONCLUSION: This research gives some insights regarding the challenges associated with mental diseases management in the UAE. Majority of responders had a negative perception of mental health service due to a lack of awareness regarding treatment effectiveness for mental disorders.

Introduction

World Health Organization (WHO) defined mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (World Health Organization., 2018a, World Health Organization, 2018b). Indeed, mental health disorders was defined as a wide spectrum of diseases, with various symptoms and signs, but are all characterized by some combination of atypical emotions, thoughts and behavior. Such illnesses include schizophrenia, bipolar disorder, depression, autism, and numerous disorders. Most of these diseases are treatable (Manderscheid et al., 2010, World Health Organization, 2012).

There are three components of mental health, that if altered, can increase the risk of developing a mental illness. The first component of mental health is emotional well-being. This involves interest in life, happiness, and satisfaction. The second component is psychological well-being. This involves individuals liking most parts of their personality, having good relationships with others, managing the responsibilities of daily life, and being satisfied with one’s own life. The last component is social well-being. This refers to positive functioning and involves feeling part of a community or having something to contribute to society (Galderisi et al., 2015, Thirunavurakasu et al., 2013).

Mental illness is becoming a global problem. According to WHO report, around 450 million individuals all over the world are suffering from a mental health condition, making mental illness in the top five disorders leading to disability according to global disability-adjusted life years (DALYs). Depression diseases ranked fourth among the global disease burden and is expected to become the second by 2020 (International Pharmaceutical Federation., 2015, Wainberg et al., 2017, World Health Organization, 2018b). Although treatments are obtainable, but around 70% of people with mental illness don’t seek help from healthcare providers (Crowe et al., 2016).

Currently, according to WHO report in 2015, United Arab Emirates (UAE) recorded the highest level of depression among all countries at Eastern Mediterranean Region with 5.1% of the population suffering from the disease and around 354,000 cases of anxiety noted in the same year. Studies performed in UAE however indicate anxiety and depression are the leading cause of 75% of the mental health disorders in the country (World Health Organization, 2017).

Mental health services in the UAE officially began in 1975 in Abu Dhabi. In 1981, a strategy to develop mental health services was initiated with the opening of Al Amal Hospital in Dubai. Despite an increasing number of psychiatrists and psychologists in UAE over the years, the numbers are still insufficient (Al-Yateem et al., 2017). Many people have difficulty finding a proper health care provider or do not seek help for treatment of their mental health condition (Al Kindi and Haque, 2015). These barriers are significant as untreated mental health issues can lead to serious and possible life-threatening situations including suicide (Charara et al., 2017).

This study aims to identify UAE population opinions regarding the barriers that prevent them from seeking professional help for mental health conditions and the consequences of untreated disease. This study will also look at the outcomes associated with obtaining help from healthcare providers.

Methods

This study was a cross-sectional survey based that was conducted among population of three different cities at United Arab Emirates (UAE): Abu Dhabi, Dubai and Sharjah. A scoping literature review of several studies was undertaken to aid in the development of a questionnaire to study the barriers for care and the outcomes of treatment in mental health patients.

The face validity, content validity and appropriateness of the questions were assessed by members of the faculty of pharmacy and medicine at University of Sharjah. The scale’s reliability was assessed by calculating Cronbach’s alpha coefficient.

The survey was conducted in English and Arabic since these are the most common languages used by people living in UAE. The survey contained 9 main questions distributed among four sections. Table1 outlines the details of each section.

Table 1

Description of survey sections.

Survey Section title	Description of the section
Population characteristics	This section included information about gender, age, education level, living status, nationality and whether the participant is medically trained professional.
Barriers for not seeking help from healthcare professionals regarding mental diseases a	Fifteen statements were conducted in this section. Each question included 3 statements as follows: agree, neutral and disagree.
Consequences of untreated mental illness b	This section consisted of five. Each participant could choose more than one statement.
Outcomes of professional treatment in mental illness b	This section contained 7 statements. Each participant had the option to choose more than one statement regarding the outcomes of help-seeking.

Cronbach’s alpha for the barriers section was 0.789.

Cronbach’s alpha for the outcomes and consequences sections was 0.648.

Using a convenient sampling method, the sample size was calculated using Raosoft® calculator with confidence level of 95% ± 5% and response distribution of 50% to calculate the minimum sample size. The calculated sample size was 300. A total of 377 participants from different communities in the Emirates of Abu Dhabi, Dubai and Sharjah were randomly selected and participated in the survey. Participants were from various companies, universities, restaurants, malls, and social community groups. Self-administered questionnaires were distributed to the participants over a period of three months, from January 2018 until March 2018.

Before the study began, approval for distributing the questionnaires was obtained from University of Sharjah Research Ethics Committee. Participants were informed about the aim and content of the survey prior to answering it. The inclusion criteria was Arabic and English speakers above the age of 18 years. Participants below the age of 18 years old were excluded from the study.

The data was analyzed by using the Statistical Package for Social Science “SPSS”, Version 20 from IBM company, United States of America (USA). Percentage (%) was utilized to present descriptive data and Chi-Square test was conducted to assess the significant barriers that prevent people from obtaining healthcare provider’s help in mental illness. P-value < 0.05 was taken as cut off for statistical significance.

Results

Participant sociodemographic characteristics

A total of 341 out of 377 questionnaires were returned with response rate of 90.5%.

Table 2 shows the frequency of responders based on sociodemographic characteristics. With respect to sex, 170 males (49.9%) participated in this study and 171 females (50.1%). There were more participants in age group 18–30 years old (n = 112, 32.8%) and age group 31–40 years old (n = 125, 36.7%) compared with age groups. The highest number of responders were Arab (n = 196, 57.5%) and most of them were living with their families (n = 236, 69.0%). Moreover, majority of people included in this research didn’t have medical background (n = 238, 69.8%) and were graduates with bachelor’s or diploma degree (n = 257, 75.4%).

Table 2

Sociodemographic information.

Characteristics	n (%)
Total	341 (100.0)
Gender
Male	170 (49.9)
Female	171 (50.1)
Age
18–30	112 (32.8)
31–40	125 (36.7)
41–50	80 (23.5)
51 and above	24 (7.0)
Nationality
Arab	196 (57.5)
Non-Arab	145 (42.5)
Living status
Alone	70 (21.0)
With family	236 (69.0)
With friends	35 (10.0)
Do you have medical background?
Yes	103 (30.2)
No	238 (69.8)
Educational level
No education	3 (0.9)
High school	21 (6.2)
Undergraduate	60 (17.6)
Bachelor/Diploma	257 (75.4)

Barriers to professional help-seeking in mental illness

Table 3 identifies the barriers that prevent people from asking for healthcare provider’s assistance regarding mental disorders. High proportion of people agreed that thinking that the disease will go away by itself without taking any treatment (n = 205, 60.1%) and feeling embarrassed or shamed (n = 201, 58.9%) are the most common obstacles for obtaining help from health professionals. Fewer number of participants believed that fear of disapproval from family members (n = 114, 33.4%) and being to unwell to ask for assistance (n = 116, 34.0%) might be barriers for not asking for help.

Table 3

Barriers for not seeking help from healthcare providers.

Statements	n (%)			P-value
	Agree	Neutral	Disagree
2. Fear of disapproval from family members	114 (33.4)	112 (32.8)	115 (33.7)	0.980
3. Uncertainty of where to get professional help	168 (49.3)	111 (32.6)	62 (18.2)	0.000*
4. Fear that the diagnosis will hinder the academic performance	118 (34.6)	112 (32.8)	111 (32.6)	0.882
5. Wanting to solve problems by themselves	185 (54.3)	97 (28.4)	59 (17.3)	0.000*
6. Fear of being put in hospital against their will	142 (41.6)	100 (29.3)	99 (29.0)	0.005*
7. Concerns that it might harm their chances when applying for jobs	184 (54.0)	86 (25.2)	71 (20.8)	0.000*
8. Thinking the problem will go away by itself	205 (60.1)	81 (23.8)	55 (16.1)	0.000*
9. Feeling embarrassed or ashamed or being seen as “crazy”	201 (58.9)	66 (19.4)	74 (21.7)	0.000*
10. Not being able to afford financial costs	160 (46.9)	118 (34.6)	63 (18.5)	0.000*
11. Concerns that people they know might find out	173 (50.7)	104 (30.5)	64 (18.8)	0.000*
12. Preferring alternative form of care (Spiritual care)	144 (42.2)	142 (41.6)	55 (16.1)	0.000*
13. Being too unwell to ask for help	116 (34.0)	116 (34.0)	109 (32.0)	0.866
14. Concerns about side effects of the medications if prescribed	162 (47.5)	102 (29.9)	77 (22.6)	0.000*
15. Dislike talking about feelings and emotions	134 (39.3)	125 (36.7)	82 (24.0)	0.000*
16. Thinking they don’t have a problem (Denial)	186 (54.5)	80 (23.5)	74 (21.7)	0.000*

P < 0.05, Significant.

All but 3 barriers turned out to be statistically significant. The majority of participants agreed with numerous statements. However, only three barriers were having insignificant differences in the frequency between agree, neutral and disagree as follows: fear of disapproval from family, being too unwell to ask for help and fear that the diagnosis will prevent their academic performance.

Consequences of untreated mental illness

This study reported five effects of untreated mental health disorders in Fig. 1. These include: social problems with friends and family (69.2%), suicidal thoughts (56.3%), financial problems (51.0%), discontinuation from university or work (50.4%) and a reduction in academic performance (49.0%).

Fig. 1

Consequences of untreated mental disorders.

Outcomes of seeking help from healthcare providers in mental illness

Fig. 2 shows the UAE population outcomes of seeking professional help in patients with mental health issues. Over 70% of participants noted an improvement in confidence (78.9%), improvement in relationship with family and friends (73.0%) and improvement in social skills (70.7%) with professional help. Improvement in academic or work performance was demonstrated in 61.6% of participants. Fifty percent of participants had physical improvement. Financial issues (15.5%) or no improvement in outcomes at all were the least common outcomes reported.

Fig. 2

Outcomes of healthcare professional’s help-seeking in mental illness.

Discussion

Mental health disorders are ranked first in world burden of disease based on years lived with disability (YLDs) at the rate of 32·4% of YLDs (Vigo et al., 2016). Despite this fact, many individuals globally are still untreated (Kisely et al., 2006). Treatment delay in mental health disorders may lead to worse clinical and social outcomes (Kanehara et al., 2015); The focus of this study was on the barriers that prevent people from obtaining professional help in mental health diseases, the consequences of untreated mental health disorders and the outcomes of help-seeking to better understand the UAE general public’s point of view on mental health conditions.

Our research found that the most common and significant barriers for not obtaining help were: thinking that the disease will go by itself (60.1%), feeling shamed (58.9%) and thinking that they don’t have problem (54.5%). These finding were consistent with a previous study performed in the United Kingdom population that found difficulty to recognize mental illness and the inability to obtain easily accessible help where the most common barriers among people (Salaheddin and Mason, 2016). In addition, a systemic review of 20 research papers regarding the same issue found that feeling embarrassed, difficulty to identify the symptoms and preference for self-dependence were the significant obstacles (Gulliver et al., 2010). All these barriers ensue due to lack of awareness regarding mental illness (Kanehara et al., 2015).

Currently, the WHO has developed a comprehensive global mental health action plan for 2013 to 2020. One of the important goals of this plan was to encourage mental well-being, prevent mental diseases and provide care. In addition, this plan recognized the important role of healthcare providers in giving general information to the general population regarding mental health, answering patient inquires and screening for mental disorders (World Health Organization 2013). In addition to psychiatrists, other health workers such as pharmacists, can have significant role in increasing awareness. According to research, pharmacists are the most trusted and the most easily available healthcare providers to the public (Al-Tameemi and Sarriff, 2019, Lynas, 2012, Manolakis and Skelton, 2010). They can educate the general population or those with diagnosed mental health disorders and provide advice regarding mental health issues. Moreover, pharmacists can detect signs and symptoms of mental health disorders and then refer individuals at risk of an undiagnosed mental diseases to psychiatrists. For example, community pharmacists in Australia delivered unpaid education brochures giving advice on how to recognize the first signs of mental health disorders. Pharmacists in Portugal distributed education leaflets regarding depression (International Pharmaceutical Federation, 2015). All health workers should cooperate to increase and share awareness amongst the general public regarding the importance of seeking help and early treatment of mental diseases (Mclaughlin, 2004).

According to the results of our study, there is a high number of individuals (n = 160, 46.9%) who think being unable to afford financial cost is a barrier that prevents people from seeking help and 56.3% believed that suicidal thoughts are one of the consequences of untreated diseases. Clearly, some individuals with severe mental illness enter the medical care system even without health insurance coverage, and some with insurance also experience a delay in treatment. Given the level of suicide attempts and substance abuse among those with untreated mental illness, they are likely to enter the emergency room or a public clinic. Entering the medical care system through these mechanisms in some ways is getting too little care (Koronfel, 2002). Similarly, in United Kingdom, a cross-sectional study showed that financial problems are one of the factors that cause poor mental well-being (Richardson et al., 2017).

In terms of the outcomes of professional help-seeking, most participants in this survey believed that obtaining help will enhance individuals’ confidences (78.9%), improve their social relationships (73.0%) and raise the academic or work performance (61.6%). Many countries worldwide started educating people regarding the advantages of help-seeking in early stage of mental illness. In Germany, educational programs were initiated in schools and police academies about mental health. Activities like art exhibitions created by people with mental illness were also developed. Educating the public about mental health will help improve the understanding of one’s condition which leads to an improvement in quality of life (Rüsch et al., 2005).

Regarding the consequences of untreated mental illness, people responded to this study identified relationship problems (69.2%) and financial problems (51.0%) as the most common issues. Untreated mental health disorders increase the rates of disability and mortality as well as can lead to many social and health problems. Studies showed that depression can raise the likelihood of diabetes and myocardial infarction if not well controlled and at the same time, diabetes and myocardial infarction can increase the possibility of having depression (World Health Organization, 2013).

Only 30.2% of the participants in our research had a medical background. Adding mental health related courses in the education curriculum in the UAE for medical and non-medical students in schools and universities will help in educating the public and medical professionals about mental illness and can reduce the stigma by gaining knowledge and a better understanding of it.

Strengths and limitations

This is the first survey conducted in the UAE that identifies population barriers for not seeking professional help in mental illness, the outcomes of obtaining health workers’ help and the consequences of untreated mental disorders. This study used the convenience sampling technique and conducted only at three cities in UAE, out of seven, so the results of this research cannot extrapolate to predict the attitudes of whole UAE population. Further researches that include other cities might be conducted in the future.

Conclusion

Overall, the research findings provide some insights regarding UAE population’s opinions about mental illness. Numerous barriers appear to prevent people from obtaining health workers’ assistance in mental health disorders and that could lead to dangerous consequences. Therefore, raising awareness and educating the population about mental health is important for the future.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

The authors declare that there is no conflict of interest.

Barrier	Agree	Neutral	Disagree
1- Fear of disapproval from family members
2-Uncertainty of where to get professional help
3- Fear that the diagnosis will hinder the academic performance
4- Wanting to solve problem by themselves
5- Fear of being put in hospital against their will
6- Concerns that it might harm their chances when applying for jobs
7- Thinking the problem will go away by itself (Just a phase)
8- Feeling embarrassed or ashamed or being seen as “crazy”
9- Not being able to afford financial costs
10- Concerns that people they know might find out
11- Preferring alternative form of care (Spiritual care)
12- Being too unwell to ask for help
13-Concerns about side effects of the medications if prescribed
14-Dislike talking about feelings or emotions
15- Thinking they don’t have a problem (Denial)

Financial problems
Decrease in academic performance
Problems with family and friends
Suicidal thoughts
Discontinuation from university or work

Improvement in social skills
Improve academic or work performance
Physical improvement (appearance)
Improve confidence
Improvement in relationship with family and friends
No improvement in health
Financial problems