Factors Affecting Drug Compliance in an Egyptian

Chairman of the Board AHMED OKASHA

Editor- in- Chief FAROUK LOTAIEF

Assistant to Editor- in- Chief ADEL SADEK

Honorary Editor MOSTAFA KAMEL

Senior Associate Editors MOHAMED GHANEM MOHAMED REFAAT

Editorial Advisory Board ABD EL MONEIM ASHOUR ADEL SHASHAAI AFAF HAMED

MAHMOUD SAMI A. GAWAD MOUNIER FAWZY SAIED ABD EL AZIM ZIENAB EL BISHRY YOUSRY ABDEL MOUHSEN

Associate Editors NAGLA EL MAHALAWY SAFIA EFFAT

International Advisory Board ABOU SALEH M.T. (U.K.) ANDREASEN N. (U.S.A.) BROWN G.W. (U.K.) CAZZULLO C.L. (ITALY) FREEMAN H. (U.K.) FUKUDA T. (JAPAN) LOPEZ-IBOR J.J. (SPAIN) LIEH MAK F. (HONG KONG) MEZZICH J.E.(U.S.A.) SARTORIUS N.(SWISS) WATSON J. (U.K.)

Assistant Editors AHMED SAAD TAREK ASSAD MONA MANSOUR ABDELNASSERMAHMOUD MAHA SAVED MOHAMED YOUSSEF HEBA ESSAWY Editorial Manager AIDA SEIF EL DAWLA Secretary NEVIN FAROUK

A

Vol. 8 No.2 July 2001

Current Psychiatry

Table of Contents 119-Transcranial Magnetic Stimulation (TMS) in Tobacco Smokers

203-Pathway to Psychiatric Care in Yemen

El Said N.

Al-Eryani A. H.

125-A Neurophysiologic Study Children With Collagen Disease

211- Psychiatric Assessment of Patients with Mild Traumatic Brain Injury

in

El Gamal Y., El Sayed N. , Tomoum H.

Magda T. Fahmy, Wafaa L. Haggag , Ahmed Osama,and Mohamed Negm

143-Factors Affecting Drug Compliance in an Egyptian Sample of Relapsing Schizophrenic and Bipolar Affective Patients

227-Education and the Performance of the Mini-Mental State Examination as a Screening Test for Dementia in a United States Community

Haroun El Rasheed A, Soliman A, Ghanem M, Effat S 161-Stress Related Chorioretinopathy

Aboraya,A. S., Anthony, Ph.D.

Badr M. G., Badr M.,.Omar A. M., FathyS. and El said N..

Amin A. Abdel aziz 175-Personality Profiles in Alcohol and Opioid Dependent Patients: A Comparison of Finding from Tpq Mahmoud,

Riyad,

James

C.

239-Rediagnosis of inpatients termed “Hysterical” in Saudi military hospital and their use of medical services: Retrospective clinical study Mokhtar, Aly, Raslan, MR, Abu Ela Iman Ibrahim, Abd ElHakim Ragab

167-Distribution of psychiatric disorders in an outpatient clinic in Qatar and their socio-demographic correlation

Rashad, M. Mohamed,

.P.H.

A.

183-Usability of “Organic Personality Disorder” as a clinical concept in a forensic setting: A pilot study. MansourA. K. , DaoudA. O., Mountjoy Ch.

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Vol. 7 No.3 November 2000

Publisher INSTITUTE OF PSYCHIATRY Copyright. All rights reserved. No part of this journal may be reproduced without prior written rnnsp.nt rif the. F.riitnr

Please refer all correspondence to The Editor: CURRENT PSYCHIATRY INSTITUTE OF PSYCHIATRY Ain Shams University Hospitals Abbasia, Cairo, Egypt. TELE.: 2022824738 FAX: 2022824738 E-Mail: fpsych @ intouch, corn Printed in Egypt

The symbol on the cover is Ba, the pharonic representative of the psyche

Current Psychiatry

Guidance for Authors The editorial staff will be most grateful for your assistance in relation to the matters listed below. Please read these instructions carefully before preparing a submission. Four copies of the manuscript in English should be submitted to: Professor Farouk Lotaief Institute of Psychiatry Ain Shams University Abassia, Cairo. Egypt. Review and Actions Manuscripts are examined by the editorial staff and are generally sent to outside reviewers. Decisions about manuscripts will usually be given within six weeks. Inquiries should be addressed to the editorial manager, Institute of Psychiatry Ain Shams University Hospitals Fax/ Answer phone : 2824738. Ethical Standards Articles are accepted on the understanding that they are subject to editorial revision. Submissions should be accompanied by a signed statement from all authors saying that :(a) the material has not been published in whole or in part elsewhere; (b) the paper is not currently being considered for publication elsewhere; (c) all authors have been personally and actively involved in substantive work leading to the report, and will hold themselves jointly and individually responsible for its contents; (d) all relevant ethical safeguards have been met in relation to patient or subject protection, or animal experimentation. Length Submissions should be double spaced and clearly legible. There is no maximum length for articles. We ask authors to be as concise as possible and will negotiate with you personally and sympathetically if we feel shortening would improve communication. Case reports should be of similar length to short communication; i.e. not more than six typewritten pages and letters not more than two typewritten pages. Please avoid unnecessary referencing. C


Current Psychiatry 18. Titles of Journals should not be abbreviated Illustrations These should not be inserted in the text each provided separately and numbered on the back with Figure numbers, titles of paper and name of author. Illustrations should be prepared about twice their final size. Four copies of all figures must be submitted. All photographs, graphs and di- agrams should be referred to as Figures and should be numbered consecutively in the text in Arabic numerals, (e.g. Fig. 3). The approximate position of each illustration should be indicated in the text. A list of captions for the figures should be submitted on a separate sheet and should make interpretation possible without reference to the test. Captions should include keys to sym- bols.

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Current Psychiatry

Transcranial Magnetic Stimulation (TMS) in Tobacco Smokers El Said N. Abstract Nicotine is a highly addictive substance and cigarette smoking is a major cause of premature death among human. Little is known about the site of action of nicotine in the human brain. Such knowledge might help in the development of new behavioral and pharmacological therapies to aid in treating nicotine dependence and to improve smoking cessation success rates. Methods: Transcranial magnetic stimulation (TMS) over the frontal cortex was used to examine the CNS effects of chronic nicotine use in 20 subjects. The results were compared with that obtained from non-smokers’ controls. Results: Nicotine produced shorter cortical motor evoked potentials (cMEP) in smokers compared with non-smokers. Conclusion: Nicotine increase the neuronal activity in the frontal lobes. Such areas have been previously shown to participate in behavioral and cognitive properties of other stimulants as amphetamines and opiates to produce reinforcing and dependence effects. Introduction: dopaminergic pathway projecting from the ventral segmental area to the cerebral cortex and limbic system (Corrigall et al., 1992).

Tobacco depedence is the most common substance abuse disorder. It is estimated that 22% of Americans are smoking. As a result of medical reports & health information the percentage of persons who smoke is decreasing.

In addition to activating the reward and dopamine system, nicotine causes an increase in the concentrations of circulating norepinephine and epinephrine and an increase in the release of vasopressin, Bendorphin, adrenocorticotrophic hormone (ACTH) and cortisol. Those hormones contribute to the basic stimulatory effects of nicotine on the CNS (Le Houezec & Benowitz, 1991).

The rate of quitting smoking has been fastest among well educated men and less among teenagers & women (Stolerman & Jauvis, 1995). The primary adverse effects of smoking cigarettes is death. Cause of death include bronchogenic cancer, myocardial infarction and cerebrovascular disease (Perkins et al., 1993). Tobacco meets all the DSM IV criteria for drug dependence, including compulsive use, difficulty in quitting and withdrawal symptoms.

Nicotine produces profound behavioral effects in humans, including memory facilitation, locomotor activation and appetite suppression. However, little is known of nicotine’s effect on neuronal activity at a system level. Understanding the sites and mechanisms of action of nicotine in the human brain may lead to new concepts related to the central mechanisms of drug dependence and the development of novel cessation therapies.

The psychoactive component of tobacco is nicotine, which has its central nervous system (CNS) effects by acting as an agonist at the nicotine subtype of acetylcholine receptors. Nicotine is believed to have positive reinforcing and addictive properties because it activates the

119


Current Psychiatry TMS was performed in a quiet semidark room, with the patient sitting on a chair. The disc electrodes chosen for recording were made of silver / silver chloride (5mm diameter) with a conducting jelly. The muscle chosen for recording the motor evoked potential was the thenar muscle. The active electrode was placed over the belly of the muscle, while the reference electrode was placed over the tendon of the same muscle.

Objectives: TMS allows noninvasive study of human brain activity by measuring amplitude and latency of waves resulting from activating neuronal cells. We used this tool to identify neuroanatomical regions activated by nicotine in the human brain. We hypothesized that frontal lobe structures would be activated by nicotine consistent with the drug’s mood altering and attenational properties.

The Magistem Stimulator was used. The stimulating figure of eight coil was attached to the stimulator. The magnetic stimulator was connected to standard EMG amplifier mounted in a dantec 2000c.

Subjects: Subjects were recruited from the hospital employees. They were generally healthy individuals about 20 males between the ages of 25-45y with smoking histories averaging 7-5y (range = 2-20 years). The current use of about 20 cigarretes /day.All subjects had no history of any neurological, medical or psychiatric disorder. Brief physical examination was conducted and caffeine consumption was restricted 12 hours before testing .20 non smokers were examined as controls they were matched to the previous groups in terms of age, sex, education and sociocultural aspects.

All evoked muscle responses (amplitude and latencies) were amplified and displayed on a high resolution display screen. For excitation of the small hand muscles, the center of the coil was placed over C3 (left cortex), the coil was positioned so that the inducing amounts were directed clockwise when viewed from above. The intensity of stimulation was adjusted as 80% of the threshold for each subject. Voluntary contraction of the tested muscle was usually required during testing to facilitate the response 5 consecutive motor evoked potentials were recorded the chosen response for measurement was the one with the shortest latency and largest amplitude.

Methods: Transcramial (TMS):

magnetic

stimulation

Results: Table (1): Demographic data for subjects sharing in the study. Smokers

Non-smokers

No

20

20

Age

25-45

25-45

Sex

males

Males

No of smoking years

7.5 (2-20y).

-----

No of cigarettes/d

20 cig/d

-----

120


Current Psychiatry

Table (2): TMS in both groups Smokers

Non smokers

Cortical latency Lt.

20.90 ± 3.54

22.45 ± 2.84

0.05 for bipolar affective

146


Current Psychiatry and inability to work in particular were significantly associated with noncompliance. Other associated side effects included weight gain, and sleepiness in schizophrenic patients. On the other hand, extrapyramidal side effects particularly tremors and rigidity, dysphoria, and constipation in bipolar affective patients were significantly associated with noncompliance.

two extremes regarding either the number of relapses or the number of hospitalizations. As displayed in table 2 non-compliant schizophrenic patients were significantly older than those who were compliant and had significantly more frequent hospitalization. On the other hand, noncompliant bipolar affective patients who had significantly shorter overall duration of illness. Moreover, non-compliant patients in both groups had significantly older age of onset of illness.

Table 5 shows the relationship between beliefs about medication and noncompliance. Patients were non-compliant although they knew they needed the medication, that the medication was a must in schizophrenic patients, also the need for medication was not protective in bipolar affective disorder patients, moreover the finding that they improved on medication and that they expected continuation of improvement on medication were significantly associated with non-compliance as well.

As table 3 shows larger doses of antipsychotics, oral medication and certain types of antipsychotics were more significantly associated with noncompliance. Previous non-compliance was statistically highly significantly associated with current non-compliance. Moreover, boredom from taking treatment in schizophrenic patients as well as financial burden of drug therapy in both schizophrenic and bipolar affective disorder patients. As shown in table 4 extrapyramidal side effects, negative symptoms in general

Table 6 shows that there was no association between non-compliance and any of the patients’ environmental factors.

Table (1): Illness-related Factors Associated with Non-Compliance factors related to the illness

Diagnosis: schizophrenia paranoid hebephrenic undifferentiated schizophrenic symptoms positive symptoms only negative symptoms only bipolar affective manic without psychotic symptoms

schizophrenic disorder % in nc

% in c

chisqua re or fischer exact

P-value

bipolar affective disorder % in NC

33.33 66.67 0

5.044

>0.05

85.19

100

2.268

>0.05

14.81

0

-

-

-

20.83

147

Chi-square or Fischer exact

P-value

-

55.56 33.33 11.11

-

% in C

-

8.33

1.001

>0.05

Vol. 8 No.2 July 2001 manic with symptoms

psychotic

insightless stigma substance abuse the month preceding relapse

Current Psychiatry -

-

-

79.17

91.67

44.44

100

12.222

0.05

22.22

0

3.259

>0.05

25

0

3.750

>0.05

44.44

0

8.381

0.05

* = Statistically significantly associated with non-compliance (P0.05 >0.05 0.05

3.750 6.429 1.667 1.667 1.667

>0.05 0.05 >0.05 >0.05

3.750 1.071 3.750

>0.05 >0.05 >0.05


Current Psychiatry

0 11.11 0

0 12.5 0

48.15 0 7.41 0 33.33 0

25 0 8.33 0 25 0

* = Statistically significantly associated with non-compliance (P0.05

50

-

>0.05

87.5

100

% in C

Bipolar affective disorder

91.33

P-value

% in NC

% in C

0 0

Chisquare or Fischer exact 1.667

>0.05 -

0 12.5

>0.05

100

10.000

0.05

P-value

* = Statistically significantly associated with non-compliance (P0.05

100

58.33

66.67

50

1.179

>0.05

87.5

50

8.438

0.05

75 12.5 41.67

0 0 8.33

22.500 1.667 0.272

0.05 >0.05

88.89

50

9.982

0.05

152


Current Psychiatry

replaced by other forms of therapy as psychotherapy) Treatment can help solving my problems Delusions that treatment is harmful Treatment is stopping patient from reaching his/her goals Patient appear to be on psychiatric drug treatment

12.96

0

1.740

>0.05

58.33

11.11

0

1.467

>0.05

0

22.22

0

3.259

>0.05

37.5

11.11

0

1.467

>0.05

0

1.077

>0.05

-

-

50

0.625

>0.05

50

26.667

0.05

0.946

>0.05

22.92

50

3.468

>0.05

0.219

>0.05

75

58.33

1.313

>0.05

3.259

>0.05

37.5

41.67

0.071

>0.05

0.300

>0.05

12.5

58.33

11.882

0.05

25

83.33

14.067