Saudi Pharmaceutical Journal 28 (2020) 971–976

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Saudi Pharmaceutical Journal

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Original article

Challenges associated with mental health management:

Barriers and consequences
Osama H. Mohamed Ibrahim a,b, Rana M. Ibrahim a, Noor Kifah Al-Tameemi a,⇑, Karen Riley c
a
College of Pharmacy, University of Sharjah, United Arab Emirates
b
Faculty of Pharmacy, Cairo University, Egypt
c
College of Pharmacy, University of Florida, Guainseville, USA

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Mental illness has become a global public health issue and according to WHO report in
Received 19 May 2020 2015, United Arab Emirates (UAE) recorded the highest level of depression among all countries at
Accepted 26 June 2020 Eastern Mediterranean Region. Many people frequently suffer from mental health diseases but tend
Available online 2 July 2020
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
Keywords: the consequences of untreated mental health disorders. The study also aimed to examine outcomes in
Psychiatric illness
patients when help was provided by health care providers.
Depression
Mental illness
Methods: A self-administrated survey was distributed among 377 people randomly selected from general
Mental health population of three different cities at United Arab Emirates (UAE): Abu Dhabi, Dubai and Sharjah. Their
Public health perception of the barriers, consequences and outcomes was analyzed to achieve the objectives of the
United Arab Emirates 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 respon-
ders reported building confidence (78.9%) and improvement in relationships (73.0%) as outcomes for tak-
ing 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.
Ó 2020 The Author(s). Published by Elsevier B.V. on behalf of King Saud University. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction Indeed, mental health disorders was defined as a wide spectrum

of diseases, with various symptoms and signs, but are all character-
World Health Organization (WHO) defined mental health as ‘‘a ized by some combination of atypical emotions, thoughts and
state of well-being in which every individual realizes his or her behavior. Such illnesses include schizophrenia, bipolar disorder,
own potential, can cope with the normal stresses of life, can work depression, autism, and numerous disorders. Most of these dis-
productively and fruitfully, and is able to make a contribution to eases are treatable (Manderscheid et al., 2010; World Health
her or his community” (World Health Organization, 2018a). Organization, 2012).
There are three components of mental health, that if altered,
can increase the risk of developing a mental illness. The first com-
⇑ Corresponding author at: Department of Pharmacy Practice and Pharmacother-
apeutics, College of Pharmacy, University of Sharjah, United Arab Emirates.
ponent of mental health is emotional well-being. This involves
E-mail address: [email protected] (N.K. Al-Tameemi). interest in life, happiness, and satisfaction. The second component
Peer review under responsibility of King Saud University. 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
Production and hosting by Elsevier to positive functioning and involves feeling part of a community or

https://doi.org/10.1016/j.jsps.2020.06.018
1319-0164/Ó 2020 The Author(s). Published by Elsevier B.V. on behalf of King Saud University.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
972 O.H. Mohamed Ibrahim et al. / Saudi Pharmaceutical Journal 28 (2020) 971–976

having something to contribute to society (Galderisi et al., 2015; Table 1

Thirunavurakasu et al., 2013). Description of survey sections.

Mental illness is becoming a global problem. According to WHO Survey Section title Description of the section
report, around 450 million individuals all over the world are suffer- Population characteristics This section included information
ing from a mental health condition, making mental illness in the about gender, age, education level,
top five disorders leading to disability according to global living status, nationality and whether
disability-adjusted life years (DALYs). Depression diseases ranked the participant is medically trained
professional.
fourth among the global disease burden and is expected to become Barriers for not seeking help from Fifteen statements were conducted in
the second by 2020 (International Pharmaceutical Federation, healthcare professionals this section. Each question included 3
2015; Wainberg et al., 2017; World Health Organization, 2018b). regarding mental diseases a statements as follows: agree, neutral
Although treatments are obtainable, but around 70% of people with and disagree.
Consequences of untreated mental This section consisted of five. Each
mental illness don’t seek help from healthcare providers (Crowe
illness b participant could choose more than
et al., 2016). one statement.
Currently, according to WHO report in 2015, United Arab Emi- Outcomes of professional treatment This section contained 7 statements.
rates (UAE) recorded the highest level of depression among all in mental illness b Each participant had the option to
countries at Eastern Mediterranean Region with 5.1% of the popu- choose more than one statement
regarding the outcomes of help-
lation suffering from the disease and around 354,000 cases of anx-
seeking.
iety noted in the same year. Studies performed in UAE however
a
indicate anxiety and depression are the leading cause of 75% of Cronbach’s alpha for the barriers section was 0.789.
b
Cronbach’s alpha for the outcomes and consequences sections was 0.648.
the mental health disorders in the country (World Health
Organization, 2017).
Mental health services in the UAE officially began in 1975 in Before the study began, approval for distributing the question-
Abu Dhabi. In 1981, a strategy to develop mental health services naires was obtained from University of Sharjah Research Ethics
was initiated with the opening of Al Amal Hospital in Dubai. Committee. Participants were informed about the aim and content
Despite an increasing number of psychiatrists and psychologists of the survey prior to answering it. The inclusion criteria was Ara-
in UAE over the years, the numbers are still insufficient (Al- bic and English speakers above the age of 18 years. Participants
Yateem et al., 2017). Many people have difficulty finding a proper below the age of 18 years old were excluded from the study.
health care provider or do not seek help for treatment of their men- The data was analyzed by using the Statistical Package for Social
tal health condition (Al Kindi and Haque, 2015). These barriers are Science ‘‘SPSS”, Version 20 from IBM company, United States of
significant as untreated mental health issues can lead to serious America (USA). Percentage (%) was utilized to present descriptive
and possible life-threatening situations including suicide data and Chi-Square test was conducted to assess the significant
(Charara et al., 2017). barriers that prevent people from obtaining healthcare provider’s
This study aims to identify UAE population opinions regarding help in mental illness. P-value < 0.05 was taken as cut off for sta-
the barriers that prevent them from seeking professional help for tistical significance.
mental health conditions and the consequences of untreated dis-
ease. This study will also look at the outcomes associated with
obtaining help from healthcare providers. 3. Results

3.1. Participant sociodemographic characteristics

2. Methods
A total of 341 out of 377 questionnaires were returned with
This study was a cross-sectional survey based that was con- response rate of 90.5%.
ducted among population of three different cities at United Arab Table 2 shows the frequency of responders based on sociode-
Emirates (UAE): Abu Dhabi, Dubai and Sharjah. A scoping literature mographic characteristics. With respect to sex, 170 males (49.9%)
review of several studies was undertaken to aid in the develop- participated in this study and 171 females (50.1%). There were
ment of a questionnaire to study the barriers for care and the out- more participants in age group 18–30 years old (n = 112, 32.8%)
comes of treatment in mental health patients. and age group 31–40 years old (n = 125, 36.7%) compared with
The face validity, content validity and appropriateness of the age groups. The highest number of responders were Arab
questions were assessed by members of the faculty of pharmacy (n = 196, 57.5%) and most of them were living with their families
and medicine at University of Sharjah. The scale’s reliability was (n = 236, 69.0%). Moreover, majority of people included in this
assessed by calculating Cronbach’s alpha coefficient. research didn’t have medical background (n = 238, 69.8%) and were
The survey was conducted in English and Arabic since these are graduates with bachelor’s or diploma degree (n = 257, 75.4%).
the most common languages used by people living in UAE. The sur-
vey contained 9 main questions distributed among four sections.
Table1 outlines the details of each section. 3.2. Barriers to professional help-seeking in mental illness
Using a convenient sampling method, the sample size was cal-
culated using RaosoftÒ calculator with confidence level of 95% ± 5% Table 3 identifies the barriers that prevent people from asking
and response distribution of 50% to calculate the minimum sample for healthcare provider’s assistance regarding mental disorders.
size. The calculated sample size was 300. A total of 377 participants High proportion of people agreed that thinking that the disease
from different communities in the Emirates of Abu Dhabi, Dubai will go away by itself without taking any treatment (n = 205,
and Sharjah were randomly selected and participated in the sur- 60.1%) and feeling embarrassed or shamed (n = 201, 58.9%) are
vey. Participants were from various companies, universities, the most common obstacles for obtaining help from health profes-
restaurants, malls, and social community groups. Self- sionals. Fewer number of participants believed that fear of disap-
administered questionnaires were distributed to the participants proval from family members (n = 114, 33.4%) and being to
over a period of three months, from January 2018 until March unwell to ask for assistance (n = 116, 34.0%) might be barriers
2018. for not asking for help.
 O.H. Mohamed Ibrahim et al. / Saudi Pharmaceutical Journal 28 (2020) 971–976 973

Table 2 of participants noted an improvement in confidence (78.9%),

Sociodemographic information. improvement in relationship with family and friends (73.0%) and
Characteristics n (%) improvement in social skills (70.7%) with professional help.
Total 341 (100.0) Improvement in academic or work performance was demonstrated
Gender in 61.6% of participants. Fifty percent of participants had physical
Male 170 (49.9) improvement. Financial issues (15.5%) or no improvement in out-
Female 171 (50.1) comes at all were the least common outcomes reported.
Age
18–30 112 (32.8)
31–40 125 (36.7)
41–50 80 (23.5) 4. Discussion
51 and above 24 (7.0)
Nationality Mental health disorders are ranked first in world burden of dis-
Arab 196 (57.5)
ease based on years lived with disability (YLDs) at the rate of 32
4%
Non-Arab 145 (42.5)
Living status of YLDs (Vigo et al., 2016). Despite this fact, many individuals glob-
Alone 70 (21.0) ally are still untreated (Kisely et al., 2006). Treatment delay in
With family 236 (69.0) mental health disorders may lead to worse clinical and social out-
With friends 35 (10.0)
comes (Kanehara et al., 2015); The focus of this study was on the
Do you have medical background?
Yes 103 (30.2)
barriers that prevent people from obtaining professional help in
No 238 (69.8) mental health diseases, the consequences of untreated mental
Educational level health disorders and the outcomes of help-seeking to better under-
No education 3 (0.9) stand the UAE general public’s point of view on mental health
High school 21 (6.2)
conditions.
Undergraduate 60 (17.6)
Bachelor/Diploma 257 (75.4) Our research found that the most common and significant bar-
riers for not obtaining help were: thinking that the disease will go
by itself (60.1%), feeling shamed (58.9%) and thinking that they
All but 3 barriers turned out to be statistically significant. The don’t have problem (54.5%). These finding were consistent with a
majority of participants agreed with numerous statements. How- previous study performed in the United Kingdom population that
ever, only three barriers were having insignificant differences in found difficulty to recognize mental illness and the inability to
the frequency between agree, neutral and disagree as follows: fear obtain easily accessible help where the most common barriers
of disapproval from family, being too unwell to ask for help and among people (Salaheddin and Mason, 2016). In addition, a sys-
fear that the diagnosis will prevent their academic performance. temic 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
3.3. Consequences of untreated mental illness (Gulliver et al., 2010). All these barriers ensue due to lack of aware-
ness regarding mental illness (Kanehara et al., 2015).
This study reported five effects of untreated mental health dis- Currently, the WHO has developed a comprehensive global
orders in Fig. 1. These include: social problems with friends and mental health action plan for 2013 to 2020. One of the important
family (69.2%), suicidal thoughts (56.3%), financial problems goals of this plan was to encourage mental well-being, prevent
(51.0%), discontinuation from university or work (50.4%) and a mental diseases and provide care. In addition, this plan recognized
reduction in academic performance (49.0%). the important role of healthcare providers in giving general infor-
mation to the general population regarding mental health, answer-
3.4. Outcomes of seeking help from healthcare providers in mental ing patient inquires and screening for mental disorders (World
illness Health Organization 2013). In addition to psychiatrists, other
health workers such as pharmacists, can have significant role in
Fig. 2 shows the UAE population outcomes of seeking increasing awareness. According to research, pharmacists are the
professional help in patients with mental health issues. Over 70% most trusted and the most easily available healthcare providers

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.
974 O.H. Mohamed Ibrahim et al. / Saudi Pharmaceutical Journal 28 (2020) 971–976

100.0%
Percentage of responders 90.0%
80.0% 69.2%
70.0%
56.3%
60.0% 51.0% 50.4% 49.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Problems with family Suicidal thoughts Financial problems Disconnuaon from Decrease in
and friends university or work academic
performance
Consequenes
Fig. 1. Consequences of untreated mental disorders.
Percentage of responders

100.0%
90.0% 78.9%
80.0% 73.0% 70.7%
70.0% 61.6%
60.0% 50.4%
50.0%
40.0%
30.0% 15.5%
20.0% 7.3%
10.0%
0.0%
Improve Improvement Improvement Improve Physical Financial No
confidence in relaonship in social skills academic or improvement problems improvement
with family work
and friends performance
Outcomes
Fig. 2. Outcomes of healthcare professional’s help-seeking in mental illness.

to the public (Al-Tameemi and Sarriff, 2019; Lynas, 2012; the factors that cause poor mental well-being (Richardson et al.,
Manolakis and Skelton, 2010). They can educate the general popu- 2017).
lation or those with diagnosed mental health disorders and provide In terms of the outcomes of professional help-seeking, most
advice regarding mental health issues. Moreover, pharmacists can participants in this survey believed that obtaining help will
detect signs and symptoms of mental health disorders and then enhance individuals’ confidences (78.9%), improve their social rela-
refer individuals at risk of an undiagnosed mental diseases to psy- tionships (73.0%) and raise the academic or work performance
chiatrists. For example, community pharmacists in Australia deliv- (61.6%). Many countries worldwide started educating people
ered unpaid education brochures giving advice on how to regarding the advantages of help-seeking in early stage of mental
recognize the first signs of mental health disorders. Pharmacists illness. In Germany, educational programs were initiated in schools
in Portugal distributed education leaflets regarding depression and police academies about mental health. Activities like art exhi-
(International Pharmaceutical Federation, 2015). All health work- bitions created by people with mental illness were also developed.
ers should cooperate to increase and share awareness amongst Educating the public about mental health will help improve the
the general public regarding the importance of seeking help and understanding of one’s condition which leads to an improvement
early treatment of mental diseases (Mclaughlin, 2004). in quality of life (Rüsch et al., 2005).
According to the results of our study, there is a high number of Regarding the consequences of untreated mental illness, people
individuals (n = 160, 46.9%) who think being unable to afford finan- responded to this study identified relationship problems (69.2%)
cial cost is a barrier that prevents people from seeking help and and financial problems (51.0%) as the most common issues.
56.3% believed that suicidal thoughts are one of the consequences Untreated mental health disorders increase the rates of disability
of untreated diseases. Clearly, some individuals with severe mental and mortality as well as can lead to many social and health prob-
illness enter the medical care system even without health insur- lems. Studies showed that depression can raise the likelihood of dia-
ance coverage, and some with insurance also experience a delay betes and myocardial infarction if not well controlled and at the
in treatment. Given the level of suicide attempts and substance same time, diabetes and myocardial infarction can increase the pos-
abuse among those with untreated mental illness, they are likely sibility of having depression (World Health Organization, 2013).
to enter the emergency room or a public clinic. Entering the med- Only 30.2% of the participants in our research had a medical
ical care system through these mechanisms in some ways is get- background. Adding mental health related courses in the education
ting too little care (Koronfel, 2002). Similarly, in United Kingdom, curriculum in the UAE for medical and non-medical students in
a cross-sectional study showed that financial problems are one of schools and universities will help in educating the public and med-
 O.H. Mohamed Ibrahim et al. / Saudi Pharmaceutical Journal 28 (2020) 971–976 975

ical professionals about mental illness and can reduce the stigma c- Undergraduate
by gaining knowledge and a better understanding of it. d- Bachelor/ Diploma

4.1. Strengths and limitations 6. Nationality:

a. Arab
This is the first survey conducted in the UAE that identifies pop- b. Non-Arab
ulation barriers for not seeking professional help in mental illness,
the outcomes of obtaining health workers’ help and the conse- B- Barriers for not seeking help
quences of untreated mental disorders. This study used the conve- 7. In your point of view, what are the barriers for not seeking psy-
nience sampling technique and conducted only at three cities in chologist/psychiatrist?
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.
Barrier Agree Neutral Disagree
5. Conclusion 1- Fear of disapproval from
family members
Overall, the research findings provide some insights regarding 2-Uncertainty of where to get
UAE populations opinions about mental illness. Numerous barriers professional help
appear to prevent people from obtaining health workers assistance 3- Fear that the diagnosis will
in mental health disorders and that could lead to dangerous conse- hinder the academic
quences. Therefore, raising awareness and educating the popula- performance
tion about mental health is important for the future. 4- Wanting to solve problem by
themselves
Funding 5- Fear of being put in hospital
against their will
This research did not receive any specific grant from funding 6- Concerns that it might harm
agencies in the public, commercial, or not-for-profit sectors. their chances when applying
for jobs
Declaration of Competing Interest 7- Thinking the problem will go
away by itself (Just a phase)
The authors declare that there is no conflict of interest. 8- Feeling embarrassed or
ashamed or being seen as
Acknowledgements ‘‘crazy”
9- Not being able to afford
The authors acknowledge all participants who have spent their financial costs
time to fill the survey and Ms Reham Yeshar and Ms Nourhan 10- Concerns that people they
Hesham for collecting the survey data. know might find out
11- Preferring alternative form of
Appendix 1 care (Spiritual care)
12- Being too unwell to ask for
A- Demography help
13-Concerns about side effects of
the medications if prescribed
1. Age: 14-Dislike talking about feelings
a. 18-30 or emotions
b. 30-40 15- Thinking they don’t have a
c. 40-50 problem (Denial)
d. 50 and above

2. Gender: C- Consequences of untreated mental illness

a. Male 8. In your opinion, what are expected consequences of
b. Female untreated mental condition? Choose more the one.

3. Do you have a medical background?

a. Yes
b. No Financial problems
Decrease in academic performance
4. Living status: Problems with family and friends
a. Alone Suicidal thoughts
b. With family Discontinuation from university or work
c. With friends

5. Education level: Specify others if any

a- No education
b- High school D- Management
976 O.H. Mohamed Ibrahim et al. / Saudi Pharmaceutical Journal 28 (2020) 971–976

9. What do you think are the expected outcomes after seeking Kisely, S., Scott, A., Denney, J., Simon, G., 2006. Duration of untreated symptoms in
common mental disorders: association with outcomes: international study.
help? Choose more than one.
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Reid survey. Canadian Pharm. J.: CPJ 145 (2), 55. https://doi.org/10.3821/145.2.
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Improve academic or work performance
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