SOCIODEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF
ADULTS ADMITTED TO THE PSYCHIATRIC SERVICE OF A
TERTIARY HOSPITAL IN THE EMIRATE OF ABU DHABI, UNITED
ARAB EMIRATES
Mas e ’s disse a ion submi ed in pa ial ul illmen o he equi emen s o he deg ee o
Mas e in Men al Heal h Policy and Se ice
By
Jenni e Jean Williams
Supe iso : P o esso G aca Ca doso
Ma ch 2017
UNIVERSIDADE NOVA DE LISBOA
Faculdade de Ciências Médicas
ABSTRACT
Backg ound: While he p e alence o men al diso de s con inues o inc ease globally
and mos men al heal h se ices in Abu Dhabi a e deli e ed by he e ia y psychia ic
hospi al, scan in o ma ion is a ailable o in o m men al heal h se ice de elopmen in
he emi a e. This s udy desc ibed he sociodemog aphic and clinical cha ac e is ics and
discha ge disposi ions o pa ien s who use his se ice.
Me hods: An elec onic heal h eco d e iew was conduc ed on a andomly selec ed
sample (n=285) o pa ien s aged 18 yea s and olde admi ed o he psychia ic hospi al in
Abu Dhabi ci y om 1 Janua y 2015 o 31 Decembe 2015.
Resul s: Eigh y-se en pe cen o pa ien s we e om Abu Dhabi egion, 75.8% we e aged
18-34 yea s and 69.5% we e male. The mos common discha ge diagnoses we e mood
diso de s (29.5%) and psycho ic diso de s (24.9%), excep among Emi a i males who
we e mos commonly diagnosed wi h subs ance use diso de s (48.2%). The psychia ic
hospi al was mos commonly iden i ied as he in ended p o ide o ollow-up ca e
(52.6%) and 94% o hese pa ien s we e scheduled o ecei e ou -pa ien ca e deli e ed
by psychia is s. A leas 32.3% o ci izens o o he coun ies had discha ge plans
indica ing hey equi ed ollow-up in hei home coun ies.
Conclusions: Wi h he limi ed esou ces a ailable o und men al heal h se ices and
gi en ha specialized psychia ic hospi als a e cos ly, unde s anding hose who use he
specialized psychia ic se ice in Abu Dhabi is c i ical o add essing he cu en and
p ojec ed ea men gaps. This s udy in o ms he de elopmen o an e ec i e local model
o se ice deli e y ha ma ches bes - i clinicians wi h se ice use s ac oss a ange o
se ices ha a e humane, e ec i e and sus ainable o e he long- e m.
Key wo ds: men al heal h, psychia ic se ices, Middle Eas , clinical, sociodemog aphic
cha ac e is ics
RESUMO
Plano de undo: Enquan o a p e alência de ans o nos men ais con inua a aumen a
globalmen e e a maio ia dos se iços de saúde men al em Abu Dhabi são
disponibilizados pelo hospi al psiquiá ico e ciá io, pouca in o mação es á disponí el
pa a in o ma o desen ol imen o de se iços de saúde men al no emi ado. Es e es udo
desc e eu as ca ac e ís icas sociodemog á icas e clínicas e disposições de al a dos
pacien es que u ilizam es e se iço.
Mé odos: Uma e isão de egis o ele ónico de saúde oi ealizada em uma amos a
selecionada alea o iamen e (n=285) dos pacien es com 18 anos ou mais elhos in e nados
no hospi al psiquiá ico na cidade de Abu Dhabi, en e 1 de janei o de 2015 e 31 de
dezemb o de 2015.
Resul ados: Oi en a e se e po cen o dos pacien es e am da egião de Abu Dhabi, 75,8%
inham uma idade si uada en e os 18 e os 34 anos e 69,5% e am do sexo masculino. Os
diagnós icos mais comuns e am ans o nos do humo (29,5%) e ans o nos psicó icos
(24,9%), exce o en e homens dos Emi ados que e am mais equen emen e
diagnos icados com ans o nos elacionados com o uso de subs âncias. O hospi al
psiquiá ico oi mais comummen e iden i icado como o p o edo p e endido de cuidados
de pós-al a (52,6%). En e es es pacien es, 94% es a a p og amado pa a ecebe cuidados
ambula ó ios, disponibilizado po psiquia as. Pelo menos 32,3% dos cidadãos de ou os
países inha planos de al a indicando que necessi a am de acompanhamen o nos seus
países de o igem.
Conclusões: Com os ecu sos limi ados disponí eis pa a inancia os se iços de saúde
men al, e dado que os hospi ais psiquiá icos especializados são ca os, comp eende
aqueles que usam o se iço psiquiá ico especializado em Abu Dhabi é undamen al pa a
abo da as lacunas dos a amen os a uais e u u os. Es e es udo in o ma o
desen ol imen o de um modelo e e i o local de p es ação de se iços que co esponda
melho os clínicos com os usuá ios do se iço, a a és de uma gama de se iços que são
mais humanos, e icazes e sus en á eis a longo p azo.
RESUMEN
An eceden es: Mien as que a ni el global el p edominio de desó denes men ales
con inúa en ascenso y la mayo ía de se icios de salud men al en Abu Dabi p o ienen del
hospi al de a ención psiquiá ica e cia ia, exis en muy pocas uen es de in o mación que
p omue an el desa ollo de los se icios de salud men al en el emi a o. Es e es udio
desc ibe las ca ac e ís icas clínicas, sociodemog á icas y disposiciones de al a
hospi ala ia de pacien es que u ilizan dicho se icio.
Mé odos: Se lle ó a cabo una e aluación del egis o elec ónico de salud en base a una
mues a alea o ia (n=285) de pacien es de 18 años en adelan e, ing esados al hospi al
psiquiá ico de la ciudad de Abu Dabi du an e el pe íodo del 1 de Ene o al 31 de
Diciemb e de 2015.
Resul ados: El ochen a y nue e po cien o de los pacien es e an de la egión de Abu
Dabi, el 75.8% se encon aba en e las edades de 18 y 34 años, y el 69.5% e a de sexo
masculino. El diagnós ico de al a más común e a po as o nos del es ado anímico,
(29.5%) y as o nos psicó icos (24.9%), excep uando a los emi a íes de sexo masculino
que ue on más comúnmen e diagnos icados con as o nos de i ados del uso de
subs ancias. El hospi al psiquiá ico ue usualmen e el p o eedo designado de cuidados
luego de la dada de al a (52.6%). Den o de es os pacien es, al 94% se le p og ama on
ci as de consul a ex e na pa a se a endidos po psiquia as. Po lo menos un 32.2% de
ciudadanos de o os países ue on dados de al a con la indicación de que p ecisaban
seguimien o en sus países de o igen.
Conclusiones: Con la limi ada can idad de ecu sos disponibles pa a inancia los
se icios de salud men al, y omando en cuen a que el cos o de hospi ales psiquiá icos
especializados es ele ado, es i al en ende a los usua ios de se icios psiquiá icos
especializados en Abu Dabi pa a abo da las de iciencias en a amien o, an o ac uales
como a u u o. Es e es udio da a conoce el desa ollo de un modelo local de p es ación
de una amplia gama de se icios, donde los p o esionales médicos idóneos a iendan a los
usua ios que lo necesi a, de una o ma humana, e ec i a y sos enible a la go plazo.
i
Table o con en s
PART 1: BACKGROUND AND REVIEW OF THE EVIDENCE
1.
In oduc ion
1
1.1.
Abu Dhabi geopoli ically …………………………………………
1
1.2.
Heal hca e in Abu Dhabi emi a e ………………………………...
3
1.2.1.
Heal h se ice egula ion ……………………………………………
3
1.2.2.
Public heal h se ice managemen ……………………………….….
5
1.3.
Abu Dhabi men al heal h se ices …………...……………….......
6
1.3.1.
Managemen o psychia ic/ men al heal h se ices
6
1.4.
S a emen o he p oblem………………………………….………
8
1.5.
Pu pose ……………………………………………………………
8
1.6.
Signi icance o he s udy ………………………………….……....
9
1.7.
Resea ch ques ions ………………………………………….….....
9
1.8.
Backg ound/ li e a u e e iew ………………………………….…
10
1.8.1.
Global bu den o disease and Men al and Subs ance Use Diso de s …...
11
1.8.1.1.
Wo ld Men al Heal h Su eys ………………………………….……
12
1.8.1.2.
Global Bu den o Disease S udy ………………………….…………
13
1.8.1.3.
Global bu den o diseases: Men al and Subs ance Use Diso de s
p e alence ………………………………………………..………..
14
1.8.2.
Men al Heal h se ices globally ……………………………..………
15
1.8.2.1.
Op imal mix o men al heal h se ices ………………………..……..
15
1.8.2.2.
Resou cing men al heal h se ices …………………………….…….
18
1.8.2.3.
Men al heal h ac ion plan:2013-2020 ………………………….…….
18
1.8.3
Regional Bu den o Men al and Subs ance Use Diso de s: A abia …....
19
1.8.3.1
A abia’s High Income Coun ies and esou ces o men al heal h …...…
22
1.8.3.2.
Men al Heal h as a egional p io i y …………………………………
24
1.8.4.
Men al heal h in he Uni ed A ab Emi a es ……………………….….
26
1.8.5.
Abu Dhabi emi a e and men al heal h ………………………….……
27
1.8.5.1.
Popula ion………………………………………………………..…
28
1.8.5.2.
Mig a ion ……………………………………………………..……
30
1.8.5.3.
Gende and he ole o women ………………………………………
33
1.8.5.4.
Wa and con lic ……………………………………………………
35
1.8.5.5.
Cul u al con ex and pe cep ions o heal h and illness ……………….…
37
1.8.5.6.
S igma ………………………………………………………….….
39
1.8.6.
Bu den o men al diso de s, Abu Dhabi ……………………….…….
40
1.8.7.
T ea men gap………………………………………………..……..
43
1.8.8.
Men al heal h se ices in Abu Dhabi ………………………...………
46

ii
Pa 2: Pe sonal con ibu ion
2.
Me hods
50
2.1.
Me hodology and s udy design ………………………….………..
50
2.2.
S udy popula ion and sampling ………………………….………..
55
2.2.1.
Se ing …………………………………………………….……….
55
2.2.2.
Popula ion ………………………………………………….………
56
2.2.3.
Sampling p ocedu e ………………………………………….……..
56
2.2.3.1.
Uni o analysis …………………………………………….………
56
2.2.3.2.
Sampling ame ………………………………………….…………
56
2.2.3.3.
Sampling me hod ………………………………………..………….
57
2.2.4.
Measu emen ……………………………………………..….……..
57
2.2.2.1.
Va iables …………………………………………………….…….
57
2.3.
P ocedu e and ime ame …………………………………………
61
2.3.1.
Da a collec ion …………………………………………….……….
61
2.3.2.
Time ame …………………………………………………..……..
63
2.4.
Da a managemen and analysis …………………………….…….
63
2.5.
E hical and legal conside a ions …………………………….……
64
3.
Resul s
67
3.1
Sociodemog aphic cha ac e is ics o sample …………….……….
67
3.2.
Clinical cha ac e is ics o sample ………………………….……..
68
3.2.1.
His o y o se ice use ………………………………………………
69
3.2.2.
Access o an admission uni …………………………………….…..
71
3.2.3.
Cou se o in-pa ien s ay…………………………………….………
73
3.3.
Discha ge om in-pa ien se ice …………………………...……
78
4.
Discussion
80
4.1.
Sociodemog aphic cha ac e is ics o sample ……………….…….
80
4.1.1.
Age ………………………………………………………………...
80
4.1.2.
Gende …………………………………………………………..….
80
4.1.3.
Region ……………………………………………………………..
81
4.2.
Clinical cha ac e is ics o sample ………………………………...
82
4.2.1.
His o y o se ice use ……………………………………………….
82
4.2.2.
Access o an admission uni …………………………………………
84
4.2.2.1.
Re e al sou ce ……………………………………………………..
84
4.2.2.2.
Admission poin o depa u e ……………………………………….
85
4.2.2.3.
Psychia ic isk assessmen …………………………………………
86
4.2.3.
S ay in in-pa ien se ice ……………………………………………
88
4.2.3.1.
Res ain s …………………………………………………………..
88
4.2.3.2.
Diagnoses…………………………………………………………..
91
4.2.3.2.1.
Se ious men al diso de s …………………………………………...
91
4.2.3.2.2.
Subs ance use diso de s …………………………………………….
92
iii
4.2.3.2.3.
In ellec ual disabili y ……………………………………………….
94
4.2.3.2.4.
Demen ia ………………………………………………………….
95
4.2.3.2.5.
Psycho opic medica ions …………………………………………...
96
4.2.3.2.6.
Como bid medical condi ions ………………………………………
98
4.3.
Discha ge …………………………………………………………
100
4.3.1.
Disposi ion …………………………………………………………
100
4.3.2.
Follow-up pos discha ge …………………………………………...
101
4.4.
S eng hs and limi a ions ………………………………………….
103
5.
Conclusions and Recommenda ions
106
5.1.
Recommenda ions ………………………………………………….
106
5.2.
Conclusion …………………………………………………………
108
6.
Re e ences
110
Lis o ables
Table 1.
UAE dis ibu ion o popula ion by egion (HAAD, 2013) …………..
2
Table 2.
Compa ison o global HICS ac oss bu den o disease, esou ces and
se ices …………………………………………………………
19
Table 3.
Causes o DALYs a ibu able o MSUDs in A ab HICS by gende
in 1990, 2005 and 2010 ………………………………………….
21
Table 4.
Compa ison o egional HICS ac oss bu den o disease, esou ces
and se ices …………………………………………….……….
23
Table 5.
BSP se ice usage by yea , 2012-2015 ...………………………….
56
Table 6.
Sociodemog aphic a iables, coding and analyses o ques ion 1…….
58
Table 7.
Clinical a iables, coding and analyses o ques ion 2 ……………….
60
Table 8.
Clinical a iables, coding and analyses o ques ion 3 ……………….
61
Table 9.
Sociodemog aphic cha ac e is ics o pa ien s admi ed o he in-
pa ien se ice …………………………………………………...
68
Table 10.
His o y o se ice use o pa ien s admi ed o he in-pa ien se ice ...
70
Table 11.
Re e al sou ce, access and psychia ic isk o pa ien s admi ed o
he in-pa ien se ice ………………………………………..…...
72-73
Table 12.
Res ain use, diagnoses and ea men o pa ien s admi ed o he in-
pa ien se ice …………………………………………………..
76-77
Table 13.
Discha ge disposi ion and ollow-up o pa ien s discha ged om he
in-pa ien se ice ………………………………………………..
79
i
Lis o igu es
Figu e 1.
Clinical se ice line de elopmen (HAAD, 2013) ………….…
4
Figu e 2.
Op imal mix o se ices o men al heal h (WHO, 2003) ……..
15
Figu e 3.
Popula ion py amid by age, gende and ci izenship (HAAD,
2013) …………………………………………………………
29
Figu e 4.
Age, gende and na ionali y o adul s admi ed o in-pa ien
se ice …………………………………………………………
68
Figu e 5.
Psychia ic diagnoses by na ionali y and gende ………………
74
Lis o appendices
Appendix 1.
Map o he Uni ed A ab Emi a es ……………………………..
132
Appendix 2.
Map o Abu Dhabi egions …………………………………….
133
Appendix 3.
F amewo k o abs ac ing da a om Elec onic Medical
Reco ds ………………………………………………………...
134-
135
Appendix 4.
In a a e eliabili y o 28 se s o duplica e da a (double
abs ac ion o iles) …………………………………………….
136
Appendix 5.
P o ocol o da a abs ac ion …………………………………..
137-
139
Appendix 6.
Discha ge medica ion classes p esc ibed by psychia ic
diagnos ic g oup ……………………………………………….
140-
141
Appendix 7.
Discha ge ICD-9 codes by diagnos ic bands ……………………...
142
Appendix 8.
Psycho opic medica ions by d ug class …………………………….
143
ACRONYMS
BSP
Beha io al Sciences Pa ilion
CDS
Conduc Diso de Scale
CHAMPSEA
Child Heal h and Mig an Pa en s in Sou h-Eas Asia
CPT
Eu opean Commi ee o he P e en ion o To u e and Inhuman o
Deg ading T ea men o Punishmen
DALY
Disabili y Adjus ed Li e Yea s
DASS
Dep ession Anxie y and S ess Scale
ECT
Elec ocon ulsi e he apy
ED
Eme gency Depa men
EHR
Elec onic Heal h Reco d
EMRO
Eas e n Medi e anean Regional O ice
FGM
Female Geni al Mu ila ion
GBDS
Global Bu den o Diseases S udy
GCC
Gul Coope a ion Council
GP
Gene al P ac i ione
HAAD
Heal h Au ho i y Abu Dhabi
HFU
High F equency Use
HIC
High Income Coun y
ICD
In e na ional Classi ica ion o Diseases
IHD
Ischaemic Hea Disease
IMHE
Ins i u e o Heal h me ics and E alua ion
IRB
Ins i u ional Re iew Boa d
5
In Decembe 2014 HAAD launched a i e- yea s a egic plan, iden i ying i s p io i y
a eas as:
1. in eg a ed con inuum o ca e o indi iduals (including men al heal h p og ams in
he communi y);
2. imp o ing quali y o heal h ca e (including h ough suppo ing esea ch in
heal hca e);
3. a ac ing, aining and e aining quali ied heal hca e p o essional;
4. eme gency p epa edness;
5. wellness and p e en ion o imp o e public heal h;
6. ensu ing alue o money and sus ainabili y o heal hca e spending; and
7. an e-heal h p og am (HAAD, 2014).
This launch was publicized h ough he media and epo ed on i s websi e. This was
ollowed by he publica ion o i s Capaci y Mas e Plan (HAAD, 2016).
1.2.2. Public Heal h Se ices Managemen
SEHA (A abic o “heal h”) is he company ha manages he go e nmen ’s heal hca e
acili ies ac oss he emi a e (12 hospi als and 57 p ima y heal h cen e s). In o al, 65% o
all in-pa ien beds a ailable o he popula ion belong o SEHA, including 100% o
psychia ic se ices in bo h he Wes e n and Eas e n egions, and 75% in he Abu Dhabi
egion. I has 156 psychia ic admission beds, 123 a Sheikh Khali a Medical Ci y
(SKMC) in he capi al and 33 in Al Ain hospi al.

6
1.3. Abu Dhabi men al heal h se ices
As o 2013, he UAE has a s and-alone men al heal h policy/ plan, indica ed as being
“a ailable and pa ially implemen ed” (WHO Men al Heal h A las, 2014). Howe e , his
is no a ailable in he public domain. A new men al heal h ac , p oposed in 2013 is no
ye passed (Sheikh Saud Bin Saq Al Qasimi Founda ion o Policy Resea ch, 2015) and
is s ill no a ailable in d a o m in he public domain. The exis ing men al heal h law,
Fede al Law no. (28) o 1981, makes p o ision o compulso y admission o a psychia ic
in-pa ien se ice i a psychia ic e iew boa d de e mines a “loss o con ac wi h eali y”,
ei he alone o in a pe son wi h “any o he men al diso de , men al e a da ion o
pe sonali y diso de ” (Al-Hassani, 2015). The e is no o mal legal p ocess o in olun a y
admission. Should a pe son a high psychia ic isk e use admission, he law equi es he
police a e in o med. Only ecen ly ha e changes o HAAD’s policy suppo ed an
in olun a y admission p ocess ha may be ini ia ed by a psychia is based upon he
psychia ic isk and compe ency assessmen s (Elsheikh, 2017).
Li le in o ma ion is a ailable in he public domain on he men al heal h (o illness) o he
popula ion o Abu Dhabi. No a e he e ecen di ec da a a ailable on he p e alence o
men al and subs ance use diso de s, men al heal h se ice u iliza ion and cha ac e is ics
o se ice use s, o he han hose epo ed by HAAD.
1.3.1. Managemen o psychia ic/ men al heal h se ices
Psychia ic se ices a SKMC a e un ou o he Beha io al Sciences Pa ilion (BSP), a
specialis se ice wi hin he b oade hospi al complex. Adminis a i ely and inancially a
pa o SKMC, i is licensed by HAAD as a sepa a e hospi al. While echnically all i s
123 beds a e lis ed as acu e admission beds, 46 a e used o long- e m pa ien s admi ed
7
mo e han i e yea s ago. O he emaining 77 beds, 20 in he male Chemical
Dependency Uni a e ese ed o male Emi a is only and 14 a e in he male Fo ensic
Uni . No in-pa ien beds a e a ailable o child en and no specialized o ensics o
chemical dependency uni s a e a ailable o women who a e abso bed in o he gene al
acu e se ice (Al Ga hy, 2016). In keeping wi h SKMC’s se ice model, BSP is
physician-led. The e a e 21 psychia is s (13 a e consul an s- one each o liaison
psychia is and child en and adolescen s).
In addi ion, BSP uns an Ou -pa ien clinic (OPC) o adul s and child en and a day
cen e . Re e als o he OPC, accep ed om gene al p ac i ione s (GPs), psychia is s in
p i a e p ac ice and SKMC’s liaison psychia ic se ice, a e by scheduled appoin men
be ween 0830 and 1500 Sunday o Thu sday. Those equi ing access wi hou a e e al o
ou o o ice hou s can only do so h ough he liaison psychia y se ice (which accep s
e e als om wi hin SEHA’s gene al hospi al in-pa ien and eme gency depa men s).
Admission o an acu e bed is only ia he OPC, Eme gency Depa men (ED) and SKMC
gene al hospi al and only psychia is s ha e admi ing p i ileges. While a e e al
pa hway exis s o accessing in-and ou -pa ien psychia ic se ices, he e e se is no he
case.
The acu e se ice is ende ed by psychia is s, suppo ed by non-psychia ically ained
gene al nu ses. One liaison psychia ic consul an and psychia ic esiden s cons i u e he
liaison psychia ic se ice o he h ee SEHA hospi als in Abu Dhabi and a psychia ic
consul an ende ing a se ice o Co niche Ma e ni y hospi al. Excep o hese wo
se ices, BSP is nei he in eg a ed in o gene al SEHA se ices no in o o he se ice
le els wi hin he cu en heal h se ice. I exis s in he absence o a clea ly a icula ed,
8
well-publicized ision, plan o s a egy o men al heal h se ices, poo ly delinea ed
e e al sys ems, a lack o specialized communi y men al heal h se ices o clea ly
de ined oles and esponsibili ies o i s clinicians owa ds p ima y heal h clinicians and
has no clea links wi h in o mal men al heal h se ices.
1.4. S a emen o p oblem
By 1996 Men al and Subs ance Use Diso de s we e esponsible o mo e han 25% o all
disabili y wo ldwide, 8 imes mo e han hea disease and 20 imes mo e han cance s
(Bax e , 2013). By 2010, he Global Bu den o Diseases s udy (GBDS) demons a ed ha
hese diso de s we e he leading cause o yea s li ed wi h disabili ies wo ldwide
(Whi e o d, 2013). Consis en wi h his pic u e, he leading cause o disabili y in he UAE
is neu opsychia ic condi ions (WHO, 2015). In 2010 HAAD p io i ized men al heal h as
one o i s op i e public heal h p io i ies (HAAD, 2010). In 2013 i ecognized ha a
“se e e” capaci y gap exis ed wi hin psychia y and an icipa ed an o e all g ow h in
demand (HAAD, 2013). As was bo ne ou by he esul s o GBDS 2013, he egional as
well as local bu den con inues o inc ease (GBDS, 2015). Despi e his, li le is known
abou he cha ac e is ics o he pa ien s who use his se ice, making planning o add ess
he ea men gap especially di icul .
1.5. Pu pose
The pu pose o his quan i a i e s udy wi h a c oss sec ional, e ospec i e cha e iew
design is o desc ibe he sociodemog aphic and clinical cha ac e is ics o pa ien s
admi ed o he men al heal h se ice (BSP) o Sheikh Khali a Medical Ci y. Wi h he
9
an icipa ed inc ease in admissions and he absence o local published da a, he e is an
u gen need o gene a e baseline in o ma ion on his popula ion so as o in o m he
discussion o wha cons i u es an e ec i e se ice model and p o ision o bes - i
clinicians o adul s wi h men al and subs ance use diso de s in Abu Dhabi.
1.6. Signi icance o he s udy
Epidemiological s udies guide he de e mining o na ional and local heal h p io i ies, as
does esea ch in o he deli e y o se ices (WHO, 2001). Bax e e al, (2013) speak o he
global dea h o popula ion s udies, highligh ing ha “clinically- ele an cases”
de e mine heal h se ice planning. Gi en he exis ence o a model o ca e ou o sync
wi h WHO’s ecommenda ions (WHO, 2003) and he g owing global unde s anding o
he eno mi y o he p oblem, he absence o epidemiological and se ice da a mus be
add essed as a ma e o u gency o in o m he discussion o wha cons i u es a iable
se ice deli e y model and e ec i e access and ca e by bes - i se ice p o ide s in he
UAE. This is wo h se ious conside a ion om s akeholde s since, in he absence o
adequa e, e ec i e, accessible communi y se ices, i seems a likely con ibu o o people
p esen ing in c isis and equi ing hospi al admission.
1.7. Resea ch ques ions
Hypo hesis: no hypo hesis is o mula ed gi en he desc ip i e design o his s udy.
1. Wha a e he sociodemog aphic cha ac e is ics (age, gende , na ionali y, ma i al
s a us, a ea o esidence, e e al sou ce, employmen s a us) o adul pa ien s
admi ed o he in-pa ien men al heal h se ice?
10
2. Wha a e he clinical cha ac e is ics (admission and discha ge diagnoses, leng h o
s ay, use o physical es ain s, medica ion, ECT, use o BSP se ices p io o
admission) o adul pa ien s admi ed o he in-pa ien men al heal h se ice?
3. Wha a e he discha ge disposi ions and e e als o adul pa ien s admi ed o he
in-pa ien men al heal h se ice?
1.8. Backg ound
I beho es one o conside men al heal h and illness in Abu Dhabi wi hin he well-
es ablished associa ions be ween ch onic medical condi ions and men al heal h and
b oade de e minan s o men al heal h.
These heal h de e minan s canno only be iewed a he indi idual and local le els, bu be
si ua ed wi hin a b oade socie al, na ional and in e na ional con ex , ha include:
 global and egional p e alence o men al and subs ance use diso de s, ac oss he
li espan,
 he high le els o con lic and associa ed displacemen and dis ess in he egion and
egional poli ical s abili y,
 mig an labo ,
 he ole and expe iences o women, bo h wi hin he amily and socie y, and he
expe iences o indi iduals wi hin he amily,
 cul u ally si ua ed explana o y models o men al illness,
 s igma, and

11
 he absence o men al heal h se ice in eg a ion in o p ima y, seconda y and specialis
gene al medical se ices locally and egionally along wi h he ecogni ion o he
signi ican con ibu ion made by he in o mal heal h se ice.
1.8.1. The Global Bu den o Disease and Men al and Subs ance Use
Diso de s (MSUDs)
When combined, Yea s o Li e Los (YLL), a measu e o mo ali y, and Yea s Li ed wi h
Disabili y (YLD), a measu e o disabili y, o m he Disabili y Adjus ed Li e Yea s
(DALY), a compound measu e ha e lec s yea s o heal hy li e los due o a disease o
diso de (Mu ay and Lopez, 1996). Using hese measu es allows o meaning ul
compa ison ac oss diso de s, gi en ha uni s o desc ip ion a e s anda dized. Thus, he
bu den associa ed wi h an inju y can be compa ed o ha o hea disease and ha o
Majo Dep essi e Diso de (MDD). This hinking has done much o b ing MSUDs o he
o e, highligh ing he signi icance o hese p e iously dis ega ded, bu hugely disabling,
condi ions.
Two key pieces o e ol ing epidemiological esea ch illumina ing he global bu den o
disease ela i e o MSUDs a e WHO’s Wo ld Men al Heal h Su ey (WMHS) and he
Global Bu den o Diseases S udy (Mu ay and Lopez, 1996). Bo h epo on p e alence
and use o DALYs o e lec mo bidi y and mo ali y. As ea ly as 1990, using he YLD,
he ini ial GBDS demons a ed ha i e o he en mos disabling condi ions we e
neu opsychia ic condi ions (Whi e o d e al, 2013) and p ojec ions om he WMHS
we e ha Unipola Dep ession would be he numbe one cause o global disabili y by
2030 (Alonso, 2012).
12
1.8.1.1. Wo ld Men al Heal h Su eys (WMHS)
While epo ing on simila measu es, me hodologies di e . The WMHS is a c oss-
na ional compa a i e s udy ha epo s on he p e alence and se e i y o men al
diso de s. One o i s aims is o de elop capaci y h ough assis ing coun ies ha lack
esea ch esou ces and in as uc u e o conduc high-quali y esea ch. Using
s anda dized in e iew ools, i allows o assessmen o men al diso de s (using WHO’s
Composi e In e na ional Diagnos ic In e iew) and, gi en ha he Sheehan Disabili y
Scales a e embedded in he in e iew schedule, ole impai men .
Wang e al (2012) demons a ed a 12-mon h p e alence o men al diso de s o 16.7% in
High Income Coun ies (HICS) as opposed o 14.8% in Low Income Coun ies (LICS).
Fu he , hey we e able o iden i y ha 24.5% o diso de s we e “se ious” while 37.8%
we e “mode a e” ac oss all s udies. They also inc eased ou unde s anding o he
ea men gap which is de ined as he “ ue p e alence a e and he p opo ion o hose
who ecei e any kind o ea men ” (Tho nic o and Tansella, 2012). They iden i ied ha
he global a e age use o se ices o men al diso de s was 9.0%, wi h he highes being
18.0% in he USA. Despi e some limi a ions ela ing o esponse a es, missing da a and
possible diagnos ic disc epancies, his su ey clea ly demons a es ha , while he bu den
associa ed wi h men al diso de s is huge, ea men is la gely neglec ed a ound he wo ld.
By 2012, his s udy had been conduc ed in 28 coun ies (Alonso, 2012).
Ra he han examining he bu den, S ein e al, (2013) demons a ed a u he alue o his
s udy. By using his c oss-na ional da a, hey we e able o explo e Pos T auma ic S ess
Diso de (PTSD), de e mining ha p e alence does no di e be ween HICS and LICS,
ha i is mo e p e alen in males and ha i is no ela ed o he ype o auma exposu e,
13
bu a he mul iple exposu es a ea lie ages. Conside ing he deg ee o con lic and wa
in he Middle Eas and he esul ing la ge-scale displacemen o i s popula ions in
conjunc ion wi h i s limi ed men al heal h se ices, s udies o his na u e a e c i ical ools
o in o m in e na ional and na ional heal h policies and s a egies.
1.8.1.2. Global Bu den o Disease S udy (GBDS)
The Global Bu den o Diseases S udy (GBDS) ex ended ac oss 188 coun ies and 240
causes o dea h by 2013 (GBD, 2015), using da a la gely ex ac ed om a ious eco ds
a ailable wi hin coun ies. Based on hese da a, s a is ical models a e used o es ima e
mo ali y and mo bidi y in e ms o age and gende so as o p o ide an o e iew o he
disease bu den a coun y, egion and global le el. Al hough de ini ions ha e changed
o e ime, ca ego ies ha e inc eased and epo ing has become inc easingly e ined, ca e
is aken o upda e p e ious esul s ela i e o he da a so as o be meaning ul o e ime.
Global bu den esea ch does much o shed ligh on he na u e and scope o heal h
challenges, in o ming planne s and esea che s alike, no only o wha knowledge exis s,
bu also on la ge-scale gaps needing o be in es iga ed and add essed.
In he GBD 2010 s udy, Lozano e al (2012) epo ed ha dea hs due o communicable
diseases accoun ed o 24.9% o he global bu den, inju ies (including sel -ha m) o
9.6% and non-communicable diseases ( he ca ego y inclusi e o men al and subs ance
use diso de s) o 65.5%. Using cu en GDB da a, a ious au ho s ha e ex ac ed and
epo ed on sub-se s o da a o u he expand ou unde s anding e.g. Haagsma e al
(2015) who examined inju ies.
No s udy o his size o complexi y can be wi hou limi a ions, bo h in e ms o he
quali y o da a a ailable and how hey a e collec ed. Howe e , he e is no dispu ing he
14
pu e size o he s udy and he expe sc u iny i s me hodologies and esul s ha e been
subjec ed o. And gi en i s alue as a ool o in o m na ional and in e na ional policy,
especially in he absence o good quali y local s udies, i is a ool o subs an ial wo h.
1.8.1.3. Global Bu den o Diseases: Men al and Subs ance Use Diso de s
p e alence
Whi e o d e al (2013) ex ac ed da a om he la ge GBD s udy o examine Men al and
Subs ance Use Diso de s (MSUDs) agains esul s o he 1990 s udy. While
ca dio ascula disease accoun s o he la ges p opo ion o o al DALYs (11.9%), i
only accoun s o 2.8% o YLDs. In con as , he i h la ges p opo ion o o al DALYs
(7.4%) is a ibu able o MSUDs which accoun s o 22.9% o all YLDs. O e all,
dep essi e and anxie y diso de s accoun s o he la ges YLDs (42.5% and 15.3%
espec i ely) and subsequen ly he la ges bu den exp essed as DALYs (40.5% and
14.6%). In his ca ego y, alcohol use diso de s accoun o he la ges YLLs (44.1%), bu
a e closely ollowed by d ug use diso de s a 41.7%. By a he highes impac is on he
age g oup 10-29 yea s.
The au ho s also de e mine ha be ween 1990 and 2013 he bu den o disease o
MSUDs inc eased by 37.6%, la gely a ibu able o popula ion g ow h and ageing, excep
o alcohol, opioid and cocaine dependence which canno be explained by hese ac o s
alone. While hese s a is ics a e ala ming in hemsel es, Bax e e al (2013) iden i y gaps
in knowledge due o he s udy’s design and posi ha , because o hese, he s udy likely
unde -es ima ed p e alence. Indeed, Vigo, Tho nic o and A un (2016) a gue ha his
unde es ima ion amoun s o mo e han one hi d o he epo ed bu den.
21
disabling MSUD o bo h gende s. Simila o he global pic u e, i is highe among
women. As opposed o women, whe e he second mos disabling diso de is anxie y,
among males i is d ug use.
Table 3. Causes o DALYs a ibu able o MSUDs in A ab HICS by gende in 1990, 2005 and 2010
( anking o yea in b acke s)
MALE
1990
2005
2010
Majo Dep essi e Diso de (6)
Majo Dep essi e Diso de (5)
Majo Dep essi e Diso de (4)
D ug Use Diso de (9)
D ug Use Diso de (7)
FEMALE
Majo Dep essi e Diso de (3)
Majo Dep essi e Diso de (1)
Majo Dep essi e Diso de (1)
Anxie y Diso de s (8)
Anxie y Diso de s (5)
While he e is a pauci y o men al heal h epidemiological and se ice da a in he UAE,
wha is known sounds a clea call o u gen esea ch and ac ion. In 2014 he GBD
Mo ali y and Causes o Dea h Collabo a o s epo ed ha by 2013, on a global scale,
inc easingly dea h was due o non-communicable diseases, and ha dea hs due o inju ies
we e inc easing, as we e hose due o d ug use diso de s. B eaking he 240 causes o
dea h down by egion, no MSUDs ank in he op en o he No h A ica Middle Eas
egion. When examining he coun ies in he egion, speci ically he UAE howe e , only
oad inju ies, ischemic hea disease (IHD), congeni al diso de s and s okes claim mo e
li es han sel -ha m. The 7 h leading cause o dea h is D ug Use Diso de s. Ga e and
Saeed (2015), epo ha global suicide a es inc eased by 60% o e he pas 45 yea s,
ha a ea men gap o mo e han 90% exis s in he Eas e n Medi e anean Region and
ha men al diso de s’ p e alence a es mus be educed as a ma e o u gency.

22
1.8.3.1. A abia’s High Income Coun ies and esou ces o men al heal h
W i ing abou men al heal h in he Eas e n Medi e anean Region (EMR), Sa aceno
(2001) no ed h ee p io i y a eas:
1. Human igh s ( espec o hose admi ed o men al heal h acili ies and he need
o shi he ocus om ins i u ionaliza ion o communi y ca e);
2. The illegal d ug ade and he close ela ionship be ween use o hese d ugs and
o he diseases like HIV wi h associa ed socioeconomic p oblems;
3. De eloping a heal h sys em in A ghanis an, gi en he de as a ion caused by
wa .
Fi een yea s la e , despi e global shi s, men al heal h legisla ion ( he p esence o , i s
con en wi h espec o human igh s and he en o cemen o i ), empowe men o se ice
use s and hei engagemen in de eloping legisla ion, inancing o men al heal h and
ins i u ionaliza ion a e a om ideal (Ga e & Saeed, 2015). Illici d ugs a e a majo
con ibu o o egional mo ali y and mo bidi y (GBD, 2013) and he wa s in Sy ia, Libya
and Yemen accoun o much dea h and de as a ion. This wi hin he ongoing con lic s
gene ally in he wide Eas e n Medi e anean Region and he unde lying poli ical
ins abili y as e idenced by he so-called A ab Sp ing.
When compa ing he si ua ion among he egion’s HICS using da a om he Men al
Heal h A las (WHO, 2014), i is clea ha he e is a gene al absence o esou ces and
se ices ela i e o global coun e pa s (Table 4). Despi e simila le els o income, he
egion’s weal hies s a es clea ly di e in e ms o esou ce alloca ion. While Bah ain and
Kuwai a e below global a e ages o psychia is s and nu ses, hey a e hea ily esou ced
wi h men al heal h wo ke s o he han designa ed p o essionals (doc o s, nu ses,
23
psychologis s, occupa ional he apis s and social wo ke s). When conside ing he
p opo ions o di e en ca ego ies o beds agains WHO’s men al heal h se ices model,
clea ly men al hospi al se ices a e o e - esou ced ela i e o communi y-based se ices.
Table 4. Compa ison o egional HICS ac oss bu den o disease, esou ces and se ices
HICS
Pe 100,00 o he popula ion
Bu den
Human esou ces
Se ices
DALYs
Suicide
To al
Men al
Heal h
Wo ke s
Psychia is
Nu se
Men al
Hospi al
beds
Gene al
hospi al
psych beds
Residen ial
beds
Global HICS
18.7
6.6
31.9
30.9
11.5
9.9
Bah ain
4,100
7.2
37.0
4.8
22.7
16.8
Kuwai
3,600
0.9
34.0
3.3
19.2
17.2
Oman
2,828
1.0
15.8
2.3
12.8
5.6
0.3
Qa a
4,214
4.6
16.3
2.9
8.8
3.0
0.0
0.0
KSA
2,917
0.4
16.5
2.1
10.5
19.5
0.3
UAE
4,241
3.2
0.8
0.4
0.0
Oman (2008), Bah ain (2010) and Saudi A abia (2010) a e he only egional HICS in
which he Wo ld Heal h O ganiza ion Assessmen Ins umen o Men al Heal h Sys ems
(WHO-AIMS) we e conduc ed. Qa a published i s na ional men al heal h s a egy in
2013. This is amed by i s Na ional Vision 2030, launched in 2008 and i s Na ional
De elopmen S a egy 2011-2016 which included a Na ional Heal h S a egy. Wi hin
his, men al heal h was iden i ied as a key p ojec and he ision is aligned wi h WHO’s
model o se ice deli e y (Sup eme Council o Heal h, Qa a , 2013). Gi en he high
le el o poli ical engagemen in he o e all p ocess, a Men al Heal h S a egy was
un eiled in 2013 (Funk and D ew, 2015). Mokdad e al (2016) iden i y Qa a as one o
only wo egional coun ies in es ing in p e en ion e o s as a s a egy o add ess he
spi aling bu den associa ed wi h men al heal h p oblems.
24
Saudi A abia has he mos widely-a ailable and accessible published in o ma ion on his
men al heal h sys em among he HICS, including publica ions ha map he
sociodemog aphic and clinical cha ac e is ics o i s se ice use s and epo on he men al
heal h sys em. I has de eloped i s men al heal h se ices in line wi h WHO’s op imal
se ice mix and add esses o he key aspec s o WHO’s men al heal h sys em
componen s, including policy, in o ma ion managemen , inancing and human esou ces,
based upon WHO-AIMS (Qu eshi e al. 2013). Almu ai i (2015) iden i ies ha men al
heal h esea ch p io i ies include men al illness among women, inequi able dis ibu ion o
se ices, ba ie s o help-seeking and s igma as well as e alua ing he e ec i e o
in e en ions.
1.8.3.2. Men al heal h as a egional p io i y
Since 2014, WHO’s Eas e n Medi e anean Regional O ice (EMRO) has been ac i ely
engaged in suppo ing he de elopmen o egional men al heal h sys ems, using he
Global Men al Heal h Ac ion Plan 2013-2020 as a oadmap o ac ion. Challenges
iden i ied include:
 mos egional polices, whe e hey do exis , a e inconsis en wi h in e na ional
human igh s s anda ds and a e no ully implemen ed;
 legisla ion is ou da ed and incompa ible wi h human igh s s anda ds;
 se ice use s and ca e-gi e o ganiza ions a e poo ly de eloped;
 men al heal h esou ces ( acili ies, unding and human) a e concen a ed in
men al hospi als and heal h p omo ion and illness p e en ion s a egies a e
absen ;
25
 he men al heal h wo k o ce is small and unde -quali ied o deli e app op ia e
se ices (Alwan & Saeed, 2015);
 absence o in e -sec o al collabo a ion o deli e heal h p omo ion, illness
p e en ion and in e en ions in mul iple se ings and ac oss di e en pla o ms
(Rahman, 2015);
 li le o no sys ems o men al heal h su eillance and in o ma ion managemen
sys ems (Chisholm and Dow ick, 2015).
Alwan and Saeed (2015) no es mul iple ba ie s o ansla ing he Global Men al Heal h
Ac ion Plan in o p ac ice in his egion, including:
 Di e se inancial, cul u al and na ional cha ac e is ics,
 Widesp ead na ional insecu i y and humani a ian c ises,
 Di e en s ages o economic de elopmen e lec ed in heal h ou comes, heal h
sys em pe o mance and heal h expendi u e.
In 2014, egional e o s o de elop a amewo k o scaling up ac ion and knock-on
na ional ac ion plans wi hin he con ex o he global plan esul ed in a se o egional
s a egic in e en ions (b oadly wi hin he a eas o go e nance, heal h ca e, p omo ion
and p e en ion and su eillance, moni o ing and esea ch) ha coun ies we e expec ed o
p io i ize (WHO EMRO, 2015) and epo back on in Oc obe 2015 (Ga e , Saeed &
Rahman, 2015).
26
1.8.4. Men al heal h in he Uni ed A ab Emi a es
When seeking o e alua e a coun y’s men al heal h sys em, WHO ecommenda ions can
se e as a s anda d o compa ison. In i s se ice o ganiza ion module (Funk, Sa aceno
and Pa ha e, 2003) au ho s highligh ha , commonly, lowe income coun ies a e
se iously challenged o p o ide adequa e esou ces (bo h se ice and human), while
coun ies wi h highe incomes a e p essed o imp o e iden i ica ion o diso de s and
in e ene a p ima y se ice le el as well as add ess con lic s a ising be ween di e en
seconda y le el men al heal h se ices. Gene al ecommenda ions o op imal se ice
p o ision, which a e all po en ially con e ible in o measu able indica o s, include:
 De ol ing se ices and esou ces om e ia y o p ima y le els o ca e,
 Blocking new admissions o psychia ic hospi als o la ge psychia ic ins i u ions
and eplacing hem wi h acu e se ices wi hin gene al hospi als,
 Realloca ing esou ces o o he se ice le els,
 In eg a ing men al heal h se ices in o p ima y and seconda y le els o ca e,
 De eloping capaci y in he in o mal ca e sec o , including h ough de eloping
ad ocacy g oups and including hem in de eloping and p o iding se ices,
 Using a sys em o inancial ewa ds o encou age a change in he men al heal h
se ices,
 Using p ima y and communi y se ices o each unde -se ed communi ies,
 T aining should be ex ended o include issues ela ing o psychosocial aspec s o
li e.
Wo ld Heal h O ganiza ion is clea ha , while each coun y is unique and hus mus
de e mine he ul ima e con igu a ion o se ices based on needs, he b oad amewo k o

27
he op imal mix o se ices is uni e sally applicable and ha he p inciples o
accessibili y, e ec i eness, equi y, human igh s, coo dina ion and con inui y o ca e
apply o all. Fo coun ies like he UAE and o he be e - esou ced ones, i s
ecommenda ions include:
 Se p io i ies based on cu en p e alence o men al diso de s,
 Upskill p ima y heal h ca e se ice p o ide s h ough aining, supe ision and
suppo o deli e a basic package o se ices,
 Dedica e men al heal h specialis s o deal wi h e e als om p ima y heal h ca e,
 Es ablish ca chmen a eas o se ices and de elop pa hways o access e ia y
ca e ( o use s) and suppo ( o p o ide s),
 De elop in-pa ien beds in gene al hospi als,
 Pa ne wi h NGOs o p o ide se ices o child en and adolescen s,
 Reduce beds in men al hospi als.
1.8.5. Abu Dhabi emi a e and men al heal h
In conside ing how one meaning ully ansla es hese ecommenda ions in o p ac ice in
he emi a e, one mus conside no only he di e si y o he popula ion, bu also he social
de e minan s o heal h likely o impac on la ge po ions o he popula ion. Biological and
psychological ac o s impac heal h- his is e lec ed in psychia y’s p e ailing
ea men s: biological knowledge ela ed o gene isk and neu o-imaging ha e con ibu ed
o de elopmen s in psycho opic ea men s while psychologically e ec i e ea men s
a e a ailable. Howe e , he social de e minan s o heal h a e la gely neglec ed as a eas
o in e en ion. Sa aceno e al (2009) a ibu e his o he challenges inhe en in
28
de eloping esou ces and in e en ions ou side he a ea o in luence o clinicians. Ye ,
unde s anding hese ac o s- and how hey a e associa ed wi h men al heal h and illness-
c ea e oppo uni ies o in e en ions ha a e no only eac i e, bu also p o-ac i e in
na u e and hus po en ially impac u u e gene a ions. These include po e y, con lic and
wa , gende oles and income and job secu i y.
I is also wo h no ing ha he UAE is ela i ely young, has apidly ansi ioned om
po e y o weal h and ha Abu Dhabi is a so e eign s a e wi hin a ede a ion.
1.8.5.1. Popula ion
His o ically he wo mos populous a eas in he Emi a e we e he se lemen s o Abu
Dhabi and Al Ain. In he 1970s mig an s we e la gely A abs om he Middle Eas , some
o whom s ill emain in he coun y wi h he suppo o hei o sp ing who now wo k
he e. Cu en ly he majo i y o mig an wo ke s a e Asian, la gely ec ui ed in o
cons uc ion and social de elopmen p ojec s (Fa gues, 2011; Lo i, 2011). This g oup has
been supplemen ed by wo ke s in o he hospi ali y, heal h ca e and domes ic labo
ma ke s, some o hem emale (Kahn, 2011). The popula ion cu es o Abu Dhabi
(Figu e 3) di e be ween he local Emi a i and expa ia e popula ions, e lec ing wha is
essen ially wo sepa a e popula ions esiding wi hin he bo de s o one coun y. The
median age o Emi a is is 19 yea s while o expa ia es i is 31 yea s (HAAD, 2015).
Among mig an wo ke s, i is hea ily skewed be ween he ages 20 o 59, especially o
males. The d op a 60y s is explained by his being he o icial e i emen age and
mig an wo ke s on wo king isas a e no longe eligible o esidency s a us. The e a e
cu en ly no da a desc ibing Abu Dhabi’s expa ia e popula ion by na ionali y. Howe e ,
29
in he UAE, he mos populous na ionali ies a e Indian (28%) and Pakis ani (13%),
compa ed o Emi a i (11%). Collec i ely, ci izens o China, S i Lanka, Nepal, Philippines
and Bangladesh make up 21%. The la ges A ab g oups a e ci izens o I an (5%) and
Egyp (4%). The balance accoun s o ci izens o all o he coun ies (95 e al, 2017).
Figu e 3. Popula ion py amid by age, gende and ci izenship (HAAD, 2013)
While inancial secu i y, empowe men , social pa icipa ion and social suppo ne wo ks
a e ecognized o bu e agains men al illness, he con e se is ue. The mig an
popula ion, many isola ed om amily and communi y, impo e ished and wi h
po en ially limi ed access o adequa e nu i ion, op imal heal h se ices and he basic
eedoms associa ed wi h mo e weal hy communi ies a e hus logically a g ea e isk o
de eloping men al diso de s, gi en hei ulne abili ies (WHO, 2004). Due o he
di e si y wi hin his g oup, one can bu look b oadly a hese social de e minan s o
men al heal h in conside ing no only hose cu en ly using men al heal h se ices, bu
also how exis ing and new se ices should de elop o be mos e ec i e. These include:
30
1.8.5.2. Mig a ion
The annual a e age g ow h a e o expa ia e males a mid-2015 was 7.7 o males and
9.0 o emales as opposed o he 2011 a es o 10.0 and 5.7 espec i ely (S a is ics
Cen e Abu Dhabi, 2016). Mig a ion may ha e di e en , o e lapping causes, including
leeing poli ically-mo i a ed iolence o con lic . Mo e han 80% o he UAE’s
popula ion is expa ia e. Wo ke s in he UAE en e unde he ka ala o sponso ship
sys em, and all wo ke s a e egis e ed in one o ou ca ego ies:
 ‘Whi e-colla ’ p o essionals and hei amilies wi h he wo ke ha ing a leas a
diploma as a highe quali ica ion and specialized in ce ain ields including
consul ancy, medical se ices, and law,
 P i a e sec o employees in adminis a i e o oca ional posi ions and hei
amilies,
 Domes ic wo ke s and o he s employed in “non-p o essional” jobs and hei
amilies, including ishe men and axi d i e s,
 All unskilled labo including hose in cons uc ion (Mahdawi, 2011).
Ba niji el al (2014) highligh ha many o he mos ly Asian mig an s o GCC na ions
encoun e p ac ices ha di e based on hei ci izenship s a us, including exclusion om
social se ices like pension plans as is he si ua ion in he UAE. Rahman (2011),
explo ing he lo o mig an wo ke s in Saudi A abia om Bangladesh demons a ed ha
deb s a e acc ued, o en by he amily, o inance he mig a ion wi h he hope o eaping
inancial gain. This places he amily in a p eca ious inancial posi ion and he wo ke is
compelled o emain in a si ua ion in which he e is high isk o exploi a ion, iolence and
37
and adap ing o a di e en cul u e. Hillia d e al (2012), in he USA, specula ed ha in
e ugee amilies he e may well be high le els o undiagnosed men al diso de s esul ing
in ine ec i e pa en al coping and in e ac ions wi h child en.
1.8.5.5. Cul u al con ex and pe cep ions o heal h and illness
In ying o unde s and he challenges expe ienced by Aus alians o Middle Eas he i age
in using men al heal h se ices, Kay ouz e al (2015) iden i ied cul u al ba ie s inclusi e
o eelings o shame, ea s ela ed o being labeled, dis us in men al heal h se ices,
language ba ie s and eligious belie s o illness causa ion a a iance wi h biomedical
models o disease. And Hillia d e al (2012), om he clinician pe spec i e, ecommend
adap ing p ac ice when wo king wi h amilies om he Middle Eas , ecognizing ha
membe s o his g oup may, con a y o hei Wes e n coun e pa s,
 Rega d Wes e n medicine p ac i ione s highly and so expec he clinician o be a
sou ce o wisdom and au ho i y. Thus, engaging wi h he pe son o amily and
seeking hei inpu and p e e ences may be in e p e ed as clinical incompe ence,
a he han pa ien -o ien a ed ca e.
 Focus on he physical a he han men al (pe haps due o s igma associa ed wi h
men al illness), and so ejec he apies o he han medica ion since hey a e no
seen o add ess he physical p esen ing complain ,
 See ques ions posed as pa o he assessmen as being o a pe sonal na u e and
hus no o be sha ed ou side he amily; and i sha ing in o ma ion, may speak
me apho ically a he han using ac ual language,
 May ha e an al e na i e explana o y model o illness, and
 May seek adi ional healing as a i s eso , bu no disclose his o he clinician.

38
Heal h (and illness) a e bo h socially de ined and exp essed. Kleinman (1988) employed
he e m “explana o y models o illness” o desc ibe ou own illness expe iences in e ms
o cause, na u e, se e i y, cou se and ea men . In seeking o unde s and how hese
models play ou in he egion, one can gain insigh om he wo k o esea che s in
psychia y like Okasha, Ka am and Okasha (2012) who iden i ied ha cul u al belie s
a ound men al illness include possession by e il spi i s and becoming ill due o ano he ’s
en y. Gi en ha adi ional/ eligious heale s a e hose who deal wi h he unknown, hey
a e hus he logical place o seek healing o symp oms associa ed wi h men al illness.
Looking o he belie s ha unde pin se ious illness, Sinky e al (2015) sough o iden i y
cul u al models o b eas cance in Saudi A abia. Th ough in e iews wi h women ei he
wi h, o suppo ing a woman wi h, b eas cance o elici hei s o ies o he illness,
esea che s ound h ee majo hemes eme ged:
 Tha he disease is always a al and hey had no con ol o i . Women asc ibed
he cause o he disease o Allah (God’s will and hus ou o a human’s con ol).
This is si ua ed in eligious belie s a ound se ious illnesses and seen as some hing
ha mus be accep ed. Associa ed wi h his is he belie in ‘ain ( he e il eye, o
jealousy by someone else di ec ed o he woman) as causa i e. ‘Ain is gene a ed
when someone admi es he pe son bu ails o nega e i by saying MashaAllah
(“as Allah in ended”), hus causing en y and ill will.
 Tha he disease h ea ens a woman’s abili y o ul ill he adi ional ole.
Being a wi e and mo he is highly alued and inex icably bound wi h a woman’s
alue. I she becomes ill and canno mee he oles she is po en ially seen, by
o he s and he sel , as socially less. Gi en ha such emphasis is placed on he
39
woman-as-nu u e , being in eceip o ca e, e en in a lo ing amily, is iewed by
women hemsel es as p oo o hei ailu e.
 P e e ing adi ional a he han biomedical ea men . Gi en he cause o
he disease and i s si ua ion wi hin a eligious belie s uc u e, he cu e is hus
also o be ound wi hin he adi ional. The women in his s udy sough ea men
h ough p aye , eci ing eligious sc ip s and d inking Zamzam (holy) wa e o
using i o cleansing.
Simila ly, in a selec i e e iew o he li e a u e a ound belie s o men al illness causa ion
among Muslims, Ci ci e al (2013) ound ideas a ound disease being a punishmen om
God, due o possession by jinni (e il spi i ), due o ‘ain (e il eye) o ha e il con ained in
an objec can be ans e ed o he pe son.
1.8.5.6. S igma
People wi h men al illnesses a e subjec ed o s igma and disc imina ion (Ci ci e al,
2013; Egbe e al, 2014; Sewilim e al, 2015; WHO, 2001). In Muslim communi ies Ci ci
e al (2013) iden i ied ha hose wi h symp oms o men al illness:
 may choose no o engage wi h men al heal h se ices so as o escape being
labeled,
 gi en ha physical illness is pe cei ed as mo e socially accep able, may exp ess
hei symp oms physically (soma iza ion o con e sion),
 may deny symp oms, including o hemsel es- o amilies may deny hem- due o
eeling shamed and wishing o p o ec he amily’s hono o pa icipa e in social
ac i i ies highly alued (like being ma ied).
40
One specula es ha among mig an s, simila beha io s may occu , e en whe e cul u al
adi ions a y. HAAD used global p e alence igu es o model demand in he Emi a e
(excep o subs ance abuse whe e i used egional p e alence a es), a he han ely on
local da a. This decision was based on he conclusion ha MSUDs a e unde - epo ed-
s a is ical da a collec ed o e a six-mon h pe iod in 2010 showed ha only 25,000 people
we e in need o se ices compa ed o he 107,541 indica ed using global and egional
es ima es. They asc ibe his disc epancy o s igma a ached o men al diso de s (HAAD,
2011).
1.8.6. Bu den o Men al and Subs ance Use Diso de s in Uni ed A ab Emi a es
The e is a ma ked absence o ecen local s udies, despi e a p o essed awa eness o he
need o men al heal h esea ch and se ices. In 2004 neu opsychia ic condi ions
accoun ed o he la ges disease bu den in he UAE (HAAD, 2010). This si ua ion is
cu en ly unchanged (WHO, 2015). Re lec ing his, men al heal h was iden i ied as
among he op i e na ional esea ch p io i y a eas (Gha a , 2010) and among Abu
Dhabi’s op i e heal h p io i ies (HAAD, 2010). Fou local s udies be ween 2001 and
2006 desc ibed he p e alence o men al and subs ance use diso de s in di e en sec o s
o he popula ion. These s udies, while o e ing gene al insigh s o cu en esea che s,
a e a guably o limi ed ele ance in guiding se ice planne s oday since he heal h
landscape has changed since hey we e published.
In he i s o hese, Abou-Saleh, Ghubash and Da adkeh (2001), ecognizing ha men al
diso de s a e public heal h p oblems and ha ela ed communi y s udies a e essen ial o
planning and de eloping psychia ic se ices, used he A abic ansla ions o a modi ied
41
Composi e In e na ional Diagnos ic In e iew (CIDI), he Sel -Repo ing Ques ionnai e
(SRQ-20) and he S uc u ed Clinical In e iew o DSM-IV Axis I Diso de s (SCID) o
de e mine li e ime and one-week p e alence o men al diso de s and dis ess. This s udy,
conduc ed in Al Ain, sys ema ically sampled 1696 households and ep esen ed 1394
indi iduals aged 18 yea s and olde . Li e ime p e alence o psychia ic diso de s was
es ablished as 8.2% (95% CI: 6.7-9.7). Li e ime men al dis ess was 18.9% (95% CI:
11.5-25.9) and one-week dis ess was 15.6% (95% CI: 11.8-19.5). They de e mined an
o e all p e alence o 11.4% in emales compa ed o 5.1% in males, a a io o 2.3:1.
La e , Ghubash e al (2004), using a b ie sociodemog aphic ool and an A abic
ansla ion o he Ge ia ic Men al S a e In e iew (GMS-A3), de e mined an o e all
ou -week p e alence a e o 20.2% o dep ession, 5.6% o anxie y and 4.4% o
hypochond iasis among olde Emi a is. This s udy used a simila sampling s a egy o he
ea lie s udy, en olling 610 pa icipan s aged six y yea s and olde .
Also in 2004, Al-Banna e al de e mined he poin p e alence o conduc diso de among
77 ju eniles (60% Emi a is) in ou ju enile de en ion cen e s using an A abic ansla ion
o he Conduc Diso de Scale (CDS) o be 24.7%. They iden i ied a signi ican
associa ion be ween he p esence o a conduc diso de and ha ing a non-Emi a i mo he ,
being he p oduc o a polygamous ma iage and low pa e nal educa ion and employmen .
In he only local s udy o in es iga e pos -pa um dep ession in Emi a i women, G een,
B oome and Mi abella (2006) de e mined he p e alence in 125 women who ga e bi h
in Abu Dhabi o be 22% a h ee mon hs on he Edinbu gh Pos na al Dep ession Scale. A
u he 22% o women ell in he bo de line ca ego y. A six mon hs, he p e alence was
12.5% and 19.6% espec i ely.
42
Two s udies shed ligh on he men al s a e o mig an wo ke s in he UAE:
1. Al-Maska i e al (2011) used he Dep ession Anxie y and S ess Scale (DASS-42)
o de e mine ha 25.1% o he sample o 318 male mig an s li ing in labo camps
in Al Ain in 2008 me he c i e ia o dep ession. They epo ha 6.3% had
hough s o suicide and 2.5% had a emp ed i . While he au ho s a emp ed o
andomly selec pa icipan s, hey ecognized ha his was no achie ed. In
addi ion, he popula ion and loca ion o hese camps biased hei sample owa ds
lowe paid, less educa ed and skilled ag icul u e-based wo ke s which makes
gene alizing hese indings di icul .
2. De ic e al (2012) epo ed on suicide a es and sociodemog aphic cha ac e is ics
o he 594 pe sons whose dea hs we e egis e ed as suicides in Dubai om 2003
o 2009. They es ablished a es o 6.3 pe 100 000 among expa ia es compa ed o
0.9 in he Emi a i popula ion. Among bo h g oups, mos ic ims we e male, olde
han 30 yea s, single, employed and had seconda y le els o educa ion o lowe .
These esul s oo should be in e p e ed wi h cau ion, gi en he s igma associa ed
wi h suicide, ha suicide is illegal as well as being iewed as “ha am” ( eligiously
unaccep able), and ha no egis e is a ailable o suppo he uni o m collec ing
and epo ing o da a. A mo e ealis ic e e ence is likely o be he Global Bu den
o diseases s udy which iden i ied sel -ha m as being he i h leading cause o
dea h in he UAE ou o 240 possible causes (GBD, 2013).
An addi ional wo s udies epo ed speci ically on use s o he UAE’s Na ional
Rehabili a ion Cen e (NRC) in Abu Dhabi, he p ima y se ice o ea men o
Subs ance Use Diso de s among Emi a is in he UAE. Elkashe e al (2013) e iewed

43
medical eco ds o he 591 male pa ien s admi ed o ea men om 2002 o 2011.
These pa ien s had a mean age o 32.4 yea s and 69.1% we e om Abu Dhabi emi a e.
In a enous d ug use s (44%) we e mo e likely o be diagnosed wi h Hepa i is C ha
o he d ug use s (11%) and no pa ien s we e HIV+ since his is an exclusion c i e ia o
se ice use. 70% we e discha ge on no medica ion o add ess elapse. Mainly hese
pa ien s used alcohol (41.3%), p esc ip ion medica ions (20%) and he oin (16%).
In a ollow-up s udy o 250 male se ice use s o he NRC, Alblooshi e al (2016)
epo ed ha hose aged 19 o 29 yea s used mul iple subs ances i e imes mo e o en
han o he pa ien s (mos ly opioids and alcohol) and ha he d ugs commonly used we e
he oin, mo phine, T amadol, P egabalin, P ocyclidine, Codeine and Ca isp odol.
1.8.7. T ea men gap
Globally he di e ence be ween he need o ea men by hose wi h se ious men al
diso de s and i s a ailabili y is 76%-85%. In HICS i is es ima ed a 35-50% (WHO, 2013
Ac ion plan). This is despi e e idence ha he inancial cos o ailing o ac will cos he
global communi y US$ 1.5 illion pe yea o he nex 20 yea s (Chisholm e al, 2016)
and ha e e y one dolla spen on e ec i e ea men o dep ession and anxie y yields a
ou - old e u n on in es men (Kleinman e al, 2016). The Men al Heal h Ac ion Plan
2013-2020 (WHO, 2013) se s ou a ge s which speci ically aim o add ess his, including
ha se ice co e age will be inc eased and ha p omo ion and p e en ion p og ams will
be a ailable ac oss coun ies.
44
I is likely ha he ea men gap in he Middle Eas Region is 90% (Sa aceno e al,
2015). Mokdad e al (2014) poin o he egion’s poo eco d o in es ing in in e en ions
wi hin a public heal h app oach as a con ibu ing ac o o he poo pe o mance o heal h
sys ems gene ally, no ing ha e en hose coun ies whe e public heal h is de eloped,
pe o m below expec a ions. In examining he esul s o he la es GBDS egionally
Mokdad e al (2016) no e ha he u gen , la ge-scale esponse needed o add ess he
bu geoning e ec s o men al and d ug use p oblems is no o hcoming. Indeed, many
coun ies s ill ail o p io i ize he issue a na ional le el.
The Eas e n Medi e anean Regional O ice, in i s oadmap o scaling up se ices,
p oposes speci ic indica o s o go e nance, heal h p omo ion, illness p e en ion and
heal hca e. These indica o s a e clea ly o ien a ed o human igh s wi hin a legisla i e
amewo k, inancing by go e nmen o in eg a ion o men al heal h in o he coun y’s
heal h sys em in acco dance wi h WHO’s op imal se ice mix, and in e -sec o ial
engagemen (EMRO, 2015).
Gi en he huge dispa i ies be ween di e en sec o s o he Abu Dhabi popula ion, he
eali y o some may be close o ha o he egional gap o 90%. Fac o s impac ing his,
besides hose b oade issues al eady highligh ed, may also be due o mo e localized
ba ie s like:
 Public awa eness: he e may no be knowledge wi hin local communi ies/
households on wha he symp oms o men al illnesses a e, wha se ices and
ea men s a e a ailable and how o access hem;
 Language as a ba ie : gi en ha he o icial language o he coun y is
A abic and he o icial language o educa ion and comme ce is English, many
45
who may wish o seek access may no be awa e o se ices since hey canno
ead o speak ei he o hese languages;
 Communi y esou ces a e ill-in o med: adi ional and eligious leade s,
school eache s, police se ices and NGOs may, since excluded om he
heal hca e ne wo k, be unawa e o how and when o e e and access help;
 Gende : due o cul u al es ic ions, many women may no seek ca e on hei
own o p esen hemsel es in public unchape oned. They may also p e e a
emale p ac i ione and one om a simila cul u al backg ound which may be
in sho supply;
 Resis ance om wi hin he o mal men al heal h se ice: Abu Dhabi
heal h se ice, like much o he Middle Eas , has a eac i e a he han
p oac i e app oach o men al heal h (K on ol, 2012). Public and p i a e
se ices a e physician-d i en and, as such, p esumably p o ide / se ice
a he han needs-led. These ac o s, coupled wi h a la gely Middle Eas e n
psychia ic wo k o ce, likely con ibu e o he cu en s a us quo.
 Gene al heal hca e p o ide s: gi en he lack o in eg a ion o heal h
se ices and he absence o men al heal h aining o communi y heal h
p o essionals, gene al heal hca e p o ide s may be ailing o adequa ely
ecognize ha many o he isks associa ed wi h gene al medical condi ions
a e commonly associa ed wi h men al diso de s, ha some o he ea men s
hey p esc ibe can po en ially induce o exace ba e symp oms, and ha
e ec i e in e en ions a e wi hin hei scope. While no speci ic o Abu
Dhabi, WHO-mhGAP (2008) epo s a gene al dea h o o icial in-se ice
46
aining a ailable o p ima y heal hca e clinicians ela ed o men al heal h and
illness.
 Lack o in o ma ion o in o m policy decisions: he e a e ew ecen
publica ions om he UAE o Middle Eas ha shed ligh on issues a ound
men al heal h in he UAE o Abu Dhabi. P e alence s udies conduc ed among
Emi a is by Abou-Saleh, Ghubash and Da adkeh (2001) and Ghabash e al
(2004) ha e li le ele ance oday, gi en he eno mous changes in he coun y
o e he pas en yea s. In 2010 he na ional Minis y o Heal h accep ed
esponsibili y o de eloping a na ional esea ch pla o m and sys em, aiming
o b ing oge he s akeholde s om ac oss he spec um including policy
make s, esea che s and legisla o s. I ecognized ha men al heal h esea ch
was one o he op i e UAE p io i ies, oge he wi h esea ch in o cance ,
nu i ional diso de s, ch onic diseases and oad a ic acciden s (UAE
Minis y o Heal h, 2010). Li le is a ailable publicly o measu e p og ess in
how his ansla es in o s a egies o build capaci y among men al heal h
clinicians o conduc and use esea ch, und i , o de elop a sus ainable
in as uc u e o suppo aspec s o esea ch, be i epidemiological, economic,
heal h sys ems o in e en ion- ela ed.
1.8.8. Men al heal h se ices in Abu Dhabi
HAAD (2011) iden i ied ha one o he six a eas wi h se e e capaci y gaps in Abu Dhabi
was men al heal h se ices. When his epo was p oduced, he e we e 31 beds a ailable
in Al Ain and 125 in Abu Dhabi ci y a SKMC’s BSP. O hese, 84 we e o males (26 o
53
in eg i y o he da a du ing he collec ion p ocess, manage missing da a o educe
a iabili y in da a abs ac ion.
O he s esea che s ha e add essed aspec s in hei epo s, including Shim e al (2013)
who epo ed ha wo abs ac o s we e used in hei s udy o pa ien s wi h bipola
diso de in Sou h Ko ea and Lachman e al (2012) who no ed a single abs ac o was used
in hei desc ip ion o adolescen se ice use s wi h dual diagnosis in Sou h A ica.
Nei he o hese epo s p o ide addi ional in o ma ion, howe e . In 2014 Weins ock e
al. o e ed a mo e de ailed insigh in o hei me hodology when hey desc ibed he
cha ac e is ics o pa ien s who ecei e ou o mo e psycho opic medica ions. They
p o ide in o ma ion on how da a we e ex ac ed and by whom, how hese we e coded
and how checked o e o . By epo ing on hese issues, all hese acknowledge alidi y
and eliabili y conce ns in he esea ch design. Howe e , none epo on hem
sys ema ically o agains he b oade me hodological amewo k pu o h by hose
au ho s who ha e add essed ways o suppo ing da a accu acy.
I he abili y o gene alize a s udy’s indings is dependen upon high quali y da a and
sampling, hen hese should be epo ed as pa o he me hodology, jus as sampling
s a egies a e (Fox, Hunn and Ma he s, 2009). This idea is echoed by Kahn e al (2015)
who ecognize poo da a quali y as a “se ious h ea ” o gene alizabili y. In p esen ing
hei amewo k delinea ing he s eps in he da a collec ion cycle, hey make 20
ecommenda ions o epo ing on he quali y o da a in e ospec i e EHR e iews.
These include ha he o igin o da a, me hods o da a cap u ing and abs ac ing,
de ini ions o a iables and hei cons uc ion be epo ed. Fu he , ha o each a iable,

54
desc ip i e s a is ics be p o ided. This amewo k will guide he epo ing o he esul s
o his s udy.
Zozus e al (2015), a he han looking o ecommenda ions on epo ing, look o ac o s
ha a ec he quali y o abs ac ed da a. No ing ha no o mal guidelines exis o add ess
quali y assu ance issues which se iously limi s his design, hey gene a ed an ex ensi e
lis o ac o s co e ing di e en aspec s o he medical eco d abs ac ion p ocess h ough
a combina ion o li e a u e e iew and Delphi me hodologies. These ac o s will guide
me hodological decisions in his s udy (see Appendix 3).
Conside ing he s a egies iden i ied by Findley and Daum (1989), Ede e al. (2005) and
G ego y and Rado insky (2012) o educe a ia ion and inc ease gene alizabili y, and
consis en wi h he me hodological guidelines se ou by Wo s e e al (2004) and Gea ing
e al (2006), he ollowing ac ions we e aken in addi ion o ha ing a comple e sampling
ame in his s udy:
 A clea p o ocol o da a abs ac ion was de eloped ha guided he o de o cha s o
be accessed and s eps o ollow when da a is missing.
 The compu e ized da a cap u ing ool, wi h a iables in he o de hey a e a ailable
om he cha , had he codes o each a iable immedia ely a e i s name. This i s
ow was ozen o ensu e his in o ma ion was always isible.
 Each a iable’s code was mu ually exclusi e and da a we e eco ded as a ailable
(e.g. age was eco ded as da e o bi h).
 Da a we e eco ded di ec ly in o he abs ac ion ool.
 Missing da a we e coded and add essed a he end o da a collec ion.
55
 Since da a abs ac ion was done by he esea che , in a a e eliabili y is epo ed.
E e y 10 h case in he sample was abs ac ed i s . Then, commencing om case 1,
da a we e abs ac ed esul ing in 29 double abs ac ions. A each double abs ac ion
poin , a compa ison is a ailable on in a a e eliabili y (Appendix 4). This allowed
o ongoing moni o ing o he abs ac ion p ocess and sough o educe he
possibili y o abs ac o “d i ” ela ed o o e - amilia i y wi h documen a ion
pa e ns and o e -con idence by he abs ac o . In a a e eliabili y is epo ed on
he EHRs ha a e double-ex ac ed as a % whe e 100% eliabili y is ‘no a ia ion’.
2.2 S udy popula ion and sampling
2.2.1. Se ing
SKMC is an 834-bed acu e ca e hospi al o e ing in- and ou pa ien specialis and
eme gency se ices o adul s and child en ac oss he emi a e o Abu Dhabi. When
conside ing he o e all se ice in o ma ion om BSP’s annual clinical po olios i is
clea ha se ice usage is inc easing o e ime bo h in e ms o numbe s seen in he
Eme gency depa men (ED) and numbe o acu e psychia ic admissions (Table 5).
Since 2012, when s a is ics we e i s colla ed, he numbe o admissions o BSP has
almos doubled. The numbe o ECT sessions, lowe in 2014 han 2012, has mo e han
doubled- his despi e he eady a ailabili y o psycho opic medica ions in he emi a e.
56
Table 5. BSP se ice usage by yea , 2012-2015
yea
o al ED o
SKMC
admissions
o al
psychia y
consul s
in ED
o al ED o
BSP
admissions
% o ED
consul s
esul ing in
admission
o al BSP
acu e
admissions
% ED
admissions
o o al
BSP
admissions
admissions
om BSP
sou ce
ECT
sessions
in BSP
SKMC
liaison: o al
SEHA
liaison (new
isi s)
2015
11860
1622
993
61.2%
1202
82.6%
209
360
350: 442
2014
11535
1254
856 
61.2%
1118
76.6%
262
165
356: 450
2013
10151
1255
764
60.9%
1086
70.4%
322
125
346: 431
2012
no da a
1136
728
64.1%
1051
76.5%
323
182
352: 462
2.2.2. Popula ion
The popula ion o his s udy was all adul s aged 18 yea s and olde admi ed o SKMC’s
psychia ic se ice om 1 Janua y 2015 o 31 Decembe 2015 o whom a clinical
admission encoun e was ini ia ed.
2.2.3. Sampling p ocedu e
2.2.3.1. Uni o analysis
The uni o analysis was he indi idual elec onic medical eco d.
2.2.3.2. Sampling ame
The Elec onic Heal h Reco d (EHR) is a ully compu e ized sys em linked o
he o ganiza ion’s billing sys em. All pa ien s a e accoun ed o elec onically.
Wi hin 24 hou s o esump ion o he elec onic se ice a e an in e up ion, all
pape eco ds a e ans e ed in o he elec onic sys em. A comp ehensi e epo o
admission encoun e s was gene a ed wi h clinical ile numbe s (p e ix SK) a anged
nume ically. All duplica e eco ds, iden i ied by epea ile numbe s, we e manually
57
emo ed by he esea che . Those aged younge han 18 yea s a hei las admission
o 2015 we e also emo ed om he epo .
2.2.3.3. Sampling me hod
Simple andom sampling was used o iden i y he equi ed sample size (a a
con idence in e al o 0.05% and a con idence le el o 95%) using a sample size
calcula o a ailable a h p://www.nss.go .au/nss/home.ns /pages/Sample+size+calcula o . The sample
a ge was 285, calcula ed on a popula ion o 1100. Each consecu i e ile in he
sampling ame was assigned a esea ch uni numbe 1- 1100. A able o numbe s
was gene a ed and co esponding SK ile numbe s we e copied in o a mas e excel
sp ead shee . The da a abs ac ion poin was he las eco ded admission o BSP in
2015 (i.e. i h ee admissions in he yea , he las admission).
2.2.4. Measu emen
2.2.4.1. Va iables
All a iables a e cu en ly a ailable in he eco d. Da a ela ed o se ice con ac a e
au oma ically logged a poin o se ice (e.g. admission) and an elec onic ime
eco ding is embedded in he sys em. O he da a we e abs ac ed om he clinical
no es as pe p o ocol (Appendix 5). The amewo ks guiding a iable coding and
analysis a e a ailable o sociodemog aphic cha ac e is ics (Table 6), clinical
cha ac e is ics (Table 7) and discha ge disposi ion (Table 8).
 Socio-demog aphic da a is au oma ically gene a ed in he sys em when an
indi idual’s na ional iden i ica ion ca d o passpo is scanned on admission. Da a
we e abs ac ed on he ollowing:
 Gende (as male o emale);
58
 Age (as da e o bi h) which we e collapsed in o age as yea s and, u he ,
in o age bands;
 Na ionali y (as ci izen o UAE o expa ia e);
 Geog aphical esiden ial egion as pe h ee egions o Abu Dhabi emi a e
and o he a eas (as Abu Dhabi / Al Ain/ Wes e n egion/ o he emi a e/ o he
coun y).
Table 6. Sociodemog aphic a iables, coding and analyses o ques ion 1
Resea ch ques ion 1: Wha a e he sociodemog aphic cha ac e is ics o adul pa ien s
admi ed o he in-pa ien men al heal h se ice?
Va iable
Coding
Type o da a
Analysis
Gende
0=male/ 1= emale
Nominal
F equencies and pe cen ages
Age
as da e o bi h
Con inuous
Desc ip i e s a is ics
(pa ame e s, dis ibu ions)
Na ionali y
0=na ional 1=ci izen o o he coun y
Nominal
F equencies and pe cen ages
Geog aphical
esiden ial egion
0=Abu Dhabi ci y/ 1=Al Ain ci y/
2=Wes e n egion/ 3=o he emi a e/
4=o he coun y
Nominal
F equencies and pe cen ages
 Clinical da a: Resea ch ools we e no used o e i y accu acy o diagnosis,
gi en he objec i es o he s udy. Diagnoses a e de ined as hose made by a
SKMC psychia ic consul an . These a e eco ded as pe ICD-9 diagnos ic code
om a d op-down menu in he EHR. Whe e he physician a he pa ien
encoun e is no a psychia ic consul an , he sys em equi es diagnosis
e i ica ion by he consul an (designa ed as Mos Responsible Physician)
wi hin 24h s o he eco d o be p ocessed.
Psychia ic and isk assessmen s a e conduc ed a all h ee access poin s. No
discha ge om he psychia ic se ice can be comple ed un il he EHR

59
discha ge summa y is signed o by he consul an . All es ain s used in he
psychia ic se ice mus be p esc ibed by a physician. Psychia ic (physical)
es ain s a e applied by a eam o ained esponde s and o en used in
conjunc ion wi h chemical es ain ( apid anquiliza ion) h oughou SKMC.
 Da a we e collec ed o he ollowing:
 Re e al sou ce (b ough o se ice by whom);
 Admission poin o depa u e (poin a which decision o admi was made);
 Main psychia ic diagnosis;
 Violence and suicide isk le els a admission poin o depa u e;
 Use o physical and/ o chemical es ain a leas once in i s 24 hou s o
admission;
 ECT ecei ed du ing admission;
 Leng h o s ay in BSP;
 Discha ge medica ions p esc ibed by psychia is ;
 Main medical diagnosis a discha ge;
 Numbe o BSP admissions in i e yea s p io o las admission in 2015;
 Numbe o BSP ou pa ien isi s in 6 mon hs p io o las BSP admission;
 Numbe o ED isi s o any eason in 6 mon hs p io o las BSP admission;
 Discha ge disposi ion;
 Re e al a discha ge.
60
Table 7. Clinical a iables, coding and analyses o ques ion 2
Resea ch ques ion 2: Wha a e he clinical cha ac e is ics o adul pa ien s admi ed o he
in-pa ien men al heal h se ice?
Va iable
Coding
Type o da a
Analysis
Re e al sou ce
0=sel / 1= amily o iend/ 2=police/
3=o he SEHA hospi al/ 4=o he
Nominal
F equencies and pe cen ages
Main psychia ic
diagnosis a
discha ge-
Da a will be en e ed di ec ly as
diagnos ic code and will be collapsed
in o he ollowing ca ego ies: 0=No
eco d/1=290–294/ 2=295/ 3=296/
4=297/ 5=298/ 6=299/ 7=300/ 8=301/
9=302/ 10=303–305/ 11=308/ 12=309/
13=312–316/ 14= 317–319/ 15= 311/
16=345 (as some imes en e ed as
p ima y psychia ic diagnosis in
sys em)/ 17=E958.9/ 18=307/ 19=306/
20=310
Nominal
F equencies and pe cen ages
Violence isk le el
0=low/1= medium/ 2=high
O dinal
F equencies and pe cen ages
Suicide isk le el
0=low/1= medium/ 2=high
O dinal
F equencies and pe cen ages
Res ain s: 24h s o
admission
0=no es ain / 1=chemical es ain
only/ 2=physical and chemical es ain
Nominal
F equencies and pe cen ages
ECT ecei ed du ing
admission
0=yes 1=no
Nominal
(dicho omous)
F equencies and pe cen ages
BSP: Leng h o s ay
In days
Nume ical (disc e e)
Desc ip i e s a is ics
(pa ame e s, dis ibu ions)
Discha ge
psycho opic
medica ions
As a name
Nume ical
Desc ip i e s a is ics
(pa ame e s, dis ibu ions)
Main medical
diagnosis a
discha ge
Da a will be en e ed di ec ly as
diagnos ic code and will be collapsed
in o he ollowing ca ego ies: 0= No
eco d/ 1=1-139/ 2=140-239/ 3=240-
279/ 4=280-289/ 5= 320-389/ 6=390-
459/ 7=460-519/ 8=520-579/ 9=580-
629/ 10=630-679/ 11= 680-709/ 12=
710-739/ 13=740-759/ 14=760-779/
15=800-999
Nominal
F equencies and pe cen ages
BSP admissions p io
o las 2015
admission
As a numbe coun (back o las
admission da e minus one s a ing om
2012 i.e. 3 yea s)
Nume ical
Desc ip i e s a is ics
(pa ame e s, dis ibu ions)
BSP ou pa ien isi s
in 6 mon hs p io o
las BSP admission
As a numbe coun
Nume ical
Desc ip i e s a is ics
(pa ame e s, dis ibu ions)
SEHA ED isi s in 6
mon hs p io o las
admission
As a numbe coun
Nume ical
Desc ip i e s a is ics
(pa ame e s, dis ibu ions)
61
Table 8. Clinical a iables, coding and analyses o ques ion 3
Resea ch ques ion 3: Wha a e he discha ge disposi ions and e e als o adul pa ien s
admi ed o he in-pa ien men al heal h se ice?
Va iable
Coding
Type o da a
Analysis
Discha ge disposi ion
0=No eco ded/ 1=Le Agains
Medical Ad ice/ 2=Ca e o sel /
3=Ca e o amily o gua dian/
4=SKMC’s ED/ 5=Ca e o police/
6=Ca e o sponso
Nominal
F equencies and pe cen ages
Re e al a discha ge
0=no appoin men o e e al named/
1=BSP psychia is / 2=Gene al
p ac i ione o p ima y heal h se ice/
3=P ison psychia is / 4=BSP day
cen e/ 5=BSP communi y RN/
6=Follow up in home coun y/
7=SKMC’s ED/ 8= ollow up no
applicable/ 9=Re used u he ca e/
10=Chemical Dependency OPC as
needed/ 11= BSP psychome is / 12=
BSP psychologis / 13=1+12
Nominal
F equencies and pe cen ages
2.3. P ocedu e and ime ame
2.3.1. Da a collec ion
Da a we e abs ac ed om each EHR and coded di ec ly in o a da a collec ion ool in
acco dance wi h he da a collec ion p o ocol. Psycho opic medica ions we e
collapsed in o classes (Appendix 7) while psychia ic diagnoses we e collapsed in o
diagnos ic ca ego ies (Appendix 8). The same esea che (JW) abs ac ed all da a. A
maximum o en iles we e abs ac ed pe day o e a pe iod o six weeks. This
p e en ed he esea che om de eloping an abs ac ion pa e n and po en ially
dec eased he possibili ies o e o s. Since da a abs ac ion was done by he
esea che , in a a e eliabili y was moni o ed. E e y en h case was checked
agains i sel on an ongoing basis a each double abs ac ion poin , making i was
possible o iden i y inconsis encies wi h assigned codes. Twen y-six a iables we e
selec ed which included binomial, o dinal and collapsed a iables (e.g. age as yea
62
collapsed in o age band). Because nominal a iables a e disc e e en i ies, hey a e
ei he 100% co ec ( eliable) o no because he ca ego ies a e exac ly alike and hus
o e all pe cen age ag eemen e lec s he deg ee o eliabili y. The app op ia e
measu e o in a a e eliabili y o nominal a iables is Cohen’s kappa coe icien
(Gwe , 2008). Each duplica e pai o da a was en e ed in o SPSS-20 in adjacen
columns and Cohen’s kappa calcula ed. The o e all pe cen age ag eemen be ween
en ies was 97.4% (see Appendix 4 o eliabili y o indi idual pai s).
Th ough his exe cise, he ollowing p oblems wi h codes we e iden i ied:
 Case 21: Va iable named “ e e al a discha ge”: iden i ied ha no
appoin men was p o ided a discha ge (code in oduced o co ec o his)
 Case 91: Va iable named “discha ge disposi ion”: iden i ied ha pa ien was
ans e ed a discha ge o e e ing hospi al (code in oduced o co ec o
his)
 Case 101: Va iable named “discha ge disposi ion”: iden i ied ha no
appoin men was p o ided a discha ge due o in en ion o cancel esidence
isa (code in oduced o e lec ha pe son would need o seek ollow-up
se ices in home coun y).
Building in hese checkpoin s allowed he esea che o iden i y disc epancies ( alues
less han 1.000) which could be examined and co ec ed in he da a cap u ing ool. The
alue o his exe cise is demons a ed in he example o case ile 91 whe e kappa was
0.837:
 o he 26 a iables assessed, he las was in e p e ed as ‘missing’ since i was
missing om he i s abs ac ion bu a ailable in he second;
69
a iables gende and na ionali y o suppo an unde s anding o se ice use
cha ac e is ics.
3.2.1. His o y o se ice use
Mos pa ien s had no been admi ed o BSP in he i e yea s p io o he index admission
(n= 195, 68.4%). O he 90 who we e admi ed in his pe iod, only one was admi ed o
bo h he Al Ain and BSP se ice. O all hose admi ed, 31 (34.4%) had one o wo
admissions.
The emaining i y-nine me he c i e ia o equen use s i.e. had a leas wo, exclusi e
o he index admission (mean numbe o admissions 4.3, SD=3.3, ange 2-18). Fi y-one
o he 59 had a leas wo admissions wi hin he h ee yea s p io o hei index admission.
Among Emi a is, who accoun ed o 125 (43.9%) o he o al numbe o admissions, 34
me he c i e ia o equen se ice use. Twen y-one o he 85 male Emi a is admi ed
(24.7%) ell in o his ca ego y, while 13 o he 40 emale Emi a is (32.5%) did. Fo y-
se en o he 90 eadmi ed pa ien s (52.2%) had been discha ged om he se ice wi hin
he p e ious six mon hs.
A mino i y o pa ien s used SEHA eme gency depa men s in he six mon hs p io o
admission (n= 107, 37.5%). These pa ien s had a mean o 3.4 isi s (SD=4.0, ange 1-23).

70
Table 10. His o y o se ice use o pa ien s admi ed o he in-pa ien se ice
P e ious admission o psychia ic se ice
Na ionali y
Gende
Male
Female
Ci izen o UAE
No
55 (19.2%)
21 (7.4%)
Yes, BSP only
6 (2.1%)
19 (6.7%)
To al
85 (29.8%)
40 (14.0%)
Ci izen o o he
coun y
No
83 (29.1%)
36 (12.63%)
Yes, BSP only
29 (10.12%)
11 (3.9%)
Yes, BSP & o he
1 (0.4%)
0 (0.0%)
To al
113 (39.6%)
47 (16.5%)
To al
198 (69.5%)
87 (30.5%)
F equency o use in las i e yea s (including index admission)
Na ionali y
Gende
Male
Female
Ci izen o UAE
Nil p e ious
55 (19.2%)
21 (7.4%)
1-2 admissions
9 (3.2%)
6 (2.1%)
3 o mo e
21 (7.4%)
13 (4.6%)
To al
85 (29.8%)
40 (14.0%)
Ci izen o o he
coun y
Nil p e ious
83 (29.1%)
36 (12.6%)
1-2 admissions
11 (3.9%)
5 (1.8%)
3 o mo e
19 (6.7%)
6 (2.1%)
To al
113 (39.6%)
47 (16.5%)
To al
198 (69.5%)
87 (30.5%)
Discha ge om psychia ic se ice wi hin p e ious six mon hs
Na ionali y
Gende
Male
Female
Ci izen o UAE
No
67 (23.5%)
28 (9.8%)
Yes, BSP only
18 (6.3%)
12 (4.2%)
To al
85 (29.8%)
40 (14.0%)
Ci izen o o he
coun y
No
100 (35.1%)
43 (15.1%)
Yes, BSP only
13 (4.6%)
4 (1.4%)
To al
113 (39.6%)
47 (16.5%)
To al
198 (69.5%)
87 (30.5%)
SEHA Eme gency Depa men p esen a ions wi hin p e ious six mon hs
Na ionali y
Gende
Male
Female
Ci izen o UAE
Nil
39 (13.7%)
20 (7.0%)
1-3
30 (10.5%)
16 (5.6%)
4 o mo e
16 (5.6%)
4 (1.4%)
To al
85 (29.8%)
40 (14.0%)
Ci izen o o he
coun y
Nil
89 (31.2%)
30 (10.5%)
1-3
18 (6.3%)
17 (6.0%)
4 o mo e
6 (2.1%)
0 (0.0%)
To al
113 (39.6%)
47 (16.5%)
To al
198 (69.5%)
87 (30.5%)
71
3.2.2. Access o an admission uni :
Mos commonly, pa ien s we e b ough o assessmen by iends, amily and colleagues
(n=131, 46.0%). O e all, he second mos common e e al sou ce was he police (n=74,
26%). Howe e , his was he mos common ou e by which Emi a i males accessed he
se ice. Twen y-se en pa ien s (9.5%) p esen ed on hei own seeking help (ele en o
whom we e diagnosed wi h Mood [a ec i e] diso de s, eigh wi h Men al & beha iou al
diso de s due o psychoac i e subs ance, se en wi h Neu o ic, s ess- ela ed and
soma o o m diso de s and one wi h Schizoph enia, schizo ypal and delusional diso de s).
Access o an admission bed was p ima ily h ough SKMC’s eme gency depa men (n=
195, 68.4%) o h ough SEHA’s acu e hospi al liaison se ice (n=42, 14.7%). Among
Emi a i emales and expa ia e males and emales, admissions h ough ED as a
pe cen age o o al admissions we e 70.0%, 74.3% and 76.6% espec i ely. Only 55.3%
o Emi a i males we e admi ed ia ED. An addi ional 24.7% we e admi ed as a esul o
a cou o de (one wi h a diagnosis o Delusional diso de , one wi h Alcohol dependence
synd ome, eigh wi h D ug dependence and 11 wi h Nondependen abuse o d ugs).
The ini ial assessmen by he psychia is includes a ool o documen psychia ic isk.
Iden i ying isk ac o s gene a es isk sco es o guide he decision o admi . Agg ession/
iolence isk was no eco ded o 101 (35.4%) pa ien s while suicide/ sel -ha m isk was
no eco ded o 108 (37.9%) pa ien s. Fo 14 pa ien s (13.9%) his was indica ed by he
psychia is as due o he pa ien ’s condi ion.
72
Table 11:. Re e al sou ce, access and psychia ic isk o pa ien s admi ed o he in-pa ien se ice
Re e al sou ce
Na ionali y
Gende
Male
Female
Ci izen o UAE
Sel
9 (3.2%)
5 (1.8%)
Family/ iend/ colleague
28 (9.8%)
18 (6.3%)
P osecu o / cou o de
36 (12.6%)
5 (1.8%)
SEHA, no SKMC (Liaison)
4 (1.4%)
5 (1.8%)
SKMC (Liaison)
5 (1.8%)
5 (1.8%)
O he hospi al (no SEHA)
3 (1.1%)
1 (0.4%)
Ai po police
0 (0.0%)
0 (0.0%)
O he
0 (0.0%)
1 (0.4%)
To al
85 (29.8%)
40 (14.0%)
Ci izen o o he
coun y
Sel
6 (2.1%)
7 (2.5%)
Family/ iend/ colleague
64 (22.5%)
21 (7.4%)
P osecu o / cou o de
22 (7.7%)
11 (3.9%)
SEHA, no SKMC (Liaison)
11 (3.9%)
2 (0.7%)
SKMC (Liaison)
5 (1.8%)
3 (1.1%)
O he hospi al (no SEHA)
1 (0.4%)
2 (0.7%)
Ai po police
4 (1.4%)
1 (0.4%)
O he
0 (0.0%)
0 (0.0%)
To al
113 (39.6%)
47 (16.5%)
To al
198 (69.5%)
87 (30.5%)
Admission poin o depa u e
Na ionali y
Gende
Male
Female
Ci izen o UAE
ED
47 (16.5%)
28 (9.8%)
BSP clinic, booked
2 (0.7%)
0 (0.0%)
BSP clinic, walk-in
7 (2.5%)
2 (0.7%)
SEHA (Liaison, SKMC)
8 (2.8%)
10 (3.5%)
F om cou / jail
21 (7.4%)
0 (0.0%)
To al
85 (29.8%)
40 (14.0%)
Ci izen o o he
coun y
ED
84 (29.5%)
36 (12.6%)
BSP clinic, booked
3 (1.1%)
2 (0.7%)
BSP clinic, walk-in
8 (2.8%)
3 (1.1%)
SEHA (Liaison, SKMC)
18 (6.3%)
6 (2.1%)
F om cou / jail
0 (0.0%)
0 (0.0%)
To al
113 (39.6%)
47 (16.5%)
To al
198 (69.5%)
87 (30.5%)
Psychia ic isk on ini ial assessmen : Agg ession/ iolence
Na ionali y
Gende
Male
Female
Ci izen o UAE
No eco d
30 (10.5%)
16 (5.6%)
Pa ien condi ion p e en s
3 (1.1%)
1 (0.4%)
Low
43 (15.1%)
19 (6.7%)
Medium
7 (2.5%)
3 (1.1%)
High
2 (0.7%)
1 (0.4%)
To al
85 (29.8%)
40 (14.0%)
Ci izen o o he
coun y
No eco d
39 (13.7%)
16 (5.6%)
Pa ien condi ion p e en s
6 (2.1%)
4 (1.4%)
Low
64 (22.5%)
26 (9.1%)
Medium
2 (0.7%)
1 (0.4%)
High
2 (0.7%)
0 (0.0%)
To al
113 (39.6%)
47 (16.5%)
To al
198 (69.5%)
87 (30.5%)
73
Table 11 (con inued): Re e al sou ce, access and psychia ic isk o pa ien s admi ed o he in-
pa ien se ice
Psychia ic isk on ini ial assessmen : Suicide
Na ionali y
Gende
Male
Female
Ci izen o UAE
No eco d
32 (11.2%)
16 (5.6%)
Pa ien condi ion p e en s
3 (1.1%)
1 (0.4%)
Low
48 (16.8%)
17 (6.0%)
Medium
2 (0.7%)
5 (1.8%)
High
0 (0.0%)
1 (0.4%)
To al
85 (29.8%)
40 (14.0%)
Ci izen o o he
coun y
No eco d
43 (15.1%)
17 (6.0%)
Pa ien condi ion p e en s
6 (2.1%)
4 (1.4%)
Low
54 (18.9%)
23 (8.1%)
Medium
8 (2.8%)
3 (1.1%)
High
2 (0.7%)
0 (0.0%)
To al
113 (39.6%)
47 (16.5%)
To al
198 (69.5%)
87 (30.5%)
3.2.3. Cou se o in-pa ien s ay
Pa ien s had a mean leng h o s ay o 16.1 days (SD=18.1), anging om less han one
ull day o 103 days. Wi hin 24 hou s o admission in o he se ice, 34 pa ien s (11.9%)
we e es ained- 20 wi h a combina ion o chemical and physical, hi een only
chemically, and one only physically (Table 12).
Mood [a ec i e] diso de s (n= 84, 29.5%), Schizoph enia, schizo ypal and delusional
diso de s (n= 71, 24.9%), Men al and beha iou al diso de s due o psychoac i e
subs ances (n=43, 15.1%), Beha iou al and emo ional diso de s wi h onse usually
occu ing in childhood and adolescence (n=30, 10.5%) and Neu o ic, s ess- ela ed and
soma o o m diso de s (n= 25, 8.8%) we e he mos common discha ge psychia ic
diagnoses, collec i ely accoun ing o 88.8% o diagnoses (Figu e 5).
74
Figu e 5. Psychia ic diagnoses by na ionali y and gende
Among hose wi h Mood [A ec i e] diso de s, he majo i y (n=69, 82.1%) we e
diagnosed wi h Episodic Mood Diso de . O he 43 pa ien s diagnosed wi h subs ance-
ela ed diso de s, he majo i y (86%) we e diagnosed wi h d ug- ela ed diso de s while
six had a diagnosis ela ed o alcohol misuse.
Six pa ien s wi h diagnoses indica i e o men al e a da ion we e all younge han 30
yea s (mean age 24.2 yea s, SD=3.7, ange 19-29) and i e had seconda y psychia ic
diagnoses (one wi h Schizoph enic diso de , wo wi h O he nono ganic psychoses, one
wi h Anxie y, dissocia i e and soma o o m diso de s and one wi h Dis u bance o
conduc no elsewhe e classi ied).
Fo y-six pa ien s we e no discha ged on medica ion o hei psychia ic condi ion. The
majo i y (n= 239, 83.9%) ecei ed be ween one and six psycho opic medica ions.
Mood
[a ec i e]
diso de s
Schizoph enia
, schizo ypal
and
delusional
diso de s
Men al &
beha iou al
diso de s due
o
psychoac i e
subs ance
Beha iou al
and
emo ional
diso de s wi h
onse usually
occu ing in
childhood &
adolescence
Neu o ic,
s ess- ela ed
and
soma o o m
diso de s
UAE male
18.8
17.6
48.2
3.5
4.7
UAE emale
45
22.5
2.5
2.5
17.5
O he coun y male
29.2
32.7
0.9
15.9
8.9
O he coun y emale
36.2
21.3
0
17
8.5
0
10
20
30
40
50
diagnosis as % o all diagnoses
UAE male
UAE emale
O he coun y male
O he coun y emale

75
Medica ions a e desc ibed agains he discha ge diagnos ic ca ego ies in Appendix 6. A
mino i y o pa ien s (n=11, 3.9%) ecei ed ECT. All ele en we e discha ged on a leas
one psycho opic medica ion.
The majo i y o pa ien s had no co-mo bid medical diagnoses (n=196, 68.8%). Twen y-
h ee pa ien s (7%) we e admi ed wi h a diagnosis o Suicide and sel -in lic ed beha io
(ICD 9 code E958.9). The mos common medical diagnoses a discha ge we e Endoc ine,
nu i ional and me abolic diseases and immuni y diso de s (n=20, 7.0%) and Diseases o
he ci cula o y sys em (n= 20, 7.0%), while six pa ien s (2.1%) had diagnoses ca ego ized
as Inju y and poisoning and a u he six (2.1%) had a combina ion o speci ic diagnoses
o diabe es co-mo bid wi h a ca diac diso de .
76
Table 12: Res ain use, diagnoses and ea men o pa ien s admi ed o he in-pa ien se ice
Res ain s used in i s 24 hou s o admission
Na ionali y
Gende
Male
Female
Ci izen o UAE
No es ain
78 (23.4%)
36 (12.6%)
Chemical es ain only
0 (0.0%)
2 (0.7%)
Physical & chemical
es ain
7 (2.5%)
2 (0.7%)
Physical es ain only
0 (0.0%)
0 (0.0%)
To al
85 (29.8%)
40 (14.0%)
Ci izen o o he
coun y
No es ain
94 (33.0%)
43 (15.1%)
Chemical es ain only
7 (2.5%)
4 (1.4%)
Physical & chemical
es ain
11 (3.9%)
0 (0.0%)
Physical es ain only
1 (0.4%)
0 (0.0%)
To al
113 (39.6%)
47 (16.5%)
To al
198 (69.5%)
87 (30.5%)
Main psychia ic diagnosis a discha ge
Na ionali y
Gende
Male
Female
Ci izen o UAE
Schizoph enia, schizo ypal
and delusional diso de s
15 (5.3%)
9 (3.2%)
Mood [a ec i e] diso de s
16 (5.6%)
18 (6.3%)
Men al & beha iou al
diso de s due o
psychoac i e subs ance
41 (14.4%)
1 (0.4%)
Beha iou al & emo ional
diso de s wi h onse usually
occu ing in childhood &
adolescence
3 (1.1%)
1 (0.4%)
Neu o ic, s ess- ela ed and
soma o o m diso de s
4 (1.4%)
7 (2.5%)
To al
79 (27.7%)
36 (12.6%)
Ci izen o o he
coun y
Schizoph enia, schizo ypal
and delusional diso de s
37 (13.0%)
10 (3.5%)
Mood [a ec i e] diso de s
33 (11.6%)
17 (6.0%)
Men al & beha iou al
diso de s due o
psychoac i e subs ance
1 (0.4%)
0 (0.0%)
Beha iou al & emo ional
diso de s wi h onse usually
occu ing in childhood &
adolescence
18 (6.3%)
8 (2.8%)
Neu o ic, s ess- ela ed and
soma o o m diso de s
10 (3.5%)
4 (1.4%)
To al
99 (34.7%)
39 (13.7%)
To al
178 (62.5%)
75 (26.3%)
77
Table 12 (con inued): Res ain use, diagnoses and ea men o pa ien s admi ed o he in-pa ien
se ice
Psycho opic medica ion a discha ge: d ug coun
Na ionali y
Gende
Male
Female
Ci izen o UAE
Nil p esc ibed
30 (10.5%)
5 (1.8%)
one d ug
18 (6.3%)
10 (3.5%)
wo d ugs
16 (5.6%)
11 (3.9%)
h ee d ugs
10 (3.5%)
10 (3.5%)
ou d ugs
10 (3.5%)
3 (1.1%)
i e d ugs
0 (0.0%)
0 (0.0%)
six d ugs
1 (0.4%)
1 (0.4%)
To al
85 (29.8%)
40 (14.0%)
Ci izen o o he
coun y
Nil p esc ibed
5 (1.8%)
6 (2.1%)
one d ug
31 (10.9%)
12 (4.2%)
wo d ugs
41 (14.4%)
15 (5.3%)
h ee d ugs
23 (8.1%)
12 (4.2%)
ou d ugs
12 (4.2%)
2 (0.7%)
i e d ugs
1 (0.4%)
0 (0.0%)
six d ugs
0 (0.0%)
0 (0.0%)
To al
113 (39.6%)
47 (16.5%)
To al
198 (69.5%)
87 (30.5%)
Elec ocon ulsi e he apy adminis e ed
Na ionali y
Gende
Male
Female
Ci izen o UAE
No
83 (29.1%)
38 (13.3%)
Yes
2 (0.7%)
2 (0.7%)
To al
85 (29.8%)
40 (14.0%)
Ci izen o o he
coun y
No
109 (38.2%)
44 (15.4%)
Yes
4 (1.4%)
3 (1.1%)
To al
113 (39.6%)
47 (16.5%)
To al
198 (69.5%)
87 (30.5%)
Main medical diagnosis a discha ge (mos common)
Na ionali y
Gende
Male
Female
Ci izen o UAE
Endoc ine, nu i ional &
me abolic diseases &
immuni y diso de s
4 (1.4%)
9 (3.2%)
Diseases o he ci cula o y
sys em
4 (1.4%)
1 (0.4%)
Diabe es and a ca diac
diso de
4 (1.4%)
2 (0.7%)
Inju y and poisoning
2 (0.7%)
1 (0.4%)
To al
14 (4.9%)
13 (4.6%)
Ci izen o o he
coun y
Endoc ine, nu i ional &
me abolic diseases &
immuni y diso de s
6 (2.1%)
1 (0.4%)
Diseases o he ci cula o y
sys em
7 (2.5%)
3 (1.1%)
Diabe es and a ca diac
diso de
0 (0.0%)
0 (0.0%)
Inju y and poisoning
2 (0.7%)
1 (0.4%)
To al
15 (5.3%)
5 (1.8%)
To al
29 (10.2%)
18 6.3%)
78
3.3. Discha ge om in-pa ien se ice
Mos pa ien s we e discha ged in o he ca e o hei amily/ gua dian (n= 93, 32.9%) o
he police (n= 72, 25.3%). Fo y-se en (16.5%) le agains medical ad ice. Among he
259 pa ien s wi h a discha ge plan, 145 (56.0%) we e e e ed o a BSP psychia is as
opposed o h ee (1.2%) who we e e e ed o a amily doc o and a u he h ee (1.2%)
o a BSP psychologis . O he 146 expa ia es wi h documen ed plans indica ing a need
o men al heal h se ice ollow-up, app oxima ely one hi d (n=51, 34.9%) we e no ed o
be e u ning o hei own coun y. All o hese pa ien s we e discha ged on psycho opic
medica ion.
O he 154 pa ien s who ecei ed a ollow-up appoin men s a BSP, i y-six o he
se en y-se en Emi a is (74.5% o males and 70.0% o emales) kep hese. Among he
se en y-se en ci izens o o he coun ies simila ly accommoda ed, 65.4% o males and
76.0% o emales kep hei ollow-up appoin men s (Table 13). Wi hin he cu en
sys em i is no possible o iden i y he easons why pa ien s we e los o ollow-up.
85
powe ul male ela i e may ha e been able o o ce compliance by a less powe ul
emale) o he na u e o ac o s p ecipi a ing admission (e.g. dep ession a he han
subs ance wi hd awal).
4.2.2.2. Admission poin o depa u e
Mos pa ien s accessed he psychia ic se ice ia he eme gency depa men (68.4%).
They we e, mos commonly, discha ged wi h a diagnosis in he g oup Schizoph enia,
schizo ypal and delusional diso de s (n=108, 55.3%) and Beha io al and emo ional
diso de s wi h onse usually occu ing in childhood and adolescence (n=23, 11.8%). Only
nine pa ien s (4.6%) wi h a diagnosis o dep ession we e admi ed ia ED. This di e s
om ha epo ed by Downey e al (2009) who ound ha he ou mos common
diagnoses o hose using an Ame ican ED we e dep ession (25%), pe sonali y diso de
(20%), bipola diso de (15%) and schizoph enia (13%).
Gi en how se ice deli e y models di e be ween coun ies, compa ison o diagnoses
may be o li le alue. Ra he , one migh e lec on why he ED is used as a poin o
access o psychia ic se ices since pa ien s wi h men al diso de s p esen o he
eme gency depa men o mo e han jus admission o men al diso de s. Reasons
include c isis managemen o men al diso de s, physical condi ions (Mo phe e al, 2012)
and gene al managemen o men al diso de s whe e exis ing se ices do no mee hei
needs (S one e al, 2011). Downey e al (2009) ound ha mos pa ien s epo ed using
he se ice because hey pe cei ed i o be a mo e accessible way o ecei ing ca e. In he
Middle Eas , K on ol (2012) iden i ied ha eme gency se ices a e used by many i hey

86
a e p ima y ca e acili ies. This he asc ibes o access being ba ed o hose se ices o
easons ha include limi ed opening imes o p ima y ca e se ices, inadequa e anspo
se ices and una ailabili y o ca e o dependen s du ing hei ope a ing hou s.
Taken oge he , hese ac o s migh simila ly explain he use o SKMC’s eme gency
depa men by pa ien s and hei amilies, especially since he hospi al’s ca e s anda d
equi es ha pa ien s in he eme gency depa men ecei e a psychia ic consul a ion
wi hin wo hou s o he e e al being submi ed. Because his e e al is gene a ed as a
“c isis consul a ion o a sca ce se ice”, he implica ion is ha he hospi al will abso b
he consul a ion cos i he pa ien ’s medical insu ance does no co e psychia ic
se ices.
4.2.2.3.Psychia ic isk assessmen
This s udy ound ha agg ession/ iolence isk was assessed as “low” o 152 (53.3%)
pa ien s and no documen ed o a u he 101 (35.4%) pa ien s. Suicide/ sel -ha m isk
was assessed as “low” o 142 (49.8%) o pa ien s and no eco ded o 108 (37.9%)
pa ien s. This inding mus be conside ed agains an unde s anding o he na u e and ole
o clinical isk assessmen in psychia y. I can be concep ualized as consis ing o in e -
linked aspec s including isks o iolence/ agg ession, suicide/ sel -ha m, elapse o
men al illness, sel -neglec and ecidi ism i.e. mee ing c i e ia o he e ol ing doo
phenomenon (Woods, 2013).
In he ini ial pe iod o c isis when he pa ien engages wi h a psychia ic se ice, i is
os ensibly he ini ial wo isks which a e he ocus o clinical in e es . The aim o a
psychia ic assessmen se es ul ima ely o guide he clinician o e ec i ely manage isk,
87
including h ough he use o admission o a secu e uni un il he isk is such ha he
pe son may be sa ely discha ged. As a icula ed by S owell e al (2012), assessing he
po en ial o isk in he eme gency se ing is essen ial o de elop an app op ia e
disposi ion plan.
Wi hin he ini ial 24 hou s o admission o SKMC and hus BSP, psychia ic isk
assessmen is ocused on he isks o agg ession/ iolence and suicide/ sel -ha m. An
o ganiza ional equi emen is ha all pa ien s a e sc eened o isk, including hose
deemed o be ulne able o a high isk like pa ien s wi h con i med o suspec ed men al
and/ o subs ance use diso de s (SKMC policy, 2016). Speci ically, o hose pa ien s
admi ed o BSP, a posi i e isk sc een mus esul in a comp ehensi e isk assessmen
conduc ed by he psychia is as pa o he ini ial assessmen p io o admission (BSP
policy, 2016).
Implied in hese SKMC policies, and by he p esence o isk assessmen ools o bo h
agg ession/ iolence and suicide/ sel -ha m in he EMR’s ini ial psychia ic assessmen ,
is ha isk assessmen upon en y in o he SKMC se ice is concep ualized as ha ing
bo h an ac ua ial and a s uc u ed clinical judgemen componen . By in e ence, hose
esponsible o assessing pa ien s and making decisions o admi o he psychia ic se ice
a e no only compe en o conduc he ac ua ial pa o he assessmen , bu su icien ly
skilled o apply clinical judgemen o he decision-making p ocess.
I may be ha hese isk assessmen s we e conduc ed bu no documen ed and his gap
e lec s an o e all p oblem wi h documen a ion by psychia is s. I may also be ha
because isk was no ound i was no documen ed. Bu i may as likely indica e ha no
isk assessmen was conduc ed which aises he ques ion o why pa ien s we e admi ed
88
o he psychia ic se ice. I should be no ed ha admission decisions ou side o he ED
a e made by specialis and consul an psychia is s. Howe e , a h ee- ie sys em is
employed in he ED whe e he ini ial assessmen is conduc ed by a junio doc o . I
desi ed, a elephonic consul a ion is ini ia ed wi h he on-call specialis who may escala e
his o he on-call consul an psychia is .
This s udy did no aim o speci ically examine ac o s associa ed wi h pa ien s admi ed
ia ED, no does i cas e any ligh on hose pa ien s assessed in ED who we e assessed
and discha ged. While he e may be no di e ence be ween isk assessmen done by hose
in ED o ia o he se ice access poin s in e ms o p opo ion, he shee numbe s o
pa ien s using ED as a poin o men al heal h se ice access aises conce n as his
ep esen s a much la ge numbe o ac ual pa ien s. The ac ha hese gaps we e ound o
exis a all is o conce n since hese pa ien s a e being assessed by ela i ely junio and
possibly less expe ienced clinicians who may no be bes equipped o make c i ical
decisions d awing hea ily on clinical judgemen , a skill ha de elops o e ime (Woods,
2013).
4.2.3. S ay in in-pa ien se ice
4.2.3.1.Res ain
This s udy ound ha , wi hin he ini ial 24 hou s o admission, 34 (11.9%) pa ien s we e
es ained a leas once. O hese, 21 pa ien s we e es ained physically wi h hea y-du y
can as es ain s. Gi en he di e ences in de ini ions used in s udies on he use o
psychia ic es ain s epo ed in he li e a u e as well as he di e en en i onmen s and
pe iods o e which e en s we e measu ed, one is unable o de e mine a meaning ul
e e ence agains which o compa e his inding.
89
A ecen e iew o he li e a u e published be ween 1990 and 2010 examined he
p e alence o es ain use ac oss coun ies and ound he p e alence o es ain use in
acu e psychia ic se ices o be 6-17%, wi h s udies epo ed om he USA, UK,
Aus alia, Ge many, Finland, Swi ze land, No way and Japan (Beghi e al, 2013). Mind
(2013), epo ing on he si ua ion in hospi als in he UK, indica ed as ly di e en use o
es ain s ac oss he coun y ( om 38 o 3346 epo ed es ain e en s). In he eme gency
se ing, Simpson e al, (2014) epo ed a p e alence o 14% in he USA (8-24%) while in
Aus alia Kno e al, (2007) epo ed i s p e alence a 4.1% in Vic o ian EDs as opposed
o 0.04% in Adelaide epo ed by Ge ace e al (2014).
I is wo h e lec ing on he use o es ain as a ool used by men al heal h clinicians,
especially gi en he his o y o iola ion o human igh s o pa ien s wi h men al diso de s
in psychia ic hospi als. The p o essional p ac ice o heal h ca e se ice p o ide s in Abu
Dhabi and hus in BSP is amed by hei p o essions’ e hical p inciples. This would be
consis en wi h he medical e hical impe a i es o au onomy, non-male icence and
clinical bene icence. In BSP, as in SKMC, w i en gene al consen o ea men is
equi ed p io o any se ices being deli e ed. T ea men is deli e ed by he app op ia e
licensed heal h ca e p o ide . In o med consen is one sa egua d employed in heal h
se ices o suppo e hical p ac ice. In i s simples o m, i is he culmina ion o a p ocess
in which a designa ed heal h p o essional explici ly p o ides he pa ien wi h adequa e
accu a e in o ma ion abou a clinical ac ion o plan upon which he pa ien is able o
make a decision o whe he o accep he p oposed ac ion o no . I implies ull disclosu e
o in o ma ion, olun a y choice and equal powe be ween he pa ies (Ame , 2013).
90
Gi en ha es ain is allowed wi hin bo h SKMC and BSP, consen ing o admission and
ea men implies consen ing o being es ained. In BSP and SKMC’s ED, es ain may
ake he o m o chemical o physical ( hick can as s aps applied o he w is s, ankles
and wais ) es ain o bo h o in ol e, in BSP, seclusion in a locked, pu pose-buil oom.
Tha es ain and seclusion mus be p esc ibed by a psychia is implies ha hese
p ac ices a e deemed o ha e he apeu ic alue.
In BSP, chemical and physical es ain is conside ed a s a egy o manage psychia ic
isk (BSP policy, 2015). I is hus easonable o suppose ha , like admission in o a locked
psychia ic wa d, i is linked o he ini ial assessmen o isk. Tha i is used so equen ly
may hus simila ly be an indica ion o he le el o clinical compe ence o ela i ely junio
s a who ac as ga ekeepe s o he acu e psychia ic se ice and/ o he a i udes o some
heal h ca e p o ide s wo king in BSP.
Howe e , an addi ional explana ion sugges s i sel when one conside s when and how
pa ien s access he se ice. Wi hin a con ex whe e police a e o -used o acili a e
engagemen wi h he se ice, le els o s igma owa ds hose wi h men al diso de s a e
high and explana o y models place he causes o men al illness ou side a biopsychosocial
amewo k, i is possible ha he pa ien ’s beha io , a he han an unde s anding by
signi ican o he s ha hey a e seeing he symp oms o a men al diso de , is he d i e
behind p esen a ion o he psychia ic se ice.
In his ins ance, ea ly in e en ion, i any, was likely deli e ed in he communi y by
p o ide s ou side o he o mal heal hca e se ice. Wi h hese se ices unable o manage
he se iousness o he beha io , labeled in SKMC as psychia ic isk, he pe son was
b ough in o con ac wi h he psychia ic se ice because he isk o ha m o sel o o he s

91
was pe cei ed o be g ea e han any social ba ie s o accessing ca e. Thus, i may be ha
many pa ien s a e p esen ing o he se ice wi h a deg ee o beha io beyond which can
be sa ely managed in he communi y.
Conside ing he in e na ional li e a u e, his is highly con en ious p ac ice (Beghi e al,
2013; Ge ace e al, 2014; Helle s ein e al, 2007; Knox & Holloman, 2012; Raguan e al,
2015; Recupe o e al, 2011; Sailas & Wahlbeck, 2005; Simpson e al, 2014). The e is a
high isk o physical and psychological ha m o pa ien s (Ge ace e al, 2014; Lazzino e
al, 2013; Mind, 2013; Recupe o e al, 2011) and s a (Holloman & Sco , 2012; Lazzino
e al., 2015). Pa ien s subjec ed o physical es ain epo ea o heal h ca e p o ide s
(Moh e al, 2004) and auma ic expe iences wi h se e e dis ess (Holloman & Sco ,
2012; Mind, 2013). As a back as 1997, he Eu opean Commi ee o he P e en ion o
To u e and Inhuman o Deg ading T ea men o Punishmen (CPT, 1997) ound i o be
“ a ely jus i ied” and indica ed ha i used a all, should be manual only as opposed o
he use o ins umen s like s aps. Despi e his, i emains a ea u e in many psychia ic
se ices a ound he wo ld.
4.2.3.2. Diagnoses
4.2.3.2.1. Se ious men al diso de s (Mood [a ec i e] diso de s and Schizoph enia,
schizo ypal and delusional diso de s)
As an icipa ed, mos pa ien s in his s udy had ICD-9 diagnoses indica i e o a se ious
psychia ic diso de . Mos common we e Mood diso de s (n=84, 29.5%) and diagnoses
indica i e o psychosis (n=71, 24.9%). When one discoun s he sub-g oup o pa ien s
wi h subs ance use diso de s who is almos exclusi ely Emi a i males, hese condi ions
92
we e he mos common ac oss bo h gende s and among Emi a is as well as ci izens o
o he coun ies.
O he 84 pa ien s wi h a mood diso de diagnosis, 69 (82.1%) we e diagnosed wi h
Episodic mood diso de s. This inding is simila o ha epo ed om a na ional I alian
coho by Balle ini e al (2007) who ound mos commonly, ha pa ien s wi h i s
admissions o acu e psychia ic hospi al uni s had discha ge diagnoses consis en wi h
psychoses, mood o subs ance use diso de s. In he Uni ed Kingdom, Thompson e al
(2004) ound ha dep ession wi h anxie y was he mos common diagnos ic combina ion,
ahead o schizoph enia and ela ed psychoses and subs ance misuse.
S udies om wi hin he Middle Eas e lec simila esul s. In Saudi A abia, AbuMadin
and Rahim (2002), in hei examina ion o clinical eco ds o 1366 pa ien s o e 10 yea s
admi ed o psychia ic se ices in gene al hospi als, ound ha 20% we e diagnosed wi h
schizoph enia, 10% wi h bipola diso de and 10%, mos ly emale, wi h majo
dep ession. In Sudan (WHO, 2009 in Sha aheeli e al, 2015), mos equen ly he
psychia ic diagnoses o hose admi ed o psychia ic se ices was Mood diso de s
(22%), Schizoph enia (15%) and Subs ance abuse (10%). Gi en ha dep ession may, like
schizoph enia, ollows a ch onic disease cou se (Kessle and B ome , 2013), i mus be
conside ed ha hose wi h se ious men al diso de s and hus will po en ially need se ices
ac oss he li e-span.
4.2.3.2.2. Subs ance use diso de s
Subs ance use diso de s, wi h only wo excep ions, was exclusi ely diagnosed among
Emi a i males. Among his g oup i was he single mos common g oup o diagnoses
93
(48.2%), compa ed o Mood diso de s (18.8%) and Schizoph enia, schizo ypal and
delusional diso de s (17.6%). Only one Emi a i woman had a subs ance use diso de
diagnosis.
This appea s o ollow a simila pa e n o Saudi A abian whe e, in 2012, male pa ien s
admi ed o Minis y o Heal h men al hospi als in Saudi A abia we e mos commonly
diagnosed wi h Subs ance abuse (28%) and Schizoph enia (14%). Sha aheeli e al (2015)
in hei e ospec i e EMR e iew o 1777 pa ien s admi ed o he Alamal Hospi al in
Riyadh, a psychia ic and addic ion hospi al, iden i ied ha 83.5% had a diagnosed
subs ance use diso de , 6.9% had schizoph enia and 4.8% had bipola diso de . Mos
commonly, hose wi h subs ance use diso de s we e aged 21-30 yea s, 99% we e male
and 98% we e Saudi na ionals.
The 41 male Emi a i pa ien s in his s udy anged in age om 18-53 yea s and had a
mean age o 29.73 yea s (SD +-9.6) making hem younge han ha epo ed in he NRC
coho who had a mean age o 32.4 yea s (Elkashe e al, 2013). Unlike he 41.3% o
NRC pa ien s who used mainly alcohol, only 12.2% we e diagnosed wi h alcohol
dependence, as opposed o 36.6% wi h d ug dependence and 51.2% wi h nondependen
abuse o d ugs. This may be indica i e o he si ua ion desc ibed by Alblooshi e al
(2016) whe e hose younge han 30 yea s we e mo e likely o use pha maceu ical
opioids like T amadol and p esc ip ion medica ion o non-medical use like P egabalin
and P ocyclidine. Six y h ee pe cen o he BSP pa ien s we e discha ged on no
psycho opic medica ion which is simila o he 70% epo ed by Elkashe e al (2013).
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4.2.3.2.3. In ellec ual disabili y
A sub-g oup o ou een pa ien s’ bea s men ioning, gi en ha hey a e likely o need
li e-long, specialized se ices o complex needs, despi e cons i u ing only 4.9% o he
o al sample. Six o hese pa ien s we e diagnosed wi h men al e a da ion ( i e had a
como bid psychia ic diagnosis) and a u he eigh pa ien s we e diagnosed wi h speci ic
nonpsycho ic men al diso de s due o b ain damage (none o whom had como bid
psychia ic diagnoses. Twel e we e aged 18 o 29 and he oldes was 49 yea s. Despi e
he absence o diagnosed psychia ic diso de s, hi een we e discha ged on psycho opic
medica ion (six on mono he apy, ou on wo medica ions, wo on h ee and one on ou ).
None we e e e ed o a psychologis a discha ge.
In he egion, G ey e al, (2015) no ed ha li le in o ma ion is a ailable on he use o
psychia ic se ices by hose who a e in ellec ually disabled. In hei examina ion o he
eco ds o 537 pa ien s using a psychia ic se ice in Bah ain, hey iden i ied ha he
p inciple eason o pa ien s making con ac wi h he se ice was dis u bed beha io .
They oo ound ha he ea men o choice was pha macological wi h no e e al made
o psychological o beha iou al in e en ions. Despi e 64% o pa ien s being p esc ibed
psycho opic medica ion, 90% had no psychia ic diagnosis, leading he esea che s o
sugges ha i would be help ul o examine A ab psychia is s’ a i udes and
unde s anding o he causes and in e en ions app op ia e o pe sons wi h in ellec ual
disabili y.
101
This s udy did no seek o desc ibe he le el o isk assessed as pa o he discha ge
decision o men al capaci y o he pa ien assessed a discha ge. Un il ecen ly, UAE law
and egula o y equi emen s ceded au ho i y o e a pa ien o a emale o he sponso o
male ela i e, hampe ing a emp s by clinicians o in e cede on behal o pa ien s o
engage police in suppo ing pa ien s a high psychia ic isk om disengaging wi h
men al heal h se ices.
Recen changes in UAE law p e en s a pa ien o legal gua dian om discon inuing an
in-pa ien hospi al admission agains medical ad ice unless a isk and capaci y
assessmen has de e mined ha psychia ic isk is low. I he pa ien , i espec i e o
gende , and gua dian ha e a di e ence o opinion, he pa ien ’s decision holds sway i
she o he is de e mined o be capable and he psychia ic isk is low. HAAD has
subsequen ly changed i s consen guidelines in line wi h his and endo sed he shi ing o
powe o consen om a senio male amily membe o spouse o he pa ien (i ma ied
o olde han 18 yea s, i espec i e o gende ) unless capaci y is comp omised (Elsheik,
2017).
4.3.2. Follow-up pos discha ge
O he 154 pa ien s wi h plans a discha ge indica ing he need o u he psychia ic
se ices, 145 (94.2%) pa ien s we e scheduled o ollow-up wi h a BSP psychia is . One
hund ed and nine y (71.5%) pa ien s kep hei ou -pa ien appoin men s. Male ci izens o
o he coun ies we e los o ollow-up 34.6% o he ime as opposed o 24% o emale
ci izens o o he coun ies, 25.5% o Emi a i males and 30% o Emi a i emales.

102
Gi en he absence o any local longi udinal s udies examining wha happens o pa ien s
pos discha ge, one possible explana ion is ha he emales a e sponso ed by hei male
ela ions and so s ay in he coun y, while some males a e epa ia ed upon discha ge. A
u he explana ion is ha males emain in he coun y, bu ail o s ay in ol ed wi h he
se ice. I his is he case, some possible explana ions a e ha hei needs a e no
consis en wi h he se ices o e ed, ha hey deny he exis ence o he need o ollow-
up, ha hey conceal hei need o ollow-up in a bid o s ay in hei employmen o ha
hey do no con inue wi h hei medica ion and hus do no need a u he p esc ip ion.
Reasons o ailu e o main ain con ac wi h a se ice a e likely o be as a iable as he
pa ien s hemsel es. Ce ainly, o pa ien s wi h schizoph enia, Cheng e al, (2014)
de e mined ha he e was an associa ion wi h male gende , misuse o a leas one
subs ance, being p esc ibed an a ypical an ipsycho ic and e mina ing hospi aliza ion
agains medical ad ice. Ou -pa ien a endance pos discha ge has a demons able
posi i e impac on pa ien ou comes, no ably by educing hospi al eadmission and
suicide incidence (Nelson e al (2000) in P ei e e al, 2012). Howe e , no signi ican
impac was demons a ed when his engagemen was wi hin se en days o discha ge
(P ei e e al, 2012).
One hund ed and i y-eigh pa ien s o he 160 ci izens o o he coun ies had
documen a ion pe aining o pos -discha ge ca e. Fo 51 (32.3%) o hem his indica ed
hey we e being epa ia ed and would need o ollow up wi h a psychia ic se ice in
hei home coun ies. None o hese plans indica ed ha ei he a discha ge e e al le e
was p o ided o an appoin men made on he pa ien ’s behal . None o hese pa ien s
eappea ed in he elec onic medical eco d. Fo 78% o he males and 93% o he
103
emales in his g oup, his was hei i s admission o he Abu Dhabi public men al heal h
se ice, al hough hey may ha e accessed o he men al heal h se ices in his coun y o
elsewhe e. O conce n, gi en he implica ions ela ed o ch onici y, mo bidi y and
mo ali y, quali y o li e and impac on amilies, is ha 91.9% o he males and 78.6% o
he emales we e diagnosed wi h se ious men al diso de s.
4.4. S eng hs and limi a ions
The p ima y s eng hs o his IRB-app o ed s udy a e ha i :
1. Ga he ed much-needed da a quickly on a ulne able popula ion while
complying wi h e hical guidelines;
2. Used a comple e sampling ame, gene a ed by SKMC’s In o ma ion
Technology Depa men , om which a andom sample was collec ed;
3. Suppo ed he alidi y o esul s by ollowing clea guidelines on da a
abs ac ion (Appendix 3) which ensu ed ha he p o ocol was logical and
clea , ha he o de o da a abs ac ion was de e mined by he s uc u e o
he EMR i sel and ha da a was en e ed in o a p e-se o m ha e lec ed
he EMR;
4. Ex aneous, po en ially misleading da a we e no collec ed e.g. ma i al
s a us whe e he pa ien may no , due o mig an s a us, li e as pa o a
ma i al couple;
5. E e y en h case was double-abs ac ed and checked o in a a e
eliabili y which allowed he esea che o iden i y p oblems wi h
a iables and po en ially educed a iabili y. The la ge size o he sample
104
oge he wi h his p ac ice se ed o o se any possible inco ec da a
en ies by he esea che .
Se e al limi a ions should be conside ed when in e p e ing he esul s o his s udy:
1. I used a c oss-sec ional, e ospec i e design, allowing only o desc ip ions o
a iables abs ac ed as seconda y da a. The EMR om which da a was abs ac ed
has a ully in eg a ed pa ien index, allows o epo ing o esul s, p esc ibing o
ea men and eco ding o assessmen s h ough checklis s suppo ed by ee ex .
Howe e , clinical pa hways and ca e plans a e no buil in o he sys em and do no
o mally exis as pape documen s in BSP. Nei he does he cu en EMR
gene a e e idence-based e e ences and ale s on en ies made o equi e
minimum adequa e documen a ion o a ge symp oms, side e ec s, ea men s o
ou comes. Due o he e ospec i e na u e o his s udy, a ia ion in clinician
p ac ice in e ms o quali y o documen a ion could no be add essed.
While psychia is s diagnose based on se c i e ia, s anda dized assessmen and
diagnos ic p ac ices could no be es ablished and we e no con i med h ough an
al e na e me hod like a s uc u ed assessmen in e iew. Thus, he e was no way
o e i y ha he o iginal clinical no es did no con ain e o s which a ose due o
inaccu a e documen a ion by he clinician, accu a e documen a ion o a clinical
e o in judgemen o ailu e o documen clinically ele an da a. Since his s udy
collec ed only da a ex ending back o i e yea s, u he e o s we e no
in oduced h ough ansc ibing o pape eco ds in o he EMR.
2. All hose younge han 18 yea s a he ime o hei las admission in 2015 we e
excluded. This excluded a segmen o BSP se ice use s who a e a guably in need
105
o specialized in-pa ien se ices, including hose who use subs ances and young
women who a e ma ied.
3. Social and clinical a iables ha could ha e expanded he unde s anding o he
con ex o pa ien s (e.g. coun y o o igin and seconda y psychia ic diagnosis)
we e no included. While he expa ia e pa ien popula ion in his s udy (and he
emi a e) may seem o be a homogeneous g oup, his is no an accu a e e lec ion.
Ra he , his g oup ep esen s mul iple na ionali ies and a ange o socio-economic
g oups, meaning ha ca e mus be aken no o d aw assump ions abou he la ge
g oup.
4. The e is an absence o cu en local (bo h o Abu Dhabi and he UAE) s udies o
in o m hese esul s and place hem in he p ope con ex . Some indings om his
s udy (e.g. gende di e ences in admissions om Wes e n Region) canno be
meaning ully discussed as no s udies a e a ailable on gene al se ice access, use
and pa ien popula ion cha ac e is ics.
106
5. Conclusions and Recommenda ions
5.1. Recommenda ions
This s udy desc ibes he cha ac e is ics o pa ien s admi ed o Abu Dhabi ci y’s
psychia ic se ice. By i s e y na u e, gi en he eali y o a ea men gap es ima ed o be
mo e han 90% in he Eas e n Medi e anean Region (WHO, 2012 in Ga e and Saeed,
2015), i s popula ion accoun s o bu a small po ion o hose who need se ices.
Gi en ha he cu en se ice is ou o sync wi h in e na ional ecommenda ions
pe aining o se ices o pa ien s wi h men al diso de s which a e espec ul o human
igh s, suppo i e o access o he co ec ype o se ice and inancially sus ainable, i is
ecommended ha ac ions aken o add ess his include:
1. Adop ion o al e na e models o se ice deli e y ha include an op imal se ice
mix (WHO, 2001) and balanced ca e (Tho nic o and Tansella, 2013).
2. F aming a na ional men al heal h plan aligned wi h he egional amewo k and
de eloping legisla ion in keeping wi h WHO guidelines.
3. Delinea ion by he heal h egula o o esponsibili y o se ice deli e y ac oss he
public-p i a e mix in Abu Dhabi.
4. Iden i ica ion and egula ion o clinical oles in men al heal h ha ex end beyond
only psychia is s. This should include o he heal h p o essionals as well as hose
p o iding in o mal se ices like adi ional heale s.
5. De elopmen o sys ems o add ess ca e o mig an s who a e discha ged om he
psychia ic se ice and epa ia ed.

107
6. De eloping a clea amewo k ha add esses inancing o men al heal h se ices
ha shi he bu den om he indi idual wi h a men al diso de and he / his
amily.
7. De eloping and ac ing on he na ionally and locally iden i ied p io i y o men al
heal h se ices and esea ch.
To in o m app op ia e, e ec i e se ices o all esiden s, u gen esea ch s udies a e
needed, wi hin he egional, na ional and local agendas ha :
1. Desc ibes g oups o pa ien s who sugges ed hemsel es as o ming dis inc sub-
popula ions (including women, adolescen s, men and women who a e
in ellec ually disabled and hose wi h demen ia) and iden i ies hei needs.
2. In o ms discha ge planning and ollow-up se ice access o mig an s who a e
epa ia ed and equi e ongoing men al heal h suppo and in e en ions in o he
coun ies.
3. Iden i ies he needs and engages wi h hose cu en ly no in con ac wi h a men al
heal h se ice who ha e exis ing men al diso de s o use o he se ices e.g.
p i a e hospi als and gene al p ac i ione s.
4. P ospec i ely s udy se ice use s and hei amilies as hey engage wi h hese
se ices and sys ems.
5. Measu es he e ec i eness o any o hcoming local men al heal h model and
plan wi hin exis ing esou ces like he egional men al heal h amewo k.
6. Economically e alua es he cu en and al e na i e se ice and unding models.
108
7. Tes s cu en e idenced-based in e en ions wi hin he UAE’s mul i-cul u al
con ex wi hin an unde s anding o wha cons i u es access ba ie s and
acili a o s.
5.2. Conclusions
The e a e no ecen s udies desc ibing he sociodemog aphic o clinical cha ac e is ics o
pa ien s admi ed o psychia ic se ices in Abu Dhabi o he UAE. I can be a gued ha ,
wi hin he global con ex , his s udy is i ele an as i is conduc ed in a se ice ou o sync
wi h he well-es ablished p ac ices o deins i u ionaliza ion and he mo e o communi y-
based ca e in High Income Coun ies. By implica ion, he esul s o his s udy may no be
gene alizable ou side o his speci ic se ice.
Reg e ably, he egional u h makes his s udy especially ele an , since policy-make s,
unde s and se ice planne s need o unde s and his popula ion o se ice-use s as so o
in o m he de elopmen o men al heal h se ice deli e y models, ye li le in o ma ion is
a ailable egionally and locally. No coun y in he Eas e n Medi e anean Region has a
men al heal h plan o policy ha is one hund ed pe cen implemen ed and only 52% o
coun ies ha e a s and-alone policy o plan which was upda ed since 2010 (WHO Men al
Heal h A las, 2014). Among he egion’s HICs, he UAE has he highes bu den o
disease ep esen ed by DALYs, he ewes men al hospi al beds pe 100,000 o he
popula ion, no esiden ial beds and no men al heal h beds in gene al hospi als. Nei he is
men al heal h in eg a ed in o communi y heal h se ices.
Al hough BSP’s popula ion is small when compa ed o he o e all SEHA gene al hospi al
popula ion, he cos o p o iding se ices a his specialized se ice is high. Men al heal h
109
plans de eloped he e, wi hin he egional amewo k, mus be e idence-based, e ec i e
and inancially sus ainable o e he long- e m. They mus also be in line wi h WHO’s
ecommenda ion o an “op imal mix” o se ices (WHO, 2003). This s udy which no
only desc ibes he cha ac e is ics o se ice-use s, bu highligh s he di e ences be ween
sub-g oups o hose who use SKMC’s psychia ic se ice, in o ms u u e discussions on
se ice de elopmen a local and na ional le el.
110
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133
Appendix 2: Map o Abu Dhabi egions (HAAD, 2014)
Appendix 3: F amewo k o abs ac ing da a om medical eco ds (Zozus el al,
2015):
1. Abs ac o Human Resou ces
yes
no
NA
a. Abs ac o quali ica ion
•Abs ac o amilia wi h how da a a e eco ded in he medical eco d
•Abs ac o expe ienced in clinical a ea o which she is abs ac ing
•Abs ac o expe ience abs ac ing in any clinical a ea
•Abs ac o ha ing a clinical c eden ial in he a ea in which he o she is abs ac ing
•Abs ac o ha ing passed a compe ency es
b. Communica ion wi h abs ac o s
•P o iding eedback o abs ac o s, e.g. om pe iodic e iew o cases
•Ongoing communica ion wi h abs ac o s, e.g. oppo uni y o discuss di icul cases
c. Abs ac o p ojec speci ic aining
•T aining abs ac o s
•Ongoing abs ac o aining
2. Abs ac ing en i onmen :
yes
no
NA

134
•A suppo i e and posi i e ela ionship wi h local physicians, nu ses, and medical eco ds colleagues
•Minimizing in e up ions du ing abs ac ion
•Minimizing ime p essu e, i.e. limi ed ime in which o abs ac
•Easy access o medical eco ds
3. Abs ac ion me hods and ools:
yes
no
NA
a. Abs ac ion p ocess
•Using da a collec ion o ms, i.e. abs ac ion o ms
•Conduc ing a pilo s udy o he abs ac ion
•Re iewing he en i e o ele an pa s/ ime pe iod o he medical eco d be o e abs ac ing
b. Applying me hods ha dec ease human e o
•A ailabili y o abs ac ion ools, e.g. guidelines, con en ions, de ini ions
c. Abs ac ion guidelines
•Speci ying he loca ion in he medical eco d whe e he da a elemen is o be ound
•P io i izing he loca ions in he medical eco d whe e da a elemen s may be ound
•Documen ing inclusion and exclusion c i e ion de ining which cases should be in he s udy o egis y
•Documen ing ules o dealing wi h missing in o ma ion
•An a ailable glossa y wi h synonyms and abb e ia ions
d. Da a elemen de ini ion
•De ining each da a elemen
•Speci ying ca ego ies o deno e unknown in o ma ion
•Deno ing and p io i izing c i ical da a elemen s
•P o iding con en ions desc ibing handling o common p oblems o each da a elemen
•Valid alues o ca ego ical da a elemen s
•Choosing alid alues ha esol e mino disc epancies, i.e. b oad ca ego ies
•De ining and collec ing da a elemen s as s uc u ed da a a he han ee ex
•De ining da a elemen s as aw da a, i.e. da a ha a e abs ac ed di ec ly om medical eco ds
•Assu ing ha da a elemen s a e ou inely documen ed in medical eco ds
•A oiding subjec i e da a elemen s h ough de ini ion o make he da a elemen mo e objec i e
•Iden i ying da a elemen s abs ac ed less accu a ely
•Using da a elemen s ha a e he o iginal eco ding
e. Da a collec ion o abs ac ion o m
•Using a well-designed da a collec ion o m
•Using he same o m a mul iple da a collec ion si es
•Lis ing codes on he da a collec ion o m o da a elemen s whe e he abs ac o assigns a code du ing
abs ac ion
•O de ing ques ions on he da a collec ion o m ollowing he o de in he medical eco d
. Compu e use in abs ac ion
•En e ing da a in o a compu e as he da a a e abs ac ed
•Use o compu e ized e o checks du ing da a en y
•Use o compu e ized e o checks a e da a en y o missing
•Minimizing ansc ip ion s eps
•Use o independen da a sou ces o e i y da a, e.g. checking da a agains ano he sou ce o he same da a
Appendix 3(con inued): F amewo k o abs ac ing da a om medical eco ds
(Zozus el al.2015):
4. Inhe en ac o s ha dec ease he accu acy o abs ac ed da a
yes
no
NA
•E o and inconsis ency in he medical eco d
•The p ac ice o p o ide s no documen ing esul s o assessmen s ha a e “no mal”
•Missing in o ma ion
•Missing cha s
•Con lic ing in o ma ion in he medical eco d
•Illegible in o ma ion in he medical eco d
•Unce ain y in he medical eco d, i.e. s a emen s such as “possible in a c ion” a he han a i m diagnosis
•Va iabili y o documen a ion p ac ices among clinicians
•Va iabili y o assessmen skills, i.e. o he clinician examining he pa ien
5. Aspec s o e-abs ac ion:
yes
no
NA
•Re-abs ac ion o da a
•Re iewing o e-abs ac ing a ep esen a i e selec ion o cases a he han all o he cases
•Independen o ex e nal e-abs ac ion, i.e. e-abs ac ion by someone o he han he ini ial abs ac o
135
•Pe iodic e-abs ac ion h oughou he p ojec , i.e. e e y ew mon hs o a ew imes pe yea
•Re iewing e-abs ac ion esul s, i.e. disc epancies o di icul y a eas, wi h abs ac o s
•Measu emen o in e - o in a a e eliabili y, i.e. a measu e o ag eemen be ween wo abs ac ions
Appendix 4. In a a e eliabili y o 28 se s o duplica e da a (double
abs ac ion o iles)
Duplica es pai s
Measu e o Ag eemen : Kappa
Value
App ox. Sig.
1-1:1-2
26 a iables
1.000
.000
11-1:11-2
26 a iables
1.000
.000
21-1:21-2
26 a iables
.888
.000
31-1:31-2
26 a iables
1.000
.000
41-1:41-2
26 a iables
1.000
.000
51-1:51-2
26 a iables
.948
.000
61-1:61-2
26 a iables
1.000
.000
71-1:71-2
26 a iables
1.000
.000
81-1:81-2
25 a iables
1.000
.000
91-1:91-2
25 a iables
.837
.000
101-1:101-2
26 a iables
.943
.000
111-1:111-2
26 a iables
.898
.000
121-1:121-2
26 a iables
1.000
.000
131-1:131-2
26 a iables
1.000
.000
141-1:141-2
26 a iables
1.000
.000
151-1:151-2
26 a iables
1.000
.000
161-1:161-2
25 a iables
1.000
.000
171-1:171-2
26 a iables
.942
.000
181-1:181-2
26 a iables
1.000
.000
191-1:191-2
26 a iables
1.000
.000
201-1:201-2
26 a iables
1.000
.000
211-1:211-2
26 a iables
.896
.000
221-1:221-2
26 a iables
.945
.000
231-1:231-2
25 a iables
1.000
.000
241-1:241-2
26 a iables
1.000
.000
251-1:251-2
26 a iables
.951
.000
261-1:261-2
26 a iables
1.000
.000
271-1:271-2
26 a iables
1.000
.000
281-1:281-2
25 a iables
1.000
.000
136
Appendix 5: P o ocol o da a collec ion
Open Pg. 2- hide all ows no ending in '1" and abs ac da a om he 28 isible iles only. This is 10% o in a a e
eliabili y. Mo e o page 1 and abs ac 285
1
uni #
Each clinical ile in sample is a consecu i e uni - eco d he e as i em coun 1-
285
2
Random eco d numbe (RRN)
Each clinical ile in sample has a unique andom numbe - iden i y om
andom numbe able and eco d he e
3
KM numbe
Use RRN o ind KM on mas e lis . Each is numbe ed consecu i ely in
column A- sc oll o ind RRN and iden i y KM
1. hen open Mala i cha using KM numbe
V1
Gende : 0= male 1= emale
a op o page, iden i y
V2
Age as da e o bi h
a op o page, iden i y
V3
Age as numbe a las admission
a op o page, iden i y
V4
Age as collapsed band o analysis:
1=15-19/2=20-24/3=25-29/4=30-
34/5=35-39/6=40-44/ 7=45-49/8=50-
54/9=55-59/10=60-64/11=65-69/12=70-
74/1 3=75/ 14=80
Collapse in o 4-y age bands a e da a collec ed. This a iable
also o be epo ed on o IRR.
2. sc oll down o ab PATIENT INFORMATION: his has wo abs o hese da a
V5
Na ionali y s a us 0= Ci izen 1=
Ci izen o o he coun y
Tab 1 (demog aphics): eco d code o Race (na ionali y)
V6
Geog aphical a ea o esidence 0=
Abu Dhabi 1= Al Ain 2= Wes e n
Region 3= o he emi a e
4= o he coun y
Tab 1 (demog aphics): eco d code (Add ess= egion). I
disc epancy be ween his da a and in o ma ion in clinical no es,
e ain his in o ma ion and s a e con lic in "commen " no e
a ached o cell. Fo e iew a 2-weekly mee ing whe e commen
no e o be amended. All no es o be add essed a e all da a
collec ed.
V7
BSP leng h o s ay in days o pa he eo
Tab 2 (Visi lis ): eco d numbe o days as a simple
sub ac ion (use a calenda o coun ) o discha ge days
minus admission da e.
V8
Follow-up in BSP-OPD wi hin 1/12 pos
discha ge 0=no 1=yes
Tab 2 (Visi lis ): eco d i ollow-up appoin men wi h
psychia is a BSP clinic wi hin one mon h pos LAST
DISCHARGE in 2015 as a code
V9
Numbe o SEHA ED isi s in 6 mon hs
p io o index admission
Tab 2 (Visi lis ): eco d numbe o isi s, including o
KUCC in six mon hs p io o LAST ADMISSION in
2015 as a coun
V10
I YES, discha ged in p e ious 6/12, how
many days ago as numbe
Tab 2 (Visi lis ): eco d numbe o days as a coun pe
calenda days om day p io o las admission o de by
psychia is in 2015 as a coun
V11
P e ious admission o psychia ic se ice
0= no 1= yes, BSP 2= yes,
o he SEHA 3= yes, BSP &
o he SEHA
Tab 2 (Visi lis ): eco d code o Admissions p io o
LAST ADMISSION in 2015 as a coun
V12
Numbe o p e ious admissions o BSP in
3 yea s (including index admission)
Tab 2 (Visi lis ): eco d numbe o admissions p io o
LAST ADMISSION in 2015 as a coun
V13
High equency use : 3 0=nil p e ious
1= 1-2 imes in 3y s, including his
admission 2= 3 o mo e imes in 3
y s., including his admission
Collapse in o bands a e da a collec ed. This a iable
also o be epo ed on o IRR.
V14
Admissions o SEHA in p e ious 5 yea s as a numbe
V15
High equency use : 5 0=nil p e ious 1= 1-2 imes in 5y s, including his admission
2= 3 o mo e imes in 5 y s., including his admission
V16
Numbe o weeks since p e ious discha ge
in six weeks as a collapsed band
Tab 2 (Visi lis ): eco d discha ge om BSP in six
mon hs p io o LAST ADMISSION in 2015 as a da e
137
Appendix 5 (con inued): P o ocol o da a collec ion
3. Sc oll down o ab DOCUMENT VIEWING: open ED o OPSC o Liaison psychia is consul a ion no e on
lis immedia ely abo e wa d admission no e in lis .
V17
Admission poin o depa u e 0=
ED 1= clinic scheduled
2= clinic walk-in 3= home ca e RN
4= liaison SKMC 5= liaison
SEHA
Reco d as pe Psychia ic Consul . I no in consul no e,
e e o admission no e by psychia is . I wo o mo e
sou ces, eco d i s as pe code. S a e addi ional sou ce
and b ie no e in "commen ". All no es o be add essed
a e all da a collec ed.
V17
Re e al sou ce 0= no eco d/ 1=sel /
2= amily o iends/ 3=police/ 4=o he
SEHA hospi al/ 4= o he
Reco d as pe Psychia ic Consul . I no in consul no e,
e e o discha ge summa y. I wo o mo e sou ces,
eco d i s as pe code. S a e addi ional sou ce and b ie
no e in "commen ". All no es o be add essed a e all
da a collec ed.
V18
Violence/Agg ession Risk le el as
de e mined by psychia y in same documen
as admission o de 0= No eco d
1= low 2= medium 3= high
Code as pe assessmen eco ded du ing consul
V19
Suicide Risk le el as de e mined by
psychia y in same documen as admission
o de 0= No eco d 1= low 2=
medium 3= high
Code as pe assessmen eco ded du ing consul
4. in DOCUMENT VIEWING: look o ECT adminis a ion eco d.
V20
ECT ecei ed du ing admission
0= No 1= Yes
Reco d as pe code
V21
Numbe o ECT sessions ecei ed du ing
admission
Reco d as a coun - each ECT session equi ed sepa a e
eco d
5. in DOCUMENT VIEWING: look a discha ge summa y.
7
Discha ge p inciple psychia ic diagnos ic
ICD-9 code 0=No eco d/ eco d ICD-
9 diagnos ic codes
I eco ded bu no ICD-9 code, eco d as ee ex - code
as pe ICD-9 code. I mo e han one diagnosis, eco d all
hese IN THE ORDER THEY APPEAR AND collapse
in o app op ia e band. I mix o bands, selec p ima y
discha ge diagnosis as code & e e o psychia ic
consul an o check
V23
Discha ge p inciple psychia ic diagnos ic code by g oup Collapse in o diagnos ic bands as
mapped by D . Ga hy 0= no eco d / 1=O ganic, including symp oma ic,
men al diso de s (290-294) 2=Men al and beha io al diso de s due o psychoac i e subs ance use (303-
305) 3=Schizoph enia, schizo ypal and delusional diso de s(295, 297, 298) 4=Mood [a ec i e]
diso de s(296,311) 5=Neu o ic, s ess- ela ed and soma o o m diso de s(300,308,309) 6=Beha io al
synd omes associa ed wi h physiological dis u bances &physical ac o s ( ) 7=Diso de s o adul
pe sonali y and beha io (301) 8=Men al e a da ion (317-319) 9=Diso de s o psychological
de elopmen ( ) 10=beha io al and emo ional diso de s wi h onse usually occu ing in childhood and
adolescence (299,312-316) 11=Unspeci ied men al diso de (307.9) 12=Psychosexual diso de s (302)
13=epilepsy (345) 14=Suicide and sel -in lic ed beha io (E958.9)
V24
Discha ge disposi ion 0= no s a ed o unable o
de e mine/ 1= le agains medical ad ice/
2= discha ged o home, sel / 3= discha ged o
home, ca e o amily/ 4= discha ged o acu e hospi al/
5= discha ged ca e o police ( o p ison)/ 6= died/
7= o he
eco d as pe discha ge summa y
V25
Re e al a discha ge 0= no s a ed o unable o
de e mine/ 1= o BSP OPC/ 2= o
GP/ 3= o p ison psychia is / 4= o
p i a e heal h ca e p o ide / 5= BSP day cen e / 6=
BSP CCMT/ 7= o he
eco d as pe discha ge summa y
V26
Numbe o discha ge psycho opic
medica ions as a coun
Sc oll o heading: Medica ion lis , iew Ac i e
Medica ion, iew O de ed. I una ailable, use ab
138
V27
Discha ge psycho opic medica ions
MEDICATION LIST (change display o "all medica ion"
& sc oll o da e o las admission. Find heading
P esc ip ion o discha ge p esc ip ion
Appendix 5(con inued): P o ocol o da a collec ion
V28
Discha ge psycho opic medica ions by
class 0= an ipsycho ic
1= an idep essan 2=benzodiazepine
3= mood s abilize 4= hypno ic
5= o he
Reco d as pe code- comple e a e da a abs ac ed.
V29
Discha ge p inciple medical diagnosis
ICD-9 code
Reco d as ICD ca ego y
V30
Discha ge p inciple medical diagnosis pe
NCD g oups 0=ca dio ascula 1=
diabe es 2=cance 3=ch onic
espi a o y 4= o he
I mo e han one diagnosis, eco d all hese IN THE
ORDER THEY APPEAR- will be idied and e e ed o
medical specialis RN o collapsing in o bands
6. Open FORM BROWSER. Rese o da e p io o index admission. Sea ch o o m "RESTRAINT
INITIATION"
V31
Res ain s in i s 24h s o admission as
pe es ain o m 0=no es ain /
1=chemical es ain only/ 2=physical
es ain only/ 3=physical and chemical
es ain
I Res ain ini ia ion o m/s, open all and code 3 i any
e lec his. I no , code 1 o 2 as pe eco d " ype o
es ain "
V32
Leng h o s ay in day (as gene a ed in epo )

139
Appendix 6: Discha ge medica ion classes p esc ibed by psychia ic diagnos ic
g oup
Main psychia ic diagnosis a discha ge
Schizoph enia, schizo ypal and delusional diso de s
Gende
Male
Female
Discha ge
psycho opic
medica ions
no medica ion by psychia is
0
1
an i-dep essan (AP)
3
0
an i-psycho ic (AP)
12
6
benzodiazepine (BDZ)
1
0
AD+AP
4
2
AD+BDZ
1
0
AP+AP
6
3
AP+BDZ
8
2
AP+mood s abilize (MS)
3
0
AP+hypno ic (H)
2
0
AP+o he (O)
1
0
BDZ+MS
1
0
AD+AP+AP
1
1
AD+AP+BDZ
2
2
AD+BDZ+BDZ
0
1
AD+BDZ+H
1
0
AP+AP+AP
0
1
AP+AP+BDZ
4
1
AP+AP+MS
1
3
AP+AP+H
3
0
AP+BDZ+MS
1
2
AD+AP+AP+BDZ
1
1
AD+AP+AP+H
0
1
AD+AP+BDZ+MS
1
0
AD+BDZ+BDZ+MS
1
0
AP+AP+BDZ+BDZ
1
0
AP+AP+BDZ+MS
3
0
AP+AP+BDZ+O
1
0
AP+BDZ+MS+MS
0
1
AP+AP+BDZ+BDZ+MS
0
1
Main psychia ic diagnosis a discha ge
Neu o ic, s ess- ela ed and soma o o m diso de s
Gende
Male
Female
Discha ge
psycho opic
medica ions
no medica ion by psychia is
5
6
an i-dep essan (AP)
2
3
an i-psycho ic (AP)
4
0
benzodiazepine (BDZ)
4
2
AD+AP
5
0
AD+BDZ
1
0
AD+H
0
1
AP+BDZ
0
2
AD+AP+BDZ
1
0
AP+BDZ+BDZ
1
0
AD+AP+AP+BDZ
1
0
AD+AP+BDZ+BDZ
0
1
140
Appendix 6 (con inued): Discha ge medica ion classes p esc ibed by psychia ic
diagnos ic g oup
Main psychia ic diagnosis a discha ge
Mood [a ec i e] diso de s
Gende
Male
Male
Discha ge
psycho opic
medica ions
no medica ion by psychia is
2
2
an i-dep essan (AP)
1
4
an i-psycho ic (AP)
5
5
benzodiazepine (BDZ)
2
0
mood s abilize (MS)
0
1
hypno ic (H)
0
1
AD+AP
1
2
AD+BDZ
2
0
AD+MS
1
0
AD+H
0
1
AP+BDZ
7
1
AP+MS
6
7
AD+AD+AP
1
0
AD+AP+BDZ
1
0
AD+AP+MS
1
0
AD+AP+H
0
3
AD+BDZ+BDZ
0
1
AD+BDZ+H
1
0
AP+AP+BDZ
3
0
AP+AP+MS
1
3
AP+BDZ+BDZ
0
1
AD+BDZ+H
1
0
AP+AP+BDZ
3
0
AP+AP+MS
1
3
AP+BDZ+BDZ
0
1
AP+BDZ+MS
5
1
AP+BDZ+H
2
0
AD+BDZ+H
1
0
AP+AP+BDZ
3
0
AP+AP+MS
1
3
AD+AP+BDZ+MS
2
0
AD+AP+BDZ+H
0
1
AP+AP+BDZ+MS
6
0
AP+AP+MS+H
2
0
AP+BDZ+MS+MS
1
0
AP+BDZ+MS+H
2
0
AP+AP+BDZ+BDZ+MS+MS
1
0
Main psychia ic diagnosis a discha ge
Men al & beha iou al diso de s due o
psychoac i e subs ance
Gende
Male
Female
Discha ge
psycho opic
medica ions
no medica ion by psychia is
26
0
an i-dep essan (AP)
2
0
an i-psycho ic (AP)
7
0
mood s abilize (MS)
1
0
o he (O)
1
0
AD+AP
1
1
AP+BDZ
1
0
AP+H
1
0
AD+AP+BDZ
1
0
AP+BDZ+O
1
0
141
Appendix 7: Discha ge ICD-9 codes by diagnos ic bands
Diagnos ic band
ICD-9 diagnos ic code
O ganic, including symp oma ic, men al
diso de s
290-294
Men al and beha io al diso de s due o
psychoac i e subs ance use
303-305
Schizoph enia, schizo ypal and delusional
diso de s
295, 297, 298
Mood [a ec i e] diso de s
(296 ,311)
Neu o ic, s ess- ela ed and soma o o m
diso de s
300, 308, 309
Diso de s o adul pe sonali y and
beha io
(301)
Men al e a da ion
(317-319)
Diso de s o psychological de elopmen
Beha io al and emo ional diso de s wi h
onse usually occu ing in childhood and
adolescence
299,312-316
Unspeci ied men al diso de
307.9
Psychosexual diso de s
302
Suicide and sel -in lic ed beha io
E958.9
142
Appendix 8: Psycho opic medica ions by d ug class
An ipsycho ics
a ipip azole
amisulp ide
clozapine
halope idol
olanzapine
palipe idone
que iapine
espi idone
i luope azine
zip asidone
An idep essan s
clomip amine
cip alex
duloxe ine
des enla axine
esci alop am
luoxe ine
mi azapine
pa oxe ine
se aline
enla axine
Benzodiazepines
alp azolam
b omazepam
lo azepam
Mood s abilize s
ca bamazepine
li hium
lamo igine
alp oic acid
Hypno ics
zopiclone
O he
baclo en
(muscle
elaxan )
p ome hazine (used o seda i e
e ec )