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\begin{document}

\title{Treatment and perspectives of patients diagnosed with psychiatric
disorders living in rural areas in Jordan: identifying barriers and role
of pharmacists.}



\author[1]{Eyad Qunaibi}%
\author[2]{Malak Afeef}%
\author[2]{Bayan Othman}%
\author[2]{Abdullah  Al-zoubani}%
\author[3]{Iman Basheti}%
\affil[1]{Jerash University}%
\affil[2]{Affiliation not available}%
\affil[3]{Applied Science Private University}%


\vspace{-1em}



  
  \date{June 16, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
Introduction: Patient adherence is a cornerstone in successful
management of psychiatric disorders and is affected by patient
perspectives and barriers, differing from rural to urban areas. In this
perspective, pharmacists have a vital role in identifying patients in
need of help and in dealing with barriers to adherence. This paper
investigates perspectives of patients diagnosed with psychiatric
disorders, living in rural areas in Jerash, Jordan, regarding their
awareness about their psychiatric conditions, including religious and
cultural factors, adherence to their treatment and related barriers,
with special focus on pharmacist's role. Methods: This cross-sectional
survey study was conducted in Jordan from August to November 2019. A
validated questionnaire was administered by two pharmacists, asking
patients as they were waiting in the psychiatric clinic (following the
specialists' approval). Data were analyzed using the Statistical Package
for the Social Science (SPSS). Results: Most patients (n= 120, age
39.4\selectlanguage{ngerman}±9.5, 66.7\% males) reported that they always/usually adhere to
their medications (71.0\%), and 47.5\% of them reported complete control
of their symptoms after treatment. Most patients (69.2\%) reported that
they perceive their psychological illness in terms of religious faith as
being counted for their favor in the Hereafter, and 52.5\% of them
always/usually looked at themselves positively and unaffected by the
existence of their illness; with both factors correlating significantly
with better treatment adherence (p \textless{} 0.045 and p \textless{}
0.001; respectively). Barriers affecting adherence included mainly
suffering from adverse effects (31.9\%) and being unconvinced that they
needed a medication (23.3\%). Only 14.2\% of patients reported that they
refer to the pharmacist to get information about their medications.
Conclusion: Most psychiatric patients reported suboptimal control of
their symptoms. Nonadherence is one reason, with barriers identified.
Positive religious and cultural perspectives are associated with better
adherence, and most patients do not refer to pharmacists for medication
informatio%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{What is already known about this topic?~}

The rate of psychological disorders continues to grow globally,
affecting millions of people worldwide. Although primary healthcare
teams exist in rural areas to provide services to chronically ill
patients, including those diagnosed with psychiatric disorders, barriers
exist. Identifying barriers and relationship of patient beliefs and
values, and proper adherence can help in optimizing the management of
patients.

\textbf{What does this article add?~}

This paper reports the perspectives of patients diagnosed with
psychiatric illnesses, living in rural areas in Jerash, Jordan,
regarding their awareness about their psychological conditions,
including religious and cultural factors, adherence to their treatment
and related barriers, with special focus on pharmacist's role. Most
psychiatric patients reported suboptimal control of their symptoms.
Nonadherence is one reason, with barriers identified. Positive religious
and cultural perspectives are associated with better adherence, and most
patients do not refer to pharmacists for medication information.

\textbf{Introduction}

The rate of psychological disorders continues to grow globally,
affecting millions of people worldwide. To have a deeper insight into
the proportions of specific psychological conditions, it has been
reported that 264 million people suffer from depression, 45 million from
bipolar disorder and 20 million from schizophrenia (1),(2). In Jordan,
the number of patients diagnosed with psychological disorders has not
been published, however, it was documented in a World Health
Organization (WHO) report that there are 64 mental health outpatient
facilities in Jordan, which provide services to an estimated 305 users
per 100,000 population, with the most commonly assigned diagnosis at
both outpatient facilities and mental hospitals being schizophrenia (3).
According to the WHO, Jordan has been identified as a country in need of
intense support for strengthening the mental health system (4). As is
the case all around the world, in Jordan, females suffer from
psychological conditions more than males (5),(6).

With the growing burden of psychiatric disorders worldwide, creating a
partnership relationship between patients and their healthcare
professionals is vital for proper management (7, 8). This can be done by
taking into consideration patients' preferences, needs and values (7,
8). Hence, assessing patient's beliefs and how it affects the management
of their condition would be useful (9).

Over the past years, the pharmacists' role has developed to include
numerous patient-oriented clinical services (10). Being at the front
line, pharmacists have a unique position due to their direct contact
with patients (11). Hence, pharmacists can successfully identify
patients in need of help, including psychologically ill patients
hesitant to visit their specialist to get help (12-14).

In addition to their accessibility, the important role of the
pharmacists in the psychological healthcare sector was found to be
acknowledged by both healthcare professionals and patients around the
world (15). Pharmacists were found to enjoy a high level of patient
trust in Arab countries as well, including Jordan (13), assisting in
opportunistic screening for depression and anxiety (12).

Adherence to treatment is important for psychologically ill patients
considering the young age of the population, the high alert medications
used in their management (16), the side effects of treatment and
withdrawal symptoms due to misuse. Identifying barriers and relationship
of patient beliefs and values, and proper adherence can help in
optimizing the management of a culturally and religiously oriented group
of patients (17, 18).

Previous studies reported a positive effect of religious beliefs of
Muslims on coping with mental disorders and other distressing conditions
(19-22). However, the impact of religious beliefs on the perception of
psychiatric illnesses and adherence to medications by the Muslim
population has not been assessed as yet.

Culturally, perceived public mental illness stigma and self-stigma,
causes a delay in active help-seeking behavior (23). However, the size
of this stigma among patients who do seek help in the relatively
``closed'' rural cultures and its effect on adherence has not been
evaluated.

In addition, several studies on patients with psychiatric disorders have
revealed overall high rates of perceived benefits of psychotherapeutic
interventions, including a study in Amman, the capital of Jordan, which
involved a sample of 100 patients who received psychosocial expert
interventions (23). No previous study, however, has evaluated the
awareness and preference of psychotherapy among patients with
psychiatric disorders in rural areas.

Although primary healthcare teams exist in rural areas to provide
services to chronically ill patients, including those diagnosed with
psychiatric disorders, barriers exist (15, 24). No previous study has
looked into the perspectives of patients with psychological illnesses
living in rural areas in Jordan when it comes to the management and
awareness of their condition, barriers to adherence, and the role of the
pharmacist.

This brings us to the aim of this study, which is to investigate
perspectives of patients diagnosed with psychiatric disorders, living in
rural areas in Jerash, Jordan, regarding their awareness about their
psychiatric conditions and their treatment, adherence to their
treatment, and related barriers, with special focus on the pharmacist's
role.

\textbf{Methods}

\textbf{Study Setting}

The study objectives were addressed via a descriptive cross-sectional
face-to-face survey, conducted in Jarash, Jordan, from August to
November 2019. Jerash is located in Northern Jordan, and although it has
a population of about 50,745, it is surrounded by a large number of
remote and rural areas that lack specialized hospitals, making Jarash
Hospital (located in the city of Jarash Governorate) the center of care
and medication provision for many patients.

Data were collected from patients diagnosed with psychological
conditions visiting the out-patient psychiatric clinic at Jerash
Hospital, following the specialists' informed consent. Ethics approval
was obtained from the Faculty of Pharmacy, Applied Science Private
University. Participation in the study did not pose any risk to patients
and was voluntary. Patients who accepted to participate in the study and
met all of the inclusion criteria were informed about the nature of the
study and were asked to provide a written consent before participation.
The inclusion criteria were patients above 18 years of age, diagnosed by
a specialist with a psychiatric disorder, and is currently taking a
medication for a psychiatric disorder with no change in treatment and/or
dose for the past one month. Exclusion criteria included the presence of
a cognitive problem or a sensory impairment which could prevent
communication with the patient, those who rely on their
parents/caregivers to visit the psychiatric clinic in order to obtain
their medication/s (hence physically were not present), and patients not
able to write and/or read Arabic.

\emph{Study tool}

The study tool (the survey) was developed following an extensive review
of the literature. The survey contained close and open-ended questions.
The questionnaire was administered in Arabic since Arabic is the
official language of patients in Jordan. Several sources were used to
generate a pool of questions considered to be relevant to the study
objectives. The questions were tabled and reviewed by the research team
in order to combine concepts and to remove duplicates if any.

To ensure face validity, the first draft of the questionnaire was
evaluated by independent academics who have previous experience in
pharmacy practice and education. The items in the questionnaire that
were not clear or difficult to comprehend were removed. Feedback and
comments provided were considered by the research team and then
incorporated where appropriate. Finally, the research team revised the
items as necessary to make them concise and to be completed within 10-15
minutes by the researcher during patient's interview. The questionnaire
was then piloted by a group of volunteer patients (n=5) to test the
clarity of questions over a 2 weeks period. Refinements and comments
were incorporated into the final version of the survey.

The survey incorporated Likert scale questions and consisted of three
parts. The \emph{first part} was designed to collect data on patients'
demographic characteristics including age, gender, weight, exercising,
caffeine intake and insurance coverage. The \emph{second part} was
designed to assess patients' awareness of the management of their
condition, adherence, barriers to adherence, faith level and its impact
on their adherence. The \emph{third part} was designed to evaluate
patients' perspective of the role of healthcare professionals, with a
focus on the pharmacist role.

\emph{Survey implementation}

Following recruitment, patients were asked by practiced researchers
(n=2) to answer the survey items found in the survey as the items were
read out by the researchers. A female pharmacist approached female
patients, and a male pharmacist approached male patients. Both
researchers practiced together well to unify the way they approached and
interviewed the patients. Patients were given the time needed to
complete the survey (10 to 15 minutes). Patients who completed the
survey observed the researcher as she/he inserted it in a sealed
envelope. Every envelope was given a number for participant privacy.

Data were coded and all completed surveys were kept in a locked cabinet
that was only accessed by the researcher. Following data entry, data
were kept in a computer with a password protection known only by the
researcher.

Following survey completion, data verification was done by the
researcher including age, medical condition/s, date of treatment
commencement, name of medication/s, dosage, therapeutic regimen and
reason of use from the computerized hospital data.

\textbf{Data analysis}

Data were analyzed using the Statistical Package for the Social Science
(SPSS) version 22 (SPSS Inc., Chicago, IL, USA). The quantitative
variables were described using mean and standard deviation (SD), and the
qualitative variables were described using frequency and percentages.
Pearson's \selectlanguage{greek}χ\selectlanguage{english}2 test was used to determine the relationship between
adherence level to treatment and selected variables. Correlation testing
exploring associations between the different variables was identified
using Pearson's correlation and Pearson's \selectlanguage{greek}χ\selectlanguage{english}2 test for significance. A
probability value of \textless{} 0.05 was considered to be statistically
significant for all analysis tests.

\textbf{Results}

Demographics, diagnosis, and treatment :

A convenience sample of 150 patients attending the outpatient
psychiatric clinic located in Jerash Hospital was approached. Eligible
patients (n= 120, response rate of 80\%) who accepted to complete the
survey and gave consent were recruited into the study. The mean age of
patients was 39.4\selectlanguage{ngerman}±9.5 and the mean weight was 78.7± 18.2. More than half
of the patients were males (66.7\%), most of them (68.3\%) reported not
to perform any exercise, and 75\% of the patients had health insurance
(Table 1). Only 32.6\% of the patients were employed before their
diagnosis, and more than half of these patients (56.5\%) reported loss
of their job due to their psychological illness.

With regard to the type of diagnosed psychological illness, more than
half of the patients (53.3\%) reported being diagnosed with depression,
followed by schizophrenia (30\%), obsessive compulsive disorder (9.2\%)
and Bipolar (7.5\%). No family history of a psychological illness was
reported by 70.8\% of the patients.

Most of the participants (87.5\%) agreed that they have a psychological
illness, 2.5\% were not sure, and 10.0\% were not convinced. They
reported that their first psychological symptom started at a much
earlier age (27.2±1.2) when compared to their current mean age
(39.4±9.5).

Almost all of the patients (98.4\%) reported that they started taking a
medication to treat their psychiatric disorder. It was the specialist
who advised the patients to start taking their medication in most cases
(97.5\%). The medications used by the patients included antidepressants
and antipsychotics (Table 2), comprising mostly Citapram® (citalopram,
21\%), Kemadrin® (procyclidine hydrochloride, 14\%), and Haldol®
(haloperidol Injection, 13.5 \%).

Patient perspectives about their psychiatric disorders and their
medications :

Following medication use, less than half of the patients (47.5\%)
reported complete control over their illness. Others reported partial
control (43.3\%), while few reported poor control (9.2\%).

A deeper insight into patient's perspectives of the causes that led to
their physiological illnesses (Figure 1) included family problems
(41.0\%), death of a beloved person (20\%), work problems (15\%) and
financial problems (10\%). Patients reported that they visited the
specialist merely due to the advice of a family member (74.2\%), others
followed the general practitioner's advice (10.8\%), and 8.3\% visited
the specialist based on their own decision.

Around half of the patients (51.7\%) believed that their medications
lead to addiction, yet they reported that this did not prevent them from
taking it. Some patients (46.7\%) believed that their medications do not
cause addiction. Two patients said that they do not take their
medication because they believed it might cause addiction.

The sources of information about psychiatric illnesses are important for
psychiatric patients and are reported in Figure 2. It was the specialist
who gave the patients such information in most cases (92.5\%), followed
by the use of the internet (3.3\%), or via a pharmacist consultation
(1.7\%). When patients were specifically asked about the source of
information regarding their medications (Figure 2), the majority
reported that it was the specialist (78.3\%), followed by the pharmacist
(14.2\%) then the internet (5.8\%).

When asked if they had questions about their psychiatric illnesses which
were not answered, most patients responded that this never (46.7\%) or
only slightly (19.2\%) happened. When asked if they had questions about
their psychiatric medications that were not answered, most patients
responded that this never (58.3\%) or only slightly (15.0\%) happened.
Reasons for not getting answers about medications included neither
visiting nor calling the specialist in the first place (29.2\% of all
patients), the specialist did not give enough time (6.7\%) and neither
visiting nor calling the pharmacist (5.8\%).

Patient awareness and preference of psychotherapy :

Most of the patients (89.2\%) did not hear about psychotherapy before,
and all of them were never exposed to it prior to study entry. After
psychotherapy was explained to the patients, the majority (65.9\%) of
them strongly agreed/agreed that they would have chosen psychotherapy
prior to starting treatment if they had known about it before (9.2\%
were neutral and 25\% strongly disagreed/disagreed).

Adherence to treatment and barriers :

Most of the patients (71.0\%) responded that they always/usually adhere
to their medications. The most frequent barrier to adherence reported by
the patients was suffering from adverse effects (31.9\%). Others
reported different barriers, such as being unconvinced that they needed
a medication (23.3\%), believing that their illness symptoms would get
resolved without the use of a medication (11.2\%), and not being able to
afford their medication when it was not provided by the hospital
(11.2\%).

A high proportion of patients (59.2\%) reported that they regard their
psychological illness in terms of religious faith as counting for their
benefit in the Hereafter and these patients reported a significant
better adherence to treatment (Pearson correlation, p=0.046).; others
(10\%) believed their illness is a sort of divine punishment, while the
rest thought it was neither due to the pre-mentioned reasons (30.8\%).

In response to questions related to perceived public psychiatric
disorder stigma and self-stigma, 52.5\% of patients always/usually
looked at themselves positively and unaffected by the existence of their
psychiatric problem; which correlated significantly (r- 0.394,
p\textless{}0.001) with better treatment adherence. On the other hand,
41.7\% said that the felt embarrassed that their family, friends, or
people in their surrounding know that they are taking a medication for a
psychological problem.

As for adherence to the advice provided by the specialist, the majority
(89.2\%) reported that they would not stop taking their medication on
their own even if their symptoms faded away. Others (10.8\%) reported
that they would stop taking their medication gradually once their
symptoms disappeared.

\textbf{Discussion}

This study is the first to evaluate psychiatric patients living in rural
areas in Jordan with regards to their perspectives of their illness,
adherence to treatment, barriers to adherence, and the role of the
pharmacist. Results revealed that less than half of the patients
reported complete control of their symptoms with treatment, and most of
them always/usually adhered to their treatment.

Religious and cultural perspectives were unveiled; as the majority of
patients (72.5\%) believed that the psychiatric disorders are
never/slightly caused by a weakness of faith. Also, 69.2\% of them dealt
positively with their illness as being counted for their favor in the
Hereafter; this positive outlook about their illness correlated
significantly with better adherence to drug therapy (p\textless{}0.046).

Barriers to adherence included mainly suffering from medication adverse
effects. Only 14\% of patients reported that they refer to the
pharmacist to get information about their medications.

The study unveiled high rates of perceived public psychiatric disorder
stigma and self-stigma in patients who do seek medical help. This is
just one part of the more general picture since mental health stigma and
low mental health literacy were previously found to be the most powerful
barriers to seeking help (25). In this current study, anecdotal comments
provided by patients and their families present at the study clinic
indicate that many mental health patients in the rural areas in Jordan
do not come to the hospital to pick up their medications. Such behavior
cancels out any chance of being counseled and educated by the pharmacist
or even other healthcare professionals and delivery of evidence-based
therapy. This highlights the importance of socially destigmatizing these
disorders in rural areas, in which local pharmacists can play a crucial
role. Mental health education programs have been shown to positively
impact mental health literacy and stigmatizing attitudes and may be an
effective tool to use in rural areas (26).

In this study, most of the patients relied on the specialist to get
information regarding their mental illnesses and treatment. Similarly, a
previous study in Northern Jordan reported the same finding, as the
majority (68\%) of patients referred to their specialists for
information about their treatment (27). Although pharmacists are the
experts in medication use; lack of mental health counselling skills
might be the cause behind this hindered role (28). To be able to provide
professional care to those patients, pharmacists should improve their
skills and reflect on their attitude and belief when assisting patients
in need (29, 30).

Unlike pharmacists at community pharmacies, who are highly
accessibl\textbackslash{}soute, pharmacists in public hospitals of rural
areas like Jerash have weaker chances for counseling the patient, since
medications get dispensed through a window to patients or the patients'
relatives who would usually be standing in line before receiving their
medication, presenting physical and time barrier prohibiting optimal
pharmacist care.

It has been acknowledged previously that the majority of Muslims depend
on their religious believes when it comes to coping with their mental
distresses (19-22). This fact was consolidated through a study conducted
in Jordan previously, which involved patients with mental disorders who
reported that religion is an important factor affecting their treatment
(31). In this study, 69\% of the patients associated their mental
illness with their faith, considering it a source of good deeds.

In a previous study on psychiatric illnesses, the leading factors for
medication nonadherence were: ``not willing to use medication'', ``not
accepting the disease'', and ``being disturbed by side effects'' in the
bipolar disorder group, ``not accepting the disease'' in the
schizophrenia/schizoaffective disorder group, and ``feeling well'' in
the depression group (32). In our study, the main reason for reported
nonadherence was suffering from adverse effects, which signifies the
early involvement of the pharmacist in the management plan to recognize
and resolve these adverse effects in collaboration with the
psychiatrist.

Psychotherapy based interventions for mentally ill patients have been
shown to be effective for this group of patients (33-36). Most of the
patients in this study did not know about psychotherapy and reported
that they would have chosen it before medications if they had known
about it in the first place. Including psychotherapy in the management
of these patients, as an adjunct therapy with the pharmacological
treatment used, is important and can improve patient's adherence to
treatment (34). It could be associated with less stigma barrier and
increase the patient courage to seek help.

One recommendation from our research is for the academic institutes in
Jordan to introduce the subspecialty of ``psychiatric pharmacy'', in
which the pharmacist is provided with specialized knowledge, skills, and
training for working with patients with psychiatric or neurologic
disorders (37).

Limitations of the study include the fact that it was conducted in one
public hospital, which may not be representative of the situation in
other hospitals and psychiatric clinics in Jordan. This can limit the
generalizability of the study. Another barrier was shown thought the
anecdotal comments provided by many people present in the clinic at the
time of the study, indicating that a large number of patients do not
come to the clinic themselves to pick up their medications. Hence, the
present sample of patients does not cover those who do not attend the
clinic themselves to pick their medications and/or see the specialist.

\textbf{Conclusion}

This study provides insight into the perspectives of psychiatric
patients in rural areas with regards to their illnesses and their
medications, adherence, barriers to adherence, and the role of the
pharmacist. Less than half of the patients reported complete control
over their illness and most of them reported adherence to treatment.
Positive religious and cultural viewpoints correlated with better
adherence, while the main barriers decreasing adherence included
suffering from medication adverse effects and being unconvinced of the
need for medication. Most patients did not know about psychotherapy and
most of them declared that they would have chosen it before medication.
Choosing the pharmacist as a source of medication information was
minimal. Relevant strategies should be developed to improve pharmacist
participation in identifying patients in need for help and in dealing
with barriers to evidence-based therapy.

References

1. James SL, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, et al.
Global, regional, and national incidence, prevalence, and years lived
with disability for 354 diseases and injuries for 195 countries and
territories, 1990--2017: a systematic analysis for the Global Burden of
Disease Study 2017. The Lancet. 2018;392(10159):1789-858.

2. Chong WW, Aslani P, Chen TF. Health care providers' perspectives of
medication adherence in the treatment of depression: a qualitative
study. Soc Psychiatry Psychiatr Epidemiol. 2013;48(10):1657-66.

3. WHO. WHO-Aims Report on Mental Health System in Jordon URL:
https://www.who.int/mental\_health/evidence/mh\_aims\_report\_jordan\_jan\_2011\_en.pdf?ua=1.
2017.

4. WHO. Mental health in Jordan URL:
http://www.emro.who.int/jor/jordan-news/mental-health-in-jordan.html.
2008.

5. Kulkarni J, Liew J, Garland KA. Depression associated with combined
oral contraceptives--a pilot study. Aust Fam Physician. 2005;34(11):990.

6. Daradkeh TK, Alawan A, Al Ma'aitah R, Otoom SA. Psychiatric morbidity
and its sociodemographic correlates among women in Irbid, Jordan. 2006.

7. Gerteis M. Through the patient's eyes: understanding and promoting
patient-centered care. 1993.

8. Robb G, Seddon M. Quality improvement in New Zealand healthcare. Part
6: keeping the patient front and centre to improve healthcare quality.
The New Zealand Medical Journal (Online). 2006;119(1242).

9. Kennedy BM, Rehman M, Johnson WD, Magee MB, Leonard R, Katzmarzyk PT.
Healthcare providers versus patients' understanding of health beliefs
and values. Patient experience journal. 2017;4(3):29.

10. Ismayilova L, Hmoud O, Alkhasawneh E, Shaw S, El-Bassel N.
Depressive symptoms among Jordanian youth: results of a national survey.
Community Ment Health J. 2013;49(1):133-40.

11. Alkoudsi KT, Basheti IA. Prevalence of anxiety and depression among
women with Polycystic Ovary Syndrome living in war versus non-war zone
countries: A randomized controlled trial assessing a pharmacist
intervention. Res Social Adm Pharm. 2019;9(18):30751-4.

12. Roy Morgan News Poll. Images of Professions Survey.
http://www.roymorgan.com/findings/5531-image-of-professions-2014--201404110537
(accessed April 15, 2018) {[}

13. Basheti IA, Qunaibi EA, Hamadi SA, Abu-Gharbieh E, Saleh S, AbuRuz
S, et al. Patient Perspectives of the Role of the Community Pharmacist
in the Middle East: Jordan, United Arab Emirates and Iraq. Pharmacol
Pharm. 2014;5:588-99.

14. Basheti IA, Tadros OK, Aburuz S. Value of a Community-Based
Medication Management Review Service in Jordan: A Prospective Randomized
Controlled Study. Pharmacotherapy. 2016;36(10):1075-86.

15. Cicutto L, Dingae MB, Langmack EL. Improving asthma care in rural
primary care practices: a performance improvement project. J Contin Educ
Health Prof. 2014;34(4):205-14. doi: 10.1002/chp.21254.

16. Chapman SC, Horne R. Medication nonadherence and psychiatry. Current
opinion in psychiatry. 2013;26(5):446.

17. LeDoux J, Mann C, Demoratz M, Young J. Addressing spiritual and
religious influences in care delivery. Professional case management.
2019;24(3):142-7.

18. Swihart DL, Martin RL. Cultural religious competence in clinical
practice. StatPearls {[}Internet{]}: StatPearls Publishing; 2020.

19. Hestyanti YR. Children survivors of the 2004 tsunami in Aceh,
Indonesia. A study of resiliency. Annals of the New York Academy of
Sciences. 2006;1094:303-7.

20. Scholte WF, Olff M, Ventevogel P, de Vries G-J, Jansveld E, Cardozo
BL, et al. Mental health symptoms following war and repression in
eastern Afghanistan. Jama. 2004;292(5):585-93.

21. Eapen V, Revesz T. Psychosocial correlates of paediatric cancer in
the United Arab Emirates. Supportive care in cancer. 2003;11(3):185-9.

22. Koenig H, King D, Carson V. Coping with stress. Handbook of religion
and health, 2nd edn Oxford University Press, NewYork. 2012:74-93.

23. Karnouk C, Böge K, Hahn E, Strasser J, Schweininger S, Bajbouj M.
Psychotherapy in Jordan: An Investigation of the Host and Syrian Refugee
Community's Perspectives. Frontiers in Psychiatry. 2019;10(556).

24. Basheti IA, Reddel HK, Armour CL, Bosnic-Anticevich SZ. Counseling
about turbuhaler technique: needs assessment and effective strategies
for community pharmacists. Respir Care. 2005;50(5):617-23.

25. Waqas A, Malik S, Fida A, Abbas N, Mian N, Miryala S, et al.
Interventions to Reduce Stigma Related to Mental Illnesses in
Educational Institutes: a Systematic Review. Psychiatr Q.
2020;5(10):020-09751.

26. Corrigan PW, Morris SB, Michaels PJ, Rafacz JD, Rusch N. Challenging
the public stigma of mental illness: a meta-analysis of outcome studies.
Psychiatr Serv. 2012;63(10):963-73. doi: 10.1176/appi.ps.201100529.

27. Al\selectlanguage{english}-Jaddou H, Malkawi A. Prevalence, recognition and management of
mental disorders in primary health care in Northern Jordan. Acta
psychiatrica scandinavica. 1997;96(1):31-5.

28. Kirschbaum M, Peterson G, Bridgman H. Mental health first aid
training needs of Australian community pharmacists. Currents in Pharmacy
Teaching and Learning. 2016;8(3):279-88.

29. Douglass M, Moy B. Evaluation of the impact of a social
media--focused intervention on reducing mental health stigma among
pharmacy students. Mental Health Clinician. 2019;9(3):110-5.

30. Chowdhary A, Zlotnikova V, Lucas C, Lonie JM. How do mental health
first aid\selectlanguage{english} interventions influence patient help-seeking behaviours? A
dilemma for pharmacist mental health first aid responders. Research in
Social and Administrative Pharmacy. 2019;15(1):106-8.

31. Conrad R, Geiser F, Schilling G, Sharif M, Najjar D, Liedtke R.
Cross-cultural comparison of explanatory models of illness in
schizophrenic patients in Jordan and Germany. Psychological reports.
2007;101(2):531-46.

32. Mert DG, Turgut NH, Kelleci M, Semiz MJPp, adherence. Perspectives
on reasons of medication nonadherence in psychiatric patients.
2015;9:87.

33. Gonzalez JM, Prihoda TJ. A case study of psychodynamic group
psychotherapy for bipolar disorder. American journal of psychotherapy.
2007;61(4):405-22.

34. Gonzalez JM, Tinsley HE, Kreuder KR. Effects of psychoeducational
interventions on opinions of mental illness, attitudes toward help
seeking, and expectations about psychotherapy in college students.
Journal of College Student Development. 2002.

35. Giannakopoulos G, Assimopoulos H, Petanidou D, Tzavara C, Kolaitis
G, Tsiantis J. Effectiveness of a school-based intervention for
enhancing adolescents' positive attitudes towards people with mental
illness. Mental illness. 2012;4(2).

36. Shadish WR, Navarro AM, Matt GE, Phillips G. The effects of
psychological therapies under clinically representative conditions: a
meta-analysis. Psychological bulletin. 2000;126(4):512.

37. Goldstone LW, DiPaula BA, Caballero J, Park SH, Price C, Slater
MZJTMHC. Improving medication-related outcomes for patients with
psychiatric and neurologic disorders: value of psychiatric pharmacists
as part of the health care team. 2015;5(1):1-28.

\textbf{Table 1.} Patients' demographic characteristics (n=120).\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\begin{minipage}[b]{0.48\columnwidth}\raggedright\strut
\textbf{Gender}\strut
\end{minipage} & \begin{minipage}[b]{0.48\columnwidth}\raggedright\strut
n (\%) 80 (66.7) 40 (33.3)\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Male\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Female\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textbf{Age group}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
21-30\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
26 (21.7)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
31-40\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
38 (31.7)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
41-50\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
41 (34.2)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
51-60 61-70\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
14 (11.7) 1 (0.8)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textbf{Exercise} None Moderate Regularly\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
82 (68.3) 16 (13.3) 22 (18.3)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textbf{Caffeine intake}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
None Mild Moderate Sever\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
7 (5.8) 52 (43.3) 17 (14.2) 44 (36.7\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textbf{Insurance}\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Yes No\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
90 (75.0) 30 (25.0)\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2.} Medications used by the study participants (n= 120).\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
Percent \% & Frequency & Drug name\tabularnewline
\midrule
\endhead
21 & 33 & Citapram (citalopram)\tabularnewline
14 & 22 & Kemadrin (procyclidine hydrochloride)\tabularnewline
13.5 & 21 & Haldol (haloperidol) Injection\tabularnewline
10.3 & 16 & Prexal (olanzapine)\tabularnewline
5.1 & 8 & Camcolots (lithium)\tabularnewline
4.5 & 7 & Depakin (sodium valproate)\tabularnewline
4.5 & 7 & Lexopan (bromazepan)\tabularnewline
3.87 & 6 & Rispal (rispridone)\tabularnewline
3.22 & 5 & Tegretol (carbamazepine)\tabularnewline
2.5 & 4 & Esperal (quetiapine)\tabularnewline
2.5 & 4 & Prozac (fluoxetine)\tabularnewline
2.5 & 4 & Saroten (amitriptyline)\tabularnewline
1.9 & 3 & Eciphram (escitalopram)\tabularnewline
1.9 & 3 & Deanxit (flupenthixol)\tabularnewline
1.9 & 3 & Gabatrex (gabapentin)\tabularnewline
1.9 & 3 & Rivoram (clonzaepam)\tabularnewline
1.6 & 2 & Lamictal (lamotrigane)\tabularnewline
.6 & 1 & Stilnox (zolpedim)\tabularnewline
.6 & 1 & Olexa (olanzapine)\tabularnewline
.6 & 1 & Cilanem (imipenem)\tabularnewline
.6 & 1 & Paroxetine (paroxat)\tabularnewline
\bottomrule
\end{longtable}

\textbf{Figure legends}

\textbf{Figure 1.} Patients' perspectives (n= 120) on the cause that led
to their psychological illness.

\textbf{Figure 2.} Source of information about the psychological
illnesses and treatments reported by the patients (n=120).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/fig1/fig1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/fig2/fig2}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

