Oman. Sociodemographic and Clinical Characteristics of Patients attending Psychotherapy in a Tertiary Care Hospital in

the Omani health care system. This study aimed to investigate the sociodemographic and clinical characteristics of attendees at a psychotherapy clinic at a tertiary care hospital. Methods: An analysis was carried out of 133 new referrals to the Psychotherapy Service at Sultan Qaboos University Hospital, a tertiary care hospital. Results: The majority of referrals were females (59%), aged 18–34 years, employed (38%), had ≤12 years of formal education (51%), and were single (54%). A total of 43% were treated for anxiety disorders (including obsessive compulsive disorder), while 22% were treated for depression. A total of 65% were prescribed psychotropic medications. The utilisation of the Psychotherapy Service and its user characteristics are discussed within the context of a culturally diverse Omani community which has unique personal belief systems such as in supernatural powers ( Jinn ), contemptuous envy ( Hassad) , evil eye ( Ain ) and sorcery ( Sihr ) which are often used to explain the aetiology of mental illness and influence personal decisions on utilising medical and psychological treatments. Conclusion: Despite the low number of referrals to the Psychotherapy Service, there is reason to believe that psychotherapy would be an essential tool to come to grips with the increasing number of mental disorders in

S tudies have been conducted (mainly within Euro-American populations) to explore factors associated with the utilisation of psychotherapy services as they are increasingly being prescribed, in addition to medical treatments, to mitigate emotional and cognitive disorders. [1][2][3][4][5][6][7][8] In recent years, the proportion of persons seeking outpatient treatment for depression has increased, in addition to the prescription of antidepressant medications. 8 In contrast, over a ten year period the number of persons seeking psychotherapy had decreased which may suggest an increase in the trend to seek biological interventions. 8 Others have suggested that the decline in the utilisation of psychotherapy may be due to the growth of 'self-help' materials, the increasing popularity of complementary and alternative medicines, and the increased accessibility of over-the counter medications. [9][10][11][12][13] Therefore, exploring trends in the utilisation of psychotherapy is important to shed light on the patterns of health care utilisation. Recent studies have explored the demographic, gender, ethnic and cultural characteristics of psychotherapy users and found that females are more likely to participate in psychotherapy than males, and that there is a preponderance towards Caucasian populations utilising psychotherapy. 7,14,15 The cultural context of psychotherapy utilisation is therefore significant. Psychotherapy, rather than medical treatments, is favoured more generally by Euro-American populations who have greater access to wider health care information and treatment choices. Until relatively recently, within non-Western societies, culturally˗driven healing practices were traditionally used to manage mental health problems. However, the rapid urbanisation and globalisation of non-Western societies has now led to an increased interest in the application of Western psychotherapy. 16 This indicates increased awareness about the benefits of psychotherapy and its outcomes, 17 but there is a dearth of information about the development and utilisation of psychotherapy in non-Western societies. 18 Evidence suggests that socio-cultural patterning through the generations has had a significant influence on the assumptions of health care authorities about the therapeutic and economic value of developing psychotherapy services. This may be due to the inherent self-exploration component of psychotherapy which is discouraged within non-Western societies in favour of a collectivist approach to well-being. In addition, it may be that non-Western societies value traditional social support systems and thus perceive modern "talking therapies" as similar to these, thereby reducing the perceived value of speaking with a professionally qualified practitioner. 14 Generally, within Arab countries, there is limited access to and availability of mental health services. Therefore, even without considering the sub-specialty of psychotherapy, there is a paucity of studies investigating the demographic and clinical characteristics of mental health service users; this includes sources and reasons for referral, diagnosis of the client, psychotropic medication use, and the need for inpatient care. In Oman, general mental health services have developed slowly with recent reports indicating that there are approximately 39 qualified registered mental health professionals in the country. 19 Considering that Oman has a population of approximately three million people distributed over 300,000 square kilometers, this indicates that the mental health needs of the population will be largely unmet. 19 Furthermore there is scarcity of professionally qualified Arabic speaking psychotherapists. 17 Investigating these trends in the sociocultural context of Oman is of special interest as Oman is economically a developing country experiencing rapid modernisation, urbanisation, and acculturation. Oman has its own unique cultural and religious teachings in comparison with other Arab populations and these are transmitted by older generations to younger cohorts. 33 As a result, the development and expression of a unique individualistic self may be compromised by collectivist beliefs. 20 Omani culture also has unique beliefs about seeking professional mental health consultation. Data from within Oman has shown that, contrary to expectations, traditional Omani persons do not hold stigmatising views about people diagnosed with mental illness. 21 However, some cultural beliefs regarding the attribution of mental illness may be associated with supernatural powers (Jinn), contemptuous envy (Hassad), the evil eye (Ain) and sorcery (Sihr), 20 which are held by both younger and older generations. These beliefs may impact the utilisation of psychotherapy services. Therefore, our study objective was to investigate the clinical and demographic characteristics of a psychiatric population utilising a newly developed (and to our knowledge the only), psychotherapy service within the Omani public health care system.

Methods
All consenting patients who were referred to the Psychotherapy Service within the Department of Behavioural Medicine at Sultan Qaboos University tertiary care hospital (SQUH) were included in this study. Data were collected for both inpatients and outpatients (n = 133) during the period September 2009 to March 2010. The progress notes of patients, kept in the SQUH elextronic system, were reviewed to obtain the socio-demographic and clinical information of patients for the study. Referrals were taken through an internal system within the Department of Behavioural Medicine (Psychiatry) and from other hospital medical departments. Referral forms collected information on patient demographics, psychiatric diagnosis, reason/s and level of urgency for the referral and other relevant medical information such as medical diagnosis, medications use, and comorbidities. External referrals from private hospitals, Ministry of Health hospitals, and primary care health centres were made directly to the Psychotherapy Service and were included in the sample. The study design is a retrospective one with a non-probability convenient sampling of patients.
The psychotherapy service was a newly established team within the Department of Behavioural Medicine and comprised three staff members. There were two postgraduate qualified psychologists (Ph.D. Health Psychology and an M.A. in Clinical Psychology) and one assistant psychologist (B.Sc. Psychology). All staff provided psychotherapy after training in Western academic educational institutions in the UK, the USA and Canada. All staff members received regular individual and group peer supervision. Individual supervision was conducted once a week (2 hours) for each staff member by the senior member of the team (PhD) and the senior psychologist received regular individual supervision from an overseas clinical supervisor through telephone and video sessions. Peer group supervision was conducted once a month with all staff to discuss challenging cases.
Psychotherapy sessions mainly utilised cognitive behavioural therapy (CBT) as a mode of treatment due to the wealth of data on the efficacy of CBT to treat Axis I disorders (these include all clinical psychiatric disorders-major mental disorders, learning disorders and substance use disorders). 22 Therapy commenced with a first assessment consultation and then with follow-up psychology consultation sessions. Psychotherapy sessions lasted 90 minutes for the first assessment, with a consultation follow-up session lasting 50 minutes. Information about patients' diagnoses was collected at the time of the referral from the referring physician. Patients were diagnosed by consultant psychiatrists and physicians based on the International Classification of Diseases, 10th Edition (ICD-10) diagnostic criteria. 23 Patients who were referred to the Psychotherapy Service were grouped into ten ICD-10 diagnostic categories: schizophrenia; bipolar disorder; depression; phobias; other anxiety disorders; obsessive compulsive disorder; reactive stress and adjustment disorders; dissociative and somatoform disorders; non-organic sleep disorders, personality disorders; and emotional disorders of childhood. Information concerning psychotropic medication use was collated from the electronic medical record at the time of their first psychotherapy session and classified according to British Formulary System therapeutic classes, 24 e.g., antipsychotics, benzodiazepines, mood stabilizers, antidepressants and lithium.

Results
The total number of referrals to the Psychotherapy Service was 133 patients. Females were more prevalent in the referral sample (59%) compared to males (41%). The age range was from 13 to over 65 years. A total of 38% of the referred patients were employed, 25% were unemployed and approximately a third of the sample was students. As to education levels, 34% of patients had less than 12 years of formal education, 46% had a diploma or Bachelor's degree (13-16 years of education), while about 3% had graduate education. As for marital status, 42% were married, 54% single and 7% separated/divorced or widowed.
A total of 91% of the referrals came internally from the Department of Behavioural Medicine (psychiatry), with most patients being referred for the treatment of a primary mental health disorder [ Table 1]. The remainder of the referrals was from other SQUH medical departments/wards, and the request was to treat psychological adjustment difficulties associated with medical conditions such as migraines, musculoskeletal and neurological conditions. Only 4% of referrals came from external regional hospitals, primary care health clinics from the capital city (Muscat), or from rural areas.
The majority of referrals (28%) were for the treatment of anxiety disorders with 14% for phobias (primarily social phobia), 22% for clinical depression and 15% for obsessive compulsive disorder (OCD); the latter, with other comorbid conditions, constituted 10% of all referrals for mental health reasons. Approximately 65% of the sample was prescribed psychotropic medications and the majority of these were on antidepressants (84%). Only 12% of referrals were hospitalised either at the start of psychotherapy (i.e. referred as inpatients), or were admitted to the hospital psychiatric ward during the course of psychotherapy (see Table 1 for a summary of referral data).

Discussion
A significant proportion of the referrals in our population was young adults between 18 and 44 years old. In addition, there was a preponderance of females in our sample which also corroborates with other studies. 6,7 This may suggest that female gender is more likely to be associated with greater utilisation of mental health services in a clinical setting, and not only in a community setting as previously reported. 20 Two hypotheses for this difference might be suggested. First, women from non-Western societies experience more socio-cultural stressors (e.g. financial, familial, marriage) compared with males and are therefore more vulnerable to mental distress and seek greater support from health care services. However, this gender specific finding has not been generally observed in the region. 26 Second, it is possible that "masculine" identity (e.g. strength, dominance, authority) within a predominantly male -orientated culture as in Oman may prevent males from seeking psychological support. It has been speculated that 'expressing one's feelings' may be seen as sign of wounded masculinity. 27 Previous studies have been inconsistent regarding the utilisation of psychotherapy and users' educational level. Previous studies have found that persons with little formal education are less likely to seek psychotherapy services compared to their more educated counterparts, 6,7,28 whereas a more recent study has shown that psychotherapy is no longer the province of intelligent and successful individuals. 29 Our results indicated that patients with a low level of formal education were the predominant users of the psychotherapy service. This may be explained by the fact that Oman has a universal free health care system for all of its nationals which allows them to utilise a wide variety of services across the country. 30 Also, the Department of Behavioural Medicine serves patients from all levels of education, but it so happened that those referred were those with lower education as they are unable to access more expensive private treatment. It may have been concluded from previous data that educated persons are more likely to have higher socio-economic status and therefore are more able to afford expensive psychotherapy treatments which are not always freely available in Western cultures, or prioritised only for severely unwell patients. The trend shown in this study is welcome given that persons with little formal education have been found to have a greater prevalence of mental health disorders. 31 Some studies have shown that there is an inconsistent relationship between rates of psychotherapy utilisation, employment status and income level. 6,7 However, recent trends have shown that there is a significant increase in the rate of psychotherapy for unemployed adults which are consistent with the findings of our study. 7 Previous studies have found that separated/ divorced persons are more likely to utilise psychotherapy compared to married persons; 6,7 however, our results found that separated and divorced patients constituted only a small proportion of the referrals. This may be explained by the stigma placed on divorcees in the Arab/Islamic societies 32 although it may be possible that emotional distress was reduced in this population due to the support of a communal society with close family networks. In contrast, in our study, married persons and never married (single) persons constituted the majority of attendees to psychotherapy sessions. The larger number of single and married persons may reflect the cultural and religious emphasis on importance of marriage at a relatively young age. This cultural emphasis stems from the socio-cultural teaching that that marriage is a strong institution for the wellbeing of the society. 33 As a result, single young adults were experiencing a cognitive conflict of cultures that required them to engage in new traditions of higher education and work whilst adhering to older traditions of marriage and family.
Our study showed that a third of psychotherapy referrals were for anxiety disorders which is consistent with recent data emerging from other Arab countries which have shown that anxiety levels were higher in four Arab countries when compared to four Western countries. The authors conclude that rapid societal transition within these cultures from a collectivist world view to an individualistic orientated attitude has brought additional stressors, responsibilities and negative experiences which have heightened general anxiety within the population. 34 Furthermore, the rate of depressed patients within the referrals may also reflect the changes within Omani society in the last 25 years which has undergone significant socio-cultural modernisation and urbanisation. These changes may be associated with increasingly high depression rates. 30,35 The very small proportion of referrals for persons diagnosed with other disorders such as dissociative and somatoform disorders, schizophrenia, bipolar disorder and personality disorders may reflect a bias by referring psychiatrists who may be less inclined to refer persons who may require more frequent long-term therapy and who they may believe would have a less beneficial outcome from psychotherapy. The service was predominantly utilised by young adults; however, as the older population were under-represented in the sample, this number may actually be an underestimation of those in need of professional mental health services. 20 One broad hypothesis may provide a suggestion about the gap between service utilisation and the older generation which could be related to the beliefs about the value of psychiatric/mental health services and social/cultural teachings in treating mental health disorders. This is evidenced by the equal number of persons utilising allopathic and non-allopathic care services, with approximately 60% of Arabic patients visiting a traditional healer before seeking help from a psychiatrist. 20,36 The perceived value of traditional healers who adopt a culturally-sensitive therapeutic framework may play a role in the desire of traditional (and older) Omani persons to seek treatment through traditional means. From a cultural perspective, traditional healers help distressed people to relieve their stress through spiritual means, given that distress is attributed to external forces such as Ain (evil or envious eye) and Jinn (supernatural powers). A recent study conducted in Oman described the attitudes of women towards help-seeking behaviour for emotional distress and the views of their general physician. The data showed that both professionals and patients believed in external forces such as Ain and Jinn and in fate or God's will as a rationale for coping with mental health problems. Both professionals and patients prioritised traditional and faith practices, such as praying and reading the Qu'ran, as an initial treatment method to relieve emotional distress rather than seeking medical consultation. 37

Conclusion
This study has revealed trends in the referral process to a newly developed Psychotherapy Service in Oman. Such trends are relevant to the emerging changes in Omani society. Data suggest that the prevalence of anxiety, particularly social phobia and depression, within the sample may indicate that rapid socio-cultural changes and urbanisation are impacting the population's mental health. Recent affluence in the country through the discovery of oil fields and rapid modernisation has eroded traditional values and the simple outlook on life which was prevalent only 25 years ago. These changes will have repercussions for the adjustment of the older population in particular. However with a predominantly younger generation now being exposed to a wider global view it is possible that we are seeing a trend developing in their need for selfexpression which can be seen through the utilisation of psychotherapy. This study serves as the basis for future research on psychotherapy utilisation in Oman. It is important for health care planners in Oman to start to prioritise the specialist education and training of mental health practitioners and to explore the psychotherapy service requirements for a nation of people who are tentatively beginning to value and embrace its concepts, methods and outcomes.
This study has several limitations. The Psychotherapy Service study sample was from a tertiary care university teaching hospital in the capital city of Oman, where referrals were mainly made by hospital psychiatrists after seeking patients' consent to be referred for psychotherapy. Our study population may have had more severe psychiatric problems compared to patients being seen within the primary care health care sector (e.g. private health clinics), or in provincial hospitals in Oman. However, our patients may also be more stable than treatment resistant cases that are treated within specialist mental health services within Oman (Ibn Sina Hospital). Also our ability to generalise to a wider Omani population from a more rural geographic location may be limited as, for logistical reasons, the majority of our patients were from the capital city or nearby towns. Finally, patients who are self-selecting and motivated to prioritise psychotherapeutic treatments over medication usage were more common in our study population which may be significant for the type of psychiatric problems identified within the service.