Oman is an Arab-Islamic country that lies on the eastern side of the Arabian Peninsula. It is bordered on the East by the Indian Ocean and on the West by Saudi Arabia and the United Arab Emirates. Oman’s population has an extremely large youth base, with about 65% below the age of 20 years.1 Each year, it is estimated that 0.3% to 0.4% of the population of Oman will incur brain injuries, principally from road traffic accidents, domestic accidents, and falls from date palms (a major cash crop).2,3 Other major causes of brain injuries in Oman are the "diseases of affluence"—mainly diabetes, hypercholesterolemia, and obesity—that lead to cerebral vascular diseases.1 Acquired brain injury is a growing public health problem in Oman.4 For these victims, healthcare protocols have been limited to the reduction of mortality in the past several years. With the advent of effective emergency care, faster transportation, and improved acute medical management, the mortality rate among the brain injured has decreased in Oman. These advances have left the medical system with increased responsibility in addressing the needs of the survivors, especially the long-term issues of disability.5,6 Disability results not only from physical and cognitive impairment, but also from deficits in the areas of emotion and initiation as well.7—9 These latter deficits often provide a vexing obstacle to the realization of a more advanced functional ability.10 The issue of lack of initiative or passivity is not unique to that with acquired brain injury. The incidence of passivity has been shown to vary from 18% to 90% for various neuropsychiatric and neurological populations.6,11—16
Marin,17 Starkstein, Petracca, Chemerinski,18 and Andersson, Krogstad, and Finset13 have suggested that the common overriding characteristic of these disorders could be encapsulated into a concept of apathy. Marin17,19 has operationalized the concept of apathy in terms of ability, interest, initiation of activity, motivation, awareness, and effective functioning into an 18-item rating scale, the Apathy Evaluation Scale (AES). Although the AES was essentially designed to diagnose and measure the severity of apathy,17 it has also been employed for case identification in neurological populations.6,13,20 Its psychometric properties have been found to be effective in some studies14,15,21—23 but not in others.24 Interestingly, the concept of neurologically based apathy has been difficult to distinguish from depression in some patients.25 Both seem to occur in significant proportions in the brain injury population.26 While some studies have noted that apathy and depression seem to refer to separate entities, these studies were not executed in cross-cultural populations. Further, few studies have examined the validity of the AES in cross-cultural populations. It is not clear that a measure of apathy developed in a Western culture might have such a broad applicability as to appropriately apply in Oman. The AES may rely on behaviors and attitudes essentially limited to European and North American cultural groups. Further, it is not clear that the problem of passivity or apathy that is so prevalent among those with brain injury in the West might also be as prevalent in the culture of Oman. If we are to apply the AES to those who suffer brain injury outside of the European cultural catchment, we must first explore whether such a use is appropriate. As an initial step, studies are needed to clarify whether a disturbance of motivation is similarly prevalent or disruptive in cross-cultural populations. Second, it is important to determine whether there is a distinction between depression and apathy in the Omani population. For example, Pang et al.27 showed that, in contrast to their American counterparts, patients with Alzheimer’s disease in a Chinese environment exhibit apathy and depression that are unlikely to be viewed with contempt or as a social burden by their society. In the Arab world, disturbances of mood frequently manifest in a somatic metaphor28 that contrasts with the "cognitive metaphor" often discussed among populations in the industrialized world. To explore these issues, therefore, it is important to first measure the incidence of apathy. We, therefore, sought to use the AES to measure the incidence of apathy in an Omani brain-injury population. Since the AES elicits symptoms of both apathy and depression, we also examined whether AES could discriminate between depression and apathy among patients in our sample.
The specific aims of this study were 1) to screen and detect the prevalence and severity of apathy among males and females who have sustained traumatic brain injury (TBI) in Oman; 2) to assess the validity of the Arabic version of the AES as a screening instrument for a TBI population in Oman; and 3) to determine whether depression and apathy could be seen as separate entities in an Omani brain-injury population.