Clinical reappraisal of the Composite International Diagnostic Interview Version 3.0 in the Saudi National Mental Health Survey

Suicidal thoughts and behaviors in the Kingdom of Saudi Arabia

OBJECTIVE

Suicidal thoughts and behaviors (STB) constitute an escalating public health concern globally. Despite the growing burden of suicidal ideation, plan, and attempts, national information on the trends of STB is lacking in the Kingdom of Saudi Arabia (KSA). Therefore, we aim to report on the prevalence, correlates, and treatment-seeking behaviors associated with STB in the country using nationally representative information from The Saudi National Mental Health Survey (SNMHS).

METHODS

The SNMHS is a national household survey of Saudi citizens aged 15-65 (n = 4004). The adapted Composite International Diagnostic Interview (CIDI) 3.0 was administered to produce lifetime and 12-month prevalence and treatment estimates of STB in the KSA. Associated correlates were calculated using cross tabulations and logistic regressions.

RESULTS

Suicidal ideation, plan, and attempt had respective lifetime prevalence rates of 4.90 %, 1.78 %, and 1.46 %; 12-month prevalence rates of 1.82 %, 0.89 %, and 0.63 %. Significant correlates of STB include younger age, female gender, low education, urban rearing, and singe marital status. STB were also significantly associated with the presence of prior mental disorders, childhood adversities, and low treatment-seeking.

CONCLUSIONS

High unmet need and significant sociocultural and psychological risk factors have been identified in association with STB in the KSA. Given the community-based nature of the SNMHS and the limited national data on STB in the Middle East and North Africa region, our findings can extend to inform the necessary healthcare policies, treatment plans, and prevention strategies needed to alleviate the burdens of STB in the region.

Clinical reappraisal of the composite international diagnostic interview version 3.3 in Qatar's National Mental Health Study

OBJECTIVES

Lifetime DSM-5 diagnoses generated by the lay-administered Composite International Diagnostic Interview for DSM-5 (CIDI) in the World Mental Health Qatar (WMHQ) study were compared to diagnoses based on blinded clinician-administered reappraisal interviews.

METHODS

Telephone follow-up interviews used the non-patient edition of the Structured Clinician Interview for DSM-5 (SCID) oversampling respondents who screened positive for five diagnoses in the CIDI: major depressive episode, mania/hypomania, panic disorder, generalized anxiety disorder, and obsessive-compulsive disorder. Concordance was also examined for a diagnoses of post-traumatic stress disorder based on a short-form versus full version of the PTSD Checklist for DSM-5 (PCL-5).

RESULTS

Initial CIDI prevalence estimates differed significantly from the SCID for most diagnoses (χ 1 2 ${\chi }_{1}^{2}$  = 6.6-31.4, p = 0.010 < 0.001), but recalibration reduced most of these differences and led to consistent increases in individual-level concordance (AU-ROC) from 0.53-0.76 to 0.67-0.81. Recalibration of the short-form PCL-5 removed an initially significant difference in PTSD prevalence with the full PCL-5 (fromχ 1 2 ${\chi }_{1}^{2}$  = 610.5, p < 0.001 toχ 1 2 ${\chi }_{1}^{2}$  = 2.5, p = 0.110) while also increasing AU-ROC from 0.76 to 0.81.

CONCLUSIONS

Recalibration resulted in valid diagnoses of common mental disorders in the Qatar National Mental Health Survey, but with inflated prevalence estimates for some disorders that need to be considered when interpreting results.

The epidemiology of obsessive-compulsive disorder in the Kingdom of Saudi Arabia: Data from the Saudi National Mental Health Survey

AIMS

There is ongoing debate about the extent to which the epidemiology of OCD is similar across the world, given the lack of nationally representative data from key regions like the Middle East and North Africa. Using the nationally representative dataset from the Saudi National Mental Health Survey (SNMHS), we aimed to delineate the epidemiological profile of OCD in the Saudi population.

METHODS

A subsample of 1981 participants from the SNMHS was assessed. Prevalence estimates and correlates of OCD were determined using logistic regressions and cross tabulations.

RESULTS

The lifetime, 12-month, and 30-day prevalence estimates for OCD were 4.2%, 1.8%, and 1.6%, respectively, with hoarding being the most common symptom dimension. The mean age-of-onset of OCD was 16.8 years. In over two-thirds of respondents with lifetime (72.2%) or 12-month (71.2%), OCD was accompanied by comorbid mental disorder, particularly impulse control, anxiety, and mood disorders. Among individuals with 12-month OCD, 77.5% reported severe impairment, and only 9.2% received treatment.

CONCLUSIONS

In Saudi Arabia, OCD is a prevalent and persistent condition, characterized by early onset, high odds of mental comorbidity, and significant associated impairment. These findings emphasize the universality of OCD epidemiology and the need for improved diagnosis and treatment globally.

Dual burden of chronic physical conditions and mental disorders: Findings from the Saudi National Mental Health Survey

Introduction

Comorbidities of mental disorders and chronic physical conditions are a common medical burden reported among Western countries. National estimates of such comorbidities among the general population of Arab countries like Saudi Arabia are unknown. This study examined the prevalence of lifetime chronic physical conditions among the Saudi general population with DSM-IV 12-month mental disorders, and the associations with disability in the Kingdom of Saudi Arabia (KSA).

Methods

The Saudi National Mental Health Survey, a cross-sectional household study - part of the World Mental Health (WMH) Survey Consortium - was conducted between 2013-2016 in the KSA, with 4,001 Saudi citizens aged 15-65 (response rate 61%). The World Health Organization Composite International Diagnostic Interview 3.0 was used to assess prevalence of lifetime chronic physical conditions and 12-month mental disorders; disability was measured in terms of days out of role.

Results

The prevalence of any comorbid 12-month mental disorder among those with chronic physical conditions was 24%. Major depressive disorder, social phobia, and adult separation anxiety disorder were the most common comorbid mental disorders across all chronic physical conditions. Gender, education, income, urbanicity, region, and employment were associated with the presence of any chronic physical condition. Respondents with mental / physical comorbidities had 2.97 days out of role (on average) in the last 30 days.

Conclusion

Comorbidities of mental disorders and chronic physical conditions are common among Saudis. National efforts are needed to increase awareness of such comorbidities among the general population, and develop prevention and treatment services tailored to the needs of individuals at-risk for comorbidities.

Understanding the burden of mental and physical health disorders on families: findings from the Saudi National Mental Health Survey

OBJECTIVE

To assess prevalence and correlation of factors of family burden associated with mental and physical disorders in the general population of Saudi Arabia.

SETTING AND PARTICIPANTS

A secondary analysis of data from the Saudi National Mental Health Survey (SNMHS).

OUTCOME MEASURES

Mental and physical health disorders of first-degree relatives and objective (time, financial) and subjective (distress, embarrassment) family burden.

RESULTS

We found significant caregiver burden for family members with mental health disorders. Around one-third of the sample was providing care for a family member with a health issue. Within this group, 40% had a mental health diagnosis. 73% of the study population reported experiencing some form of burden as a result of the care they are obligated to provide for their family members. We found the highest burden on male caregivers, in providing care for family members with serious memory disorders, mental retardation, schizophrenia or psychosis, followed by, alcohol and drug disorders, anxiety, depression or manic depression.

CONCLUSION

Our findings for family burden were statistically significant, indicating potential negative impact on caregiver coping ability with the demands of caring for family members with health issues. A comprehensive review of national mental health policies is required to integrate aspects of community mental health promotion, scale-up prevention, screening interventions and social support to protect against the difficulties of mental illness and reduce the burden on caregivers, the family, society, health system and the economy.

Design and field procedures for the clinical reappraisal of the Composite International Diagnostic Interview version 3.3 in Qatar's national mental health study

BACKGROUND

The Composite International Diagnostic Interview (CIDI) has been clinically reappraised in several studies conducted mainly in the US and Europe. This report describes the methodology used to conduct one of the Middle East's largest clinical reappraisal studies. The study was carried out in conjunction with the World Mental Health Qatar-the first national psychiatric epidemiological study of common mental disorders in the country. This study aimed to evaluate the diagnostic consistency of core modules of the newly translated and adapted Arabic version of the CIDI 5.0 against the independent clinical diagnoses based on the Structured Clinical Interview for DSM-5 (SCID-5).

METHODS

Telephone follow-up interviews were administered by trained clinicians using the latest research edition of the SCID for DSM-5. Telephone administered interviews were key in the data collection, as the study took place during the COVID-19 pandemic.

RESULTS

Overall, within 12 months, 485 interviews were completed. The response rate was 52%. Quality control monitoring documented excellent adherence of clinical interviews to the rating protocol.

CONCLUSIONS

The overall methods used in this study proved to be efficient and effective. For future research, instrument cultural adaptation within the cultural context is highly recommended.

Urbanization and mental health: A perspective from Riyadh City, Kingdom of Saudi Arabia

BACKGROUND

While global studies demonstrated that features of urban living are associated with the risk of developing mental disorders, there remains a significant knowledge gap surrounding this topic in the Middle East and North Africa region.

AIMS

This study aims to assess the prevalence, severity, correlates, and treatment of mental disorders in Riyadh City by examining certain aspects of urban living such as exposure to traumatic events, early exposure to urbanization, and seeking treatment.

METHODS

The Saudi National Mental Health Survey is a community epidemiological survey in a nationally representative sample of citizens aged 15 to 65 in KSA. The World Health Organization Composite International Diagnostic Interview (CIDI 3·0) was used to estimate the 12-month prevalence of common mental disorders.

RESULTS

The prevalence of any mental disorder in Riyadh City was 29.2%. The most common disorders were anxiety disorders and mood disorders. Female, young, and previously married respondents were at higher risk for developing mental disorders. Exposure to traumatic events was associated with all types of mental disorders. Only 2.9% of those with any mental disorder sought mental health treatments.

CONCLUSIONS

We found a high prevalence of mental disorders in Riyadh City that could be attributed to certain features of urban living. These results may point to potential interventions in urban areas that can mitigate the adverse consequences of urban living and promote the salutogenic aspects of cities.

Lifetime prevalence and treatment of mental disorders in Saudi youth and adolescents

Previous global and regional studies indicate that adolescents and young adults (i.e., youth) are affected by various mental disorders with lifelong consequences. However, there are no national estimates of mental disorders prevalent among Saudi youth. Using data from the Saudi National Mental Health Survey (SNMHS), we examined the lifetime prevalence, treatment, and socio-demographic correlates of mental disorders among Saudi youth (aged 15-30). A total of 4004 interviews were conducted using the adapted Composite International Diagnostic Interview (CIDI 3.0). Cross tabulations and logistic regression were used to generate estimates for the SNMHS youth sample (n = 1881). The prevalence of a mental disorder among Saudi youth was 40.10%, where anxiety disorders affected 26.84% of the sample, followed by disruptive behavior disorders (15.44%), mood disorders (9.67%), substance use disorders (4%) and eating disorders (7.06%). Sex, education, parental education, income, marital status, region, and family history of disorders were significant correlates of various classes of mental disorders. Only 14.47% of Saudi youth with any mental disorder received treatment for a lifetime disorder. Age, parental education, and family history of disorders emerged as significant correlates of mental health treatment. Lifetime mental disorders are highly prevalent among Saudi youth. There is an unmet need for culturally sensitive and age-appropriate treatment of lifetime mental disorders among youth in Saudi Arabia.

The prevalence and correlates of bulimia nervosa, binge-eating disorder, and anorexia nervosa: The Saudi National Mental Health Survey

OBJECTIVE

Limited studies have been conducted in the Kingdom of Saudi Arabia on eating disorders (EDs). This study presents national epidemiological survey data on the prevalence and correlates of anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED) and their association with other mental health disorders, impairment in role functioning, and individual help-seeking behaviors in the Saudi National Mental Health Survey (SNMHS).

METHOD

A face-to-face survey was conducted in a nationally representative household sample of Saudi citizens aged 15-65 (n = 4004). The Composite International Diagnostic Interview (CIDI 3.0) was used to produce estimates of lifetime and 12-month prevalence and treatment of common DSM-IV mental disorders.

RESULTS

Twelve-month prevalence of any of the three EDs was 3.2%; the overall lifetime prevalence was 6.1%. Education and marital status were significantly associated with both 12-month and lifetime EDs prevalence. Significant mental health comorbidities associated with 12-month EDs were anxiety, mood, and impulse-control disorders, while lifetime EDs were significantly related to all disorders. A similar percentage of respondents that reported having ED-related treatment at some point in their lifetime utilized healthcare and nonhealthcare sector. There was a significant relationship between body mass index category, and lifetime BED and BN.

DISCUSSION

The 12-month prevalence of EDs in the Saudi population was higher than the EDs rates reported worldwide. These findings can help healthcare experts, and policymakers in the implementation of initiatives for raising awareness of EDs among the Saudi population, and the development of a country-wide plan for the prevention of EDs.

PUBLIC SIGNIFICANCE STATEMENT

The study presents data on the prevalence, correlates, and help-seeking behaviors of AN, BN, and BED, in the Saudi National Mental Health Survey (SNMHS). Obtaining information on this underrepresented region is essential due to the large differences in cross-national data in addition to cultural beliefs about mental illness and treatment seeking to exert an important influence on eating disorders. Such knowledge could provide a better understand of mechanisms underlying the development of eating disorders and thereby improve prediction, prevention, and treatment.

The comparative importance of mental and physical disorders for health-related days out of role in the general population of Saudi Arabia

Background

A major component of illness burden is role impairment. As part of the recently-completed Saudi National Mental Health Survey (SNMHS), we compare the number of days out of role in the Saudi population associated with ten core mental disorders assessed in the survey to those associated with ten commonly occurring chronic physical disorders.

Methods

The SNMHS was a household survey that assessed prevalence of ten common anxiety, mood, disruptive behavior, and eating disorders in a nationally representative sample of n = 1981 citizens of the Kingdom of Saudi Arabia (KSA) ages 15–65. Comparison information was obtained on prevalence of ten common chronic physical disorders and number of health-related days out of role (DOR) in the 30 days before interview. Generalized linear models were used to examine univariate and multivariable associations of disorders with DOR and to calculate population attributable risk (PAR) separately and overall for the disorders controlling for socio-demographics.

Results

19.9% of respondents had one or more of the selected mental disorders and 47.1% had one or more of the selected physical disorders. Nine mental disorders and two physical disorders were associated with increased DOR. PAR was 32.9% for mental disorders, 27.0% for physical disorders, and 59.9% for both combined.

Conclusions

Mental disorders are associated with a substantial proportion of all health-related DOR in the Kingdom of Saudi Arabia. Programs to detect and treat mental disorders might lead to substantially decreased role impairment in the Kingdom.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12721-z.

Conducting a state-of-the-art mental health survey in a traditional setting: Challenges and lessons from piloting the World Mental Health Survey in Qatar

OBJECTIVES

A small country in the Arabian Peninsula, Qatar experienced rapid economic growth in the last 3 decades accompanied by major socio-demographic shifts towards a younger and more highly educated population. To date, no national epidemiological study has examined the prevalence, associated factors, or sequelae of mental disorders in Qatar's general population.

METHODS

The World Mental Health Qatar (WMHQ) is a national mental health needs assessment survey and is the first carried out in collaboration with the World Mental Health Survey initiative to assess the prevalence and burden of psychiatric illnesses among the full Arabic speaking population (nationals and non-nationals) within the same country.

RESULTS

Standard translation and harmonization procedures were used to develop the WMHQ instrument. A survey quality control system with standard performance indicators was developed to ensure interviewer adherence to standard practices. A pilot study was then carried out just prior to the COVID-19 pandemic. Endorsement from public health authorities and sequential revision of the interview schedule led to full survey completion (as opposed to partial completion) and good overall response rate.

CONCLUSIONS

The WMHQ survey will provide timely and actionable information based on quality enhancement procedures put in place during the development and piloting of the study.

Twelve-month treatment of mental disorders in the Saudi National Mental Health Survey

OBJECTIVES

To estimate treatment rates of 12-month mental disorders in the Saudi National Mental Health Survey (SNMHS).

METHODS

The SNMHS is a face-to-face community epidemiological survey in a nationally representative household sample of citizens ages 15-65 in the Kingdom of Saudi Arabia (KSA) (n = 4,004). The World Health Organization Composite International Diagnostic Interview (CIDI) was used to produce estimates of 12-month prevalence and treatment of common DSM-IV mental disorders.

RESULTS

About one eighth (13.7%) of respondents with a 12-month DSM-IV/CIDI disorder received 12-month treatment. The highest proportion of treatment occurred in the general medical sector (53.0%). Close to half (45.2%) of patients received treatment rated at least minimally adequate using standard treatment guidelines. Although serious disorders were significantly more likely to be treated (20.2%) than mild or moderate disorders (8.5-10.7%), no association was found between disorder severity and probability of receiving adequate treatment. Sociodemographic correlates were for the most part nonsignificant.

CONCLUSIONS

A high level of unmet need for treatment of mental disorders exists in KSA. Further analyses of the SNMHS data might provide insights into modifiable barriers to treatment and policy options to address the problem of unmet need for treatment.

The Saudi National Mental Health Survey: Survey instrument and field procedures

OBJECTIVES

To present an overview of the survey and field procedures developed for the Saudi National Mental Health Survey (SNMHS).

METHODS

The SNMHS is a face-to-face community epidemiological survey of DSM-IV mental disorders in a nationally representative sample of the household population in the Kingdom of Saudi Arabia (KSA) (n = 4,004). The SNMHS was implemented as part of the WHO World Mental Health (WMH) Survey Initiative. WMH carries out coordinated psychiatric epidemiological surveys in countries throughout the world using standardized procedures designed to provide valid cross-national comparative data on prevalence and correlates of common mental disorders. However, these procedures need to be adapted to the unique experiences in each country. We focus here on the adaptations made for the SNMHS.

RESULTS

Modifications were needed to several interview sections and expansions were needed to address issues of special policy importance in KSA. Several special field implementation challenges also had to be addressed because of the need for female interviewers to travel with male escorts and for respondents to be interviewed by interviewers of the same gender.

CONCLUSIONS

Thoughtful revisions led to a high-quality field implementation in the SNMHS.

Lifetime treatment of DSM-IV mental disorders in the Saudi National Mental Health Survey

OBJECTIVES

To estimate lifetime treatment rates of mental disorders in the Saudi National Mental Health Survey (SNMHS).

METHODS

The SNMHS is a face-to-face community epidemiological survey in a nationally representative household sample of citizens ages 15-65 in the Kingdom of Saudi Arabia (KSA) (n = 4,004). The World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) was used to produce estimates of lifetime prevalence and treatment of common DSM-IV mental disorders.

RESULTS

Lifetime treatment ranged from 52.2% for generalized anxiety disorder to 20.3% for attention deficit/hyperactivity disorder, had a median (interquartile range) of 35.5% (30.6-39.5%) across disorders, and was 28.3% for people with any lifetime DSM-IV/CIDI disorder. Half (49.0%) of patients received treatment in the mental health specialty sector, 35.9% in the general medical sector, 35.2% in the human services sector, and 15.7% in the complementary-alternative medical sector. Median (interquartile range) delays in help-seeking after disorder onset among respondents who already sought treatment were 8 (3-15) years. Odds of seeking treatment are positively related to age-of-onset and comorbidity.

CONCLUSIONS

Unmet need for treatment of lifetime mental disorders is a major problem in KSA. Interventions to ensure prompt help-seeking are needed to reduce the burdens and hazards of untreated mental disorders.