Current state of psychiatry in Saudi Arabia

Workforce estimate to treat mental disorders in the Kingdom of Saudi Arabia

BACKGROUND

Mental, neurological, and substance abuse (MNS) disorders describe a range of conditions that affect the brain and cause distress or functional impairment. In the Middle East and North Africa (MENA), MNS disorders make up 10.88 percent of the burden of disease as measured in disability-adjusted life years. The Kingdom of Saudi Arabia (KSA) is one of the main providers of mental health services and one of the largest contributors to mental health research in the region. Within the past decade, mental health resources and services has increased.

METHODS

We employ a needs-based workforce estimate as a planning exercise to arrive at the total number of psychiatrists, nurses, and psychosocial care providers needed to meet the epidemiological need of mental health conditions of the population of KSA. Estimates for a potential mental health workforce gap were calculated using five steps: Step 1-Quantify target population for priority mental health conditions. Step 2-Identify number of expected cases per year. Step 3-Set target service coverage for each condition. Step 4-Estimate cost-effective health care service resource utilization for each condition. Step 5-Estimate service resources needed for each condition.

RESULTS

The planning exercise indicates an epidemiologic need for a total of 17,100 full-time-equivalent (FTE) health care providers to treat priority MNS disorders. KSA appears to have a need-based shortage of 10,400 health workers to treat mental disorders. A total of 100 psychiatrists, 5700 nurses, and 4500 psychosocial care providers would be additionally needed (that is, above and beyond current levels) to address the priority mental health conditions. The shortfall is particularly severe for nurses and psychosocial workers who make up 98.9 percent of the shortfall. This shortage is substantial when compared to other high-income countries. Overall, the workforce needed to treat MNS conditions translates to 49.2 health workers per 100,000 population.

CONCLUSION

Challenges to addressing the shortfall are Saudi specific which includes awareness of cultural customs and norms in the medical setting. These challenges are compounded by the lack of Saudi nationals in the mental health workforce. Saudi nationals make up 29.5 percent of the physician workforce and 38.8 percent of the nursing workforce. Policymakers and planners supplement this shortfall with non-Saudi providers, who must be mindful of Saudi-specific cultural considerations. Potential solutions to reducing the shortfall of mental health care workers includes nurse task shifting and training of general practitioners to screen for, and treat, a subset of MNS disorders.

Labeled As Mentally Ill: Community Perspective Toward Mental Illness in Al Ahsa, Saudi Arabia

Background

Communities hold different opinions toward mentally ill people and treat them negatively, irrespective of their behavior. Differences in beliefs can impact not only affected individuals but the entire network and opportunities. This study aimed to examine beliefs about mental illness among different populations of the Saudi community.

Methodology

This descriptive study was conducted among 840 participants from several groups (different family roles, professions, medical and non-medical students, educated and uneducated, etc.) aged 18-75 years in Al Ahsa, Saudi Arabia. Information regarding participants’ demographics and beliefs toward mental illness was collected through validated measures. Data were analyzed using SPSS version 21 (IBM Corp., Armonk, NY, USA).

Results

Data analysis showed that individuals over the age of 30 years believed that mental illness is socially dysfunctional, incurable, and a subject of embarrassment. Married couples also considered mental illness to be socially dysfunctional and a subject of embarrassment. Similarly, unemployed participants had more negative views of mental illness than working individuals and students. Furthermore, educators and other professionals believed that mental illness is more socially dysfunctional than healthcare providers. In addition, community groups with a history of mental illness stated that mental illness is incurable. In the family context, grandparents’ beliefs toward mental illness were more negative than other family members’ views.

Conclusions

This study highlights the diversity in beliefs about mental illness among different groups of Arab society. The influence of poor knowledge, religious beliefs, and subjective attitudes should be explored further, and anti-stigma interventions should be implemented to increase community awareness about mental illness.

Saudi service users' perceptions and experiences of the quality of their mental health care provision in the Kingdom of Saudi Arabia (KSA): A qualitative inquiry

This paper presents, as part of a larger mixed-methods design, a study generating a theoretical understanding of issues pertinent to the quality of mental health care in the KSA from the perspective of those using services. Semi-structured interviews were undertaken with thirty service users admitted to inpatient psychiatric wards, using an interview guide developed by the researchers, based on relevant literature. Findings from the thematic analysis showed five themes: (1) The hospital as a prison: a custody versus care dilemma, (2) quality of interactions between staff and service users, (3) quality of services, (4) staff qualities and (5) suggestions for achieving quality of care. A theoretical model drawing upon Donabedian Health Care Model for Evaluating quality of care and the Andersen Behavioural Model of Health Service Use is evident from the data. Structural aspects of care include staff experience and qualifications and key enablers around social and financial support, service users' health needs and status and the physical infrastructure and ward rules. These drive processes of care based upon robust rates of interaction between staff and service users and appear central to quality of mental health care in KSA. Quality of mental health care in KSA is manifested by a therapeutic ethos with a high degree of interaction between professional carers and service users, with the former being highly educated, competent, compassionate, with a high degree of self-awareness, and specialized in mental health. We have uncovered elements of Fanon and Azoulay's 'Cultural Originality' as well as contemporary examples of Goffman's mortification of the self.

Geriatric Mental Health and COVID-19: An Eye-Opener to the Situation of the Arab Countries in the Middle East and North Africa Region

While the detrimental ramifications of the COVID-19 outbreak on the mental wellbeing of the general public continue to unravel, older adults seem to be at high risk. As the geriatric population continues to grow in the Middle East and North Africa (MENA) region, it is essential to explore the influence of this outbreak on geriatric mental health, a topic often neglected. In this review, we depict the status of geriatric psychiatry in the Arab countries of the MENA region, exploring the variations from one nation to another. While some have a null exposure to the field, resources and expertise in other countries range from very limited to extensive. Furthermore, we highlight the measures implemented in the Arab region to address mental health during the COVID-19 outbreak; these tend to be insufficient when targeting the geriatric population. Finally, we provide short- and long-term recommendations to stakeholders that aim at enhancing the mental healthcare of older adults in the Arab countries of the MENA region, particularly during this pandemic.

Psychiatric education and training in Arab countries

Little is known about psychiatric education among the Arab countries. This article aims at giving an overview on the current situation regarding the availability and quality of psychiatric undergraduate, postgraduate, and specialized training programmes in different Arab countries. A brief questionnaire was developed by the authors to assess the presence and duration of each programme as well as the teaching and assessment methods used. All participating countries reported having undergraduate programmes for medical students, most of them ranging from 3-7 weeks. A variety of teaching methods and objective assessment methods are used to evaluate the students. The duration of psychiatry residency training ranges from 3-5 years in the participating countries. All participating Arab countries have a national board of psychiatry in addition to the Arab board of psychiatry to certify the residency training programmes. Egypt offers a High Diploma, Master, and Doctorate (MD) degrees in psychiatry. Many residency training programmes in some Arab countries are based on and accredited from the American Board of Psychiatry and others are based on the Royal College of Psychiatrists curriculum in the UK. Great progress has been made in the past few years both in undergraduate and postgraduate psychiatric education among the different counties in the Arab world. However, still more effort is needed in order to reach standardization compared with other countries.

A Survey on Public Attitudes Toward Mental Illness and Mental Health Services Among Four Cities in Saudi Arabia

PURPOSE

Our objectives are to assess the public attitude toward mentally ill people and mental health services and to compare the attitudes of those who have past history of mental illness, those who have been exposed to mentally ill people, and those who have not.

MATERIALS AND METHODS

We conducted a cross-sectional study among subjects (n=1268) in four Saudi Arabian cities (Riyadh, Abha, Dammam, and Jizan), recruiting participants from malls and parks. All participants were administered "the knowledge and attitudes toward mental illness and mental health services scale".

RESULTS

Participants were divided into three groups; non-exposed to mental illness group (n=687, 54.1%), exposed to mental illness group (n=305, 24%), and having past history of mental illness group (n=276, 21.8%). Results revealed that non-exposed group had the lowest knowledge about mental illness (p <0.001). Exposed group had the best attitude toward mentally ill people (p=0.002), mental health services (p< 0.001), the lowest impact of traditional beliefs (p<0.001), and the best help-seeking decisions (p = 0.001). Regression models show the variables that predicted attitude toward the mentally ill were the attitude toward mental health services (p=0.001), impact of traditional beliefs (p=0.001), and residency (p=0.04). The predictors of attitude toward mental health services were impact of traditional beliefs (p<0.001), knowledge (p<0.001), and residency (p=0.028). And the variables that account for predicting future decisions were impact of traditional beliefs (p<0.001), attitude toward mental health services (p=0.001), and having past history of mental illness (p=0.006).

CONCLUSION

This study demonstrates significant differences in attitudes toward mental illness among different groups of participants. Lesser impact of traditional beliefs and better knowledge about mental illness were the factors most associated with better attitudes toward mentally ill people and mental health services and with better help-seeking behavior.

The Arab Region's Contribution to Global Mental Health Research (2009-2018): A Bibliometric Analysis

Background: Mental health research output in the Arab region is increasing, yet little is known about its recent landscape. This study provides a bibliometric analysis of mental health research in all 22 Arab countries over the past decade. Method: We used 760 journals and numerous keywords to search for articles published between 2009 and 2018 by individuals affiliated with institutions located in the Arab region. We analyzed data within Arab countries and between Arab and non-Arab countries. Results: We found that research output in the Arab world has increased by almost 160% in the past ten years, in comparison to 57% for the rest of the world. The quality of publications has also steadily improved, and so did international collaboration. Despite the progress, the number of articles per capita remains remarkably lower for the Arab world compared to the rest of the world. Also, the majority of articles continue to emanate from a limited number of countries (Egypt, Saudi Arabia, and Lebanon) and institutions within these countries. Mental health research topics in the Arab region are similar to those found in low- and middle-income countries of Africa, Asia, Latin America, and the Caribbean. Conclusion: The region needs to invest more in mental health research to close the gap with other medical and healthcare research areas and with the rest of the world. The region also needs to increase its international collaboration and research training to produce higher-quality studies, attract more funding, and publish more in top journals. As the region's population continues to face increasing trauma as a result of war and terrorism, among others, the field is afforded an opportunity to establish a major standing in the healthcare domain. Researchers are uniquely poised to use their body of research evidence to effectively help people reengage with their environments and return to daily life activities.

Mental health research in the Kingdom of Saudi Arabia: A review of trend and visibility over four decades

In the last few decades, there has been significant advancement in higher education and research in the Kingdom of Saudi Arabia (KSA) However, no research has quantified the studies on mental health in Saudi Arabia. The aim of this review was to review literature on mental health in KSA over the last four decades and compare it with studies done in other medical and surgical specialties. This narrative review is based on research published in the global scientific database of Web of Science, Scopus and Medline/PubMed. Mental Health Research of Saudi Arabia published since 1975 was retrieved. Publications related to other medical specialties such as surgery, internal medicine and pharmacology were also retrieved for comparison. A total of 159,796 studies related to medical and non-medical specialties were conducted in Saudi Arabia. A total of 52,699 related to medical specialties, 670 of which were on mental health and 52,029 on other medical specialties. At the beginning of the last decade there was a sharp increase in medical research (including mental health) publications from Saudi Arabia. Mental health research does not differ from research in other medical specialties in its output. In spite of the huge strides made in research in KSA, the provision of support for mental health research in the Kingdom is inadequate. Possible challenges and recommendations have been identified.

Media portrayals of mental disorder in Saudi Arabia: a review of popular newspapers

Newspapers are influential sources of information and opinion on mental health, but careless reporting may reinforce stigma. This review examined portrayals of mental disorder in Saudi Arabian newspapers. A cross-sectional sample (N = 200) of relevant articles was obtained from four of the most popular newspapers. These were categorised for descriptive and thematic analysis, using an established framework. The theme of highest frequency was advocacy, actions, and concerns; such articles were likely to have a positive impact by raising public awareness. Similarly, numerous reports with the theme of treatment and recovery informed readers of developments in mental health care, potentially breaking down barriers to seeking help. The theme of blame was found in a quarter of the articles; in addition to discussing environmental and genetic factors, there were several commentaries or reports on spiritual possession, which could perpetuate stigmatising ideas. While portrayals of mental disorder in Saudi newspapers show similarities to media coverage in other countries, distinct cultural perspectives were evident, including the prevailing notion of the 'evil eye'. The authors recommend collaboration of mental health experts, patients and family carers to devise guidelines for more accurate reporting of mental disorder by Saudi media.

Healthcare ecosystems research in mental health: a scoping review of methods to describe the context of local care delivery

BACKGROUND

Evidence from the context of local health ecosystems is highly relevant for research and policymaking to understand geographical variations in outcomes of health care delivery. In mental health systems, the analysis of context presents particular challenges related to their complexity and to methodological difficulties. Method guidelines and standard recommendations for conducting context analysis of local mental health care are urgently needed. This scoping study reviews current methods of context analysis in mental health systems to establish the parameters of research activity examining availability and capacity of care at the local level, and to identify any gaps in the literature.

METHODS

A scoping review based on a systematic search of key databases was conducted for the period 2005-2016. A systems dynamics/complexity approach was adopted, using a modified version of Tansella and Thornicroft's matrix model of mental health care as the conceptual framework for our analysis.

RESULTS

The lack of a specific terminology in the area meant that from 10,911 titles identified at the initial search, only 46 papers met inclusion criteria. Of these, 21 had serious methodological limitations. Fifteen papers did not use any kind of formal framework, and five of those did not describe their method. Units of analysis varied widely and across different levels of the system. Six instruments to describe service availability and capacity were identified, of which three had been psychometrically validated. A limitation was the exclusion of grey literature from the review. However, the imprecise nature of the terminology, and high number of initial results, makes the inclusion of grey literature not feasible.

CONCLUSION

We identified that, in spite of its relevance, context studies in mental health services is a very limited research area. Few validated instruments are available. Methodological limitations in many papers mean that the particular challenges of mental health systems research such as system complexity, data availability and terminological variability are generally poorly addressed, presenting a barrier to valid system comparison. The modified Thornicroft and Tansella matrix and related ecological production of care model provide the main model for research within the area of health care ecosystems.

Prevalence and determinants of physical activity in a mixed sample of psychiatric patients in Saudi Arabia

OBJECTIVES

To estimate prevalence of physical activity and its associations with various psychiatric disorders and the use of psychotropic medications.

METHODS

A cross-sectional observational study was carried out between July 2012 and June 2014. Patients were enrolled from a number of hospitals located in 5 regions of the Kingdom of Saudi Arabia.

RESULTS

A total of 1185 patients were included in current analysis: 796 were outpatients, and 389 were inpatients. Out of 1,185 patients, 153 (12.9%) were physically active. Much higher rates of physical activity were reported among males than females (15.9% versus 9.6%, p less than 0.001). According to the univariate analysis, higher rates of physical activity were positively correlated with primary bipolar disorders, the use of antianxiety medications and, to a lesser extent, use of antipsychotic medications, but they were negatively correlated with primary anxiety disorders, use of antidepressant medications, and use of multiple psychotropic medications. The associations between physical activity and primary bipolar disorders (odds ratio [OR]=2.47, p=0.002), use of antianxiety medications (OR=3.58, p=0.003), and use of multiple psychotropic medications (OR=0.33, p less than 0.001) remained significant after adjusting for demographic and clinical characteristics.

CONCLUSION

We report a variable but generally low prevalence of physical activity among a large, mixed sample of psychiatric patients in Saudi Arabia. These findings may highlight the importance of assessing physical activity status of psychiatric patients and the critical need for physical activity promotion programs among this group of disadvantaged patients.

Low Bone Mass Secondary to Antipsychotic Medications

Background and Objective:

Antipsychotic medications are known to cause low bone mass. The objective of this study was to assess the prevalence of osteopenia and osteoporosis secondary to patients taking antipsychotic medications.

Patients and Methods:

This prospective study included 175 patients taking antipsychotic medications and attending the psychiatric clinics at the King Fahd Hospital of the University, Al-Khobar, Saudi Arabia. Demographic data, antipsychotic medications, type, and duration of administration of medication were collected. All patients had bone mass measurement using dual energy X-ray (DXA) absorptiometry. Patients were divided into 5-year groups, from ≤35 to ≥51 years. The data were entered in the database and analyzed using SPSS Inc version 20.

Results:

The average age of patients was 40.75 ± 7.16 years (range: 26–56 years), there were 120 (82.8%) males and 25 (17.2%) females. Our results indicate that the average duration of anti-psychotic medication use was 8.45 ± 5.4 years. DXA of the hip revealed that 25 (14.2%) patients were osteoporotic and 104 (59.42%) were osteopenic, while on the basis of the T-score of the lumbar spine, 77 (44%) patients were osteoporotic and 80 (45.7%) were osteopenic. On the basis of the spinal bone mineral density (BMD), 89.7% had low bone mass.

Conclusion:

Anti-psychotic medications have a strong influence on the reduction of bone mass even in younger populations. The BMD of patients who are prescribed anti-psychotic medication need to be monitored for low bone mass and provided with the appropriate treatment.

Medication use for chronic health conditions among adults in Saudi Arabia: findings from a national household survey

PURPOSE

Chronic diseases and their risk factors are believed to be common in the Kingdom of Saudi Arabia (KSA). Most of them require long-term management through medications. We examined patterns of medication use for chronic health conditions (CHC) in KSA based on a national survey.

METHODS

The Saudi Health Interview Survey was a cross-sectional nationally representative household survey of 10,735 individuals aged 15 years or older in 2013. The survey consisted of a detailed health questionnaire. Current medications for CHC were assessed and classified based on the Anatomical Therapeutic Chemical classification.

RESULTS

Among the respondents, 11.8% (standard error = 0.4) reported taking at least one medication for CHC with a mean number of 2.05 (standard error = 0.05) medication items. In addition to older age (odds ratio = 1.94 per each decade, 95%CI: 1.83-2.05) and male gender (odds ratio = 1.22, 95%CI: 1.06-1.41), those with higher income were more likely to take medication. The most common medicines were drugs used for diabetes (A10 Anatomical Therapeutic Chemical code). The top 20 drugs accounted for about 80% of all medications. Only 32.7% of medications were reported to be used exactly as prescribed.

CONCLUSIONS

Compared with the prevalence of CHC in KSA, our study indicates a potential underuse of medications as well as non-adherence to the directions for use. Interventions such as improved clinical guidelines for healthcare providers to increase utilization of necessary medication and educational programs to improve patients' adherence are needed.

Depression in patients with chronic kidney disease on dialysis in Saudi Arabia

OBJECTIVE

Patients with chronic kidney disease on hemodialysis experience considerable psychological stress due to physical and social changes brought on by illness, increasing the risk of depressive disorder (DD). We examined the prevalence of DD and depressive symptoms, identified treatments for depression, and determined baseline demographic, social/behavioral, physical, and psychological correlates.

METHODS

A convenience sample of 310 dialysis patients in Jeddah, Saudi Arabia, was screened for DD using the Structured Clinical Interview for Depression and for depressive symptoms using the Hamilton Depression Rating Scale (HDRS). Established measures of psychosocial and physical health characteristics were administered, along with questions about current and past treatments. Bivariate and multivariate analyses identified independent correlates of DD and symptoms.

RESULTS

The prevalence of DD was 6.8 % (major depression 3.2 %, minor depression 3.6 %), and significant depressive symptoms were present in 24.2 % (HDRS 8 or higher). No patients with DD were being treated with antidepressant medication, whereas 28.6 % (6 of 21) were receiving counseling. Being a Saudi national, married, in counseling, or having a history of antidepressant were associated with DD in bivariate analyses. Correlates of depressive symptoms HDRS in multivariate analyses were Saudi nationality, marital status, stressful life events, poor physical functioning, cognitive impairment, overall severity of medical illness, and history of family psychiatric problems.

CONCLUSIONS

The prevalence of DD and depressive symptoms is lower in Saudi dialysis patients than in the rest of the world, largely untreated, and is associated with a distinct set of demographic, psychosocial, and physical health characteristics.