THE MENTAL HEALTH LANDSCAPE IN SAUDI ARABIA

MENTAL HEALTH The mental health landscape in Saudi Arabia

Promoting and improving wellbeing during the COVID-19 pandemic, while reducing the stigma of mental illness

The COVID-19 pandemic has been an unprecedented global crisis. Uncertainty, loss of loved ones, social distancing, and economic insecurity have had a marked effect on mental health and exacerbated problems for those already suffering from mental disorders. How are Saudis coping with psychological distress, and how is the country dealing with this demanding situation? A few recent studies and surveys have offered an overview of the services, attitudes and challenges related to mental healthcare and wellbeing in the Kingdom.

Mental healthcare by the numbers

There were only two psychiatric hospitals in Saudi Arabia in the early 1980s, but mental health research and treatment have been made a greater priority and an urgent concern in past decades. The Kingdom’s General Department for Mental and Social Health, created in 1983, focused on allocating funding to mental healthcare, developing modern infrastructure, and training staff. Furthermore, in line with Saudi Vision 2030, the Ministry of Health aims to develop a new patient-centred healthcare system that takes into account social, mental, and physical wellbeing.1 The number of counselling clinics that provide primary mental healthcare has grown to 55.2

Saudi Arabia devotes 4% of its healthcare budget to mental health disorders, above the world average (<2%) but still behind other high-income countries (6%).3,4 With 19.4 mental health professionals per 100,000 citizens, the Kingdom’s rate is higher than the global average (6.6 per 100,000) but much lower than the world’s wealthiest countries (64.3 per 100,000).

While depression and anxiety disorders were some of the most prevalent mental illnesses even before COVID-19, the crisis has taken a toll on the mental health of a larger segment of the population. Researchers at King Saud University set up a social media survey to monitor mental health symptoms during the pandemic. They have reported that around 21% of the participants experienced moderate to very severe depression, 17.5% anxiety, and 12.6% stress.5 In keeping with findings from China, Italy and Spain, young adults, women, and people with a history of mental illness were more likely to suffer from severe symptoms.6,7

“This research is important to recognize the effect of COVID-19 and devise strategies for prevention and treatment,” says Ahmad N. AlHadi, an associate professor at King Saud University who led the study.5 He also emphasises the need for further studies and prevention and treatment programmes for other mental health issues, such as bullying, behavioural addictions (online gaming and social media), and burnout.

Providing counselling and focusing on prevention

Traditionally, studies on mental health carried out in the Kingdom have focused on specific diseases or populations, such as patients in hospitals. The first comprehensive scientific survey was conducted between 2011 and 2016, when Saudi Arabia became the first Gulf Cooperation Council state to join the World Mental Health Survey Initiative. The Saudi National Mental Health Survey (SNMHS), launched in 2010, which included 4,004 male and female participants between the ages of 15 and 65, found that approximately one in three Saudis are diagnosed with a mental health condition at some point in their lifetime. These results are comparable with data collected in France and the Netherlands.8,9

A number of initiatives have been organised in the Kingdom to help prevent or overcome the psychological distress caused by COVID-19. For example, the National Center for Mental Health launched the ‘Labayh Al Amal’ initiative in 2020 to provide confidential psychological counselling through a free smartphone app, as well as engaging public sector employees through the ‘Promoting Mental Health in the Work Environment’ programme to enhance their efficiency and productivity at work.10

Furthermore, the Saudi Center for Disease Prevention and Control published a ‘Preventive Guide for Mental and Social Health’, which recommends some best practices for mental health during the COVID-19 pandemic.11 For example, the guide highlights the importance of physical exercise, because integrating mental and physical health is considered an important prevention strategy. Saudi Arabia has the highest rate of physical inactivity among the Gulf Cooperation Council countries, and a recent Saudi survey found that moderate aerobic physical activity is associated with lower depression among male participants, leading to fewer symptoms of anxiety and depression.12

Open challenges: stigma and community perception toward mental health

The SNMHS survey also revealed that 80% of Saudis with severe mental health disorders do not seek any treatment, and around 9% of the population consult religious or non-medical healers.9 Stigma and other social barriers prevent people from visiting mental health experts, adhering to treatments, or even taking part in surveys related to mental health.13 As a result, vulnerable individuals delay medical treatments, making their condition become harder to treat.

The high prevalence rate of untreated mental disorders in the Kingdom, together

Globally, the COVID19 pandemic has had a detrimental effect on mental health and exacerbated problems for those already suffering from mental disorders.

with the negative perception and experience in mental health hospitals, highlight some of the unsolved challenges facing the country.14 Several studies also point to the need to invest in more research on mental health in women, migrants, the elderly, and young people, as well as the need for more support facilities tailored to them.

“Despite various attempts to address mental illness, this area of study is still in its early stages in Saudi Arabia,” explains Adel F Almutairi, a population health expert at KAIMRC and the King Saud Bin Abdulaziz University for Health Sciences.15 “Further research on women’s mental illness, societal barriers to getting assistance, stigmatization and adherence to treatments are all needed to control the rising risk of adverse mental health in the country.”

Promoting conversations around mental health can break taboos, encourage a positive attitude toward people with mental illness, and improve wellbeing.16 Researchers at Sulaiman Al Rajhi University found that a large majority of medical students had positive attitudes towards the mentally ill, and those who were more exposed to mental illness or were planning to specialise in psychiatry were also more willing to share a room with, or even marry someone with mental illness. This suggests that experience with mental illness and an interest in studying it reduce stigma, and promote inclusive and supportive behaviour.17

“Stigmatization of people with mental illness is an evident public health obstacle,” says Osama Zitoun, who led the study. “Further efforts should be needed to assess the situation and possibly propose interventions to tackle stigmatization of mental illness among the general population.”. Awareness of mental health issues, especially among youths, has been boosted by international celebrities opening up about their personal struggles with mental illness during COVID-19. While this is a heartening development, the data show that more can and should be done to address the stigma around mental illness and provide support for those who need it.

1. https://europepmc.org/article/MED/33245612 2. https://www.moh.gov.sa/en/Ministry/nehs/Pages/ vision2030.aspx 3 . Al-Subaie, Abdullah S., AbdulHameed Al-Habeeb, and Yasmin A. Altwaijri. “Overview of the Saudi National Mental Health Survey.” International Journal of Methods in Psychiatric Research 29.3 (2020): e1835. https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC7507437/ 4. World Health Organization. (2018a). Mental health atlas 2017. Geneva, Switzerland: World Health Organization. https://cdn.who.int/media/docs/default-source/ mental-health/mental-health-atlas-2017-countryprofiles/sau.pdf?sfvrsn=f82734c1_1&download=true 5. AlHadi, Ahmad N., Mohammed A. Alarabi, and Khulood M. AlMansoor. “Mental health and its association with coping strategies and intolerance of uncertainty during the COVID19 pandemic among the general population in Saudi Arabia: cross-sectional study.” BMC psychiatry21.1 (2021): 1-13. 6. Mazza C, Ricci E, Biondi S, Colasanti M, Ferracuti S, Napoli C, et al. A Nationwide survey of psychological distress among Italian people during the COVID-19 pandemic: immediate psychological responses and associated factors. Int J Environ Res Public Health. 2020;17(9):3165. https://doi.org/10.3390/ijerph17093165. 7. González-Sanguino C, Ausín B, Castellanos MÁ, Saiz J, López-Gómez A, Ugidos C, et al. Mental health consequences during the initial stage of the 2020 coronavirus pandemic (COVID-19) in Spain. Brain Behav Immun. 2020; 87:172–6. https://doi.org/10.1016/j.bbi.2020.05.040. 8. http://www.healthandstress.org.sa/Publications/ Articles/Al-Subaie%20et.%20al%202020%20-%20 Overview%20of%20the%20Saudi%20National%20 Mental%20Health%20Survey.pdf 9. Saudi National Mental Health Survey - Technical Report: http://www.healthandstress.org.sa/Publications/Articles/Al-Subaie%20et.%20al%202020%20 -%20Overview%20of%20the%20Saudi%20National%20 Mental%20Health%20Survey.pdf 10. Hassounah, Marwah, Hafsa Raheel, and Mohammed Alhefzi. “Digital response during the COVID-19 pandemic in Saudi Arabia.” Journal of Medical Internet Research 22.9 (2020): e19338. Journal of Medical Internet Research - Digital Response During the COVID-19 Pandemic in Saudi Arabia (jmir.org) 11. https://covid19.cdc.gov.sa/wp-content/uploads/2020/04/ EN_Preventive-Guide-for-Mental-and-Social-Health.pdf and https://covid19.cdc.gov.sa/community-public/mental-health/ 12. Althumiri, Nora A., Mada H. Basyouni, and Nasser F. BinDhim. “Exploring the Association Between Physical Activity and Risk of Mental Health Disorders in Saudi Arabian Adults: Cross-sectional Study.” JMIR Public Health and Surveillance7.4 (2021): e25438. 13. Alissa, Nawal A. “Social barriers as a challenge in seeking mental health among Saudi Arabians.” Journal of Education and Health Promotion10.1 (2021): 143. https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC8224481/ 14. Al Mousa, Yaqoub, et al. “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.” International journal of mental health nursing30.1 (2021): 300-316. 15. Almutairi, Adel F. “Mental illness in Saudi Arabia: an overview.” Psychology research and behavior management8 (2015): 47. 16. Dawood, Eman, and Omar Modayfer. “Public attitude towards mental illness and mental health services in Riyadh, Saudi Arabia.” Res Hum Soc Sci6 (2016): 63-75. 17. Zitoun, Osama A., et al. “Attitudes of medical students in Saudi Arabia towards mental illness and their beliefs regarding its causes and treatability.” Asian Journal of Psychiatry 56 (2021): 102515.