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http://dx.doi.org/10.2147/NDT.S48782
Mental health system in Saudi Arabia: an overview
Naseem Akhtar Qureshi1
Abdulhameed Abdullah Al-Habeeb2
Harold G Koenig3
1General Administration for Research and Studies, 2Mental Health and Social Services, Ministry of Health, Riyadh, Saudi Arabia; 3Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
Correspondence: Naseem Akhtar Qureshi General Administration for Research and Studies, Sulaimania Medical Complex, Ministry of Health, Riyadh 11176, Saudi Arabia Tel +966 1 473 5038 Fax +966 1 473 5039 email [email protected]
Background: There is evidence that mapping mental health systems (MHSs) helps in planning and developing mental health care services for users, families, and other caregivers.
The General Administration of Mental Health and Social Services of the Ministry of Health
over the past 4 years has sought to streamline the delivery of mental health care services to
health consumers in Saudi Arabia.
Objective: We overview here the outcome of a survey that assessed the Saudi MHS and suggest strategic steps for its further improvement.
Method: The World Health Organization Assessment Instrument for Mental Health Systems was used systematically to collect information on the Saudi MHS in 2009–2010, 4 years after
a baseline assessment.
Results: Several mental health care milestones, especially provision of inpatient mental health services supported by a ratified Mental Health Act, were achieved during this period. However,
community mental health care services are needed to match international trends evident in
developed countries. Similarly, a larger well-trained mental health workforce is needed at all
levels to meet the ever-increasing demand of Saudi society.
Conclusion: This updated MHS information, discussed in light of international data, will help guide further development of the MHS in Saudi Arabia in the future, and other countries in the
Eastern Mediterranean region may also benefit from Saudi experience.
Keywords: Saudi Arabia, mental health system, organization, legal issues, research, training
Introduction The global scenario of mental health systems (MHSs) is in continuous flux, and includes
the following nine interconnected components: “(1) mental health policies, plans and
programs, (2) legislation and regulations governing mental health service organization
and practice, (3) mental health financing and payment arrangements, (4) organization
of service programs for detection and treatment of mental illness, including reliable
supply of psychotropic medicines, and rehabilitation services, (5) systems for train-
ing of mental health practitioners from all relevant disciplines, (6) the mental health
information systems that enable planning, monitoring and evaluation, (7) programs
that are devoted to mental health promotion and illness prevention, (8) social arrange-
ments that promote social participation including work and income support for people
with mental illness, and (9) the political, sociocultural and economic environment in
which all this occurs.”1 Previously, we have described the MHS in Saudi Arabia (SA).2
Subsequently, a project initiated by the World Health Organization (WHO) Eastern
Mediterranean Regional Office (EMRO) was conducted to collect data systematically
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on the Saudi MHS using the WHO Assessment Instrument for
Mental Health Systems (AIMS) 2.2.3 This paper will briefly
review the global landscape regarding MHSs, describe the
current MHS in SA, and then discuss the findings based on
what is known about MHSs in other countries.
Literature search We conducted a computer search of PubMed, Medline,
Quertle, and Google Scholar using the keywords “mental
health system,” “rights of patients and policy,” “primary
care psychiatry,” “psychiatric training,” and “mental
health research.” Many articles across the four websites
were retrieved (n = 35,670). First, we excluded those articles not relevant to the main topic of MHS (n = 33,430). Then, we excluded articles not published in English peer-reviewed
journals (n = 235). Articles without abstracts (n = 540) were also excluded. Articles overlapping across three websites
were also excluded (n = 1,371). Finally, only full papers (n = 94) that focused on MHSs and were published in peer-reviewed English journals were retained for further
intensive review. The retained papers included had random-
ized designs, and were original research papers, systematic
reviews, meta-analyses, scientific reports, and publications
on WHO websites.
Global landscape of MHSs The MHS in the US is a large industry that spends more than
$113 billion/year on mental health treatment, which makes
up 5.6% of national health care spending.4 The amount the
US invests in its MHS is similar to that of other high-income
countries, such as Australia, though according to a WHO
report, Egypt leads the group of surveyed countries, spending
9% of its health care budget on MHSs.5 Despite this large
investment in MHSs, access to mental health professionals
is limited in the US compared to other physician specialties,
and millions of people live in mental health service-shortage
areas.6 Furthermore, many child and adult patients with men-
tal health problems (up to 70%) and addictions (90%) do not
get mental health care. Nearly one-half (46%) of patients with
mental health problems give high costs as a barrier to treat-
ment, though stigma against mental disorders also remains
an important barrier to seeking psychiatric treatment.7
Kazdin and Rabbitt have summarized the challenges the
US MHS faces, discussing barriers to utilization of mental
health services, and offering novel models of delivering
psychological services to people most in need.8 More or less
similar trends in the prevalence of mental disorders, modes
of service delivery, access to mental health care services,
focus on community services, costs, and challenges are
reported by other Organisation for Economic Co-operation
and Development countries.9 Notably, six strategies have
been suggested to improve the Canadian MHS, including one
that focuses on achieving greater awareness, the workplace,
children, youth, and seniors.10 Olson compares the MHSs
of four high-income countries: the UK, Norway, Canada,
and the US.11 Each system is described under five headings:
overview, needs for MHSs, policies and programs, delivery
systems and financing systems, and evaluation. Evaluation
focuses on access and equity, quality and efficacy, cost and
efficiency, financing and fairness, protection and participa-
tion, and population relevance.11
The quality of the MHS varies by country.12 Improving
MHSs and reforms is globally needed, but especially in
low- and middle-income countries (LAMICs), including
the Middle East. According to that review, resources needed
for good mental health care are well articulated, and include
appropriate policy and infrastructure support, an adequate
range of MHSs, community resources, appropriate numbers
of mental health professionals, and adequate funding. Scarcity
of available resources, poor distribution, and inefficiencies
are the three main obstacles to better mental health in LAM-
ICs.13,14 However, high-income countries are also facing these
barriers and challenges, and their MHSs are often reported
to be failing.15,16 Most urgently, MHS reforms should include
opening more clinics, updating existing clinics, changing
public attitudes toward mental illness, educating the public
regarding effective treatments, promoting wellness efforts
to prevent mental health problems, integrating behavioral
health care into primary health care (PHC), developing com-
munity mental health services, expanding access to mental
health facilities, and generally raising standards for mental
health care services.17,18
Information about MHSs is essential for developing a
mental health care plan, a mental health care policy, and
making decisions to reduce the burden of neuropsychiatric
disorders. The majority of LAMICs lack this information
compared to high-income countries.19 This brief review of the
global scenario of MHSs informs us that low-, middle-, and
high-income countries are facing diverse mental health care
challenges, MHSs are failing, and resources are needed to
scale up mental health care services for mental patients, their
families, and other caregivers.
Objective The purpose of this project was to collect information on
MHS changes in SA since a 4-year plan was developed as
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Mental health system in Saudi Arabia
part of the Saudi Arabian Mental and Social Health Atlas
2006 using the WHO-AIMS 2.2. A secondary aim was
to document MHS areas in which further improvement is
needed and evidence-based plans developed to bridge these
gaps. A third objective was to compare collected data with
international trends in MHSs of other countries.
Methods In response to a WHO EMRO project initiative, data on
the Saudi MHS were collected from Ministry of Health
(MOH) settings in 2009–2010 using the WHO-AIMS
2.2.3 The WHO-AIMS questionnaire was provided by the
WHO EMRO in Cairo. All items of WHO-AIMS under six
domains including 28 facets and 156 items were completed
by two authors (NAQ and AAAH). In this instrument, there
is an option to address missing data by providing “the best
estimate.” Based on responses from and discussion with
our psychiatric consultants and other reliable sources, the
best estimate was given for questions with missing data.
The completed WHO-AIMS 2.2 questionnaire was emailed
back to the regional advisor, Mental Health and Substance
Abuse Unit, WHO-EMRO, Cairo, Egypt, for the purpose
of review. The process of revisions and corrections of MHS
information continued until all agreed to the final completed
questionnaire, the data of which were entered into an Excel
spreadsheet. Finally, these data were analyzed by a regional
advisor at the WHO EMRO. Two of us (NAQ and AAAH),
in coordination with the regional advisor, formed the results
into a Saudi country report, which was also edited a number
of times by the regional advisor at the WHO EMRO. The
final Saudi country report was published on the WHO EMRO
website (http://www.emro.who.int; a copy of this report is
available upon request from AAAH).
The website contains only a country report. In this
manuscript, we review and cite relevant literature, describe
the WHO-AIMS 2.2, and comprehensively discuss and com-
pare the findings of this survey to data collected from other
countries. We also discuss the implications of the findings for
delivery of services, establishing community mental health
services, meeting human-resource needs, and developing
necessary infrastructure, none of which are addressed in the
country report. We also discuss the limitations of the data,
and provide conclusions, research implications, and make
recommendations for future actions.
wHO-AiMS 2.2 version Not all components of mental health assessment and monitor-
ing questionnaires typically used in high-income countries are
relevant to LAMICs. The WHO has recently conceptualized
and developed the WHO-AIMS 2.2 for this purpose.3 This
instrument for assessing MHSs is specifically designed for
LAMICs. The WHO used an iterative process that included
input from in-country and international experts on the clarity,
content, validity, feasibility, and piloting of this instrument.
The WHO-AIMS 2.2 assesses six domains, which are interde-
pendent, conceptually connected, and overlapping: (1) policy
and legislative framework, (2) mental health services, (3)
mental health in primary care, (4) human resources, (5) public
information and links with other sectors, and (6) monitoring
and research. These six domains address the ten recommended
areas in the World Health Report 2001. The consensus of
experts was that all six domains of the WHO-AIMS 2.2
needed to be assessed to form a basic and broad picture of an
MHS. The WHO-AIMS 2.2 collects essential information that
is used for multiple purposes, including mental health policy,
development of plans, monitoring of progress made, and
service delivery. This instrument has been used in more than
40 LAMICs.20 In addition, the WHO-AIMS 2.2 is relevant
and applicable to resource-poor settings within high-income
countries. Saxena et al provide further details on the develop-
ment and benefits of the WHO-AIMS 2.2.19 The sources of
information collected using the WHO-AIM 2.2 in SA were
the MOH annual reports, regional health directorate and
mental hospital reports, and data provided by the ministries
of education, finance, social affairs, and several independent
health organizations. In addition, practicing psychiatrists were
contacted to clarify and supplement this information.
Data analysis All data collected with the WHO-AIMS 2.2 questionnaire
were entered into the WHO-AIMS Excel (v2.2, World Health
Organization, Geneva, Switzerland) data program. Prior to
entry, the data for each WHO-AIMS question was reviewed
and clarified through inquiries to several psychiatric consul-
tants, thus obtaining the most accurate and complete answers.
This process was guided by the regional advisor of the Mental
Health and Substance Abuse Unit, WHO EMRO, in Cairo,
Egypt, who also reviewed the data.
Results As previously noted, the complete results from the project
are available on the WHO-EMRO website. We summarize
the main findings here (Table 1), and discuss them in light
of world literature. We integrate our findings in SA with
what has been discovered and learned in other countries and
health care settings. The implications we propose for the
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development of MHSs in SA are based on the findings and
what we have discovered elsewhere in the world.2,19,20
Discussion Policy and legislation The Saudi government has recently passed a Mental Health
Act (MHA) that focuses on the following areas: (1) improving
access to mental health care generally, (2) ensuring the least
restrictive level of care, (3) preserving the rights of patients,
family members, and other caregivers, (4) streamlining com-
petence, capacity, and guardianship issues, including volun-
tary and involuntary treatment, (5) ensuring the accreditation
of professionals and facilities, (6) enforcing mental health
laws and other legal issues, and (7) establishing mechanisms
to implement these provisions. The MHA is important
because it puts governmental authority behind the mental
health policy guidelines developed in 2008 that followed the
2006 Saudi Arabian Mental and Social Health Atlas.2 The
latter sought to streamline the delivery of mental health care
services to health consumers, families, and caregivers over
the next 4 years. The MHA was developed after reviewing
what other countries were doing globally over a period of 5
years. The MHA establishes the procedures and policies for
safeguarding the rights of persons with mental illness (an
MHA copy is available from AAAH upon request).21
Financing mental health care services The available finances for mental health care today are
spent largely on the salaries of mental health professionals
and paramedical personnel working in mental hospitals, on
Table 1 Summary of results
Items Remarks
Mental health expenditure 4% of total health budget expenditure for mental hospitals 22% on mental health hospitals Beds in mental hospitals 12 beds/100,000
Distribution: mental hospitals (90%), community facilities (10%) Patients treated in mental health facilities (per 100,000 population) Mental hospitals (40%) and 50% in outpatient facilities, 10% in other facilities Female users treated in mental health facilities Mental hospitals (46%), outpatient facilities (50%), and 4% other facilities Diagnosis (inpatient versus outpatient) Mood disorders (35% vs 20%), schizophrenia (13% vs 50%), neurotic disorders
(36% vs 1%), drug abuse (9% vs 20%) Length of stay in inpatient facilities Mental hospitals, 45 days; community residential facilities, 30–60 days PHC staff 2-day training in mental health in the last year PHC doctors 60%, PHC nurses 65% Total human resources in mental health setting 22/100,000 population: nurses, 13/100,000; psychiatrists, 2/100,000 Average number of staff per bed in mental hospitals: nurses, 0.39; psychosocial, 0.21; psychiatrists, 0.09 Professionals who have graduated in mental health/100,000 Nurses, 1.8; psychiatrists, 0.4; psychologists, 0.19; social workers, 0.95 Mental health training of special staff Up to 20% of police officers, and even a few judges and lawyers, have
participated in mental health educational activities Consumer organizations Five consumer organizations, ie, people with mental health problems that
advocate for mental health
Abbreviations: PHC, primary health care; vs, versus.
infrastructure development, and on the training of mental
health professionals. Four percent of the entire health care
budget of the MOH is directed towards mental health care.
Of all mental health expenditure, 78% goes to mental hos-
pitals. Most of the population now has free access to psy-
chotropic medications and nondrug psychological and social
services. However, mental health financing needs further
support from the Saudi government. According to a WHO
report, “mental health financing is a powerful tool with which
policy-makers can develop and shape quality MHSs. Without
adequate financing, mental health policies and plans remain
in the realm of rhetoric and good intentions.”5
Human rights policies A Saudi human rights committee made up of mental health
experts has responsibility for overseeing inspections in
mental health facilities and imposing sanctions on facilities
that persistently violate patients’ rights. People with mental
disorders around the world are exposed to a wide range of
human rights violations.22 They must deal with the stigma of
their illness, are often ostracized from society, fail to receive
necessary mental health care, and are subject to abuse and
neglect. They also face discrimination in the fields of edu-
cation, employment, and housing. The WHO has suggested
several strategies to prevent such violations: (1) changing
negative attitudes by raising awareness, (2) increasing
attention on human rights in mental health facilities,
(3) empowering mental health service users and families,
(4) replacing long-term inpatient psychiatric hospitalization
with community care, (5) increasing national expenditure for
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There are still not enough hospital beds for providing
inpatient services, and this gap could be bridged by reserv-
ing beds in general hospitals for psychiatric patients and by
developing mobile crisis mental health teams that go out into
the community. A number of studies have highlighted men-
tal hospital bed metrics and other components of MHSs in
at least 40 countries.2,19,20 In a comprehensive review, Lipsitt
discusses the global role of general hospitals in managing
patients with acute and chronic psychiatric problems. He has
encouraged the establishment of inpatient beds, outpatient
clinics, emergency services, and psychosocial rehabilitation
units in general hospitals, all supported by consultation–
liaison psychiatrists.28 This review stimulated ten commen-
taries that highlighted the pros and cons of general hospital
psychiatry, though most supported the use of psychophar-
macological and nondrug treatments in the management of
psychiatric patients with substance abuse or geriatric, child,
or adolescent disorders. Another study describes the use
of crisis mental health teams to provide acute emergency
care to those in crises at home, finding that such teams
tend to reduce admission rates and decrease utilization of
inpatient beds compared with standard care.29 Inpatient and
outpatient services for psychiatric patients, then, need to be
integrated and expanded at all levels, including academic
centers, specialized hospitals, general hospitals, and other
health institutions, in order to improve the quality and cost
of mental health care.
In particular, mental health services also need to be
integrated into PHC settings. The WHO and the World
Organization of Family Doctors have developed a compre-
hensive report that describes how to integrate mental health
into PHC.30 This report highlights successful integration
projects in several countries and discusses ten strategies
for improving mental health integration:30 (1) develop-
ing policy to incorporate mental health care into PHC,
(2) improving advocacy to improve attitudes and behavior
regarding mental health care, (3) training of PHC workers
in screening for mental disorders, (4) limiting PHC tasks to
those that are doable, (5) having mental health specialists
and facilities readily available to support PHC physicians,
(6) providing PHC physicians access to essential psycho-
tropic medications, (7) focusing on integration over time
(not a single event), (8) assigning a mental health-service
coordinator in PHC clinics, (9) collaborating with other gov-
ernment nonhealth sectors, nongovernmental organizations,
village and community health workers, and volunteers,
and (10) adequate funding for necessary staff and mental
health specialists.
mental health, and (6) adopting policies, laws and, services
that promote human rights.22
This human rights committee is not permanent, but rather
need-driven. Whenever there is a major problem in psychiatric
hospitals, the committee is called to inspect and investigate
the problem. Consequently, only 40% of mental hospitals in
the country have had one or more review of human rights
protections for patients, and only 10% of community-based
psychiatric inpatient units and community residential facili-
ties have had such a review. This committee also advises the
government on mental health policies, legislation, service
planning, monitoring, and quality assessment. In terms of
training, an unknown percentage of staff at mental hospitals
and psychiatric units at general hospitals had had 1 day or
more of training on human rights issues at the time of the
present survey. Training of mental health staff in human
rights is now mandatory. Health authorities have established
a patients’ rights department at each psychiatric hospital in
SA for monitoring, training, and supervising hospital staff
to ensure that patients’, families’, and caregivers’ rights are
respected.
Mental health organization and services The MOH is the main provider of public mental health
services. Under its umbrella, the General Administration
for Mental Health and Social Services plans, implements,
coordinates, evaluates, and monitors mental health-service
delivery, and also follows the core themes of the WHO in
developing mental health services. One of the main tasks of
the MOH is to improve the integration of services through
mental health action plans and policy development.23 There
is now a relatively good network of mental health facilities
in SA, although there is need for a better balance between
mental hospitals and community mental health services.
Mental health services in SA are organized on a regional
basis, each of which has a mental health hospital that deliv-
ers basic outpatient, inpatient, and emergency services.
Child and adolescent services are delivered through mental
health facilities in children and maternity hospitals, academic
universities, and in specialized and general hospitals.24 Private
mental health services paid for out of pocket or through
insurance also contribute substantially to mental health care
services. Community mental health clinics and PHC centers
provide additional outpatient services, all of which need
further expansion and support by well-trained specialists and
an allied workforce.25–27 Community mental health facilities
include inpatient and outpatient services, residential units,
and services in PHC clinics.
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PHC physicians across SA need comprehensive initial
and then continuing training in clinical psychiatry to increase
their knowledge and clinical skills.31–33 Most importantly,
following mental health training, PHC physicians should be
given clinical responsibilities to apply the knowledge learned.
Clinical responsibilities include referring patients with
mental health problems to psychiatric hospitals, prescribing
psychotropic drugs when necessary, and consulting with
psychiatrists affiliated with psychiatric hospitals.32,33 Based
on the hybrid model, mental health clinics are beginning to
be developed in existing PHCs in SA. Already established
are two or more such clinics in all 13 regions of SA. In
the US, integrating psychiatry into PHC has improved the
acceptability of mental health services and has increased
treatment engagement in low-income populations.34 Other
benefits of integrating mental health into PHC include reduc-
tion in stigma, better access to care, and better mental health
outcomes overall.35
Public outpatient facilities The MOH now supports approximately 94 public outpatient
mental health facilities. Twenty of these for children and
women are located in specialized children and maternity
hospitals. Outpatient clinics treat 1,846 users per 100,000
population per year. Females comprise about 50% of
patients seen in outpatient settings, and they are more
likely to utilize mental health care services than males.36
Six percent of those seen in outpatient settings are children
and adolescents. Patients treated in outpatient facilities are
most likely to be diagnosed with mood disorders (35%),
neurotic, stress-related, or somatoform disorders (36%),
schizophrenia (13%), substance abuse (9%), personal-
ity disorders (2%), and others (5%). In the US National
Comorbidity Survey, a study that assessed a representative
sample of the population, Kessler et al estimated lifetime
and 12-month prevalence of 14 Diagnostic and Statistical
Manual of Mental Disorders III-R conditions. Major depres-
sive episodes, substance-use disorders, social phobia, and
simple phobia were the most common disorders, and more
than 50% of all lifetime disorders occurred in 14% of the
population, many with a history of three or more comor-
bid disorders. Those with comorbid disorders included
the vast majority of people with severe disorders as well.
Furthermore, women had elevated rates of affective and
anxiety disorders compared to men, who had elevated rates
of substance-use and antisocial personality disorders.37
Data on lifetime psychiatric disorders in the community is
not yet available for SA, although there is now a national
community-based survey in the field that is systematically
collecting such information.
The average number of outpatient visits for those with an
identified psychiatric problem in SA is 2.5 per year. About
one in five (19%) outpatient facilities provides follow-up
care in the community, while an unknown percentage has
mobile mental health teams. In terms of available treat-
ments, 21%–50% of psychiatric outpatients in the past year
received one or more psychosocial interventions. Almost all
facilities (100%) have at least one psychotropic medicine
available onsite from each major drug class (ie, antipsychot-
ics, antidepressants, mood stabilizers, anxiolytic drugs, and
mood-stabilizing antiepileptics). Kessler et al also reported
that less than 40% of those with a lifetime disorder had ever
received professional treatment, and less than 20% of those
with a recent disorder had been in treatment during the past
12 months.37 The types of psychiatric disorder seen in outpa-
tient and inpatient settings are similar in the US and SA.
There are only three day-treatment facilities in SA,
which serve a variety of patients with acute and chronic
mental disorders. The goal is to minimize admissions and
to optimize independent living skills and vocational reha-
bilitation, and to provide support in the recovery process by
emphasizing the development of healthy coping skills in the
community. A multidisciplinary team provides comprehen-
sive, needed services that include case management, group
therapies, individual support, occupational services, leisure
assessment and counseling, and medication monitoring
and administration.38–40 Adequately staffed day-treatment
facilities and programs need to be expanded in the Saudi
setting.
inpatient facilities Patients with severe mental health problems are hospitalized
in community-based psychiatric inpatient facilities, residen-
tial units, mental hospitals, and forensic or other residential
facilities. Unlike in high-income countries, where deinstitu-
tionalization has resulted in a variety of outreach, vocational
and psychosocial rehabilitation programs, psychoeducational
efforts, and diversified housing programs,41 most inpatient
services in SA and most other Middle Eastern countries are
currently provided by traditional mental health hospitals.
Community-based facilities These are rented facilities similar to halfway houses for
chronic patients whose care is managed by nursing staff,
other support personnel, and on-call psychiatrists. There are
five community-based psychiatric inpatient units in SA for
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a total of 0.41 beds per 100,000 population, with an average
length of stay of 30 days. No beds are reserved for children
or adolescents, since inpatient admission is generally discour-
aged and if admission is required, it is done regardless of bed
availability and only briefly. Diagnoses of admitted patients
are unknown, but in general tend to be schizophrenia, bipolar
disorder, and organic psychoses. About one-quarter to one-
half of these patients had received at least one psychosocial
intervention in the past year, and all patients had received at
least one psychotropic medication in terms of antipsychot-
ics, antidepressants, mood stabilizers, or anxiolytic drugs.
Regarding patients living in halfway houses and supported
housing, the primary goal of many developed nations has
been to move these individuals to independent housing, along
with keeping them stable and increasing their living skills. In
one UK study, two clusters of patients emerged: those with
no stated goals or with the aim of staying healthy (often with
lower quality of life and more psychopathology), and those
with an aim to move to independent housing (with better qual-
ity of life and less psychopathology). This study suggested
that besides better training of staff, more conceptual and
practical efforts were needed to manage the transformation
of these settings from homes for life to transitional facilities
where residents receive specific interventions.42
Community-based residential facilities There are only two community residential facilities in SA,
and there is need for more. The average length of stay is
60 days. No beds are reserved for children or adolescents
with psychiatric problems. If children or adolescents need
long-term, residential care, they stay in facilities for the
mentally handicapped that are supervised by the Ministry of
Social Affairs. Although community-based services focus on
providing mental health services in the least restrictive set-
ting, children with severe psychiatric or behavioral problems
often require inpatient care. Consequently, there is a range of
mental health services in community or outpatient settings to
manage young people with serious mental health problems
who are at risk for admission to an inpatient unit. In a sys-
tematic review of seven randomized controlled trials with a
total of 799 participants, researchers evaluated four models
of care: multisystemic therapy at home, specialist outpatient
services, intensive home treatment, and intensive home-based
crisis intervention. Young people showed some improvement
with multisystemic therapy at home, although quality of care
was equivocal.43 Two other systematic reviews further sup-
ported alternative treatment options, especially “admission
avoidance hospital at home” care for reducing admission
of adolescents to inpatient units.44,45 In another systematic
review, it was concluded that community-based residential
crisis services may provide a feasible and acceptable alter-
native to hospital admission that may be cost-effective and
enhance patient satisfaction.46
Mental health hospitals Twenty-one mental hospitals in SA provide twelve beds per
100,000 population, a number that has remained roughly the
same between 2005 and 2010. All have outpatient facilities.
Japan has the highest rate of psychiatric beds per 100,000
people in the world. The total number of beds for the men-
tally ill in Japan is approximately 340,000, ie, 35.2 beds per
100,000 population, of which general hospitals have only
about 20,000 (5.8% of beds). Thus, like SA, inpatient mental
health care in Japan is mostly provided in mental hospitals.47
In SA, mental hospitals treat 1.92 users per 100,000 per year.
The primary diagnoses of patients admitted to these facili-
ties are schizophrenia, mood disorders, and substance-use
disorders, similar to psychiatric inpatients in the US.48
The average length of inpatient stay in SA is 45 days, and
most patients (70%) spend less than 1 year in these facilities.
The rest spend 1–10 or more years. Across the world, the
average length of inpatient stay in mental hospitals is on the
decrease compared to hospital stays for physical disorders.49
This has been attributed to managed care, the development of
innovative community and home mental health care services,
the freedom to leave against medical advice, and prospec-
tive payment systems.47,49,50 Hospital-at-home services can
provide a safe, effective alternative to inpatient care for
patients appropriate for this level of care. Furthermore, home
treatment has the potential to reduce costs, reduce pressure
on inpatient services, and provide care that is acceptable to
patients and their families.50,51
Forensic and other residential facilities There are 50 additional beds in forensic inpatient units and
an unknown number of beds in other residential facilities,
such as homes for the mentally retarded, inpatient facilities
for drug or alcohol abuse/dependence, and homes for the
destitute in SA. Fifty percent of patients spend less than
12 months in forensic units, 25% of patients spend 1–4 years,
and the rest spend from 5–10 or more years. Between 51%
and 80% of Saudi prisons have at least one prisoner per month
in treatment with a mental health professional. The Saudi
forensic units do not work like European forensic units, which
have three levels of security: high, medium, and low. Security
has been viewed as a therapeutic modality, and mapping of
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forensic mental health services by risk stratification is needed
to transfer in a timely fashion the patients at higher risk and
minimize unnecessary incarceration.52 Globally, the time
spent in forensic units depends on an individual’s recovery
and progress towards rehabilitation. A mental patient who
has committed a minor crime should not be imprisoned,
since the mental condition tends to worsen in prison and
this increases the risk of self-harm.53 In addition, researchers
have recommended several treatment strategies for mentally
ill offenders that include development of more and better
community services, timely referral to psychiatric services,
and an increased role for family members54 in meeting chal-
lenges to prevent the inappropriate arrest and incarceration
of persons with severe mental disorders.55 Improved MHS
services also reduce children and adolescent involvement in
the juvenile justice system.56
Outpatient and inpatient diagnoses While the majority of patients seen in outpatient settings have
neurotic (36%) or mood disorders (35%), those admitted
to inpatient mental hospitals are more likely to suffer from
schizophrenia (50%), substance-abuse disorders (20%), and
mood disorders (20%). In a retrospective Saudi study from
the mental hospital in Taif, schizophrenia (89%) and drug
addictions (61%) were the most common inpatient diagnoses,
followed by mental retardation (18%), personality disorders
(4%), and epilepsy (2%).57 The distribution of diagnoses in SA
settings is consistent with the pattern of psychiatric disorders
reported in noninstitutionalized populations in the US.37
Human rights and equity The percentage of involuntary admissions to community-
based inpatient units or mental hospitals in SA is unknown,
as is the percentage of patients who are restrained or secluded.
Determining rates and types of involuntary treatment is
needed for proper monitoring. Most psychiatry inpatient
facilities are located in or near large cities, often limiting their
access by those from rural areas. There is also evidence that
persons residing in rural areas are generally in poorer health
and receive less health care compared to those living in urban
areas.58 This suggests that more focus should be on develop-
ing mental health care services in rural areas. Unlike in SA,
lack/variation of access to specialist mental health services
due to linguistic, ethnic, religious, or other minority issues
is a major problem in high-income countries.59 Regarding
female psychiatric patients, about 50% are seen in psychiatric
outpatient settings, 46% are admitted to mental hospitals, and
the rest receive care in different community facilities.
In an ecological analysis of involuntary admission and
bed availability for those with mental illness in the UK, the
National Health Service concluded that the increased rate of
bed closures seen there would increase the number of invol-
untary admissions.60 Despite the introduction of alternative
community services in the UK, the rate of involuntary admis-
sion is indeed on the rise. Bed closures/closure of mental
hospitals have been associated with a decrease in voluntary
admissions.61 In LAMICs including Saudi Arabia, both
developing community mental health care services based on
innovative health care models and closing beds in traditional
hospitals are extremely challenging tasks.
Mental health in primary care Many patients with mental health problems in SA are first
seen by primary care physicians,62,63 which is different than
in such countries as Japan, where patients first seek care in
mental health facilities, general hospitals, or hospitals in the
private sector.64 Thus, information on the training of PHC
staff with regard to mental health screening and psychiatric
referral in SA is essential.25–27,32,33
PHC medical clinics PHC clinics in SA are physician-based, and only 20%
use assessment and treatment protocols for mental health
conditions. About 20% of these clinics refer one or more
patients per month to a mental health professional. In terms
of interaction of PHC staff with mental health professionals,
only a small percentage had had such contact in the last year.
No physician-based PHC clinic staff or mental health care
facility staff had interacted in the past year with complemen-
tary and alternative medicine (CAM) practitioner, despite the
fact that as many as 90% of Saudi patients use some form of
CAM treatment, at least those with cancer.65 There are several
reasons for this. First, the National Center for Complementary
and Alternative Medicine under the umbrella of the MOH
in SA is purely administrative and has not yet established
outpatient clinics that offer clinical CAM services. Second,
patients either frequently use CAM therapies themselves or
consult CAM practitioners in the private sector. However, it is
a challenging task to integrate CAM into psychiatric/general
hospitals and PHC clinics in SA due to the way the current
system is set up. Elsewhere, the benefits of the integration
of complementary therapies into community mental-health
practice have been realized as CAM therapies (massage,
acupuncture, reiki, and healing touch) hold the promise of
enhancing mental health outcomes and improving quality of
life for long-term users of mental health services.66 A review
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of literature also provides evidence for the effectiveness of
CAM therapies in the treatment of mood disorders.67
Thus, there is a need to establish community mental
health centers and/or psychosocial care centers in PHC in
Saudi Arabia, because these facilities will reduce the burden
on mental health hospitals, reduce the rate of admission and
improve outcomes, provide comprehensive care for users
and families in crisis, reduce the health care cost, improve
academic partnerships, and increase patient satisfaction by
improving access to mental health care and early detection
and treatment of mental problems.68–71
Treatment options in PHC settings Allied PHC workers such as nurses, pharmacists and psy-
chologists are not allowed to prescribe psychotropic medica-
tions under any circumstances, even in emergencies. PHC and
family physicians can prescribe, but with some restrictions.
Although they can prescribe oral antidepressants, they are
not allowed to prescribe antipsychotic drugs and anxiolytics,
except for patients with acute emergencies who are agitated
or violent. For the latter, medical physicians can give intra-
venous diazepam 5–10 mg or intramuscular chlorpromazine
25–50 mg before transferring them to a secondary psychi-
atric care hospital. PHC physicians are also allowed to refill
prescriptions for chronic psychotic patients referred from
psychiatric hospitals for follow-up at PHCs. Only about 20%
of PHC clinics have one or more psychotropic medications
in each therapeutic category (antipsychotics, antidepressants,
mood stabilizers, and anxiolytics) available year-round. This
is rapidly changing, however, and health authorities are now
ensuring that essential psychotropic drugs are available at
all PHCs across the country. In some high-income countries,
physicians, psychiatric nurses and prescribing psychologists
who are trained and licensed are allowed to prescribe nonpsy-
chotropic and psychotropic medications,72 although this issue
is still highly controversial. There are other nonphysicians,
including pharmacists, naturopaths, certified midwives, and
others, who have also been allowed to write drug prescrip-
tions in some countries.73
Training of PHC staff Very little PHC physician training is devoted to mental health
care in SA. The situation is the same for nurses and even more
so for other PHC staff, including pharmacists. About 1% of
PHC physicians or nurses had received 2 days or more of
continuing education on mental health during the past year,
and almost no training was received by other PHC staff.
Thus, while continuing-education programs exist for mental
health staff, such programs for PHC staff are infrequent or
nonexistent, despite the high prevalence of mental disorders
seen in patients at PHC centers.25–27 Furthermore, many of
these disorders remain unrecognized by PHC physicians,
with detection rates varying from 30% to 60%. In a Brazilian
study of mental disorder detection by PHC physicians, being
female, married, having medically unexplained symptoms,
and frequent service use predicted higher rates of detection.
The high frequency of mental disorders in PHC highlights
the need for improving physician and other staff training
so that they may accurately recognize and treat psychological
problems in these patients.74
Human resources Mental health care workforce The total number of psychiatrists, medical physicians, nurses,
psychologists, social workers, occupational therapists,
and other workers in mental health facilities and private
psychiatric practice in SA is 22 per 100,000 population.
By profession, this breaks down to three psychiatrists,
13 nurses, two psychologists, three social workers, and one
other mental health worker (auxiliary staff, occupational
therapists, health assistants, medical physicians, medical
assistants, professional and paraprofessional counselors).
For comparison of these rates with those in other countries,
the reader is referred to other sources on mental health work-
force metrics and mental health system human resources.2,19,20
The majority of psychiatrists (80%) work in public mental
health facilities, whereas others work in private practice or
for-profit mental health facilities. Slightly more than two-
thirds of psychosocial staff, which includes psychologists,
social workers, nurses, and occupational therapists, work in
government facilities.
Regarding location of employment, 380 psychiatrists are
employed in outpatient facilities and 263 in mental hospitals.
Approximately 145 medical physicians work in mental health
outpatient facilities and 165 in mental hospitals. Regarding
other providers, 1,980 nurses work in mental health outpatient
facilities and 1,176 in mental hospitals, and 515 psychosocial
allied staff work in outpatient facilities and 611 in mental
hospitals. In terms of the staffing of mental hospitals, there
are 0.09 psychiatrists per hospital bed, 0.39 nurses, and 0.21
other mental health care staff, including psychologists and
social workers.
Despite challenges in access to mental hospitals, the dis-
tribution of human mental health resources between urban
and rural areas is nearly equal. The density of psychiatrists
in moderate-to-large cities is only 0.19 per 100,000 lower than
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the density of psychiatrists in the entire country (although
80% of the population of SA is urban). Likewise, the density
of nurses is only 1.16 per 100,000 lower in large cities than in
the rest of the country. In terms of support for child and ado-
lescent mental health, 15% of primary and secondary schools
have either part-time or full-time school counselors, and many
schools (between 51% and 80%) have activities to promote
mental health and prevent mental disorders. According to
Stephan et al, school mental health education helps in reducing
stigma, enhancing access to mental health services, and pre-
venting mental disorders. They suggest a variety of strategies
for expanding mental health in schools.75
There is a mental health care workforce gap around the
world, although it is more obvious in LAMICs, and Saudi
Arabia is no exception. Bruckner et al and Patel addressed
this important issue, suggesting strategies for efficient use
of existing mental health human resources, shared compe-
tencies, substitution between health professions, multiple
tasking, and task-shifting, which rationally redistributes
tasks among teams.76,77 These strategies may compensate for
shortages of specialist mental health professionals in many
countries. In an important development realized worldwide,
mental health consumers and carers employed in identified
and unidentified positions in the mental health sector and in
the broader community may facilitate the recovery of those
suffering from psychosocial problems.78 The WHO Europe
regional office further highlighted the importance of empow-
erment of users/carers in mental health and focused on the
removal of formal or informal barriers and the transforma-
tion of power relations between individuals, communities,
services, and governments.79
Training of mental health care workforce The number of professionals graduating from academic
institutions in SA per 100,000 per year is as follows:
0.4 psychiatrists, 3.8 other medical doctors, 1.8 nurses,
0.2 psychologists, 1.0 social workers, and an unknown number
of occupational therapists. A number of these psychiatrists
emigrate to other countries within 5 years of completing their
training in SA, often in order to obtain advanced training.
With regard to continuing education in mental health, nearly
all psychiatrists in the past year had attended training on
rational use of drugs, half (51%) said they had had a course on
psychosocial interventions, and one in five (19%) had taken a
course on child mental health. Among general medical doctors
in psychiatric hospitals working full-time managing comorbid
physical conditions in psychiatric patients, less than one in five
had had a course on rational use of psychotropic medicines,
32% on psychosocial interventions, and 19% on child mental
health issues. Among psychiatric nurses, only 4% had had
training on rational use of drugs, 11% on psychosocial inter-
ventions, and 1% on child mental health. Dramatic changes
have been occurring in the delivery of mental health care
services, and hence educational programs and reforms need
to be tailored to keep pace with these changes. Hoge et al
identified 16 recommended “best practices.”80 These include
that professional training should instill an understanding of
the competing paradigms of service delivery and the diverse
scientific, professional, economic, and social forces that shape
health care and teaching methods. These should be used in
combination and need to be evidence-based (interactive,
academic detailing, audit and feedback, reminders, opinion
leaders, and consumer-mediated interventions). This will help
guide efforts to improve workforce education and training in
the field of behavioral health.
Consumer advocacy groups and public awareness Consumer and family associations There are now at least five active consumer organizations,
ie, people with mental health problems who advocate for
mental health, now in SA. In addition, there are also now
family organizations being developed. Because the General
Administration for Mental Health and Social Services feels
that more consumers should be involved in the formulation
and implementation of mental health policies, plans, and
legislation, the government provides support, including
financial funding for such groups. Although the amount of
interaction between mental health facilities and consumer
associations is increasing, the role of consumer groups like
those in Western countries81 needs to be greatly expanded in
SA. In addition to consumer associations, there are a number
of nongovernmental organizations that provide individual
assistance such as counseling, housing, or other support
for people with mental health problems, including those
with mental retardation, cerebral palsy, autism, or attention
deficit/hyperactivity disorder. Saxena et al have identified
other roles of nongovernmental organizations in LAMICs,
including the achievement of access to mental health care
for all who need it.13
Financial support Some mental health facilities in SA have programs that pro-
vide outside employment for persons with mental disorders.
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Severe mental disability also makes one eligible for social
welfare benefits. Saudi laws require employers to hire a certain
percentage of employees who are disabled, including mental
disability, and give people with mental disorders priority in
obtaining state housing and subsidized housing. Fortunately,
these laws are beginning to be applied across the nation. In
the US, the Social Security Disability Insurance program
provides financial assistance to mental patients. As a result,
millions of people who are receiving social security disability
benefits in the US have been diagnosed with a mood disorder.
Mental illness has become the second-commonest diagnostic
category for beneficiaries, behind musculoskeletal system
disorders and connective tissue disease.82
Public education and awareness Public education for enhancing mental health literacy has
become a priority, since this will improve early detection,
early help-seeking, and treatment intervention by those with
mental problems.83 There is an urgent need to partner with
the public school system so that young people can become
knowledgeable about mental health issues, as well as to
partner with the criminal justice system, so that prisoners
can get the mental health care they need.52–56,75 Government
agencies, professional organizations, and international health
groups in SA have promoted public education and awareness
campaigns during the past 4 years. These campaigns have
targeted the general public, children, and adolescents. There
have also been campaigns targeting professional groups:
teachers, leaders, politicians, social service staff, psycholo-
gists, and health care providers. Only about 20% of police
officers, and even a few judges and lawyers, have participated
in educational activities related to mental health in the past
4 years. In high-income countries, cost-effective programs
based on new models of learning are tailored to train police
officers in order to expand further proper interactions between
police and mental patients,84 and LAMICs can learn tremen-
dously from their experience.
Quality control The General Administration for Mental Health and Social
Services of the MOH in SA receives yearly data from all
mental hospitals, community-based psychiatric inpatient
units, and outpatient mental health facilities in the country.
Outpatient clinics report the number of patients seen and
patient diagnoses. Inpatient and residential facilities report
information on number of beds, admissions, lengths of stay,
and patient diagnoses. However, no data are collected on
number of involuntary admissions or number of patients
restrained, though such information is always available in
patients’ medical records. A yearly report that also includes
mental health data is published by the MOH based on data
from all regional health directorates, although it is not clear
who actually reviews this report. A mental health-information
system supported by advanced health-information technol-
ogy needs to be in place to address gaps in the Saudi MHS.
According to the WHO, “A mental health information
system is a system for action: it should exist not simply for
the purpose of gathering data, but also for enabling well-
informed decision-making in all aspects of the mental health
system.”85
Mental health research and monitoring In terms of academic research, only a small percentage of
peer-reviewed journal publications from SA are on mental
health, although that percentage is likely to increase as more
funds are now being reserved for health research in this
country. This has resulted in a higher number of research
publications in open-access journals, though several barriers
still need to be overcome.86,87 Papers published so far have
primarily focused on hospital-based epidemiology of mental
disorders and health-services research. There remains a large
gap in mental health research, and filling that gap needs to
become a health-system priority. The Saudi MOH has begun
to encourage research across all regions of SA by allocating
a budget for researchers and further grant support is now
available from the King Abdulaziz City for Science and Tech-
nology in Riyadh. In order to build capacity for psychiatric
research, the MOH is also providing funds for continuing
training of psychiatric nurses, social workers, psychologists,
and other psychiatric staff. There is evidence accumulating
that research in SA can help to transform the understanding
and treatment of mental illness, as has been the vision of
the National Institute of Mental Health (NIMH) in the US.88
High-priority research at the NIMH that is relevant to LAM-
ICs includes: (1) identifying trends and gaps in mental health
disparities, women’s mental health, and global mental health
to guide priority-setting for research funding; (2) monitoring
research efforts involving nondomestic institutions and
domestic grants with foreign components; and (3) supporting
capacity-building, research-infrastructure development, and
research mentoring in order to develop a multidisciplinary
mental health research workforce.88 The MOH needs to col-
laborate with the NIMH and other partners in order to develop
a multidisciplinary research workforce in SA.
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Limitations We have summarized only some of the findings from this
study in Table 1, since detailed results are readily available
on the WHO EMRO website. The strength of this paper is
that we have discussed our findings in light of international
trends in MHSs in other nations. Another limitation of this
project is that although information was collected from
multiple sources for completing the WHO-AIMS ques-
tionnaire, some sources may have been missed that could
have led to bias in our findings. However, the information
collected here on the Saudi MHS has been reviewed by
a variety of experts, including the WHO EMRO regional
advisor. Regardless, the WHO-AIMS 2.2 questionnaire
has identified a number of strengths and weaknesses of
Saudi MHS in a comprehensive fashion that can now be
addressed.
Recommendations and conclusion Over the past 4 years, there have been many advances in the
Saudi MHS. All of these changes have positively impacted
the delivery of mental health services in this country. The
MHS in SA provides outpatient, inpatient, and residential
services to consumers and their families. These services are
supplemented by a growing private mental health sector.
Almost all facilities now have access to essential psychotro-
pic drugs on their premises. Although human rights review
bodies exist that regularly visit mental health treatment
facilities, a more streamlined system is needed to guarantee
patients’ rights in all treatment settings, especially those
related to involuntary admissions and restraining of patients.
The new MHA recently passed by the Saudi government
will help to enforce patient rights at the local and national
level. Most finances for mental health are now spent on
salaries of medical and paramedical personnel working in
mental hospitals, mental hospital infrastructure, and train-
ing of mental health staff. Greater diversification of funding
streams is needed to implement the next steps proposed
here. There is also a need to increase mental health research
through public policy changes, development of research
guidelines, and establishing a national mental health
research institute similar to that in the US.89 Improving
mental health care services and treatment outcomes needs
to become a priority in strategic planning, implementation
of targeted programs, and systematic evaluation, as echoed
in a WHO report.90
The assessment of the Saudi MHS presented in this report
is the first of its kind, and provides a baseline against which
progress in the MHS can be compared in the future. The MHS
has made relatively good progress across the six domains
described here during the past 4 years, especially compared
to where it was 30 years ago.91 Based on this information,
a number of strategic steps need to be taken to strengthen
the MHS in SA. These include the (1) enforcement of the
recently passed MHA, which protects the rights and safety
of mentally ill persons in all treatment and nontreatment
settings; (2) expansion and strengthening of community-
based facilities, PHC psychiatry clinics, community-based
psychiatric inpatient units, day-care centers, community
mental health centers, and residential facilities (following
the WHO recommendations92); (3) expansion of mental
health training and continuing education programs for
mental health staff, PHC staff, nurses, school teachers,
police officers, and criminal justice staff; (4) increasing
the number of competent, well-trained psychosocial staff;
(5) improvement of information systems and data-collection
procedures that monitor services provided, ensure quality
control, and identify facilities that do not follow national
policies and procedures; (6) building up of capacity for
conducting research on mental health, since many topics
need systematic examination to improve the recognition and
treatment of mental disorders; (7) regular evaluation of train-
ing programs that educate mental health professionals, PHC
physicians and staff, and other professionals about mental
illness; (8) development of strategies to increase the involve-
ment of families and consumers in policy development and
implementation; (9) development of programs to enhance
public education on mental health and improve the mental
health literacy of children, adolescents, and adults, as done
elsewhere in the world;93 (10) improvement of interactions
between mental health professionals, health professionals
in complementary and alternative medicine, and traditional
practitioners; (11) emphasis on the detection and treatment
of those with emotional or mental illness in PHC settings by
training primary care physicians; and (12) development of
partnerships with international health organizations such as
the WHO and the US National Institutes of Mental Health to
help improve the delivery of clinical services, mental health
training, systematic research, and the formulating of health
policies and planning.
Acknowledgments We gratefully acknowledge the help of Dr Khalid Saeed
of the WHO EMRO, Cairo, Egypt. He made available
WHO-AIMS 2.2 to us and initiated this project by inviting
us to collect information on the MHS of SA in order to write
a country report. We are highly indebted to his technical and
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Mental health system in Saudi Arabia
editorial skills and also the support of the Geneva WHO team
headed by Dr Shekhar Saxena.
Disclosure None of the authors have conflicts of interest related to this
work.
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