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Open Access Full Text Article

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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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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