Exploring Mental Health Literacy and Its Associated Factors: A National Cross-Sectional Study in Saudi Arabia, 2023.

Objective: The aim of this study is to examine, for the first time, the mental health literacy of the Saudi general population. Additionally, we aim to identify demographic factors associated with elevated mental health literacy scores. Methods: A cross-sectional study using a phone interview survey with quota sampling was conducted for equal distribution of sexes, age and administrative regions. Mental health literacy was assessed by the previously validated mental health literacy scale (MHLS). The MHLS ranges from 35 to 160, and a higher score indicates greater level of mental health literacy. Results: In this study, 4,547 (70.2%) agreed to complete the interview. The sample was equally distributed across Saudi Arabia's 13 administrative regions with 50.1% female and mean age 35.9 (SD: ±12.8). In terms of education, 55.1% have a bachelor's degree or above. The nationally weighted score on the original MHLS was 110.75. the MHLS Saudi validation score was influenced by various variables including: marital status, healthcare-related job, sex, education level, and proximity to individuals with mental health issues. Conclusion: The study offers data for the first time on Saudi Arabian mental health literacy status. The high MHLS score reflects good societal awareness and understanding of mental health related concepts and issues in the Saudi population. The results of this study set the baseline for mental health literacy in Saudi Arabia. Future research may focus on utilizing the validated MHLS and the method used in this study to explore the effect of other social and individual factors on mental health literacy.

Validation and psychometric testing of the Arabic version of the mental health literacy scale among the Saudi Arabian general population.

OBJECTIVE: This study aimed to validate the Arabic Version of the Mental Health Literacy Scale (Arabic-MHLS) among the Saudi Arabian general population, assessing its internal consistency, test-retest reliability, and structural validity. METHODS: A total of 700 Arabic-speaking Saudi adults were randomly selected to complete the electronic questionnaire in May 2023, which generated 544 participants. Data were coded and stored in the ZdataCloud research data collection system database. Test-retest reliability was assessed using a subsample of 48 participants who completed the questionnaire twice, with a one-week interval. Structural validity was examined using confirmatory factor analysis (CFA) and Exploratory Factor Analysis (EFA). RESULTS: The Arabic-MHLS demonstrated good internal consistency (Cronbach's alpha = 0.87) and test-retest reliability (intraclass correlation coefficient = 0.89). EFA revealed a four-factor model closely resembling the model identified in the Slovenian validation of MHLS, with factor loadings ranging from 0.40 to 0.85. The four factors included knowledge of mental health disorders, knowledge of help-seeking, knowledge of self-help strategies, and knowledge of professional help also showed good internal consistency. CONCLUSION: The Arabic-MHLS is a valid and reliable tool for assessing mental health literacy in the Saudi Arabian general population. However, further research is needed to refine the measurement tool and understand the complex relationships between mental health literacy and other mental health-related concepts. This will contribute to the development of targeted interventions and policies aimed at improving mental health literacy and promoting mental well-being in the Saudi Arabian population and beyond.

Saudi Expert Consensus-Based Autism Spectrum Disorder Statement: From Screening to Management.

BACKGROUND: There is a large gap between the needs of individuals diagnosed with autism spectrum disorder (ASD) and the currently available services in Saudi Arabia. Services are often difficult to access, inconsistent in quality, incomplete, unsatisfactory, and costly. As such, there is a national need for expert consensus on the appropriate standards for the assessment and management of children on the autism spectrum. METHODOLOGY: A guideline development group (GDC) was formed by professionals representing all related specialties and institutions involved in the management of individuals on the autism spectrum in Saudi Arabia. They met on a regular basis over 21 months. The guideline development process consisted of five steps starting from reviewing existing guidelines and ending with discussing and writing this manuscript. A formal voting process was utilized and recommendations were discussed until a consensus was reached. RESULTS: There was consensus on the following: A specialized diagnostic assessment needs to be carried out by an experienced multidisciplinary team for children referred to assess for ASD. They should be assessed for medical etiology, their behavioral history carefully reviewed, and symptoms directly observed. Longitudinal assessments are encouraged to reflect the effects of symptoms on the individual's ability to function while with their family, among peers, and in school settings. An additional formal assessment of language, cognitive, and adaptive abilities as well as sensory status is essential to complete the diagnostic process. Interventions should be individualized, developmentally appropriate, and intensive, with performance data relevant to intervention goals to evaluate and adjust interventions. Target symptoms must be identified to address and develop monitoring systems to track change. CONCLUSION: ASD is a complex condition with widely varying clinical manifestations, thus requiring evaluation and intervention by a range of professionals working in coordination. Behavioral and environmental interventions are the key to optimal outcomes, in conjunction with medications when indicated for specific symptoms. Parental involvement in interventions is vital to sustaining therapeutic gains.

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

BACKGROUND: A major component of illness burden is role impairment. As part of the recently-completed Saudi National Mental Health Survey (SNMHS), we compare the number of days out of role in the Saudi population associated with ten core mental disorders assessed in the survey to those associated with ten commonly occurring chronic physical disorders. METHODS: The SNMHS was a household survey that assessed prevalence of ten common anxiety, mood, disruptive behavior, and eating disorders in a nationally representative sample of n = 1981 citizens of the Kingdom of Saudi Arabia (KSA) ages 15-65. Comparison information was obtained on prevalence of ten common chronic physical disorders and number of health-related days out of role (DOR) in the 30 days before interview. Generalized linear models were used to examine univariate and multivariable associations of disorders with DOR and to calculate population attributable risk (PAR) separately and overall for the disorders controlling for socio-demographics. RESULTS: 19.9% of respondents had one or more of the selected mental disorders and 47.1% had one or more of the selected physical disorders. Nine mental disorders and two physical disorders were associated with increased DOR. PAR was 32.9% for mental disorders, 27.0% for physical disorders, and 59.9% for both combined. CONCLUSIONS: Mental disorders are associated with a substantial proportion of all health-related DOR in the Kingdom of Saudi Arabia. Programs to detect and treat mental disorders might lead to substantially decreased role impairment in the Kingdom.

Saudi Arabia Mental Health Surveillance System (MHSS): mental health trends amid COVID-19 and comparison with pre-COVID-19 trends.

Background: The impact of the COVID-19 pandemic on populations' mental health has started to emerge. Objectives: To describe the mental health trends of the risk of major depressive disorder (MDD) and generalized anxiety disorder (GAD) between May and August 2020. It also compares the results with pre-COVID-19 results and identifies risk factors associated with increased likelihood of being at risk of MDD and GAD. Method: This study utilizes repeated cross-sectional design, at national-level coverage of mental health screenings via computer-assisted phone interviews conducted in four waves monthly (between May and August 2020). Arabic-speaking adults from Saudi Arabia were recruited via a random phone list. The questionnaire includes the Arabic version of the Patient Health Questionnaire (PHQ-9) and the General Anxiety Disorder-7 (GAD-7). Pre-COVID-19 comparison was done using the PHQ-2 score to allow for comparison with a previous and similar national study conducted in 2018. Results: Across the four waves, 16,513 participants completed the interviews, with an overall response rate of 81.3%. The weighted national prevalence of people at risk of MDD was 14.9% overall, and 13.8%, 13.6%, 16.8%, and 15.3% in Waves 1, 2, 3, and 4, respectively. The weighted national prevalence of people at risk of GAD was 11.4%, overall, and 10.9%, 10.7%, 12.4%, and 11.7% in Waves 1, 2, 3, and 4, respectively. The weighted national proportion of individuals who were at risk of MDD and GAD at the same time was 7.4% overall. The risk of MDD on PHQ-2 increased by 71.2%, from 12.5% in 2018 to 21.4% in 2020. Conclusions: The risks of MDD and GAD in this study are relatively high. These results can help decision makers to understand the impact of the COVID-19 pandemic on the population's mental health and the most-impacted subgroups.

Antecedentes: El impacto de la pandemia COVID-19 en la salud mental de la población ha comenzado a emerger.Objetivos: Describir las tendencias en salud mental del riesgo de tener un trastorno depresivo mayor (MDD por sus siglas en inglés) y un trastorno de ansiedad generalizado (GAD por sus siglas en inglés) entre Mayo y Agosto de 2020. También compara los resultados con los resultados pre COVID-19 e identifica factores de riesgo asociados con el aumento de la probabilidad de estar en riesgo de sufrir MDD y GADMétodo: Este estudio utiliza un diseño transversal repetido, a un nivel de cobertura nacional de tamizaje sobre salud mental vía entrevistas telefónicas asistidas por computador, conducidas en 4 olas mensualmente (entre Mayo y agosto de 2020). Adultos que hablasen árabe de Arabia Saudita fueron reclutados mediante una lista aleatoria de teléfonos. El cuestionario incluía la versión árabe del Cuestionario de Salud del Paciente (PHQ-9) y de La Escala del Trastorno de Ansiedad Generalizada (GAD-7). Se hicieron comparaciones pre-COVID 19 usando el puntaje del PHQ-2 para permitir la comparación con un estudio previo nacional de características similares que fue realizado el 2018.Resultados: A través de las cuatro olas, 16.513 participantes completaron las entrevistas, con una tasa de respuesta promedio de 81.3%. La prevalencia nacional calculada de personas en riesgo para MDD fue de 14.9% en general y de 13.8%, 13.6%, 16.8% y 15.3% en Olas 1, 2, 3 y 4 respectivamente. La prevalencia nacional calculada de personas en riesgo para GAD fue 11.4% en general y 10.9%, 10.7%, 12.4% y 11.7% en Olas 1, 2, 3 y 4 respectivamente. La proporción nacional calculada de individuos que estaban en riesgo para MDD y GAD al mismo tiempo fue de 7.4% en general. El riesgo de MDD según el PHQ-2 aumentó en un 71.2%, de 12.5% en 2018 a 21.4% en 2020.Conclusiones: El riesgo de MDD y GAD encontrado en este estudio es relativamente alto. Estos resultados pueden ayudar a entender a las personas que toman decisiones del impacto de la pandemia COVID-19 en la salud mental de la población y en los subgrupos más impactados.

Adapting evidence-based clinical practice guidelines for people with attention deficit hyperactivity disorder in Saudi Arabia: process and outputs of a national initiative.

BACKGROUND: We recently adapted the published National Institute for Health and Care Excellence (NICE) Attention deficit hyperactivity disorder (ADHD) diagnosis and management guideline to the Saudi Arabian context. It has been postulated that adaptation of evidence-based clinical practice guidelines to the local healthcare context rather than de-novo development will improve their adoption and implementation without imposing a significant burden on resources. The objective of this paper is to describe the adaptation process methodology utilized for the generation of the first national guideline for management of people with ADHD in Saudi Arabia. METHODS: We used the KSU-Modified-ADAPTE methodology for the guideline adaptation process. We describe the full process in detail including the three phases of set-up, adaptation, and finalization. The process was conducted by a multidisciplinary guideline adaptation group in addition to an external review for the clinical content and methodology. RESULTS: The group adapted ten main categories of recommendations from one source CPG (NICE). The recommendations include: (i) service organisation and training, (ii) recognition, identification and referral, (iii) diagnosis, (iv) support, (v) managing ADHD, (vi) dietary advice, (vii) medication, (viii) maintenance and monitoring, (ix) adherence to treatment, and (x) review of medication and discontinuation. Several implementation tools were compiled and developed to enhance implementability including a clinical algorithm, quality measures, coding system, medication tables, translations, patient information, and online resources. CONCLUSIONS: The finalized clinical practice guideline provides healthcare providers with applicable evidence-based guidance for the management of people with ADHD in Saudi Arabia. The project also demonstrated the effectiveness of KSU-Modified-ADAPTE, and emphasized the value of a collaborative clinical and methodological expert group for adaptation of national guidelines.

A Mental Health Surveillance System for the General Population During the COVID-19 Pandemic: Protocol for a Multiwave Cross-sectional Survey Study.

BACKGROUND: The COVID-19 outbreak can potentially be categorized as a traumatic event. Public health surveillance is one of the cornerstones of public health practice, and it empowers decision makers to lead and manage public health crises and programs more effectively by providing timely and useful evidence. OBJECTIVE: This paper presents the protocol for a study that aims to identify, track, and monitor trends in the population in Saudi Arabia at risk of major depressive disorders and anxiety during the COVID-19 pandemic. METHODS: This study utilizes continuous, cross-sectional, national-level mental health screening via computer-assisted phone interviews, conducted in four waves on a monthly basis (between May and August 2020). Arabic-speaking adults, aged ≥18 years, and living in Saudi Arabia were recruited via a random phone list. This surveillance system used the proportional quota sampling technique to achieve an equal distribution of participants, stratified by age and gender, and region, within and across the 13 administrative regions of Saudi Arabia. A sample size of 4056 participants per wave was calculated to achieve enough power to detect changes in mental health status. The questionnaire includes the Arabic version of the Patient Health Questionnaire-9 (PHQ-9) to measure depressive symptoms and the General Anxiety Disorder-7 (GAD-7) to measure anxiety. In addition, it will collect data on sociodemographic variables and potential risk factors. RESULTS: Study recruitment began in May 2020. The data analysis was completed in October 2020, and the final report is expected to be published by the end of December 2020. CONCLUSIONS: Monitoring the population's mental health status during the COVID-19 pandemic will inform decision makers of any potential deterioration in mental health on a national level and among subgroups, including across regions, age groups, and gender groups. It will allow decision makers to recognize issues and intervene sooner. It will also provide valuable scientific data to help understand the effects of epidemics and pandemics on mental health. As far as we know, this is the only study that attempts to monitor the mental health status of the general population on a monthly basis. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/23748.

Effect of probiotic interventions on depressive symptoms: A narrative review evaluating systematic reviews.

Depression is one of the most prevalent mental illnesses and is often associated with various other medical disorders. Since the 1980s, the primary pharmacological treatment has been antidepressants, but due to the recent discovery of the association between the gut microbiome and mental health, probiotics have been proposed as an adjunctive or alternate treatment. In this narrative review, we aim to provide a holistic perspective by synthesizing and evaluating existing evidence, discussing key biological mechanisms, exploring the history of probiotic use, and appreciating the influence of modern diet on mental health. Five online databases were searched for relevant studies up to December 2017. Systematic reviews that included randomized controlled trials assessing the efficacy of probiotics in the treatment of depressive symptoms were included. Seven systematic reviews met the inclusion criteria. Three of these reviews conducted meta-analyses, out of which, two concluded that probiotics improved depressive symptoms in the sample population. Out of the four reviews that conducted qualitative analysis, three reviews concluded that probiotics have the potential to be used as a treatment. Due to the differences in clinical trials, a definitive effect of probiotics on depressive symptoms cannot be concluded. Nonetheless, probiotics seem to potentially produce a significant therapeutic effect for subjects with pre-existing depressive symptoms. Further studies are warranted for definitive conclusions.

Symptom attribution in first episode psychosis: a cortical thickness study.

One dimension of insight in psychosis is the ability to attribute correctly one's symptoms to a mental disorder. Recent work suggests that gray matter volumes of the orbitofrontal cortex (OFC) are correlated with aggregate symptom attribution scores in first-episode schizophrenia. Whether regions beyond the OFC are important for symptom attribution remains to be established. Further, whether common or separable neural systems underlie attribution of specific symptoms (e.g., delusions, asociality) has not been studied. In the current magnetic resonance imaging study, 52 people with a first-episode psychosis (FEP) were rated with the Scale for Assessment of Unawareness of Mental Disorder on attribution of hallucinations, delusions, flat affect and asociality. Attribution ratings were regressed on cortical thickness at 81,924 vertices. Mapping statistics revealed that delusion misattribution was associated with thickness in the OFC [Brodmann's area (BA) 11/47]. Delusion, flat affect and asociality misattribution were associated with cortical thinness in the dorsolateral prefrontal cortex (BA 9/46). Differential associations emerged between each attribution item and cortical thickness/thinness in a variety of frontal, temporal, parietal and occipital areas. The results imply a selective role for the OFC in delusion misattribution in FEP. Evidence for cortical thickness covariation in a variety of regions suggests partial independence in the neural architecture underlying attribution for different symptoms in FEP.

Low-Dose Risperidone-Induced Oculogyric Crises in an Adolescent Male with Autism, Tourette's and Developmental Delay.

This article will review the case of a young patient with mental retardation, autistic disorder, and Tourette Syndrome who exhibited a favourable treatment response preferentially to risperidone. His presentation, however, was complicated by an exquisite sensitivity to risperidone displayed in the form of recurrent oculogyric crises. In this article, we will outline a review of the case, a survey of the incidence and risk factors of oculogyric crises, as well as a review of the literature on risperidone sensitivity, followed by a review of alternate options for the prevention of oculogyric crises.

Cortical thickness is associated with poor insight in first-episode psychosis.

Through conceptualizing poor insight in psychotic disorders as a form of anosognosia (neurological deficit), frontal lobe dysfunction is often ascribed a vital role in its pathogenesis. Whether non-frontal brain regions are important for insight remains to be investigated. We used a multi-method approach to examine the neural morphometry of all cortical regions for insight in first-episode psychosis. Insight was rated in 79 people with a first-episode psychosis with the awareness of illness and awareness of treatment need and efficacy items of the Scale for assessment of Unawareness of Mental Disorder. Participants were assessed with magnetic resonance imaging. Cortical thickness analysis and voxel-based morphometry were utilized to identify the possible neuroanatomical basis of insight. Cortical thickness technique revealed that poorer awareness of illness was associated with regional thinning in left middle frontal and inferior temporal gyri. Poorer awareness of treatment need and efficacy was associated with cortical thinning in left medial frontal gyrus, precuneus and temporal gyri. No significant associations emerged between any insight measure and gray matter density using voxel-based morphometry. The results confirm predictions derived from the anosognosia/neuropsychology account and assert that regional thickness in frontal cortex is associated with awareness of illness in the early phase of psychosis. The fact that prominent thickness reductions emerged in non-frontal regions of the brain in parietal and temporal cortices for both awareness of illness and awareness of treatment need and efficacy suggests that the neural signature of insight involves a network of brain structures, and not only the frontal lobes as previously suggested.

Positional and surface area asymmetry of the human cerebral cortex.

Previous studies of cortical asymmetry have relied mainly on voxel-based morphometry (VBM), or manual segmentation of regions of interest. This study uses fully automated, surface-based techniques to analyse position and surface area asymmetry for the mid-surfaces of 112 right-handed subjects' cortical hemispheres from a cohort of young adults. Native space measurements of local surface area asymmetry and vertex position asymmetry were calculated from surfaces registered to a previously validated hemisphere-unbiased surface-based template. Our analysis confirms previously identified hemispheric asymmetries (Yakovlevian torque, frontal and occipital petalia) in enhanced detail. It does not support previous findings of gender/asymmetry interactions or rightward planum parietale areal increase. It reveals several new findings, including a striking leftward increase in surface area of the supramarginal gyrus (peak effect 18%), compared with a smaller areal increase in the left Heschl's gyrus and planum temporale region (peak effect 8%). A second finding was rightward increase in surface area (peak effect 10%) in a band around the medial junction between the occipital lobe, and parietal and temporal lobes. By clearly separating out the effects of structural translocation and surface area change from those of thickness and curvature, this study resolves the confound of these variables inherent in VBM studies.

Automated 3-D extraction and evaluation of the inner and outer cortical surfaces using a Laplacian map and partial volume effect classification.

Accurate reconstruction of the inner and outer cortical surfaces of the human cerebrum is a critical objective for a wide variety of neuroimaging analysis purposes, including visualization, morphometry, and brain mapping. The Anatomic Segmentation using Proximity (ASP) algorithm, previously developed by our group, provides a topology-preserving cortical surface deformation method that has been extensively used for the aforementioned purposes. However, constraints in the algorithm to ensure topology preservation occasionally produce incorrect thickness measurements due to a restriction in the range of allowable distances between the gray and white matter surfaces. This problem is particularly prominent in pediatric brain images with tightly folded gyri. This paper presents a novel method for improving the conventional ASP algorithm by making use of partial volume information through probabilistic classification in order to allow for topology preservation across a less restricted range of cortical thickness values. The new algorithm also corrects the classification of the insular cortex by masking out subcortical tissues. For 70 pediatric brains, validation experiments for the modified algorithm, Constrained Laplacian ASP (CLASP), were performed by three methods: (i) volume matching between surface-masked gray matter (GM) and conventional tissue-classified GM, (ii) surface matching between simulated and CLASP-extracted surfaces, and (iii) repeatability of the surface reconstruction among 16 MRI scans of the same subject. In the volume-based evaluation, the volume enclosed by the CLASP WM and GM surfaces matched the classified GM volume 13% more accurately than using conventional ASP. In the surface-based evaluation, using synthesized thick cortex, the average difference between simulated and extracted surfaces was 4.6 +/- 1.4 mm for conventional ASP and 0.5 +/- 0.4 mm for CLASP. In a repeatability study, CLASP produced a 30% lower RMS error for the GM surface and a 8% lower RMS error for the WM surface compared with ASP.