Social determinants of anxiety and mood disorders in a nationally-representative sample - Results from the Saudi National Mental Health Survey (SNMHS).

INTRODUCTION: Social determinants of health (SDH) influence and modify the risk for mental health disorders. To our knowledge, no study has explored SDH in the context of mental health in Saudi Arabia (SA) using population-based data. This study investigated the association between several SDH and anxiety and mood disorders in SA. METHODS: We utilized data from the nationally-representative Saudi National Mental Health Survey (SNMHS) conducted in 2014 to 2016. This study examined associations between personal-level, socioeconomic, physical health, and family environment characteristics and anxiety and mood disorders. Participants were classified as having anxiety-only disorders, mood-only disorders, or comorbidity of both disorders. Multinomial logistic regression models were employed to examine the associations between SDH and anxiety and/or mood disorders, comparing them to participants who had not experienced these disorders. RESULTS: A total of 4,004 participants were included in this analysis; the lifetime prevalence of disorders was: anxiety only (18%), mood only (3.8%), and comorbidity of both (5.3%). Regression models indicated that females, young adults (26-35 years), individuals with a higher level of education, and those who were separated or widowed had higher odds of experiencing anxiety and/or mood disorders. Furthermore, there was a significant and direct association between having physical chronic conditions and all three categories of anxiety and mood disorders. Experiencing Adverse Childhood Events (ACEs) was also associated with a significant risk of developing anxiety and/or mood disorders, with the highest risk associated with physical or sexual abuse, followed by violence and neglect. CONCLUSION: This study underscores the correlation between several personal-level, socioeconomic, and environmental SDH and anxiety and mood disorders in SA. These findings provide a foundation for future analyses examining the intricate interplay between upstream and downstream SDH in SA. Such research can enhance local scientific knowledge, aid in planning for social services, and inform policy decisions and treatment strategies.

Urbanization and mental health: A perspective from Riyadh City, Kingdom of Saudi Arabia.

BACKGROUND: While global studies demonstrated that features of urban living are associated with the risk of developing mental disorders, there remains a significant knowledge gap surrounding this topic in the Middle East and North Africa region. AIMS: This study aims to assess the prevalence, severity, correlates, and treatment of mental disorders in Riyadh City by examining certain aspects of urban living such as exposure to traumatic events, early exposure to urbanization, and seeking treatment. METHODS: The Saudi National Mental Health Survey is a community epidemiological survey in a nationally representative sample of citizens aged 15 to 65 in KSA. The World Health Organization Composite International Diagnostic Interview (CIDI 3·0) was used to estimate the 12-month prevalence of common mental disorders. RESULTS: The prevalence of any mental disorder in Riyadh City was 29.2%. The most common disorders were anxiety disorders and mood disorders. Female, young, and previously married respondents were at higher risk for developing mental disorders. Exposure to traumatic events was associated with all types of mental disorders. Only 2.9% of those with any mental disorder sought mental health treatments. CONCLUSIONS: We found a high prevalence of mental disorders in Riyadh City that could be attributed to certain features of urban living. These results may point to potential interventions in urban areas that can mitigate the adverse consequences of urban living and promote the salutogenic aspects of cities.

The prevalence and correlates of bulimia nervosa, binge-eating disorder, and anorexia nervosa: The Saudi National Mental Health Survey.

OBJECTIVE: Limited studies have been conducted in the Kingdom of Saudi Arabia on eating disorders (EDs). This study presents national epidemiological survey data on the prevalence and correlates of anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED) and their association with other mental health disorders, impairment in role functioning, and individual help-seeking behaviors in the Saudi National Mental Health Survey (SNMHS). METHOD: A face-to-face survey was conducted in a nationally representative household sample of Saudi citizens aged 15-65 (n = 4004). The Composite International Diagnostic Interview (CIDI 3.0) was used to produce estimates of lifetime and 12-month prevalence and treatment of common DSM-IV mental disorders. RESULTS: Twelve-month prevalence of any of the three EDs was 3.2%; the overall lifetime prevalence was 6.1%. Education and marital status were significantly associated with both 12-month and lifetime EDs prevalence. Significant mental health comorbidities associated with 12-month EDs were anxiety, mood, and impulse-control disorders, while lifetime EDs were significantly related to all disorders. A similar percentage of respondents that reported having ED-related treatment at some point in their lifetime utilized healthcare and nonhealthcare sector. There was a significant relationship between body mass index category, and lifetime BED and BN. DISCUSSION: The 12-month prevalence of EDs in the Saudi population was higher than the EDs rates reported worldwide. These findings can help healthcare experts, and policymakers in the implementation of initiatives for raising awareness of EDs among the Saudi population, and the development of a country-wide plan for the prevention of EDs. PUBLIC SIGNIFICANCE STATEMENT: The study presents data on the prevalence, correlates, and help-seeking behaviors of AN, BN, and BED, in the Saudi National Mental Health Survey (SNMHS). Obtaining information on this underrepresented region is essential due to the large differences in cross-national data in addition to cultural beliefs about mental illness and treatment seeking to exert an important influence on eating disorders. Such knowledge could provide a better understand of mechanisms underlying the development of eating disorders and thereby improve prediction, prevention, and treatment.

Patterns and correlates of patient-reported helpfulness of treatment for common mental and substance use disorders in the WHO World Mental Health Surveys.

Patient-reported helpfulness of treatment is an important indicator of quality in patient-centered care. We examined its pathways and predictors among respondents to household surveys who reported ever receiving treatment for major depression, generalized anxiety disorder, social phobia, specific phobia, post-traumatic stress disorder, bipolar disorder, or alcohol use disorder. Data came from 30 community epidemiological surveys - 17 in high-income countries (HICs) and 13 in low- and middle-income countries (LMICs) - carried out as part of the World Health Organization (WHO)'s World Mental Health (WMH) Surveys. Respondents were asked whether treatment of each disorder was ever helpful and, if so, the number of professionals seen before receiving helpful treatment. Across all surveys and diagnostic categories, 26.1% of patients (N=10,035) reported being helped by the very first professional they saw. Persisting to a second professional after a first unhelpful treatment brought the cumulative probability of receiving helpful treatment to 51.2%. If patients persisted with up through eight professionals, the cumulative probability rose to 90.6%. However, only an estimated 22.8% of patients would have persisted in seeing these many professionals after repeatedly receiving treatments they considered not helpful. Although the proportion of individuals with disorders who sought treatment was higher and they were more persistent in HICs than LMICs, proportional helpfulness among treated cases was no different between HICs and LMICs. A wide range of predictors of perceived treatment helpfulness were found, some of them consistent across diagnostic categories and others unique to specific disorders. These results provide novel information about patient evaluations of treatment across diagnoses and countries varying in income level, and suggest that a critical issue in improving the quality of care for mental disorders should be fostering persistence in professional help-seeking if earlier treatments are not helpful.

Perceived helpfulness of treatment for social anxiety disorder: findings from the WHO World Mental Health Surveys.

PURPOSE: To investigate the prevalence and predictors of perceived helpfulness of treatment in persons with a history of DSM-IV social anxiety disorder (SAD), using a worldwide population-based sample. METHODS: The World Health Organization World Mental Health Surveys is a coordinated series of community epidemiological surveys of non-institutionalized adults; 27 surveys in 24 countries (16 in high-income; 11 in low/middle-income countries; N = 117,856) included people with a lifetime history of treated SAD. RESULTS: In respondents with lifetime SAD, approximately one in five ever obtained treatment. Among these (n = 1322), cumulative probability of receiving treatment they regarded as helpful after seeing up to seven professionals was 92.2%. However, only 30.2% persisted this long, resulting in 65.1% ever receiving treatment perceived as helpful. Perceiving treatment as helpful was more common in female respondents, those currently married, more highly educated, and treated in non-formal health-care settings. Persistence in seeking treatment for SAD was higher among those with shorter delays in seeking treatment, in those receiving medication from a mental health specialist, and those with more than two lifetime anxiety disorders. CONCLUSIONS: The vast majority of individuals with SAD do not receive any treatment. Among those who do, the probability that people treated for SAD obtain treatment they consider helpful increases considerably if they persisted in help-seeking after earlier unhelpful treatments.

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.

Evaluating survey consent to social media linkage in three international health surveys.

BACKGROUND: The use of Twitter data for health-related research has been increasing over time. While the organic nature of the data offer new opportunities, the limited understanding of how and by whom the data are generated poses a challenge for advancing health-related research. Individual-level data linkage could shed light into the data generation mechanism. OBJECTIVES: This paper investigates whether consent to link survey data with Twitter public data is associated with sociodemographic and Twitter use pattern factors and whether consenters and non-consenters differ on health-related outcomes. METHODS: Data from three health related surveys that use probability samples of the target population were used: 1) A college population web survey in KU Leuven University, 2) An adult population web survey of the US population, and 3) A population face-to-face survey in the Kingdom of Saudi Arabia (KSA). In all surveys, respondents reported whether they have a Twitter account, and Twitter users were asked to provide consent for linking their survey responses to their public Twitter data. RESULTS: Consent rate estimates from the two web surveys in Belgium and the US were 24% and 27% respectively. The face-to-face survey in KSA yielded a higher consent rate of 45%. In general, respondents' sociodemographic characteristics were not significantly associated with consent to link. However, more use of social media and reporting sensitive information in the survey were found to be significantly correlated with higher consent. Consenters and non-consenters were not found to be statistically different on any of the health related measures. CONCLUSIONS: Very few differences were found between those who consented to link their survey data with their Twitter public data and those who did not. Modifiable design variables need to be investigated to maximize consent while maintaining balance between consenters and non-consenters.

The Saudi National Mental Health Survey: Survey instrument and field procedures.

OBJECTIVES: To present an overview of the survey and field procedures developed for the Saudi National Mental Health Survey (SNMHS). METHODS: The SNMHS is a face-to-face community epidemiological survey of DSM-IV mental disorders in a nationally representative sample of the household population in the Kingdom of Saudi Arabia (KSA) (n = 4,004). The SNMHS was implemented as part of the WHO World Mental Health (WMH) Survey Initiative. WMH carries out coordinated psychiatric epidemiological surveys in countries throughout the world using standardized procedures designed to provide valid cross-national comparative data on prevalence and correlates of common mental disorders. However, these procedures need to be adapted to the unique experiences in each country. We focus here on the adaptations made for the SNMHS. RESULTS: Modifications were needed to several interview sections and expansions were needed to address issues of special policy importance in KSA. Several special field implementation challenges also had to be addressed because of the need for female interviewers to travel with male escorts and for respondents to be interviewed by interviewers of the same gender. CONCLUSIONS: Thoughtful revisions led to a high-quality field implementation in the SNMHS.

Lifetime prevalence and age-of-onset distributions of mental disorders in the Saudi National Mental Health Survey.

OBJECTIVES: To estimate lifetime prevalence of mental disorders in the Saudi National Mental Health Survey (SNMHS). METHODS: The SNMHS is a face-to-face community epidemiological survey in a nationally representative household sample of citizens ages 15-65 in the Kingdom of Saudi Arabia (KSA) (n = 4,004). The World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) was used to estimate lifetime prevalence of common DSM-IV mental disorders. RESULTS: Estimated lifetime prevalence of any DSM-IV/CIDI disorder is 34.2% and lifetime morbid risk is 38.0%. Anxiety disorders are by far the most prevalent (23.2%) followed by disruptive behavior (11.2%), mood (9.3%), eating (6.1%), and substance use (4.0%) disorders. Synthetic estimates of cohort effects suggest that prevalence of many disorders has increased in recent cohorts. Onsets typically occur in childhood for a number of anxiety and disruptive behavior disorders and in adolescence or early adulthood for most other disorders, although age-of-onset distributions for drug abuse is much later (median age of 31) than in CIDI surveys carried out in other high-income countries. CONCLUSIONS: Lifetime mental disorders are highly prevalent in Saudi Arabia and typically have early ages-of-onset.

Twelve-month prevalence and severity of mental disorders in the Saudi National Mental Health Survey.

OBJECTIVES: To estimate 12-month prevalence and severity of mental disorders in the Saudi National Mental Health Survey (SNMHS). METHODS: The SNMHS is a face-to-face community epidemiological survey in a nationally representative household sample of citizens aged 15 to 65 in the Kingdom of Saudi Arabia (KSA) (n = 4,004). The World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) was used to estimate 12-month prevalence of common DSM-IV mental disorders. RESULTS: Twelve-month prevalence of any DSM-IV/CIDI disorder is 20.2%. Most common are anxiety disorders (12.3%) followed by mood (6.8%), disruptive behavior (5.4%), eating (3.2%), and substance use (1.9%) disorders. The proportion of 12-month cases rated serious (39.0% of all cases) is high across virtually all disorders relative to the proportions found in CIDI surveys in other high-income countries. Younger people have significantly elevated odds of mood and disruptive behavior disorders and serious disorders. Women have significantly elevated odds of anxiety and mood disorders and serious disorders. Previously married people have significantly elevated odds of most disorder classes and serious disorders. CONCLUSIONS: Both 12-month prevalence and severity of DSM-IV/CIDI disorders are high in Saudi Arabia compared to other high-income countries that carried out comparable surveys.

Clinical reappraisal of the Composite International Diagnostic Interview Version 3.0 in the Saudi National Mental Health Survey.

OBJECTIVES: The DSM-IV diagnoses generated by the fully structured lay-administered Composite International Diagnostic Interview Version 3.0 (CIDI 3.0) in the Saudi National Mental Health Survey (SNMHS) were compared to diagnoses based on blinded clinical reappraisal interviews. METHODS: Telephone follow-up interviews were administered using the clinician-administered non-patient edition of the Structured Clinical Interview for DSM-IV (SCID) in separate sub-samples of SNMHS respondents who screened positive for four disorders that are of special importance in Arab countries: obsessive-compulsive disorder, separation anxiety disorder, social phobia, and major depressive episode. RESULTS: Initial diagnoses based on the CIDI were found to have higher prevalence than those based on the SCID for all four disorders. For reasons having to do with respondent denial of symptoms in the SCID reported in the CIDI, we interpreted these differences as due more to under-diagnoses in the SCID than over-diagnoses in the CIDI. Nonetheless, CIDI diagnostic thresholds for three of the four disorders were increased to make sure prevalence estimates based on the CIDI were conservative. The procedures used to implement these recalibrations are described in this paper. CONCLUSIONS: The CIDI interviews used in the SNMHS generated valid but conservative diagnoses of common mental disorders in the Saudi population.

Overview of the Saudi National Mental Health Survey.

OBJECTIVES: To present background information for the Saudi National Mental Health Survey (SNMHS) on the Saudi mental healthcare delivery system and previous epidemiological research on the prevalence and treatment of mental disorders in the Kingdom of Saudi Arabia (KSA). METHODS: Archival information and the results of a literature review are presented. RESULTS: KSA is the largest sovereign nation in the Middle East and the largest free market economy in the Middle East and North Africa. A national mental health policy has been in existence since 2006, but mental health spending still is less than in most other high-income countries. The Ministry of Health has recently begun developing a new healthcare system based on a patient-centered model of care that will integrate care of mental disorders with care of physical disorders. Previous epidemiological research on mental disorders in KSA has been limited, making the SNMHS important for policy planning purposes to obtain accurate estimates of prevalence, treatment, and barriers to treatment. CONCLUSIONS: The SNMHS will provide valuable information for policy planning purposes on the burden of untreated mental disorders in KSA and barriers to treatment.

Twelve-month treatment of mental disorders in the Saudi National Mental Health Survey.

OBJECTIVES: To estimate treatment rates of 12-month mental disorders in the Saudi National Mental Health Survey (SNMHS). METHODS: The SNMHS is a face-to-face community epidemiological survey in a nationally representative household sample of citizens ages 15-65 in the Kingdom of Saudi Arabia (KSA) (n = 4,004). The World Health Organization Composite International Diagnostic Interview (CIDI) was used to produce estimates of 12-month prevalence and treatment of common DSM-IV mental disorders. RESULTS: About one eighth (13.7%) of respondents with a 12-month DSM-IV/CIDI disorder received 12-month treatment. The highest proportion of treatment occurred in the general medical sector (53.0%). Close to half (45.2%) of patients received treatment rated at least minimally adequate using standard treatment guidelines. Although serious disorders were significantly more likely to be treated (20.2%) than mild or moderate disorders (8.5-10.7%), no association was found between disorder severity and probability of receiving adequate treatment. Sociodemographic correlates were for the most part nonsignificant. CONCLUSIONS: A high level of unmet need for treatment of mental disorders exists in KSA. Further analyses of the SNMHS data might provide insights into modifiable barriers to treatment and policy options to address the problem of unmet need for treatment.

Barriers to Mental Health Treatment in the Saudi National Mental Health Survey.

Objectives: To examine barriers to initiation and continuation of treatment among individuals with common mental disorders in the Saudi National Mental Health Survey (SNMHS). Methods: The SNMHS is a community-based epidemiological survey in a nationally representative household sample of respondents aged 15-65 in the Kingdom of Saudi Arabia. The World Health Organization Composite International Diagnostic Interview (CIDI) 3.0 was used. Predictors of barriers to treatment were analyzed with multivariable logistic regression. Results: Among participants with a 12-month DSM-IV/CIDI disorder (n = 711), 86.1% reported no service use. Of those (n = 597), 50.7% did not think they needed any help (categorized as "low perceived need") and 49.3% did perceive need. Of those who perceived need (n = 309), the majority (98.9%) reported attitudinal barriers to initiation. In contrast, 10.3% of those with a perceived need reported structural barriers. Respondents who were previously married or indicated below-average income were more likely to believe they needed help. Conclusions: Among people with a diagnosed mental disorder, low perceived need and attitudinal barriers are the primary barriers to mental health treatment in the KSA. The results suggest that addressing poor mental health literacy may be essential factor in reducing the unmet need for mental health treatment in the KSA.

Lifetime treatment of DSM-IV mental disorders in the Saudi National Mental Health Survey.

OBJECTIVES: To estimate lifetime treatment rates of mental disorders in the Saudi National Mental Health Survey (SNMHS). METHODS: The SNMHS is a face-to-face community epidemiological survey in a nationally representative household sample of citizens ages 15-65 in the Kingdom of Saudi Arabia (KSA) (n = 4,004). The World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) was used to produce estimates of lifetime prevalence and treatment of common DSM-IV mental disorders. RESULTS: Lifetime treatment ranged from 52.2% for generalized anxiety disorder to 20.3% for attention deficit/hyperactivity disorder, had a median (interquartile range) of 35.5% (30.6-39.5%) across disorders, and was 28.3% for people with any lifetime DSM-IV/CIDI disorder. Half (49.0%) of patients received treatment in the mental health specialty sector, 35.9% in the general medical sector, 35.2% in the human services sector, and 15.7% in the complementary-alternative medical sector. Median (interquartile range) delays in help-seeking after disorder onset among respondents who already sought treatment were 8 (3-15) years. Odds of seeking treatment are positively related to age-of-onset and comorbidity. CONCLUSIONS: Unmet need for treatment of lifetime mental disorders is a major problem in KSA. Interventions to ensure prompt help-seeking are needed to reduce the burdens and hazards of untreated mental disorders.

Sexual maturation affects diet-blood total cholesterol association in children: Project HeartBeat!

BACKGROUND: Cardiovascular disease (CVD) does not become clinically manifest until adulthood. However, children and young adults have evidence of atheromatous lesions and fatty streaks in their aortas and coronary vessels. Most longitudinal studies in children are not designed to evaluate the dynamics of change in CVD risk factors. There is a need to describe the trajectory of CVD risk factors as growth processes, to better understand their relationships. This study assesses the associations between dietary variables and blood total cholesterol concentration (BTCC) among children and adolescents aged 8-18 years after adjustment for sexual maturation. METHODS: There were 678 boys and girls aged 8, 11, and 14 years at baseline who were followed for up to 4 years, allowing the creation of a synthetic cohort analytically, from ages 8-18 years. Multilevel modeling was used to longitudinally assess BTCC, dietary intake, Tanner stage, and BMI. RESULTS: For every 1-mg/day increase in dietary cholesterol, BTCC increased by 0.012 mg/dL. However, no associations were evident between BTCC and dietary total fat, saturated fatty acids, polyunsaturated fatty acids, or monounsaturated fatty acids. In girls, none of the dietary variables was significantly associated with BTCC after controlling for Tanner stage for breast. In boys, with the exception of dietary cholesterol, no other dietary variable was significantly associated with BTCC after controlling for Tanner stage for genitalia. CONCLUSIONS: Sexual maturation exerts a strong influence on BTCC in children and adolescents aged 8-18 years, obscuring most associations between diet and BTCC. The inclusion of sexual maturity stage is important in studies of blood lipids among children and adolescents.