The epidemiology of obsessive-compulsive disorder in the Kingdom of Saudi Arabia: Data from the Saudi National Mental Health Survey.

AIMS: There is ongoing debate about the extent to which the epidemiology of OCD is similar across the world, given the lack of nationally representative data from key regions like the Middle East and North Africa. Using the nationally representative dataset from the Saudi National Mental Health Survey (SNMHS), we aimed to delineate the epidemiological profile of OCD in the Saudi population. METHODS: A subsample of 1981 participants from the SNMHS was assessed. Prevalence estimates and correlates of OCD were determined using logistic regressions and cross tabulations. RESULTS: The lifetime, 12-month, and 30-day prevalence estimates for OCD were 4.2%, 1.8%, and 1.6%, respectively, with hoarding being the most common symptom dimension. The mean age-of-onset of OCD was 16.8 years. In over two-thirds of respondents with lifetime (72.2%) or 12-month (71.2%), OCD was accompanied by comorbid mental disorder, particularly impulse control, anxiety, and mood disorders. Among individuals with 12-month OCD, 77.5% reported severe impairment, and only 9.2% received treatment. CONCLUSIONS: In Saudi Arabia, OCD is a prevalent and persistent condition, characterized by early onset, high odds of mental comorbidity, and significant associated impairment. These findings emphasize the universality of OCD epidemiology and the need for improved diagnosis and treatment globally.

Suicidal thoughts and behaviors in the Kingdom of Saudi Arabia.

OBJECTIVE: Suicidal thoughts and behaviors (STB) constitute an escalating public health concern globally. Despite the growing burden of suicidal ideation, plan, and attempts, national information on the trends of STB is lacking in the Kingdom of Saudi Arabia (KSA). Therefore, we aim to report on the prevalence, correlates, and treatment-seeking behaviors associated with STB in the country using nationally representative information from The Saudi National Mental Health Survey (SNMHS). METHODS: The SNMHS is a national household survey of Saudi citizens aged 15-65 (n = 4004). The adapted Composite International Diagnostic Interview (CIDI) 3.0 was administered to produce lifetime and 12-month prevalence and treatment estimates of STB in the KSA. Associated correlates were calculated using cross tabulations and logistic regressions. RESULTS: Suicidal ideation, plan, and attempt had respective lifetime prevalence rates of 4.90 %, 1.78 %, and 1.46 %; 12-month prevalence rates of 1.82 %, 0.89 %, and 0.63 %. Significant correlates of STB include younger age, female gender, low education, urban rearing, and singe marital status. STB were also significantly associated with the presence of prior mental disorders, childhood adversities, and low treatment-seeking. CONCLUSIONS: High unmet need and significant sociocultural and psychological risk factors have been identified in association with STB in the KSA. Given the community-based nature of the SNMHS and the limited national data on STB in the Middle East and North Africa region, our findings can extend to inform the necessary healthcare policies, treatment plans, and prevention strategies needed to alleviate the burdens of STB in the region.

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.

Dual burden of chronic physical conditions and mental disorders: Findings from the Saudi National Mental Health Survey.

Introduction: Comorbidities of mental disorders and chronic physical conditions are a common medical burden reported among Western countries. National estimates of such comorbidities among the general population of Arab countries like Saudi Arabia are unknown. This study examined the prevalence of lifetime chronic physical conditions among the Saudi general population with DSM-IV 12-month mental disorders, and the associations with disability in the Kingdom of Saudi Arabia (KSA). Methods: The Saudi National Mental Health Survey, a cross-sectional household study - part of the World Mental Health (WMH) Survey Consortium - was conducted between 2013-2016 in the KSA, with 4,001 Saudi citizens aged 15-65 (response rate 61%). The World Health Organization Composite International Diagnostic Interview 3.0 was used to assess prevalence of lifetime chronic physical conditions and 12-month mental disorders; disability was measured in terms of days out of role. Results: The prevalence of any comorbid 12-month mental disorder among those with chronic physical conditions was 24%. Major depressive disorder, social phobia, and adult separation anxiety disorder were the most common comorbid mental disorders across all chronic physical conditions. Gender, education, income, urbanicity, region, and employment were associated with the presence of any chronic physical condition. Respondents with mental / physical comorbidities had 2.97 days out of role (on average) in the last 30 days. Conclusion: Comorbidities of mental disorders and chronic physical conditions are common among Saudis. National efforts are needed to increase awareness of such comorbidities among the general population, and develop prevention and treatment services tailored to the needs of individuals at-risk for comorbidities.

Understanding the burden of mental and physical health disorders on families: findings from the Saudi National Mental Health Survey.

OBJECTIVE: To assess prevalence and correlation of factors of family burden associated with mental and physical disorders in the general population of Saudi Arabia. SETTING AND PARTICIPANTS: A secondary analysis of data from the Saudi National Mental Health Survey (SNMHS). OUTCOME MEASURES: Mental and physical health disorders of first-degree relatives and objective (time, financial) and subjective (distress, embarrassment) family burden. RESULTS: We found significant caregiver burden for family members with mental health disorders. Around one-third of the sample was providing care for a family member with a health issue. Within this group, 40% had a mental health diagnosis. 73% of the study population reported experiencing some form of burden as a result of the care they are obligated to provide for their family members. We found the highest burden on male caregivers, in providing care for family members with serious memory disorders, mental retardation, schizophrenia or psychosis, followed by, alcohol and drug disorders, anxiety, depression or manic depression. CONCLUSION: Our findings for family burden were statistically significant, indicating potential negative impact on caregiver coping ability with the demands of caring for family members with health issues. A comprehensive review of national mental health policies is required to integrate aspects of community mental health promotion, scale-up prevention, screening interventions and social support to protect against the difficulties of mental illness and reduce the burden on caregivers, the family, society, health system and the economy.

Lifetime prevalence and treatment of mental disorders in Saudi youth and adolescents.

Previous global and regional studies indicate that adolescents and young adults (i.e., youth) are affected by various mental disorders with lifelong consequences. However, there are no national estimates of mental disorders prevalent among Saudi youth. Using data from the Saudi National Mental Health Survey (SNMHS), we examined the lifetime prevalence, treatment, and socio-demographic correlates of mental disorders among Saudi youth (aged 15-30). A total of 4004 interviews were conducted using the adapted Composite International Diagnostic Interview (CIDI 3.0). Cross tabulations and logistic regression were used to generate estimates for the SNMHS youth sample (n = 1881). The prevalence of a mental disorder among Saudi youth was 40.10%, where anxiety disorders affected 26.84% of the sample, followed by disruptive behavior disorders (15.44%), mood disorders (9.67%), substance use disorders (4%) and eating disorders (7.06%). Sex, education, parental education, income, marital status, region, and family history of disorders were significant correlates of various classes of mental disorders. Only 14.47% of Saudi youth with any mental disorder received treatment for a lifetime disorder. Age, parental education, and family history of disorders emerged as significant correlates of mental health treatment. Lifetime mental disorders are highly prevalent among Saudi youth. There is an unmet need for culturally sensitive and age-appropriate treatment of lifetime mental disorders among youth in Saudi Arabia.

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.

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.

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.

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.

Using knowledge management tools in the Saudi National Mental Health Survey helpdesk: pre and post study.

BACKGROUND: With the growth of information technology, there is a need for the evaluation of cost-effective means of monitoring and support of field workers involved in large epidemiological surveys. AIM: The aim of this research was to measure the performance of a survey help desk that used knowledge management tools to improve its productivity and efficiency. Knowledge management tools are based on information technologies that improve the creation, sharing, and use of different types of knowledge that are critical for effective decision-making. METHODS: The Saudi National Mental Health Survey's help desk developed and used specific knowledge management tools including a computer file system, feedback from experts and a call ticketing system. Results are based on the analyses of call records recorded by help desk agents in the call ticketing system using descriptive analysis, Wilcoxon rank-sum test (p < 0.01) and Goodman and Kruscal test (gamma). The call records were divided into two phases and included details such as types of calls, priority level and resolution time. RESULTS: The average time to resolve a reported problem decreased overall, decreased at each priority level and led to increased first contact resolution. CONCLUSION: This study is the first of its kind to show how the use of knowledge management tools lead to a more efficient and productive help desk within a health survey environment in Saudi Arabia. Further research on help desk performance, particularly within health survey environments and the Middle Eastern region is needed to support this conclusion.

Implementing the TRAPD model for the Saudi adaptation of the World Mental Health Composite International Diagnostic Interview 3.0.

BACKGROUND: The World Mental Health-Composite International Diagnostic Interview (CIDI) 3.0, originally in English, is a fully-structured interview designed for the assessment of mental disorders. Although Arabic translations of CIDI from countries like Lebanon and Iraq exist, a Modern Standard Arabic translation was developed to suit the Saudi population. While the translation model used in the present paper has been used to translate instruments in Asian and European languages, there is no study to the best of our knowledge which has used this specific model to translate a validated instrument from English to Arabic. CASE PRESENTATION: This paper describes the Saudi adaptation of CIDI 3.0. The TRAPD team translation model-comprising of translation, review, adjudication, pretesting and documentation-was implemented to carry out the Saudi adaptation of CIDI 3.0. Pretests involving cognitive interviewing and pilot study led to translation revisions which consequently confirmed that Saudi respondents had a good understanding of various items of the instrument. The adaptation procedures for the Saudi CIDI 3.0 were well documented and the instrument was linguistically validated with the Saudi population. CONCLUSION: The TRAPD model was successfully implemented to adapt the CIDI 3.0 to be used as the main survey instrument for the Saudi National Mental Health Survey, findings of which will provide health policy makers mental health indicators for health decision making and planning.

Evidence-based guideline implementation of quality assurance and quality control procedures in the Saudi National Mental Health Survey.

BACKGROUND: The World Mental Health surveys have been known to apply high standards of quality control, but few studies have been published to document this. Furthermore, the effectiveness of quality control has rarely been reported in the Middle East. CASE PRESENTATION: The focus of this paper was to highlight the implementation of quality control procedures in the Saudi National Mental Health Survey under the World Mental Health Survey Consortium. The paper summarizes the guidelines implemented for the various phases of survey quality control-the quality assurance procedures, the quality control procedures and the quality control appraisal components-as per previously prescribed recommendations in literature. CONCLUSIONS: Survey quality management is a process and not reducible to a single event. Midstream corrections are warranted by detecting problems and intervening appropriately. The Saudi National Mental Health Survey implemented such procedures through continuous quality improvement.

The Saudi National Mental Health Survey: Methodological and logistical challenges from the pilot study.

Several challenges exist in carrying out nation-wide epidemiological surveys in the Kingdom of Saudi Arabia (KSA) due to the unique characteristics of its population. The objectives of this report are to review these challenges and the lessons learnt about best practices in meeting these challenges from the extensive piloting of the Saudi National Mental Health Survey (SNMHS), which is being carried out as part of the World Mental Health (WMH) Survey Initiative. We focus on challenges involving sample design, instrumentation, and data collection procedures. The SNMHS will ultimately provide crucial data for health policy-makers and mental health specialists in KSA.

Mental health system in Saudi Arabia: an overview.

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.