The Mental Health System in the Kingdom of Saudi Arabia

In recent years, mental health has gained recognition as a significant public health concern in Saudi Arabia. Evidence-based studies have shed light on the prevalence and impact of mental health disorders in the population. For instance, research has shown that depression and anxiety disorders are among the most common mental health issues faced by Saudis. Furthermore, studies have highlighted the association between mental health disorders and various factors such as socioeconomic status, gender, and cultural influences.

This paper aims to describe the current mental health system and garner the support of stakeholders and decision-makers in facilitating evidence-based mental health plans with actionable targets. Following previous evaluations, the World Health Organization Assessment Instrument for Mental Health Systems 2.2 [1] was recently used in 2021-2024 to collect information about the mental health system in the Kingdom of Saudi Arabia (KSA).

The World Health Organization (WHO) Assessment Instrument for Mental Health Systems (AIMS) 2.2 is a detailed evaluation tool designed for assessing mental health systems, primarily in middle- and low-income countries, but also applicable in high-income settings [2]. It covers six key areas: policy and legislative framework, mental health services, mental health in primary care, human resources, public education and links with other sectors, and monitoring and research Saxena S, et al. [2]. The Kingdom of Saudi Arabia (KSA) has used WHO-AIMS 2.2 to track its mental health system's progress, noting legislative frameworks and service improvements since the 1950s despite limited financial resources [3-5]. This paper aims to comprehensively detail KSA's current mental health system, using data collected from various government ministries and organizations. The methodology included quantitative and qualitative data gathered through multiple communication channels from 2019 to 2024. This report is intended to inform policymakers and stakeholders about and advance mental health initiatives in KSA.

Key informants were contacted through various methods to gather unpublished and confidential information, and data were collected from official reports and presentations from several ministries and the Saudi Health Council. Additional data were obtained from official websites and reports from the Saudi government and other organizations.

The Saudi Vision 2030 and the Health Sector Transformation Program have outlined ambitious goals for improving healthcare services in Saudi Arabia, including a strong emphasis on mental health and well-being. The 2030 Vision aims to enhance the quality of life for all citizens by promoting holistic health, which includes mental well-being as a crucial component. The Health Sector Transformation Program complements this vision by focusing on initiatives to modernize healthcare infrastructure, improve access to healthcare services, and enhance the quality of care across the country. As part of these efforts, there is a growing recognition of the importance of addressing mental health challenges and promoting mental well-being.

Policy and legislative framework

The Kingdom of Saudi Arabia (KSA) ensures the right to healthcare through laws emphasizing the state's responsibility to provide comprehensive services, including mental health. The Ministry of Health offers free healthcare, aligning with national health goals. The Mental Health Care Law in the Kingdom of Saudi Arabia (KSA) was established following the publication of the first Mental and Social Atlas and is implemented across all mental health settings [3,4,6]. It defines 'mental disorder' and sets comprehensive guidelines for access to care, patients' rights, and the responsibilities of supervisory boards and committees. The Basic Law of Governance [7] and the Disability Welfare Law [8] emphasize justice, equality, and the rights of disabled persons, including those with mental disorders. The Law of Protection from Abuse [9] and amendments to the Criminal Procedure Law [10] provide legal protections against abuse and harassment, including in the workplace and for vulnerable groups like children [11]. Islamic law prohibits suicide, with specific guidelines for handling attempted cases [12]. Monitoring and training on human rights are stipulated, although gaps remain in implementation [4,13]. The MoH's budget has grown, but mental health care remains underfunded [4,14]. Mental health disorders impose significant burdens on caregivers and communities, highlighting the need for improved support systems and public awareness [15]. Regarding plans, the national strategy-Model of Care for Mental Health, Addictions, and Development Disorders-developed as part of the Saudi Vision 2030 is currently underway. Despite the growing need for mental health care among the population, only 4% of the governmental health expenditure is directed towards mental health [4,14].

Mental health services

The development of mental health services in the Kingdom of Saudi Arabia (KSA) has been thoroughly documented [16,17]. The Ministry of Health (MoH) is the primary provider and regulator of mental health and addiction services, overseeing public and private sectors and working with the Saudi Health Council and Saudi Commission for Health Specialties for legislative and licensing matters. Non-governmental organizations (NGOs) contribute by providing charitable mental health services. The Ministry of Justice (MoJ) and the Ministry of Interior (MoI) offer legal and forensic services. At the same time, the Ministry of Human Resources and Social Development (MHRSD) handles social integration and post-treatment services. The Ministry of Education (MoE) manages mental health training and school programs, with universities and research institutes leading research and development. The National Center for Mental Health Promotion (NCMH), established in 2019, aims to develop mental health programs, promote awareness, and improve psychological services [18]. It collaborates with various authorities to create policies and standards, and it researches topics like suicide, community knowledge, and the COVID-19 pandemic [19-21].

Mental health facilities in KSA include 21 specialized hospitals providing 80% of the country's mental health services, with both inpatient and outpatient options [22,23]. The Al-Amal Complexes focus on addiction treatment. Outpatient services are also available through entities like the National Guard, MoI, MoD, and MoE, with specialized clinics for conditions such as autism [23,24]. One hundred thirty-three clinics in public hospitals and 120 centers/clinics in the private sector also offer mental health care [24], all regulated by the MoH and SCFHS. The healthcare system in Saudi Arabia has also made strides in addressing mental health needs, with an increasing focus on evidence-based interventions and treatments. Efforts have been made to integrate mental health services into primary care settings, providing greater access to screening, diagnosis, and treatment options for individuals with mental health concerns. Despite these advancements, challenges remain, including stigma surrounding mental illness and limited resources in certain regions.

Overall, 4,440 beds are allocated across the Kingdom for psychiatric and addiction inpatients, denoting five beds per 10,000 population [24]. Of the total, 2,520 beds are designated for psychiatric inpatients in general, 1,177 for addiction treatment, and 499 beds are in halfway houses; the remaining number are considered inactive [24].

Although the number of mental health professionals has increased compared to previous years, there is still a significant gap between demand and current workforce supply across all sectors. There are just 3.4 psychiatrists for every 100,000 people, compared to an average of 8.6 in high-income countries. Similarly, there are only 3.2 psychologists per 100,000 people, whereas high-income countries average 10.7 [25]. Only a few accredited psychologists in the KSA report having prior clinical training and postgraduate education. Additionally, specialized mental health services for women, specialists in child and adolescent psychiatry, eating disorders, geriatric psychiatry, forensic psychiatry, psychotherapeutic approaches, and occupational therapy continue to be deficient.

E-health in Saudi Arabia

The Ministry of Health (MoH) in Saudi Arabia is advancing telemedicine and e-health by implementing the National E-Health Strategy. The National Health Information Center facilitates health information exchange and initiated the Saudi Telehealth Network to connect remote healthcare facilities via telemedicine, enhancing service quality and cost-effectiveness. Various platforms, such as "Sehhaty," "Qareboon," and the 937 Call Center, streamline health services and improve access to care [26]. The Virtual Clinics Service on "Sehhaty" enables remote medical care, reducing non-emergency visits and enhancing patient satisfaction [27]. The Seha Virtual Hospital provides specialized services to 170 hospitals, supporting over 480,000 patients annually with a range of virtual health services, aligning with national health sector transformation goals [28].

Substance use in the Kingdom of Saudi Arabia

In the Kingdom of Saudi Arabia (KSA), despite religious and legal prohibitions, approximately 7-8% of Saudis use drugs, with 70% of users aged 12-22 [29]. Commonly abused substances include amphetamines, heroin, alcohol, and cannabis. Throughout Saudi Arabia, there are 99 publicly funded mental health outpatient clinics and 19 public mental health hospitals run by the Ministry of Health, which include beds for psychiatric and addiction patients. Moreover, eight additional government-run tertiary or general hospitals with psychiatric inpatient facilities exist. A small number of private hospitals offer about 7% of the total psychiatric inpatient beds [25]. Data on substance use is primarily from males due to societal challenges faced by women, with limited resources and research available on female substance use [30]. A case-control study on 207 female patients in Jeddah highlighted factors such as marital instability and family conflicts associated with substance use. The 2023 National Report on Drug Abuse indicated a five-fold increase in psychoactive substance abuse from 1999 to 2022, with cases rising from 10,727 to 66,724. The prevalence rate among adults was 4.8%, with an estimated 780,000 adult Saudi drug users. Most drug-related apprehensions were of individuals aged 21-30, with Saudis comprising 83.8% of consumption cases and 64.3% of smuggling cases. The report highlighted the need for systematic monitoring and periodic surveys to measure drug use prevalence [31].

Suicide in the Kingdom of Saudi Arabia

In Saudi Arabia, an Islamic country where suicide is prohibited, the annual suicide rate is approximately 1.1 per 100,000 people [32]. Despite the low global incidence, hanging is identified as the most common method of suicide in the country [33]. Reports from the Ministry of Interior (MoI) and Ministry of Human Resources and Social Development (MHRSD) indicate that suicide cases have been increasing annually since 2015, with numbers ranging between 400-700 cases each year. From 2014-2018, there were 24,294 cases of deliberate self-harm, with the highest incidences occurring in the Eastern Region, Al-Ahsa, and Al-Baha [34]. In 2010, autopsy reports from the Forensic Medicine Center in Dammam revealed that 83.13% of 160 suicide cases involved hanging, with other methods including firearms (5%) and various others. Psychological issues, family troubles, and substance use were documented in over 40 cases, with most suicides involving non-Saudis, mainly Indian nationals, and over 80% were laborers, maids, homemakers, or unemployed individuals [32].

Public education and links with other sectors

In collaboration with governmental sectors, NGOs, and international organizations, the National Center for Mental Health Promotion (NCMH) in Saudi Arabia coordinates public education and awareness campaigns on mental health through lectures, workshops, exhibitions, and digital applications like Qareboon. These campaigns target various groups, including the general population, children, adolescents, women, and special groups [35,36]. Specific campaigns also focus on healthcare providers, Imams, teachers, and social service staff [36].

The Disability Law in KSA ensures employment support for people with disabilities, including those with mental disorders, protecting them from workplace discrimination. The Mowaamah program facilitates supportive work environments, while the Human Resources Development Fund (HADAF) collaborates with the Authority for the Care of Persons with Disabilities (APD) to design training and employment initiatives [37]. The Tawafuq employment program and Qaderoon initiative support the employment of individuals with disabilities in the private sector [7]. Regarding housing, people with disabilities receive priority in housing support, though specific provisions for those with mental disorders are unclear [34]. The Mental Health Care Law mandates referring psychiatric patients without homes to recovery facilities [38].

Formal collaborations include partnerships with SABIC, social media influencers, and pharmaceutical companies for mental health awareness and support [5]. An NCMH initiative educates Imams and preachers on mental health, benefiting over 500 religious leaders [36].

Schools now have part-time or full-time counselors and activities promoting mental health, supported by NCMH, MoE, and MoH [7]. The "Universities Mental Health Enhancement Initiative," launched by NCMH, aims to improve mental health awareness and services in universities. A study assessing the extent of universities' efforts in promoting mental health and the specific approaches they use in Saudi Arabia was conducted across eleven Saudi governmental universities. The study highlights that while universities are making environmental changes to promote mental health, they still lack comprehensive mental health policies, capacity building, and community coordination. It emphasizes the crucial role of educators and administrators in supporting student well-being by creating inclusive and empowering environments. The findings suggest that a multifaceted approach involving policy implementation, capacity building, and coordinated community efforts is essential for effectively reducing psychological distress and improving student mental health [39].

In Saudi Arabia, all mental health facilities routinely compile defined data, with 100% reporting to the government health department, which publishes periodic national reports on mental health. The latest Mental and Social Health Atlas was published in 2016, and recent research supported by the Ministry of Health (MoH) has focused on the prevalence and treatment of mental disorders [40,41].

Mental health research in Saudi Arabia has grown significantly since the mid-1980s, with publications increasing from virtually none before 1975 to a substantial number in recent decades [42]. In 2013, were 35,324 researchers in the KSA, although current estimates of those focused on mental health are unknown? Researchers typically come from academic institutions, government organizations, and the healthcare sector.

One major initiative is the Saudi National Mental Health Survey (SNMHS), a comprehensive scientific survey conducted between 2011 and 2016 to estimate the prevalence, treatment patterns, and social costs of mental disorders in Saudi Arabia. This survey was part of the World Mental Health initiative led by the World Health Organization and Harvard University, collaborating with various Saudi institutions [43]. A literature search on PubMed highlighted an increase in mental health publications over the past decade. However, concerns about the quality and reliability of search engine results persist [44]. Despite progress, challenges in mental health research in Saudi Arabia include inadequate training, limited funding, stigma, and low awareness [45]. More resources are needed to support Saudi Vision 2030 goals to enhance research quality and inform policymakers and stakeholders.

In conclusion, the mental health system in Saudi Arabia has undergone substantial development since the establishment of its first mental hospital in the 1950s. Implementing comprehensive legislation, such as the Mental Health Care Law and the National Center for Mental Health Promotion (NCMH), proactive efforts have been pivotal in advancing mental health services and increasing public awareness. The system now includes outpatient clinics, services for particular groups, and mental health support in academic institutions, marking significant progress [5,17,46].

However, several challenges persist that hinder the system's effectiveness. The proportion of the financial budget allocated to mental health care has remained low for over a decade, and national health insurance schemes cover only part of the costs, leaving some individuals to pay significant out-of-pocket expenses [4,14,23,24,47]. Additionally, routine monitoring and human rights inspections in mental health facilities are insufficient, with a lack of official documentation and data auditing [23].

The demand for mental health services continues to outpace the available resources, with facilities often overburdened and services for women, children, adolescents, and the elderly still lacking [23]. While the number of mental health professionals has increased, there remains a significant gap between the workforce supply and demand, especially in specialized areas such as developmental disorders, eating disorders, geriatrics, and various types of psychotherapy [22,48].

Public education and awareness campaigns, coordinated by the NCMH in collaboration with other governmental and non-governmental organizations, have effectively reached various population groups. However, these campaigns often lack coordination across sectors and are predominantly focused on prevention, with limited efforts to provide comprehensive knowledge about mental health issues [23,34,35].

Despite these challenges, the mental health information reporting system has improved, with all facilities collecting data related to care services. Nevertheless, the exact proportion of facilities that maintain these records routinely is unclear, and the number of professionals involved in mental health research across the Kingdom is unknown [23,42]. To support the goals of Saudi Vision 2030 and further advance the mental health system, it is crucial to allocate more resources, enhance coordination across sectors, and develop robust research frameworks that feed into evidence-based treatment and policy development. By addressing these gaps, Saudi Arabia can continue to improve its mental health care system and better meet the needs of its population.

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