Country profiles

Saudi Arabia

Overview

Based on the most recent statistics, the population of people below 15 years of age and above 65 years of age, in 1993, was estimated as 41.8% and 2.6%, respectively. In 1996, the total adult literacy rate and the female adult literacy rate were 74.9%and 64.5%, respectively.

The crude birth rate in 1990 was calculated to be 35.2 per 1000 population. In 1995, the total life expectancy was estimated to be at 71.4 years. In the same year the infant mortality rate was 21 per 1000 live births. In 1990, the under-five mortality rate was estimated at 34 per 1000 live births. The maternal mortality rate, in 1993, was estimated at 1.8 per 10 000 live births.

Mental health

The development of mental health care in Saudi Arabia can be seen to fall into two clear phases. Until 1983, mental health care in the country was mainly provided by the Taif Mental Hospital. This was a hospital meant for 250 patients, but serving a larger number of patients (for example, in 1978, there were 1800 patients). This also meant that patients had to travel long distances to obtain mental health care. This often resulted in delays in seeking care and, problems of discharge into the community.

Since 1983, a shift occurred in the form of setting-up of smaller-sized (20-120 beds) hospitals all over the country along with outpatient clinics. The next phase envisages further integration of mental health with primary health care.

Taif Hospital has 570 beds. There are 14 other mental hospitals with an average bed capacity of 30-120 beds in other parts of the country, isolated from the general hospitals and working independently.

Psychiatric departments and clinics attached to general hospitals total 61 in number, having 20-30 beds each.

There are three Amal Hospitals with 280 beds each under the joint administration of the Ministries of Health and Interior for treatment of persons with alcohol and drug dependence. Two years ago, a unit attached to the general hospital in Qassin, was opened with a bed capacity of 20 beds.

There are, in addition, 165 beds for psychiatric inpatients in other governmental health sectors, such as military, national guard and university hospitals.

There are many private units and 146 beds in general private hospitals for psychiatric care, as well as outpatient services.

Six school health units provide some psychiatric services in Riyadh, and other such units are planned in other regions after training of the staff in the School Health Unit. Following a royal decree of 1988,

Rehabilitation services for persons with mental disorders were planned but are currently concentrated in the privatean NGO sector.

The services for the mentally retarded consist of beds in Taif and other mental hospitals. There are secure sections for the treatment of mentally ill prisoners and those charged with crimes and mentally ill in Taif and some other mental hospitals.

At present, child psychiatric services are delivered mainly on an outpatient basis, and emergency cases can be admitted to paediatric departments or to general hospitals under the supervision of the nearest psychiatrist.

Integrated data are available for services in all mental hospitals, general hospitals, psychiatric units and outpatient clinics. These data are compiled from returns by the psychiatrists from each centre. Between 1991 and 1996, there was an increase of about 26% in outpatient attendances, including new contacts. Similarly, there was an equal increase in both first admissions and readmissions to inpatient care. This indicates that the services are being increasingly used by the population.

There are about 498 psychiatrists in the country. Of these, 286 are working in Ministry of Health facilities, 108 in other governmental sectors and 64 in the private sector. There are a disproportionate number of expatriates; there are only 78 Saudi psychiatrists. There are 183 social workers working in mental hospitals. There are 108 psychologists working in Ministry of Health facilities, and 1271 nurses. All the psychologists and social workers are Saudi nationals, but the majority of nurses not.

There are four universities with medical schools- King Saud University, Riyadh, Jeddah, Abha and King Faisal University, Dammam. There are approximately 270 new medical graduates per year.

There are two postgraduate programmes in psychiatry, one at King Faisal University in Dammam and the other at King Saud University in Riyadh. Gradually, more Saudi nationals are taking up psychiatry. There are also training programmes in the psychiatric units in military hospitals, national guard hospitals and King Faisal Specialist Hospital in Riyadh.

The Saudi national mental health programme was developed in 1989. The objectives of the programme are:

• to make essential mental health services available to all citizens and residents in the country, paying more attention to those who are more in need of these services and to underserved areas

• to develop a mental health care model in keeping with the social, cultural and religious values of the country

• to encourage community participation in the development of mental health care services

• to use mental health knowledge and skills in order to help solve psychosocial problems, and to encourage the application of mental health principles for promotion of social health and enhancing socioeconomic development of society, as well as improving the quality of life

• to decrease the untoward impact of social and economic development on society such as drug abuse, smoking, delinquency and crime.

Strategies for the programme are:

• integration of mental health services with general health services

• supporting the present mental health services and making these services available in all areas and providing mental health services to the more vulnerable groups

• incorporating mental health services into primary health care through existing health staff by suitable additional training

• linking, the primary health care centres to mental health services and to teaching centres through a series of referral systems

• training and supervising by mental health professionals of the medical personnel who will form the treatment teams at primary health care level

• providing the essential neuropsychiatric drugs at primary health care level

• cooperating with non-health sectors, (community leaders, nongovernmental organizations, religious establishments, etc.) in planning and implementation of the programme.

A Directorate of Mental and Social Health has been created in the Ministry of Health. It is clear the primary health care level is the principal avenue through which mental health services can reach those in the community most in need of them

The Directorate has set up a well designed training programme for the mental health component of primary health care. The programme has been undertaken as follows: First, a training manual was prepared and sent to all centres that are staffed by Ministry psychiatrists. Second, a series of workshops has been set up to train psychiatrists in how to improve the skills of primary health care physicians in the recognition and management of common mental disorders. A third initiative has been taken jointly by the Directorates of Primary Health Care and of Mental and Social Health. They require all medical staff in primary health care centres throughout the country to attend a training programme on the recognition and management of common mental disorders. The details of such training courses vary between regions, . A common pattern is to have the doctors meet the psychiatrists, either at the primary health care centre or a hospital, for a few hours a week for two months and all must attend at some stage; Most primary health care physicians and nurses are not Arabic speakers, but all other staff are Saudis, which makes communications with the psychiatric patients possible. All antidepressants and neuroleptics and some anti-epileptics are exempt from the controlled drug list, and only minor tranquillizers and hypnotics remain controlled. So, primary health care physicians are allowed to initiate the prescription of these non-controlled drugs.

With the inception of the recent programme in schools, more could be done by the Ministry of Health.

There have been encouraging efforts made through the Directorate of Mental and Social Health to develop educational programmes with schools, the police and other sectors. The impression is that more activity should be considered with the police, who are an indisputably important pathway to care. Similarly, consideration might be given to increasing dialogue and collaboration with religious leaders, teachers and local authorities.

Programmes are carried out during the events of World Mental Health Day in October every year and this will be continued. Health education is mainly the responsibility of a special department in the Ministry of Health, which carries out all health educational programmes, including mental health educational programmes.

Traditional healers or sheikhs (respected persons) continue to play a large part in mental health care, and this includes the treatment of some common neurotic disorders. Some psychiatrists working in the provinces see collaboration as useful, and there is a great deal of collaboration between them and some religious healers.

A mental health act, already prepared, is awaiting formal approval from the legislator. It has been formulated after consideration of similar legislation in many countries and recommendations from the United Nations and the World Health Organization. This document contains the basic regulations for admission and discharge in mental hospitals, beside the main human rights of the psychiatric patient. The Directorate has developed and is using a manual of processes and regulations for all mental health institutions in the country until the mental health act is approved.

Saudi Arabia is fortunate that its culture, religion and policies have, up to the present, ensured a low level of drug and alcohol dependence problems, The Amal Hospitals concentrate more on preventive, early recognition and family counselling programmes.

Future plans

• To continue establishing outpatient clinics in the general hospitals and to upgrade some of these clinics to psychiatric units with a limited number of beds (20-30).

• To revise and update the national mental health programme according to progress and experiences gained since 1989.

• To collaborate with the Directorate of Health Centres of the Ministry of Health for the integration of mental health care into primary health care services by training of trainers (60), who are going to train about 2000 primary health care physicians in the regions during 1998 and also to prepare another manual for training of the nonmedical staff in the primary health care centres.

• To provide more psychological counselling and guidance centres in the general hospitals in other regions after the successes achieved in the Riyadh region.

• To foster coordination and collaboration between the Directorate of Mental and Social Health and other institutions and agencies for the implementation of the primary mental health care programme, especially with the Ministry of Education and General Presidency of Girls for training in school health units.

• To organize training programmes for psychiatrists, psychologists and social workers in collaboration with the universities, health institutes and some big mental health hospitals.