¹Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia

²Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia

Corresponding author email: salfakeh@kau.edu.sa

Article Publishing History

INTRODUCTION

Belief is a definite feeling that something exists or that a claim is true, and misconceptions are incorrect ideas based on misinterpreting situations. Beliefs and misconceptions differ widely between cultures and individuals (Dardas and Simmons 2015). Misconceptions about psychiatric disorders are widespread in many cultures. This is problematic because such misconceptions about psychiatric disorders may cause people with psychiatric disorders to be unwilling to seek appropriate care. In the case of Saudi Arabia, mental health is an issue of growing importance (Elbur et al. 2014), but its taboo nature in Saudi culture has adversely affected the willingness of people in Saudi Arabia to seek psychiatric care. Abolfotouh et al. (2019) have recently shown the lack of knowledge and stigmatizing attitude contributed to Saudis toward psychiatry consultation. Recently, Mahsoon et al. (2020) have  also  demonstrated  that   patients with psychiatric illnesses regardless  of the positive view to help seeking and family support  have   significant prejudices about mental health in Saudi Arabia, (Mahsoon et al. 2020).

Several studies have investigated stigmas around psychiatric disorders in various cultures. For example, Abdullah and Brown (2011) , who conducted such an investigation by analyzing the beliefs and values of different cultural groups, reported that people of Middle Eastern descent usually value family honor, which is grounded in maintaining good appearances and reputations, concealing emotions, and respecting patriarchal norms. Abdullah and Brown concluded that these values contribute to the stigma that generally surrounds psychiatric disorders in Middle Eastern cultures. Similarly, Al-Adawi et al. (2002) reported that the attitudes of Omanis towards psychiatric disorders are mainly affected not by demographic variables but rather by the degree to which traditional beliefs are accepted.

A study that investigated attendance at a mental health facility in Riyadh found that the factors contributing to nonattendance included, but were not limited to, negative beliefs about psychiatric disorders in general, the standard ways of treating psychiatric disorders in the community, and the perceived ineffectiveness of available mental health treatments (Alnamlah 2006). The reluctance to seek medical advice and to admit the presence of a psychiatric disorder is found in a study done among emirates by Eapen and Ghubash (2004). Furthermore, Soheilian and Inman (2009) found that most Americans of Middle Eastern descent would avoid psychiatric counseling for the sake of avoiding damage to their families’ reputations and images.

Similar findings have been reported by studies focused on non–Middle Eastern populations. For example, Henderson et al. (2013) analyzed data from England and identified multiple barriers that can prevent an individual from seeking psychiatric help, such as the inability to identify psychiatric disorders, ignorance concerning how to access psychiatric services, and preconceptions and assumptions that psychiatric patients will be unfairly treated by society.

Similarly, Corrigan et al. (2014) reviewed studies from around the world and reported that stigmas around psychiatric disorders can prevent an affected individual from pursuing psychiatric care. Moreover, the available literature on the utilization of psychiatric care in military and veteran populations indicates that beliefs and misconceptions concerning mental health contribute to individuals being unwilling to access psychiatric services (Vogt 2011). Individuals with psychiatric disorders who are unemployed commonly encounter various barriers when attempting to obtain psychiatric care, such as discrimination and a lack of knowledge concerning mental health and the conditions of psychiatric services (Staiger et al. 2017).

Gulliver et al. (2010) reported that young adults and adolescents can encounter similar obstacles, and Jang et al. (2011) showed that older individuals frequently have negative perceptions of mental health services, with many believing that having psychiatric issues would disappoint and upset not just the affected person but also the affected person’s family. Most of the available studies concerning attitudes towards psychiatric disorders have focused on cultures, groups, and countries outside the Middle East, and few studies have been conducted in Saudi Arabia. We, therefore, investigated the beliefs and misconceptions that Saudis hold about psychiatric disorders, people with such disorders, and psychiatric care. We hope that elucidating such beliefs and misconceptions will facilitate the development of appropriate interventions to counteract their harmful effects.

MATERIAL AND METHODS

The aim of this study is to find what keeps Saudis population from seeking psychiatric help. Where we conducted a cross-sectional survey of residents of Jeddah, Saudi Arabia, between January 2019 and May 2019. We randomly distributed electronic and paper surveys based on a modified version of the Community Attitude towards the Mentally Ill (CAMI) scale in multiple settings and accepted responses from any Saudi who was willing to participate. We translated the CAMI questionnaire to Arabic language and then rechecked it to make CAMI culturally appropriate for Saudi. The responses were collected from 1,424 individuals, of whom 1,170 completed the CAMI questionnaire and were included in our analyses. Thus, the response rate was 82.1%. The collected data were analyzed with SPSS software version 26 (IBM, Armonk, NY, USA). These analyses included the use of the χ2 test to determine whether responses to certain questionnaire items varied with respondents’ ages and genders. We selected p < 0.05 as our statistical significance threshold.

RESULTS AND DISCUSSION

Of the 1,170 individuals whose survey data were included in our analyses, 53.2% were younger than 25 years and 79.7% were female (Table 1).

Table 1. Demographic characteristics of the respondent sample (n = 1,170)

Variable	No. (%) of respondents in the category
Age, y 15–24 25–34 35–44 45–54 ≥55	622 (53.2%) 221 (18.9%) 204 (17.4%) 94 (8.0%) 29 (2.5%)
Gender Male Female	238 (20.3%) 932 (79.7%)
Education level Basic education Technical education University Postgraduate studies	271 (23.2%) 82 (7.0%) 747 (63.8%) 70 (6.0%)

The study sample is representative of the Saudi population as the median age of Saudi Arabia is 30 years according to the statistical yearbook done in 2018 by the General Authority of Statistics. Many of the respondents disagreed with most of the questionnaire statements listed in (Table 2), which generally expressed negative attitudes towards persons with psychiatric disorders, mental health facilities and services, and expenditures on psychiatric care. The questionnaire also included some statements that expressed support for using traditional methods, such as spiritual mediators and folk medicine, to treat psychiatric disorders.

Table 2. Responses concerning psychiatric disorders and services, a psychiatric patient and their integration into the community

Statement	No. (%) of respondents who agreed	No. (%) of respondents who disagreed
“Mental patients should be encouraged to assume the responsibilities of normal life.”	1,060 (90.6%)	24 (2.1%)
“I would not want to live next door to someone who has been mentally ill.”	76 (6.5%)	844 (72.1%)
“The mentally ill should be isolated from the rest of the community.”	19 (1.6%)	656 (56.1%)
“The mentally ill are a burden on society.”	78 (6.7%)	948 (81.0%)
“A woman/man would be foolish to marry someone who has suffered from mental illness, even though they seem fully recovered.”	162 (13.8%)	805 (68.8%)
“Less emphasis should be placed on protecting the public from the mentally ill.”	70 (6.0%)	294 (25.1%)
“The best way to handle the mentally ill is to keep them behind locked doors.”	22 (1.9%)	1,082 (92.5%)
“Anyone with a history of mental problems should be excluded from public places.”	61 (5.2%)	957 (81.8%)
“Mental hospitals are an outdated means of treating the mentally ill.”	655 (56%)	146 (12.5%)
“The mentally ill do not deserve our sympathy.”	28 (2.4%)	1,062 (90.8%)
“Mental health facilities should be kept out of residential neighborhoods.”	126 (10.7%)	778 (66.5%)
“The mentally ill should not be given any responsibility.”	104 (8.9%)	785 (67.1%)
“It is best to avoid anyone who has mental problems.”	95 (8.1%)	836 (71.5%)
“Mental health care is expensive.”	262 (22.3%)	110 (9.4%)
“Increased spending on mental health services is a waste of money.”	39 (3.4%)	1,071 (91.5%)
“Mentally ill persons can be treated by spiritual mediators.”	241 (20.6%)	494 (42.2%)
“Mentally ill persons can be treated by traditional methods ‘folk remedies.’”	283 (24.2%)	344 (29.4%)
“Medications for mental illnesses affect the personalities of patients and make them insensible.”	438 (37.4%)	244 (20.9%)
“Medications for mental illness cause addiction.”	986 (84.2%)	33 (2.8%)

Although 90% of respondents believed that psychiatric patients should assume normal responsibilities in society, 37.4% agreed that psychiatric medications affect patients’ personalities and make them insensible. Moreover, 84% thought that psychiatric medications can be addictive. When asked about their perceptions of mental hospitals, 50.6% agreed that they are an outdated means of treating psychiatric disorders. Furthermore, most respondents agreed that psychiatric care is expensive. When we tested for relationships between the respondents’ ages and their attitudes towards mental health, we observed no significant differences in the levels of agreement with most statements (Table 3).

Table 3. Attitudes towards persons with psychiatric disorders and psychiatric care according to age group

Statement and possible responses	No. (%) of respondents aged ≤35 years (n = 843) providing a given response	No. (%) of respondents ages >35 years (n = 327) providing a given response	χ2 test result for between-group difference in responses	p Value
“Mental health care is expensive.”
Agree Disagree Neutral	431 (51.1%) 84 (10.0%) 328 (38.9%)	154 (47.1%) 31 (9.5%) 142 (43.4%)	2.01	0.3
“The mentally ill should be isolated from the rest of the community.”
Agree Disagree Neutral	43 (5.1%) 480 (56.9%) 320 (38.0%)	10 (3.1%) 183 (56.0%) 134 (41.0%)	2.7	0.2
“Mental hospitals are an outdated means of treating the mentally ill.”
Agree Disagree Neutral	477 (56.6%) 123 (14.6%) 243 (28.8%)	178 (54.4%) 23 (7.0%) 126 (38.5%)	18.02	<0.001
“Medications for mental illnesses affect the personalities of patients and make them insensible.”
Agree Disagree Neutral	312 (37.0%) 182 (21.6%) 349 (41.4%)	126 (38.5%) 62 (19%) 139 (42.5%)	0.9	0.6

However, individuals who were 35 years old or younger were more likely than older respondents to agree that mental hospitals are outdated as treatment settings (p < 0.001). Furthermore, when we tested for relationships between the respondents’ genders and their attitudes towards mental health, we found gender-based differences in responses (Table 4).

Table 4. Attitudes towards persons with psychiatric disorders and psychiatric care according to gender

Statement and possible responses	No. (%) of men (n = 238) providing a given response	No. (%) of women (n = 932) providing a given response	χ2 test result for between-group difference in responses	p Value
“Mental health care is expensive.”
Agree Disagree Neutral	100 (42.0%) 17 (7.1%) 121 (50.9%)	485 (52.0%) 98 (10.5%) 349 (37.4%)	14.4	0.001
“The mentally ill should be isolated from the rest of the community.”
Agree Disagree Neutral	8 (3.4%) 121 (50.8%) 109 (45.8%)	45 (4.8%) 542 (58.2%) 345 (37.0%)	6.4	0.04
“Mental hospitals are an outdated means of treating the mentally ill.”
Agree Disagree Neutral	120 (50.4%) 43 (18.1%) 75 (31.5%)	535 (57.4%) 103 (11.1%) 294 (31.5%)	9.1	0.01
“Medications for mental illnesses affect the personalities of patients and make them insensible.”
Agree Disagree Neutral	91 (38.2%) 52 (21.8%) 95 (39.9%)	347 (37.2%) 192 (20.6%) 393 (42.2%)	0.4	0.8

Relative to male respondents, female respondents were less likely to be neutral on the questions of whether mental health care is expensive (p = 0.001) and whether psychiatric patients should be isolated from the community (p = 0.04). Female respondents were also more likely to agree that mental hospitals are outdated as treatment settings (p = 0.01). In this study, we did not find evidence of negative attitudes towards persons with psychiatric disorders being common among Saudis. Furthermore, we did not find strong evidence of sociodemographic factors being relevant to such beliefs and misconceptions among Saudis, although we did observe some gender-based differences in beliefs concerning psychiatric care and whether psychiatric patients should be isolated from the community.

Some people may avoid seeking help because their relatives harbor unfavorable attitudes towards psychiatric patients (Al-Adawi et al. 2002). However, we did not find evidence of such attitudes being common among Saudis. In fact, we found that many survey respondents favored integrating persons with psychiatric disorders into society, did not believe that protecting the public from such persons should be emphasized, and did not believe that increased public expenditures on mental health services would be a waste of money. Most of our respondents encouraged persons with psychiatric disorders to assume normal responsibilities in society. This last finding is similar to the finding of Al-Adawi et al. (2002) that most of their Omani respondents believed that patients with psychiatric disorders can be treated and should be considered members of the community. Futhermore, discrimination against psychiatric patients remains a barrier that prevents some people from seeking help (Gulliver et al. 2010).

Where a study by (AlAteeq et al. 2018) concluded that family participation in the care plan for a patient and cultural differences had a big impact in developing self-stigmatization. Moreover, keeping a patient privacy and over protecting it is another explanation of the discrimination facing psychiatric patients, mental health care and its services. The negative attitude of young adults investigated by Mahsoon et al. (2020) toward patients with psychiatric illnesses regardless the positive view to help seeking and family support shows the significant prejudice about mental health in Saudi Arabia.

Our survey respondents generally agreed with statements describing psychiatric hospitals as outdated institutes. However, Jang et al. (2011), who surveyed Hispanic older adults in the US, found that their respondents generally had positive attitudes towards mental health services, although this did not extend to psychiatric counseling specifically. The mental health system in Saudi Arabia has been improving by the support of the Ministry of Health, where Primary health care incorporated outpatient, inpatient, residential facilities and mental health hospitals dedicated toward psychiatric patients (Qureshi et al. 2013).

A study of attendees at a mental health facility in Riyadh found that many respondents held negative attitudes towards psychotropic medications, believing that such drugs are ineffective or only become effective after they have been taken for a long time (Alnamlah 2006). Gulliver et al. (2010) found that a lack of knowledge is a potential barrier preventing young people from accessing mental health services. The same authors also found that misconceptions concerning psychiatric medications, such as the belief that such drugs are addictive or can affect patients’ personalities, were also potential barriers. Abolfotouh et al.(2019) have recently shown the lack of knowledge and stigmatizing attitude contributed to Saudis toward psychiatry consultation.

In this study, we did not find a significant difference between the use of traditional and psychiatric methods among Saudis. This is despite the fact that traditional approaches are not clinicians’ first choices for treating psychiatric disorders. Notably, the aforementioned study from Riyadh found that belief in traditional healing methods was a potential reason for not seeking psychiatric care, with many members of the Saudi public attributing psychiatric disorders to demonic influences (Alnamlah 2006).

We encourage future studies in Saudi Arabia about the approaches to treating psychiatric disorders and the need for psychiatric care, health services awareness and the use of technologies among the population in treating the patients.This study’s major limitation was the manual distribution of questionnaires, which made it difficult to obtain fully answered surveys. Another limitation was the overrepresentation of certain groups such as female responders more than male and university graduates in general.

CONCLUSION

We investigated the beliefs and misconceptions that may prevent Saudis from seeking psychiatric evaluations, and we found that many Saudis hold the belief that psychiatric treatment is expensive and that mental hospitals are outdated. Moreover, our findings suggest that the stigmatization of psychiatric disorders and discrimination against persons with psychiatric disorders may not be major factors preventing Saudis from seeking psychiatric care. Furthermore, positive attitudes towards traditional methods and spiritual mediators were not as common as we had expected.

ACKNOWLEDGEMENTS

We are immensely grateful to Mr. Abdulrahman Alghamdi, Marwa Abdelmoaty, Ibtisam Gasm, Afaf Alsaiari, Nouf Aljahdali, Mawadah Magadmi, Shouq Bahuraysh, Albandri Alahmari, and Jood Alhemdi for their assistance with the data collection and data entry. Any errors are our own and should not tarnish the reputations of these esteemed individuals.

Declaration of competing interest: The authors report no relationships that could be construed as a conflict of interest.

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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