This issue of the journal brings together a collection of the first set of papers from a landmark mental health epidemiological study in the largest country in the Middle East: the Saudi National Mental Health Survey (SNMHS). While there have been sporadic psychiatric epidemiological studies reported from Saudi Arabia in the past (e.g., Abumadini, 2019; Alharbi, Almalki, Alabdan, & Haddad, 2018; Hickey, Pryjmachuk, & Waterman, 2016), the SNMHS is by far the most systematic evaluation to date of the patterns and correlates of mental disorders in the country. Adding to the importance of the study is the fact that it was carried out in conjunction with the World Health Organization's (WHO) World Mental Health (WMH) Survey Initiative. The latter helped guarantee that the survey was carried out using rigorous internationally comparable standards and created easy access to valuable international comparisons. Based on these features, the SNMHS will serve as a valuable benchmark for studies in the region and elsewhere.

As pointed out by the authors, Saudi Arabia differs from other high‐income countries in several important ways: a relatively young population, government based on strict Islamic law, associated with high levels of religiosity, limited female economic participation along with relatively low participation in the labour force despite wages comparable to men (Omair et al., 2020). There is also currently a high level of government spending on wages, but a commitment to make the transition to a knowledge economy and reduce entitlements as a source of income. This commitment is occurring in conjunction with recent admirable reforms to increase female empowerment and one of the most dramatic increases in the proportion of the population attending university of any country in the world (World Bank, 2020).

The mental health system also, unlike other high‐income countries, presents several challenges: a lower per capita ratio of mental health professionals than in other high‐income countries; a greater concentration of mental health care in large institutions, with a focus on inpatient care; and a relatively low proportion of overall government health spending dedicated to mental health.

The studies serve both as an excellent introduction to the epidemiology of mental disorders in Saudi Arabia and as a primer in mental health epidemiology more broadly. Several innovative, rigorous, and best‐in‐class approaches to population‐based mental health research deserve mention: a systematic approach to translation and adaptation of an international survey instrument to ensure cultural applicability, strict quality control, the use of audio computer‐assisted self‐interviewing for sensitive areas of questioning, adaptation of the sampling design with mid‐stream corrections to contain costs (without compromising on representativeness), and an inclusion of an embedded clinical reappraisal study for selected conditions to increase validity by recalibrating the prevalence estimates produced by the larger study. Additionally, the collection of DNA samples from very carefully phenotyped samples will enable future collaboration in large‐scale genetic analyses.

The studies also highlight the challenges in such large scale internationally comparable mental health epidemiological studies and underscore the nontrivial nature of such an undertaking. The SNMHS is positioned to provide comparable data to other countries in the region that have used similar approaches as part of the WHO's WMH Surveys, most notably Lebanon (Karam et al., 2006) and Iraq (Alhasnawi et al., 2009), and with other in‐progress WMH surveys in Iran and Qatar. This will provide a rich picture of mental health in a region that is undergoing very rapid transitions, while experiencing conflicts that in some cases have resulted in with large scale displacements of populations. Mental health issues will clearly need more attention from health systems in these areas than they have received thus far.

The SNMHS finds that about one in three adults in Saudi Arabia has experienced a diagnosable mental disorder in the course of their lifetime and nearly one in four adults have a lifetime risk of developing a such a disorder. The study reveals a surprisingly high prevalence of separation anxiety disorder, especially among adults, obsessive compulsive disorder, especially at subthreshold levels, and social phobia. While alcohol disorders are understandably rare given the Islamic faith, overall substance use disorders are comparable to other settings due largely to abuse of prescription medications. Six percent of adults have suffered from major depressive disorder in their lifetime. Separation anxiety disorder and attention‐deficit/hyperactivity disorder are considerably more common than in other high‐income countries. One‐fifth of respondents were in an active episode of a mental disorder at some time in the 12 months before the survey.

While these numbers are a matter of concern, even more sobering is the fact that a large majority of these conditions were said to have begun in childhood or early adulthood, nearly one in four were considered serious, and of those with a mental disorder in the past year four out of 10 had more than one condition. About 40% of all those with a disorder in the past 12 months that had more than one condition, accounted for more than half of all serious cases.

The treatment gap in mental disorders in Saudi Arabia remains large with less than one‐third of people with a lifetime disorder receiving any type of treatment. And those individuals who obtained treatment typically did so only after a substantial delay. Even among those with a disorder in the past 12 months only about one in seven received treatments. Equally, if not more, concerning is that less than half of these patients received treatment that would be considered even minimally adequate based on accepted treatment guidelines. Unlike in most other settings, women do not seem to be more likely to receive treatment.

Finally, the SNMHS suggests that more recent cohorts may be more likely to have a mental disorder than previous cohorts. This means that already inadequate services might leave behind even more people in the future than today unless changes are made now.

There are several ways the health system could respond to these challenges given that cost‐effective solutions have been documented to exist that can be used to scale up mental health interventions. First, primary care providers need to be trained in the recognition and management of common mental disorders through implementation and scale up of WHO's mental health gap action programme (mhGAP) (World Health Organization, 2018). Second, a shift is needed in resources from large‐scale institution‐based care to primary care while integrating services to provide truly integrated people‐centered health‐care services (World Health Organization, 2016) that ensure early detection, compliance with evidence‐based treatment guidelines, and continuity of care. Third, a health promotion campaign will be needed to increase awareness among the general public about early symptoms of mental health conditions and reduce stigma. Such a campaign should be implemented, though only after putting in places the system changes needed to absorb the increased demand that the campaign will create. Engagement of both religious and political leaders should be included in this campaign to ensure wide reach of the message. Fourth, it will be important to invest in mental health implementation research to identify barriers to seeking care, adhering to treatment, and practical strategies designed for the local setting to scale‐up and improve quality of services.

The high prevalence of mental disorders and the huge gap in treatment documented in the current studies must be recognized by policy makers as placing a huge burden on families and caregivers and coming at an enormous societal cost. The impact on future generations is likely to be immense. If the promise of leaving no one behind in the Sustainable Development Agenda and Universal Health Coverage is to be fulfilled, these results must be a clarion call to the country to take notice and, more importantly, take action.

本期杂志汇集了中东最大国家一项具有里程碑意义的心理健康流行病学研究的第一组论文：沙特国家心理健康调查 (SNMHS)。虽然过去曾有来自沙特阿拉伯的零星精神流行病学研究报告（例如，Abumadini, 2019 ; Alharbi, Almalki, Alabdan, & Haddad, 2018 ; Hickey, Pryjmachuk, & Waterman, 2016)，SNMHS 是迄今为止对该国精神障碍模式和相关性最系统的评估。增加这项研究的重要性的是，它是与世界卫生组织 (WHO) 的世界心理健康 (WMH) 调查倡议一起进行的。后者有助于保证调查是使用严格的国际可比标准进行的，并且可以轻松获得有价值的国际比较。基于这些特点，SNMHS 将成为该地区和其他地方研究的宝贵基准。

正如作者所指出的，沙特阿拉伯在几个重要方面与其他高收入国家不同：人口相对年轻、政府基于严格的伊斯兰法律、宗教信仰程度高、女性经济参与有限以及参与度相对较低。尽管工资与男性相当（Omair 等人，2020 年）。目前政府在工资方面的支出也很高，但承诺向知识经济过渡并减少作为收入来源的权利。这一承诺与最近为增强女性赋权而进行的令人钦佩的改革以及世界上任何国家就读大学的人口比例最显着的增长之一相结合（世界银行，2020）。

与其他高收入国家不同，精神卫生系统也面临若干挑战：精神卫生专业人员的人均比例低于其他高收入国家；在大型机构中更加集中精神卫生保健，重点是住院治疗；政府整体卫生支出中用于精神卫生的比例相对较低。

这些研究既可以很好地介绍沙特阿拉伯的精神疾病流行病学，也可以作为更广泛的精神健康流行病学的入门读物。一些以人群为基础的心理健康研究的创新、严谨和一流的方法值得一提：翻译和改编国际调查工具以确保文化适用性的系统方法、严格的质量控制、使用音频计算机辅助对敏感问题区域进行自我访谈，调整抽样设计并进行中游校正以控制成本（不影响代表性），并纳入针对选定条件的嵌入式临床重新评估研究，以通过重新校准产生的患病率估计值来提高有效性通过更大的研究。此外，

这些研究还强调了如此大规模的国际可比心理健康流行病学研究中的挑战，并强调了这项工作的重要性。SNMHS 的定位是向该地区其他使用类似方法作为世卫组织 WMH 调查一部分的国家提供可比数据，最值得注意的是黎巴嫩（Karam 等人，2006 年）和伊拉克（Alhasnawi 等人，2009 年）)，以及在伊朗和卡塔尔进行的其他 WMH 调查。这将为一个正在经历非常迅速的转变，同时经历在某些情况下导致大规模人口流离失所的冲突的地区提供丰富的心理健康图景。精神健康问题显然需要这些领域的卫生系统比迄今为止得到的更多关注。

SNMHS 发现，沙特阿拉伯约有三分之一的成年人在其一生中经历过可诊断的精神障碍，近四分之一的成年人终生有患上这种疾病的风险。该研究揭示了分离焦虑症的高患病率，特别是在成年人中，强迫症，特别是在阈下水平，以及社交恐惧症。虽然考虑到伊斯兰信仰，酒精障碍是可以理解的罕见，但总体物质使用障碍与其他环境相当，主要是由于滥用处方药。6% 的成年人在其一生中患有重度抑郁症。与其他高收入国家相比，分离焦虑症和注意力缺陷/多动障碍更为常见。

虽然这些数字令人担忧，但更令人警醒的是，据说这些疾病中的绝大多数是在儿童期或成年早期开始的，近四分之一的人被认为是严重的，而在那些患有精神障碍的人中过去一年，十分之四的人患有不止一种疾病。在过去 12 个月内患有不止一种疾病的疾病患者中，约有 40% 的患者占所有严重病例的一半以上。

沙特阿拉伯的精神障碍治疗差距仍然很大，只有不到三分之一的终生精神障碍患者接受任何类型的治疗。而那些获得治疗的人通常只是在相当长的延迟之后才这样做。即使在过去 12 个月患有疾病的人中，也只有大约七分之一的人接受了治疗。同样，如果不是更多，令人担忧的是，这些患者中只有不到一半接受了根据公认的治疗指南甚至被认为是最低限度的治疗。与大多数其他环境不同，女性似乎不太可能接受治疗。

最后，SNMHS 表明最近的队列可能比以前的队列更有可能患有精神障碍。这意味着，除非现在做出改变，否则已经不充分的服务在未来可能会留下比现在更多的人。

鉴于已经证明存在可用于扩大心理健康干预的具有成本效益的解决方案，卫生系统可以通过多种方式应对这些挑战。首先，初级保健提供者需要通过实施和扩大世卫组织的精神卫生差距行动计划 (mhGAP) 接受常见精神障碍的识别和管理培训（世界卫生组织，2018 年）。其次，需要将资源从基于机构的大规模医疗转向初级医疗，同时整合服务以提供真正以人为本的整合医疗保健服务（世界卫生组织，2016) 确保早期发现、遵守循证治疗指南和护理的连续性。第三，需要开展健康促进运动，以提高公众对心理健康状况早期症状的认识并减少耻辱感。应该实施这样的活动，尽管只有在实施所需的系统更改以吸收活动将产生的增加的需求之后。这场运动应包括宗教和政治领袖的参与，以确保信息的广泛传播。第四，重要的是投资于心理健康实施研究，以确定寻求护理、坚持治疗的障碍，以及为当地环境设计的实用策略，以扩大和提高服务质量。

政策制定者必须认识到，当前研究中记录的精神障碍的高患病率和巨大的治疗差距给家庭和照顾者带来了巨大的负担，并带来了巨大的社会成本。对后代的影响可能是巨大的。如果要兑现在可持续发展议程和全民健康覆盖中不让任何人掉队的承诺，这些结果必须是号召国家注意，更重要的是采取行动的号角。