Closing the gaps in mental health epidemiology—New survey data from Qatar

To understand mental disorders, we need to describe the patterns of different mental disorders across time and place. There are many different ways to count the frequency of mental disorders (e.g. incidence, 12 months and lifetime prevalence, lifetime morbid risk etc). From a practical perspective, we rely on population-based registers and surveys to enumerate the frequency of mental disorders in the community. Registers can provide a wealth of information, especially if datasets can be linked. However, these registers can be biased. Most registers are designed for administrative needs, and thus often oversample individuals who seek help from health settings or who have more severe disabling disorders. These registers ignore individuals who do not seek help for their mental disorders. To address these biases, community-based surveys provide an important perspective on the mental health of societies (Wang et al., 2011). While surveys also have biases (related to participation rates and recall of past events), they allow health planners and researchers to drill down into important topics related to the causes and consequence of mental disorders. From a planning perspective, it is valuable to have data on duration of untreated disorder, the adequacy of treatment and the participants' perspective of the impact of the disorder on their daily life. From a research perspective, it is important to explore potential risk factors that may have caused the disorder. This includes a range of questions related to exposure to childhood adversity, natural disasters, war and civilian conflict, pandemics and other stressors.

The empirical foundation of mental health epidemiology has been enriched over the last few decades, as more sites have conducted large, well-planned community-based surveys. In particular, the field of psychiatric epidemiology has greatly benefited from the international collaboration under the banner of the WHO World Mental Health (WMH) Surveys (Scott et al., 2018). Design features, survey instruments and analytic strategies have been shared, enhancing workforce skills and enabling, cross-national studies (Kessler et al., 2018). For example, in 2007 data were available from a total of 16 countries on key mental health estimates related to age of onset, lifetime prevalence, and cumulative lifetime risk (Kessler et al., 2007). Sixteen years later, data from 13 additional countries were available (McGrath et al., 2023). The updated study included data from 32 WMH surveys conducted in 29 countries (including 12 low- and middle-income).

With all these new surveys, it would be fair to ask if we still need additional community-based surveys. The answer is simple—yes. Put bluntly, ‘if you don't count it, it doesn't count’ (McGrath et al., 2018). There are still many gaps in the global landscape of mental health epidemiology (Kestel et al., 2022; Patel et al., 2018). Health service providers need to understand which types of mental disorders are most common, and how different mental disorders first emerge at different stages across the lifespan. Equipped with this information, health planners can better match the services needed by people with mental disorders. This is particularly important in low and middle-income countries, where the relative proportion of communicable versus non-communicable diseases is shifting (GBD 2019 Diseases and Injuries Collaborators, 2020). The metaphor often used in teaching describes these changes succinctly: ‘as the tide of infectious and nutritional disorders goes out, the rocks of mental disorders are laid bare’.

In this volume, we are privileged to present a set of papers reporting the first comprehensive survey of mental health in Qatar. Qatar has joined the elite club of nations that have hosted both the FIFA World Cup and conducted a WMH survey. A mental health survey may not attract as much international attention as a World Cup, but it is a great credit to the Qatar-based researchers who set this study up and delivered quality estimates to guide future mental health services in this young nation. These researchers also managed to conduct one of the largest mental health surveys in Qatar to date during a difficult time as the COVID-19 global pandemic affected Qatar and the world.

The data from Qatar add to prior WMH surveys from the Middle East, including Lebanon, Israel, Iraq, and Saudi Arabia. As outlined in the first paper (Khaled et al., 2024a), Qatar is a unique nation. It is a relatively young country (achieving independence from the UK in 1971), with a growing population and a booming economy. While only 11,000 square kilometers in size, it has a population of approximately 2.9 million, of which only approximately 18% are Qatari citizens. It is ranked as one of the richest nations in the world. Most of the population live in the capital Doha, which has undergone breathtaking modernization and development.

There are several features of the new Qatari study that warrant particular attention. The design of the study had to be overhauled in response to the COVID-19 pandemic, replacing the standard face-to-face interview with a computer-aided telephone interview (Khaled et al., 2024e). There are valuable lessons to be learnt from our colleagues in Qatar. For example, nearly all adults in Qatar have at least one mobile phone (98%). As more people around the world have access to mobile phones, phone surveys become an attractive alternative to face-to-face surveys (e.g. they may be less susceptible to biases related to the exclusion of certain segments of the population). In preparation for the use of phone surveys, the investigators made a series of pragmatic adjustments to recruitment methods and survey instruments. Eventually, 5195 participants were interviewed, with the interviews lasting an average of 77 min in duration. As one would expect, dropouts during the interview (referred to as ‘break-offs’) were common—68% of initial participants dropped out before interview completion (Khaled et al., 2024f). A clinical re-appraisal study (Khaled et al., 2024d) compared the Structured Clinical Interview for DSM-5 (SCID) versus the Composite International Diagnostic Interview (CIDI). This study allowed for adjustments to the CIDI scoring to improve diagnostic concordance rates, hence, potentially improving the clinical utility of the collected data.

Overall, the respondents in Qatar had similar patterns of mental disorders as found in many nations around the world (Khaled et al., 2024b, 2024c). The lifetime prevalence of any mood or anxiety disorder was 28.0%, (17.3% for mood and 21.5% for anxiety disorder). The study found that the lifetime prevalence for any mental disorder was higher in the younger cohorts, females, and migrants. Of those with any mental disorder, treatment contacts in the year of the disorder were low (13.5%). The median delay in receiving treatment was 5 years (inter quartile range = 2–13). While 28.2% met the criteria for at least one disorder in their lifetime, slightly more than 11.6% met the criteria for two or more disorders. The projected lifetime risk of any mood or anxiety disorder at age 65 was 36.4%. Curiously, marital status was not significantly associated with an altered lifetime risk of any anxiety or mood disorder. This is most likely because of living arrangements of most Arab migrants living in Qatar: while married, these individuals live alone in Qatar and send money to their spouses and families back home. Interestingly, the authors outline that lifetime risk was also higher in Arab migrants compared to Qatari citizens, and among women compared to men. Despite the disproportional burden of mental disorders among women in Qatar, both gender and other sociodemographic variables were not associated with lower lifetime treatment contact. These findings are important and can guide future service planning to better meet the needs of vulnerable groups with mental disorders in Qatar.

The Qatari survey team and their US-collaborators (who were involved in design and training) are to be congratulated for the scholarly way they addressed the major challenges in conducting this community-based survey. The many findings in the study provide inspiration for future specific research questions. In addition, the research team invited a subset of respondents to have functional Magnetic Resonance Imaging scanning, and publications from this part of the study are in progress. The findings of the survey have provided an empirical framework to guide future service planning in Qatar (Plana-Ripoll et al., 2021), which in turn can contribute to better outcomes for people with mental disorders in this dynamic young nation.

John J. McGrath: Conceptualization; writing - original draft; writing - review & editing.

The authors declare no conflicts of interest.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.