Mental health research in the Arab region in response to the COVID-19 pandemic: a scoping review

Search strategy

This study is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) reporting guidelines.8 A priori registered protocol was not developed. We conducted a systematic literature search of the WHO COVID-19 database from its inception to the date on which the search was conducted (24 October 2020). The WHO COVID-19 database regularly curates COVID-19-specific citations from multiple bibliographical databases including MEDLINE, PsycINFO, Scopus, CINAHL, Embase, Web of Science, in addition to preprint servers, manual searches and experts’ referrals.9 10

A search query was constructed using mental health-related keywords and the names of the 22 Arab countries: (Egypt* OR Saudi* OR KSA OR Leban* OR Tunis* OR Emirat* OR UAE OR Jordan* OR Qat* OR Moroc* OR Iraq* OR Kuwait* OR Palestin* OR Bahrain* OR Alger* OR Sudan* OR Syria* OR Yemen* OR Libya* OR Somalia* OR Mauritania* OR Djibouti* OR Comoros OR Oman*) AND (Mental* OR Psych* OR stress* OR depress* OR anx* OR addict* OR schizo* OR mood*). No COVID-19-related keywords were added to the query due to the high topical specificity of the WHO COVID-19 database.

Inclusion and exclusion criteria

All articles published by authors affiliated with Arab countries and reporting on the diagnostic, prognostic, or therapeutic aspects of psychiatric disorders or psychological well-being with respect to COVID-19 were included. A coauthoring country was considered as an Arab country if it was one of the 22 member states of the Arab League (ie, Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Kingdom of Saudi Arabia (KSA), Somalia, Sudan, Syria, Tunisia, United Arab Emirates (UAE), and Yemen).11 Besides including only articles published in English or Arabic with full texts available online, no restrictions were placed on study design, publication type, or publication status. We excluded publications lacking affiliation to Arab countries or unrelated to COVID-19 and mental health research. Similarly, publications in languages other than English or Arabic or with unavailable online full texts were excluded.

Article screening and data extraction

Three of the authors (IHEA, EA-J, and YZ) independently screened the titles, abstracts, and affiliation details of all retrieved citations against our eligibility criteria for full-text screening.

Articles lacking abstracts and/or affiliation information were automatically included for full-text review. Subsequently, full texts of the articles that passed the preliminary eligibility screening were retrieved and examined for final inclusion or exclusion in the study. Articles lacking full-text availability online were excluded from further data extraction and analysis.

Subsequently, the following parameters from the included articles were abstracted independently by the same three authors, using a standardised and piloted data collection form:

• Study title

• Country of author’s affiliation (in case of articles whose authors’ affiliations include multiple Arab countries, each country was recorded)

• International collaboration (defined by the presence of at least one author affiliation from a different country)2 4

• Publication type

• Study design

• Target population characteristics, including age, population type, and setting.

Discrepancies during screening and data extraction were identified and resolved by referring to two other authors (SO and OW).

Data summary and synthesis

Charted data were synthesised and stored in a tabular format using a Microsoft Excel-based spreadsheet. Then, descriptive content analysis was conducted to identify key research themes emerging from included research articles. Accordingly, two of the authors (MHMOH and IHEA) independently examined the charted data and full texts of included research studies. Editorials, letters, expert opinion reviews, and case reports were excluded from this process as they were not considered as primary research articles. Consequently, broad codes corresponding to key research themes were assigned to each study based on their research questions and target population characteristics; assigning more than one theme per study was allowed. Disagreement in this process was resolved through discussion and consensus between the same two authors. Finally, abstracted parameters were aggregated and displayed in summary graphs (tables and bar charts) and statistics (counts and percentages).

Quality assessment

Two authors (MHMOH and IHEA) assessed the methodological quality of the included research articles independently and in duplicate. At this point, qualitative research studies were excluded from the assessment as there is no consensus regarding a reliable method for examining the quality of qualitative research in systematic reviews.12 The quality of included case-control and cohort studies was assessed using the Newcastle–Ottawa Scale (NOS),13 and cross-sectional studies were evaluated by the modified version of the NOS.14 Both instruments assess studies based on three broad categories: the selection of the study groups, the comparability of the groups, and the ascertainment of either the exposure or the outcome.13 14 A visual star-based scoring system was adopted for the studies: seven stars or more were considered to be of high quality, six or five stars were considered to be of moderate quality, and four stars or less were considered as low quality. Disagreements in scoring were resolved by consensus and by consulting a third author (SO).

Search results

Two-hundred and twelve records were retrieved using the search query. After removing duplicates, 195 records remained. Of these, 93 were excluded: 67 had irrelevant topics (examined areas of the COVID-19 outbreak not included in our inclusion criteria--knowledge and practice of physicians during the pandemic, the impact of the outbreak on patient care and medical education, public misconceptions, region-specific and climate-specific prevalence and incidence, infection rate prediction models, and precautionary measures). Only 102 articles were included for further analysis. Figure 1 illustrates the PRISMA flow chart of the inclusion and exclusion process. Details of the included individual publications are provided in online supplemental table 1.

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Publications by Arab countries

The three most productive countries were KSA (n=36, 35.3%), Jordan (n=20, 19.6%), and Egypt (n=15, 14.7%), respectively. Fourteen other countries contributed the remaining proportion, and five countries had no publications (figure 2).

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Scholarly collaboration

More than half of the publications (n=56, 54.9%) involved international collaboration; nearly two-thirds of these were with institutions from non-Arab countries (n=35). The remainder of the publications (n=46, 45.1%) had collaboration with domestic institutions within the same country.

Publication types

Most publications were original research papers (n=84, 82.4%), the majority of which were cross-sectional studies (n=81, 79.4%). No longitudinal or interventional studies were identified (figure 3).

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Research themes

Ten main research themes were identified. Thirty-six studies investigated the mental health burden of COVID-19 and lockdown measures on the general public (42.9% (36/84)), 26 studies focused on frontline healthcare providers (31.0% (26/84)), and 22 studies examined general healthcare providers (26.2% (22/84)). These three research themes accounted for 78.6% (66/84) of the included research studies (figure 4).

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Quality assessment

As detailed in the online supplemental tables 2–5, of the 82 eligible and included research studies, only 23 (28.0% (23/82)) of them were high quality, while 34 (41.5% (34/82)) and 25 (30.5% (25/82)) studies were of moderate and low quality, respectively. The most common methodological shortcomings were poor representativeness of samples, absence of sample size justification, and lack of description of non-respondents.

Main findings and comparison with global literature

Despite adopting broad selection criteria, only a modest body of evidence was identified, averaging 4.6 publications per Arab country. These figures are in contrast to the global trend showing a massive expansion of medical publications amidst the pandemic.15 However, this finding is consistent with previous studies reporting low Arab World contribution to global mental health research.5

A majority of the included publications from Arab countries demonstrated international collaboration. The proportion of these collaborative efforts outweighed previous reports from the region4 and the aggregate global figures (22%) for COVID-19-related mental health research.2

None of the published studies were interventional, and most of the observational studies were cross-sectional, with no prospective studies identified. This could be because we analysed publications within the first eight months of the pandemic; interventional and prospective studies require a longer period before publication.16 Another explanation is that authors from Arab countries resort to cross-sectional studies because they are easier to conduct, inexpensive, and require fewer resources.17

Our quality assessment indicated that only a minority of studies were of high methodological quality. This aligns with a previous study which showed that Arab countries fell behind other countries in terms of publishing mental health research publications in top-quartile journals.4

The predominant focus of the identified studies concerned the impact of COVID-19 and its socioeconomic implications on the psychological well-being of the public and other diverse healthcare provider groups. Another area of interest in a notable proportion of the included studies was the impact of the pandemic with the associated closure of educational facilities on the mental health of students and staff. These findings are consistent with recently published results from other regions18 that might reflect a global concern towards the rising burden of mental health problems among these population groups.19–31

Strengths and limitations

Our study is the first, to our knowledge, to have examined the scope and quality of COVID-19 mental health research in Arab countries. Our study met all PRISMA-ScR checklist criteria, other than not developing a registered protocol before conducting this study. We used inclusive selection criteria and search query terms with high sensitivity. We also used standardised instruments. In addition, all studies were independently assessed by a group of assessors, and discrepancies were resolved by a separate group. We extended the scoping purpose of the review by mapping the quality and scientific rigour of the included research articles, which might not be achieved through traditional descriptive quantitative and thematic analyses.32

This scoping review has a number of limitations. We only searched the WHO COVID-19 database for this review. However, this database gathers scientific publications from the most important databases in the medical field.9 10

Moreover, as many of the backbone indexes of the WHO-COVID-19 database have higher coverage of English than non-English publications (eg, PubMed/MEDLINE,33 Scopus, and Web of Science34 35), a proportion of evidence might not be covered in our work.

Despite employing a comprehensive search strategy, there is also a possibility that some relevant topics might have not been fully retrieved by our query, especially if they were introduced as abbreviations (eg, ‘BD’ instead of ‘bipolar mood disorder’ and ‘PTSD’ instead of ‘post-traumatic stress disorder'). Finally, our results do not represent the complete course of the fast-growing literature of the current pandemic, since the COVID-19 pandemic continues to evolve.

Implications

This review delineates a wide quantitative and qualitative gap in the Arab world mental health literature that necessitates a timely response from policymakers and researchers.

This work outlines that the amount of research that has come from the Arab world has not been able to meet the population demands produced by the COVID-19 pandemic. Although the number of publications about mental health from Arab countries has been growing at a much faster rate than the rest of the world,4 36 steps need to be taken to promote both quantity and quality of mental health research in the region. The current pandemic sheds light on the importance of the inter-relationship between physical and mental health.37 An adequate response to the pandemic must also entail addressing mental health issues.38 Planning an optimal mental health response plan tailored to the needs of each country or region largely relies on scientific research from that same country or region, since extrapolating data from other countries and regions is not always possible or beneficial.39

Our findings emphasise the urgent need for more research that investigates the mental health problems of diverse, vulnerable, and underprivileged social groups. Ideally, these results will stimulate directing investments for future research that will address the gaps we have identified in the literature.

In addition, our scoping review identified high research activity related to the pandemic-induced mental health burden of the general population, healthcare workers, students, and educational staff. This finding indicates that further work is needed to gain deeper insight into these groups’ psychological needs and inform tailored interventions to address these needs.

Our findings also demonstrated that the preponderance of COVID-19-related mental health literature emerging from the Arab world was cross-sectional studies, the majority of which were of substandard methodological quality. Cross-sectional studies are useful to examine the prevalence and generate hypotheses. However, they have several limitations, including the inability to investigate the temporal relationships between outcomes and risk factors, and the difficulty to interpret the exact meaning of any statistical associations that might be observed.17 40 They are also more prone than other types of studies to non-response bias, recall bias, and confounding bias.17 In the hierarchy of scientific evidence, cross-sectional studies are generally regarded as being among the weakest, superior only to case reports and case series.41 42 That mental health studies in the Arab world are primarily cross-sectional illustrates that the quality of research still largely lags behind international standards, despite some observed improvement over the last few years.4 5

Our review helped identify that most publications produced by Arab countries were not just lower in the evidence hierarchy, but also suffered various methodological shortcomings. These methodological flaws can severely impede the generalisability of any findings and seriously affect the quality of the studies.43 Since the objective of any research is to extrapolate data beyond the studied sample, these flaws are rendered as severe limitations.43 44 It is crucial that actions are taken to improve the quality of mental health research in Arab countries. These actions could include greater emphasis on research skills in mental health training programmes and increased incentives for high-quality research in the field.5 Academic institutions in Arab countries need to prioritise psychiatric research and pool resources, if possible, through mutual collaborations.5 Such collaborations have previously been associated with higher quality research publications4 5 and may help promote mental health research in the Arab world. Finally, our analysis has revealed the expansion of international research collaboration between Arab and non-Arab countries, and this finding could further nurture these collaborative efforts.