Prevalence of psychological symptoms in Saudi Secondary School girls in Abha, Saudi Arabia

BACKGROUND AND OBJECTIVES: Adolescence is characterized by rapid physiological, social and cognititive changes. Aim of the present work is to study mental health of Saudi adolescent secondary school girls in Abha city, Aseer region, Saudi Arabia. METHODS: A cross-sectional study was conducted in 10 secondary schools for girls using the Arabic version of the symptom-revised checklist 90 (SCL 90-R), a mental health questionnaire that was administered to the girls by fourth-year female medical students. RESULTS: The most prevalent mental symptoms in the 545 female students were phobic anxiety (16.4%), psychoticism (14.8%), anxiety (14.3%), and somatization (14.2%). The prevalence of depression, paranoid ideation and interpersonal sensitivity amounted to 13.9%, 13.8% and 13.8%, respectively. The least prevalent mental symptoms were hostility (12.8%) and obsessive-compulsive behavior (12.3%). Overall, psychological symptoms (in terms of a positive global severity index) were found in 16.3% of the girls. In a multivariate logistic regression analysis, no significant relationship was found with sociodemographic factors. CONCLUSION: Psychological symptoms and disorders are prevalent in secondary school girls and health professionals need to be able to recognize, manage and follow-up mental health problems in young people. Further research is needed to explore the magnitude of the problem at the national level.

A dolescence (11 to 19 years of age) is characteri i ized by rapid physiological, social and cognii i tive changes. 1 Poor mental health during this period has been linked to mental health problems in adulthood. 2 Worldwide, about 16% of adolescents sufi i fer from mental health problems. 3 In the United States, the direct cost of mental health services accounted for 69 billion US dollars, which represents 7.3% of total health spending. 4 However, mental health promotion may help to prevent a wide range of healthidamagi i ing behavior as well as improving the quality of life of young people. 5 In the United States, about 20% of children and adolescents are estimated to have mental health disorders. 6 In Canada, 9.5% of boys and 12% of girls have mental health problems. 7 Reports from India have estimated the prevalence of mental disorders from 2.6% to 35.6%. 8 In the neighboring country of the United Arab Emirates, 22.2% of children aged 6 to 18 years were reported to have mental health problems. 9 A large proportion of the population of Saudi Arabia is young, with 69% under 30 years old, and 47% uni i der 15 years. 10 However, there is a general paucity of research in the area of adolescent mental health. A rei i cent study of boys in secondary school (age range from 15i18 years) in Abha city reported that more than onei third (38.2%) had depression, while 48.9% had anxiety and 35.5% had stress. 11 Like other countries, adolescent girls in Saudi Arabia face rapidly changing challenges in their social and physical environment. 5,7i9 Therefore, the purpose of this study was to estimate the prevalence of mental health symptoms among secondary school girls in Abha City in southwest Saudi Arabia and to assess related sociodemographic characteristics.

METhODS
This crossisectional study was conducted during the 2006i2007 scholastic year in Abha. The subjects were girls in secondary school (representing the tenth, elevi i enth and twelfth years of general education in Saudi Arabia, which starts at 7 years of age). Abha is the capii i tal city of the Aseer region in the southwest of Saudi Arabia, with a total population of 300 000. In Saudi Arabia, schools for girls are segregated from boys.
The city has a total of 10 secondary schools for girls, including 7 general schools and 3 Islamic (Tahfez Ali Quran) schools. All information about the study was provided to schools through the Abha School Health unit. All schools agreed to participate in the study. Field activities were conducted by trained fourthiyear female medical students who were supervised by the staff of the Family and Community Medicine Department, College of Medicine, King Khalid University. Two classes were randomly selected from each school (first, second and third year). The purpose of the study was explained to the pari i ticipants in the classrooms. All students were clearly informed that they could choose not to participate. Subjects were assured of anonymity and confidentiality. All students in the selected classes during the study pei i riod were considered for inclusion in the study. Signed informed consent was given by each participant stui i dent.
The mental health questionnaire was based on the Arabic validated version of the Symptoms Check List 90irevised (SCL 90iR) questionnaire. 12 This scale is used extensively to screen for mental health sympi i toms. 13 The SCL 90iR test is a selfireporting instrui i ment intended to measure severity of psychiatric sympi i toms on a number of different subscales. It contains 90 items and can be completed in just 12 to 15 minutes. Students rated the 90 symptoms of distress on a 5istep Likertiscale with 0 being 'not at all' and 4 being ' extremei i ly' . Subjects were instructed to indicate the amount they were bothered by each of the symptoms during the prei i ceding week. Relevant dimension scores were summed and the 't' transformation of the scores was performed. The positive dimension was considered when relevant t scores were 61 or more. The test helps in measuring nine primary symptom dimensions and three global ini i dices of distress. It is designed to provide an overview of symptoms and their intensity at a specific point in time. The dimension includes somatization (the process by which psychological needs are expressed in physical symptoms), obsessiveicompulsive (a form of personali i ity marked by obsessions and compulsions), interperi i sonal sensitivity (relating to a conflict in the relations and social exchanges between persons), depression (a mental state of depressed mood characterized by feeli i ings of sadness, despair and discouragement), anxiety (the unpleasant emotional state consisting of psychoi i physiological responses to anticipation of unreal dani i ger), hostility (tendency to feel anger toward and to seek to inflict harm upon a person or group), phobic anxiety (fear that is recognized as being excessive or unreasoni i able by the individual himself ), paranoid ideation (peri i sistent delusions of persecution or delusional jealousy and behaviour such as suspiciousness, mistrust and combativeness), and psychoticism (a person will exhibit some qualities commonly found among psychotics such as disregard for common sense). 14 The three global indii i ces are Global Severity Index (GSI), Positive Symptom Distress Index (PSDI) and Positive Symptom Total (PST). GSI is designed to measure overall psychologii i cal distress. PSDI is designed to measure the intensity of symptoms. The PST reports the number of selfirei i ported symptoms.
Statistical analysis was conducted using the SPSS version 15. All tests were carried out at the 5% level of significance. A multivariate logistic regression analysis was used to identify potential sociodemographic risk factors that might affect mental symptoms. Adjusted odds ratio and concomitant 95% confidence intervals were calculated.

RESUlTS
Five hundred and fortyifive Saudi secondary school girls were included in the present study (Table 1). Their ages ranged from 14 to 19 years with a mean (SD) of 17.1 (1.1) years and a median of 17 years. Twenty stui i dents (3.7%) were married. Their ages ranged from 16 to 19 years. The majority (89.0%) had parents living toi i gether. The rest had separated (0.2%), divorced parents (4.2%) or a deceased father or mother (6.6%). The most frequent level of education among fathers was a univeri i sity education (39.4%), while 7.9% were illiterate. On the other hand, the mothers' education was most often primary (29.9%), followed by none (28.3%). The most frequent occupation of fathers was as a military or govi i ernmental employee (46.0%). Most mothers were not working (87.9%). The majority of students (74.35%) were from families whose family size ranged from 5 to 10 persons. The average monthly family income ranged from 5000 to 10 000 Saudi Riyals (SR) (1 US dollar equals 3.75 SR) in 47.5% of the study sample. The rei i mainder were either below 5000 or above 10 000. Table 2 shows the overall prevalence of mental symptoms among adolescent secondary school girls. The most frequent mental symptoms were phobic anxii i ety (16.4%), psychoticism (14.8%) and anxiety (14.3%). The least frequent dimensions were obsessiveicomi i pulsive behavior (12.3%) and hostility (12.8%). Some students had more than one symptom. Fortyinine girls (9.0%) had simultaneously 2 symptoms, 31 girls (5.7%) had 3 symptoms and 24 girls (4.4%) had 4 symptoms. Table 3 shows the global indices of distress. The posii i tive global severity index (GSI) amounted to 16.3%, which indicates that at least one out of each of six girls suffers from one or more mental health symptoms. The  a categorization was based on "t" transformation of Scl r-90 scores. positive dimension was considered when "t" scores are 61 or more. a total is more than 100% as some students have more than one disorder (comorbidity) positive Symptoms total (pSt) 14.0 a categorization was based on "t" transformation of Scl r-90 scores. positive dimension was considered when "t" scores are 61 or more. Table 4. Adjusted odds ratio (aor) and 95% confidence intervals (ci) for potential sociodemographic risk factors that might be associated with the highest three prevalent mental symptoms among secondary school girls in Abha, Saudi Arabia (n=545), by multivariate analysis.

Potential Socio-demographic Risk Factor Phobic Anxiety Psychotocism Anxiety
Age (<17 years vs. positive symptoms distress index was 13.7% and posii i tive symptoms total was 14.0%. Table 4 shows multivariate logistic regression analyi i sis of potential sociodemographic risk factors affecting the highest three prevalent mental symptoms: phobic anxiety, psychotocism and anxiety. None of the poteni i tial sociodemographic factors (age, type of school, marii i tal status, family size, parental status, parental educai i tion and occupation and average of family income) were found to significantly affect the highest three prevalent dimensions of mental health. The same findings were present in the rest of the mental health dimensions.

DISCUSSION
Using a standardized instrument that assesses a broad range of mental health problems, we found that sympi i toms were prevalent among secondary school girls, with 16.3% suffering from one or more mental health symptoms.
In a previous study conducted on secondary school boys in the same area using Depresion, Anxiety and Stress Scale (DASS) questionnaire, indicated that of 1723 Saudi adolescent school boys, 59.4% had at least one of the three studied disorders (depression, anxiety or stress), 40.7% had at least two and 22.6% had all three disorders. Moreover, more than oneithird of the participants (38.2%) had depression, while 48.9% had anxiety and 35.5% had stress. Depression, anxiety and stress were strongly, positively and significantly correi i lated. 11 Fehan et al reported that 63% of New Zealand adolescents have mental illness. 15 Other studies found rates of 22.2% in United Arab Emirates, 8 18.5% in USA, 16 17.9% in Puerto Rico, 17 22.5% in Switzerland, 18 9% among boys and 12% among girls in Canada, 6 8% in India, 7 and 20.3% in Taiwan. 19 The prevalence ranged from 1% to 51% (mean=15.8%) conducted over the last 40 years from 20 countries. 3 This variation could be rei i lated to using different measure tools.
The most frequent mental symptoms were phobic anxiety (16.4%), psychoticism (14.8%) and anxiety (14.3%), which is in agreement with the literature that indicates that anxiety disorders are the most common psychiatric diagnosis in adolescents. 20,21 In an eari i lier study of 1723 male high school students in Saudi Arabia using an Arabic version of DASS, nearly 49% were found to have an anxiety disorder. 11 Studies indii i cate that females have a higher prevalence of anxiety. 7,22 On the other hand, the least frequent dimensions in this study were obsessiveicompulsive (12.2%) and hosi i tility (12.9%). In the UAE, Eapen et al reported that 7% and 9% of adolescents have phobia and anxiety, respeci i tively. 8 Fehan et al found that in New Zealand, anxiety and simple phobia were present in 65% and 41%, rei i spectively. 15 The majority of students came from families that ranged in size from 5 to 10 persons, which is in agreei i ment with the average Saudi family size reported in previous research. 10 About twoithirds of mothers had either a primary education (29.9%) or were illiterate (28.3%). Unlike our finding, Brandon found that chili i dren whose mothers are employed were more likely to have emotional problems which can be secondary to the differences. Average family income was less than 5000 SR in 21.8%. However, this did not significantly affect the nine dimensions of mental health. Neither did othi i er potential sociodemographic risk factors (age, school type, marital status, family size, rank among brothers and sisters, parental status, parental education and oci i cupation and average monthly family income (Table 4). A risk factor does not necessarily imply a direct causal relationship. It has been reported that emotional probi i lems are most likely to be due an interaction between biological and environment factors. 24 Integration of mental health into medical setting might improve care and reduce stigmatization of mental illness. 25 Primary health care centers care offer a setting for the preveni i tion and detection of mental health problems in adoi i lescents. Further research is needed to determine the magnitude of psychiatric disorders at national level.
The questionnaire used in this study had the advani i tage of being psychometrically validated and developed in consideration of cross cultural and linguistic issues. However, this study has some limitations: it was rei i stricted to female adolescents, which led to an inabili i ity to determine sexispecific psychopathology. Since it was a schoolibased study, it might miss adolescents in the community who do not attend schools. However, the results would reflect the state of psychopathology among adolescents.
In conclusion, the high prevalence of mental sympi i toms represents one of the major health problems affecti i ing adolescents in Abha city. Further inidepth studies are needed to study mental disorders in the area and to identify potential supporting counseling and cognitioni behavior therapy. In this context, a national program for mental health in this age group is crucial.