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Mental health disorders are common in Saudi Arabia with a 34% lifetime prevalence. Cognitive behavioral therapy (CBT), a type of psychotherapy, is an evidence-based intervention for the majority of mental disorders. Although the demand for CBT is increasing, unfortunately, there are few therapists available to meet this demand and the therapy is expensive. Computerized cognitive behavioral therapy (cCBT) is a new modality that can help fill this gap.
We aimed to measure the knowledge of cCBT among mental health care professionals in Saudi Arabia, and to evaluate their attitudes and preferences toward cCBT.
This quantitative observational cross-sectional study used a convenience sample, selecting mental health care professionals working in the tertiary hospitals of Saudi Arabia. The participants received a self-administered electronic questionnaire through data collectors measuring their demographics, knowledge, and attitudes about cCBT, and their beliefs about the efficacy of using computers in therapy.
Among the 121 participating mental health care professionals, the mean age was 36.55 years and 60.3% were women. Most of the participants expressed uncertainty and demonstrated a lack of knowledge regarding cCBT. However, the majority of participants indicated a positive attitude toward using computers in therapy. Participants agreed with the principles of cCBT, believed in its efficacy, and were generally confident in using computers. Among the notable results, participants having a clinical license and with cCBT experience had more knowledge of cCBT. The overall attitude toward cCBT was not affected by demographic or work-related factors.
Mental health care professionals in Saudi Arabia need more education and training regarding cCBT; however, their attitude toward its use and their comfort in using computers in general show great promise. Further research is needed to assess the acceptance of cCBT by patients in Saudi Arabia, in addition to clinical trials measuring its effectiveness in the Saudi population.
Mental health disorders are very common in Saudi Arabia, which are present in approximately 34% of the general population [
Computerized cognitive behavioral therapy (cCBT) provides a flexible health care delivery process in which patients can start their therapy with a low-intensity intervention involving only limited practitioner support. cCBT provides many advantages for the user, such as flexibility and privacy, as patients can start cCBT at any favorable setting and time [
Technology-based interventions and computer-aided psychotherapy, including virtual apps and internet-based solutions, provide an attractive alternative in digitally developed countries such as Saudi Arabia, where most of the population has access to computers and mobile phones [
Moreover, most mental health care professionals consider that therapy using computers is better utilized for protection and for mild to moderate psychological conditions [
There is a rising interest in mental health care professionals’ attitudes toward cCBT as a vital additional treatment modality [
A quantitative observational cross-sectional study was performed. We translated the knowledge assessment test from Donovan et al [
This study targeted health care workers who could potentially deliver cCBT such as psychiatrists, psychologists, and social workers, among others, and was carried out between February and March of 2018 on a clustered sample spanning tertiary hospitals in Riyadh, Saudi Arabia. Due to poor responses and limited resources, an expanded data collection to span electronically collected data from mental health professionals in the Kingdom of Saudi Arabia was needed; therefore, we altered the sampling technique to convenience sampling. Similar to the Australian study results [
Considering a nonresponse rate of 30%, the total target sample size was 117 participants (90+27). With relaxation of the sampling technique, a total sample size of 121 participants was reached. A pilot study was performed with 10 mental health care professionals at King Khalid University Hospital in Riyadh (who were not included in the sample) to estimate the time needed to fill out the survey, assess the questionnaire’s comprehensibility, and determine any additional logistical requirements.
All participants were informed of the purpose of the study and their right to withdraw at any time without any obligation toward the study team via a consent form. No incentives or rewards were provided for participation. The study design and purpose of the study were approved by the King Saud University Institutional Review Board before data collection commenced.
The questionnaire was designed as a self-administrated electronic form to maximize the response rate and cover multiple demographics.
Knowledge was measured using six statements regarding computerized interventions. Participants chose between options of “true,” “false,” or “unsure.” This scale was adapted from Donovan et al [
Attitude and comfort toward computer-assisted therapy were measured using the Computer-Assisted Therapy Attitudes Scale [
The third part of the questionnaire included demographics and work-related questions such as those related to CBT experience and clinical license.
Data were analyzed using Statistical Package for Social Sciences version 22 (IBM Corp). Continuous variables such as age are expressed as mean (SD), whereas categorical variables are expressed as frequency and percentages. The
The questionnaire was sent to 132 mental health care professionals. We excluded 10 participants from the final analysis because they were also involved in our pilot study. Only one person refused to participate in the survey, and we had a near 100% completion rate from the participants who started the electronic survey, for a total of 121 participants, most of whom were women (73/121, 60.3%). The demographic characteristics of the participants, and the mean total scores for knowledge about cCBT and the feeling of using computers in therapy are summarized in
To measure the knowledge of cCBT, a test of cCBT facts was used, and the results are summarized in
The results assessing the mental health care professionals’ feelings toward using computer-assisted therapy programs are summarized in
Demographic characteristics of the participants, and total scores for knowledge about computerized cognitive therapy and feelings toward using computers in therapy (N=121).
Characteristic | Value | Knowledge about computerized cognitive therapy | Feeling comfortable toward using a computer in therapy | ||||||||
|
|
Correlation coefficient or mean (SD)a | Correlation coefficient or mean (SD)b | ||||||||
Age (years), mean (SD), median | 36.55 (9.11), 37.00 | –0.040 | .67 | 0.051 | .58 | ||||||
|
|
|
.31 |
|
.16 | ||||||
|
Female | 73 (60.3) | 0.86 (1.28) |
|
37.07 (6.16) |
|
|||||
|
Male | 48 (39.7) | 0.79 (1.03) |
|
37.71 (4.92) |
|
|||||
|
|
.69 | .32 | ||||||||
|
Psychiatry | 29 (23.97) | 1.04 (1.21) |
|
37.43 (4.24) |
|
|||||
|
Psychology | 80 (66.12) | 0.76 (1.19) |
|
37.01 (6.00) |
|
|||||
|
Sociology | 8 (6.61) | 1.00 (1.20) |
|
41.25 (6.96) |
|
|||||
|
Nursing | 2 (1.65) | 1.00 (1.41) |
|
35.00 (4.24) |
|
|||||
|
Other | 2 (1.65) | 0.00 (0.00) |
|
35.00 (5.66) |
|
|||||
|
|
.72 | .13 | ||||||||
|
Riyadh | 80 (66.67) | 0.80 (1.16) |
|
36.51 (5.70) |
|
|||||
|
Makkah | 19 (15.83) | 0.74 (1.10) |
|
39.58 (5.59) |
|
|||||
|
Madinah | 3 (2.50) | 0.33 (.58) |
|
35.33 (7.23) |
|
|||||
|
Eastern | 12 (10.00) | 1.33 (1.61) |
|
39.25 (4.65) |
|
|||||
|
Aser | 2 (1.65) | 1.50 (2.12) |
|
35.00 (0.00) |
|
|||||
|
Jazan | 2 (1.67) | 0.50 (0.71) |
|
43.00 (4.24) |
|
|||||
|
Al Baha | 2 (1.67) | 0.50 (0.71) |
|
41.50 (0.71) |
|
|||||
|
|
.23 | .48 | ||||||||
|
Public Hospital | 49 (40.50) | 0.980 (1.41) |
|
36.47 (5.80) |
|
|||||
|
Psychiatric hospital | 24 (19.83) | 1.08 (1.28) |
|
38.76 (5.01) |
|
|||||
|
Primary care center | 5 (4.13) | 1.00 (0.70) |
|
39.60 (4.28) |
|
|||||
|
Home care facilities | 13 (10.74) | 0.31 (0.48) |
|
37.23 (7.79) |
|
|||||
|
Other | 30 (24.79) | 0.60 (0.89) |
|
37.20 (5.16) |
|
|||||
|
|
.01 | .07 | ||||||||
|
Yes | 112 (92.6) | 0.88 (1.21) |
|
37.22 (5.49) |
|
|||||
|
No | 9 (7.44) | 0.22 (0.44) |
|
38.67 (8.00) |
|
|||||
|
|
.12 | .75 | ||||||||
|
Fellowship/board | 20 (16.53) | 1.20 (1.32) |
|
37.10 (4.53) |
|
|||||
|
PhD | 6 (4.96) | 0.33 (0.52) |
|
39.83 (4.54) |
|
|||||
|
Master | 40 (33.06) | 1.03 (1.49) |
|
37.20 (7.30) |
|
|||||
|
Bachelor | 55 (45.45) | 0.62 (0.85) |
|
37.23 (4.85) |
|
|||||
|
.001 |
|
.32 | ||||||||
|
Yes | 7 (5.79) | 2.57 (1.13) |
|
39.43 (5.16) |
|
|||||
|
No | 114 (94.21) | 0.73 (1.11) |
|
37.20 (5.71) |
|
aBased on a total possible score of 6.
bBased on a total possible score of 55.
Knowledge about computerized cognitive behavioral therapy (N=121).
Question (correct answer) | True, n (%) | Unsure, n (%) | False, n (%) |
Computerized interventions are only available online (False) | 9 (7.4) | 83 (68.6) | 29 (24.0) |
All computerized interventions involve therapist contact (False) | 32 (26.4) | 70 (57.9) | 19 (15.7) |
Computerized interventions are less effective than face-to-face therapy (False) | 36 (29.8) | 76 (62.8) | 9 (7.4) |
Computerized interventions automatically tailor to individual needs (False) | 31 (25.6) | 81 (66.9) | 9 (7.4) |
People who receive computerized interventions are generally satisfied (True) | 12 (9.9) | 106 (87.6) | 3 (2.5) |
Computerized interventions are not interactive (False) | 20 (16.5) | 78 (65.4) | 23 (19.0) |
Therapist attitudes and access to computer-assisted therapy (N=121).
Question | Strongly disagree, n (%) | Disagree, n (%) | Neither agree nor disagree, n (%) | Agree, n (%) | Strongly agree, n (%) |
If given the opportunity and training, I would like to use computers in therapy | 1 (0.8) | 2 (1.6) | 17 (13.9) | 66 (54.1) | 36 (29.5) |
I feel apprehensive about using computers during therapy | 28 (23.0) | 42 (34.4) | 39 (32.0) | 11 (9.0) | 2 (1.6) |
I am afraid that if I begin to use computers, I will become dependent upon them and lose some of my own skills | 18 (14.8) | 48 (39.3) | 34 (27.9) | 18 (14.8) | 4 (3.3) |
Using computers in therapy will interfere with rapport | 5 (4.1) | 30 (24.6) | 48 (39.3) | 32 (26.2) | 7 (5.7) |
My clients will be more likely to drop out of treatment if I use a computer program as part of the therapy | 9 (7.4) | 42 (34.4) | 49 (40.2) | 22 (18.0) | 0 (0) |
My clients would find it engaging to learn new skills using a computer | 0 (0) |
6 (4.9) | 50 (41.0) | 57 (46.7) | 9 (7.4) |
I believe that using computer programs in therapy will lead to better outcomes for my clients | 0 (0) | 9 (7.4) | 56 (45.9) | 47 (38.5) | 10 (8.2) |
The challenge of learning about the use of computers in therapy seems overwhelming to me | 9 (7.4) | 47 (38.5) | 46 (37.7) | 20 (16.4) | 0 (0) |
I am confident that I can learn the skills to use computer-assisted therapy | 1 (0.8) | 2 (1.6) | 14 (11.5) | 80 (65.6) | 25 (20.5) |
My clients are not sufficiently computer savvy to use computers in therapy | 0 (0) | 21 (17.2) | 52 (42.6) | 46 (37.7) | 3 (2.5) |
I have sufficient access to computers to use them in sessions | 19 (15.6) | 42 (34.4) | 33 (27.0) | 22 (18.0) | 6 (4.9) |
Our study assessed mental health care professionals’ knowledge and attitudes toward cCBT. Most of the participants were uncertain and lacked knowledge. However, the majority of participants agreed and believed in cCBT, and were confident about using it. One of the main reasons for this lack of knowledge is the lack of availability of cCBT programs in Arabic. Moreover, it appears that lack of knowledge about cCBT is not limited to Saudi Arabia, as this issue has also been demonstrated in other regions [
In another study, Computer-Based Training Attitudes Scale scores were higher among therapists who reported having previously used computer-based training. Negative responses toward computer-based training largely originated from those facing greater practical barriers to the use of computer-based training [
Clinically, cCBT can be beneficial. Reviewed advantages include flexibility in time and location, cost-effectiveness, reduction of personal stigma, time of the mental health care professional, time of waiting for treatment, the behavior of asking for help and guidance, and being satisfied by the provided treatment [
Future research should aim to recruit greater numbers of participants with various levels of training, skills, and different backgrounds so that effective comparisons can be made [
We used an electronic questionnaire to reach the participants in Riyadh through data collectors. We did not receive a sufficient number of responses because of the limited mental health care professionals in Riyadh, and therefore we reached out to different cities in Saudi Arabia by sending an invitation through WhatsApp groups and emails. Future research should expand this approach by including a larger participant population. Future research should also provide participants with a broader range and more items in the knowledge test.
The results of this study suggest that mental health care professionals in Saudi Arabia are in need of more education and training regarding cCBT; however, their attitudes toward its use, and their comfort in using computers in general, show great promise.
Lack of knowledge did not affect the participants’ attitude toward cCBT, as they demonstrated a positive attitude overall. In addition, we recognize that mental health care professionals need more involvement in various up-to-date therapeutic approaches and need more resources for cCBT in Arabic. Further research should be performed to assess patients’ acceptance of cCBT in Saudi Arabia along with clinical trials measuring its effectiveness in the Saudi population.
cognitive behavioral therapy
computerized cognitive behavioral therapy
Preliminary results of this project were presented at the 27th European Congress of Psychiatry, April 6-9, 2019, in Warsaw, Poland. This research was funded by the SABIC Psychological Health Research and Applications Chair, Department of Psychiatry, College of Medicine, Deanship of Post Graduate Teaching, King Saud University. We would like to thank all of the people who participated in the research for their patience and kindness.
None declared.