“If Someone Walks In On Us Talking, Pretend to be My Friend, Not My Therapist": Challenges and Opportunities for Digital Mental Health Support in Saudi Arabia

KSA is the largest sovereign nation in the Middle East [9]. Among the Saudi population, 51% are men and 49% are women. Children and young adults represent more than two-thirds of the Saudi population [52]. Arabic is the official language, the primary ethnic group is Arab, and the official religion is Islam. The holy book of Islam, the ‘Quran’, and ‘Hadith’ (sayings of the Prophet Muhammad) are the source of the laws, daily life, and spiritual experiences of Saudis [105]. The family is a significant unit in Saudi culture. It is typical for adult children to live with their family or near them even after marriage.

Mental health disorders are considered a growing problem in the KSA, where around 34% of Saudis have experienced a mental disorder during their life [31]. According to the Saudi National Mental Health Survey (SNMHS) [31], mental health conditions are highly prevalent in recent generations of the Saudi population. In particular, 40% of young adults (15-34) meet the criteria for a mental disorder, a rate that is almost double compared to the older population (50-65). Anxiety disorders (i.e., separation anxiety disorder, social phobia, obsessive-compulsive disorder (OCD) and generalized anxiety disorder) are the most common mental conditions among the KSA population (23%), followed by disruptive behaviour disorders (11%) and mood disorders (9%) (i.e., major depressive disorder (MDD), bipolar I–II disorders (BD)). With regard to gender differences, Saudi women have a significantly higher risk of MDDs and anxiety disorders than men [31].

Mental healthcare services are provided freely to citizens via the MoH hospitals and other governmental sectors such as military and university hospitals [4, 16, 20]. In addition to public sectors, mental health services can be accessed via private healthcare providers [9]. The number of mental health professionals practicing in the KSA, including psychiatrists, psychologists, social workers, and nurses, is 19.4 per 100,000 population. Specifically, there are 1.3 psychiatrists per 100,000 people, accounting for just 7% of mental health professionals in the KSA, a lower proportion compared to the global average (20%) and high-income countries (20%). The number of psychologists is 2 per 100,000 people, making up 10% of mental health professionals in the KSA, in contrast to the global and high-income country averages of 14% [9]. According to a survey of 63 mental health professionals practicing in the KSA, the most common approach used was pharmacotherapy, followed by supportive therapy, cognitive behaviour therapy (CBT), a combined approach, psychodynamic and family therapies, and group therapy, respectively [20].

According to the SNMHS, 86% of surveyed Saudis who met the criteria for a mental disorder do not seek any treatment [16]. Barriers to seeking mental health services were primarily the lack of perceived need for treatment and attitudinal barriers (e.g., wanting to solve their problem by themselves and fear of stigma). This is followed by structural barriers (e.g., service availability and financial constraints) [16] where governmental services are linked with long waiting times, and financial constraints limit some individuals from seeking private services [7, 15]. This suggests that barriers to seeking mental health services in the KSA may be related more to individual beliefs and perceptions than the availability and accessibility of the services [16]. The stigma surrounding mental health disorders, psychiatric patients, mental health facilities, and their services still prevails in Saudi society [17, 19, 25, 95]. Difficulties related to mental health or personality development may stigmatize the family as stigma-by-association (‘courtesy stigma’), leading to social disapproval and devaluation by others [19, 20]. Therefore, explaining psychological and psychiatric symptoms as magic, evil eye, and possession by “Jinn” [5] and thus seeking help from faith healers is more socially acceptable in Saudi society than seeking psychiatric or psychological help [20, 27]. While these supernatural beliefs also carry some stigma, they are viewed as treatable through faith healing, thereby posing less harm to the family’s reputation than mental illness, which can adversely affect marriage, employment, and the social image of individuals and their families [2, 20]. Consequently, these cultural factors significantly shape individuals’ attitudes towards seeking mental health care [20].

In 2016, the government of the KSA launched “Saudi Vision 2030" [1] with the ambition of shifting from an oil-based to a knowledge-based economy [90, 106]. It aims to reduce reliance on oil and endorse economic diversification and investing in improving the healthcare system, well-being, infrastructure construction, tourism and other economic domains [90, 102, 106]. Following the Vision’s launch, the KSA has witnessed an unprecedented shift in economic, digital, and sociocultural aspects [53, 59, 106]. The Vision has notably accelerated digital transformation in various domains, including the healthcare sector, with a particular focus on mHealth [14, 26, 112]. This high interest in mHealth from healthcare providers was also paired with notable interest from Saudi citizens in accessing services through their smartphones [22, 32, 57]. COVID-19 further supported and tested this digital transition, and the KSA’s digital response to it was noteworthy [59].

The Saudi MoH has launched various mHealth apps to support the Saudi Vision 2030 of digital health transformation [26]. For instance, Seha (“Health”) [91] enables individuals to receive online audio–video medical consultations in all medical specialities [109, 112] and Anat platform [83] allows licensed healthcare providers to issue e-prescriptions to their patients to facilitate telemedicine [70]. In addition to governmental services, the private sector has released mHealth apps for online medical consultations, including mental health care, such as Cura, Maya Clinic, and Nala [59].

Despite the rising interest in mHealth from the healthcare ecosystem and stakeholders in the KSA[23], we lack significant research on the availability, adoption and acceptance of mobile apps in mental health practice in Saudi Arabia [29]. Atallah et al. [32] have studied the prevalence of using mHealth apps for mental health in Saudi Arabia, where 376 participants with self-reported symptoms of depression, anxiety or stress were surveyed. Results showed that approximately half of the participants used one or two healthcare apps, and most of them accessed their health information using mobile phones. Most participants were willing to use a mobile app daily to track their mental health. Furthermore, 82% of surveyed Saudis in the SNMHS who perceived the need for mental health treatment decided to handle their problem on their own outside the healthcare settings [16]. While Saudi individuals are interested in using mobile apps to maintain their mental health, less is known about the state of apps in the Saudi marketplace and their characteristics and also professionals’ viewpoints around them.

We recruited participants through snowball sampling, with an initial sample of four clinicians from the researchers’ professional network. Participants were recruited according to the following inclusion criteria: (i) they were certified clinicians (psychiatrists or psychologists), (ii) they regularly worked with patients with mental illness in Saudi Arabia, and (iii) they were fluent in either English or Arabic. After receiving initial responses from the potential participants, we asked them to provide their contact details. We sent them a participant information sheet and consent form and contacted them to check the accuracy of the collected data if necessary. A total of twelve clinicians (5 men and 7 women) with time in practice ranging from one year to 10+ years were interviewed as a final sample. We managed to recruit and interview five psychiatrists and seven psychologists. This was despite the fact that the number of psychiatrists and psychologists in the KSA is only 1.3 and 2 per 100,000 population, respectively [9]. Participants were not compensated for taking part in the interview. Table 2 and Figure 2 present participants’ demographics and practice characteristics. Information like gender and age have been excluded to preserve their anonymity. In this paper, we refer to the psychiatrists and psychologists as PR and PL, respectively.

All interviews were conducted remotely over Microsoft Teams between January and February of 2022, and participants consented to be audio recorded using a standalone recording device. Interviews lasted between 30 and 90 minutes, with an average of about 60 minutes. Participants were initially asked to provide information about their clinical background and prior experience with technology in practice. Next were questions about clinicians’ current practices in delivering mental healthcare in Saudi clinical settings; the main challenges they and their patients face in current mental health practice; the main benefits and opportunities that exist in the application of mobile health in the current Saudi mental health context; perception, experience and perspectives around existing mental health apps (based on clinicians’ perception and previous experience with existing apps in their practice); the main barriers to adopting mental health mobile apps in the current mental health practice; the main challenges that exist in the application of mobile health in the current Saudi mental health practice; and their perspectives and considerations to support adopting mental health apps in Saudi mental healthcare. The first and second authors conducted the interviews in Arabic to encourage effective communication since all participants were native Arabic speakers and some of them were not able to speak English fluently. The audio recordings were manually transcribed by the first author after redacting and anonymizing all personally identifiable information. Transcripts were initially analyzed by the first and second authors (who are bilingual) in the main source language to accurately capture the full meaning. Then, excerpts and codes were translated into English by the first author for the purpose of both the team discussion (that included English-speaking authors) and research reporting. Improving mental health support accessibility in diverse populations is part of all authors’ interests. The research team comprises Saudi authors, including a psychiatrist and a developer of an Arabic mental health self-help mobile app, currently living in both the KSA and a Western country, and it also includes Western authors with psychology and computer science backgrounds. Regarding the background and experience of the primary researchers in this study, the first author, with a computer science background and HCI research work focused on digital mental health, received an intensive training course in qualitative research methods in health care research. The second author, a consultant psychiatrist with research work in the KSA focused on mental disorders and their associated stigma, had prior qualitative research experience.

The anonymized transcripts were analyzed using ‘codebook’ thematic analysis (TA) [41]. Thematic analysis is widely used in qualitative research regarding perspectives on digital health and well-being interventions, facilitators and barriers to adopting them [35, 78, 131, 138]. According to Braun and Clarke [39, 40, 41], the ‘codebook’ TA sits between ‘reflexive’ TA and ‘coding reliability’ TA, adopting a structured coding approach similar to ‘coding reliability’ (without using coding reliability measures) with the broadly qualitative philosophy of ‘reflexive’ TA. The codebook was used to map and document the analysis in this exploratory study with some flexibility, allowing new codes to be added for new data and interpretations [40]. Two authors (first and second) from different backgrounds, computer science and psychiatry, separately reviewed a subset of the interviews (n = 4). They inductively coded these transcripts and independently generated initial codes and identified candidate categories by grouping related codes. Generated codes and categories were discussed, merged and collapsed through team discussions to derive a common codebook. Then, using this initial codebook, the next 4 transcripts were independently coded by the two authors and new codes were discussed and added to the codebook as the analysis progressed, and previously coded transcripts were reviewed. Generated codes and categories and analysed data were discussed through regular team discussions. Then, the remaining interviews (n = 4) were coded by the first author using the adjusted codebook. Themes were collaboratively developed through team discussions of the data and the codebook.

Coding was performed using the qualitative analysis software package ATLAS.ti Version 22, which better supports Arabic transcripts analysis.

This study has received ethics approval from the University of Oxford Central University Research Ethics Committee (CUREC) (Ethics reference: 576-21). For national ethical review, the Institutional Review Board (IRB) of Princess Nourah bint Abdulrahman University (PNU) Research Ethics Committee has determined that this study poses no more than minimal risk to participants; therefore, it has been deemed EXEMPT from local IRB review (IRB log number:21-0474E).

To retrieve relevant mental health and mental well-being apps from the Saudi Apple App Store and Google Play, we used available scripts—namely SerpApi [111] and google-play-scraper [94]—to automatically retrieve search results for the Arabic keywords found in Table 1. Our search terms included technical mental well-being and mental health-related terms with a particular focus on depression and anxiety (i.e., mental health, anxiety, depression, mood disorders, psychological stress and mental well-being) as well as related common layperson synonyms (i.e., stress, mood, emotions). Keywords were identified based on search terms used in previous related app reviews [28, 118, 134]. We separately scraped apps on the Saudi stores (Apple App Store and Google Play Store). The scraper function was set to retrieve the first 200 app results for each keyword in both app stores (similar to previous related app reviews [24, 72]). It is worth noting that only one term, namely “mental health" on the Apple App Store, hit this limit. Recorded information included each app’s name, description, price, rating, date of last update, developer’s details, app’s link, and app store category. For each app store, we wrote a custom script to combine the search results for all keywords. In total, 2411 records were retrieved through multiple search keywords on both the Apple App Store and Google Play stores. After removing duplicates, 1492 apps were resulted for manual screening.

Following similar reviews [28, 118, 121], for each app, we manually screened the titles, app store descriptions and screenshots. To be included in our analysis, apps had to fulfil the following inclusion criteria: (1) explicitly focused on mental health or mental well-being (app name or description included one of our keywords), and (2) support the Arabic language. We excluded apps if they fell into any of the following categories: not focused on mental health or mental well-being (e.g., the Arabic word for “Stress", has multiple meanings in Arabic, such as psychological stress and data compression), did not support the Arabic language, targeted clinicians only, or were e-books (consistent with previous methodologies [104, 121]). This yielded 141 potentially relevant apps.

We downloaded each app and reviewed them in detail to ensure that apps are functional and accessible to the Saudi population. Apps that were non-functional or inaccessible (e.g., required a mobile number for registration and did not accept Saudi phone numbers) were excluded. In addition, we double-checked that the downloaded apps provided what they claimed in their store descriptions to validate that they meet the inclusion criteria and did not fall into any of the exclusion categories described above in 3.2.2. After this process, 121 apps satisfied all the inclusion/exclusion criteria. Subsequently, in cases where an app was present in both the Apple App Store and Google Play, we maintained a single record for subsequent feature analysis, as our primary objective is to analyze apps’ content and the employed strategies rather than the distinctions between iOS and Android versions of the same app. Upon completion of this process, we identified 110 apps for analysis.

In this paper, the Mobile App Rating Scale (MARS) tool was used to collect descriptive information about the collected apps and code their features. The MARS is the most commonly used tool for analyzing mental health mobile apps [24, 28, 77]. We coded the following variables for each included app according to the app classification in MARS [120]: app name, focus (i.e., what the app targets), theoretical background/strategies (defined in Appendix A), supported platforms, category of the app on app stores, average rating, date of last update, affiliations, supported languages, price. In detail, the first author and a collaborating researcher (with a research background in Natural Language Processing for mental health topics, with a particular focus on mood disorders) independently reviewed and classified features (theoretical background/strategies, focus, affiliations) in 75 apps based on the MARS tool [120] (see Appendix A). We tested for inter-rater reliability using Cohen’s kappa [44] and obtained 0.85. Cohen’s kappa values over 0.80 indicate almost perfect agreement [79]. Any disagreement was discussed until an agreement was reached. The first author then coded the remaining 35 apps. Other variables were coded automatically from the scraped results. Lastly, apps were analysed by each variable using descriptive statistics performed by Python.

Therapeutic tools remain paper-based. Despite the high penetration of smartphones in the general population, clinicians reported that therapeutic tools for screening, assessment, and treatment (e.g., assessment scales, CBT worksheets and exercises, etc.) remained paper-based in clinics. This extended to when these tools were given to patients for home self-report; for example, PR24 said: “We print papers for patients, that we want them to fill out at home, to record their thoughts, feelings, behaviours, etc., as homework, and we ask them to bring these papers to the next session." PR16 also mentioned that “Patients filled out the printed assessment scales and submitted them to clinicians during visits."

However, paper-based tools present privacy challenges. For instance, some patients expressed concern that, as their written notes were easily left exposed, they could be easily read by others. These concerns included privacy concerns about family members; PL11 said: “Many clients share their room with other family members and were afraid that someone may read their papers." PL11 also discussed stigma as a common barrier associated with using paper tools and mentioned “Part of the effective treatment is that clients record their thoughts or events immediately, capturing their intensity accurately. However, clients experienced the embarrassment of writing on paper in public or in front of others, if something happened." Fear of social stigma was also relevant within clinical settings, where patients were concerned about who might access or read their papers. PR16 described that “Some clients ask about who will scan their filled scales and ask me to do it myself. Sometimes, they resist the scanning if a nurse will do it." This concern was often rooted in a fear of social stigma where they might be recognised by any member of the clinic staff.

To mitigate reported issues with the paper-based approach, professionals noticed that many clients are using built-in smartphone apps, namely the Notes app, to record their thoughts and symptoms or document their CBT homework. The Notes app was seen to provide better confidentiality by being under their control. Specialists also mentioned using email for transferring documents and communicating with their clients. Overall, professionals appreciated digital capabilities in managing data privacy compared to paper-based approaches.

Adoption of technology to support virtual clinics. As a response to the COVID-19 pandemic, most healthcare facilities in the KSA were obliged to adopt technology to provide their services. Therefore, almost all of our clinicians have experience in virtual clinics to provide mental health teleconsultations. For instance, PL10 said: “Within the government facility where I work, we provide 3 types of sessions: face-to-face, audio consultations, and virtual video-based sessions through a mobile app founded by the facility." Interviewees reported that most of the provided teleconsultations were audio, based on clients’ requests.

Nearly all clinicians were aware of available commercial apps providing online psychological consultations. For example, PL15 said “Labayh is the most well-known platform in the Arab world, followed by Famcare and Estenarh," (see Section 4.2.3 for apps’ description). Furthermore, half of our participants reported providing their services via existing commercial apps. Except for online consultation apps, most clinicians reported a weak awareness of available mobile apps supporting their therapeutic practice with clients, such as assessment, tracking and meditation. For instance, PR19 said: “Ummm.... I do not know what kind of apps are available to support mental health." Moreover, they lack knowledge about what kind of mental health apps their clients used themselves to manage their condition. PL9 said: “I have never heard from my clients about apps they use."

Most clinicians reported a lack of Arabic mental health apps for education, meditation and tracking. For instance, PL18 said: “The available online Arabic mental health information is very dry [scarce]!" For meditation, some interviewees discussed their practices if a client does not speak English. PL11 said: “I advise them to record our meditation session via their mobiles and use it later to practice meditation at home" and PL18 said: “I do not mention any meditation apps. I know it is a limitation!" Otherwise, if the client speaks English, a few clinicians reported recommending some popular English meditation/mindfulness apps. PL10 said: “I usually recommend my clients, who speak English well, use Headspace for meditation." For the CBT tasks, only one psychologist (PL11) mentioned adopting a CBT-based mobile app specifically created in Arabic. This psychologist was actively involved in the app’s development and used it as a tool to enhance their clinical practice with clients. For self-tracking tasks, some professionals discussed their reluctance towards digital self-tracking apps. They debated that digital tracking may increase the risk of anxiety, stress and obsession or trigger negative emotions such as guilt, disappointment, and frustration. For example, PL10 said: “It may increase anxiety among clients with perfectionism, paranoia or OCD symptoms due to feeling observed." Clinicians further criticise the perceived objectiveness of passive digital tracking since contextual information and personal interpretations were not captured. PL18 mentioned that “Individuals want objectivity; [but] actually you do not need objectiveness! For example, if you are tired, the last thing you need is a smart tracker telling you that you are ready to face your day!" Such subjective data is crucial to understanding the context behind the numbers and reducing the possibility of misinterpretation. For example, when assessing a client’s sleep, specialists wanted to know any sleep-related data highlighting the effect of circumstantial causes and sleep hygiene on sleep quality. On the other hand, other clinicians believe that self-tracking apps could be adopted to increase client self-awareness and adherence and encourage them to perform activities.

Maintaining privacy. Clinicians discussed the advantage of privacy facilitated by technology in supporting seeking mental health help in Saudi society. For instance, PR20 said “Individuals, especially women, who experience family resistance to therapy benefited from remote services as they can receive mental care privately at home, without anyone knowing about it." PL15 further mentioned that “I receive many online appointments from clients at night when their families are asleep, as they don’t want them to know about seeing a therapist," and “Some women clients told me if someone walks in on us talking, pretend to be my friend, not my therapist." Professionals also reported that most of their clients maintained a degree of privacy by keeping their cameras off during online sessions. For instance, PL11 mentioned that “Almost all of my women clients do not turn on their cameras." Professionals’ attitudes regarding clients’ behaviour of keeping their cameras off varied. Some professionals perceived this as a challenge to the effective examination and building a therapeutic alliance with clients. For instance, PR20 said: “It is supposed to be visual, but most clients refuse to turn on the camera. Non-visual consultation affects the examination process." PL23 also mentioned that “Keeping the camera off is related somehow to Saudi social norms, and it is a common behaviour online, but it could hinder the therapeutic alliance." Accordingly, some professionals limited their services to visual sessions only. PR16 said “If clients insist on keeping their cameras off, I usually apologize, refund and ask them to see another clinician instead. Even though some of the women clients, wear the Niqab ¹ before turning on the camera, at least I can see who is behind the screen and notice their reactions." A clinician (PL11) further suggested that “Turning on the camera during the session should be mandatory." On the other hand, some professionals prioritized the importance of supporting service accessibility in the current time over service quality. PR19 discussed “Stigma still exists; We are keen to improve the situation gradually. At the current time, we should be careful not to add more obstacles like obligating clients to turn on their cameras for better service. We hardly reached them and adding more obstacles may take us a step back." The clinicians’ attitudes toward keeping their cameras on from their sides were also discussed. Most clinicians mention that they usually keep their cameras on and encourage their clients to do the same, while others reported that they themselves prefer to provide non-visual sessions. For instance, PR19 said “It is more convenient, you know I do not have to wear a hijab ² when my camera is off." To maintain service quality, a psychologist (PL23) further suggested that “Clinicians should be obligated to turn on their cameras while making it optional for clients. This is not charity; this is a paid service and should be professional!"

Maintaining anonymity. Clinicians also discussed the remarkable role of implementing anonymity within commercial apps in supporting seeking psychological help within Saudi society. PL15 said “I was not expecting that, but I have seen a massive turnout for such apps." PR20 also mentioned that “It helped a lot of individuals to seek mental healthcare as a lot of them have concerns about visiting psychiatric clinics." PL15 also discussed the advantage of anonymity for some Saudi individuals as “It helps some people to talk freely about sensitive or highly stigmatized problems that are not aligned with the religion or culture." Professionals had diverse perceptions regarding seeing anonymous clients. Some clinicians discussed the possible adverse effects of anonymity on the treatment process, therapeutic alliance and stigma. They expressed their concerns about seeing anonymized clients as they tend to hide basic information to protect their identities, such as marital status, education level, occupation, etc. Professionals think this behaviour could negatively affect the treatment process, and therefore, they do not prefer to see anonymized clients. PR22 said “an anonymous client was talking for 45 mins. about her case and hiding every identifiable information to protect her identity. At the end of the session, she provided some essential basic information that I usually find in the patient’s file in a different scenario." PR20 further expressed concerns about anonymity hindering building therapeutic alliance: “Transparency, starting from the client’s real name and background, usually helps in breaking the boundaries." Moreover, a psychiatrist (PR16) stated that they do not accept anonymous clients due to ethical concerns. On the other hand, some clinicians acknowledged the challenges introduced by anonymity but prioritized responding to the current mental health crises by supporting service accessibility at the current time. PR20 said “Currently, we have a documented problem in the KSA where 86% of people who are in need of psychological care do not seek treatment. Would we think about the consequence of anonymity in the long term?! We should now focus on supporting people to seek treatment. We can address the consequence of anonymity on the therapeutic alliance and stigma after a while after things are resolved."

Views on Stigma. Clinicians argued about the impact of anonymity, facilitated by commercial apps, on mitigating the stigma associated with mental disorders. Some professionals noticed that the ability to be anonymous considerably encouraged Saudi individuals to seek help as such apps helped to mitigate internal or self-stigma. However, they expressed their concerns about anonymity inadvertently reinforcing the stigma around mental illness in general. PR22 mentioned that “Based on my observation, such apps helped to reduce self-stigma. However, they may have a negative impact on the public and structured stigma." For instance, PR22 further explained that “By marketing such apps reduce stigma is in itself reinforcing stigma. They claim to provide a less stigmatizing platform, which in turn indicates that other means such as clinics have a higher level of stigma." PR16 also said “Anonymity implies that there is an actual big issue around mental illness and you should hide it. It exacerbates the stigma!" On the other hand, some professionals believed that by supporting service accessibility, the stigma would be mitigated over time, as they noticed that clients who perceived the benefit of treatment via these commercial apps encouraged their family and friends to seek help.

Doctor shopping behaviour. Some professionals expressed concerns exacerbated by technology as some clients on online private platforms simultaneously see several professionals during the same period, sometimes on the same day, for the treatment of the same problem without any communication between these specialists. Clinicians commented that while this phenomenon of visiting multiple doctors for the same complaint is seen in practice and could be a part of clients’ symptoms or personalities, it is easier to be noticed and controlled in traditional clinics and harder for clients to continue doing it. However, in technology, it is only one click to see another clinician, especially in online commercial platforms. For instance, PR22 said “Clients were trying many specialists as if they were wandering between shops and stores; they were happy to hear about this and did not like that, to the extent that there was a client who called me after seeing another therapist just an hour before me in the same app." Professionals stated that this notable technology-facilitated pattern of frequent changes in clinicians without a professional referral adversely affects both sides, clients and clinicians. It hinders therapeutic alliance and clients’ adherence to the treatment plan resulting in poor outcomes. Moreover, the practice of seeing clients mostly for one time and losing connection with them has negatively affected some professionals’ experience and their service quality with existing commercial platforms. PR22 said “Even for me as a clinician, I was concerned during the session as I have limited time, around 30 mins., and probably I will not see these clients again based on my previous experience. So, sessions turn on providing them with as much as possible of general one-size advice before the end of our first and last session! This could adversely affect the psychotherapy outcomes and thus its image in society."

Expectation of instantaneous responses and immediate diagnosis. Professionals noticed that clients on online platforms expect instantaneous services and immediate responses. Clinicians also discussed common expectations from their online clients that one session is sufficient for a diagnosis and treatment plan. PL18 said “Maybe when we say e-consultation compared to consultation, we lost the human in between. I mean, when we see e (for electronic), we assume that there is an instantaneous service. Clients when seeking online services expect that everything will be provided instantaneously including the diagnosis!" PL23 also mentioned that “I have noticed that if I am late even for some minutes, they easily get upset and start texting me! I have not noticed this in the traditional clinic, and I do not know why this occurs online. Do they assume that I am available since the services are provided on mobiles?"

Supporting access control, data confidentiality and interoperability. Empowering clients to control access to their collected data and support sharing them confidentially with their clinicians was highlighted by clinicians. PL9 said: “Suppose there is a shared platform that my clients and I could access, based on clients’ access permissions, to review their documentation. In other words, from the client’s perspective, I do choose what I share with clinicians for the period I want." Interoperability requirement was also emphasized to overcome the challenges of data accessibility and integration into clinical systems. PL15 said “Having the needed tools in one app will improve the effectiveness of our online experience." A psychiatrist (PR19) further suggested adding caregivers and family members to the app where they can provide their recorded data and insights related to the client’s case directly and confidentially to the clinician. PR19 said: “In my clinic, sometimes families who did not want to talk in front of clients wrote their notes on paper and handled them to me during the session. So, I think supporting the ability to involve a family member in monitoring apps is helpful."

Personalization and considering individuals’ preferences and professionals’ recommendations. Professionals valued considering individuals’ preferences, supporting customization and providing a variety of features and options. For example, PL18 said: “No matter which tool they use. If it works for them, it works for me." In addition, some specialists highlighted leveraging smart devices’ capabilities such as notifications and reminders to provide tailored services and support clients’ engagement. They stated that such alerts could help clients maintain their daily routines and increase adherence to treatment practices. Clinicians also explained the importance of taking into account individuals’ differences and clinicians’ expertise while designing mental health mobile apps to maximize effectiveness and reduce potential harm to clients. For instance, professionals advised supporting flexibility while determining individuals’ goals and avoiding fixed numeric targets (e.g., a specified number of daily steps) to mitigate potential negative consequences on clients when they fail to meet these goals exactly.

Most of the reviewed apps (81 apps, or 74%) were categorized under Health and Fitness, Medical purposes, and Lifestyle in the app stores’ categories. They targeted a number of mental health-related goals as named by app descriptions, mostly improving overall mental health (45 apps or 41%), overcoming depression (43 apps or 39%), reducing anxiety (42 apps or 38%), and relieving stress (36 apps or 33%). Regarding the cost, all apps could be downloaded for free, and 28 apps (25%) had in-app purchases. We found during the analysis that apps that provided a connection with professionals (i.e., counselling) (n = 18) did not specify that they had in-app purchases on their store page; however, these services are fee-based. Moving to other attached costs, 56 apps (51%) had in-app ads. Regarding the employed native language, 89 apps (81%) were primarily in Arabic, while 21 apps (19%) were primarily in English and supported other languages, including Arabic. More descriptive details about the reviewed apps including average star rating, last update and source and affiliations are illustrated in Table 3.

The analyzed apps employed a variety of theoretical backgrounds/strategies as detailed in Figure 3. Around 43% (47 apps) of the examined apps employed more than one strategy/theoretical background with a maximum of 11 strategies and an average of 3 strategies. The most commonly offered strategy was information/education in 61 apps (55%). Relaxation is offered by 24 apps (22%). Out of these relaxation strategies, 18 apps offered music and natural sounds, 14 apps provided written or recorded (audio or video) instructions for breathing exercises, and 2 apps provided suggestions for physical exercise or yoga. These were followed by the feedback strategy provided by 20 apps (18%) and counselling services with 18 apps (16%) offered sessions with mental health professionals. Strategies employed in the evaluated apps further included mindfulness/meditation in 16 apps (15%) and assessment in 16 apps (15%). Other strategies used in the analyzed apps were monitoring/tracking in 15 apps (14%), including mood tracking (n = 13), thought tracking (n = 10), behaviour tracking (n = 2), sleep tracking (n = 2), physical exercise tracking (n = 2), symptom monitoring (n = 1), medication tracking (n = 1), body measurements and vital signs recording (n = 1). Spiritual/religious-based strategies, such as providing audio recordings of the Holy Quran and religious-based advice, emerged during our coding process and were offered by 12 apps (11%). Positive psychology principles such as practicing optimistic thinking and expressing gratitude were provided by 11 apps (10%). Notably, the number of apps that provided therapeutic intervention, such as CBT, is rather low (8 apps, or 7%). Peer support (i.e., the ability to join online forums, ask questions, and talk to others) was the least employed feature in the reviewed apps (2 apps, or 2%). Looking at the employed strategies based on the apps’ native language, among the translated apps (n = 21), 10 provided mindfulness/meditation, 4 offered mood tracking, 3 provided gratitude/affirmations, 2 were based on CBT, and 2 offered translated educational content.

Five apps (5%) of the reviewed apps stated that they were accredited by the Saudi MoH. Three of them were commercial apps that offered fee-based teleconsultations mainly such as “Labayh", “Famcare", and “Estenarh". Labayh [71] is the leading commercial mobile app for psychological, family and personal online consultations in the KSA. It is a KSA-based platform founded in 2017 by a Saudi young man. It aimed to tackle the stigma around mental health issues in Saudi society. Accordingly, Labayh was designed to anonymously connect individuals looking for therapeutic and well-being services with licensed mental health specialists to mitigate stigma. In detail, individuals can explore a wide range of consultants, including psychiatrists and psychologists and book their appointments with the ability to be an anonymous client tailored to the Saudi population’s needs. In addition to teleconsultation, Labayh provided other features, including assessments, mood tracking and support groups. In 2022, Labayh had more than one million users and more than 300 licensed specialists [92]. Likewise, Famcare [49] and Estenarh [48] were released after the notable acceptance of Labayh within Saudi society to offer psychological, family and social teleconsultation with the ability for users to receive services while being anonymous. The other two apps were “Qareboon" and “E-Directory for Psychological Health," both were released by the National Committee for Mental Health Promotion (NCMHP). Qareboon [82] provided mental health educational materials in various forms, such as text, infographics, and video content, along with free psychological text consultations. E-Directory for Psychological Health [51] provided comprehensive information about the hospitals, private clinics, rehabilitation centers, associations and committees located in the KSA, including the services provided and contact details. It aimed to support individuals in need in recognizing available mental health healthcare providers in the KSA and obtaining relevant information.