Lupus (2017) 0, 1–6

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CONCISE REPORT

Medication adherence, depression and disease activity among

patients with systemic lupus erythematosus
N Alsowaida1, M Alrasheed2, A Mayet3, A Alsuwaida4 and MA Omair5
1
Pharmacy Services, King Saud University Medical City, Riyadh, Saudi Arabia; 2College of Pharmacy, King Saud University, Riyadh, Saudi
Arabia; 3Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia; 4Division of Nephrology,
Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia; and 5Division of Rheumatology, Department of
Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Introduction: Medication non-adherence is an important cause of treatment failure among

patients with systemic lupus erythematosus (SLE). Depression is a common neuropsychiatric
disorder associated with SLE. The aims of this study are to assess the prevalence of both
medication non-adherence and depressed mood among Saudi patients with SLE by using
validated tools and to explore the impact of both depressive symptoms and disease activity
on medication non-adherence. Methods: A cross-sectional study was conducted in outpatients
with SLE. Medication non-adherence was assessed by using the Morisky Medication
Adherence Scale, and the severity of depressed mood was evaluated with the Beck’s
Depression Inventory. Disease activity was measured using the SLE Disease Activity Index
(SLEDAI). Multiple logistic regression models were used to identify the multivariate pre-
dictors of medication non-adherence. Results: Out of 140 patients, 134 (95.7%) were females
with a mean (SD) age of 35.6 (11.3) years and a disease duration of 8.8 (6.7) years.
Medication non-adherence and depressed mood were detected in 62.1% and 35% of the
patients, respectively. A moderate or severe depressed mood was significantly associated
with medication non-adherence (p ¼ 0.04). There was a significant correlation between disease
activity and the severity of depressed mood (r ¼ 0.31, p ¼ 0.003). Disease activity did not
correlate with medication non-adherence. Logistic regression demonstrated that moderate-
to-severe depressed mood increased the probability of medication non-adherence (OR 2.62;
1.02–6.71). Conclusion: Medication non-adherence and depressive symptoms are highly
prevalent among Saudi SLE patients. Routine screening could facilitate the early detection
and management of depression and medication adherence. Lupus (2017) 0, 1–6.

Key words: Systemic lupus erythematosus; depression; adherence

Introduction literature to assess patient adherence to medica-

tions. The Morisky Medication Adherence Scale-4
The current management of systemic lupus erythe- (MMSA4) is a self-reported scale used widely in
matosus (SLE) has led to improved quality of life research since it has been validated in a wide
and survival.1 Treatment regimens are usually com- range of diseases, especially for patients with
plex and long-term, which can predispose patients chronic conditions. In Saudi Arabia, the Morisky
to medication non-adherence. Similar to other Scale has been used in liver transplant patients,4
chronic conditions,2 the presence of depression patients with depression5 and patients on warfarin
may aggravate medication non-adherence in therapy.6 It has the advantage of ease of adminis-
patients with SLE and may lead to disease flares, tration and a short duration to complete the ques-
a decreased quality of life and increased healthcare tionnaire. However, the most important
system costs.3 There are many tools used in the disadvantage is its inability to identify barriers to
adherence. Similar to many other aspects of the
disease, differences in ethnicity may affect the bar-
Correspondence to: Mohammed A. Omair, Division of riers to medication adherence.7,8
Rheumatology, Department of Medicine, King Saud University,
Riyadh, Saudi Arabia, P.O. Box 2925 Riyadh 11321.
In two retrospective studies, neuropsychiatric
Email: momair@ksu.edu.sa manifestations were detected in 27.6% and depres-
Received 4 September 2016; accepted 18 July 2017 sion was detected in 15.2% of Saudi Arabian
! The Author(s), 2017. Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav 10.1177/0961203317725585
 Medication Adherence and Depression in Lupus
N Alsowaida et al.
2
patients with SLE.9,10 The retrospective nature of
these studies may underestimate neuropsychiatric
manifestations, especially milder forms that do
not require treatment. There are no current data
on medication non-adherence in our patient
population.
The aims of this study are to assess the preva-
lence of both medication non-adherence and
depressive symptoms among Saudi patients with
SLE by using validated tools and to explore in
these patients the impact of both a depressed
mood and disease activity on medication non-
adherence. All medications were available through
the government-funded healthcare system.
Materials and methods
Study subjects
This was a cross-sectional study of SLE patients.
Subjects were enrolled between May 2015 and
February 2016 from the rheumatology and neph-
rology outpatient clinics. The inclusion criteria
were age 18 years, Saudi nationality, fulfilment
of the Systemic Lupus International Collaborating
Clinics (SLICC) classification criteria,11 a disease
duration of 24 weeks, and ability to complete
the questionnaire. The exclusion criteria were preg-
nancy, a confirmed diagnosis of malignancy or the
presence of endstage organ disease. Informed con-
sent was obtained before study inclusion. The study
was approved by the Institutional Review Board
(IRB) of the College of Medicine.
Healthcare is provided to all Saudi Arabian citi-
zens by the government through a national health-
care system, which covers all costs including
medications. All medication refills were provided
through the hospital pharmacy.
Patients’ data were collected through a standar-
dized data collection sheet that included demo-
graphics, marital status, education level, initial
clinical presentation at diagnosis, disease duration
and medication profile.
The validated Arabic version of Beck’s
Depression Inventory (BDI)12 was used to measure
the severity of current depressive symptoms. The
tool consists of 21 questions (a total of 63 points),
with score categories that range from an absence of
depression (0–13 points) to mild (14–19 points),
moderate (20–28 points) or severe depression
(29–63 points).
The validated Arabic version of the Morisky
Medication Adherence Scale-4 items (MMAS-4)
tool was used to assess treatment regimen
Lupus
adherence.10 The MMAS-4 consists of four ques-
tions with a score that begins at 0, which indicates
high adherence.12
SLE Disease Activity Index (SLEDAI) and SLE
International Collaboration Clinics/ACR (SLICC/
ACR) index were calculated for all patients. The
assessment of disease activity was performed by
using the SLEDAI, with a scoring system that
ranges from 0 to 105 points.11 Based on the score,
the patients were classified as inactive (0–4 points)
or having mild-to-moderate (5–12 points) or severe
disease activity (>12 points).
Data analysis
Descriptive statistics were used for the demograph-
ics and patient characteristics. The categorical data
were summarized as numbers and percentages,
whereas the continuous data were summarized as
the mean, standard deviation, median and inter-
quartile range. Comparison between the groups
for categorical variables was performed by using a
Chi-square test or Fisher’s exact test, whereas for
the continuous data, the Student t-test or Mann-
Whitney test were used as appropriate. Multiple
logistic regression models were used to identify
the multivariate predictors of low and medium
adherence. To quantify the strength of the multi-
variate association, we used odds ratios with 95%
confidence intervals. An association with a p-value
0.05 was considered statistically significant. All
analyses were performed by using SAS version 9.2
(SAS Institute, Inc., Cary, NC). The reporting of
the study results was performed by using the
Strengthening the Reporting of Observational
Studies in Epidemiology (STROBE) Statement:
Guidelines for reporting observational studies.13
Results
One hundred and forty consecutive patients were
included in this study. Of these, 134 (95.7%) were
females, and 78 (55%) were married. The mean
(SD) age was 35.6 (11.3) years, and the mean
disease duration was 8.8 (6.7) years. The socio-
demographic characteristics, clinical manifest-
ations, immune profile and disease activity are
presented in Table 1.
According to the SLEDAI score, 31 patients
(22%) had mild-to-moderate disease activity,
whereas 37 patients (24%) had severe disease activ-
ity. The SLICC/ACR damage index was greater
than 0 in 63.8% of patients with a median value
of 2 [interquartile range (IQR); 1-3].
 Medication Adherence and Depression in Lupus
N Alsowaida et al.
3

Table 1 Demographic characteristics and clinical 20 (14.3%) and six (4.3%) patients, respectively.
manifestations of the patient population Patients with minimal or mild depressive symptoms
Characteristics No. (%) (n ¼ 114) had an average SLEDAI score of
5.16  SD, whereas patients with moderate or
Gender severe symptoms (n ¼ 26) had an average
Female 134 (95.7%) SLEDAI score of 9.96  SD. A strong correlation
Male 6 (4.3%)
Age (years)
between disease activity and severity of depressed
<30 49 (35%) mood was found (r ¼ 0.31, p ¼ 0.003). Univariate
30–40 41 (29.2%) analyses showed that being married (p ¼ 0.01),
>40 50 (35.7%) having a low level of education (p ¼ 0.05), a
Marital status
higher SLEDAI score (p < 0.001), and a longer dis-
Unmarried 53 (37%)
Married 78 (55%) ease duration (p ¼ 0.05) were associated with the
Widow 9 (6.4%) presence of moderate-to-severe depressed mood.
Education In the multivariate analysis, only disease activity
High school 36 (25.7%) was associated with a depressed mood (the odds
Bachelor 66 (47.1%)
Other 38 (27.1%)
ratio is 1.12 for every one-unit increase in the
Obesity SLEDAI score (CI 1.04–1.21, p ¼ 0.004)). Other
Normal 55 (39.2%) details are presented in Table 2.
Overweight 66 (47.1%) Medication non-adherence was reported in 87
Obese 18 (12.8%) (62.1%) patients according to the MMAS-4. Low
Laboratory data
Serum creatinine 95  127 mmol/L
and medium medication adherence were noted in
Urine protein 0.9 g/day  0.5 16.4% and 45.7%, respectively. The number of
Medications medications did not impact the adherence rate.
Prednisolone 91 (65%) The mean number (SD) of medications were 3.5
Hydroxychloroquine 123 (87.8%)
(1.6), 2.8 (1.5) and 3.4 (1.7) in the low,
Mycophenolate mofetil 29.2 (41%)
Azathioprine 20 (28%) medium and high adherence groups, respectively
Tacrolimus 4.2 (6%) (p ¼ 0.8). Logistic regression revealed that a
ACE/ARB 48 (34.2%) younger age and a moderate-to-severe depressed
Clinical presentation at diagnosis (%) mood were associated with non-adherence (OR
Arthritis 71.4
Malar rash 41.4
2.62; 1.02–6.71). However, no significant effect on
Oral ulcer 34.3 medication non-adherence was found regarding
Renal 24.3 disease duration, steroid use, marital status, educa-
Photosensitivity 29.3 tional level or SLEDAI score (Table 3).
Serositis 2.1
Haematological 17.1
Discoid rash 14.3
Cerebral 5.7 Discussion
Positive SLEDAI components No. (%)
Arthritis 40 (29)
Proteinuria 35 (25) Depression and medication non-adherence were
Low complement 25 (17.8) prevalent in our study population. According to
Pyuria 23 (16.4) the Hopkins Lupus cohort, the incidence of depres-
New rash 21 (15) sion is 29.7/1000 person-years.14 In the systematic
Alopecia 20 (14.2)
Haematuria 15 (10.7)
review by Palagini et al.,15 the rate of depression
Mucosal ulcers 11 (7.9) ranged between 17% and 75%. Van Exel reported
Others 29 (20.7) that the prevalence of depression in lupus patients
anti-dsDNA 140 (100) was triple the prevalence of depression in the
ANA 140 (100)
normal European population.16 Our study indi-
anti-dsDNA: Anti-double stranded DNA; ANA: cates that one-third of our patients have some
Antinuclear antibody form of depression. Many patients’ depression
had not been clinically detected or managed appro-
priately. Many risk factors for depression were
Forty-nine (35%) patients had evidence of cur- identified. These included female gender,17 higher
rent depressive symptoms, according to their BDI steroid use,14 neurological involvement,14 and the
score. Mild, moderate and severe forms of presence of fatigue.16 Our study could not detect a
depressed mood were identified in 23 (16.4%), difference in gender because of the small male
Lupus
 Medication Adherence and Depression in Lupus
N Alsowaida et al.
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Table 2 Logistic regression for the predictors of depression among patients with SLE
Depression

Minimal and Moderate and

Covariate Statistics level mild N ¼ 114 severe N ¼ 26 p-value

Gender N (Col %) Male 6 (5.26) 0 (0) 0.2

N (Col %) Female 108 (94.74) 26 (100)
Age N (Col %) <30 41 (35.96) 8 (30.77) 0.5
N (Col %) 30–40 35 (30.7) 6 (23.08)
N (Col %) 40þ 38 (33.33) 12 (46.15)
Education N (Col %) High school 28 (24.56) 8 (30.77) 0.05
N (Col %) Bachelor 59 (51.75) 7 (26.92)
N (Col %) Other 27 (23.68) 11 (42.31)
Marital status N (Col %) Unmarried 49 (42.98) 4 (15.38) 0.01
N (Col %) Married 60 (52.63) 18 (69.23)
N (Col %) Widow 5 (4.39) 4 (15.38)
Obesity N (Col %) Normal 48 (42.11) 7 (28) 0.42
N (Col %) Overweight 52 (45.61) 14 (56)
N (Col %) Obese 14 (12.28) 4 (16)
Prednisolone N (Col %) No 44 (38.6) 5 (19.23) 0.06
N (Col %) Yes 70 (61.4) 21 (80.77)
Hydroxychloroquine N (Col %) No 13 (11.4) 4 (15.38) 0.58
N (Col %) Yes 101 (88.6) 22 (84.62)
ACE/ARB N (Col %) No 75 (65.79) 17 (65.38) 0.96
N (Col %) Yes 39 (34.21) 9 (34.62)
SLE duration N 113 25 0.05
Mean 8.31 11.31
Median 7 7
Std. Dev 6.33 8.24
QRANGE 9 11
SLEDAI score N 114 26 <0.001
Mean 5.16 9.96
Median 4 8
SD 5.16 8.71
IQR 10 8
Creatinine N 111 26 0.48
Mean 98.95 79.15
Median 62 59.5
SD 137.35 70.33
IQR 23 31
DNA N 45 10 0.08
Mean 365.6 614.62
Median 200.3 484
SD 388.37 418.16
IQR 458.23 634

representation in our sample. There are conflicting
data whether active disease increases the vulnerabil-
ity to depression. Miguel et al. and Utset et al. have
shown an association with active neuropsychiatric
lupus but found no relations between serology or
other manifestations of active disease.18,19 Zakeri
et al. found that only severe forms of active lupus
are associated with depression.20 Carr et al. found a
correlation between depression and self-reported
disease activity.21 In contrast, the two studies
reported by Shortall et al. and Van Exel et al.
found no relation between disease activity and
depression.16,22 Our findings suggest a positive rela-
tionship between depression and disease activity.
Lupus
Similar to depression, drug adherence is multi-
factorial and difficult to evaluate.23 Depending on
the tool that is used, the rate of non-adherence in
the literature ranges between 3% and 76%.23
In SLE patients, both intentional and unintentional
non-adherence are important to address.
Psychosocial abnormalities are recognized as
important contributing factors. We found that the
presence of depressive symptoms was strongly asso-
ciated with non-adherence. Similar findings were
reported by Julian et al. and Olivera et al.3,24
In contrast to the study by Julian et al.,3 we
found no relation between medication non-adher-
ence and disease activity. Pharmaceutical care,
 Medication Adherence and Depression in Lupus
N Alsowaida et al.
5

Table 3 Logistic regression for the predictors of adherence medications through the government-funded
among patients with SLE healthcare system. Third, the male gender was not
Response ¼ low and medium well represented, and the study results cannot be
adherence generalized on this subgroup. A study with a
Odds 95% 95%
larger sample size would be better to explore the
Covariate Level ratio CI low CI high p-value most influential cause of medication non-adherence
that is most associated with depression in SLE
Gender Male 0.37 0.03 4.37 0.427 patients. Finally, the impact of poor adherence on
Education High school 0.99 0.30 3.27 0.985
Bachelor 0.76 0.25 2.33 0.631
achieving remission was not assessed among these
Marital status Unmarried 1.19 0.12 11.56 0.882 patients, and this factor requires long-term follow-
(single) Married 1.60 0.21 12.32 0.651 up and will be better assessed in a longitudinal
Prednisolone Yes 0.62 0.26 1.48 0.277 study.
Hydroxychloroquine Yes 1.29 0.35 4.79 0.699
Body weight Overweight 1.06 0.29 3.95 0.929
In conclusion medication non-adherence and
Depression Moderate-to-severe 2.62 1.02 6.71 0.04 depression are highly prevalent among patients
Age One-unit increase 0.92 0.86 0.99 0.021 with SLE in Saudi Arabia. Early detection and
SLE duration One-unit increase 1.03 0.95 1.10 0.492 management of depression and medication adher-
SLEDAI score One-unit increase 1.01 0.94 1.08 0.796
ence could be achieved by incorporating pharma-
Creatinine One-unit increase 1.01 0.99 1.02 0.409
ceutical care and psychosocial evaluation.
SLEDAI: SLE Disease Activity Index

which incorporates a clinical pharmacist into a Ethical approval

multidisciplinary patient management team, has
All procedures that were performed in this study
been shown to improve medication adherence in
that involve human participants were in accordance
chronic diseases such as diabetes and hyperten-
with the ethical standards of the Institutional
sion.25,26 Accordingly, this is a potential solution
Ethical Committee and the 1964 Helsinki
for SLE patients that should be explored.
Declaration and its later amendments or compar-
Health systems and healthcare services are
able ethical standards.
important determinants of medication adherence.
The extent of medication non-adherence in low-
and middle-income countries is greater than in Informed consent
developed countries because of a lack of health
resources and unequal access to healthcare.27
The healthcare system in Saudi Arabia provides Informed consent was obtained from the patients
free services to all Saudi citizens, and the cost is before their inclusion in the study.
covered by the government. This characteristic
eliminates the impact of patients’ income on
Declaration of conflicting interests
adherence.28 Nonetheless, almost two-thirds of
the patients admitted their medication non-adher-
ence. This finding is critical when constructing The authors declared no potential conflicts of inter-
policy to improve adherence to medications.25 est with respect to the research, authorship, and/or
Our study is considered to be the first study to publication of this article.
address the relation between depression and medi-
cation non-adherence among SLE patients in the
Funding
region. This study was also the largest cross-sec-
tional study that has been conducted in Saudi The authors received no financial support for the
Arabia. research, authorship, and/or publication of this
This study has some limitations. First, the cross- article.
sectional design cannot establish causality.
However, it may be argued that the possibility of
selective loss to follow-up or non-random treat- References
ment changes is eliminated in such a design.
Second, patient income was not measured in this 1 Thumboo J, Strand V. Health-related quality of life in patients with
study, despite this variable’s association with systemic lupus erythematosus: An update. Ann Acad Med Singapore
depression because all patients received their 2007; 36: 115–122.

Lupus
 Medication Adherence and Depression in Lupus
N Alsowaida et al.
6
2 Grenard JL, Munjas BA, Adams JL, Suttorp M, Maglione M,
McGlynn EA, et al. Depression and medication adherence in the
treatment of chronic diseases in the United States: A meta-analysis.
J Gen Intern Med 2011; 26: 1175–1182.
3 Julian LJ, Yelin E, Yazdany J, Panopalis P, Trupin L, Criswell LA,
et al. Depression, medication adherence, and service utilization in
systemic lupus erythematosus. Arthritis Rheum 2009; 61: 240–246.
4 Albekairy AM, Alkatheri AM, Jarab A, Khalidi N, Althiab K,
Alshaya A, et al. Adherence and treatment satisfaction in liver
transplant recipients. Saudi J Gastroenterol 2016; 22: 127–132.
5 Aljumah K, Ahmad Hassali A, AlQhatani S. Examining the rela-
tionship between adherence and satisfaction with antidepressant
treatment. Neuropsychiatr Dis Treat 2014; 10: 1433–1438.
6 Mayet AY. Patient adherence to warfarin therapy and its impact
on anticoagulation control. Saudi Pharm J 2016; 24: 29–34.
7 Mosley-Williams A, Lumley MA, Gillis M, Leisen J, Guice D.
Barriers to treatment adherence among African American and
white women with systemic lupus erythematosus. Arthritis Rheum
2002; 47: 630–638.
8 Lam WY, Fresco P. Medication adherence measures: An overview.
Biomed Res Int 2015; 2015: 217047.
9 Al Arfaj AS, Khalil N. Clinical and immunological manifestations
in 624 SLE patients in Saudi Arabia. Lupus 2009; 18: 465–473.
10 Abid N, Khan AS, Al Otaibi FH. Systemic lupus erythematosus
(SLE) in the eastern region of Saudi Arabia. A comparative study.
Lupus 2013; 22: 1529–1533.
11 Petri M, Orbai AM, Alarcon GS, Gordon C, Merrill JT, Fortin
PR, et al. Derivation and validation of the Systemic Lupus
International Collaborating Clinics classification criteria for sys-
temic lupus erythematosus. Arthritis Rheum 2012; 64: 2677–2686.
12 Abdel-Khalek AM. Internal consistency of an Arabic adaptation
of the Beck Depression Inventory in four Arab countries. Psychol
Rep 1998; 82: 264–266.
13 von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC,
Vandenbroucke JP, et al. The Strengthening the Reporting of
Observational Studies in Epidemiology (STROBE) statement:
Guidelines for reporting observational studies. Lancet 2007;
370(9596): 1453–1457.
14 Huang X, Magder LS, Petri M. Predictors of incident depression in
systemic lupus erythematosus. J Rheumatol 2014; 41(9): 1823–1833.
15 Palagini L, Mosca M, Tani C, Gemignani A, Mauri M,
Bombardieri S. Depression and systemic lupus erythematosus: A
systematic review. Lupus 2013; 22: 409–416.
16 van Exel E, Jacobs J, Korswagen LA, Voskuyl AE, Stek M,
Dekker J, et al. Depression in systemic lupus erythematosus,
Lupus
dependent on or independent of severity of disease. Lupus 2013;
22: 1462–1469.
17 Macedo EA, Appenzeller S, Costallat LT. Gender differences in
systemic lupus erythematosus concerning anxiety, depression and
quality of life. Lupus 2016; 25: 1315–1327.
18 Miguel EC, Pereira RM, Pereira CA, Baer L, Gomes RE, de Sa
LC, et al. Psychiatric manifestations of systemic lupus erythema-
tosus: Clinical features, symptoms, and signs of central nervous
system activity in 43 patients. Medicine (Baltimore) 1994; 73:
224–232.
19 Utset TO, Golden M, Siberry G, Kiri N, Crum RM, Petri M.
Depressive symptoms in patients with systemic lupus erythemato-
sus: Association with central nervous system lupus and Sjogren’s
syndrome. J Rheumatol 1994; 21: 2039–2045.
20 Zakeri Z, Shakiba M, Narouie B, Mladkova N, Ghasemi-Rad M,
Khosravi A. Prevalence of depression and depressive symptoms in
patients with systemic lupus erythematosus: Iranian experience.
Rheumatol Int 2012; 32: 1179–1187.
21 Carr FN, Nicassio PM, Ishimori ML, Moldovan I, Katsaros E,
Torralba K, et al. Depression predicts self-reported disease activity
in systemic lupus erythematosus. Lupus 2011; 20(1): 80–84.
22 Shortall E, Isenberg D, Newman SP. Factors associated with mood
and mood disorders in SLE. Lupus 1995; 4: 272–279.
23 Costedoat-Chalumeau N, Pouchot J, Guettrot-Imbert G, Le
Guern V, Leroux G, Marra D, et al. Adherence to treatment in
systemic lupus erythematosus patients. Best Pract Res Clin
Rheumatol 2013; 27: 329–340.
24 Oliveira-Santos M, Verani JF, Klumb EM, Albuquerque EM.
Evaluation of adherence to drug treatment in patients with sys-
temic lupus erythematosus in Brazil. Lupus 2011; 20: 320–329.
25 Obreli-Neto PR, Guidoni CM, de Oliveira Baldoni A, Pilger D,
Cruciol-Souza JM, Gaeti-Franco WP, et al. Effect of a 36-month
pharmaceutical care program on pharmacotherapy adherence in
elderly diabetic and hypertensive patients. Int J Clin Pharm 2011;
33: 642–649.
26 Neto PR, Marusic S, de Lyra Junior DP, Pilger D, Cruciol-Souza
JM, Gaeti WP, et al. Effect of a 36-month pharmaceutical care
program on the coronary heart disease risk in elderly diabetic
and hypertensive patients. J Pharm Pharm Sci 2011; 14: 249–263.
27 WHO. Adherence to Long-Term Therapies: Evidence for Action.
Geneva: World Health Organization, http://www.who.int/chp/
knowledge/publications/adherence_report/en/ (2003).
28 Almalki M, Fitzgerald G, Clark M. Health care system in Saudi
Arabia: An overview. East Mediterr Health J 2011; 17: 784–793.