Background: Burnout, defined as persistent work-related stress, is a critical concern among healthcare workers (HCWs), particularly in high-demand environments such as the Middle East, North Africa, and Turkey (MENAT) region. This systematic review and meta-analysis aimed to assess the pooled prevalence of burnout and examine its associated risk and protective factors among HCWs in the MENAT context. Methods: A comprehensive search of studies published between 2013 and 2024 identified 123 studies involving 36,769 participants. Only studies using the Maslach Burnout Inventory - Human Services Survey (MBI-HSS) were included. Burnout was evaluated across its three dimensions: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). The protocol is registered with PROSPERO (CRD420251051167). Results: The pooled prevalence was 40% for high emotional exhaustion, 31% for high depersonalization, and 38% for low personal accomplishment. The overall mean scores were 22.02 for EE, 10.07 for DP, and 25.49 for PA. Substantial heterogeneity across studies reflected wide variation in healthcare system capacity and workforce conditions. Burnout was more pronounced in countries such as Saudi Arabia, Iran, and Turkey. Common risk factors included high workload, lack of institutional support, younger age, and female gender. Protective factors were linked to increased autonomy, leadership support, and strong peer relationships. Conclusion: Burnout is prevalent among HCWs across the MENAT region, with significant variability across countries. Targeted interventions to reduce occupational stressors and enhance protective workplace structures are urgently needed to safeguard provider wellbeing and improve healthcare delivery. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD420251051167 , identifier CRD420251051167

Suicide is one of the leading causes of mortality among adolescents and young adults, with suicidal ideation and attempts representing critical predictors of suicide-related outcomes. Although global evidence highlights rising trends in suicidal behaviors, regional patterns remain varied. In the MENAT region (Middle East, North Africa, and Turkey), where cultural stigma, conflict, and insufficient mental health infrastructure may exacerbate vulnerability, evidence remains fragmented. This study systematically reviewed and meta-analyzed the prevalence, risk factors, and protective factors associated with suicidal ideation and suicide attempts among young people in the MENAT region. The study protocol was registered with PROSPERO (ID: CRD420251101524) and conducted following PRISMA guidelines. A systematic search of six electronic databases (PubMed, MEDLINE, Scopus, Web of Science, Embase, and PsycINFO) was conducted for studies published between January 2010 and June 2025. Eligible studies were observational in design, published in English, and reported the prevalence of suicidal ideation or suicide attempts among individuals aged ≤25 years in the MENAT region. Many included studies relied on single-item measures of suicidality rather than validated multi-item scales, which was considered when interpreting results. Pooled prevalence and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models. Heterogeneity, sensitivity analyses, and publication bias were examined. A total of 47 studies encompassing 115,152 participants were included. The pooled prevalence of suicidal ideation was 25% (95% CI: 0.19–0.31), while suicide attempts were reported by 12% (95% CI: 0.06–0.19). Suicidal ideation reached as high as 52.7% in individual studies from Jordan, while suicide attempts were most prevalent in studies from Kuwait. Female gender, bullying (OR = 1.6), loneliness (OR = 2.2), substance use, including smoking (OR = 2.0), alcohol (OR = 3.0), and amphetamines (OR = 3.5), as well as depression (OR = 1.5), anxiety (OR = 2.1) and history of sexual abuse (OR = 2.0) were significantly associated with suicidal ideation. Suicide attempts were strongly linked to alcohol (OR = 3.0), cannabis use (OR = 1.7), anxiety (OR = 3.1), depression (OR = 1.5), and a history of sexual abuse (OR = 2.2). Evidence on protective factors such as family connectedness, religiosity, and social support was limited and inconsistently reported across studies, highlighting a major research gap in understanding resilience factors among youth in the MENAT region. Suicidal ideation and attempts are prevalent among young people in the MENAT region and were significantly associated with psychosocial stressors and substance use. However, the reliance of many included studies on single-item assessments of suicidality limits the precision and comparability of estimates. These findings highlight the urgent need for culturally tailored, evidence-based suicide prevention strategies and enhanced mental health services in this vulnerable population. Not applicable.

Background: Gender dysphoria (GD) involves a marked incongruence between an individual's experienced gender and their sex assigned at birth. Individuals with GD often experience a strong desire to be treated as another gender and frequently face significant health disparities, including limited access to care, higher risks of depression, and suicide. These challenges are often exacerbated by healthcare providers' knowledge gaps and discriminatory attitudes. This study's objective is to assess the knowledge, attitudes, and practices (KAP) of healthcare providers in Saudi Arabia regarding GD and to identify gaps that could inform targeted educational interventions. Methods: A cross-sectional online survey was conducted with healthcare providers in Saudi Arabia (Nov 2024–Jun 2025). A total of 156 responses were gathered. The questionnaire included domains of knowledge (9 items), attitude (11 items), and practice (4 items) on a 7-point Likert scale. Missing responses, including “I don't know,” were imputed. Descriptive statistics were used to summarize participant responses. Associations among knowledge, attitude, and practice scores were examined using Spearman's rank-order correlation, with additional subgroup analyses conducted to explore variations by demographic characteristics. Results: Participants demonstrated moderate to strong knowledge and generally positive attitudes toward individuals with GD, particularly regarding pronoun use, mental health assessment, and awareness of health disparities. However, practical engagement was limited, with only 19% reporting direct clinical experience and a few having received GD-related training. Scores varied by age, training level, and specialty, as respondents aged 24–39 years showed the strongest knowledge and attitude scores, and practice scores were highest among those aged 40–49 years, while senior registrars demonstrated the highest overall KAP scores, and psychiatry showed the strongest overall specialty profile. Conclusion: Healthcare providers demonstrate foundational knowledge and supportive attitudes but limited practical experience in managing GD. Targeted training and structured clinical exposure are recommended to improve culturally competent and inclusive care.

Background: Treatment-resistant schizophrenia (TRS) affects up to one-third of individuals with schizophrenia and remains a major clinical challenge despite optimized pharmacotherapy. Repetitive transcranial magnetic stimulation (rTMS) has been proposed as a neuro-modulatory intervention for refractory symptoms, yet evidence specific to TRS remains limited and inconsistent. Objectives: To evaluate the efficacy and safety of rTMS for reducing global symptom severity, negative symptoms, and auditory hallucinations in adults with treatment-resistant schizophrenia, and to examine the influence of stimulation parameters on treatment outcomes. Methods: A systematic review and meta-analysis was conducted following PRISMA guidelines and registered with PROSPERO (CRD420251143558). Eight electronic databases were searched up to 10 ^th September 2025. Randomized controlled trials including adults with TRS and comparing rTMS with sham stimulation were eligible. Standardized mean differences (Hedges’ g) were pooled using REML-based random-effects models. Heterogeneity and subgroup effects were examined, and publication bias was explored through visual inspection of funnel plots. Results: Across included trials, rTMS was not associated with statistically significant improvements in overall symptom severity measured by PANSS (SMD 0.14, 95% CI −0.26 to 0.54), negative symptoms (SMD 0.37, 95% CI −0.12 to 0.86), or auditory hallucinations measured by AHRS (SMD −0.03, 95% CI −0.26 to 0.20), based on post-treatment outcome scores. Substantial heterogeneity was observed for PANSS and negative symptoms, while heterogeneity for AHRS was low. Subgroup findings were exploratory and should be interpreted cautiously. Conclusions: Current evidence does not support a consistent therapeutic benefit of rTMS over sham stimulation for symptom reduction in treatment-resistant schizophrenia. While some subgroup analyses suggested variability in effect estimates across stimulation protocols, these findings were exploratory and should be interpreted with caution. Further large-scale, well-designed trials are needed to clarify the role of rTMS in this population. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251143558 , identifier CRD420251143558.

Treatment-resistant depression (TRD) remains a major clinical challenge worldwide and across the Gulf Cooperation Council (GCC) countries, where the burden

Antipsychotic monotherapy is considered the standard for schizophrenia treatment. However, many patients with schizophrenia and other psychotic disorders receive antipsychotic polypharmacy (APP). This can be associated with increased adverse effects, drug interactions, and treatment costs. This review aims to synthesize evidence on the prevalence of APP in the Middle East, North Africa, Turkey, and the Eastern Mediterranean (MENAT/EMRO) countries. Eight databases were systematically searched for studies published up to February 2026 that reported APP prevalence among patients with schizophrenia and psychotic disorders in MENAT and EMRO countries. The methodological quality was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist, while the overall certainty of evidence was evaluated using GRADE conceptual approach (Grading of Recommendations Assessment, Development and Evaluation). The pooled prevalence was estimated using random-effects meta-analysis, and statistical heterogeneity was assessed using tau-squared (τ²) and I² statistic. Potential sources of heterogeneity were explored through subgroup and meta-regression analyses, and publication bias was assessed using funnel plots and Egger’s tests. Seventeen studies with 6,053 individuals with schizophrenia and other psychotic disorders were included. The pooled prevalence of APP was 50% (95% CI: 37%–62%), with substantial heterogeneity (I² = 98.4%), and was commonly associated with second-generation antipsychotics. Evidence linking APP to specific demographic and clinical variables was limited to a few studies, which found APP associated with higher number of hospitalizations. A pooled prevalence across nine of the APP studies revealed that only 12% (95% CI: 8% to 18%) were receiving clozapine. APP is highly prevalent in MENAT/EMRO countries. Given the potential harms of polypharmacy and the limited evidence supporting it, we recommend efforts to reduce APP and increase clozapine utilization among eligible patients. Evidence-based guidelines, clinician training, and improved clozapine accessibility are crucial to optimizing schizophrenia management in the region.