our search failed to find a validated scale to measure rtms knowledge and attitude among professionals . therefore , we developed a new questionnaire for this study based on other studies that have measured knowledge of and attitude toward ect . the demographic and general information section included age , sex , training abroad , subspecialty , conference attendance , and other related questions . these items had 3 response options : yes , no , and i do n't know . i do n't know  responses were marked as zero points because both represented a lack of knowledge . these items used a 5-point likert scale with options of strongly agree , agree , neutral , disagree , and strongly disagree . the responses were scored from 0 to 4 based on whether the attitude statement was positive or negative . as no previous studies existed regarding knowledge and attitude toward rtms , we decided to consider those who answered more than 50% of the items correctly to have sufficient knowledge . those who obtained more than half of the total possible score were considered to have a positive attitude toward rtms . after designing the questionnaire , was conducted to assess the questionnaire 's reliability through the test - retest method , and feedback was then obtained . the reliability of the knowledge and attitude sections of the questionnaire was tested using cronbach  and yielded a score of 0.74 . we calculated a required sample size of 93 ( z : 1.96 for 95% confidence level , proportion : 0.6 , d : 0.1 ) . the questionnaire was e - mailed to approximately 300 psychiatrists , and those who responded were included in the study ( convenience sampling ) , resulting in a response rate of 33% . the e - mail list was obtained from several sources , primarily the saudi psychiatric association , the saudi commission for health specialties , and personal communication . junior residents are the first- and second - year residents in the psychiatry training program , whereas senior residents are the third- and fourth - year residents in the program . specialists who got the psychiatry training certificate and did not finish the 3 years were required after the program to be a consultant . participants provided consent , and they were informed of the objectives and aims of the research . data were analyzed using the statistical package for social sciences ( armonk , ny ) , version 21.0 . analysis of variance ( anova ) , post hoc analysis ( scheff method ) , and t tests were used to compare subgroups . in addition , pearson correlation was used to assess the relationship between different variables . only statistically significant differences at p < 0.05 are reported . an anonymous , self - administered online survey was completed using the google documents platform . our search failed to find a validated scale to measure rtms knowledge and attitude among professionals . therefore , we developed a new questionnaire for this study based on other studies that have measured knowledge of and attitude toward ect . the demographic and general information section included age , sex , training abroad , subspecialty , conference attendance , and other related questions . these items had 3 response options : yes , no , and i do n't know . i do n't know  responses were marked as zero points because both represented a lack of knowledge . these items used a 5-point likert scale with options of strongly agree , agree , neutral , disagree , and strongly disagree . the responses were scored from 0 to 4 based on whether the attitude statement was positive or negative . as no previous studies existed regarding knowledge and attitude toward rtms , we decided to consider those who answered more than 50% of the items correctly to have sufficient knowledge . those who obtained more than half of the total possible score were considered to have a positive attitude toward rtms . after designing the questionnaire , was conducted to assess the questionnaire 's reliability through the test - retest method , and feedback was then obtained . the reliability of the knowledge and attitude sections of the questionnaire was tested using cronbach  and yielded a score of 0.74 . we calculated a required sample size of 93 ( z : 1.96 for 95% confidence level , proportion : 0.6 , d : 0.1 ) . the questionnaire was e - mailed to approximately 300 psychiatrists , and those who responded were included in the study ( convenience sampling ) , resulting in a response rate of 33% . the e - mail list was obtained from several sources , primarily the saudi psychiatric association , the saudi commission for health specialties , and personal communication . junior residents are the first- and second - year residents in the psychiatry training program , whereas senior residents are the third- and fourth - year residents in the program . specialists who got the psychiatry training certificate and did not finish the 3 years were required after the program to be a consultant . participants provided consent , and they were informed of the objectives and aims of the research . data were analyzed using the statistical package for social sciences ( armonk , ny ) , version 21.0 . analysis of variance ( anova ) , post hoc analysis ( scheff method ) , and t tests were used to compare subgroups . in addition , pearson correlation was used to assess the relationship between different variables . only statistically significant differences at p < 0.05 are reported . consultants represented 50% ( n = 48 ) of the participants , followed by specialists ( registrars ) ( 24% ) , junior residents ( 14.6% ) , and senior residents ( 11.5% ) . the sample consisted of a variety of subspecialties , primarily general psychiatrists ( n = 62 , 65% ) , child and adolescent psychiatrists ( 8% ) , psychosomatic psychiatrists ( 7% ) , and other subspecialties ( 20% ) . the study covered all regions in saudi arabia , with a participation rate of 52% in the central region , 24% in the western , 13% in the eastern , 9% in the southern , and 2% in the northern region . most psychiatrists , 79% , thought that they did not have sufficient knowledge of rtms . as seen in table 2 , 93% of the participants correctly answered the question  by using rtms , we can stimulate certain areas of the brain . about half of the participants thought that rtms is more effective than ect for treating depression , and 59% correctly said that rtms could be used in patients older than the age of 65 years . distribution of answers concerning knowledge of rtms the survey showed that 80% of the participants answered more than half of the questions correctly , with a mean of 14.25 ( out of a possible 21 points ) and a standard deviation of 8.81 . . comparisons of participant knowledge based on educational level are illustrated in figure 1 ( anova f3,92 = 8.839 ) and show that consultants had greater knowledge than both senior residents ( p = 0.017 ) and junior residents ( p < 0.001 ) . there was no statistically significant difference in level of knowledge between consultants and specialists or between junior and senior residents . specialists had a higher level of knowledge than junior residents ( p = 0.035 ) . in addition , the survey results indicated that older psychiatrists had more knowledge than younger psychiatrists ( pearson correlation r = 271 , n = 96 , p = 0.008 ) . physicians who used articles to keep their knowledge current had greater rtms knowledge than those who used textbooks ( anova f4,91 = 3.681 , p = 0.008 ) . there was no association between the level of knowledge and either having trained abroad for more than 6 months ( anova f1,94 = 668 , p = 0.416 ) or the number of conferences attended annually ( anova f4,91 = 0.16 , p = 0.958 ) . as seen in table 3 , 43% of the psychiatrists said that they would refer their patients for rtms therapy , whereas only 7.3% said that they would not . more than half of the psychiatrists ( 53.1% ) agreed with the statement ,  i would consent to receive rtms if i had a psychotic depressive condition ,  whereas one fifth ( 21.8% ) disagreed . most participants ( 80.2% ) thought that having knowledge of rtms would improve the quality of care . after calculating the attitude scores , we found that 79.2% of the participants obtained more than half of the total possible score , with a mean score of 29.58 ( out of a possible 52 points ) and a standard deviation of 12.58 . approximately 38% and 5% answered 60% and 70% of the attitude questions positively , respectively . those who had a family member or contact treated with rtms ( n = 12 ) had a more positive attitude toward rtms ( pearson correlation r = 0.4 , n = 96 , p < 0.001 ) . distribution of answers concerning attitudes toward rtms training variables ( level of training and training abroad for more than 6 months ) did not show any statistically significant association with attitude ( f3,92 = 0.928 , p = 0.430 and f1,94 = 1.567 , p = 0.214 , respectively ) . the internal consistency reliability of the overall scale was good ( cronbach  = 0.74 ) . the knowledge section was more reliable than the attitude section , with a cronbach  of 0.88 for knowledge and 0.61 for attitude . consultants represented 50% ( n = 48 ) of the participants , followed by specialists ( registrars ) ( 24% ) , junior residents ( 14.6% ) , and senior residents ( 11.5% ) . the sample consisted of a variety of subspecialties , primarily general psychiatrists ( n = 62 , 65% ) , child and adolescent psychiatrists ( 8% ) , psychosomatic psychiatrists ( 7% ) , and other subspecialties ( 20% ) . the study covered all regions in saudi arabia , with a participation rate of 52% in the central region , 24% in the western , 13% in the eastern , 9% in the southern , and 2% in the northern region . most psychiatrists , 79% , thought that they did not have sufficient knowledge of rtms . as seen in table 2 , 93% of the participants correctly answered the question  by using rtms , we can stimulate certain areas of the brain . more than two thirds did not know the correct number of rtms therapy sessions . about half of the participants thought that rtms is more effective than ect for treating depression , and 59% correctly said that rtms could be used in patients older than the age of 65 years . distribution of answers concerning knowledge of rtms the survey showed that 80% of the participants answered more than half of the questions correctly , with a mean of 14.25 ( out of a possible 21 points ) and a standard deviation of 8.81 . approximately 73% answered 60% of the knowledge questions correctly , and 63% answered 70% correctly . comparisons of participant knowledge based on educational level are illustrated in figure 1 ( anova f3,92 = 8.839 ) and show that consultants had greater knowledge than both senior residents ( p = 0.017 ) and junior residents ( p < 0.001 ) . there was no statistically significant difference in level of knowledge between consultants and specialists or between junior and senior residents . specialists had a higher level of knowledge than junior residents ( p = 0.035 ) . in addition , the survey results indicated that older psychiatrists had more knowledge than younger psychiatrists ( pearson correlation r = 271 , n = 96 , p = 0.008 ) . physicians who used articles to keep their knowledge current had greater rtms knowledge than those who used textbooks ( anova f4,91 = 3.681 , p = 0.008 ) . there was no association between the level of knowledge and either having trained abroad for more than 6 months ( anova f1,94 = 668 , p = 0.416 ) or the number of conferences attended annually ( anova f4,91 = 0.16 , p = 0.958 ) . as seen in table 3 , 43% of the psychiatrists said that they would refer their patients for rtms therapy , whereas only 7.3% said that they would not . more than half of the psychiatrists ( 53.1% ) agreed with the statement ,  i would consent to receive rtms if i had a psychotic depressive condition ,  whereas one fifth ( 21.8% ) disagreed . most participants ( 80.2% ) thought that having knowledge of rtms would improve the quality of care . after calculating the attitude scores , we found that 79.2% of the participants obtained more than half of the total possible score , with a mean score of 29.58 ( out of a possible 52 points ) and a standard deviation of 12.58 . approximately 38% and 5% answered 60% and 70% of the attitude questions positively , respectively . those who had a family member or contact treated with rtms ( n = 12 ) had a more positive attitude toward rtms ( pearson correlation r = 0.4 , n = 96 , p < 0.001 ) . distribution of answers concerning attitudes toward rtms training variables ( level of training and training abroad for more than 6 months ) did not show any statistically significant association with attitude ( f3,92 = 0.928 , p = 0.430 and f1,94 = 1.567 , p = 0.214 , respectively ) . the internal consistency reliability of the overall scale was good ( cronbach  = 0.74 ) . the knowledge section was more reliable than the attitude section , with a cronbach  of 0.88 for knowledge and 0.61 for attitude . this study is about psychiatrists ' knowledge of and attitudes toward rtms in saudi arabia . the response rate was 33% , which is similar to the average response rate to web - based surveys . the e - mail accounts that we used in distributing the survey are not 100% correct or active . the ratio of male to female ( 5:1 ) in our study is similar to the ratio of psychiatrists in saudi arabia who are registered in the saudi commission for health specialties , the license body of health workers in saudi arabia . one of the aims of the study was to assess basic rtms knowledge among different subgroups of physicians . we assume that this is because both groups had to graduate from a residency program in which they could acquire sufficient knowledge of rtms . on the other hand , consultants had greater rtms knowledge than residents , as illustrated in the results . this could be because consultants were more experienced and encountered more patients with different illnesses . in addition , they had attended more conferences and exchanged experiences with other psychiatrists worldwide . as seen in the results , physicians who used articles to keep their knowledge current had a higher level of knowledge than physicians who used textbooks . articles have more accurate and more up - to - date information compared with textbooks and are easily accessible , which could help explain these results . there was no relationship between the level of knowledge and training abroad for more than 6 months . we expect that this is because the rtms device is only available in a few hospitals both locally and abroad , and thus , both groups had a similar exposure to rtms . approximately 40% of the sample got training abroad , and at the same time only 8% of the sample have experience with rtms . psychiatrists who had family members or relatives treated with rtms had more relevant rtms experience , which positively affected their attitudes . a previous study on patients who had been treated with we can thus say that rtms is perceived as an acceptable treatment , especially among those who have experienced it . repetitive transcranial magnetic stimulation is an effective , safe , noninvasive treatment with fewer adverse effects than ect . most participants ( 80.2% ) thought that having rtms knowledge would improve quality of care . another study on ect showed that there were fewer misconceptions and a greater acceptance of ect among patients who obtained their information from a doctor . one fifth of the psychiatrists ( 22% ) stated that they would not consider having rtms therapy if they experienced psychotic depressive symptoms . another study on attitudes toward ect among hungarian psychiatrists found that 32% of the participating psychiatrists would not consider undergoing ect therapy . we believe that this difference is due to the different adverse effects of ect compared with rtms . approximately 79% of the psychiatrists thought that they lacked knowledge about rtms ; surprisingly , the study showed that 80% of them had a sufficient level of knowledge . we think that this is because rtms is a new device , and thus , participants underestimated their knowledge due to a lack of experience ( 91.7% had no experience with rtms ) . in addition , this is maybe due to physicians ' perfectionism and they want to be sure about their answers . in 1 study , about one third of family medicine residents underestimate themselves and believe they are less intelligent and less competent . in summary , most psychiatrists had a sufficient level of knowledge and a positive attitude toward rtms . those who had a high level of training and experience showed higher levels of knowledge . furthermore , we found that articles were a better source for improving physicians ' knowledge of rtms than textbooks . finally , having a family member or relative who had been treated with rtms positively affected psychiatrists ' attitudes toward rtms . we recommend conducting the same study in other countries and among other specialties ( eg , neurologists , family physicians ) to further validate these results . one limitation of the study was that the test - retest assessment of the scale 's reliability was only conducted with 5 participants . we recommend conducting the same study in other countries and among other specialties ( eg , neurologists , family physicians ) to further validate these results . one limitation of the study was that the test - retest assessment of the scale 's reliability was only conducted with 5 participants .
objectivesthe aims of this study were to assess psychiatrists ' knowledge of and attitudes toward repetitive transcranial magnetic stimulation ( rtms ) in saudi arabia and to determine the contributing factors.methodsa quantitative observational cross - sectional study was conducted using an online survey . 
 the sample consisted of 96 psychiatrists in saudi arabia . 
 a new valid and reliable questionnaire was developed.resultsa total of 96 psychiatrists enrolled in the study , 81% of whom were men . 
 half of the participants were consultants . 
 the sample mainly consisted of general psychiatrists ( 65% ) . 
 the mean age of the participants was 37 years . 
 the results showed that 80% of the psychiatrists had a sufficient level of knowledge about rtms . 
 consultants had greater knowledge than residents . 
 training abroad was not significantly associated with the level of knowledge or the type of attitude . 
 most psychiatrists ( 79% ) had a positive attitude toward rtms . 
 only 53% of the psychiatrists said they would agree to receive rtms if they experienced a psychotic depressive condition . 
 a minority of psychiatrists ( 7% ) said they would not refer their patients for rtms.conclusionsmost of the psychiatrists surveyed had good knowledge of and a positive attitude toward rtms . 
 those who had a high level of training and experience showed higher levels of knowledge . 
 articles were reported to be a better source for improving physician knowledge than textbooks . having a family member or relative who was treated with rtms positively affected psychiatrists ' attitudes toward rtms .