Psychiatric inpatient beds for youths in China: data from a nation-wide survey

doi:10.21203/rs.3.rs-17329/v1

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Psychiatric inpatient beds for youths in China: data from a nation-wide survey

https://doi.org/10.21203/rs.3.rs-17329/v1

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Background The development of child psychiatry in China is slow and very limited resources have been allocated to it. To investigate the current resources of inpatient psychiatric facilities for youth in top-tier psychiatric hospitals in China and the characteristics of youth patients hospitalized in an adult unit.

Method As part of a official national survey, 29 most representative provincial tertiary psychiatric hospitals in China were selected. Data of 1975 inpatients discharged from these hospitals from March 19 to 31, 2019 were retrieved and analyzed.

Results The mean number of youth psychiatric bed was 27.7±22.9 in these hospitals and 6/29 hospitals had zero youth beds. There were significantly more youth beds in developed regions than in less developed regions (P<0.05). Most of discharged youth patients were teenagers with severe mental illnesses, including schizophrenia, depressive disorder and bipolar disorder. 7.5% (149) of 1975 discharged patients were youth while youth beds only accounted for 3.2% (804/25136) of all psychiatric beds. 45.6% (68) of youth patients hospitalized in adult units.

Conclusion Our findings highlight a dire situation of youth inpatient service in China, especially in less developed regions. There is an urgent need to change the policy and develop mental health services, including inpatient services for child and adolescent patients.

Psychiatry

Child

Adolescent

Psychiatric

Hospitalization

China

Mental disorders are common in children and adolescents. One recent meta-analysis involving 41 studies in 27 countries showed the worldwide-pooled prevalence of mental disorders was 13.4% in children and adolescents [1]. China has a population of more than 1.3 billion, of which a quarter of billion are children and adolescents between ages of 5 to 19 [2]. Studies have shown mental disorder in children and adolescents are common in China as well, although no national data are currently available. For example, some regional surveys showed the prevalence of mental disorders in children and adolescents was approximately 20% [3], similar to that in many developed countries. Two studies in different regions in China found that the time-point (current) prevalence rates of major depressive disorder in 6 to 16 years olds were 0.61% and 1.2% respectively [4, 5]. Other studies showed the suicide attempt prevalence in adolescents was around 3% [6, 7]. Studies also showed psychotic disorders including schizophrenia were the most frequent diagnosis in youth inpatients [8, 9].

Most children and adolescent patients (youth patients, hereafter) with mental disorder can be and should be managed as outpatients in the community, therefore to maximize the involvement of their families and other resources [10, 11]. However, for some severe cases or those who are in acute crisis, psychiatric hospitalization remains a necessary and effective treatment option, although the duration has shortened significantly compared with what was in the past [12–14].

Due to their unique developmental features, it is a consensus that youth patients requiring in-patient care for mental health problems should be managed in age-appropriate facilities [15, 16]. In its policy statement, the American Academy of Child and Adolescent Psychiatry states clearly that “Unless there are compelling clinical reasons to the contrary, or serious limitations in availability, children and adolescents younger than 14 years of age should be admitted only to programs that are designed for children and adolescents and physically distinct from programs for adult psychiatric patients.” [17] On the other hand, staff on adult wards often lacked necessary training and confidence of caring youth inpatients [18].

Although child psychiatry has always been an important subspecialty of psychiatry in China, the overall development is rather slow and much improvement is urgently needed, including the scarcity of trained professionals, limited availability of treatment facilities and lack of funding and policy support [3, 19]. One recent survey showed that by the end of 2015 the children psychiatric beds only accounted for 0.89% of total psychiatric beds in Mainland of China, and only 175 out of 2936 (5.96%) psychiatric facilities in China had a child psychiatric ward [20]. In other words, nearly 95% of psychiatric facilities did not have a inpatient unit for children and adolescents.

When there are no age-appropriate children facilities available or accessible, some children may have to be hospitalized in an adult unit. However, the negative effects of mixing youth patients with adults have been reported. One study showed that over one quarter of adolescents engaged in criminal activity after they were admitted to adult inpatient unit in Ontario, Canada [21]. Another report, based on the data from England and Wales, found more than a third of youth psychiatric patients were admitted in general psychiatric wards and or pediatric wards, and a review of those cases deemed more than half of admissions as “inappropriate”. The authors believed that these young patients may have poor experiences due to high-level disturbance and commonly assaults during they hospitalized in general psychiatric wards [22].

In this study, by using data from a nation-wide survey of top-tier psychiatric hospitals, we analyzed the percentage of children beds in different hospitals and different regions. We also compared the percentage of youth beds and the percentage of discharged youth patients. The basic clinical features of youth patients hospitalized in adult units were also analyzed.

This study was a part of a large research project, the National Survey for the Evaluation of Psychiatric Hospital Performance [23]. We selected one representative provincial psychiatric hospital under the jurisdiction of the Ministry of Health (now incorporated into the new National Health Commission) in each province. We did not include Gansu and Tibet because there were no psychiatric tertiary hospitals at the time of survey. We also did not include hospitals within the jurisdiction of the Ministry of Public Security (Forensic psychiatric hospitals) and the Ministry of Social Welfare (Safety net hospitals) as their patient populations are different and they often follow different guidelines about staffing and resources allocations. In total, 29 psychiatric hospitals from 29 provinces and autonomous regions in Mainland China were selected and the basic data of each hospital including total beds and children beds were collected and verified through the government databases.

Data of discharged psychiatric patients between March 19 to 31, 2019 were retrieved, including demographic data and clinical features. The discharge diagnosis was based on the International Classification of Diseases and Related Health Problems (10th revision, ICD-10).

Summary statistics were used to describe the data. Comparisons of children beds, ratio of youth beds in various areas were calculated using ANOVA test or T test, as appropriate. A Chi-square test was used to compare the ratios. The SPSS version 22.0 software (IBM Corp, Armonk, NY) was used to perform the basic statistical analyses.

All the tests were two-sided and statistical significance was defined as P < 0.05.

Numbers of youth beds and ratio of youth beds in tertiary psychiatric hospitals

There were great variations in the number of youth beds across different hospitals in this survey, with 6/29 provincial hospitals in Hainan, Jilin, Jiangxi, Ningxia, Chongqing and Qinghai having zero youth psychiatric beds and there were 74 in Anhui province, followed by Henan (73 beds), Hubei (65 beds), Liaoning (58 beds) and Beijing (57 beds). The mean numbers of youth beds were 27.7±22.9, while median number was 30. Figure 1 shows the ratio of youth psychiatric beds out of total psychiatric beds in each hospital, with a range from 0% to 7% (mean=0.03±0.02, median= 0.03).

Regional differences in youth beds and bed ratio

We divided 29 provinces into 6 regions based on the official geographic regional classification: North, Northeast, East, Central South, Southwest and Northwest China. The mean youth beds in tertiary hospitals ranged from 14.3 to 39.8 across six regions of China. No significant region differences were found.

China is a geographically vast and socioeconomically uneven country. We then used the official GDP data of 2018 to group the 29 hospitals into developed (N=13 hospitals) and less developed (N=16) regions. We found the hospitals in developed regions had significantly more children beds (38.8±21.5) and higher children/total bed ratios (4.1%) than those in less developed regions (18.8±20.4, 2.1%) (P=0.016 and 0.018 respectively).

Demographics and clinical characteristics of discharged youth patients

The mean age of the discharged youth patients was 15.3±1.9 years old. The youngest age of those patients was six years and the most of the discharged youth patients were teenagers (13 to 17 years old, 93.3%). The three most common discharged diagnoses were schizophrenia (30.2%), depressive disorder (22.8%) and bipolar disorder (19.5%, all three accounted for 72.5%) (ICD-10).

The ratio of youth beds and the ratio of discharged youth patients

During the study period, 1975 patients were discharged from the participating hospitals, and 149 (7.5%) were youth patients (<18 years old) and 1826 were adult (≥18 years old). In the meantime, the proportion of youth beds in these hospitals was only 3.2% (804/25136). Significant differences were found between the ratio of discharged youth patients/all patients and the ratio of youth beds/all beds (p<0.001).

Among 149 discharged youth patients, 68 (45.6%) were discharged from an adult psychiatric unit. Since six hospitals had no youth beds, we excluded data from those six hospitals, and we found 43.1% (57/138) of the discharged youth patients were from an adult unit. Interestingly, 2.7% (42/1541) of discharged adult patients were from a youth unit.

Table 1: Analysis of ratio of discharged youth patients and ratio of youth beds

	Youth, No.(%)	Adult, No. (%)	x²	P Value
Beds	804 (3.2%)	24332 (96.8%)	101.96	<.001
Discharged patients	149 (7.5%)	1826 (92.5%)	101.96	<.001

This is the first study focusing on youth psychiatric beds of China based on data collected in a nation-wide survey. A few important findings need be highlighted. First, we confirmed that overall there is a great scarcity or remarkable non-existence in youth psychiatric beds in China. Six provincial psychiatric hospitals reported no children beds. As expected, more children beds were available in socioeconomically developed regions. Additionally, based on the data of discharge patients, more than two fifths of youth patients had been hospitalized in adult units.

A few limitations also need to be acknowledged: First, all the participating hospitals were tertiary hospitals and they often are the largest and have the most healthcare resources. It is possible that other psychiatric hospitals may have some youth beds. This is particularly true in developed regions such as Beijing and Shanghai (less likely in less developed regions). This missing data might have made the regional differences more significant. Second, although we estimated the percentage of youth patient who had been admitted to adult units, we have no data on individual patient; therefore we were unable to analyze the differences between patients who admitted to a children unit versus those who were admitted to an adult unit.

Critical shortage in youth psychiatric beds

In China, most healthcare resources (including mental healthcare) are located in public hospitals. So the participating psychiatric hospitals could represent the healthcare resources in each province. From our survey, only half of these psychiatric hospitals had more than 30 youth beds, while more than half of those provinces have more than seven million youth between 5-19 years olds [2]. There were no youth units in six hospitals. That means many youth patients and their caregivers have limited options and they may have to be hospitalized with adults. Of note, even some provinces have a youth psychiatric unit, this is likely the only facility in the province, which means the accessibility is often extremely limited. Of course, determining the appropriate number of inpatient beds for children and adolescents is hard and often challenging [24], it is indisputable that the current situation is not acceptable, and it is imperative to set up youth psychiatric units in all provinces.

In China, public inpatient psychiatric services are the main healthcare resources for patients with severe psychiatric disorder [25]. Despite more and more widespread recognition of the importance of mental health promotion and prevention in childhood and adolescence in China [26], there still is an enormous discrepancy between needs and inpatient service availability. This so called “access gap” happens more frequently in low-and middle-income countries than high-income countries [27].

The limited availability of age-appropriate mental health services has been found in many countries. For example, a 28-country survey of child and adolescent mental health services in Europe showed substantial heterogeneity of inpatient beds among these countries. The number of inpatient beds for youth ranged from fewer than two beds per 100000 young people in Portugal and Sweden to more than 50 beds per 100000 young people in Germany and the Netherlands [28]. The situation seemed worse in low-income and middle-income countries. A study including 42 low-and-middle-income countries showed that although children and adolescents make up 12% of the patient population in mental health outpatient facilities, less than 1% of beds in inpatient facilities are reserved for them [29].

Features of hospitalized youth patients

Most our youth patients were between 13 to 17 years old and the three most common discharge diagnoses were schizophrenia (30.2%), depressive disorder (22.8%) and bipolar disorder (19.5%). As we only extracted data based on the discharge fact sheets, we did not know the exact reason for hospitalization. It is reasonable to assume some of the common reasons were suicidality or self-harm behavior, acute exacerbation of psychosis and risk to harm others. Two recent studies showed that the rate of suicide attempt was around 3% in adolescents, and most first suicide attempt appeared when they 12 or 13 years old [6,7].

Youth patients admitted in general units

The percentage of discharged youth patients was 7.5%, which was similar to a ratio in one study in the United States that children and adolescents represent approximately 7% of the total mental health inpatient population [30]. Meanwhile, the proportion of youth beds was only 3.2%. This is expected to be bigger nationwide as most mental health institutions do not have a child or adolescent inpatient ward.

The shortage or nonexistence of youth psychiatric beds often leaves few choices to patients or their families, and they often end up being hospitalized in an adult unit. However, several concerns have been raised about this practice: First, youth patients often do not feel comfortable among adults with mental disorders [31,32]. Second, an adult psychiatric unit often have a difference physical features and designs [33,34]. Third, staff on adult wards often lacked necessary experience or training and they did not feel confident working with youth patients ¹⁸. At least one study showed that some young patients reported feeling unsatisfactory during their time on adult psychiatric wards [35]. It is a general consensus that adult wards are inappropriate for child and adolescent patients with mental illness [16].

This study provides important data about the current situation of youth beds in top-tier psychiatric hospitals in China. The overall situation is very dire and needs immediate attention from policymakers and administrators, especially in those provinces that currently have no youth psychiatric ward. It is a consensus that children and adolescent patients will receive the best care in age-appropriate facilities. We hope these findings can bring attention to the urgently needed area.

Ethics approval and consent to participate

The Ethics Committee of Chaohu Hospital of Anhui Medical University (No. 201903-kyxm-02) and each participating hospitals approved this study.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This study was supported in part by the Beijing Medical and Health Foundation (Grant No. MH180924) and the National Clinical Key Specialty Capacity Building Project.

Author Contributions

Feng Geng and Feng Jiang had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Feng Jiang, Huanzhong Liu and Yi-lang Tang.

Acquisition, analysis, or interpretation of data: Feng Geng, Yi-lang Tang.

Drafting of the manuscript: Feng Geng，Huanzhong Liu and Yi-lang Tang.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Feng Geng and Yi-lang Tang.

Obtained funding: Feng Jiang.

Supervision: Huanzhong Liu.

Acknowledgements

The authors thank the Beijing Medical and Health Foundation ( MH180924) and the National Clinical Key Specialty Capacity Building Project who funded this research, and we also appreciate the efforts of the hospital administers who facilitated the survey.

Role of the Funder/Sponsor

The sponsor did not have a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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Psychiatric inpatient beds for youths in China: data from a nation-wide survey

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