A Large Sample Epidemiological Survey of Severe Mental Disorders: Current Status and Prospects

Objective: To investigate the prevalence, distribution characteristics, medication status, and management status of patients with severe mental disorders (SMD) in Fuzhou. The medication status and management status were compared between patients in urban and non-urban areas to provide scientic evidence for improving SMD prevention, control, and treatment in primary health care institutions. Methods: Data (case types, demographic data, distribution data, medication status, and management status, etc.) of 30,362 SMD patients in 12 districts, counties, and prefectures in the urban and non-urban areas of Fuzhou City were collected From March 2018 to September 2018. Three distributions were used to describe the epidemiological characteristics of SMD. Linear trend chi-square test was used to illustrate the relationship between the prevalence of SMD and monthly changes. χ2 test method was used to compare the severity in urban and non-urban areas (qualitative data of SMD patients). Results: A total of 30,362 registered SMD patients were identied in Fuzhou City (prevalence rate, 4.17 ‰ ), of which schizophrenia accounted for the highest number (26204, 86.31%), and paranoid psychosis had the least number (47, 0.15%). Moreover, most SMD patients were aged 18 (inclusive)-44 years old (45.38%). Most patients were farmers (30.23%), had a primary school and below education level (54.17%), were poor, with most below the poverty line standard (55.35%). The time-point prevalence of SMD was highest in Minqing County (5.29 ‰ ) and lowest in Mawei District (3.80 ‰ ). The prevalence rates of SMD were signicantly different among various regions in Fuzhou (P<0.05). There was a linear trend between the month and SMD prevalence, with a statistically signicant difference (P<0.05). A total of 22,989 (75.72%) of the patients were taking medications, and only 17,509 (57.67%) were taking medications regularly. Moreover, the rate of taking medications and regular-taking rates were higher in urban areas than in non-urban areas (P(cid:0)0.05).


Research Background
The fast-paced living lifestyle has gradually increased the physical and psychological problems and mental stress of Chinese people due to the rapid progress of economic modernization and urban economy. Furthermore, the incidences of mental illness and other problems have signi cantly increased [ 1] . Severe Mental Disorder (SMD) is a group of mental illnesses with symptoms of mental illness and severely impaired daily social life. SMD includes severe schizophrenia and paranoid mental illness, schizoaffective psychosis, mental disorders caused by epilepsy, and mental retardation (mental disorders) [ 2] . The global burden of mental disorders was 7% in 2016, and SMD threatens more than 4% of adults worldwide. China has 5.81 million patients with SMD, and the overall average prevalence has increased to 17.5% [ 3] based on the Bureau of Disease Control and Prevention of the National Health Commission. The average mortality rate of SMD patients is nearly 2-3 times higher than that of the general population, indicating that the mortality rate pattern occurs in both high-and low-income patients [ 4] . SMD are common in daily lives and are characterized by mood disorders, conscious dysfunction, and cognitive system dysfunction. Most SMD patients require long-term treatment and nursing, which greatly affects the normal quality of life and social productivity among the patients and their family members [ 5] .
There are more new SMD cases each year, with a higher probability of recurrence and disability. Drug therapy is a crucial treatment for SMD patients regardless of acute illness or long-term management [ 6] .
Ensuring patients' adherence to treatment is also essential for successful mental health management [ 7] .
Several studies have shown that the chance of SMD recurrence is signi cantly reduced when patients take drugs for a long time [ 8] . Drug non-compliance can lead to serious clinical problems. Various studies have found that the compliance with the use of antipsychotic drugs is very low, as low as 20% [ 9] .
Previous research has shown various factors, such as patient-related, drug-related, disease-related, and external environmental factors, including age, 20-year-old insight, educational status, drug quantity, drug side effects, psychotic symptoms, social support, and treatment combinations, affect the compliance of using related medications [ 10] .
This study assessed the prevalence, distribution characteristics, medication status, and management status of SMD patients in Fuzhou by comparing the medication status and management status in urban and non-urban areas.

Source of information
The number of cases, general conditions, medications, and management status of SMD patients in the counties (cities) and prefectures in Fuzhou City were obtained from March 2018 to September 2018from the disease information system. The data (clinical disease classi cation, demographic data, regional distribution, time distribution, treatment status, and management status of patients with severe mental disorders) were mainly from six urban areas in Fuzhou City (Gulou District, Jin'an District, Taijiang District, Cangshan District, Mawei District, and Changle District) and six non-urban counties at the prefecture level (Minhou County, Lianjiang County, Luoyuan County, Minqing County, Yongtai County, and Fuqing City). The population data of the counties (cities) and prefectures in Fuzhou were obtained from the Statistical Yearbook of the Fuzhou Bureau of Statistics.

Research objects
Inclusion criteria: Patients who were diagnosed by psychiatric practitioners based on the 10th revised"International Statistical Classi cation of Diseases and Related Health Problems" (ICD-10) and included in the National Management of Severe Mental Disorders; All registered patients who provided informed consent and focus was on home management. Exclusion criteria: Patients who refused to register for management and those lost during follow-up for three consecutive years or were con rmed dead. Psychiatric staff at districts, counties, and prefectures in Fuzhou regularly conducted information veri cation and quality control management on the disease data of SMD patients to ensure reliability and reduce the occurrence of deviations.

Observation Indicators
The observation indicators were: Prevalence at time point (‰) (the number of new and old cases of SMD in a speci c population at a certain time/total population at that time × 1000‰). Medication rate (%)(number of SMD patients taking medication/number of SMD patients ×100%. SMD patients taking medication are registered as taking medications, including regular medication and intermittent medication by mental health staff. Regular medication rate (%)(number of SMD patients regularly taking medication/number of registered SMD patients ×100%. SMD patients s regularly taking medication are those registered as regular medications by mental health practitioners. Management rate (%) (the number of registered management/total number of SMD patients. SMD management refers to the detailed assessment of SMD patients. Continuous lock-in, unstable disease conditions, long-term continuous medication, mental retardation (may be accompanied by mental disorders), and other harmful behaviors (self-injury, attempted suicide, etc.) are associated with SMD patients. The medical staff of the community health service centre regularly assessed the regularity of medication and injury behaviors of SMD patients.

Statistical analysis
Excel 2019 software was used to organize and summarize data. ArcMap10.2 software was used to draw grade maps. SPSS20.0 software was used for data analysis, calculating prevalence and composition ratio, and descriptive analysis of regional and patient demographic characteristics. The linear trend chisquare test was used to analyze the correlation between month and the prevalence of SMD patients in Fuzhou. χ2 test was used to compare the qualitative data between groups. The test level was two-sided at α=0.05.

Distribution characteristics of SMD types in Fuzhou
A total of 30,362 registered SMD patients were identi ed in Fuzhou City (prevalence rate, 4.17‰).
Schizophrenia accounted for the highest number (26204, 86.31%). The number of patients, time-point prevalence and composition of other diseases are shown in Table 1. The distribution characteristics of various SMD types are shown in Figure 1.

Local distribution
The prevalence of SMD was lower in urban areas than in non-urban areas. Minqing County had the highest prevalence rate, followed by Yongtai County, while Mawei District had the lowest prevalence rate. SMD prevalence was signi cantly different among various Fuzhou regions (P<0.05)( Table 3 and Figure   2).

Time Distribution
The chi-square test showed a linear trend between the monthly and the time-point prevalence of SMD, with a statistically signi cant difference (P< 0.05). SMD prevalence showed a monthly linear increasing trend ( Figure 3 and Table 4).

Medications for SMD patients in Fuzhou
A total of 22,989 of 30,362 SMD patients were taking medication (75.72%). A total of 17,509 were taking the medication regularly (57.67%). The rate of taking medication and the rate of regular-taking was signi cantly higher in urban areas than in non-urban areas (P<0.05)( Table 5 and Table 6).
All SMD types were found in urban areas. Medication rate and regular-taking rate were highest among patients with mental disorders caused by epilepsy (91.60% and 80.40%, respectively) with statistically signi cant differences (P<0.05)( Table 7 and Table 8).

Management of SMD patients in Fuzhou
A total of 3065 of 30,362 SMD patients were registered for management (10.09%)(2244 (16.37%) in urban areas and 821 in non-urban areas ( 6.04%)) The management rate was signi cantly higher in urban areas than in non-urban areas (P<0.05)( Table 9).  [ 12] . Most studies [12] have shown that women, with high education levels, married, late onset, acute or subacute onset, cheerful personality before the disease, good interpersonal relations, and good social mechanisms and functions before the disease. Negative symptoms are diagnosed as the main clinical phase. Strong family social institutions and functions, timely treatment, systematic, and high compliance can positively enhance disease treatment.
Moreover, the above are considered as evaluation indexes for poor treatment effects.
Presently, typical or atypical antipsychotics are mainly used to treat SMD. Meanwhile, targeted psychological care can effectively stabilize the patient's mood, increase emotional experience and expression, reduce psychological pressure, and effectively improve the patient's psychological state and reduce the disease burden. Many experts and scholars, including Fan ChiHsuan [ 13] , have shown that support from family and other communities can effectively reduce the severity of schizophrenia symptoms in various patients. Therefore, the patient's family and community should improve their relationship with the patient to enhance monitoring and management of the symptoms of SMD patients.
Furthermore, schizophrenia in some families has been solved through improved social relationships.
About 60% of SMD cases can be treated and relieved via socialization due to the continuous development and technological advancement of modern therapeutics in China in recent years.

Comprehensive prevention and control of SMD in Fuzhou should focus on poor and patients with low educational backgrounds
This study showed that more men suffer from SMD than women in Fuzhou, consistent with Alejandra Caqueo-Urízar and other scholars [ 14] , suggesting that it may be related to mental stress in daily life and work environment.
Married people have SMD. These two age groups and married people bear more stress from school, family, work, and life, and face more emergencies, leading to a heavy mental load. Therefore, the Fuzhou Municipal Government should strengthen mental health education among young people and adults and address family mental health problems.
Most SMD patients had a primary education level and below (including semi-illiterate) (54.17%). Most people with low educational levels have little knowledge of mental health. Therefore, they would not seek medical services when they have mental health problems occur. In contrast, people with a higher level of education know more about mental illness and can seek medical attention as soon as possible. The number of SMD patients is relatively small among people with a high level of education compared with those with low educational level. In addition, people with low educational levels may have di culty adapting to the rapidly changing society, have poor psychological quality, and are more likely to have a pessimistic mood and behavior. Moreover, people with mental illness are more likely to be unemployed or are under long-term hospitalization, leading to economic di culties.
Also, Most SMD patients were farmers (30.23%) and laid-off or unemployed (25.18%). The proportion of the poor and those below the local poverty line was 55.35%, higher than other cases. Farmers, laid-off workers, and the unemployed have low incomes and poor living standards. They are more likely to have psychological problems when encountered with emergencies. They lose hope in the future and are more likely to be managed by the government.
In summary, most SMD patients have a low educational level. Therefore, the government should pay more attention to these disadvantaged groups, improve the medical insurance system, and sensitize on mental health to reduce the incidence of mental illness. Besides, the relatively high rates of unmarried and divorced patients with SMD indicate that society discriminates against them and is unwilling to interact with them. The government and communities should also spread mental health awareness among the general public to eliminate discrimination.

The prevalence of SMD in Fuzhou is lower in urban areas than in non-urban areas and has an increasing trend
Herein, Minqing County had the highest prevalence rate of SMD (5.79‰), while Mawei District had the lowest (3.80‰). The time-point prevalence of SMD (4.05‰) was lower in the six urban areas than in the six non-urban areas (4.32‰). Therefore, SMD is common in non-urban areas because mental health awareness is more effective in urban areas than in non-urban areas. Therefore, mental health joint conference system is necessary for the districts, counties and sub-districts of Fuzhou Health promotion links. Besides, the reporting system should be improved to increase the consciousness of Fuzhou residents to seek medical treatment.
Furthermore, SMD prevalence in Fuzhou City increased from March 2018 to September 2018. The prevalence rate also slightly increased in these months because SMD is a longer course disease. SMD often recurs, is more di cult to cure, has a small migration, and the patient's residence is relatively xed.
Therefore, community and hospital staff should conduct regular-follow up, assess the medication status of SMD patients discharged from the hospital, and educate family members on the importance of ensuring the patient takes medication. Meanwhile, public awareness of SMD should be further strengthened to prevent and reduce SMD cases. Herein, the taking-rate and the regular taking-rate of registered SMD patients were 75.72% and 57.67%, respectively. Presently, the national taking-rate and regular taking-rate among SMD patients are 81.30%and is 41.78%, respectively. Therefore, the rate of taking drugs is signi cantly lower than that of the current national level, while the rate of regular-taking is higher than that of the national level [ 18] . Furthermore, the medication and regular medication rates were signi cantly different between urban and non-urban areas in Fuzhou. Based on different SMD types, the medication and regular medication rates were signi cantly higher in the six urban areas than in the non-urban area. This could be because urban area has better medical resources and talent facilities than the non-urban areas, guaranteeing quality medical treatment. Moreover, community rehabilitation staff in urban areas are well-trained and can supervise SMD patients better than in non-urban areas. Therefore, patients in urban areas have access to more standardized management. Also, patients in urban areas have a higher education level, better ways of obtaining disease-related knowledge through multiple channels, and higher medication compliance than patients in non-urban areas [ 19] . Herein, the rate of medication and regular medication was highest for mental disorders caused by epilepsy, consistent with the results of Nesvåg Ragnar and other scholars [ 20] , suggesting that there are positive symptoms of schizophrenia, such as hallucinations. Some patients who have delusions believe that they are being persecuted and have poor medication compliance. The more serious the positive symptoms before treatment, the worse the medication compliance.
Among patients with recurrent schizophrenia for the rst time, 75% of patients maintain effective treatment through drugs and clinical treatments. However, the rate of patients with recurrent episodes or severe deterioration could be higher in the future, and antipsychotic drugs can prevent its recurrence.
Population and sociological factors, disease-related factors, psychological factors, drug-related factors, and other social support affect medication compliance in schizophrenia patients. Therefore, medical staff should assess the medication compliance of patients with mental disorders and the main in uencing factors of non-compliance and offer individualized intervention strategies.
The management rate of SMD patients in Fuzhou was signi cantly lower (10.09%) than the current national management rate (82.69%). Also, the management rate was signi cantly higher in urban areas than in non-urban areas, possibly because the management system is more effective in urban areas than in non-urban areas.
Moreover, patients in non-urban areas often go out for work, making it di cult for community rehabilitation workers and medical staff to manage them in a uni ed manner. Therefore, the government should strengthen the work quality of non-urban psychiatrists and improve the follow-up work in the community, targeted training of medical staff and family care management [ 21] to enhance the management rate of registered patients.

Conclusion
Schizophrenia accounts for the highest proportion of all SMD in Fuzhou and requires comprehensive prevention. Mental retardation (may be accompanied by mental disorders) also accounts for a high proportion of SMD. Therefore, the government should focus on Schizophrenia and Mental retardation, provide support to families, and formulate targeted treatment programs. However, other SMD types should not be completely ignored. Most SMD patients in Fuzhou have a low educational level, are poor, and are married. Therefore, the government should focus on these disadvantaged groups and strengthen treatment. The government should also improve the medical insurance system, establish a community rehabilitation system, and create a suitable community environment for patient rehabilitation. The medication, regular medication, and management rates of SMD patients in Fuzhou are higher in urban areas than in non-urban areas. However, the rates are lower than those of the national level. Therefore, the government should enhance mental health prevention and control work in Fuzhou, improve health institutions to reduce the prevalence of SMD, and thus protecting people's health.

Declarations
Consent for publication All participants provided informed consent, including consent to publish scienti c manuscripts based on collected data, in order to participate in the study.
Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to individual privacy but are available in summary/group level form from the corresponding author on reasonable request. Figure 1 Distribution characteristics of SMD types in Fuzhou Figure 3 Time distribution of patients with severe mental disorders in Fuzhou