A comparison of child and adolescent psychiatry in the Far East, the Middle East, and Southeast Europe

1 INTRODUCTION

There are approximately 3.1 billion people under the age of 24 worldwide, with 1.9 billion of them living in low- and middle-income countries (LMIC) (United Nations, 2019). Globally, 10%–20% of all children and adolescents experience mental disorders and half of them begin prior to 14 years of age (World Health Organization, 2020). Delayed identification, diagnosis, and treatment of child and adolescent mental health disorders can have lifelong consequences, due to the plasticity of the brain during this peak development stage of life (Kieling et al., 2011). As mental health can be affected by poor socioeconomic status, children and adolescents living in LMIC are inevitably at a higher risk for developing mental health problems (Lund et al., 2018). Despite the high proportion of the world's children and adolescents living in LMIC, 95% of all specialized child and adolescent mental health resources are concentrated in high-income countries (HIC) (Patel et al., 2013). The World Health Organization's (WHO) “Atlas: child and adolescent mental health resources: global concerns: implications for the future” emphasized that especially countries with a higher proportion of children lack mental health services as well as policies addressing the needs of children and adolescents (World Health Organization, 2005).

In Western Europe and North America, toward the beginning of the 20th century, child and adolescent psychiatry (CAP) was established as a medical specialty. After World War II, most countries in Western Europe and North America recognized it as a separate specialty (Rutter & Stevenson, 2008). However, despite the overall improved availability of CAP training programs and child and adolescent mental health services (CAMHS) across Europe, there are still considerable disparities throughout the continent (Signorini et al., 2017). Sourander et al. assessed the wellbeing and mental health of children and adolescents in Europe and Asia and found unmet needs for CAP in both regions particularly in LMIC (Sourander et al., 2018). In the United States, Thomas and Holzer found that the most significant shortages of CAP specialists and CAMHS were predominantly in low-income areas of the country (Thomas & Holzer 3rd, 2006).

1.1 The ratio of CAP specialists and the human development index

Sourander et al. additionally found a link between the ratio of CAP specialists per 100.000 children and adolescent aged 14 years or younger and the human development index (HDI) (Sourander et al., 2018). The HDI is a statistic developed and compiled by the United Nations to measure various countries' levels of social and economic development. It is composed of four principal areas of interest: the average number of years of schooling completed, expected number of years spent in school, life expectancy at birth, and gross national income per capita (United Nations Development Programme, 2020). European countries (Norway, Switzerland, and Finland), and the Asian countries (Singapore, Japan, and Israel), with the highest HDI rankings, also had the highest number of child and adolescent psychiatrists. Despite this, several Asian countries with a very high-HDI ranking were found to have too few child and adolescent psychiatrists (Sourander et al., 2018).

1.2 Availability of CAP specialists

According to WHO's Mental Health Atlas 2017, there are too few CAP specialists currently available worldwide, with less than 0.1 per 100.000 population across all income levels, with the exception of 1.19 per 100.000 average in HIC (World Health Organization, 2018). Moreover, while there are 1609 visits per 100.000 population in HIC, compared to 11 visits per 100.000 population in low-income countries (LIC), the median number of visits to CAMHS globally, is still no more than 164 per 100.000 population (World Health Organization, 2018).

The increasing prevalence of mental disorders in children and adolescents has not been accompanied by an even remotely proportionate expansion of CAMHS. In part, this is due to a dramatic failure to develop an adequate CAP workforce (Skokauskas et al., 2019). In 2015, the United Nations created the sustainable development goals (SDGs), which led to greater recognition of both the current global mental health epidemic, as well as the urgent need for countries to designate more resources to address it (Clausen et al., 2017).

1.3 Consortiums to strengthen CAMHS

In response to requests from various countries, and in line with the United Nations' SDGs, the World Psychiatric Association in Child and Adolescent psychiatry (WPA-CAP) has established Consortiums on Academic Child and Adolescent Psychiatry in the Far East (CACAP-FE), the Middle East (CACAP-ME), and Southeast Europe (CACAP-SEE). The ultimate goal of these consortiums is to promote and strengthen local resources for CAP and CAMHS (World Psychiatric Association, 2020). In order to strengthen CAMHS it is crucial to have adequately trained and certified CAP specialists, as well as child and adolescent mental health allied professionals. CAP training programs will need to equip future CAP specialists with an updated set of skills that account for the ongoing rapid developments in neuroscience, psychology, and the social sciences. Additionally, training programs should help contribute to improving the acknowledgement of the importance of understanding the public health perspective as well (Skokauskas et al., 2019). In order to improve CAP training programs, it is necessary to first compile all of the data available on current CAP training initiatives and postgraduate programs in place. The lack of this clarity in many regions contributes to the problem.

This article aims to compare the current status of CAP training programs and the CAMHS workforce in three geographical regions: Southeast Europe (SEE), the Middle East (ME), and the Far East (FE). Moreover, it aims to identify any similar problems between the regions, to highlight the success stories, and to make recommendations for future regional studies, particularly in places with high proportions of children and adolescents and underdeveloped CAMHS.

2 METHODS

This study compared CAP training programs and CAMHS workforces in the FE, the ME, and the SEE using WPA CAP regional consortiums database (i.e., CACAP-FE, CACAP-ME, and CACAP-SEE). Each consortium is comprised of child and adolescent psychiatrists who each served as representatives of their country's national CAP associations (Clausen et al., 2020; Gregoric Kumperscak et al., 2020; Hirota et al., 2019).

The first regional study was conducted in the FE in 2014, with the follow-up study conducted by the consortium in 2019 (Hirota et al., 2015; Hirota et al., 2019). The current study uses the data acquired from the 2019 study. The first FE study included the following 17 countries and regions: Brunei, Cambodia, People's Republic of China, Hong Kong (Hong Kong Special Administrative Region of the China), Indonesia, Japan, Laos (Lao People's Democratic Republic [Lao PDR]), Malaysia, Myanmar, Mongolia, Philippines, the Russian Far East Region (Russia), Singapore, South Korea, Taiwan (Chinese Taipei), Thailand and Vietnam (Hirota et al., 2019). The second study, in addition to the 17 earlier surveyed countries, also collected data from Macau (Macao Special Administrative Region of the China). Despite multiple efforts, the consortium was unable to receive any response or acquire data from East Timor and North Korea. The study on SEE included data from all 11 countries in the region: Albania, Bosnia, and Herzegovina (including the two political entities: Republika Srbska and the Federation of Bosnia and Herzegovina), Bulgaria, Croatia, Greece, Former Yugoslav Republic of Macedonia, Montenegro, Romania, Serbia, Slovenia, and Kosovo (Gregoric Kumperscak et al., 2020). For the ME study, data was collected from the 15 following territories and countries: the Kingdom of Bahrain (BHR), Egypt, Iran, Iraq, Jordan, the Kingdom of Saudi Arabia (KSA), Kuwait, Lebanon, Oman, Palestine, Qatar, Sudan, Syria, Turkey, and the United Arab Emirates (UAE). Despite multiple efforts, the consortium was unable to obtain data from Yemen (Clausen et al., 2020).

2.1 Questionnaire

The questionnaire used in each study was similar, with minor adaptations made to each version based on the local context in each region. In order to be internationally applicable, each questionnaire was written in English. The first version of the questionnaire was established in 2012. Validation of the questionnaire was based on input provided by five countries from the FE (Hirota et al., 2015). The version of the questionnaire used for the ME study omitted the question pertaining to the board certification system, as this was not yet in place throughout the region at the time of data collection. Ultimately, the questionnaire administered to the CACAP-ME comprised of 16 questions, the version administered to the CACAP-FE comprised of 17 questions, and that used by the SEE study included five additional questions (Table 1). The additional questions were included in order to address the region's specific context and to reflect the European Union of Medical Specialists' (UEMS) recommendations (Gregoric Kumperscak et al., 2020).

TABLE 1. Contents of the questionnaire used in the three regional studies 1. How many qualified (board-certified) general psychiatrists are there in your country? 2. How many of the general psychiatrists treat child and adolescent populations? 3. Is there a national guideline for postgraduate general psychiatry training? Choose YES or NO 4. What is the duration of general psychiatry training? 5. Is there any CAP exposure during general psychiatry training? If YES, answer question 5 (a) 5 (a) What is the duration of CAP exposure during general psychiatry training? 6. Is child and adolescent psychiatry recognized as a separate specialty (subspecialty)? Choose YES or NO 7 (a) Is the completion of general psychiatry training required before entering CAP training? Choose YES or NO 7 (b) Is inpatient child and adolescent psychiatry unit rotation available for trainees? Choose YES or NO 7 (c) Is child and adolescent psychiatry outpatient rotation available for trainees? Choose YES or NO 7 (d) Is consultation–liaison (psychosomatic medicine) rotation available for CAP trainees? Choose YES or NO 7 (e) Is pediatric neurology rotation available for CAP trainees? Choose YES or NO 7 (f) Is general pediatrics rotation available for CAP trainees? Choose YES or NO 7 (g) Is school consultation rotation available for CAP trainees? Choose YES or NO 7 (h) Is forensic training rotation available for CAP trainees? Choose YES or NO 7 (i) Are there exit exams in CAP training? Choose YES or NO 8. Is there a national guideline for postgraduate CAP training? Choose YES or NO 9. Are overseas CAP electives available for CAP trainees? Choose YES or NO 9 (a) If YES to question 9, in which countries? 10. Is there a need for more child and adolescent psychiatrists? Choose YES or NO 10 (a) If YES to question 10, what are the estimated numbers of required child and adolescent psychiatrists? Choose YES or NO 11. Is there a need for more child and adolescent mental health specialists other than child and adolescent psychiatrists? Choose YES or NO 11 (a) If YES to question 11, what are the estimated numbers of required child and adolescent mental health specialists other than child and adolescent psychiatrists? Choose YES or NO 12. Is there board certification system for child and adolescent psychiatrists? Choose YES or NO.a(Only included in SEE and FE) 13. How many qualified (board-certified) child and adolescent psychiatrists are there in your country? 14. How many CAP departments affiliated to universities are there in your country? 15. Is there a CAP society? Choose YES or NO 16. Is there a national CAP journal? Choose YES or NO 17. Is there a national child and adolescent mental health policy? Choose YES or NO 18. If CAP is an independent medical specialty, when did this begin?a(Only included in SEE) 19. If a Specialists society exists, when did this begin?a(Only included in SEE) 20. How long is CAP training in total?a(Only included in SEE) 20 (a). Of this CAP training time, what is the duration spent in the field of child and adolescent psychiatry?a(Only included in SEE) 20 (b). How much time does a CAP trainee spend in total in other specialties (general psychiatry, child neurology, pediatrics, etc.)?a(Only included in SEE) 21. Are you familiar with UEMS-CAP requirements regarding CAP training? Yes/Noa(Only included in SEE) 21 (a). If yes to question 21, is the training in your country in accordance with UEMS-CAP requirements? Yes/Noa(Only included in SEE) 22. Is there systematic integration of psychotherapy training during CAP training? Yes/Noa(Only included in SEE) Abbreviation: CAP, child and adolescent psychiatry; FE, Far East; SEE, Southeast Europe; UEMS, European Union of Medical Specialists'. a Abbreviations indicating the questions only included in certain regions.

In each study, the questionnaire was distributed online to the consortium members. All consortium members were asked to check the national CAP curricula in place at that time. If needed, in order to ensure reliable data was included, consortium members were asked to consult with their respective national CAP societies.

2.2 Statistics

Descriptive statistics were used to describe the main features of the data. ANOVA (one-way analysis of variance) was used to compare means between three groups (consortiums). A p value <.05 was considered to be statistically significant. Data were analyzed with IBM SPSS Statistics version 24.0.

3 RESULTS 3.1 Characteristics of countries included in the study

This study included and analyzed data from 44 countries: 18 countries in the FE, 15 countries in the ME, and 11 countries in SEE. Regarding income level, there were more HIC from both the FE and the ME, than SEE (Table 2). Sudan was the only LIC and had the lowest HDI out of all included countries (Tables 2 and 3). Out of three regions, SEE had the smallest variation with regards to HDI ranking. The difference between the regions HDI means was not statistically significant (Table 3). Overall, Singapore had the highest HDI out of all countries included in the three regional studies.

TABLE 2. Countries by income level The Far East (n = 18) The Middle East (n = 15) Southeast Europe (n = 11)1 HIC 7 (39%) 6 (40%) 3 (27%) UMIC 4 (22%) 5 (33%) 8 (73%) LMIC 7 (39%) 3 (20%) 0 LIC 0 1 (7%) 0 Note: All data provided is inclusive and representative of both. All data were retrieved from The World Bank, World Development Indicators, 2020. https://www.worldbank.org/. Abbreviations: HIC, high-income country; LIC, low-income country; LMIC, lower middle-income country; UMIC, upper middle-income country. TABLE 3. Human development index (HDI) regional and country statistics The Far Easta (n = 18) The Middle Easta (n = 15) Southeast Europea (n = 11)b p value Mean 0.78 0.76 0.82 .398 SD 0.121 0.098 0.041 Lowest HDI 0.578 (Myanmar) 0.502 (Sudan) 0.768 (Bosnia and Herzegovina) Highest HDI 0.933 (Singapore) 0.863 (UAE) 0.896 (Slovenia) Note: All data was retrieved from the United Nations development programme, 2019. http://hdr.undp.org/en/content/human-development-index-hdi. a HDI data from Macau, Taiwan, Syria. North Macedonia, and Kosovo was not available in the database at the time of data collection. b Values from Boznia and Herzegovina includes the two separate entities, Republika Srbska and the Federation of Bosnia and Herzegovina. All data provided is inclusive and representative of both. 3.2 General psychiatry training and CAP training

In the ME 13% of the countries had a national child and adolescent mental health policy. In the FE and SEE the percentages was respectively 44% and 64% of the included countries (Table 4). The majority of countries included in the study had a national curriculum for general psychiatry training in place. In the FE, all the included countries, but Cambodia and Laos, had CAP components in the curriculum for the general psychiatry (Table 4).

TABLE 4. National child and adolescent mental health policy and general psychiatry training and CAP training The Far East (n = 18) The Middle East (n = 15) Southeast Europe (n = 11) National child and adolescent mental health policy 8 (44%) 2 (13%) 7 (64%)a Countries with national curriculum for general psychiatry training 13 (72%) 14 (93%) 11 (100%)a CAP is included in general psychiatry training 15 (83%) 15 (100%) 11 (100%)a CAP is recognized as a specialty 8 (44%) 11 (73%) 10 (91%)b Specialized CAP training is available 12 (66%) 6 (40%) 10 (91%)b Abbreviation: CAP, child and adolescent psychiatry. a Values from Boznia and Herzegovina includes the two separate entities, Republika Srbska and the Federation of Bosnia and Herzegovina. All data provided is inclusive and representative of both. b Does not include Republika Srbska despite they did recognize CAP as specialty and have CAP training, since the other political entity of Bosnia and Herzegovina (The Federation of Bosnia and Herzegovina) answered NO to both questions.

All the included countries from SEE, except for the political entity of Bosnia and Herzegovina, recognized CAP as a specialty and had specialized CAP training programs in place. Republika Srpska (the other political entity of Bosnia and Herzegovina) recognized CAP as a specialty and had specialized CAP training in place (Table 4). From the ME, only six countries reported to provide specialized CAP training, even though 11 out of the 15 countries recognized CAP as a specialty. In the FE, 8 out of 18 countries recognized CAP as a specialty, yet six countries did not have specialized CAP training available (Table 4).

The SEE countries offered more training opportunities locally (i.e., more clinical rotations in various CAMHS settings), than the ME or the FE countries. Similarly, more countries in SEE had established national guidelines for CAP training than in the other two regions. Despite this, more than one third of the ME countries offered overseas electives for trainees (Table 5).

TABLE 5. Characteristics of CAP training The Far East (n = 12)a The Middle East (n = 8–15)b Southeast Europe (n = 11)c General training required prior to CAP 9/12 (75%) 6/8 (75%) 10/11 (91%) 1 NR Inpatient unit rotation 12/12 (100%) 6/8 (75%) 11/11 (100%) Outpatient clinic rotation 12/12 (100%) 10/10 (100%) 11/11 (100%) Consultation liaison rotation available 10/12 (83%) 7/10 (70%) 8/11 (73% Pediatric neuro. rotation a 7/12 (58%) 4/8 (50%) 11/11 (100%) General pediatric rotation 2/12 (17%) 3/9 (33%) 8/11 (73%) School cons. rotation 8/12 (67%) 4/9 (44%) 5/11 (45%) Forensic training rotation available 4/12 (33%) 3/8 (38%) 8/11 (73%) Exit exams required * 6/9 (67%) 10/11 (91%) National guidelines for CAP training 5/12 (42%) 5/15 (33%) 10/11 (91%) CAP overseas elective available 2/12 (17%) 5/15 (33%) 3/11 (27%) Abbreviations: CAP, child and adolescent psychiatry; NR, not reported. a Does only include data from the 12 countries in the FE that had CAP training at the time of the data collection. b The numbers of countries that received the questions was between 8 and 15, since the countries in the ME only received the questions that were relevant for the CAP training in each specific country. c Values from Boznia and Herzegovina includes the two separate entities, Republika Srbska and the Federation of Bosnia and Herzegovina. All data provided is inclusive and representative of both. 3.3 CAP services and needs

Besides Greece, all included countries from each region reported the need for more CAP specialists and allied CAMH professionals (Table 6).

TABLE 6. Need for CAP specialists and allied CAMH professionals The Far East (n = 18) The Middle East (n = 15) Southeast Europe (n = 11)a Need for more CAP specialists 18 (100%) 15 (100%) 10 (91%) Need for more allied CAMH professionals 18 (100%) 15 (100%) 10 (91%) Abbreviations: CAP, child and adolescent psychiatry; CAMH, child and adolescent mental health. a Values from Boznia and Herzegovina includes the two separate entities, Republika Srbska and the Federation of Bosnia and Herzegovina. All data provided is inclusive and representative of both.

Most of the included countries from all three studies reported to have a limited number of CAP specitalists, as well as qualified general psychiatrists, treating children and adolescents (Table 7). The highest number of general psychiatrists treating children and adolescents was observed in Japan, where almost all general psychiatrists treated children and adolescents (Table 7). The highest number of CAP specialists available per 100.000 children and adolescents was observed in Greece, with approximately 18 per 100.000. Greece also served as the only country that reported not to need additional CAP specialists or allied CAMH professionals (Tables 6 and 7). SEE had high rates of CAP specialists available per 100.000 children and the difference between the means was statistically significant (Table 7).

TABLE 7. General psychiatrists and CAP specialists The Far East (n = 18) The Middle East (n = 15) Southeast Europea (n = 11) p-value Rate of qualified general psychiatrists per. 100.000 children and adolescents

m = 15

LR (lowest rate) = 0 (Macau)

(n = 0)

HR (highest rate) = 68.4 (Japan)

(n = 14.793)

m = 3.7

LR = 0.4 (Sudan)

(n = 83)

HR =11.4 (Turkey)

(n = 3000)

m = 40.8

LR = 12.4 (Romania)

(n = 500)

HR =81.3 (Greece)

(n = 1600)

<.001 Rate of qualified general psychiatrists treating children and adolescents per. 100.000 children and adolescents

m = 8.7

LR = 0 (Macau)

(n = 0)

HR ≈ 68.4 (Japan)

(n = 14 793)

m = 1.4

LR = 0.07 (Sudan)

(n = 15)

HR ≈ 7.4 (Egypt)

(n = 3082)

m = 5.2

LR = 0 (Greece and Romania)

(n = 0)

HR = 34.1 (Montenegro)

(n = 52)

.34 Rate of certified CAP specialists per. 100.000 children and adolescents

m = 1

LR = 0 (Macau, Myanmar and Mongolia)

(n = 0)

HR = 4.6 (Taiwan)

(n = 195)

m = 0.4

LR = 0 (Iraq, Jordan and Syria)

(n = 0)

HR = 1.6 (BHR)

(n = 6)

m = 4.2

LR = 0 (Montenegro)

(n = 0)

HR = 17.8 (Greece)

(n = 350)

<.001 Abbreviations: CAP, child and adolescent psychiatry; HR, highest rate; LR, lowest rate; m, mean; n, number. a Values from Boznia and Herzegovina includes the two separate entities, Republika Srbska and the Federation of Bosnia and Herzegovina. All data provided is inclusive and representative of both. 3.4 Number of CAP academic departments

Turkey had the highest number of CAP academic departments established (48 departments), contributing to more than half of all CAP academic departments in the region (Table 8).

TABLE 8. Number of CAP academic departments The Far East (n = 18) The Middle East (n = 15) Southeast Europe (n = 11)a N of departments 61 82 22

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