Implementation of Primary Psychological Healthcare Policy to Address the Risk of Depression in Underprivileged Children and Adolescents, in the Entire Lower-Middle-Economic-Status City of China: An Observational, Multicenter, and Single-Arm Cohort Study

Abstract

Background: Given the historically high incidence of depressive disorders among children/adolescents, efforts to implement universally accessible primary psychological health care policies have been undertaken globally. However, the practical implementation and its association with depression risk reduction remain uncertain, particularly for underprivileged children/adolescents who are underrepresented in the current system. Methods: A large-scale cohort of underprivileged children/adolescent population aged 6-18 was enrolled (n = 290,239). Subgroups with specific underprivileged conditions were identified, including de facto unattended children/adolescents (dfUCA), orphans, and children/adolescents facing especially difficult circumstances, "left-behind" and "single-parent" children/adolescents. A subgroup of matched typically developing individuals was also included. These subgroups underwent longitudinal assessments for the incidence of identifying depression on Oct 30, 2022 (baseline, before implementing primary psychological health care policy), May 21, 2023 (half year follow-up), and Oct 29, 2023 (1-year follow-up), respectively. Results: At baseline, nearly twice as high incidence of depression was found in the underprivileged group (13.9%, 95% confidence interval [CI]: 13.7-14.1) as in the control group (7.5%, 7.2-7.7). After the implementation of the primary psychological policy, at the half year follow-up, a notable decrease in the incidence of depression was observed in both the underprivileged group (5.8%, relative risk reduction (RRR) = 51.6%, 51.5-51.7, p < 0.001) and the typically developing group (4.0%, RRR = 34.5%, 27.9-41.0, p < 0.001), particularly among orphan girls aged 12-18. The observed changes in depression incidence across all underprivileged populations were statistically noninferior compared to the typically developing group (all p < 0.001). At the 1-year follow-up, the observed benefits were consistent across all subgroups when compared to baseline. The average expenditure per child/adolescent was $1.6 in implementing such a health care policy. Conclusions: Implementing the primary psychological health care policy is associated with a reduction in the citywide risk of depression among underprivileged children/adolescents in low-middle-income areas.

Keywords: depression; low–middle-income areas; primary psychological health care policy; underprivileged children/adolescents.

Figure 1

Diagram for research framework and features. (a) Streamlines the research timeline and overview for the Psychological Health care Guard of China for Children and Adolescents Project of China (CPHG) at the current phrase. (b) Illustrates the workflow of the “2 + 2 model” psychological health care that the current study established, with the first two rounds for screening depressive symptoms and later two rounds for psychological cares. As an open-loop workflow, children/adolescents may be recommended for in-patient medical treatment and health care outside of this “2 + 2 model” workflow. ⁣^∗qualified healtcare specialist in school or insititute (SSI)/community-health care consultant (CC). (c) Plots a geospatial map to describe the geographic distribution of the current sample by using the map dataset from the “Aliyun” (Ali., Inc., Hangzhou, China) with permission (GS(2022)1061). The data for the economic rank of Nanchong was derived from the National Bureau of Statistics (China). (d) Provides an overview of the current study, including the research summary and study design.

Figure 2

Incidence rates of identifying depression for each included cohort at the baseline. The presence of depressive symptoms was estimated by Zung's Self-reported Depression Scale (SDS). Criterion for ranking slight, mild, and major depressive levels could be found in the Supporting Information 2. The bar embedded in the left-upper corner indicates the relative increases in incidence rates of identify depression for girls compared ones in the boys. (a) Typical developing cohort (n = 40,467). (b) De facto unattended children/adolescents (2447). (c) Orphan (n = 762) (d) Children/adolescents in especially difficult circumstance (n = 18,492). (e) Left-behind children/adolescents (n = 179,877), (f) Single-parenting children/adolescents (n = 48,270).

Figure 3

Relative risk (RR) of identifying depressive symptoms for these underrepresented, underprivileged children/adolescents compared to the typically developing ones. The dots with dark color indicate the point estimate for the original RR, with the line behind a given dot showing the 95% confidence interval (CI). The dots with light color (along with lines) indicate the same statistics by adjusting for sex, age, data collector, living areas, and the number of offspring within the family ⁣^∗p < 0.001. This figure has been redrawn for cartoon style for strengthening readability.

Figure 4

Sex-specific and age-specific changes of incidence rates of identifying depressive symptoms after implementing the primary psychological health care policy. To ensure the robustness of these findings, the data would be shown for “no data” if the frequency of participants in a given subgroup is less than 30. Age groups have been categorized at intervals of three years old (i.e., 6–8, 9–11, 12–14, 15–17, 18). Evaluations for these children/adolescents had been conducted on October 30, 2022 (T1, baseline), May 21, 2023 (T2, half year follow-up), and October 30, 2023 (T3, 1-year follow-up). ⁣^∗p < 0.25, ⁣^∗∗p < 0.01, ⁣^∗∗∗p < 0.001 (Bonferroni correction: α/2 = 0.05/2 = 0.025).

Figure 5

“V-shape” changes of incidence rates of identifying depressive symptoms after implementing the primary psychological health care policy at half year and 1-year follow-ups. The dots with dark color indicate the point estimate for the original RR, with the line behind a given dot showing the 95% confidence interval (CI).