1 Introduction

The length of stay (LOS) in psychiatric hospitals has long been a focus of concern. It is regularly used as an indicator of inpatient care efficiency and quality indicator, due to its obvious relevance as one of the primary drivers of hospital costs [1]. The worldwide trend policy for treating patients with mental illness has been to minimize LOS and establish a range of community care programs [2]. The majority of Western health-care systems have deinstitutionalized mental-health patients and moved treatment out of hospitals into the community [3]. This has resulted in considerable decreases in average LOS and overall psychiatric bed numbers with the closing of old psychiatric hospitals [4]. However, hospitalization continues to play a significant role in the treatment of a large number of patients with mental illnesses and is a key cost driver in mental health care [5].

The average LOS recorded by numerous studies varies by settings and country. Compared to low-income countries, high-income countries have reduced LOS for psychiatric hospitalizations with the deinstitutionalization movement and the growth of community-based mental healthcare [6]. In many developed countries the average LOS for psychiatric diseases has been lowered to 22.0 days [7]. In these countries, the average LOS in acute psychiatric institutions ranged from 10.5 to 55.1 days except for Japan, which recorded LOS of 75 days [8,9,10,11,12]. In South Africa, a survey found that the average length of stay in mental institutions was larger (219 days) than in general hospitals (11 days) and district hospitals (7 days) [13]. In Arab countries, scarce studies have been done that evaluated the LOS in psychiatric institute. A retrospective study done in psychiatric in-patient unit in the United Arab Emirates (UAE) between June 2012 and May 2015 has found that the mean number of days in hospital was 14.52 [14]. Another study done in King Fahd Hospital of the University in Al-Khobar, Kingdom of Saudi Arabia has found that the mean length of stay for psychiatric illness was 25 days per admission and 41 days per patient [12].

Long psychiatric hospitalizations have been linked to a variety of clinical and patient-related factors. Socio-demographic characteristics such as age, gender, marital status, education level, employment, type of insurance, and religion have been reported to influence LOS. Being single / not married [15,16,17] without any educational qualification [3, 18], being on a national health insurance plan [19, 20] have been linked to increased LOS for patients with severe mental illness. Older age and male gender were associated with increased LOS in some studies [15, 16, 19,20,21,22,23], while in other studies they were linked to shorter LOS [18, 20, 24]. In addition, clinical characteristics such as diagnosis was linked to LOS. A main diagnosis of schizophrenia or psychosis, or a mood illness, was related with higher LOS for patients with severe mental illness (SMI) [16,17,18, 20, 25, 26], while a study showed that diagnosis is a poor predictor of LOS for people with SMI [27].

Health services in all Arab countries are provided by public (government) and private sector facilities. Depending on the current economic policies, the proportionate use of various health providers differs from country to country [28]. In the delivery of health care, non-governmental organizations (NGO) have grown in importance, particularly in nations where there is internal instability [28]. The Arab Region's countries have witnessed notable advancements in the field of mental health in recent times [29]. Psychiatric units with both inpatient and outpatient facilities in regular hospitals are gradually replacing psychiatric services, which were previously entirely contained in a few mental hospitals. While most of the countries in the region have agreed in principle to incorporate mental health services into the primary health care delivery system, there has not been much implementation of this agreement to date [29]. The majority of countries have inadequate mental health services and infrastructure to meet the substantial and expanding requirements [29].

In Lebanon, the health system is characterized by a dominant private sector, a very active non-governmental organization sector and a public sector which has gradually regained its role over the past two decades [30]. Mental health services are mainly provided by the private sector and are mainly oriented towards specialist outpatient and inpatient care [30]. Private practice psychiatrists rely on private general hospitals to admit their patients, with the public sector covering some of these expenses [31]. Governmental mental health facilities do not exist as such, and the public sector leases space in private general hospitals [31]. The care of psychiatric patients in Lebanon is done through two levels: institutional and governmental levels, as well as community health care providers, particularly medical professionals [30]. Currently, there is a lack of integration between mental health and primary healthcare facilities or dispensaries [32]. Private clinics for psychiatric or psychological care, either in independent practices or within academic hospitals, make up the majority of dedicated outpatient mental health services [32]. In Lebanon, there are five active mental hospitals (28.52 beds/100,000 population) and eight psychiatric wards (all units within regular hospitals), for a total of 1.5 psychiatric beds per 100,000 people [32]. In Lebanon, there are 3.14 nurses, 3.3 psychologists, and 1.21 psychiatrists for every 100,000 people. In comparison to other Arab countries, Lebanon has made significant progress toward enhancing mental health resources, despite the adverse events in the country [32]. The largest inpatient psychiatric hospital, Psychiatric Hospital of the Cross (PHC), has over 800 beds and provides acute and long-term care to patients of all ages with mental disorders, including psychiatric illnesses and mental retardation [33]. In the PHC, the quality system at the hospital through a performance indicator generate an annual report about the LOS where the value range between 26.95 in 2019 to 29.88 in 2022.

Short LOS is nearly hard to attain in developing countries due to insufficient or non-existent community mental healthcare. Despite the launching of new acute psychiatric inpatient units, the lack of community mental healthcare and rehabilitation services remains a key barrier to maintaining a low LOS [34]. As a result, any strategy aimed at lowering LOS should be supported by the expansion of community mental health services, as well as the necessary infrastructure. A difference in the LOS and the related factors have been found between countries as demonstrated in several studies. LOS efficiency of care differed across studies that might be explained by the differences in patient demands, but they can also indicate differences in treatment philosophies and practice patterns. In Arab countries, there is a scarcity of data on the duration of stay of psychiatric patients. There were no factors identified that led to or were linked with lengthy hospital stays. Such data would be important in making strategic discussion for managing mental health in efficient and cost effective way. The main objective of this study were to assess the duration of stay in psychiatric hospital in Lebanon. The secondary objective was to evaluate the LOS associated factors.

2 Methods

2.1 Study design and setting

A five years retrospective study was conducted at the PHC hospital, the biggest psychiatric hospital in the country admitting the majority of psychiatric patients. Data related to admission to the hospital between January 2018 and December 2022 was collected. The hospital is a private setting that provides tertiary care for psychiatric patients. Services provided include long and short stay and outpatient psychiatric clinics. The duration of the stay were categorized into short and long stay based on the duration since admission. The short stay was defined as less than 3 months and for the long stay were considered as 12 months and longer. The study included patients admitted to the short stay department exclusively. We included exhaustively all patients aged 18 years or older who were admitted to the PHC. There were a total of 2533 admissions to PHC during this period.

2.2 Data sources

Data on hospital admissions was obtained from medical files, including sociodemographic and medical information about all the patients admitted in the hospital. The LOS was defined as the time in days elapsed between the admission and discharge date as noted in the medical file. Every admission for a single patient was accounted for a new entry on the dataset. Patients’ names were coded during data collection and related information was stored anonymously.

2.3 Measures

LOS was calculated as the difference between hospital discharge and admission dates for each admission.

For each admission, we also extracted the following sociodemographic variables: gender, education level, marital status, employment status, diagnosis, type of insurance, economic status, social status and age. The education level was categorized into five categories: no education (unable to read and write), primary education (less than 8 years of education), complementary (8–15 years of education), secondary (beginning at age 15 years until university) and university level (sufficient level to start higher education). The economic status was categorized into three groups (low, intermediate and high).

Patient diagnosis was retrieved from the medical files according to the treating physician assessment and categorized into five groups according to the ICD-10 classification of mental and behavioral disorders. Group 1 (schizophrenia, and schizotypical and delusional disorders), Group 2 (mood disorders), Group 3 (mental and behavioral disorders due to psychoactive substance use), group 4 (personality disorders) and the final group (other mental and behavioral disorders).

Type of Insurance were categorized into two: private and public insurance. The public insurance is funded by the Government, with citizens paying into a National Social Security Fund. This allows Lebanese citizens to access public healthcare facilities in the country. The private insurance is typically funded by policyholders who pay premiums to the insurance company in exchange for coverage.

Social status of the participants was divided into three groups (bad, intermediate, good). The variable of social status relates the ability of the patient to integrate into social life and it has been retrieved from the medical file based on the social worker assessment and coded on a three level ordinal scale going from bad to a good ability. This category was defined by the hospital medical record and filled at the admission of each participant.

The employment, economic and social status variables were evaluated at the admission of the patients.

2.4 Data analysis

SPSS software version 25 was used to conduct data analysis. A descriptive analysis was done using the counts and percentages for categorical variables and mean and standard deviation for continuous measures. When checking for normality, the dependent variable, length of stay was not normally distributed as visualized by the histogram; the skewness was 3.19, kurtosis 17.07 and the p-value of the Shapiro–Wilk test was < 0.05. Therefore, the non-parametric test were used to test the association between the variables used and the length of stay. Comparison of mean ranks was performed using Kruskal–Wallis and Mann–Whitney tests and Spearman correlation was used for linear correlation between continuous variables. A linear regression analysis was performed, taking the professional LOS as the dependent variable. The assumptions for performing a linear regression were met as there was a linear relationship between the dependent variable and the independent variables visualized by the normality line of the regression plot and the scatter plot of the residuals was verified. Also, the data show a homoscedasticity as visualized by the scatter plot. All the variables that showed a p-value < 0.2 in the bivariate analysis were included in the model to eliminate potential confounding factors. A p-value less than 0.05 was considered significant.

3 Results

Sociodemographic characteristics of the participants are described in Table 1. More than half of the participants were male (56.7%), never been employed (66.8%), single (70.0%) with low socio economic status (55.9%) and 48.5% have a low education level (complementary level and below). As a diagnosis, 38.2% have a schizophrenia disorder. The majority of the participants have a public insurance (71.0%) and have an intermediate social status (76.7%). The mean age of the participants was 42.40 ± 14.75 years.

Table 1 Sociodemographic and other characteristics of patients (N = 2533)
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The mean duration of the global length of the stay was 28.35 ± 26.57 days, with a range between 2 and 300 and a median of 21.00 days. The highest duration of the stay was found in 2020 years with a mean of 32.66 ± 38.63 days (Table 2).

Table 2 Description of the length of stay in days according to the years
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3.1 Bivariate analysis

The bivariate analysis taking the length of stay as the dependent variable are displayed in Table 3. The results showed that a significantly higher median of length of stay was found among males as compared to females (M male = 22.00 vs. M female = 21.00, p < 0.001), single as compared to married (M single = 22.00 vs. M married = 19.00, p < 0.001), having a public insurance as compared to the private (M public = 23.00 vs. M private = 16.00, p < 0.001). Also, a significantly higher median length of stay was found among those having an intermediate social level and having a schizophrenia disorder as compared to the other group. Also, higher age was significantly associated with lower length of stay (r = − 0.118, p < 0.001).

Table 3 Bivariate analysis taking the Length of stay as the dependent variable
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3.2 Multivariable analysis

A linear regression analysis taking the length of stay as the dependent variable showed that being diagnosed with schizophrenia (Beta = 10.25), having a public insurance (Beta = 4.09) and having an intermediate social status (Beta = 3.45) were significantly associated with higher length of stay. Being a female (Beta = − 5.15), married (Beta = − 3.94) and older age (Beta = − 0.17) were significantly associated with lower length of stay (Table 4).

Table 4 Multivariable analysis: Linear regression taking the Length of stay variable as the dependent variable
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4 Discussion

Nowadays, psychiatry is becoming progressively oriented toward outpatient practice. In order to understand these worldwide and local changes, research in this field is necessary to evaluate the current care situation of hospitalized psychiatric patients with relevant and consistent facts. Few studies have been carried out in Lebanon concerning psychiatric patients’ hospitalizations, let alone the length of stay and associated factors; hence, the importance of this study, the first of its kind in Lebanon, as it was conducted in one of the largest inpatient psychiatric centers in the Middle East and included a considerable number of patients.

In this study, the mean duration of LOS was 28 days, which is comparable to the results obtained in the majority of worldwide studies, mainly reporting a LOS of less than 40 days [35]. Comparing our study with studies in other developing countries, our mean is slightly higher than the average found in Brazil (25 days) [36], Ethiopia (22 days) [37] or Nepal (19 days) [38], as well as in developed countries (between 10 and 25 days according to a systematic review in the United States) [16, 39]. Considering the geographical area, our finding was higher than the average LOS in a study conducted in the UAE (14 days) [14] and Saudi Arabia (25 days) [12]. There is a clear variability of the mean LOS between low-/middle and high-income countries. Developed countries tend to have a lower LOS, which can be explained by strategies that aim to reduce negative outcomes and costs of long LOS [40,41,42]. In contrast, developing countries still witness higher LOS that reflect inadequacy and lack of development in community health-care services, thus needing solid national mental health policies.

Between the years 2018 and 2022, the mean length of stay in our study peaked in 2020 (32 days), the year of SARS-CoV2 emergence. Similar findings are also reported in the literature since during the pandemic, psychiatric hospitalizations were lengthier [43,44,45]. In 2020, the patient flow at PHC slowed down with a decrease in number of new admissions. Several matters complicated the dynamic of admissions during this period, such as temporarily stopping new inpatient admissions, limited number of rounds by psychiatrists that stagnated the course of hospitalization and delayed the decision of discharge, COVID-19 infections in patients during their hospitalizations, as well as other pandemic-related decisions that slowed patients’ functional improvement (restrictions of family visits, collective activities…).

Mixed results were reported in the literature concerning demographic factors, specifically gender and age. Some studies found association between LOS and male gender [15, 19, 20] and older age [46, 47] while others had opposite findings in regard to gender [16, 21] and age [8, 20]. Our study showed that male patients and younger age patients stayed longer at the hospital. Compared to female psychiatric patients, male patients are less compliant to treatment [48, 49] and more prone to violence [50], which might explain longer stays [48, 49, 51]. Our findings might have more to do with the hospital's financial structure and treatment strategies than with the personal traits of the patients. Younger age patients might have severe symptoms, such as psychosis, impaired insight, and low functioning that require long-term care. Furthermore, public insurance is more likely to cover individuals with severe mental diseases, which could pay for their extended hospital stays. In addition, patients who lack strong family support are more likely to require hospital care [52].

In our study, marital status was associated with a shorter LOS, corroborating other studies [16, 53, 54]. A previous study demonstrated that married patients with schizophrenia were more resilient than unmarried ones [55]. Increased social support in the form of marriage may facilitate discharge, particularly manifested by frequent family visits and human connectedness, providing a huge support to the patient. Also, social status was related to the duration of stay in our study similar to other studies [56,57,58]. A study have found that the existence of family ties and increased social support were related to shorter lengths of hospitalization [23]. Lack of support from friends and family lack of accommodation, as well as a reduction in social activities are all factors that contribute to longer hospital stays [59].

As for diagnoses implications, schizophrenia was associated with a longer LOS in this study in agreement with previous literature [37, 39, 48]. This result can be explained by the chronic character of psychotic diseases in comparison to other psychiatric disease. Moreover, at PHC, schizophrenia disorders accounted for the majority of admissions and hospitalization that might partially explain the results. Apart from it severity and its prominent clinical presentation, one study found that the stigma toward psychosis delayed the start of the treatment and eventually resulted in longer hospital stays [60].

According to our study, patients with public insurance tend to have longer stays than those with private insurance [61,62,63]. Patients who benefit from public insurance are often unemployed with a lower economic status and an absent of financial support. Consequently, the decision of discharge in such patients is often more delicate, especially with a lack of psychosocial care in Lebanon. For this reason and more, an adequate social support system in psychiatric patients is of crucial importance.

5 Limitations

Although this study is the first in Lebanon to explore the topic of LOS among psychiatric patients, its retrospective nature consisted of collecting limited and only available database from patients’ files. Other important variables should be taken into consideration in future studies which may on one hand lower the risk of confounding, and on the other, predict the length of stay among psychiatric patients, such as the type of admission (voluntary/involuntary), past medical history, illness severity, level of functioning, acuity at the time of admission, number of medications, medical comorbidities and risk of self-harm. In our study, only principal diagnoses, not comorbid psychiatric illnesses, were taken into consideration, despite the possibility of patients presenting multiple diagnosis at once. Finally, a selection bias is present since data was collected from one psychiatric hospital in Lebanon.

6 Conclusion

Although hospitalization still displays an essential role in the treatment of major psychiatric illnesses, attention is being given for shorter stays at the hospital and more community-based mental health services. Hence, it is crucial to investigate factors related to the length of stay to clearly understand it. In our study, being single, male gender and a diagnosis of schizophrenia were associated with a longer stay at the psychiatric hospital. According to our results, the importance of social factors should be highlighted, as they are necessary components of patients’ wellbeing and may facilitate the decision of discharge. However, the continuity of care concept in Lebanon is deficient due to lack of psychiatric aftercare services, resulting in higher readmission rates and longer stays in the hospitals. Eventual studies should explore the clinical implication of these results to practically use them especially in identifying patients with a higher probability for prolonged hospitalization, to plan necessary interventions for these specific situations. Deinstitutionalization measures should be adopted to move therapy from the secondary care setting to the primary care environment. This will result in a considerable decrease in the number of psychiatric beds overall and the average length of hospital stays.