Mental care difficulties on the agenda

Chinese mental illness patients enjoy their free time under a doctor's supervision in a psychiatric hospital in Weifang, Shandong province. China is making good progress in mental healthcare but many obstacles remain. Xinhua

Tackling long-standing issues on non-communicable diseases

Depression, dementia, schizophrenia and substance abuse. Such mental health issues affect around 10 percent of the world's population.

As one of the main non-communicable diseases (NCDs), mental healthcare amounts to more than $2.5 trillion globally each year, according to the World Health Organization (WHO).

In China, the ratio is even higher, with 17 percent of the population suffering from mental health problems, equating to almost 200 million people. However, there are only 20,000 psychiatrists in the world's most populous country.

More innovative methods are needed to deal with a severe shortage of mental healthcare resources, experts say.

"Of the current mental illness cases in China, only 5 percent have received psychiatric care by professionals and just 3 percent have received care from general physicians, meaning 92 percent who have mental problems have never received any type of treatment," says Michael Phillips, director of Shanghai Mental Health Center of Shanghai Jiaotong University.

In cooperation with the Ministry of Health, Phillips conducted China's largest mental health census in 2005 which surveyed 63,000 people around the country.

The findings show there is a huge treatment gap between people who need mental healthcare services and care providers, Phillips says, compared with the 30 to 35 percent ratio of people who have received treatment in high-income countries.

"China in many ways is doing better than many other countries," says Phillips, who is also executive director of the WHO Collaborating Center for Research and Training in Suicide Prevention at Beijing Huilongguan Hospital.

"The number of psychiatrists per capita is higher than in India and Brazil, but they are all in big cities," he says, adding that given the huge numbers of patients in China, it is impossible for the existing professionals to provide adequate care to the masses.

"In many countries such as India, they have community health workers who can expand the manpower of physicians," he says. "In some areas, the NGOs act to provide effective social support to serious mentally ill patients," referring to non-governmental organizations.

Doctors in rural areas already have their hands full, he says, with little time or necessary training to focus on mental health.

"We need to rethink the model and see if we can get some services (in rural locations) provided by non-medical professionals."

Phillips says the recruiting of social workers could range from high school graduates to early-retired people, either working voluntarily or being paid nominal salaries.

Shekhar Saxena, director of the Department of Mental Health and Substance Abuse at WHO, echoed this idea.

"Mental healthcare doesn't require a lot of money. It doesn't require high-cost machines. It requires innovative thinking, good policies and people who can be trained to deliver mental healthcare," said Saxena at the World Innovation Summit for Health (WISH) in Doha last December.

He added that WHO's new action plan signed in May of last year by 194 ministers of health, which recognizes mental health as a public health priority, is the milestone for global mental healthcare work.

WHO's Comprehensive Mental Health Action Plan 2013-2020 calls for comprehensive, integrated and responsive mental health and social care services in community-based settings.

According to a report published by WISH, there is a universal problem existing in many countries where mental healthcare resources are largely being used by big institutions that distance the patients from their communities.

In China's case, the Ministry of Health has intended to bring mental healthcare to community clinics for decades, but there are many practical obstacles, Phillips says.

First, psychiatry hospitals certainly will not take lightly a cut in their spending for the money to go to communities. In addition, adding psychiatric wards onto general hospitals has proved very difficult to be accepted by both the public and doctors working there.

Second, under China's current healthcare system, urban people seldom go to community clinics. In rural areas, people are willing to go, but it is tough to get proper diagnosis or treatment in the local clinics.

"The government wants to put three targets into the community clinics: hypertension, diabetes, and mental illness. So mental illness is on the agenda," says Phillips. "But changing peoples' care-seeking patterns is a very complicated issue."

Phillips suggests improving healthcare quality of town-level and county-level hospitals first. Improvements could include bringing in psychiatrists to practice there part-time, with the bigger picture for village doctors to learn from them.

Last year China announced its first mental health law to protect the patients, which is being viewed as a major breakthrough.

However, many details are still not clear, Phillips says, such as whether the financial support will come from the central government or local governments, how long it will last, how it would be implemented and if the richer provinces will take more responsibility than the poorer provinces.

"Despite all the economic change and urbanization in the country, my own feeling is the ratio of mental illness is fairly stable in China." he says.

More alcohol and drug abuse cases have surfaced recently, but the numbers remain much lower than high-income countries, he says.

"The suicide rate in China dropped by 50 percent over the past 20 years, while in other countries such as South Korea, the rate has gone up threefold," says Phillips, who is also the China representative to the International Association of Suicide Prevention.

Many factors have influenced the drop in suicide rates, including widespread economic improvements that have left fewer people below the poverty line.

Another factor is rapid urbanization which has seen millions of people moving into cities. Data show that one-third of suicides in China are impulsive acts, with many caused by the consumption of pesticide, which is less available in urban settings than it would be rurally.

"I think what China learns will be relevant to other middle income countries, especially large middle-income countries with large rural populations," Phillips adds.

China's investment in mental health has increased substantially. For example, it has launched the "868 program" to identify and monitor severe mental illness in communities and to offer free medicines.

Drug studies are being carried out by Chinese scholars using traditional medicines to deal with mental illness, such as ginkgo biloba herbal supplements to treat early-stage dementia.

Despite all the efforts, a big gap between the budget and the healthcare burden still exists. According to Phillips, mental health issues account for 11 percent of China's total healthcare burden or more, but they only account for 3 to 4 percent of the annual health budget.

The WISH report shows that in high-income countries, spending on mental health accounts for more than 5 percent of the annual healthcare budget, while in low- and middle-income countries, it is about 2 percent.