China struggles to rebuild its mental health system

From CMAJ:

The anomaly is striking.

At least a dozen workers leapt to their death in same factory compound in southern China in 2010, while nearly 30 people died and 80 were injured in a spate of school stabbings.

Yet, contrary to instinct, there is little evidence to confirm that there has been a rapid rise in the rate of mental illnesses in China, and strong evidence of a dramatic drop in suicide rates over the past two decades, says Michael Phillips, director of the Suicide Research and Prevention Center at the Shanghai Medical Center.

“Westerners believe if you have suicide, you have to have mental illness,” Phillips says. “This is not the case in China. Only 65% of people who die by suicide in China have a mental illness compared to 90% to 95% in high-income countries.”

Phillips believes many of the suicides can be attributed to impulsive personality traits and poor conflict-resolution skills, rather than the stresses of modernization, the breakdown of the traditional family structure or protests against corruption, as many have speculated.

“These are people who have underlying impulsive personalities,” Phillips says. “They are people who still got married, functioned normally, but they fly off the handle really easily. Under those stressful circumstances, you have more impulsive acts.”

Whatever the cause, what has become clear through the mist of the high-profile suicides and school shootings is that China has failed to adequately address the mental health needs of the 173 million Chinese people, or 17.5% of the population, who Phillips has estimated have mental disorders (Lancet 2009; 373:2041-53). And a vast majority of those, an estimated 158 million people, have never received any kind of professional help.

That’s because help is hard to find in China — the country has just 15 000 trained psychiatrists to serve a population of 1.3 billion.

In the late 1960s, Mao Zedong outlawed psychiatry during the Cultural Revolution and many mentally ill patients were taken from hospitals and sent to labour camps. Their illnesses were attributed to a lack of appreciation for the class struggle and they were labeled counter-revolutionists.

These days, there is a more capitalist rationale for Chinese doctors and patients don’t want to talk about mental health. Psychiatry isn’t glamorous and being an expert in the field doesn’t earn much in the way of salary and respect.

“It’s still quite low down on the totem pole of medical specialties in terms of income and status,” says Phillips.

Likewise, Chinese patients are ashamed to reveal they may need psychiatric help for fear of being labeled “crazy.”

In Chinese society, people “look down on those who have mental illness,” says King-Wa Fu, an assistant professor of journalism and media studies at the University of Hong Kong. “They don’t think you have the same ability in terms of working, learning and studying.”

“In China, there’s a lot of talk about ‘face’,” adds Fu, who studies the media’s influence on mental health and suicide. “Fu adds. “If you have family members who have mental illness, you will have lost your face. So we have many people who are not willing to come out and seek help.”

There are also economic reasons why some avoid seeking help. Many sufferers, particularly those in rural area, simply cannot afford to see a psychiatrist or don’t have access to one. There’s also a fear of job loss if an employer discovers that a worker has a a mental illness.

“Mental illness is costing us not only our health … but there is an indirect cost which can be seen in labour market participation,” says Chunling Lu, senior research associate at the Harvard Initiative for Global Health in Boston, Massachusetts, and author of a recent study which found that incomes for men declines 39%, and for women 33%, after their mental health deteriorated (J Ment Health Policy Econ. 2009; 12:157166).

Lu hopes that quantifying the economic losses incurred as a result of the prevalence of mental illness will motivate the government to invest in hospital psychiatric wards in hospitals and draft policies that protect workers with mental illnesses.

At the factory in southern China, safety nets were installed outside buildings and Buddhist monks and counselors were hired to help at-risk employees. Salaries for assembly line workers were raised by about 70%. After the school stabbings, armed guards were posted at elementary schools across the country.

The government has pledged a number of long-term initiatives, including the renovation or expansion of 550 psychiatric hospitals and departments over the next two years; the creation of free mental health counseling hotlines; and the passage of mental health legislation.

Dealing with the persisting stigma attached to mental illness may be more thorny. But Fu says media attention can start a dialogue. “Sometimes even [if people] are exposed to such terrible stories, they will tend to look at the positive side: ‘If I do the same thing, I will hurt my family members. If I do the same thing, it’s not a good experience.’”

Oddly enough, while China gropes to address the mental health problem, in some cities, psychiatry seems to have developed a cult following: the theories of Freud have become fashionable.

Elise Snyder, a New York-based psychoanalyst has, for the last two years, been training some of China's first psychotherapists through Skype conversations, while in Shanghai, workshops are offering a glimpse into the hidden realms of the unconscious.

“There’s an incredible interest in psychoanalysis here and people are making tons of money,” Phillips says. “It seems everyone wants to study Freud for some self-help, and it has consumed [people]. From a health perspective, it’s not really doing much, but it’s an indication of interest.”