1. Comment
1964 www.thelancet.com Vol 381 June 8, 2013
The report by Gonghuan Yang and colleagues1
on the
results of the Global Burden of Diseases, Injuries, and
Risk Factors Study 2010 (GBD 2010) for China provides
clear evidence of the importance of mental disorders in
the overall health of the nation. Mental and behavioural
disorders accounted for 9·5% of all disability-adjusted life-
years (DALYs) and 23·6% of all years lived with disability
(YLD). Seven of the top 20 causes of YLD are mental dis-
orders: major depressive disorder, alcohol use disorders,
schizophrenia, anxiety disorders, bipolar disorder, dys-
thymia, anddrugusedisorders.
In the past 20 years, awareness of the importance
of mental disorders in China has increased. The first
GBD study in 19962
and a subsequent meeting in Beijing
in 1999 at which the WHO Director General Gro Harlem
Brundtland announced a Global Strategies for Mental
Health initiative3
based on the GBD results helped to
reframe the perception of mental illnesses in China.
Previously recognised as various disparaged clinical
conditions, mental illnesses gradually came to be seen
as an important component of overall public health.
This positive trajectory culminated in the introduction of
China’s first national mental health law on Oct 26, 2012,4,5
a clear example of a national policy response to a group of
conditionsthatwere perceivedto have a substantial effect
onthe healthofthe nation.
To what extent will this new law, which came into effect
on May 1, 2013, reduce the burden of disease attributable
to mental disorders? One of the main goals of the law is
to expand access to mental health services by shifting the
focus of services from specialised psychiatric hospitals
in urban centres to general hospitals and community
Can China’s new mental health law substantially reduce the
burden of illness attributable to mental disorders?
brokers, rapidly spreading social media has been shownto
be a veryuseful meanstoobtain feedback.11,12
Second, the value of research that is readily translatable
to public health policy should be greatly appreciated
because it has a large effect on the general population.
The prioritisation of research funding in some areas
could be adjusted to encourage research projects that
have the potential to change health policies. Finally, well
established infrastructure, such as the Chinese Medical
Association, could be used to form a health policy
consortium at national and local levels.
To improve the health of the huge Chinese population,
sound public health policies are essential. Although
still early in a long journey, China is moving towards
evidence-based public health policy.4
With the right
knowledge, attitude, and practice, adequate investment
in the capability and capacity of implementation, and an
efficient system,this goalwill be reached.
Fan Jiang, Jun Zhang, *Xiaoming Shen
Ministry of Education-Shanghai Key Laboratory ofChildren’s
Environmental Health,Xinhua Hospital, Shanghai,China (FJ, JZ,XS);
ShanghaiChildren’s MedicalCenter, Shanghai,China (FJ,XS); and
School of Public Health, Shanghai JiaoTongUniversity School of
Medicine, Shanghai 200092, China (JZ)
xmshen@shsmu.edu.cn
We declare that we have no conflicts of interest.
1 Muir Gray JA. Evidence based policy making. BMJ 2004; 329: 988–89.
2 Jiang F, Zhang J,Wang XD, et al. Important steps to improve translation
from medical research to health policy. JTrans Med 2013; 11: 33–37.
3 Kammen J, Savigny D, Sewankambo N. Using knowledge brokering to
promote evidence-based policy-making: the need for support structures.
BullWorld Health Organ 2006; 84: 608–12.
4 LiY,Yang X, ChenY, et al. Evidence-based decision-making in public health,
China—challenge and exploration. Zhongguo Xun ZhengYi Xue Za Zhi 2008;
8: 945–50 (in Chinese).
5 KotchenTA. Historical trends and milestones in hypertension research:
a model of the process of translational research. Hypertension 2011;
58: 522–38.
6 Pfeiffer J, Beschta J, Hohl S, Gloyd S, Hagopian A,Wasserheit J.
Competency-based curricula to transform global health: redesign with the
end in mind. Acad Med 2013; 88: 131–36.
7 Jacobs JA, Jones E, Gabella BA, Spring B, Brownson RC.Tools for
implementing an evidence-based approach in public health practice.
Prev Chronic Dis 2012; 9: E116.
8 Hines A, Jernigan DH. Developing a comprehensive curriculum for public
health advocacy. Health Promot Pract 2012; 13: 733–37.
9 Lomas J, Brown AD. Research and advice giving: a functional view of
evidence-informed policy advice in a Canadian Ministry of Health.
Milbank Q 2009; 87: 903–26.
10 Orton L, Lloyd-Williams F,Taylor-Robinson D, et al.The use of research
evidence in public health decision making processes: systematic review.
PLoS One 2011; 6: e21704.
11 McKee M, Cole K, Hurst L, Aldridge RW, Horton R.The otherTwitter
revolution: how social media are helping to monitor the NHS reforms.
BMJ 2011; 342: d948.
12 King D, Ramirez-Cano D, Greaves F,Vlaev I, Beales S, Darzi A.Twitter and
the health reforms in the English National Health Service. Health Policy
2013; 110: 291–97.
See Comment page 1970
See Articles page 1987

2. Comment
www.thelancet.com Vol 381 June 8, 2013 1965
health clinics in both urban and rural communities. Many
of the difficulties that block the achievement of this goal
are the same as those that impede the transformation of
China’s health service delivery system for other chronic
non-communicable diseases (NCDs) such as diabetes and
hypertension: insufficient health providers in rural areas,
limited training of community-based medical personnel,
resistance of specialists who are unwilling to move
services from hospitals to community settings, urban
patients’ preference for treatment at hospital outpatient
departments, insufficient necessary drugs at local clinics,
poor coordination between inpatient and outpatient
services, and the highly mobile population. Chinese
health administrators are acutely aware of these issues
and continue to test alternative mechanisms to address
them.6
The success of the new mental health law in the
expansion of access will depend on the outcome of these
continuing experiments.
Another key issue that is more of a problem for mental
disorders than for other NCDs is the very low rate of
care-seeking for psychological problems. The largest
psychiatric epidemiological study in China7
found that
92% of individuals with mental disorders had never
sought any type of professional help for their disorder.
Part of the problem is the shortage of specialised services,
especially in rural areas, andthe limitedtraining of general
physicians in mental health care. However, another factor
that I believe to be more important than insufficient
services is the unwillingness of community members to
seek help for psychological problems, and the reluctance
of many health professionals to provide psychological
services. The mental health law recognises the need
to decrease the stigma associated with mental illness,
but goes no further than to dictate that “...individuals
and organizations must not stigmatize…persons with
mental disorders” (article 5).5
The public health sector
and many mental health professionals in China believe
that community education is the key to decreasing
stigma, but education alone is unlikely to change such
long-standing attitudesdirectly.The failureof community
education programmes onthe harmful effects of smoking
to reduce rates of smoking significantly (more than
50% of male doctors in China still smoke) prove that
education, although essential, is not sufficient to change
behaviour. Qualitative studies of the factors that influence
care-seeking for psychological problems and follow-up
studies that test cohort-specific interventions aimed
at increasing care-seeking are at least as important as
the development of better treatments or expansion of
the availability of services. Improvement of the quality
and availability of services will not result in substantial
improvements in mental health if affected individuals
refusetousethem.
In a positive departure from statutes in most other
countries, the law in China gives high priority to the
prevention of mental illnesses. One chapter in the law
(chapter 2),5
entitled “Promotion of psychological
wellbeing and prevention of mental disorders”, speci-
fies the responsibilities of government departments,
medical facilities, employers, schools, emergency
response organisations, prisons, and other agencies
to provide psychological support and education about
psychological wellbeing. The problem is that these
proposed interventions are made on the basis of widely
held, but largely unproven, beliefs about the social
determinants of mental disorders. Activities that raise
awareness of mental health, expand psychosocial
support networks, strengthen children’s psychological
resilience, and improve community members’ conflict
resolution skills, and similar community-based inter-
ventions might decrease subsequent rates of mental
illness; however, little evidence-based research exists
to prove this hypothesis. High-quality multidisciplinary
studies that follow patients over several years are needed
to determine whether or not these types of social
interventions are effective in preventing the onset of
mental disorders. The new law provides China with the
opportunity to test these strategies, but in view of the
Corbis

3. Comment
1966 www.thelancet.com Vol 381 June 8, 2013
intense focus of Chinese mental health researchers on
high-tech neuroscience projects, funding long-term
studies and finding qualified researchers willing to
undertake such studies will be difficult.
One area in which the new mental health law does not
take a clear stand is on alcohol. The GBD results indicate
that alcohol use in China is the ninth most important
cause of disability and the seventh most important
risk factor for overall health. Findings from several
epidemiological studies8
have shown rapidly increasing
rates of alcohol use disorders in Chinese men, but less
than 2% of these individuals ever seek treatment.7
The
main problem in addressing this issue is that the medical
profession and the community at large do not yet
recognise alcohol use as a public health problem. Unlike
the concerted efforts to end the smoking epidemic,
comparatively little research on alcohol use has been
undertaken and there are no coordinated efforts to
develop and assesstreatment or prevention programmes.
For example, no attempt has been made to stem the
flood of television advertising for alcoholic beverages that
associate drinking with upward social mobility. Hopefully,
these newGBD resultswill act as awake-up call.
The country-level data on burden presented in the
paper identify overall priorities for the prevention and
management of mental disorders, but the specific
programmes envisioned by the mental health law will
need to be informed by more detailed, region-specific,
and cohort-specific data. Substantial differences exist
by gender and age group in the prevalence, disability,
and burden associated with mental disorders, and huge
differences are evident inthe infrastructure and personnel
available for the provision of mental health services
between urban and rural communities and between
the wealthy eastern provinces and the poor western
provinces. The newly established China Burden of Disease
Research and Dissemination Center at the Institute of
Basic Medical Sciences at Peking Union Medical College
directed by Gonghuan Yang is responsible for providing
these more comprehensivedata.
China is very much in step with the increasing global
awareness of the public health, social, and economic
importance of mental disorders. On May 27, 2013,
the 66th WHO World Health Assembly adopted the
Comprehensive Mental Health Action Plan 2013–2020,9
which recognisesthe increasing burden of disease attribu-
table to mental illnesses, highlights the inadequacy of
national health systems’ response to this challenge,
and encourages member states to participate in specific
activities to rectify the situation. The new mental health
law inChina already addresses fourofthe six cross-cutting
principles in this comprehensive action plan: universal
health coverage, human rights, evidence-based practice,
and a multisectoral approach. The two remaining prin-
ciples—a life-course approach that accounts for different
needs at different ages and empowerment of persons
with mental disorders in the planning of services—could
be easily integrated intoChina’soverall activities.
China will face many challenges during the imple-
mentation, continuing assessment, and subsequent
revision of its new mental health law. However, this
process will make China an important laboratory for the
Comprehensive Mental Health Action Plan promoted
by the World Health Assembly. The various approaches
tested during the implementation of China’s new law
can be adapted for use in other nations that are, like
China, committed to reducing the growing burden of
mental illness.
Michael R Phillips
Shanghai Mental Health Center, Shanghai JiaoTong University
School of Medicine, Shanghai 201108, China; and Departments of
Psychiatry and Global Health, Emory University School of
Medicine, Atlanta, GA, USA
phillipschina@yahoo.com
I declare that I have no conflicts of interest.
1 YangG,WangY, ZengYX, et al. Rapid healthtransition inChina, 1990–2010:
findings fromtheGlobal Burden of Disease Study 2010. Lancet 2013;
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2 Murray CJL, Lopez AD.The Global Burden of Disease: a comprehensive
assessment of mortality and disability from diseases, injuries, and risk
factors in 1990 and projected to 2020. Cambridge, MA, USA: Harvard
University Press on behalf of theWorld Health Organization andTheWorld
Bank, 1996.
3 World Health Organization. Raising awareness, fighting stigma, improving
care: Brundtland unveils newWHO global strategies for mental health.
Press ReleaseWHO/67. Nov 12, 1999. http://www.who.int/inf-pr-1999/
en/pr99-67.html (accessed May 27, 2013).
4 Eleventh National People’sCongress StandingCommittee. Mental health
law ofthe People’s Republic ofChina.Oct 26, 2012 (inChinese). http://www.
gov.cn/jrzg/2012-10/26/content_2252122.htm (accessed May 27, 2013).
5 Chen HH, Phillips MR, Cheng H, et al. Mental health law of the People’s
Republic of China (English translation with annotations).
Shanghai Arch Psychiatry 2013; 24: 305–21.
6 YipWC, HsiaoWC,ChenW, et al. Early appraisal ofChina’s huge and complex
health-care reforms. Lancet 2012; 379: 833–42.
7 Phillips MR, Zhang JX, ShiQC, et al. Prevalence, associated disability and
treatment of mental disorders in four provinces inChina, 2001–2005:
an epidemiological survey.Lancet 2009; 373: 2041–53.
8 TangYL, Xiang XJ,Wang XY, et al. Alcohol and alcohol-related harm in
China: policy changes needed. BullWorld Health Organ 2013; 91: 270–76.
9 WHO. Draft comprehensive mental health action plan 2013–2020. May 16,
2013. http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_10Rev1-en.pdf
(accessed May 27, 2013).

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