Can China's new mental health law substantially reduce the burden of illness attributable to mental disorders?
1964 www.thelancet.com Vol 381 June 8, 2013
The report by Gonghuan Yang and colleagues1
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-
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
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)
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.
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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;
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Competency-based curricula to transform global health: redesign with the
end in mind. Acad Med 2013; 88: 131–36.
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11 McKee M, Cole K, Hurst L, Aldridge RW, Horton R.The otherTwitter
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See Comment page 1970
See Articles page 1987
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
The success of the new mental health law in the
expansion of access will depend on the outcome of these
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
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
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
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
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
have shown rapidly increasing
rates of alcohol use disorders in Chinese men, but less
than 2% of these individuals ever seek treatment.7
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
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
I declare that I have no conﬂicts of interest.
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University Press on behalf of theWorld Health Organization andTheWorld
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care: Brundtland unveils newWHO global strategies for mental health.
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gov.cn/jrzg/2012-10/26/content_2252122.htm (accessed May 27, 2013).
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Republic of China (English translation with annotations).
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