1964 Vol 381 June 8, 2013
The report by Gonghuan Yang and colleagues1
on the
results of the Glob...
Comment Vol 381 June 8, 2013 1965
health clinics in both urban and rural communities. Many
of the difficul...
1966 Vol 381 June 8, 2013
intense focus of Chinese mental health researchers on
high-tech neuros...
Reproduced with permission of the copyright owner. Further reproduction prohibited without
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Can China's new mental health law substantially reduce the burden of illness attributable to mental disorders?


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Can China's new mental health law substantially reduce the burden of illness attributable to mental disorders?

  1. 1. Comment 1964 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) 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. 2. Comment 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. 3. Comment 1966 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 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; 381: 1987–2015. 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. 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. (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. (accessed May 27, 2013).
  4. 4. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.