Mental health in China
China’s economic reforms have been enormously successful during the past three decades. On the other hand, rapid urbanisation and economic expansion are posing new difficulties to the country’s mental health system. Mental healthcare has historically been a low priority in China for a variety of reasons, but both the international community and the media have taken a strong interest in these services during the last 5 years. The majority of international specialists have evaluated China’s mental health system using Western criteria, focusing on the infrequent, unfavourable incidents that occur.14
In China, the most common kind of mental disorders is mood disorders with a lifetime prevalence of 7.4%,15 while the disease burden for mental disorders made up 13% of all non-communicable diseases.16 17
According to an epidemiological survey conducted in four Chinese provinces, 17.6% of the participants suffered from mental disorders including depression (6.1%), anxiety disorders (5.6%) and drug use disorders (5.9%).18 According to the WHO, the global recognition rate for mental disorders is roughly 50%, and China’s recognition rate is significantly lower than the global average. Taking depression as an example, in Shanghai only 21% of people recognised that they were depressed. Furthermore, the rate of mental disorder diagnosis and treatment is poor, with only about 150 persons per 100 000 obtaining treatment for major mental disorders on average. Treatment rates for major mental disorders are 17 times higher in high-income countries than in low-income countries.17
Many diseases are episodic, and the chance of relapse is significant.19 Provision of supplementary, customised psychological therapies to manage subthreshold symptoms appears to be critical in reducing impairment and improving quality of life.20 Despite the significant frequency, only one-fifth of people with mood disorders have ever sought treatment from a mental health professional.21 The reasons for China’s significant unmet mental health needs are numerous. There is an unequal distribution of resources between major cities and rural areas, as well as a limited mental health workforce, particularly a shortage of professional social workers and psychological therapists. The high cost of psychological counselling is exacerbated by the lack of medical insurance coverage.22 23 In recent years, the ‘686 Project’, also known as the Central Government Support for Local Management and Treatment of Serious Mental Illness Project, has helped many patients with severe mental illnesses—particularly schizophrenia—to gain more convenient and even free treatment and recovery services. To improve the population’s mental health, more emphasis must be put on bridging the gap experienced by people with non-psychotic diseases.23
In China, mental health resources and service capability are insufficient because of the following: (1) financial investment: the Chinese government’s per capita investment in psychiatric hospitals is about US$1.07,24 compared with US$35.06 in high-income countries during the same period; (2) hospital beds: the number of psychiatric beds in China per 10 000 people is 3.15, compared with 7.13 beds in high-income countries25; (3) professionals: for every 100 000 people in China, there are 3 professionals.25 26 Simultaneously, China has challenges such as attracting mental health professionals and a shortage of vocational rehabilitation personnel. Furthermore, China’s mental health resources are unevenly distributed, with the majority of hospitals and experts clustered in provincial capitals and the more developed eastern regions. It is reported that 47.21% of institutions, 42.06% of mental beds, 48.65% of physicians and 45.25% of nurses are located in 11 eastern provinces. Furthermore, the capacity of mental health staff in grassroots medical facilities is low, and the majority of the personnel are part-time.17 25 26
In China, there are only 2.19 licensed psychiatrists and 5.51 licensed nurses per 100 000 people.17 22 There is also a scarcity of counselling psychologists (estimated at 30 000–40 000 in the whole country), with a lack of an official system for accreditation, registration and licensing.27 28 Furthermore, the number of social workers in China is low with a total of roughly one million, and few of them are certified to provide mental health treatments. People’s awareness about mental health and mental health disorders has been increasing. Some of the sources of awareness about mental health are shown in figure 1.
Figure 1Sources of mental health awareness in China and Pakistan. Government plays an important role, as well as media (social and electronic), different non-government organisations (NGOs) and social workers.
COVID-19 and mental health status in China
The first case of COVID-19 was reported in Wuhan, China, and suddenly the virus spread throughout the globe.29 30 According to surveys of people’s mental health conducted nationwide in China during the COVID-19 pandemic, 35% of those with COVID-19 experienced stress, 30% experienced depression, 34% experienced anxiety and 25.2% experienced PTSD.17 27 31 COVID-19 caused sleep disturbance and PTSD in frontline medical staff as well.32–34 In China, there are approximately one million social workers, which is few for such a large population, and very few are skilled in delivering mental health services. During the pandemic, telehealth was used in universities and hospitals to deliver mental health services to some patients.35 36 Some people may seek help online; however, internet counselling may not be successful for all those who require it, and it can often result in secondary trauma due to the inability to ‘be there’ and ‘know something’.37 Previous reports38 have detailed the technical and logistic issues that mental health therapists face when providing online counselling. Poor mental health literacy, as well as the stigma associated with mental diseases, may play a role in the low use of mental health treatments.17 39 During the COVID-19 pandemic, when the general population was at home in quarantine, social media was the main source of public mental health services, information dissemination and psychological support. Mental health professionals and government workers together actively worked to enhance the mental health resilience of the public and ensure information transparency. To reduce unwarranted anxiety and panic among the public caused by fake news spread through social media, Chinese health experts had daily press conferences to deliver reliable and accurate data and news to the general population about COVID-19. Mental health education was combined with COVID-19 daily updates to increase the awareness of the general public of the pandemic. Scientific articles and books and videos were published to educate people about the pandemic. The main objectives of these publications were to strengthen people mentally.27 40 Books on psychoeducation and mental disorders associated with COVID-19 were also published.41 42 More than 300 mental health hotline services operated online counselling; hospitals and other famous applications offered online self-assessment scales for mental well-being. Telepsychiatry, telepsychology and telecommunication were enhanced to serve the general population on time and to avoid mental health problems and spreading infections.43
According to surveys, the COVID-19 pandemic is likely to cause mental health crises in regions with a large number of confirmed cases and deaths such as in Wuhan.44 Another study observed that 53.8% out of 1210 participants in a study on the psychological impact on the general population of China within the first 2 weeks of the COVID-19 epidemic stated that the pandemic had had a moderate to severe psychological impact on them.45 The quality of sleep and mental health for self-isolating people at home in central China was found to be poor, with high anxiety and low sleep quality. The behavioural and emotional contagions escalated epidemic-related negative affect responses, fear at both collective and individual levels, and psychological distress increased.46–48 The number of psychologically distressed people was greater in areas with high levels of infection than in areas with lower rates of infection and, when the awareness of death from COVID-19 increased, the fear of death anxiety and fear of infection increased in the general population.49 Death anxiety and fear can be managed by an anxiety buffering system.50 China provides facilities to its citizens. During the COVID-19 pandemic, the government built a hospital of 1000 beds in just 10 days to treat patients in Wuhan. The Chinese government also built hospitals for COVID-19 emergencies in just 5 days in some other provinces.51 52
Mental Health Law in China
The first Mental Health Law in China came into effect on 1 May 2013. This was the biggest event in the mental health field in China. The present review introduces its legislative process, its main idea and the principle and essence of formulating this Mental Health Law. Current problems with the law and possible countermeasures are also discussed.17 53 The main points of the law are to give legal rights and standard mental health services to mentally ill persons as well as treatment, prevention and rehabilitation, improve psychological well-being and maintenance of citizens, and take care of the personal safety and dignity, education, medical services and welfare of a person with mental illness. All organisations and individuals must accept and respect mentally ill people and not stigmatise, abuse or humiliate them. Violation of the rights of a mentally ill person is prohibited. The state supports and encourages the technological and scientific diagnosis, prevention, rehabilitation and treatment of mental disorders. Organisations and the government will create opportunities for specific employees and, in case of emergency, give psychological support to the people. In schools, teachers will teach students about psychological well-being and mental health. In jails, prisons and drug rehabilitation centres, the government will provide guidance and counselling. Family members will live in a friendly home environment to alleviate and prevent mental disorders. The government will support media and organisations to promote knowledge about mental health. Persons with severe mental illness will be treated as inpatients. Disabled people’s organisations and rehabilitation organisations will organise activities that meet the rehabilitation requirements for mentally ill people. The high authorities of the state are responsible for implementing the laws and regulations of mental health. The state departments will support and help mental health and give proper financial support to the state budget. A person who is not authorised or registered to treat mental health issues and is found to be practising or treating mental health issues will be issued a letter from the authorities or fined 5000 Chinese Yuan but not more than 10 000 Chinese Yuan.54
COVID-19 and mental health laws in China
The Chinese government made proper guidelines and laws for mental health during the COVID-19 pandemic. The main points of these guidelines are that all the municipalities, autonomous regions and provinces are working under the central government in response to the new pneumonia pandemic and all the necessary financial and organisational guarantees will be provided. The national health and mental health societies and associations will mobilise psychologists, psychiatrists and experts with experience in psychological crises. A psychological rescue group will be formed to provide guidance and carry out psychological counselling in an orderly manner. They will treat psychological issues and endorse social stability. For affected people, the government will provide mental health services and try to prevent the psychological impact of the pandemic. They will identify and manage severely mentally ill people to prevent them from impulsive behaviour and suicide. They will assess the population and distinguish high-risk persons from the general population. They will conduct mental health education for the general population and provide proper treatment and psychological intervention for high-risk groups. Rescue teams may work alone or collaborate as a group with a comprehensive medical team. Experts in mental health will conduct research. Online services, as well as psychological workers, and the organisation will be on duty 24 hours a day and 7 days a week. In diagnosing a patient in the initial stage of treatment and isolation, proper treatment and counselling will be started. According to the tolerance level of the patient, truthful and objective communication with the patient should be given to better form a rapport. Convey the information to the relatives of the patient and assist them. In patients with anxiety and respiratory distress, treat the severe respiratory disease first after calming the patient, and also pay attention to their emotional and behavioural disorders. The government arranges training for doctors and nurses to teach them how to deal with depression and anxiety during the outbreak. To eliminate the stress of front-line medical workers, the government provides them with logistic supports and schedule them to go to an isolated area once a month.55 56