Elsevier

The Lancet

Volume 373, Issue 9680, 13–19 June 2009, Pages 2041-2053
The Lancet

Articles
Prevalence, treatment, and associated disability of mental disorders in four provinces in China during 2001–05: an epidemiological survey

https://doi.org/10.1016/S0140-6736(09)60660-7Get rights and content

Summary

Background

In China and other middle-income countries, neuropsychiatric conditions are the most important cause of ill health in men and women, but efforts to scale up mental health services have been hampered by the absence of high-quality, country-specific data for the prevalence, treatment, and associated disability of different types of mental disorders. We therefore estimated these variables from a series of epidemiological studies that were done in four provinces in China.

Methods

We used multistage stratified random sampling methods to identify 96 urban and 267 rural primary sampling sites in four provinces of China; the sampling frame of 113 million individuals aged 18 years or older included 12% of the adult population in China. 63 004 individuals, identified with simple random selection methods at the sampling sites, were screened with an expanded version of the General Health Questionnaire and 16 577 were administered a Chinese version of the Structured Clinical Interview for Diagnostic and Statistical Manual (DSM)-IV axis I disorders by a psychiatrist.

Findings

The adjusted 1-month prevalence of any mental disorder was 17·5% (95% CI 16·6–18·5). The prevalence of mood disorders was 6·1% (5·7–6·6), anxiety disorders was 5·6% (5·0–6·3), substance abuse disorders was 5·9% (5·3–6·5), and psychotic disorders was 1·0% (0·8–1·1). Mood disorders and anxiety disorders were more prevalent in women than in men, and in individuals 40 years and older than in those younger than 40 years. Alcohol use disorders were 48 times more prevalent in men than in women. Rural residents were more likely to have depressive disorders and alcohol dependence than were urban residents. Among individuals with a diagnosable mental illness, 24% were moderately or severely disabled by their illness, 8% had ever sought professional help, and 5% had ever seen a mental health professional.

Interpretation

Substantial differences between our results and prevalence, disability, and treatment rate estimates used in the analysis of global burden of disease for China draw attention to the need for low-income and middle-income countries to do detailed, country-specific situation analyses before they scale up mental health services.

Funding

China Medical Board of New York, WHO, and Shandong Provincial Bureau of Health.

Introduction

The 1996 publication of the global burden of disease reports1, 2 triggered a change in the thinking of international mental health advocates because it emphasised the importance of neuropsychiatric conditions to the overall health of countries in a way that had not been done previously. An estimated 14% of total global burden of disease and about a third of total adult disability are attributable to neuropsychiatric conditions.3 The burden of neuropsychiatric conditions in low-income and middle-income countries accounts for an estimated three-quarters of the global burden for these conditions. In middle-income countries (including China)—where the disease burden attributable to these conditions exceeds that for infectious, cardiovascular, or neoplastic diseases—neuropsychiatric disorders are already the most important causes of illness in men and women.

Reallocation of social and health resources to address these changed priorities has been a slow and difficult process, particularly in low-income and middle-income countries where resources are scarce and individuals with mental illnesses are stigmatised. The Lancet Series4 on Global Mental Health gave new momentum to the efforts of mental health advocates to promote a rational and equitable distribution of health resources, and stimulated the development of two major international initiatives: the movement for Global Mental Health5 and the WHO Mental Health Gap Action Program.6 The main goal of these initiatives is to promote a scaling up of mental health services in low-income and middle-income countries.6, 7

Despite a broad similarity in the challenges encountered by proponents of mental health in different low-income and middle-income countries, generic, cross-national prescriptions are unlikely to be useful. Plans to improve the recognition of mental disorders and the provision of services to people who are mentally ill in any particular country have to fit together perfectly with the historical provision of services in the country and with the socioeconomic and political changes that are in progress within that country. Thus the first step in the scale up of mental health services is to do comprehensive country-specific analyses of the perceived needs, available resources, and potential barriers for mental health care. For most low-income and middle-income countries, the global burden of disease estimates of prevalence, disability, and treatment rates for mental disorders are based on projections, expert opinion, and poor quality or isolated studies, so an important component of the analysis of the country-specific situation is to validate and update these estimates. We estimated these variables from a series of epidemiological studies with a combined sampling frame of 113 million adults—12% of China's adult population—that were done in four provinces in China.

Section snippets

Sample selection and first-stage screening

We used a two-stage screening process to define the prevalence and characteristics of mental disorders in Shandong, Zhejiang, and Qinghai provinces, and in a prefecture of Gansu province (Tianshui prefecture). We identified 363 primary sampling sites in the four provinces using multistage stratified random sampling methods (panel 1; figure). 66 554 individuals aged 18 years or older were identified with simple random selection methods in these sites, and 63 004 (95%) completed the first-stage

Results

63 004 individuals were screened: 32 274 (51%) were women, 46 060 (73%) lived in rural communities, mean age was 44·8 years (SD 15·1), they had a mean of 6·3 years (4·3) of formal education, 52 148 (83%) were married, 2969 (6%) belonged to a non-Han minority group, and median income was US$322 (IQR 151–605) per person per year. 8736 (53%) of 16 577 individuals who completed the SCID diagnostic assessment were women, 11 830 (71%) lived in rural communities, mean age was 47·3 years (SD 15·2),

Discussion

The prevalence of at least one current mental disorder in adults was greater than 17% in 2001–05. The overall prevalence declined to 13% when the NOS disorders were excluded. Mood disorders and anxiety disorders—the most prevalent types—were more common in women than in men, but the overall prevalence of mental disorders was higher in men because of their much higher prevalence of alcohol use disorders. About a quarter of individuals who met diagnostic criteria for a mental disorder were

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