The transformation of China's mental health services

China Journal

Volumn , Issue 39, 1998, Pages 1-34

  Phillips, Michael R ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

HEALTHCARE; MENTAL DISORDER; MENTAL HEALTH; SERVICE PROVISION; SOCIAL DEVIANCE;

CHINA;

EID: 0031780038     PISSN: 13249347     EISSN: None     Source Type: Journal    
DOI: 10.2307/2667691     Document Type: Article

References (92)

1. During the twelve years that I have worked as a psychiatrist and clinical researcher in China, I served as an exchange scholar in the Department of Psychiatry at Hunan Medical University from August 1985 to August 1987; as Director of Research at the Ministry of Civil Affairs' main psychiatric hospital, located in Shashi, Hubei province, from September 1987 to August 1994 (during which time I spent one and a half years running a 90-bed psychiatric ward); and have been Director of the Research Centre of Clinical Epidemiology at Beijing Hui Long Guan Hospital (China's largest psychiatric hospital) since September of 1994. During this period I visited and lectured at close to a hundred other psychiatric hospitals throughout the country.
2. Vivien Ng, Madness in Late Imperial China: From Illness to Deviance (Oklahoma City: University of Oklahoma 1990); Veronica Pearson, 'The Chinese Equation in Mental Health Policy and Practice: Order Plus Control Equal Stability', International Journal of Law and Psychiatry, no. 19 (1996), pp.437-58.
3. Vivien Ng, Madness in Late Imperial China: From Illness to Deviance (Oklahoma City: University of Oklahoma 1990); Veronica Pearson, 'The Chinese Equation in Mental Health Policy and Practice: Order Plus Control Equal Stability', International Journal of Law and Psychiatry, no. 19 (1996), pp.437-58.
4. Zhang Mingyuan, Yan Heqing and Michael R. Phillips, 'Community Psychiatric Rehabilitation in Shanghai: Facilities, Services, Outcome and Culture-Specific Features', British Journal of Psychiatry, no.165 (suppl.24) (1994), pp.70-9.
5. Chinese Medical Association, Chinese Psychiatric Association and Nanjing Neurological Hospital (Zhongguo yixue hui jingshen kexue hui, Nanjing yikedaxue yiyuan), Zhongguo jingshen jibing fenlei yu zhenduan biaozhun [Chinese Classification of Mental Disorders] (2nd edn, revised) (CCMD-2-R) (Nanjing: Dongnan daxue chubanshe, 1995).
6. Li Shengxian and Michael R. Phillips, 'Witchdoctors and Mental Illness in Mainland China: A Preliminary Study', American Journal of Psychiatry, no.147 (1990), pp.221-4.
7. Coordinating Group for the 12-Region Epidemiological Survey of Mental Illnesses (12 Ditu jingshen jibing liuxingxue diacha xiezuo zu), Gelei jingshenbing, yaowu yilai, jiu yilai ji rengge zhangai de diaocha ziliao fenxi [Analysis of Survey Results of All Types of Psychiatric Illnesses, Drug and Alcohol Dependence, and Personality Disorders], Zhonghua shenjing jingshen ke zazhi [Chinese Journal of Neurology and Psychiatry], vol.19, no.2 (1986), pp.70-2; Coordinating Group for the 12-Region Epidemiological Survey of Mental Illnesses (12 Ditu jingshen jibing liuxingxue diacha xiezuo zu); 12 ditu schenjingzheng liuxingxue diaocha [Epidemiological Survey of Neuroses in the 12 Regions], Zhonghua shenjing jingshen ke zazhi [Chinese Journal of Neurology and Psychiatry], vol.19, no.2 (1986), pp.87-91. An edited English version of the study is now available: John E. Cooper and Norman Sartorius (eds), Mental Disorders in China: Results of the National Epidemiological Survey in 12 Areas (London: Gaskell, 1996). To overcome the possible under-reporting of symptoms by family members, information about possible psychotic symptoms in members of the sampled households was obtained by administering a screening instrument developed by the World Health Organization (which took 10 to 15 minutes) both to the heads of the selected households and to key informants in the community (administrators, police and health workers). Possible neurotic disorders were identified by administering a shorter screening instrument (which took 5 to 10 minutes) to a sub-sample of 6,754 persons 15 to 59 years of age. Persons who had a possible mental disorder based on the screening instrument interview were re-interviewed using the 140-item Present State Exam (PSE) for non-neurotic disorders or the 45-item PSE for neurotic disorders and diagnosed according to the criteria of the ICD-9. World Health Organization, Mental Disorders. Glossary and Guide to Their Classification in Accordance with ICD-9 (Geneva: WHO, 1978). A repeat survey involving seven of the original twelve sites was conducted in 1992 but the results have not as yet been released.
8. Coordinating Group for the 12-Region Epidemiological Survey of Mental Illnesses (12 Ditu jingshen jibing liuxingxue diacha xiezuo zu), Gelei jingshenbing, yaowu yilai, jiu yilai ji rengge zhangai de diaocha ziliao fenxi [Analysis of Survey Results of All Types of Psychiatric Illnesses, Drug and Alcohol Dependence, and Personality Disorders], Zhonghua shenjing jingshen ke zazhi [Chinese Journal of Neurology and Psychiatry], vol.19, no.2 (1986), pp.70-2; Coordinating Group for the 12-Region Epidemiological Survey of Mental Illnesses (12 Ditu jingshen jibing liuxingxue diacha xiezuo zu); 12 ditu schenjingzheng liuxingxue diaocha [Epidemiological Survey of Neuroses in the 12 Regions], Zhonghua shenjing jingshen ke zazhi [Chinese Journal of Neurology and Psychiatry], vol.19, no.2 (1986), pp.87-91. An edited English version of the study is now available: John E. Cooper and Norman Sartorius (eds), Mental Disorders in China: Results of the National Epidemiological Survey in 12 Areas (London: Gaskell, 1996). To overcome the possible under-reporting of symptoms by family members, information about possible psychotic symptoms in members of the sampled households was obtained by administering a screening instrument developed by the World Health Organization (which took 10 to 15 minutes) both to the heads of the selected households and to key informants in the community (administrators, police and health workers). Possible neurotic disorders were identified by administering a shorter screening instrument (which took 5 to 10 minutes) to a sub-sample of 6,754 persons 15 to 59 years of age. Persons who had a possible mental disorder based on the screening instrument interview were re-interviewed using the 140-item Present State Exam (PSE) for non-neurotic disorders or the 45-item PSE for neurotic disorders and diagnosed according to the criteria of the ICD-9. World Health Organization, Mental Disorders. Glossary and Guide to Their Classification in Accordance with ICD-9 (Geneva: WHO, 1978). A repeat survey involving seven of the original twelve sites was conducted in 1992 but the results have not as yet been released.
9. Coordinating Group for the 12-Region Epidemiological Survey of Mental Illnesses (12 Ditu jingshen jibing liuxingxue diacha xiezuo zu), Gelei jingshenbing, yaowu yilai, jiu yilai ji rengge zhangai de diaocha ziliao fenxi [Analysis of Survey Results of All Types of Psychiatric Illnesses, Drug and Alcohol Dependence, and Personality Disorders], Zhonghua shenjing jingshen ke zazhi [Chinese Journal of Neurology and Psychiatry], vol.19, no.2 (1986), pp.70-2; Coordinating Group for the 12-Region Epidemiological Survey of Mental Illnesses (12 Ditu jingshen jibing liuxingxue diacha xiezuo zu); 12 ditu schenjingzheng liuxingxue diaocha [Epidemiological Survey of Neuroses in the 12 Regions], Zhonghua shenjing jingshen ke zazhi [Chinese Journal of Neurology and Psychiatry], vol.19, no.2 (1986), pp.87-91. An edited English version of the study is now available: John E. Cooper and Norman Sartorius (eds), Mental Disorders in China: Results of the National Epidemiological Survey in 12 Areas (London: Gaskell, 1996). To overcome the possible under-reporting of symptoms by family members, information about possible psychotic symptoms in members of the sampled households was obtained by administering a screening instrument developed by the World Health Organization (which took 10 to 15 minutes) both to the heads of the selected households and to key informants in the community (administrators, police and health workers). Possible neurotic disorders were identified by administering a shorter screening instrument (which took 5 to 10 minutes) to a sub-sample of 6,754 persons 15 to 59 years of age. Persons who had a possible mental disorder based on the screening instrument interview were re-interviewed using the 140-item Present State Exam (PSE) for non-neurotic disorders or the 45-item PSE for neurotic disorders and diagnosed according to the criteria of the ICD-9. World Health Organization, Mental Disorders. Glossary and Guide to Their Classification in Accordance with ICD-9 (Geneva: WHO, 1978). A repeat survey involving seven of the original twelve sites was conducted in 1992 but the results have not as yet been released.
10. Coordinating Group for the 12-Region Epidemiological Survey of Mental Illnesses (12 Ditu jingshen jibing liuxingxue diacha xiezuo zu), Gelei jingshenbing, yaowu yilai, jiu yilai ji rengge zhangai de diaocha ziliao fenxi [Analysis of Survey Results of All Types of Psychiatric Illnesses, Drug and Alcohol Dependence, and Personality Disorders], Zhonghua shenjing jingshen ke zazhi [Chinese Journal of Neurology and Psychiatry], vol.19, no.2 (1986), pp.70-2; Coordinating Group for the 12-Region Epidemiological Survey of Mental Illnesses (12 Ditu jingshen jibing liuxingxue diacha xiezuo zu); 12 ditu schenjingzheng liuxingxue diaocha [Epidemiological Survey of Neuroses in the 12 Regions], Zhonghua shenjing jingshen ke zazhi [Chinese Journal of Neurology and Psychiatry], vol.19, no.2 (1986), pp.87-91. An edited English version of the study is now available: John E. Cooper and Norman Sartorius (eds), Mental Disorders in China: Results of the National Epidemiological Survey in 12 Areas (London: Gaskell, 1996). To overcome the possible under-reporting of symptoms by family members, information about possible psychotic symptoms in members of the sampled households was obtained by administering a screening instrument developed by the World Health Organization (which took 10 to 15 minutes) both to the heads of the selected households and to key informants in the community (administrators, police and health workers). Possible neurotic disorders were identified by administering a shorter screening instrument (which took 5 to 10 minutes) to a sub-sample of 6,754 persons 15 to 59 years of age. Persons who had a possible mental disorder based on the screening instrument interview were re-interviewed using the 140-item Present State Exam (PSE) for non-neurotic disorders or the 45-item PSE for neurotic disorders and diagnosed according to the criteria of the ICD-9. World Health Organization, Mental Disorders. Glossary and Guide to Their Classification in Accordance with ICD-9 (Geneva: WHO, 1978). A repeat survey involving seven of the original twelve sites was conducted in 1992 but the results have not as yet been released.
11. D. A. Regier, J. H. Boyd, J. D. Burke et al., 'One-Month Prevalence of Mental Disorders in the United States', Archives of General Psychiatry, no.45 (1988), pp.977-86; P. Bebbington, J. Hurry, C. Tennant et al., 'Epidemiology of Mental Disorders in Camberwell', Psychological Medicine, no. 11 (1981), pp.561-79.
12. D. A. Regier, J. H. Boyd, J. D. Burke et al., 'One-Month Prevalence of Mental Disorders in the United States', Archives of General Psychiatry, no.45 (1988), pp.977-86; P. Bebbington, J. Hurry, C. Tennant et al., 'Epidemiology of Mental Disorders in Camberwell', Psychological Medicine, no. 11 (1981), pp.561-79.
13. Neurasthenia, as diagnosed in China, is characterized by the presence of at least three of the following symptoms: weakness, dysphoria (namely, feelings of unhappiness), excitement, nervousness and sleep problems (Chinese Medical Association, Chinese Psychiatric Association and Nanjing Neurological Hospital, Chinese Classification of Mental Disorders). The importance and distinctiveness of the neurasthenia diagnosis in China has faded considerably since 1982. See Sing Lee, 'Cultures in Psychiatric Nosology: The CCMD-2-R and Intentional Classification of Mental Disorders', Culture, Medicine and Psychiatry, no.20 (1996), pp.421-72.
14. Neurasthenia, as diagnosed in China, is characterized by the presence of at least three of the following symptoms: weakness, dysphoria (namely, feelings of unhappiness), excitement, nervousness and sleep problems (Chinese Medical Association, Chinese Psychiatric Association and Nanjing Neurological Hospital, Chinese Classification of Mental Disorders). The importance and distinctiveness of the neurasthenia diagnosis in China has faded considerably since 1982. See Sing Lee, 'Cultures in Psychiatric Nosology: The CCMD-2-R and Intentional Classification of Mental Disorders', Culture, Medicine and Psychiatry, no.20 (1996), pp.421-72.
15. Editorial Committee for the Survey Manual (Diaocha shouce bianxie weiyuanhui), Jiangshen jibing liuxingxue diaocha shouce [Manual for the Epidemiological Survey of Mental Illnesses] (Beijing: Renmin weisheng chubanshe, 1984), pp.32-43.
16. There is, for example, an unbelievably large range in the prevalence of schizophrenia in the 12 urban locations (1.95 to 10.15 per 1,000) and in the 12 rural locations (0.00 to 8.92 per 1,000), though these differences could be due to chance variation in the rates because of the relatively small sample size assessed at each of the 24 study sites (Coordinating Group for the 12-Region Epidemiological Survey of Metal Illnesses (12 Ditu jingshen jibing liuxingxue diacha xiezuo zu) (1986c), Jingshenfenliezheng liuxingxue diaocha ziliao fenxi (Analysis of Epidemiological Survey Results for Schizophrenia). Zhonghua shenjing jingshen ke zazhi (Chinese Journal of Neurology and Psychiatry), vol.19, no.2, pp.73-6.
17. Arthur Kleinman, 'Neurasthenia and Depression: A Study of Somatization and Culture in China', Culture, Medicine and Psychiatry, no.6 (1982), pp.117-90; also see American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (3rd edn) (Washington, DC: APA, 1980).
18. Arthur Kleinman, 'Neurasthenia and Depression: A Study of Somatization and Culture in China', Culture, Medicine and Psychiatry, no.6 (1982), pp.117-90; also see American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (3rd edn) (Washington, DC: APA, 1980).
19. Hong Liyi, Ou Lihua and Mo Ganming, 'Epidemiological Studies of Alcohol Dependence in Chinese Minorities in the Eighties', Journal of the Hong Kong College of Psychiatrists, no.2 (1992), pp.21-6.
20. World Health Organization, Schizophrenia: An International Follow-up Study (New York: John Wiley & Sons, 1979).
21. Chris J. L. Murray and Alan D. Lopez, Global Health Statistics: A Compendium of Incidence, Prevalence, and Mortality Estimates for over 200 Conditions (Cambridge, Mass.: Harvard University Press, 1996); also, 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, Mass.: Harvard University Press, 1996).
22. Chris J. L. Murray and Alan D. Lopez, Global Health Statistics: A Compendium of Incidence, Prevalence, and Mortality Estimates for over 200 Conditions (Cambridge, Mass.: Harvard University Press, 1996); also, 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, Mass.: Harvard University Press, 1996).
23. Prevalence rates of mental disorders in China per 1,000 persons 15 years of age or over for 1990 reported in Global Health Statistics (ibid.) are as follows: schizophrenia 5.35; unipolar major depression 19.54; bipolar disorder 5.44; dementia 3.86; obsessive-compulsive disorder 15.20; post-traumatic stress disorder 3.20; panic disorder 5.69; alcohol dependence 6.72; and drug use disorder 0.60.
24. At the times of major international meetings. Party congresses, and important national holidays, family members of persons with schizophrenia in Beijing and other major cities are expected to sign guarantees that the patient will not cause trouble. If the family is unable or unwilling to do so, the patient may be placed in 'protective custody' at a local psychiatric hospital (at the family's expense) over the course of the meeting or holiday.
25. Robert Desjarlais, Leon Eisenberg, Byron Good and Arthur Kleinman, World Mental Health: Problems and Priorities in Low-Income Countries (New York: Oxford University Press, 1995), p.69. Even if one considers neurasthenia a type of affective disorder (depression or mania), the combined prevalence at one specific point in time of all affective disorders in China would be 1.6 per cent (from the 1982 epidemiological survey) or 2.5 per cent (from the Global Burden of Disease Study) compared to 5.1 per cent in the United States (Regier et al., One-Month Prevalence of Mental Disorder') and 7.0 per cent in Britain (Bebbington et al., 'Epidemiology of Mental Disorders'). The apparent contradiction of high suicide rates and low rates of depressive syndromes has several possible explanations: (1) The World Bank study estimates that only 5 per cent of persons with depression in China receive treatment, while 35 per cent receive treatment in developed countries (Murray and Lopez, The Global Burden of Disease); so the estimated rate of untreated depression in China is closer to that of Western countries: 1.5-2.4 per cent in China versus 3.3 per cent in the United States and 4.6 per cant in the Britain. (2) Given the different pattern of suicide by sex and residence, the social construction of suicide is obviously different in China than in the West - in China suicide may not be as closely associated with depressive syndromes as it is in the West. (3) Epidemiological studies of depression in China may grossly under-estimate the prevalence of the disorder because Western diagnostic instruments are not sensitive to the subjective experience of depressive states in China or because the greater stigmatization of mental illnesses in China may make Chinese respondents less willing to report depressive symptoms (or other symptoms) than Western subjects.
26. Robert Desjarlais, Leon Eisenberg, Byron Good and Arthur Kleinman, World Mental Health: Problems and Priorities in Low-Income Countries (New York: Oxford University Press, 1995), p.69. Even if one considers neurasthenia a type of affective disorder (depression or mania), the combined prevalence at one specific point in time of all affective disorders in China would be 1.6 per cent (from the 1982 epidemiological survey) or 2.5 per cent (from the Global Burden of Disease Study) compared to 5.1 per cent in the United States (Regier et al., One-Month Prevalence of Mental Disorder') and 7.0 per cent in Britain (Bebbington et al., 'Epidemiology of Mental Disorders'). The apparent contradiction of high suicide rates and low rates of depressive syndromes has several possible explanations: (1) The World Bank study estimates that only 5 per cent of persons with depression in China receive treatment, while 35 per cent receive treatment in developed countries (Murray and Lopez, The Global Burden of Disease); so the estimated rate of untreated depression in China is closer to that of Western countries: 1.5-2.4 per cent in China versus 3.3 per cent in the United States and 4.6 per cant in the Britain. (2) Given the different pattern of suicide by sex and residence, the social construction of suicide is obviously different in China than in the West - in China suicide may not be as closely associated with depressive syndromes as it is in the West. (3) Epidemiological studies of depression in China may grossly under-estimate the prevalence of the disorder because Western diagnostic instruments are not sensitive to the subjective experience of depressive states in China or because the greater stigmatization of mental illnesses in China may make Chinese respondents less willing to report depressive symptoms (or other symptoms) than Western subjects.
27. Robert Desjarlais, Leon Eisenberg, Byron Good and Arthur Kleinman, World Mental Health: Problems and Priorities in Low-Income Countries (New York: Oxford University Press, 1995), p.69. Even if one considers neurasthenia a type of affective disorder (depression or mania), the combined prevalence at one specific point in time of all affective disorders in China would be 1.6 per cent (from the 1982 epidemiological survey) or 2.5 per cent (from the Global Burden of Disease Study) compared to 5.1 per cent in the United States (Regier et al., One-Month Prevalence of Mental Disorder') and 7.0 per cent in Britain (Bebbington et al., 'Epidemiology of Mental Disorders'). The apparent contradiction of high suicide rates and low rates of depressive syndromes has several possible explanations: (1) The World Bank study estimates that only 5 per cent of persons with depression in China receive treatment, while 35 per cent receive treatment in developed countries (Murray and Lopez, The Global Burden of Disease); so the estimated rate of untreated depression in China is closer to that of Western countries: 1.5-2.4 per cent in China versus 3.3 per cent in the United States and 4.6 per cant in the Britain. (2) Given the different pattern of suicide by sex and residence, the social construction of suicide is obviously different in China than in the West - in China suicide may not be as closely associated with depressive syndromes as it is in the West. (3) Epidemiological studies of depression in China may grossly under-estimate the prevalence of the disorder because Western diagnostic instruments are not sensitive to the subjective experience of depressive states in China or because the greater stigmatization of mental illnesses in China may make Chinese respondents less willing to report depressive symptoms (or other symptoms) than Western subjects.
28. Robert Desjarlais, Leon Eisenberg, Byron Good and Arthur Kleinman, World Mental Health: Problems and Priorities in Low-Income Countries (New York: Oxford University Press, 1995), p.69. Even if one considers neurasthenia a type of affective disorder (depression or mania), the combined prevalence at one specific point in time of all affective disorders in China would be 1.6 per cent (from the 1982 epidemiological survey) or 2.5 per cent (from the Global Burden of Disease Study) compared to 5.1 per cent in the United States (Regier et al., One-Month Prevalence of Mental Disorder') and 7.0 per cent in Britain (Bebbington et al., 'Epidemiology of Mental Disorders'). The apparent contradiction of high suicide rates and low rates of depressive syndromes has several possible explanations: (1) The World Bank study estimates that only 5 per cent of persons with depression in China receive treatment, while 35 per cent receive treatment in developed countries (Murray and Lopez, The Global Burden of Disease); so the estimated rate of untreated depression in China is closer to that of Western countries: 1.5-2.4 per cent in China versus 3.3 per cent in the United States and 4.6 per cant in the Britain. (2) Given the different pattern of suicide by sex and residence, the social construction of suicide is obviously different in China than in the West - in China suicide may not be as closely associated with depressive syndromes as it is in the West. (3) Epidemiological studies of depression in China may grossly under-estimate the prevalence of the disorder because Western diagnostic instruments are not sensitive to the subjective experience of depressive states in China or because the greater stigmatization of mental illnesses in China may make Chinese respondents less willing to report depressive symptoms (or other symptoms) than Western subjects.
29. Articles about my current research into the reasons for this pattern of suicide appear in The New Scientist, 22 March 1997, pp.34-7, and The Economist, 8 November 1997, p.39.
30. Articles about my current research into the reasons for this pattern of suicide appear in The New Scientist, 22 March 1997, pp.34-7, and The Economist, 8 November 1997, p.39.
31. Murray and Lopez, The Global Burden of Disease.
32. K. L. Hwang, 'Face and Favor: The Chinese Power Game', American Journal of Sociology, no.92 (1987), pp.944-74.
33. Michael R. Phillips, 'Strategies Used by Chinese Families Coping with Schizophrenia', in D. Davis and S. Harrell (eds), Chinese Families in the Post-Mao Era (Berkeley: University of California Press, 1993), pp.277-306.
34. E. Fuller Torrey, Surviving Schizophrenia: A Family Manual (revised) (New York: Harper & Row, 1988).
35. Veronica Pearson, 'Community and Culture: a Chinese Model of Community Care for the Mentally III', International Journal of Social Psychiatry, no.38 (1992), pp.163-78.
36. Y. Ren, X. S. Cheng, Y. P. Zhang et al., Yu qigong youguan dejingshen thangai 43 li fenxi [Analysis of 43 Cases of Qigong-Induced Mental Disorder], Shanghai jingshen yixue, no.5 (supp.1) (1993), pp. 190-4.
37. Yang Desen (ed.), Zhongguo jingshen jibing zhenduan biaozhun yu anli [Chinese Diagnostic Criteria for Mental Disorders and Related Case Histories] (Changsha: Hunan daxue chubanshe, 1989).
38. L. Wang, 'New Clinic Helps Qigong Addicts to Recover', China Daily, 28 May 1991, p.5.
39. Lin Keh-Ming, 'Traditional Chinese Medical Beliefs and Their Relevance for Mental Illness and Psychiatry', in A. Kleinman and T. Y. Lin (eds), Normal and Abnormal Behavior in Chinese Culture (Dordrecht: Reidel, 1981), pp.95-111.
40. If, on the other hand, the ill individual manifests disruptive or socially inappropriate behaviour in the community - not only in the home - work supervisors, teachers, neighbours or community leaders often recommend (or demand) that the family seek psychiatric care as soon as possible.
41. Veronica Pearson, 'Families in China: An Undervalued Resource in Mental Health', Journal of Family Therapy, no.15 (1993), pp.163-8.
42. 'Volunteer Helpers Flock to Counselling Course', China Daily, 11 February 1987, p.3.
43. In this discussion, the provision of health and welfare services are seen as the results of policies based on different political ideologies, but it is also possible to view the provision of social services as a tool the Chinese Communist Party actively employs to maintain popular support. See Cecelia L. W. Chan and Nelson W. S. Chow, More Welfare After Economic Reform? Welfare Development in the People's Republic of China (Hong Kong: Hong Kong University Press, 1992).
44. Xingyuan Gu, Gerald Bloom, Tang Shenglan et al., 'Financing Health Care in Rural China: Preliminary Report of a Nationwide Study', Social Science and Medicine, no.36 (1993), pp.385-91.
45. Veronica Pearson, 'Community and Culture: A Chinese Model of Community Care for the Mentally Ill', International Journal of Social Psychiatry, no.38 (1992), pp.163-78; Zhang et al., 'Community Psychiatric Rehabilitation in Shanghai', pp.70-9.
46. Veronica Pearson, 'Community and Culture: A Chinese Model of Community Care for the Mentally Ill', International Journal of Social Psychiatry, no.38 (1992), pp.163-78; Zhang et al., 'Community Psychiatric Rehabilitation in Shanghai', pp.70-9.
47. Stephan M. Salzberg, 'Taiwan's Mental Health Law', International Journal of Law and Psychiatry, no.15 (1992), pp.43-75.
48. State Council of the People's Republic of China, Zhonghua renmin gong he guo canjiren baozhang fa [Law of the People's Republic of China on the Protection of Disabled Persons] (Beijing: Huaxia chubanshe, 1991).
49. Liu Xiehe, Zhonghua renmin gong he guo jingshen weisheng fa (cao an) [Draft Mental Health Law of the People's Republic of China], Huaxi yike daxue, jingshenke, unpublished manuscript, West China University of Medical Sciences, Department of Psychiatry, Chengdu, Sichuan.
50. Veronica Pearson, Mental Health Care in China: State Policies, Professional Services and Family Responsibilities (London: Gaskell, 1995).
51. Spouses attempting to divorce a mentally ill mate, however, often ask the court to obtain evidence regarding the current or past mental illness of the individual and then use this evidence as grounds for divorce.
52. Shen Zheng, Zheng Zhanpei, Wang Kejian and Lin Shuzi, Falu jingshenbingxue [Forensic Psychiatry] (Beijing: Zhongguo zhengfa daxue chubanshe [Chinese University of Politics and Law Press], 1989).
53. State Council of the People's Republic of China, Zhongguo canjiren shiye 'bawu' jihua gangyao yu peitao shishe fangan [Work Program for Disabled Persons During the Period of the 8th Five-Year National Development Plan (1991-95)] (Beijing: Huaxia chubanshe, 1992).
54. Michael R. Phillips and Veronica Pearson, 'Future Opportunities and Challenges for the Development of Psychiatric Rehabilitation in China', British Journal of Psychiatry, no. 165 (suppl.24) (1994), pp.128-42.
55. 'Network to Aid 10m Mentally Disabled', China Daily, 15 May 1993, p.3.
56. Legislative Affairs Commission of the Standing Committee of the National People's Congress of the People's Republic of China, The Laws of the People's Republic of China (1979-82) (Beijing: Foreign Languages Press, 1987).
57. Veronica Pearson, 'Population Policy and Eugenics in China', British Journal of Psychiatry, no. 167 (1995), pp.1-4
58. Zhu Baoxia, 'State-Run Hospitals Increased Last Year', China Daily, 24 February 1992, p.3.
59. Xu Qi and Liu Yue, 'Fake Doctors Plague Cities', China Daily, 8 December 1992, p.6.
60. J. W. Mao, Weisheng shiye zai shenhua gaige zhong wenbu fazhan [Stable Development of the Health Industry as the Reforms are Deepened], Jian kang gao [Health News], 4 May 1993, p.1.
61. 'Anxiety Illness: Training for Medics', China Daily, 10 February 1993, p.3.
62. Zhang Mingyuan, Yan Heqing and Michael R. Phillips, 'Community Psychiatric Rehabilitation in Shanghai'.
63. Zuoning Jiang, 'Community Psychiatry in China: Organization and Characteristics', International Journal of Mental Health, no.16 (1988), pp.30-42.
64. Xia Zhenyi, Yan Heqing and Wang Changhua, 'Mental Health Care in Shanghai', International Journal of Mental Health, no.16 (1988), pp.81-5. But Shanghai's vigorous economy is now threatening the viability of this network of mental health services. Previously, the 'guardianship network' of volunteers in the community (who helped the mentally ill and their families) and the volunteer staff at sheltered workshops was largely composed of retirees; but now many of these retirees are taking part-time jobs so it is harder to find such volunteers, even when they are paid a small honorarium. And many of the sheltered workshops that provide day-time employment to mentally ill persons are threatened with closure because they are unable to compete in Shanghai's competitive environment, even with the generous tax breaks they receive from the state.
65. 'Mental Health Service Hits Crisis Over Money and Staff, China Daily, 22 November 1993, p.3.
66. The Chinese Psychiatric Association (under the Chinese Medical Association) was finally established in 1994, decades after the founding of associations for other specialities. Prior to that time, psychiatry was the minor partner in the Chinese Association of Neurology and Psychiatry.
67. Only one-third of the 126 five-year medical schools in China have mandatory courses in psychiatry; these courses typically include only 40 hours of classes and, perhaps, one week of clinical experience. Doctors and nurses graduating from the 551 three-year courses at health schools are taught no psychiatry at all. By contrast, medical students in American four-year medical schools typically receive 12 weeks of training in psychiatry. Over the last ten years in China, courses in medical psychology have been added to the curricula in about half of the five-year medical schools, but these pre-clinical courses usually have nothing to do with psychiatry. Yang Desen, Woguo nianyi shiji chuqi jingshen yixue fazhan zhanwang [Prospects for the Development of Psychiatry in China in the Beginning of the 21st Century], Zhongguo xhenjing jingshen jibing zazhi [Chinese Journal of Nervous and Mental Diseases], vol.22, no.2 (1996), pp.65-8.
68. Over 5 per cent of all hospital beds in the country are for psychiatric patients, but only 1.1 percent of five-year medical school graduates work as psychiatrists (11,570 of 1.01 million doctors in 1991). See Editorial Committee of the China Health Annual (ed.) (Zhongguo weisheng nianjian weiyuanhui), Zhongguo weisheng nianjian, 1992 (1992 Yearbook of Public Health in the People's Republic of China) (Beijing: Renmin weisheng chubanshe, 1992). In an attempt to address this problem, in 1990 nine medical schools around the country with strong psychiatry departments started mental health divisions that provided intensive training in psychology and psychiatry to a small sub-group of each medical class (Yang Desen, Prospects for Development of Psychiatry in China). The preliminary experience with this new program is that over 50 per cent of the 200 yearly graduates from the nine programs either never go into psychiatry or leave psychiatry soon after graduation, so it is uncertain whether or not this initiative will be successful.
69. Over 5 per cent of all hospital beds in the country are for psychiatric patients, but only 1.1 percent of five-year medical school graduates work as psychiatrists (11,570 of 1.01 million doctors in 1991). See Editorial Committee of the China Health Annual (ed.) (Zhongguo weisheng nianjian weiyuanhui), Zhongguo weisheng nianjian, 1992 (1992 Yearbook of Public Health in the People's Republic of China) (Beijing: Renmin weisheng chubanshe, 1992). In an attempt to address this problem, in 1990 nine medical schools around the country with strong psychiatry departments started mental health divisions that provided intensive training in psychology and psychiatry to a small sub-group of each medical class (Yang Desen, Prospects for Development of Psychiatry in China). The preliminary experience with this new program is that over 50 per cent of the 200 yearly graduates from the nine programs either never go into psychiatry or leave psychiatry soon after graduation, so it is uncertain whether or not this initiative will be successful.
70. Marlys Bueber, 'Letter from China (no.3)', Archives of Psychiatric Nursing, no.7 (1993), pp.249-53.
71. The recent introduction of national examinations for promotions is an attempt to establish professional standards, but the proportion of the examinations related to one's medical specialty is limited, and there is no clinical component to the examinations. The examinations for psychiatrists include sections on politics, literature, science, general medicine and psychiatry; the examinations for psychiatric nurses include politics, science, general nursing, and no psychiatry.
72. In in-patient settings, group or individual sessions in which the treating physician instructs or exhorts patients on how they should change their behaviour are often inaccurately labelled 'talk psychotherapy'.
73. Nurses in China are seen as doctors' assistants, not as independent health care providers, so nursing is a relatively low-status occupation. Unlike most other countries, there are more doctors than nurses in China: in 1995 there were 1.92 million doctors (not including village doctors) but only 1.13 million nurses. See State Statistical Bureau, People's Republic of China (Guojia tongji ju), Zhongguo tongji nianjian 1996 [China Statistical Yearbook 1996] (Beijing: China Statistical Publishing House, 1996).
74. Veronica Pearson and Michael R. Phillips, 'Psychiatric Social Work and Socialism: Problems and Potential in China', Social Work, no.39 (1994), pp.280-7.
75. Phillips and Pearson, Future Opportunities and Challenges.
76. Ibid. The federation actively engaged in institution-building activities in the three years prior to Deng Xiaoping's death in 1997, building administrative offices throughout the country and successfully lobbying the central government for authority over all rehabilitation services throughout the country. The influence of the federation has not noticeably decreased since Deng's death.
77. 'Schizophrenic Criminals Face Police Action', China Daily, 23 June 1988, p.3.
78. As part of its institution-building activities, the Disabled Persons Federation has recently established associations for the relatives of persons with the seven types of disabilities under its auspices (including psychiatric disabilities) at the national, provincial and country levels; but the associations of mentally ill relatives only exist in name - they have no members and no activities.
79. World Bank, China: Long-Term Issues and Options in the Health Transition (Washington, DC: World Bank, 1992).
80. Michael R. Phillips, Lu Shaohua and Wang Ruiwen, 'Economic Reforms and the Acute InPatient Care of Schizophrenia: The Chinese Experience', American Journal of Psychiatry, no. 154 (1997), pp. 1228-34.
81. 'Medical Cost Reforms', China Daily, 19 June 1992, p.3. The proportion paid by the patient typically varies from 10 per cent to 30 per cent or the total cost. Often the proportion of copayment for in-patient services, for out-patient services and for medications are different. In several locations, insured patients must use specific hospitals and the cost of drugs will only be reimbursed if the drugs are on an approved drug list (in Shanghai 1,400 drugs are on the list). Unlike in the West, for those with comprehensive government-sponsored or work unit-sponsored health insurance, there are no limitations on the use of mental health services. Costs for psychiatric care are covered in the same way as those for medical and surgical care.
82. Gail E. Henderson, 'Increased Inequality in Health Care in China', in D. Davis and E. Vogel (eds), In China on the Eve of Tiananmen: The Impact of Reform (Cambridge, Mass.: Harvard University Press, 1990), pp.263-82. In the recent past most institutions kept the costs of care for the uninsured down by charging them only half as much as the government-covered patients, but this practice has been largely discontinued in the wake of reduced government subsidies for operating costs and demands for improved profitability.
83. Linda Wong, 'Slighting the Needy? Social Welfare Under Transition', in J. Y. S. Cheng and M. Brosseau (eds), China Review 1993 (Hong Kong: The Chinese University Press, 1993), pp.23.1-23.25.
84. Previously, urban residents obtained employment in a state firm either by being assigned to the firm after graduation from secondary school or by being given a position after the retirement of a parent who had worked in the firm - the dingti option. This gave parents of mentally ill children the opportunity to ensure employment for their disabled children. But the dingti option was rescinded in 1983 and applicants must now pass entrance examinations and successfully complete a one to three-year apprenticeship before becoming a permanent employee in a government office (which entitles one to government-sponsored health insurance) or in government-supported industry (which usually entitles one to the work unit's health insurance).
85. 'China Tries Out Medical Insurance', China Daily, 10 January 1987.
86. State Statistical Bureau of the People's Republic of China, China Statistical Yearbook 1996.
87. Michael R. Phillips, Xiong Wei and Zhao Zuan, Jingshenbing yinxing he yangxing zhengzhuang pingding liangbiao shiyong youguan wenti [Issues Involved in the Use of Scales for the Assessment of Negative and Positive Symptoms in Psychiatric Patients] (Wuhan: Hubei kexue jishu chubanshe, 1990).
88. The government plans to have a traditional Chinese medicine hospital and a Western-style hospital in every county.
89. World Bank, China: Long-Term Issues.
90. Huang Cheng and Cao Young, 'Go into Business, Health Sector Told', China Daily, 26 June 1992, p.3.
91. Editorial Commitlee of the China Health Annual (Zhongguo weisheng nianjian weiyuanhui) (ed.), Zhongguo weisheng nianjian, 1996 [1996 Yearbook of Public Health in the People's Republic of China] (Beijing: Renmin weisheng chubanshe, 1996).
92. Xiong Wei, Michael R. Phillips, Wang Ruiwen, Dai Qingqing, Joan Kleinman and Arthur Kleinman, 'Family-Based Intervention for Schizophrenic Patients in China: A Randomized Controlled Trial', British Journal of Psychiatry, no.65 (1994), pp.239-47.