Chinese Medical Journal 2008;121(14):1331-1338
Comparing models of mental health service systems between Australia and China: implications for the future development of Chinese mental health service

LIU Tie-qiao,  Ng Chee,  MA Hong,  David Castle,  HAO Wei,  LI Ling-jiang

LIU Tie-qiao (Mental Health Institute, Second Xiangya Hospital, Central-South University, WHO Collaborating Center for Psychosocial Factor, Drug Abuse and Health, Changsha, Hunan 410011, China)

Ng Chee (St. Vincent’s Mental Health Service, Department of Psychiatry, University of Melbourne; WHO Collaborating Centre in Mental Health, Victoria, Australia)

MA Hong (Institute of Mental Health, Peking University, Beijing 100083, China)

David Castle (St. Vincent’s Mental Health Service, Department of Psychiatry, University of Melbourne; WHO Collaborating Centre in Mental Health, Victoria, Australia)

HAO Wei (Mental Health Institute, Second Xiangya Hospital, Central-South University, WHO Collaborating Center for Psychosocial Factor, Drug Abuse and Health, Changsha, Hunan 410011, China)

LI Ling-jiang (Mental Health Institute, Second Xiangya Hospital, Central-South University, WHO Collaborating Center for Psychosocial Factor, Drug Abuse and Health, Changsha, Hunan 410011, China)

Correspondence to:LIU Tie-qiao,Mental Health Institute, Second Xiangya Hospital, Central-South University, Changsha, Hunan 410011, China (Tel: 86-13808422601. Fax:86-731- 5360086. E-mail:Liutieq@gmail.com)
Keywords
mental health service; China; Australia
Abstract

Mental illness is recognized as a significant social and public health problem in China, with approximately 16 million people affected with mental illness according to a report in 2002.1 In addition, approximately 30 million children and young adolescents are suffering from mood and/or behavioral disorders. Drug and alcohol problems and other psychosocial disorders affecting women, elders and survivors of disasters are also important problems adding to the overall national mental health burden. Research from both China and abroad indicate that mental and behavioral problems will continue to increase in the future. The World Health Organization (WHO) has warned that the financial burden from mental disorders in China will constitute 1/4 of total burden from various diseases in 2020.1

The Chinese central government has already acknowledged the growing mental health problems and prioritized mental health among other public health issues. This policy is significant in developing the Chinese mental health system and promoting the reform of its current service model. As advocated by many experts in this field, a key approach for Chinese mental health service reform is to integrate international experiences into the Chinese cultural context. Due to the uniqueness of Chinese history and traditional culture, specific strategies will inevitably need to be developed within the Chinese mental health service. This paper compares and contrasts mainstream mental health service models between Australia and China aiming at examining the implications for developing Chinese mental health service reform.

CHINESE SERVICE MODEL FOR PEOPLE WITH MENTAL ILLNESS

Predominantly, treatment approaches for people with mental illness in China have used a hospital-based service model. Except for a few economically developed cities and regions which have implemented elements of community services, most other areas have relied on psychiatric hospitals and outpatient services. Institutionalization and pharmacological treatment are mainly provided, particularly for patients with severe mental illness, while other interventions and services are limited to the hospital settings. Most mental health professionals are not sufficiently trained to implement community and rehabilitation services as well as secondary consultation and mental health promotion.

The characteristic pathway to care for Chinese people with mental illness starts with seeking medical help, often under the escort of families, from a general hospital or a hospital with psychiatric specialty (psychiatric hospital) (Figure 1). Here they receive assessment and treatment by outpatient clinicians. Severely psychotic patients (including those who are cognitively impaired, violent to themselves or others and/or treatment noncompliant) will be admitted to inpatient service. The duration of hospital stay may vary from 20 days to 3 months. After discharge, follow up is provided by the outpatient service with the majority of these patients being cared for at home. In China, around 90% of psychotic patients live together with families2 who have to provide all aspects of care. Due to limited resources in the community, many patients do not have access to proper treatment and rehabilitation services, especially in the rural and mountainous areas. Compounding the lack of community services, for financial reasons some hospitals may even promote institutionalization by prolonging hospital stay beyond the clinical need.


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Figure 1. Flow chart of Chinese service model for people with mental illness.

 AUSTRALIAN MENTAL HEALTH SERVICE MODEL

Although Australia initiated its mental health service changes from the early 1960s to mid-1980s with a process of deinstitutionalization, most of this occurred in an unplanned fashion. The first National Mental Health Strategy was agreed upon after an agreement by all State governments in 1992. It directed the restructuring of the public mental health service to: (1) ensure adequate service response to patients with mental illness; (2) integrate with other general health services; (3) reduce reliance on psychiatric hospital and integrate into community-based service; (4) emphasize priority to those with severe mental illness and (5) increase participation of patients, families and carers in treatment planning. This is supported by the mental health legislation that establishes principles for involuntary treatment orders in the community and confirms that mentally ill patients have rights to choose living in a community and their treatment should be provided in the least restricted setting and in the least intrusive manner.

Under the guidance of this Strategy and coordination of government at various levels, nearly all large psychiatric hospitals have been closed and resources have been shifted to the community. A largely hospital-based mental health service system has been replaced by one that is community-based even for the seriously and chronically mentally ill. Inpatient treatment for the acute mentally ill is mostly provided by general hospitals with gazetted psychiatric beds which are typically small in number (e.g. 25–40 beds per hospital). The average length of hospital stay is normally short (average 12–15 days). A range of programs are implemented by community teams to promote continuity of care, and community mental health service has become the mainstream model for treatment of patients with serious mental illness.

The State of Victoria has led the way in implementing the national mental health strategy in successful coordination and collaboration among multiple public health service departments, non-government and community agencies. After more than ten years of reform, the Victorian community mental health service underpinned by the “person-centered” model has become one of the most advanced in the world.

General practitioners (GPs) are usually the first point of contact for patients with mental health problems, where initial assessment and treatment are provided. If necessary referral is subsequently made to specialized mental health services either, private or public. Private services are provided by private psychiatric hospitals and private psychiatrists and psychologists. The public mental health system consists of clinical services and psychiatric disability rehabilitation and support services (PDRSS) which are provided by non-government agencies. The public clinical services are funded and provided by the state government, and are primarily delivered on an area basis by different services within the state (e.g. in Victoria there are 13 metropolitan areas and eight rural areas). Each area mental health service provides three types or streams of mental health service: Child and Adolescent Mental Health Services (0–18 years); Adult Mental Health Services (16–64 years); and Aged Persons Mental Health Services (≥65 years). Each stream has both hospital inpatient service and fully comprehensive community mental health services. Clinical mental health services provide assessment, diagnosis, treatment and clinical case management to people with a serious mental illness.

All area mental health services provide a full range of functions and have several different components.

Acute emergency service
Psychiatric triage nurses in the Emergency Department of General Hospitals or duty intake workers at the Community Mental Health Clinics assess all referrals of acute psychiatric problems. Depending on risk, subacute and less complicated cases are referred to community mental health service or private services directly. Complex and urgent cases are reviewed by a Crisis Assessment and Treatment Team (CATT) which provide urgent community-based assessment and short-term treatment interventions to those in psychiatric crisis. All referrals are screened in order to make a decision whether hospitalization is required or not.

Acute inpatient service
Located within acute general hospitals, the acute inpatient service provides short-term treatment for patients with acute psychiatric symptoms. They are regularly assessed to see if they have recovered sufficiently to receive treatment in the community. Upon discharge, patients will return home with continuous treatment and support from a CATT or other community treatment services.

Community mental health services
Most patients with mental illness will return home to their community where a range of community services can be accessed. A case manager is allocated to every patient treated by the public mental health service. This individual is responsible for case monitoring, clinical review and coordination of appropriate services. The case manager also develops and implements the Individual Service Plan (ISP) for every patient in collaboration with the patient and the community treatment team. The patient-centered care is provided by the Continuing Care service over a variable time period and frequently in liaison with GPs, local community agencies and public welfare service to ensure ongoing support and continuity of care for patients in the community. The Mobile Support and Treatment Team (MSTT) provides long-term assertive outreach, rehabilitation and support to high disability patients, especially those with complex psychosocial demands, recurrent problems, aggression and/or medical non-compliance. The Homeless Outreach Psychiatric Service (HOPS) mainly targets patients who are homeless and difficult to engage by providing psychosocial intervention and treatment aimed at addressing complex needs (legal, drug/alcohol dependence and housing issues).

Community Care Units (CCU) are community-based facilities that provide medium to long-term accommo- dations, clinical care and rehabilitation. Professional care is available to patients who are dependent and/or chronically disabled to teach daily living skills so that they can be transfered to other community residential facilities. Secure Extended Care Units (SECU) provide medium to long-term inpatient treatment and rehabilitation for patients who are severely psychotic and/or at risk of harming themselves or others. These patients are detained under the Mental Health Act and the units are locked.

Other services
Psychiatric Disability and Rehabilitation Support Services (PDRSS) are a group of non-government organizations providing non-clinical support focusing on addressing the impact of mental illness and the psychosocial disadvantage resulting from mental illness by maximizing patient’s opportunities to return to the community. Other specialist services which require a higher level of expertise for those with specific clinical needs are delivered on a statewide basis. These include forensic, eating disorders, neuropsychiatry, mother-baby, drug and alcohol services.

In summary, a comprehensive range of services is provided by GPs, case managers, community mental health services and various organizations (both government and non-government) that work in an integrated and cooperative manner to help patients recover and maintain maximum independence in the community. The referral flow chart is shown in Figure 2.


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Figure 2. Flow chart of Victoria mental health service mix.

THE GAP IN MENTAL HEALTH SERVICE BETWEEN CHINA AND AUSTRALIA

Inadequate financial input and limited basic resources
The total health expenditures make up only 5% of China’s GDP (Gross Domestic Product), compared to 13% in the United States, 7% in Japan and Thailand3 and 9.3% in Australia. Indeed, China uses only 1% of the world’s total health expenditures to care for 21% of the world’s population. In a recent report, there are only 965 mental health institutions, 16 000–19 000 psychiatrists and 27 000–31 000 psychiatric nurses and 160 000–180 000 psychiatric inpatient’s beds (1.2–1.4 beds/10 000 individuals) in China to provide for more than 1.3 billion people. The services delivered by clinical psychologists, social workers and occupational therapists are mostly unavailable.4 To compare this data with the global mental health resources reported by WHO in 2001 in the Mental Health Atlas Project outlining the current status in all countries, the basic resources for mental health care in China are obviously inadequate.5

Uneven distribution of limited resources
The majority of mental health service facilities in China are located in the urban areas and 80% of the total health budget in China is allocated to hospital-based treatment in the urban areas, despite the fact that urban residents account for only 30% of the population.3,6 As few mental health services are available in most rural areas, this results in unequal access to mental health services between the urban and rural residents. While rich rural patients may travel a long way to seek medical help and access expensive inpatient services in large city hospitals, the majority of the poor rural patients can only receive non-professional mental health service in rural hospitals.7

In addition, many highly qualified medical personnel migrate to the city from rural areas, attracted by better salaries and more advanced medical technology; this further depletes the medical health service in the countryside.8 The lack of trained mental health professionals remains a key obstacle to the provision of adequate mental health service in the rural areas. The situation is further aggravated by the lack of medical insurance coverage for residents in such areas.6

Imbalance owing to socioeconomic development
Owing to the significant differences in economic development among various regions in a diverse country such as China, the resources and infrastructure of the mental health services varies greatly between regions. Generally speaking, the overall resources of mental health service in metropolitan cities, such as Beijing and Shanghai, are more substantial than those in the middle or western regions.

Medical policies
Australia has a welfare oriented medical service model. Each citizen has the right to access basic medical health care service, and patients only need to pay minimal out of pocket medical cost.

In China, after the era of the cooperative medical treatment policy, many rural patients cannot afford even basic medical costs. On the other hand, with the introduction of the “contract responsibility system” in the early 1980s this has created strong incentives for hospital-based physicians to provide over-servicing (e.g. unnecessary procedures, prolonged hospitalization, and expensive medications). As the income the hospital earns increases, the higher bonuses the hospital staffs will be paid. This trend not only results in an increase of patients’ medical expenses but also undermines the roles of doctors in primary health care, prevention and rehabilitation services.9,10 The early application of mental health rehabilitation models in both urban (Shanghai) and rural (Yantai) areas failed to be replicated in other cities during the 1980s. A key reason for this is the lack of financial sustainability, because, while the model benefits patients through community rehabilitation, the hospital and staff do not derive much profit. This creates a financial disincentive for providing successful community rehabilitation.

The profit-based medical service system had a similar impact on the poor sections of the population. Although services are available, people can neither afford nor access them. About a third of 7.8 million schizophrenia patients have never received proper diagnosis and treatment.6 Another study shows that, among the lowest income social groups, 70% of patients with mental illness do not receive treatment because of their disadvantaged financial situation.11

The structure and quality of mental health service
In Australia, the mental health service model is largely community-based. Hospitals function primarily as a place for assessment and commencement of treatment for patients. Both inpatient and outpatient services are staffed by fully trained and professionally accredited mental health workers in fields of psychiatry and related disciplines. Patients have easy access to advanced treatments including novel pharmacotherapy, psychological therapies and evidenced-based treatment approaches. The majority of patients also live independently in the community instead of living together with their family members. A full range of services ranging from acute treatment to long term rehabilitation is provided by multidisciplinary professionals in the community.

In China, except for a few cities and districts that can provide some elements of community service, the mainstream model of care for patients with mental illness is hospital-based provided by psychiatric hospitals. Patients are hospitalized or prescribed some medication for home treatment. These hospitals are normally run in a custodial management style. The average length of hospital stay is about 2 months during which patients receive medications, basic mental health education and rehabilitation. Overall, however, treatment methods are relatively scarce other than medication treatment because of the high patient to staff ratio and the lack of professionally trained psychologists, social workers and occupational therapist.

In China, more than 90% of people with mental illness live with their family members or relatives who carry most of the burden of care due to the lack of community service. However, due to the lack of mental health literacy and skills to provide care in acute or difficult situations, carer givers have little choice other than to resort to large hospitals for help. Nearby hospitals are within relatively easy reach for urban residents, but accessibility for those from rural or remote areas for psychiatric care is very poor. It is not uncommon for rural patients to travel for several days to see a doctor in the city. The cost of getting adequate treatment including transport, accommodation, medical consultation and medicines is prohibitive and mostly unaffordable for rural patients. This is one of the critical reasons for the lack of treatment for rural patients.

Although the quality of Chinese mental health services is steadily improving, there are still many gaps in terms of workforce and technical expertise. The over-reliance on the medical approach to mental health care has yielded a narrow emphasis on symptom relief rather than recovery and improvement of quality of life and social function. The lack of psychological and sociological perspectives in caring for the mentally ill has severely restricted the use of the bio-psychosocial model of care that is grounded in scientific principles and research.12

The governance of mental health service facilities
The mental health service facilities in Australia are governed by the state government health departments. Therefore, they have almost sole responsibility for the delivery of public mental health service and become accountable for any problems that may arise. However, in China, mental health care facilities are managed by different departments including the Ministries of Public Health, Civil Affairs, Defense, Industry and Mining, Public Security and the People’s Liberation Army. This governance style is overly complex and has multi-levels so that it is difficult to coordinate the services, to institute common service standards and to execute service policies. Consequently, the government investment becomes not cost-effective and the ratio between input and output of resources becomes disproportionate.6

Absence of national mental health legislation
In China, there is yet no nationwide law to protect the rights of people with mental illness and ensure adequate treatment for them. There are also no clear definitions in either psychiatry or law for issues such as guardianship, compulsory treatment, and competency.9 Furthermore, no clear policies exists to prevent unlawful institutionalization, coercive ECT and medication, and inappropriate detention for psychiatry evaluation (in the absence of psychotic symptoms).6

Lack of participation of non-governmental organizations
As described earlier, a large component of mental health services in Australia is provided by non-government organizations which are integrated with the governmental agencies. This substantially decreases case load and economic pressure on the public services while complementing the government funded services by filling their gaps. In China, there are very few mental health services provided by non-governmental organizations.

SHORT-TERM GOALS — ADDRESSING THE MOST URGENT ISSUES FACED BY THE CHINESE MENTAL HEALTH SYSTEM

By comparing the mental health service models between China and Australia, several challenges faced by Chinese mental health services are evident. (1) How to improve the accessibility of the mental health service for the general population, especially in the rural areas; (2) How to enhance the quality and efficiency of national mental health services; (3) How to ensure the legal rights of patients with mental illness; and (4) How to change the current hospital-based service model to a community-based model that caters for the individual needs of patients.

The mental health system reform in Australia has taken approximately a decade. It is likely that China will take more time to achieve this level of reform given China’s current conditions. As China is still a developing country, it is unrealistic to expect to meet the mental health needs of a massive population with limited resources within a short time. Accordingly, it would appear to be practical to implement the reform strategies in several stages. The pressing issues that need to be addressed urgently include improving access to mental health care, increasing mental health literacy, enhancing community workforce skills, establishing a national mental illness database, promulgating a national mental health act and coordinating governmental resources.

To meet these challenges, emphasis should not be given to the psychiatric hospitals, especially profit-making institutions. The following are suggestions to address the urgent problems and prepare for a long-term community mental health service model.

Improving access to mental health services
Policies need to be established to specify the minimum capacity of psychiatric department services, and psychiatric beds to a population ratio based on each county’s demographic features and mental health needs. To address the disproportionate workforce, advance training programs should be available complemented by a recruitment scheme from major psychiatric hospitals.

With the use of government financial support, community medical clinics can be set up, proportionally staffed according to the local population, with country doctors who are adequately trained to treat common mental illness. They ideally ought to be managed and salaried by the health administrative department rather than the hospital administration. Apart from providing clinical services, they can also promote mental health literacy, education, psychological counseling, early intervention and relapse prevention. Those patients with serious and complicated mental illness would be admitted to the hospital, whose role is to confirm diagnosis, set up a therapeutic plan, provide initial treatment and contain immediate risks. The community clinics can subsequently take responsibility for ongoing treatment and care. Quality control and evaluation policies should be established by the government for accreditation and monitoring purposes. Adequate financial and work incentives should be given, including advanced education opportunities. Resources and facilities for mental health should be advocated within government departments based on the potential and importance of reducing rates of crime and community disturbance attributed to untreated mentally ill patients (e.g. schizophrenia and major psychiatric disorders).

Since most Chinese patients with mental illness are reluctant to attend psychiatric hospitals for treatment, general hospitals could become the main mental health service providers. However, psychiatric specialties need to be developed within general hospitals and non-psychiatric doctors would require training by mental health specialists on how to recognize and treat the psychotic patients.

Decreasing the costs of medical and psychiatric care
Extending health insurance to a greater proportion of the population with a system of universal coverage needs to be explored as a means of increasing affordability of medical treatment. Under the current national situation however, this would prove too challenging and impractical. Access to basic medical care and services could be achieved by a government health tax, designating certain numbers of non-profit medical facilities, and using inexpensive medical technology and essential drugs.

A large number of people with major diseases are protected by city-worker basic medical insurance and new rural cooperative medical service system. All workers (whose families are taken as a unit) are required by legislation to participate in this insurance system, where the insurance premium is paid by both the employer and the employee. The government may subsidize poor people to join in such social medical insurance system. In addition, advocacy is needed for the inclusion of mental health related disability to be covered by commercial medical insurance system that is purchased privately. Further, agreements with pharmaceutical companies for low-costs drugs and implementing free medication treatment to the impoverished schizophrenia patients should be considered.

Due to the high health costs for such a massive population, limited availability of governmental subsidies and uneven regional economic development, the Chinese government should also allow regional policies for different provinces as long as these policies are in accordance with the national mental health service system.

In China, although essential medications are not expensive, the main barrier to care is the hospitalization costs. Hence, if access to treatment is available in the community especially for acute and urgent conditions, the need for hospitalization due to major mental illnesses would inevitably decrease, along with the duration of the hospital stay.

Long-term goal — strategies for future reform and development
Under the current national situation in China, the strategies suggested above provide only a short-term approach for patients with mental illness. The long-term goal needs to develop into a community-based national mental health system integrating prevention, treatment and rehabilitation services together for the benefit of the general public health. Such a service system requires clear governance and cooperation between the relevant government ministries and departments in an efficient and effective fashion. To achieve this goal, the community- based mental health service model implemented in the State of Victoria, Australia, can be used as a reference. A community mental health service flow chart for Victoria State is shown in Figure 3.
 

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Figure 3. The flow chart of community mental health system.

Although numerous difficulties may be encountered China in achieving similar service level, we have to continuously aim for such longer term goals. The key issues needing to be addressed to achieve this long-term goal are discussed as below.

Government support
A key element of success in the Australian mental health service reform is the existing government support and commitment in at least four aspects: policy, financing, legal and implementation support.

In setting up a new mental health service system framework and strategy, policy-makers may need to synthesize the international experiences and China’s unique situations to consider the priorities, sustainable development and the effectiveness of the plan. Considerable government investment is needed for a smooth transition and implementation of the plan in shifting mental health resources to community services. At the same time, the Chinese mental health act must be set up as soon as possible to protect the lawful rights of patients with mental illness. The Chinese mental health act draft (the 15th manuscript) had been completed in July 2004. The initial goals of this legal document are to protect patients’ basic rights and to improve services for them. Under the law, the patients should have access to proper medical treatment and rehabilitation services that will help them return to normal life gradually.9 It is anticipated that this bill will be officially promulgated soon. Finally, a management system should be instituted where there is adequate accountability, appraisal, surveillance and supervision of the framework implementation. The most successful projects are those that provide jobholders’ with regular surveillance and continuing education opportunities.13

Work force training
The delivery of mental health service depends heavily on human resources. Mental health professionals need to be adequately trained to evaluate and treat the mental health problems in both the hospital and/or the community settings. Moreover, well-trained mental health professionals are the key to mental health service improvement and promotion of mental health literacy.6 Therefore, to implement a community-based mental health service model, it is crucial for all mental health personnel to take a role in the transition from hospital-based to community-based care through professional training and development.

In China there are less than 1.53 per 100 000 population at present in China compared to 14 per 100 000 population in Australia. It is estimated that only 1/5 of 20 000 psychiatrists have received high quality academic training.6 In addition, the various mental health professionals, such as social worker, psychiatric nurse, clinical psychologist, occupational and rehabilitation therapist, are in high demand. Therefore, the training of mental health service related professionals is a key priority which can be addressed in the following ways: (1) Up-scaling the skills of the existing mental health professionals by advanced training in community-based service approaches; (2) Medical colleges and universities may consider increasing their enrollment in related specialties such as general practitioners (GPs), community nurses, social workers, psychologists and rehabilitation therapists; (3) Those undertaking training in colleges/universities would need to meet certain requirements before obtaining certification to meet the various professional standards. Those current professionals working in hospitals should receive continuing medical education and training regularly.

Implementing the community-based mental health
service model
In China, the following issues must be considered in gradually shifting the service from hospital-based model to community-based one.

An important goal is to integrate mental health service delivery into the primary health service. The availability of local medical clinics which complement the primary health care system would allow most patients with mental illness to access medical care. Such a service model could provide for prevention, treatment and rehabilitation together. Mental health services should be established in general hospitals and large psychiatric hospitals would need to be reduced in size.

The urban model in Shanghai and rural model in Yantai for community service in the 1980’s can be reviewed to be adapted into the community-based mental health service model and network in the country.7,14

Mental health service model in urban areas: To improve service access, mental health services need to be geographically based to serve the population within a catchment area. There are several advantages in this approach including the proximity of services to the patients and care-givers, maximizing the use of the local community resources and better integration of hospital and community services. There also needs to be an adequate range of community service components to meet the diverse needs of patients. Such service components may include acute crisis teams, continuing care teams, mobile support teams and homeless outreach teams which are run by a multidisciplinary staff. The role of case managers underpins the community mental health service system. Case managers need to be trained to advocate and coordinate comprehensive patient-centered care. Appropriate community beds should be made available for those who are too disabled to live at home.

Mental health service model in rural areas: a three-level mental illness treatment, rehabilitation and prevention network should be established in the countryside, which connects the county, the township and the village. This may include the following: (1) The county level general hospital can establish psychiatric services including inpatient care. (2) The township hospitals may function as the role of the mental health community service centers in rural areas but need to be staffed by mental health professionals; preferably in multidisciplinary areas. Clinical services are provided in addition to early intervention and mental health promotion. Inpatient service could also be set up in township hospitals that lie in high-density population areas. (3) The village medical professionals should be trained to identify common mental illness at least, and to make further referrals promptly if it is needed. They could act as the community doctors to report all mental illness related information to township hospitals which then communicated to relevant departments in the county. This service model is consistent with the “Construction and Development Plan for Countryside Health Service System” issued on August 29, 2006.

Applicable to both the urban and rural model, all mental health issues related to every patient should be managed by the case manager. The responsibilities of the case manager include regular contact with the consumer patient and the family members, monitoring the consumer’s medicinal compliance and follow-up visits, referring to other appropriate agencies. They are also the first point of contact in case of crisis by the patient and family and for promoting mental health knowledge.

Multi-sector services
It is desirable to encourage non-governmental organizations to establish mental health service facilities and projects. They could be set up to supplement the government mainstream services. Special projects can be designed for special groups of patients to meet their unique needs. Moreover, once the new project is formulated, a set of systematic standards should be set up to evaluate its effectiveness.

Health education
Improving mental health literacy among the public is another important goal of mental health care. The lack of mental health knowledge can lead to the delay of early recognition and treatment of the illness. Prejudice and misunderstanding towards mental illness can cause unfair treatment to patients with mental illness in society. From a historical point of view, mental illness patients have often been considered as a threat to social order. They are labeled as social instability factors for fear that they might lose control of their behaviors. This is also one of the reasons that they have been stigmatized once diagnosed with a mental illness. The long-term stigma and labeling towards mental illness has placed psychiatry at a low social status among other heath professions. As a result of this low social status, it is very difficult to recruit well-trained mental health professionals, especially in the countryside.

Thus, the government should encourage mass media to publicize mental health knowledge vigorously. In order to change public attitudes towards mental illness, various mass media, such as newspaper, television, broadcast and websites, should report more positive information about them. Excessive reporting on negative news, like the disturbing behavior of patients with mental illness, will instigate more fear among the public against them.

CONCLUSIONS

In the past 50 years, China’s mental health care has had an uneven course. While the whole health care system is under the influence of the economic reform and development, mental health care is facing specific challenges. These challenges include ensuring universal access in the face of widespread lack of coverage, an acute shortage of services particularly in rural areas, improving the quality of care throughout the country, advocating for the rights of the mentally ill and transforming a system of hospital-based care to an efficient community-based system responsive to the specific needs of the patient population.10 Recently, the Chinese central government has put tremendous emphasis on mental health and prioritized it as a key public health issue. The government is implementing its verbal commitment to mental health system reform into practice. The Mental Health Department of the Chinese Health Ministry has organized many Chinese experts to visit Melbourne, Australia to learn the community mental health service model, and some demonstration project work has already been started in China (686 projects). We anticipate that the Chinese government will have a long-term, sustainable commitment to mental health development. At the same time, a complete and comprehensive mental health act that protects the rights of patients with mental illness needs to be formulated and promulgated as soon as possible.

REFERENCES

1. Chinese Government Document. Plan for China’s Mental Health Work (2002–2010). Shanghai Arch Psychiatry (Chin) 2003; 15: 125-128.

2. Phillips MR. Strategies used by Chinese families coping with schizophrenia. In: Davis D, Harrell S, eds. Chinese families in the post-Mao era. Berkeley: University of California Press; 1993: 277-306.

3. Zhang W. Building for the future: the social and financial structures needed to provide effective and affordable care. Symposium at the Health Care, East and West, moving into the 21st century conference, Boston, USA, 2001.

4. Zhang MY, Zhu ZQ, He YL. Thinking about the mental health service strategies in China. Shanghai Arch Psychiatry (Chin) 2002; 14: 50-52.

5. Saraceno B, Sarena S. Mental health resources in the world: results from Project Atlas of the WHO. World Psychiatry 2002; 1: 40-44.

6. Chang DF, Kleinman A. Growing pains: mental health care in a developing China. Yale-China Health Studies J 2002; 1: 85-98.

7. Wang Q, Gong Y, Niu K. The Yantai model of community care for rural psychiatric patients. Br J Psychiatry 1994; 165: 107-113.

8. Gong Y, Wilkes A, Bloom G. Health and human resource development in rural China. Health Policy Plan 1997; 12: 320-328.

9. Park L, Xiao ZP, Worth J, Park JM. Mental health care in China: recent changes and future challenges. Harvard Health Policy Rev 2005; 6: 36-45.

10. Phillips MR. The transformation of China’s mental health services. China J 1998; 39: 1-36.

11. Gao J, Tang S, Tolhurst R, Rao K. Changing access to health services in urban China: implications for equity. Health Policy Planning 2001; 12: 302-312.

12. Pearson V. Mental health care in China: state policies, professional services, and family responsibilities. London: Gaskell; 1995: 1-217.

13. Cohen A. The effectiveness of mental health services in primary care: the view from the developing world. Mental health policy and service department. Geneva: World Health Organization; 2001: 1-54.

14. Zhang M, Yan H, Phillips MR. Community-based psychiatric rehabilitation in Shanghai: facilities, services, outcome, and culture-specific characteristics. Br J Psychiatry 1994; 165: 70-79.