Expanding the Mental Health Workforce in China: Narrowing the Mental Health Service Gap

In April 2016, the World Bank and the World Health Organization (WHO) cohosted the conference “Out of the Shadows: Making Mental Health a Global Development Priority” to encourage nations to invest in resources as necessary to address common mental disorders. The event report reemphasized the need for countries to develop a comprehensive mental health system, which has also been a focus in the WHO Comprehensive Mental Health Action Plan (2013–2020) (1,2). Committed to this international initiative, China is now implementing its National Mental Health Plan (2015–2020) (3), which aims to build sustainable strategies toward a comprehensive mental health system, as stipulated by China’s National Mental Health Law (4). However, significant shortages in licensed psychiatrists and allied mental health professionals in China greatly undermine these efforts.

To address the workforce shortage, China’s National Mental Health Plan (2015–2020) established a goal to increase the number of licensed psychiatrists to 40,000 by 2020 (from 25,000 in 2015) (3). To achieve this goal, the National Family Planning and Health Commission (NFPHC) designed a comprehensive strategy to improve mental health workforce training with interventions in undergraduate medical education, graduate medical education (residency), and continuing medical education.

Strategies to improve undergraduate medical education include the establishment of undergraduate psychiatry major programs (UPMPs) that provide a proportion of the students enrolled in medical school with education in mental health that is comparable to undergraduate psychiatry education programs in developed countries (5). Most medical schools in China provide minimal exposure to mental disorders in the preclinical curriculum and do not provide an organized core clinical psychiatry clerkship where students practice diagnosis and treatment of psychiatric disorders. Mental health–related course hours in the UPMPs are three to six times higher than the standard undergraduate medical education programs in China, and a clinical clerkship is provided. In 2016, the number of medical universities with UPMPs increased to 15, up from four in 2014, and the number of students enrolled in the UPMPs increased from fewer than 400 in 2014 to 1,132 in 2016. Implementing a UPMP curriculum in all Chinese medical schools is also under discussion, and the rationale for doing so is that all medical school graduates should have basic knowledge and clinical experience in psychiatry so they can recognize mental disorders and participate in mental health treatment, including integrated and collaborative care programs.

Strategies to improve graduate medical education include increasing the capacity of psychiatric graduate medical education (residency training). In China, trainees entering psychiatry residency programs include graduates of undergraduate medical programs, having finished either a regular clinical medicine track or a dedicated psychiatry major track (5). China’s efforts to develop a nationwide system for standardized residency training began over a decade ago. In 2007, only 126 psychiatry residents started training in the 13 training sites newly certified by the Ministry of Health in elite universities and affiliated hospitals. Nationwide scale-up of a standardized psychiatry residency training system first occurred in 2014. In 2015, 130 medical institutions have received authorization to establish psychiatry residency programs, with nearly a thousand psychiatric residents enrolled in these programs each year. Eight hundred residents completed residency training in 2015.

Continuing medical education is an important component of the strategy to improve mental health workforce training. Under this approach, physicians who are already in practice receive training in psychiatry and are licensed as psychiatrists. In October 2015, the NFPHC announced a five-year psychiatrist licensing program for practicing physicians. The program is scheduled to train more than 8,500 physicians by 2020. If this goal is achieved, it will constitute a significant proportion of the increase in licensed psychiatrists envisaged by the 2015–2020 National Mental Health Plan (3). Physicians recruited for the program will engage in a one-year education program that includes 160 hours of coursework and over ten months of clinical rotations. The didactic components are divided into modules of psychiatry, clinical psychology, community mental health services, professional communication, and mental health rehabilitation. The majority of the 1,700 trainees enrolled in the first year of this program are practicing physicians with various educational backgrounds from county-level hospitals in rural areas who will return to these employers after program completion. Prioritizing these training efforts for physicians from rural and underserved regions is an effective strategy to address the uneven rural-urban distribution of psychiatrists, demonstrating commitment to developing an equitable system of mental health care nationwide.

This psychiatrist licensing program addresses much of the knowledge and many of the skills articulated in a recent Lancet report (6) on improving mental health care in China. The program’s specific aims include providing training in community mental health service, integration of primary care and mental health service, consultation-liaison psychiatry service, and management of common mental disorders. Trainees are expected to understand community mental health services as an integrated system, consisting of prevention, assessment, treatment, rehabilitation, and employment support. The curriculum was designed to equip trainees with the skills needed for psychosocial interventions and knowledge of task sharing, preparing them to work in teams with clinical psychologists, psychiatric nurses, social workers, and case managers. Other recommended areas for knowledge and skill development, such as consultation-liaison psychiatry and geriatric psychiatry, are also taught in the curriculum.

The clinical assessment framework for this psychiatrist licensing program is comprehensive and multimodal, consisting of medical record documentation, clinical knowledge, and professional competencies. A trainee’s medical record documentation is evaluated for its quality and quantity, as well as for case variety. Clinical knowledge of a trainee is assessed through on-site questioning from examiners on such topics as diagnosis and management of common mental disorders, administration of psychotropic medications and their common adverse reactions, and management of common psychiatric emergencies. Assessment of professional competencies covers areas of interpersonal communication skills, professionalism, patient safety, medical ethics, and legal awareness. This assessment is conducted by the supervising attending physician through an assessment form with clear behavioral anchors. The NFPHC is conducting process evaluation in selected training sites across China to monitor and document program implementation. One evaluation priority is the curricular content that instructs trainees to perform in a task-sharing system, such as skills to supervise community health workers.

We believe the psychiatrist workforce development efforts in China represent concrete steps to address the mental health service goals listed in the WHO Mental Health Gap Action Program and 2013–2020 Comprehensive Mental Health Action Plan. If successful, the impact will be far reaching in expanding access for the prevention, diagnosis, and treatment of mental disorders nationwide and in improving population mental health for the country.

Although these are very promising policies and programs, challenges to developing an equitable, high-quality mental health workforce for rural areas and western China is likely to continue for some time. The urban-rural disparity will likely continue because most medical graduates are attracted to the coastal, economically advanced areas for employment. A significant portion of the psychiatrist workforce, especially in rural settings, do not have sufficient academic experience to teach, in that they often have only a postsecondary associate degree from technical schools that is usually completed in two years as preparation for employment. In addition to the shortage of psychiatry faculty with teaching experience, some medical universities do not have qualified sites for psychiatry clinical education. In response, NFPHC will prioritize the establishment of UPMPs in areas with the greatest need, including western China and other economically underdeveloped regions, with the goal of establishing at least one UPMP in each province; the hope is that graduates will be more likely to remain in these regions and will be able to help train future generations of mental health clinicians. Medical universities and research institutes are being encouraged to establish collaborative training mechanisms with mental health services in undeveloped regions that have the greatest workforce needs.

Another critical component of increasing access and equity in mental health care in China is increasing the quality and numbers of the nonpsychiatric mental health professionals. Despite the critical contributions these professionals make in the treatment and prevention of mental disorders, especially less acute disorders with high incidence, such as mild to moderate depression and anxiety, the system currently suffers from a severe lack of nonpsychiatric mental health professionals, such as clinical psychologists, social workers, psychotherapists or counselors, and occupational therapists (7). In general, these allied fields are underdeveloped in China. The number of psychotherapists nationwide is only around 5,000. Only 30,000–40,000 out of 897,000 licensed counselors are engaged in mental health–related work. No nationwide data are yet available on the workforce size of either clinical social workers or occupational therapists (7). Many treatment centers do not employ sufficient numbers of nonpsychiatric mental health personnel to support intervention and prevention efforts (8). In fact, many mental health facilities in China lack nonpsychiatric mental health professionals altogether, and as is the case with the psychiatric workforce, allied mental health professionals are concentrated in urban, coastal areas (8).

In addition to low numbers of mental health professionals in China, challenges in quality and training of existing personnel are also concerns. For example, psychotherapists provide secondary prevention services for psychological and behavioral problems in settings such as community and maternal-child health centers. However, although accreditation programs exist, psychotherapists in China are not necessarily required to be systematically trained or to undergo a supervision process but instead can choose to earn a certificate awarded on passing one examination (8). This is far below international training standards for mental health professionals. Wong et al. (8) have noted that even in fields with university accreditation programs, such as for social workers and psychotherapists, field work and clinical training in particular fall well below international standards, and some instructors lack the necessary clinical experience to prepare competent mental health professionals. As China seeks to meet the tremendous mental health needs of its population, the development and maturation of training programs and licensure processes for clinical psychologists, social workers, and counselors are crucial to the success of widespread prevention and intervention efforts.

Sustained effort will be required to provide a high-quality, equitably distributed mental health workforce in China. Outcome evaluations of its education programs and mental health service research will be critical to improve these programs and to inform future policies and programming. Even though these models address only the psychiatry workforce, having sufficient numbers of psychiatrists to consult in integrated care settings is critical to ensuring a high-quality program. We believe these programs have relevance not only in China but for the global community as well.