Mental Health Care Reforms in Asia: The Urgency of Now: Building a Recovery-Oriented, Community Mental Health Service in China

Professional skills of the mental health workforce in China must be significantly improved. We can learn a great deal here from the 686 Project, China’s 2004 mental health reform initiative. First, it was modeled on the World Health Organization’s recommended framework for integrating hospital-based services with a CMHS system (7,15). Indeed, the CMHS has to be effectively integrated with hospital-based services, and mental health services have to be an integral part of general health systems. People with mental illness and their families are often frustrated at being offered treatment by different providers that do not communicate with each other and then having to negotiate the many gaps by themselves. Second, it offers a sound train-the-trainers infrastructure (382,000 individuals were trained by the end of 2011) readily transferable to other locations, and its delivery has demonstrated characteristics that seem to suit the ideology and belief systems of Chinese culture. Third, the 686 Project has secured government investment. The central government has invested an additional RMB 220 million (US$32.2 million) since its inception in December 2004 with a seed grant of RMB 6.86 million. By November 2011, 1.83 million citizens with severe mental illness were treated through the project, which covered 766 sites in 170 cities with a total catchment population of 43 million (8,15).

We also propose training for CMHS staff (including physicians specializing in mental health, social workers, nurses, and occupational therapists) in the recovery approach. We suggest that the recovery approach resonates strongly with traditional Chinese culture and is highly consistent with the values embedded within the 686 Project, such as paying more attention to the person’s level of functioning and strengths, rather than disabilities and psychopathology (15). The recovery approach emphasizes self-confidence (自信), self-help (自助), and self-sufficiency (自給自足). It is not a model of service delivery as such, but an encompassing ethos or approach that can be applied to any model (including any indigenous health initiatives) that focuses on the strengths and resources of service users and their communities, as well as mental health services (16) (online data supplement, Opportunities column).

The recovery approach draws on a series of principles and theories (such as partnership, capacity building of local service providers, and strategies to instill hope) based on three decades’ worth of studies and clinical evidence, most of which has been collected in the United States, United Kingdom, Australia, New Zealand, and, more recently, Hong Kong (17,18). From this empirical base, various international practice guidelines for supporting recovery have been developed, primarily in community settings (19). Examples of specific recovery practices are peer support services, strengths-based case management, and the Wellness Recovery Action Plan (illness self-management).

Nevertheless, it is important to investigate how recovery is redefined by individuals with personal experience of mental illness—and negotiated within—a Chinese cultural and practice context and how acceptable it is for more traditionally trained medical staff. What are the factors that facilitate or hinder recovery for individuals at different stages of their journey in the modern cultural landscape of China, where mental illness remains taboo and only limited resources are allocated to the CMHS? By gaining further insight and knowledge about the meaning of recovery for Chinese service users and how these are similar to or different from ideas of recovery espoused by mental health staff (20), a more culturally applicable CMHS can be developed, which will better address service users’ needs.

As well as building staff skills, we must also empower families and caregivers to support individuals with severe mental illness, especially in rural areas. Caregiving is absolutely central to who we are as human beings. For a number of reasons, supporting family-based caregiving is also a strategic intervention. First, up to 80% of individuals with mental illness in China (especially in rural areas) are looked after by family members at home, by choice or otherwise (13). This figure will increase as the National Mental Health Law is implemented. Second, the burden of caregiving in the Chinese context and the related feelings of strain (caused by factors such as the significant cost), coupled with family dysfunction (for example, high levels of expressed emotion and negative affective style), often have a combined negative effect on outcomes, although the mechanism of influence remains unclear. Third, there is increasing evidence of the effectiveness of family-based interventions embedded within the CMHS, in terms of relapse prevention and improved clinical outcomes (21). In such interventions, family members are supported through home visits where service users’ well-being and adherence to interventions are reinforced and their ongoing supply of medication ensured.

The number of Internet users in China has risen to 538 million, and the number of mobile Internet users has grown rapidly to 388 million (22). We must make better use of information and communications technology (ICT) to promote self-help and reduce the stigma associated with severe mental illness. China has a vast population of diverse cultures and dialects spread over a wide geographical area. The potential to use ICT in mental health interventions in the Web 2.0 era should not be underestimated. ICT applications (such as those available on 3G network phones) and Chinese social networking sites (such as Tencent QQ, Renren, and Weibo) can help fight the stigma of mental illness, combat discrimination, and create new platforms for computer-literate people, particularly those in the younger generation (23) who are affected by mild or subclinical mental health problems.

Using social networking to find out how someone with personal experience of mental illness has learned to function again and find a new role in life may inspire others and help combat stigma. Computer-automated, mobile applications–based assessments and behavioral change interventions are also being implemented around the world, and guidelines for developing computer-based adjunct psychotherapy are being established (24). Preliminary results from the Organization for Economic Cooperation and Development countries indicate that ICT improves service quality, with little corresponding increase in cost or clinicians’ time; however, limited evidence has been gathered so far in developing countries, including China. Furthermore, despite their good intentions, both clinicians and computer programmers often neglect the subtly different needs of individuals from non-European cultural backgrounds when designing high-powered, technology-based programs for use in the developing world.

Of course, the critical question is how all these proposed changes will be financed. To complicate the matter further, presently less than 4% of the total health budget was spent on mental health care, most of which went to hospital-based services, not community-based services (“Weaknesses” column in online data supplement). In contrast, mental health costs accounted for approximately 20% of total health expenses (25). On the other hand, the promising sign is that the government is planning to increase the mental health budget from 3%−4% of the total national health budget in 2010 to 7%−8% by 2015 and is planning to ensure that up to 55% of health dollars will be spent on public and rural health in particular (26). Perhaps this unprecedented challenge in human history is not only to fund huge and complex health care reforms for the 1.3 billion people in China but to find the paths to achieving its stated goals (6). These are the questions or challenges for which we do not necessarily have the answer, but they speak to the urgent need for clinicians, policy planners, researchers, service users, and caregivers alike to begin a dialogue and work together at this seminal moment for the development of community-based mental health care in China. We must open the forum now for further discussion.