Mental Health Service Use Among Chinese Adults With Mental Disabilities: A National Survey
Abstract
Objective
Mental disability in China has become a significant public health problem. However, few studies have examined utilization of mental health services in China among people with mental disabilities. This study explored patterns of service use and associated socioeconomic factors among Chinese adults with mental disabilities.
Methods
Data from a population-based survey representing approximately 75% of the Chinese population were analyzed. Mental disability was defined as having a mental disorder (cognitive, affective, or behavior disorder) lasting more than one year that limited daily life and social functioning. The study assessed use of any mental health specialty care and use of specific types: medical services only, rehabilitation services only, and medical and rehabilitation services. Standard weighting procedures were used. Population weighted numbers, weighted proportions, and the odd ratios (ORs) were calculated.
Results
A total of 1,909,199 noninstitutionalized adults (weighted N=984,698,518) age 18 and older were interviewed. The weighted prevalence rate of mental disability was .81%. More than 4.2 million adults with a mental disability (52%) had never used a mental health service. Several variables were associated with greater use of mental health services: urban residence (OR=1.65), high school education or higher (OR=1.66), being married (OR=1.12), medical insurance coverage (OR=1.39), and higher annual family income (OR=1.28).
Conclusions
The findings indicate unmet needs for mental health services among Chinese adults with mental disabilities, as well as socioeconomic inequalities in use. Strategies are needed for enhancing community mental health service systems and reducing barriers to mental health service use in China.
Mental disorders have become a global challenge—a challenge that is more evident in fast-growing developing countries (1–3). Studies have found that approximately 17% of adults in China had at least one mental disorder in the past month (4–6). By 2020, mental disorders are expected to account for 20% of the total disease burden in China (3,7).
People with mental disorders may have severe difficulties in social and cognitive functioning and may be disabled (8,9). An Australian national survey found that 24% of persons with mental disorders met criteria for moderate disability and 20% met criteria for severe disability (10). A survey in four provinces in China reported that 24% of persons with mental disorders may have had moderate to severe functional impairment (4). Among persons with mental disorders, diminishment in the capacity to carry out daily roles proceeds along multiple pathways. However, deterioration in functioning caused by illness may prevent individuals from seeking needed mental health services, including pharmacotherapy and psychosocial rehabilitation, which would further impair social and cognitive functioning. Because persons with mental disabilities may be more vulnerable to developing comorbid psychiatric and general medical conditions and thus may have greater needs for treatment and rehabilitation (11–13), an understanding of mental health service utilization by persons with mental disabilities would inform the development of intervention strategies to help these individuals achieve their full life potential and reduce the disability burden on patients, families, communities, and societies.
Many studies have addressed the high need for mental health services among persons with mental disorders (4,14–21). However, few studies have explored use of mental health services among individuals with mental disabilities. Using data from a national survey in Australia, Andrews and colleagues (16) found that 55% of persons with mental disabilities had consulted a health professional for their problem. However, such studies are lacking in China, where there were more than eight million people with mental disabilities in 2006 and where the prevalence of mental disabilities has risen significantly from .3% in 1987 to .5% in 2006 (22).
In the study reported here, we used nationally representative data from the second China National Disability Survey conducted in 2006 (23) to explore patterns of mental health service utilization and investigate the socioeconomic factors associated with utilization among Chinese adults with mental disabilities.
Methods
Data source
We used data from a nationally representative population-based survey conducted in 2006. This survey aimed to describe the prevalence of disabilities in China, explore characteristics of people with disabilities, and analyze factors related to disabilities. The survey targeted the community-dwelling population; persons in institutions were not included.
The survey employed a multistage, stratified, probability-proportional-to-size, clustered random-sampling scheme. A total of 734 counties (cities or districts), 2,980 towns (townships or streets), and 5,964 communities were selected from 31 provinces, autonomous regions, and municipalities in China. Approximately 20,000 interviewers, 6,000 doctors, and 50,000 survey assistants were trained and participated in the survey. Details of the survey sampling procedures have been described elsewhere (22). The survey was approved by the State Council of China, and all respondents gave consent to participate.
Population
During the survey, every family member of the selected households was interviewed. A disability screening scale was administered, and participants who screened positive for a suspected mental disability were then examined by psychiatrists, who used the ICD-10 (24) to provide a diagnosis and the World Health Organization Disability Assessment Schedule (WHO-DAS-II) (25) to assess severity. The survey protocol was determined by the members of the National Bureau of Statistics, the China Federation of Disabled Persons, and the United Nations (23). Details about field implementation and quality control have been published elsewhere (23)
Definitions for all types of disabilities were established by the expert committee of the Second China National Sample Survey on Disability and based on the WHO International Classification of Functioning, Disability, and Health (WHO-ICF) (26). Mental disability was defined as having a mental disorder (cognitive, affective, or behavior disorder) lasting more than one year that limited and restricted the patients’ daily life and social functioning as assessed by the WHO-ICF (26). All survey respondents age 18 years and older who had a psychiatrist-confirmed mental disability were included in the study reported here.
Variables
The primary study outcome was utilization of any mental health service or no utilization. Utilization was classified as use of any type of mental health specialty care (receipt of mental health services in settings such as psychiatric hospitals, psychiatric wards in general hospitals, and community mental health services). To assess the secondary outcome, mental health service utilization was further categorized as use of medical services only (mainly pharmaceutical treatment), use of rehabilitation services only (mainly nonpharmaceutical treatment) (27), and use of medical and rehabilitation services.
Data were obtained on age (18–24, 25–29, 30–34, 35–39, 40–44, 45–49, 50–54, 55–59, 60–64, 65–69, 70–74, 75–79, or ≥80 years), marital status (married, unmarried, or divorced or widowed), education (illiterate, elementary school, junior high school, or high school or higher), annual family income divided by the number of persons in the household (higher than the national average or equal to or lower than the national average), medical insurance coverage (yes or no), severity of mental disability (mild, moderate, severe, or extremely severe), and causes of mental disability (organic mental disorders; mental disorders due to psychoactive substance use; schizophrenia or schizotypal or delusional disorders; mood disorders; neurotic, stress-related, or somatoform disorders; disorders of adult personality and behavior; epilepsy; or other).
Data analysis
We used standard weighting procedures calculating the inverse probability of inclusion of individual survey respondents in the multistage sampling frame to construct sample weights accounting for the complex survey sample design (28). Population-weighted numbers and proportions were calculated where appropriate. Multivariate logistic regression models were used to calculate adjusted odd ratios (ORs) and 95% confidence intervals (CIs). The Taylor series linearization method was used to estimate variance and corresponding CIs (29). The procedures SURVEYFREQ and SURVEYLOGISTIC of the SAS 9.1 package were used to perform all data analyses (30). We set the significance level at p≤.05.
Results
Service use by adults with a mental disability
The total survey population was 2,526,145 persons, and the response rate was 83.5%. Among adults (≥18 years), 1,909,199 noninstitutionalized persons (weighted N=984,698,518) representing approximately 75% of the Chinese population were interviewed; a weighted eight million persons were diagnosed as having a mental disability (.6% of the Chinese population). The weighted prevalence rate of mental disability was .81% (CI=.80%–.83%). Among Chinese adults with a mental disability, more than 4.2 million (52%) had never used any mental health services.
Table 1 presents data (weighted percentages) on use of various types of services by Chinese adults with a mental disability. Use of rehabilitation services was quite low.
| Characteristic | Weighted N (thousands) | Use of services (weighted %) | No service use (weighted %) | ||
|---|---|---|---|---|---|
| Medical | Rehabilitation | Both | |||
| Gender | |||||
| Male | 3,679 | 39.5 | .9 | 7.4 | 52.2 |
| Female | 4,336 | 39.7 | 1.0 | 6.9 | 52.5 |
| Residence | |||||
| Rural | 5,920 | 37.7 | .9 | 5.4 | 56.1 |
| Urban | 2,095 | 45.0 | 1.1 | 12.1 | 41.8 |
| Education level | |||||
| Illiterate | 3,012 | 33.9 | 1.2 | 5.2 | 59.7 |
| Elementary school | 2,493 | 40.8 | .7 | 7.2 | 51.4 |
| Junior high school | 1,755 | 44.4 | 1.0 | 8.7 | 45.9 |
| High school or higher | 755 | 47.1 | 1.0 | 10.9 | 41.1 |
| Marital status | |||||
| Unmarried | 1,886 | 38.1 | 1.1 | 7.4 | 53.4 |
| Married | 4,701 | 41.0 | .9 | 7.1 | 51.0 |
| Divorced or widowed | 1,428 | 36.9 | 1.1 | 6.8 | 55.3 |
| Annual family incomeb | |||||
| ≤National average | 7,049 | 38.9 | 1.00 | 7.0 | 53.1 |
| >National average | 966 | 44.7 | .6 | 8.3 | 46.5 |
| Medical insurance | |||||
| No | 5,568 | 37.2 | 1.0 | 6.6 | 55.2 |
| Yes | 2,447 | 45.0 | .8 | 8.3 | 45.9 |
| Cause of mental disability | |||||
| Organic mental disorder | 1,596 | 37.7 | 1.4 | 8.6 | 52.3 |
| Mental disorder resulting from psychoactive substance use | 243 | 26.0 | 1.3 | 2.9 | 69.8 |
| Schizophrenia, schizotypal, or delusional disorder | 4,410 | 41.7 | .9 | 7.1 | 50.4 |
| Mood disorder | 441 | 40.8 | .1 | 8.2 | 50.9 |
| Neurotic, stress-related, or somatoform disorder | 399 | 37.9 | .5 | 7.7 | 53.9 |
| Disorder of adult personality and behavior | 82 | 36.8 | 1.6 | 7.3 | 54.3 |
| Epilepsy | 492 | 42.8 | .3 | 4.2 | 52.8 |
| Other | 353 | 28.4 | 2.0 | 5.6 | 64.1 |
| Severity of mental disability | |||||
| Mild | 3,232 | 39.9 | .9 | 6.9 | 52.3 |
| Moderate | 1,235 | 41.1 | .5 | 6.8 | 51.7 |
| Severe | 1,091 | 38.4 | .8 | 7.4 | 53.3 |
| Extremely severe | 2,457 | 39.0 | 1.3 | 7.5 | 52.3 |
a
Source: the second China National Disability Survey, 2006 (weighted total N=984,698,518)
b
Divided by the number of persons in the household
Factors associated with service use
We used two separate multivariate logistic regression models to investigate factors associated with use of mental health services. Use of any mental health service among Chinese adults with a mental disability was the primary study outcome. Several variables were associated with greater use of any service: urban residence (OR=1.65), any level of education (compared with illiterate) (elementary school, OR=1.35; junior high school, OR=1.59; high school or higher, OR=1.66), being married (OR=1.12), medical insurance coverage (OR=1.39), and higher annual family income (mean±SD household size=3.73±1.47, range of one to eight members) (OR=1.28) (Table 2). Causes of mental disability were also associated with use of any mental health service; persons with a mental disability resulting from psychoactive substance use were less likely to use mental health services (OR=.40).
| Variable | OR | 95% CI |
|---|---|---|
| Female (reference: male) | 1.04 | .96–1.13 |
| Urban residence (reference: rural) | 1.65 | 1.45–1.88 |
| Age group (reference: 18–24) | ||
| 25–29 | 1.09 | .89–1.34 |
| 30–34 | 1.03 | .85–1.24 |
| 35–39 | 1.01 | .84–1.22 |
| 40–44 | 1.07 | .88–1.29 |
| 45–49 | .95 | .78–1.16 |
| 50–54 | 1.08 | .89–1.31 |
| 55–59 | 1.01 | .82–1.24 |
| 60–64 | 1.01 | .81–1.26 |
| 65–69 | 1.14 | .91–1.43 |
| 70–74 | 1.09 | .86–1.37 |
| 75–79 | 1.00 | .76–1.30 |
| ≥80 | .93 | .71–1.22 |
| Education level (reference: illiterate) | ||
| Elementary school | 1.35 | 1.23–1.49 |
| Junior high school | 1.59 | 1.41–1.78 |
| High school or higher | 1.66 | 1.42–1.93 |
| Marital status (reference: unmarried) | ||
| Married | 1.12 | 1.00–1.25 |
| Divorced or widowed | .94 | .82–1.08 |
| Annual family income >national average (reference: ≤national average)b | 1.28 | 1.13–1.45 |
| Medical insurance (reference: no) | 1.39 | 1.24–1.55 |
| Severity of mental disability (reference: mild) | ||
| Moderate | 1.02 | .91–1.14 |
| Severe | .99 | .88–1.11 |
| Extremely severe | 1.10 | 1.00–1.22 |
| Cause of mental disability (reference: schizophrenia, schizotypal, or delusional disorder) | ||
| Organic mental disorder | 1.01 | .90–1.13 |
| Mental disorder resulting from psychoactive substance use | .40 | .32–.51 |
| Mood disorder | .89 | .76–1.06 |
| Neurotic, stress-related, or somatoform disorder | .86 | .71–1.03 |
| Disorder of adult personality and behavior | .85 | .58–1.24 |
| Epilepsy | 1.00 | .85–1.17 |
| Other | .67 | .54–.84 |
a
Source: the second China National Disability Survey, 2006 (weighted total N=984,698,518)
b
Divided by the number of persons in the household
Use of various types of services among Chinese adults with a mental disability was the secondary study outcome. Several variables were associated with greater use of medical services: urban residence (OR=1.50), any level of education (compared with illiterate) (elementary school, OR=1.33; junior high school, OR=1.55; high school or higher, OR=1.62), being married (OR=1.14), medical insurance coverage (OR=1.39), and higher annual family income (OR=1.27) (Table 3). Variables associated with greater use of both medical and rehabilitation services were urban residence (OR=2.67), any level of education (compared with illiterate) (elementary school, OR=1.61; junior high school, OR=1.91; high school or higher, OR=1.96), medical insurance coverage (OR=1.38), and higher annual family income (OR=1.42).
| Variable | Medical service | Rehabilitation service | Both | |||
|---|---|---|---|---|---|---|
| OR | 95% CI | OR | 95% CI | OR | 95% CI | |
| Female (reference: male) | 1.04 | .95–1.13 | 1.36 | .85–2.17 | 1.03 | .88–1.22 |
| Urban residence (reference: rural) | 1.50 | 1.31–1.72 | 1.63 | .98–2.71 | 2.67 | 2.09–3.42 |
| Age group (reference: 18–24) | ||||||
| 25–29 | 1.02 | .83–1.27 | 1.42 | .65–3.08 | 1.55 | .99–2.43 |
| 30–34 | .99 | .81–1.21 | .84 | .33–2.19 | 1.33 | .87–2.02 |
| 35–39 | .99 | .81–1.20 | .94 | .42–2.10 | 1.19 | .78–1.80 |
| 40–44 | 1.01 | .83–1.23 | .76 | .31–1.83 | 1.63 | 1.08–2.45 |
| 45–49 | .89 | .72–1.10 | .90 | .34–2.39 | 1.46 | .93–2.30 |
| 50–54 | 1.04 | .85–1.27 | .85 | .37–1.95 | 1.43 | .93–2.21 |
| 55–59 | .99 | .80–1.23 | .53 | .19–1.52 | 1.26 | .79–2.00 |
| 60–64 | .96 | .76–1.21 | .85 | .32–2.28 | 1.46 | .92–2.31 |
| 65–69 | 1.15 | .91–1.45 | .58 | .15–2.21 | 1.20 | .71–2.02 |
| 70–74 | 1.03 | .81–1.32 | .28 | .06–1.20 | 1.76 | 1.08–2.86 |
| 75–79 | .97 | .74–1.28 | .72 | .26–2.04 | 1.23 | .69–2.18 |
| ≥80 | .87 | .65–1.16 | .40 | .11–1.48 | 1.54 | .91–2.61 |
| Education level (reference: illiterate) | ||||||
| Elementary school | 1.33 | 1.21–1.48 | .76 | .45–1.30 | 1.61 | 1.31–1.98 |
| Junior high school | 1.55 | 1.38–1.76 | 1.15 | .70–1.91 | 1.91 | 1.52–2.41 |
| High school or higher | 1.62 | 1.39–1.90 | 1.25 | .62–2.52 | 1.96 | 1.46–2.63 |
| Marital status (reference: unmarried) | ||||||
| Married | 1.14 | 1.02–1.28 | 1.03 | .62–1.72 | .97 | .78–1.21 |
| Divorced or widowed | .97 | .84–1.12 | 1.16 | .57–2.33 | .77 | .59–1.02 |
| Annual family income >national average (reference: ≤national average)b | 1.27 | 1.12–1.44 | .75 | .37–1.49 | 1.42 | 1.13–1.80 |
| Medical insurance (reference: no) | 1.39 | 1.24–1.56 | 1.10 | .67–1.81 | 1.38 | 1.12–1.70 |
| Severity of mental disability (reference: mild) | ||||||
| Moderate | 1.04 | .92–1.17 | .51 | .26–1.00 | .99 | .79–1.25 |
| Severe | .98 | .87–1.11 | .80 | .45–1.44 | 1.09 | .86–1.38 |
| Extremely severe | 1.08 | .97–1.21 | 1.21 | .76–1.92 | 1.17 | .95–1.43 |
| Cause of mental disability (reference: schizophrenia, schizotypal, or delusional disorder) | ||||||
| Organic mental disorder | .96 | .85–1.08 | 1.69 | .97–2.94 | 1.29 | 1.05–1.58 |
| Mental disorder resulting from psychoactive substance use | .41 | .32–.53 | 1.34 | .51–3.55 | .27 | .14–.50 |
| Mood disorder | .88 | .74–1.05 | .11 | .02–.75 | 1.06 | .78–1.44 |
| Neurotic, stress-related, or somatoform disorder | .83 | .69–1.01 | .60 | .21–1.73 | 1.05 | .74–1.50 |
| Disorder of adult personality and behavior | .82 | .55–1.21 | 1.68 | .39–7.25 | .94 | .44–2.03 |
| Epilepsy | 1.06 | .91–1.25 | .39 | .12–1.29 | .66 | .44–.98 |
| Other | .63 | .50–.79 | 1.79 | .94–3.40 | .81 | .51–1.27 |
a
Source: the second China National Disability Survey, 2006 (weighted total N=984,698,518)
b
Divided by the number of persons in the household
Discussion
Persons with a mental disability may be more vulnerable to developing a comorbid condition and thus may have greater needs for treatment and rehabilitation to achieve their full life potential and reduce the burden on patients, families, communities, and societies. This analysis of data from a nationally representative survey described utilization of mental health services and associated socioeconomic factors among Chinese adults with a mental disability. Not surprisingly, less than half of this population (48%) had ever used a mental health service. This finding is consistent with low-use patterns reported by previous studies in China, although those studies focused on persons with a mental disorder rather than on those with a mental disability (4,21).
Compared with previous studies in China and studies in developed and developing countries (1,14,15,20,31–34), the proportion of persons using mental health services was higher in the study reported here. This finding may be attributable to differences in study populations—that is, persons with a mental disorder and those with a mental disability may have different patterns of mental health service use. For example, Andrews and colleagues (16) reported a higher rate of mental health service use in Australia among persons with a mental disability than among those with a past-year mental disorder (40.3% versus 17.4%). One possible explanation of this difference may be related to the escalating of severity of mental disorders; greater severity would result in greater use of mental health services (14,35,36). However, even though previous studies have found that the severity of mental disorders was positively correlated with mental health service utilization (1,14,35,36), we found that the severity of disability was not associated with utilization. A difference in instruments used to measure severity may explain this finding. For example, in the WHO World Mental Health Survey, the Sheehan Disability Scale was used (1), whereas we used the WHO-DAS-II (25) to assess severity.
It is also possible that care-seeking behavior or health beliefs among patients with mental disorders change after the disorder results in disability; that is, patients who have a mental disorder without impairment may more actively seek services when the disease progresses, whereas patients with a mental disability may not actively seek services. Thus our finding suggests the importance of taking steps to prevent disability in the course of mental health consultation and treatment. In addition, this finding further highlights the importance of assessing the disability status of patients with mental disorders when setting goals to improve their use of mental health services—a topic that has not been adequately addressed in the literature.
This study found that more than four million (52%) Chinese adults with a mental disability had never used a mental health service. Many reasons for this low utilization can be offered. Chinese policies do not support treatment seeking; China has not passed national mental health legislation that would give mental health the priority it deserves (37,38). In addition, China is currently short of state-funded mental health systems, and most insurance plans do not cover the costs of mental health consultations (39). Notably, Brazil, another developing country that is undergoing a rapid socioenvironmental transition, has a somewhat similar shortage of mental health services and incomplete insurance coverage (40). China has even fewer mental health resources than Brazil. In 2005, there were only 1.29 psychiatrists per 100,000 population and .11 psychiatric hospital beds per 1,000 population in China, compared with 4.8 and .26, respectively, in Brazil (41). Regarding insurance coverage, China is similar to Brazil in that not all costs of mental health care are covered by the current medical insurance system (39), which may partly explain why many persons in our study who had a mental disability and medical insurance remained untreated (46%). Strategies to improve mental health utilization are warranted, especially in developing countries.
Our findings differ from some previous findings (40,42,43) in that persons with a mental disability who were married in our study were more likely to seek mental health services than those who were single or widowed or divorced. However, this finding was consistent with a study in China by Zhang (44), who reported that patients with schizophrenia in rural communities who were married were more likely than those who were single or widowed or divorced to use mental health services. Because of the existence of stigma in China and widespread unawareness of mental health problems (44), it is noteworthy that significant others (spouses, relatives, or friends) were an important pathway to mental health service use. Significant others can have an important role in help-seeking behavior (45), but how this plays out in Chinese communities remains unknown, and further studies are needed to explore the underlying reasons.
Results of this study support previous findings of an association between a lower likelihood of mental health service use and public attitudes toward and beliefs about mental illness and its treatment (37,38,46), lack of insight (39), inadequate coverage of mental disability by social security systems (18,47), lower income (40,48–50), illiteracy (51), and rural residency (31). These findings suggest that current strategies to increase access and reduce barriers to mental health services should incorporate disability indicators, which are unfortunately lacking in China (39). Future initiatives could specifically target knowledge deficiency, such as training for psychiatrists to promote early intervention and identification of mental disability and public education programs to increase awareness and promote the prevention of disability.
This study also revealed unmet need for psychosocial and nonpharmaceutical rehabilitation services among Chinese adults with mental disabilities. Early in the 1980s, China began to establish psychiatric specialties in hospitals, and 30 years later mental health services are still predominantly institution based and focused on pharmaceutical treatment (39). Therefore, efforts are warranted to strengthen legislation improving insurance coverage of mental disabilities and to establish rehabilitation centers in communities. Strategies and programs to improve community-based rehabilitation should take into consideration factors such as accessibility and availability, as well as system-level factors related to integration into primary health care systems. During the current socioeconomic and health transitions in China, such efforts may be most urgently needed by socioeconomically disadvantaged populations, which have a great burden of mental disabilities.
This study had several limitations. First, recall bias could have led to an underestimated rate of mental health service utilization. Second, we did not analyze specific aspects of mental health service use, such as frequency, provider type, and adequacy of treatment. Further analysis of the quality of mental health services provided by various facilities may inform our understanding of the low use of services among Chinese adults with mental disabilities. Because persons who used mental health services may have been undertreated, further studies could focus on identifying factors to increase use of mental health services or improve and enhance these services. Despite these limitations, this study sheds light on mental health service use by persons with mental disabilities in China, where a rapid socioenvironmental transition is significantly increasing this burden (22), and calls attention to appropriate strategies to increase service use.
Conclusions
The findings of this study indicate unmet needs for mental health services among Chinese adults with mental disabilities, as well as socioeconomic inequalities in use. A substantial number of persons with mental disabilities remain untreated, and more attention and effort are required to increase their use of services.
Acknowledgments and disclosures
This study was supported by the State Key Development Program of Basic Research of China (973-2007CB511901), the Yang Zi Program of the Ministry of Education of China, and the State Key Funds of Social Science Project (Research on Disability Prevention Measurement in China, 09&ZD072).
The authors report no competing interests.
References
1.
Demyttenaere K, Bruffaerts R, Posada-Villa J, et al.: Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA 291:2581–2590, 2004
2.
Wittchen HU, Jacobi F: Size and burden of mental disorders in Europe: a critical review and appraisal of 27 studies. European Neuropsychopharmacology 15:357–376, 2005
3.
Murray CJL, Lopez AD: 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
4.
Phillips MR, Zhang J, Shi Q, et al.: Prevalence, treatment, and associated disability of mental disorders in four provinces in China during 2001–05: an epidemiological survey. Lancet 373:2041–2053, 2009
5.
Li K, Cui Z, Cui L, et al.: Epidemiological survey of mental disorders in people aged 18 or over in Hebei Province [in Chinese]. Chinese Journal of Psychiatry 40:36–40, 2007
6.
Shi QC, Zhang JM, Xu FZ, et al.: Epidemiological survey of mental illnesses in the people aged 15 and older in Zhejiang Province, China [in Chinese]. Chinese Journal of Preventive Medicine 39:229–236, 2005
7.
Phillips MR: Mental health in China: challenge and choice in the 21st century [in Chinese]. Chinese Journal of Nervous and Mental Diseases 30:1–10, 2004
8.
Ormel J, VonKorff M, Ustun TB, et al.: Common mental disorders and disability across cultures: results from the WHO Collaborative Study on Psychological Problems in General Health Care. JAMA 272:1741–1748, 1994
9.
Druss BG, Marcus SC, Rosenheck RA, et al.: Understanding disability in mental and general medical conditions. American Journal of Psychiatry 157:1485–1491, 2000
10.
Sanderson K, Andrews G: Prevalence and severity of mental health-related disability and relationship to diagnosis. Psychiatric Services 53:80–86, 2002
11.
Prince M, Patel V, Saxena S, et al.: No health without mental health. Lancet 370:859–877, 2007
12.
Sokal J, Messias E, Dickerson FB, et al.: Comorbidity of medical illnesses among adults with serious mental illness who are receiving community psychiatric services. Journal of Nervous and Mental Disease 192:421–427, 2004
13.
Nordström M, Skärsäter I, Björkman T, et al.: The life circumstances of persons with a psychiatric disability: a survey in a region in southern Sweden. Journal of Psychiatric and Mental Health Nursing 16:738–748, 2009
14.
Regier DA, Narrow WE, Rae DS, et al.: The de facto US mental and addictive disorders service system: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry 50:85–94, 1993
15.
Alonso J, Angermeyer MC, Bernert S, et al.: Use of mental health services in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) Project. Acta Psychiatrica Scandinavica Supplementum 420:47–54, 2004
16.
Andrews G, Henderson S, Hall W: Prevalence, comorbidity, disability and service utilization: overview of the Australian National Mental Health Survey. British Journal of Psychiatry 178:145–153, 2001
17.
Wang PS, Demler O, Kessler RC: Adequacy of treatment for serious mental illness in the United States. American Journal of Public Health 92:92–98, 2002
18.
McAlpine DD, Mechanic D: Utilization of specialty mental health care among persons with severe mental illness: the roles of demographics, need, insurance, and risk. Health Services Research 35:277–292, 2000
19.
Wang PS, Berglund P, Kessler RC: Recent care of common mental disorders in the United States: prevalence and conformance with evidence-based recommendations. Journal of General Internal Medicine 15:284–292, 2000
20.
Wang PS, Lane M, Olfson M, et al.: Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Archives of General Psychiatry 62:629–640, 2005
21.
Wei Z, Liu T, Hu C, et al.: The mental health service utilization in Shenzhen City [in Chinese]. Chinese Mental Health Journal 24:597–603, 2010
22.
Zheng X, Chen G, Song X, et al.: Twenty-year trends in the prevalence of disability in China. WHO Bulletin 89:788–797, 2011
23.
Communique on Major Statistics of the Second China National Sample Survey on Disability [in Chinese]. Beijing, China Statistics Press, 2006
24.
The ICD-10 Classification of Mental and Behavioral Disorders: Diagnostic Criteria for Research. Geneva, World Health Organization, 1993
25.
The World Health Organization Disability Assessment Schedule Phase II Field Trial Instrument. Geneva, World Health Organization, 1999
26.
International Classification of Functioning, Disability, and Health (ICF). Geneva, World Health Organization, 2001
27.
Xiao S, Liu F: Framework of evaluation of mental health service system in China. Chinese Mental Health Journal 24:887–892, 2010
28.
Lohr S: Sampling: Design and Analysis. Pacific Grove, Calif, Duxbury Press, 1999
29.
Korn E, Graubard B: Analysis of Health Surveys. New York, Wiley, 1999
30.
Statistical Analysis Software (SAS), Version 9.1. Cary, NC, SAS Institute Inc, 2002
31.
Bijl RV, Ravelli A: Psychiatric morbidity, service use, and need for care in the general population: results of the Netherlands Mental Health Survey and Incidence Study. American Journal of Public Health 90:602–607, 2000
32.
Kessler RC, Berglund PC, Demler O, et al.: The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 289:3095–3105, 2003
33.
Kessler RC, Demler O, Frank RG, et al.: Prevalence and treatment of mental disorders, 1990 to 2003. New England Journal of Medicine 352:2515–2523, 2005
34.
Shen YC, Zhang MY, Huang YQ, et al.: Twelve-month prevalence, severity, and unmet need for treatment of mental disorders in metropolitan China. Psychological Medicine 36:257–267, 2006
35.
Narrow WE, Regier DA, Rae DS, et al.: Use of services by persons with mental and addictive disorders. Archives of General Psychiatry 50:95–107, 1993
36.
Kessler RC, Zhao S, Katz SJ, et al.: Past-year use of outpatient services for psychiatric problems in the National Comorbidity Survey. American Journal of Psychiatry 156:115–123, 1999
37.
Hu JN, Higgins J, Higgins LT: Development and limits to development of mental health services in China. Criminal Behaviour and Mental Health 16:69–76, 2006
38.
Park L, Xiao Z, Worth J, et al.: Mental health care in China: recent changes and future challenges. Harvard Health Policy Review 2:35–45, 2005
39.
Xiao S: Critical challenge to Chinese mental health service system [in Chinese]. Chinese Mental Health Journal 23:844–847, 2009
40.
Andrade LH, Viana MC, Tófoli LF, et al.: Influence of psychiatric morbidity and sociodemographic determinants on use of service in a catchment area in the city of São Paulo, Brazil. Social Psychiatry and Psychiatric Epidemiology 43:45–53, 2008
41.
Atlas: Mental Health Resources in the World, 2005. Geneva, World Health Organization, 2005
42.
Lin E, Goering P, Offord DR, et al.: The use of mental health services in Ontario: epidemiologic findings. Canadian Journal of Psychiatry 41:572–577, 1996
43.
Wang PS, Aguilar-Gaxiola S, Alonso J, et al.: Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet 370:841–850, 2007
44.
Zhang Q: Mental health services utilization and related factors among patients with schizophrenia in rural communities [in Chinese] [PhD thesis]. Changshai, China, Central South University, 2008
45.
Boydell KM, Gladstone BM, Volpe T: Understanding help seeking delay in the prodrome to first episode psychosis: a secondary analysis of the perspectives of young people. Psychiatric Rehabilitation Journal 30:54–60, 2006
46.
He Y, Zhu Z, Zhang M: Status of mental health professionals in China [in Chinese]. Shanghai Archives of Psychiatry 14:19–22, 2002
47.
Landerman LR, Burns BJ, Swartz MS, et al.: The relationship between insurance coverage and psychiatric disorder in predicting use of mental health services. American Journal of Psychiatry 151:1785–1790, 1994
48.
Sharfstein SS: Some interesting lessons from Canada. Psychiatric Services 57:297, 2006
49.
Steele LS, Glazier RH, Lin E: Inequity in mental health care under Canadian universal health coverage. Psychiatric Services 57:317–324, 2006
50.
Vasiliadis HM, Tempier R, Lesage A, et al.: General practice and mental health care: determinants of outpatient service use. Canadian Journal of Psychiatry 54:468–476, 2009
51.
Crow MR, Smith HL, McNamee AH, et al.: Considerations in predicting mental health care use: implications for managed care plans. Journal of Mental Health Administration 21:5–23, 1994
Information & Authors
Information
Published In
Cover: The Artists' Parents in the Store, by Sidney Goodman, 1973–1975. Oil on canvas, 58½ × 77 inches. Collection of the Butler Institute of American Art, Youngstown, Ohio.
History
Published in print: July 2013
Published online: 15 October 2014
Authors
Metrics & Citations
Metrics
Citations
Export Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
There are no citations for this item
View Options
View options
PDF/ePub
View PDF/ePubGet Access
Login options
Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.
Personal login Institutional Login Open Athens loginNot a subscriber?
PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).