The magnitude of and health system responses to the mental health treatment gap in adults in India and China

Rehabilitation seeks to optimize functioning of people with impairments and includes a range of specific health services-diagnosis, treatment, surgery, assistive devices, and therapy. Evidence on access to rehabilitation services for people with disabilities in low- and middle-income countries (LMICs) is limited. A systematic review was conducted to examine this in depth. In February 2017, six databases were searched for studies measuring access to rehabilitation among people with disabilities in LMICs. Eligible measures of access to rehabilitation included: use of assistive devices, use of specialist health services, and adherence to treatment. Two reviewers independently screened titles, abstracts, and full texts. Data was extracted by one reviewer and checked by a second. Of 13,048 screened studies, 77 were eligible for inclusion. These covered a broad geographic area. 17% of studies measured access to hearing-specific services; 22% vision-specific; 31% physical impairment-specific; and 44% measured access to mental impairment-specific services. A further 35% measured access to services for any disability. A diverse range of measures of disability and access were used across studies making comparability difficult. However, there was some evidence that access to rehabilitation is low among people with disabilities. No clear patterns were seen in access by equity measures such as age, locality, socioeconomic status, or country income group due to the limited number of studies measuring these indicators, and the range of measures used. Access to rehabilitation services was highly variable and poorly measured within the studies in the review, but generally shown to be low. Far better metrics are needed, including through clinical assessment, before we have a true appreciation of the population level need for and coverage of these services.

A Systematic Review of Access to Rehabilitation for People with Disabilities in Low- and Middle-Income Countries

Eager to build an integrated community-based mental health system, in 2004 China started the ‘686 Programme’, whose purpose was to integrate hospital and community services for patients with serious mental illness. In 2015, the National Mental Health Working Plan (2015–2020) proposed an ambitious strategy for implementing this project. The goal of this review is to assess potential opportunities for and barriers to successful implementation of a community-based mental health system that integrates hospital and community mental health services into the general healthcare system. We examine 7066 sources in both English and Chinese: the academic peer-reviewed literature, the grey literature on mental health policies, and documents from government and policymaking agencies. Although China has proposed a number of innovative programmes to address its mental health burden, several of these proposals have yet to be fully activated, particularly those that focus on integrated care. Integrating mental health services into China’s general healthcare system holds great promise for increased access to and quality improvement in mental health services, as well as decreased stigma and more effective management of physical and mental health comorbidities. This article examines the challenges to integrating mental health services into China’s general healthcare system, especially in the primary care sphere, including: accurately estimating mental health needs, integrating mental and physical healthcare, increasing workforce development and training, resolving interprofessional issues, financing and funding, developing an affordable and sustainable mental health system, and delivering care to specific subpopulations to meet the needs of China’s diverse populace. As China’s political commitment to expanding its mental health system is rapidly evolving, we offer suggestions for future directions in addressing China’s mental health needs.

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Integrated mental health services in China: challenges and planning for the future.

AimsTo examine the extent and nature of coercive practices in mental healthcare and to consider the ethical, human rights challenges facing the current clinical practices in this area. We consider the epidemiology of coercion in mental health and appraise the efficacy of attempts to reduce coercion and make specific recommendations for making mental healthcare less coercive and more consensual.MethodsWe identified references through searches of MEDLINE, EMBASE, PsycINFO and CINAHL Plus. Search was limited to articles published from January 1980 to May 2018. Searches were carried out using the terms mental health (admission or detain* or detention or coercion) and treatment (forcible or involuntary or seclusion or restraint). Articles published during this period were further identified through searches in the authors' personal files and Google Scholar. Articles resulting from searches and relevant references cited in those articles were reviewed. Articles and reviews of non-psychiatric population, children under 16 years, and those pertaining exclusively to people with dementia were excluded.ResultsCoercion in its various guises is embedded in mental healthcare. There is very little research in this area and the absence of systematic and routinely collected data is a major barrier to research as well as understanding the nature of coercion and attempts to address this problem. Examples of good practice in this area are limited and there is hardly any evidence pertaining to the generalisability or sustainability of individual programmes. Based on the review, we make specific recommendations to reduce coercive care. Our contention is that this will require more than legislative tinkering and will necessitate a fundamental change in the culture of psychiatry. In particular, we must ensure that clinical practice never compromises people's human rights. It is ethically, clinically and legally necessary to address the problem of coercion and make mental healthcare more consensual.ConclusionAll forms of coercive practices are inconsistent with human rights-based mental healthcare. This is global challenge that requires urgent action.

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Reducing coercion in mental healthcare

Due to its fast economic growth and lifestyle changes, China is experiencing a rapid epidemiological transition from communicable to noncommunicable diseases (NCDs). Mental disorder such as depression is an important yet often neglected NCD and is becoming a growing cause of disability, suicides, and disease burden. This paper provides the first nationally representative estimate of the medical cost attributable to depression and depressive symptoms among the adult population in China. On the basis of the 2012 China Family Panel Studies survey, our results indicate that these mental health conditions have significant impacts on the individual medical expenditure, and they jointly contribute to 14.7% of total personal expected medical spending in China, with depression and depressive symptoms accounting for 6.9% and 7.8%, respectively. Given that patients with mental illness face multiple psychological and institutional barriers in seeking appropriate treatment, the high depression-induced medical costs may be primarily driven by the cost-shifting effect from mental health care to general health care, as mental disorders often coexist with other NCDs such as diabetes and hypertension. As an implication, our study calls for an urgent reform of China's mental health and insurance systems to remove the policy-induced obstacles for the access to mental health care resources.

Depression hurts, depression costs: The medical spending attributable to depression and depressive symptoms in China.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/j.2051-5545.2011.tb00059.x

Mental health system in China: history, recent service reform and future challenges.

Background In 2005, China implemented a demonstration program known as “686” to scale-up nationwide basic mental health services designed to improve access to evidence-based care and to promote human rights for people with severe mental disorders. As part of the 686 Program, teams “unlocked” and provided continuous mental health care to people with severe mental disorders who were found in restraints and largely untreated in their family homes. We implemented a nation-wide two-stage follow-up study to measure the effectiveness and sustainability of the “unlocking and treatment” intervention and its impact on the well-being of patients’ families.

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Unlocking Patients with Mental Disorders Who Were in Restraints at Home: A National Follow-Up Study of China’s New Public Mental Health Initiatives

Introduction

In 2005, China commenced its mental health reform by establishing a national program to move from a hospital-based service model to an integrated hospital and community treatment model for psychoses, adopting the key principles of and provisions for continuity of care, treatment accessibility and equitable mental health care. This paper reports the rate and associated factors of treatment dropout for patients with psychoses in the national program in Guangdong Province from 2006 to 2009.



Methods

Adult patients with psychoses followed-up in two demonstration sites in Guangdong Province were grouped as treatment dropout if they were lost to follow-up for three consecutive months. Dropout rate was estimated, and associated factors were explored with multifactor binary logistic regression analysis.



Results

Of 1,386 patients followed up from 2006 to 2009, 73 patients (5.29%) dropped out (five deceased patients were excluded). Poor adherence to medication, having no medication, and having worse global clinical outcome contributed to increased risk of dropout by 12.765 (P = 0.0017), 7.400 (P = 0.0063) and 6.385 times (P = 0.0207), respectively. When course of illness increased by five years, the risk of dropout increased by 1.322 times (P = 0.0031).



Discussion

Treatment dropout rate for patients with psychoses in Guangdong Province appears to be low. Implications for mental health service reform in China include assertive follow-up for patients with history of poor adherence with treatment, free medications to poor patients to increase access to appropriate and affordable treatment, and active psychoeducation for patients with poor insight and their families.

Treatment dropout of patients in National Continuing Management and Intervention Program for Psychoses in Guangdong Province from 2006 to 2009: Implication for mental health service reform in China

Jin Liu

Papers

Mental health system in China: history, recent service reform and future challenges.

Unlocking Patients with Mental Disorders Who Were in Restraints at Home: A National Follow-Up Study of China’s New Public Mental Health Initiatives

Treatment dropout of patients in National Continuing Management and Intervention Program for Psychoses in Guangdong Province from 2006 to 2009: Implication for mental health service reform in China