World Psychiatry 10:3 - October 2011
The first officially documented management of the men-
tally ill in China was in the Tang Dynasty (618-907 AD),
when homeless widows, orphans and the mentally ill were
cared for in the Bei Tian Fang, a type of charity facility ad-
ministrated by monks (1). The first western style psychiatric
hospital for the homeless mentally ill was established and
funded in 1898 by an American missionary, John Kerr, in
what is currently the Guangzhou Brain Hospital. In the
next 50 years, psychiatric hospitals were built very slowly in
a limited number of large cities. The number of psychiatrists
gradually increased to 100, and the number of beds gradu-
ally amounted to 1,000.
After the founding of the People’s Republic of China in
1949, psychiatric hospitals were gradually built in every
province. The role of these early provincial hospitals was
to maintain social security and stability. Following the first
National Mental Health Meeting in 1958, community men-
tal health work started in Beijing, Shanghai, Hunan, Sich-
uan and Jiangsu. Facilities were established in these areas to
train professionals and to develop work plans for the pre-
vention and treatment of psychoses, including early detec-
tion and treatment and relapse prevention (2).
Though community mental health programs almost
ceased during the Cultural Revolution (1966-1976), work-
rehabilitation centers for patients with psychoses and car-
ing networks were organized by neighborhood committees
(the lowest level of governmental facilities) in Shanghai (3),
and a treatment model for 256 patients with schizophrenia
and their families was developed in a suburb of Beijing (4).
In the 1980s, the health, civil affairs and public security
sectors set up a three-tier network (at city, district/county
Mental health system in China: history,
recent service reform and future challenges
MENTAL HEALTH POLICY PAPER
Jin Liu1, Hong Ma1, Yan-Ling He2, Bin Xie2, Yi-Feng Xu2, Hong-Yu Tang1, Ming Li3, Wei Hao4,
Xiang-Dong Wang5, Ming-Yuan ZHang2, CHee H. ng6, MargareT goDing7, JuLia Fraser8,
HeLen HerrMan9, HeLen F.K. CHiu10, sanDra s. CHan10, eDMonD CHiu9, Xin Yu1
1Peking University Institute of Mental Health, Beijing, China; 2Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China;
3Suzhou Psychiatric Hospital, Suzhou, China; 4Mental Health Institute, Second Xiangya Hospital, Central South University, Changsha, China; 5Western Pacific
Regional Office, World Health Organization, Manila, Philippines; 6St. Vincent’s Mental Health, University of Melbourne, Australia; 7Asia Australia Mental Health,
University of Melbourne, Australia; 8Asialink, University of Melbourne, Australia; 9Department of Psychiatry, University of Melbourne, Australia; 10Department
of Psychiatry, Chinese University of Hong Kong, China
This paper summarizes the history of the development of Chinese mental health system; the current situation in the mental health field
that China has to face in its effort to reform the system, including mental health burden, workforce and resources, as well as structural
issues; the process of national mental health service reform, including how it was included into the national public health program, how
it began as a training program and then became a treatment and intervention program, its unique training and capacity building model,
and its outcomes and impacts; the barriers and challenges of the reform process; future suggestions for policy; and Chinese experiences
as response to the international advocacy for the development of mental health.
Key words: Mental health system, China, history, service, reform, challenge
(World Psychiatry 2011;10:210-216)
and street/town levels) for the prevention and treatment of
psychoses. Successful experiences with treatment models,
such as work-rehabilitation centers in urban communities
in Shanghai and Shenyang, and family-based therapy in ru-
ral areas in Haidian District in Beijing and Yantai Shang-
dong, were extended to other places (2).
With the economic reform, hospitals were encouraged, as
part of the market economy, to make a profit. Financially de-
pendent mental health rehabilitation facilities closed or were
transformed into small-scale psychiatric hospitals. In Shang-
hai, before 1990, there was at least one community-level re-
habilitation facility in each district or town. By June 2004, the
numbers of these facilities had decreased by 62% (5).
By the late 1990s, some psychiatrists started to doubt the
rationale for large hospital-based and profit-making mod-
els for mental health service delivery, and the Ministry of
Health began to reconsider principles and approaches for
mental health care. Through advocacy by the Ministry, se-
nior ranked officials facilitated the establishment of a men-
tal health plan.
In November 1999, a high-level mental health seminar
was convened by ten Chinese Ministries and the World
Health Organization (WHO) in Beijing. The meeting re-
sulted in a declaration that all levels of government would
improve their leadership for and support of mental health
care, strengthen inter-sectoral collaboration and coopera-
tion, establish a mental health strategy and action plan, fa-
cilitate the enactment of a national mental health law, and
protect patients’ rights (6).
The first National Mental Health Plan (2002-2010) was
signed by the Ministries of Health, Public Security and Civil
Affairs, and China Disabled Persons’ Federation (CDPF) in
April 2002. It identified a series of detailed targets and indi-
ces to achieve the main goals of: a) establishing an effective
system of mental health care led by the government with
the participation and cooperation of other sectors; b) ac-
celerating the process of mental health legislation develop-
ment and implementation; c) improving the knowledge and
raising the awareness of mental health among all citizens;
d) strengthening mental health services to decrease burden
and disability; and e) developing human resources for men-
tal health services and enhancing the capacity of current
psychiatric hospitals (7).
In August 2004, the Proposal on Further Strengthen-
ing Mental Health Work was approved by the Ministries
of Health, Education, Public Security, Civil Affairs, Justice
and Finance, and the CDPF. This proposal provides explicit
instructions on interventions for psychological and behav-
ioral problems for key population subgroups (including
children and adolescents, women, the elderly and victims
of disasters), treatment and rehabilitation of mental disor-
ders, research on mental health and surveillance of mental
disorders, and the protection of the rights of the mentally
ill. The Proposal serves as the de facto Chinese national
mental health policy.
The mental health service model proposed in the above
two documents is led by psychiatric hospitals, supported by
departments of psychiatry in general hospitals, community-
based health facilities and rehabilitation centres.
The MenTal healTh sCenario in China
Mental health burden
In a large epidemiological study carried out in four prov-
inces (Shandong, Zhejiang, Qinghai and Gansu) from 2001
to 2005, the adjusted 1-month prevalence of any mental dis-
order in people aged 18 years or older was 17.5% (95% CI
16.6-18.5), and that of psychotic disorders was 1.0% (95%
CI 0.8-1.1) (8).
In health economic terms, the estimated total disability
adjusted life years (DALYs) of ten psychiatric conditions,
including unipolar depressive disorder, bipolar disorder,
schizophrenia, alcohol use disorders, Alzheimer’s and other
dementias, drug use disorders, post-traumatic stress disor-
der, obsessive-compulsive disorder, panic disorder, and in-
somnia (primary), was 253,851,896 years in China in 2004
(9). This translates into a loss of gross domestic product
(GDP) amounting to a country-wide total of CNY 2,681 bil-
lion, with schizophrenia and bipolar disorder accounting
for CNY 532 billion.
The huge burden of mental disorders highlights the
pressing need for improved mental health services. How-
ever, similar to most countries, the rate of treatment gap of
those with mental disorders is unacceptably high in China,
with 91.8% of all individuals with any diagnosis of men-
tal disorders never seeking help. For psychotic disorders,
27.6% never sought help and 12.0% saw non-mental health
professionals only (8).
Mental health workforce and resources
The vast majority of mental health professionals in Chi-
na are psychiatrists or psychiatric nurses, with few clini-
cal psychologists and social workers, and no occupational
therapists. Psychiatrists and licensed psychiatric nurses are
accredited by the Ministry of Health, psychological coun-
selors by the Ministry of Human Resources and Social Se-
curity, and psychotherapists by both Ministries.
In 2004, there were 16,103 licensed psychiatrists and
psychiatric registrars (1.24/100,000 population) and 24,793
licensed psychiatric nurses (1.91/100,000 population) (9).
Relative to the global average mental health workforce (i.e.,
4.15 psychiatrists and 12.97 psychiatric nurses per 100,000
population respectively) (10), mental health human re-
sources in China are quite limited. The shortage of skilled
mental health professionals represents one of the most criti-
cal issues facing the Chinese mental health system currently.
In 2004, there were 557 psychiatric hospitals. Among
them, 359 (64.5%) had 100 or more beds, and 44 (7.9%)
had 500 or more beds. The total number of psychiatric beds
was 129,314, i.e. 1.00/10,000 population (11), which is sig-
nificantly lower than the global average of 4.36/10,000 psy-
chiatric beds (10).
China does not organize its services in catchment areas.
Specialist mental health services remain the predominant
component of the system. China’s community-based mental
health system was largely eliminated with the introduction
of the market economy. Therefore, mental health service
provision has become primarily hospital-based. Patients
can access tertiary psychiatric hospitals directly, bypassing
the primary and secondary health care levels. This partly
reflects the disproportionate concentration of health re-
sources in large cities.
The funding model for the mental health system is com-
plex, with hospital inpatient services provided by three min-
istries, Health, Civil Affairs and Public Security, while other
facilities are administered under other ministries. According
to the WHO, only 2.35% of the total health budget is spent
on mental health and less than 15% of the population has
health insurance that includes coverage of psychiatric dis-
China is undergoing a rapid change, with an economic
growth rate of 7.5-13.0% per annum in the last ten years
(12). However, the growth in wealth has not been equita-
bly distributed, resulting in an increasing gap between the
rich and the poor. It is evident that those with the greatest
World Psychiatry 10:3 - October 2011
socio-economic disadvantage are often those with the high-
est mental health care needs (13).
naTional MenTal healTh serviCe reforM
Policy change and inclusion of mental health
in the national public health program
In October 2003, supported by the Ministry of Health,
an application process was initiated for specialized public
health projects that would have investment from the Minis-
try of Finance. All relevant public health sectors were active
in developing appropriate models with critical indicators
and drafting proposals for funding.
Although several approaches and different models were
considered, the mental health sector was yet to identify a
suitable and practical model for China. A delegation led by
Guihua Xu (Vice Director of China Centre for Disease Con-
trol) and three psychiatrists, Xin Yu, Hong Ma and Jin Liu
from Peking University Institute of Mental Health, visited
Melbourne, in order to build knowledge and understanding
of the Victorian community mental health service system.
The delegates and their Australian hosts also began to ana-
lyze the concept of community in China, and to investigate
possible ways to integrate mental health care into second-
ary and tertiary facilities in the country. Complemented by
other international exchanges with the USA, Norway, Thai-
land, Japan, UK and Germany, and guided by international
benchmarks on mental health services by WHO and pre-
vious experiences in community mental health in China, a
mental health sector model for reform emerged. The model
has at its core a patient-centered approach that is communi-
ty-based, seamless, function-oriented and multi-disciplinary.
Due to China’s vast, multi-ethnic and diverse population,
social harmony and stability is a well recognized concern
for the Chinese government. The focus on psychoses, espe-
cially those associated with violent or socially disruptive be-
haviours, was considered as a critical step to engage govern-
ment in mental health issues. Although community-based
mental health services were the long-term goal, current lack
of resources and capacity in community mental health and
primary mental health, combined with the difficulty in at-
tracting mental health professionals to work in the com-
munity, meant that a different, less ambitious and more tar-
geted model needed to be followed initially. An integrated
hospital and community treatment model for psychoses
was suggested, and a pilot project that included monitoring,
intervention, prevention and rehabilitation management of
psychoses was proposed.
In September 2004, after competing with over fifty pro-
posals and supported by a group of leading sociologists,
economists and psychiatrists in China, the program for men-
tal health service reform was the only non-communicable
disease program included in China’s national public health
program. This event became a major historical milestone for
China: mental health became officially included into public
The mental health reform program formally received sup-
port from Ministry of Finance in December 2004, and was
named the 686 Program after its initial funding of CNY 6.86
million. The National Centre for Mental Health of China lo-
cated at Peking University Institute of Mental Health was
authorized to be the implementing facility for this program
by the Ministry of Health. The project was overseen by a
national working group as well as an international advisory
group with experts mainly from the University of Melbourne.
By early 2005, 60 demonstration sites were established,
with one urban and one rural area in each of the 30 prov-
inces of China, covering a population of 43 million. The
priority in the first year was to build a capable mental
health workforce through an extensive training program. A
two-level training mode was adopted, first at the national
level utilizing a train-the-trainer approach, and then with
trained trainers delivering the programs at the provincial
level. The contents of the training included guidance on
project management, standardized treatment protocols,
case management, information management, family edu-
cation, and the training of police and neighborhood com-
Treatment and intervention program
In 2006, the 686 Program incorporated an intervention
component into the training program, which was then called
the National Continuing Management and Intervention Pro-
gram for Psychoses. The aim was to consolidate the reform
through the key provisions of continuity of care, treatment
accessibility, and equitable mental health care. Four types
of psychoses were included: schizophrenia, bipolar disorder,
delusional disorder, and schizoaffective disorder.
Patients screened for possible psychosis were referred
from psychiatric hospitals or departments, the CDPF, com-
munity and village health centres, and neighborhood or
village committees. These patients were subsequently ex-
amined by psychiatrists, and those who met diagnostic cri-
teria for psychotic disorders were evaluated for their risk
of violence based on a 0 to 5 score scale established by the
national working group.
The patients at risk of violence received monthly follow-
up and, if they were socio-economically disadvantaged, were
provided with free medication, laboratory tests, and a sub-
sidy for hospitalization. About 5% of patients who received
free medications were treatment refractory and were there-
fore provided with second generation antipsychotics, mainly
risperidone. In the event of any psychiatric emergencies or
severe cases of medication side effects, the program pro-
vided free crisis management. Moreover, as some patients
were physically restrained or chained at home, the program
provided support for the unlocking and freeing of these pa-
tients, and hospitalization when necessary. After hospital-
ization, if patients lacked finances to pay for treatment, they
were included in the free services mentioned above.
Training and capacity building
A key challenge for successful implementation of the 686
Program was the limited capacity of the workforce to deliver
the program at the local level. To meet this enormous chal-
lenge, a tripartite training program was collaboratively de-
veloped in 2007 by the Peking University Institute of Mental
Health, the University of Melbourne and the Chinese Uni-
versity of Hong Kong. The primary aim of the program was
to train up multi-skilled case workers by: a) developing un-
derstanding of the key principles of community-based men-
tal health care in general and basic case management; b)
providing practical skills in developing individualized ser-
vice plans to maximize integration and continuity of care; c)
exploring culturally appropriate ways to build partnerships
with the patient, families and community; d) building skills
to work in multidisciplinary teams; and e) providing oppor-
tunities to share ideas and plan for implementation.
Encompassing best practice principles drawn from allied
health disciplines (nursing, social work, occupational ther-
apy, psychology), a basic set of knowledge and skills for case
management was outlined (14). A key underpinning for the
training program was to provide a rehabilitation focus in a
community setting. Field site visits to a range of community
mental health facilities (e.g., day hospitals, half way houses,
training centres, mental health support programs) and su-
pervision by the community mental health team members
provided direct opportunity for such clinical experience.
outcomes and impacts
The program needed to build broad partnerships that in-
cluded different sectors and facilities into the mental health
service system, including local government, health, civil af-
fairs, public security, the CDPF and Women’s Federation. In
2009, a total of 34,861 facilities participated in this program,
including 44 provincial hospitals, 92 municipal hospitals,
168 district/county-level hospitals, 986 urban community
health centers, 2,748 urban community health stations,
1,136 township clinics, 11,480 village clinics, 5,660 urban
neighborhood committees and 12,547 village committees.
A multidisciplinary mental health team was also estab-
lished. By the end of 2009, a total of 38,227 participants
worked for the program. Among these, neighborhood/vil-
lage committee staff, who were mainly responsible for help-
ing finding the patients and leading community advocacy,
accounted for 53.3%; case managers accounted for 25%;
policemen, who mainly helped crisis intervention for vio-
lence, accounted for 7.1%; psychiatrists for 4.3%, psychiat-
ric nurses for 3.9%, and officials/administrators at different
levels for 3.4%.
Data from the police offices in 42 demonstration sites
showed that the number of minor violent events declined
from 531 in July-December 2005 to 140 in January-June
2006 (decrease of 73.6%), and that of major violent events
declined from 223 to 72 (decrease of 66.7%).
By the end of 2009, 96.88 million general population in
112 cities were covered by this program. A total of 161,800
patients were registered; 42,400 patients received regular
follow-up (the average longest one-way follow-up distance
in demonstration sites was 75 km); 15,300 economically
disadvantaged patients received free medication, 12,800
free crisis management interventions were provided, and
7,200 poor patients were given a subsidy for hospitalization;
340 previously restrained patients were freed.
In the first year of the 686 Program, a total of 602 train-
ing courses were conducted and nearly 30,000 people were
trained, including psychiatrists, psychiatric nurses, commu-
nity physicians, case managers, community workers, public
security staff and family members.
To date, nearly 500 mental health professionals from 80
districts in China have participated in tripartite program
training sessions. Ten groups of ten mental health profes-
sionals from mainland China have had practical training
in Hong Kong and more than 100 hospital directors and
heads of mental health departments have undertaken on-
site study in Melbourne.
One of the most profound impacts of the program has
been in the area of policy reform. This probably has the
greatest influence on long-term sustainability. Along with
the 686 Program, five vital national policies on mental
health have been developed: the Guiding Compendium
on Development of National Mental Health Work System
(aimed to improve inter-ministerial coordination and re-
form mental health work system); the Government Work
Report (for the first time in Chinese history, mental diseases
were addressed in the annual report of the Central Gov-
ernment); the Short-term Strategy of Health System Reform
(psychiatric hospitals were to be improved as part of pub-
lic health service capacity building); the Opinions on Im-
proving Gradual Equity of Basic Public Health Services (in
which the management of psychoses was included as one of
nine national basic public health service domains); and the
Working Criteria on Management of Psychoses (in which
responsibility of different sectors in the management of psy-
choses, and the relevant procedures, were clarified).
Barriers and Challenges To The reforM ProCess
A determined government is an essential element for
achieving success in a short period of time in China. How-
ever, the magnitude and the complexity of the mental health
problems as well as the changing situation are always
threatening the achievement of mental health reform. All
stakeholders of mental health services in China and readers
of this article should be aware that, despite the significant
World Psychiatry 10:3 - October 2011
progress, mental health service system development and
service delivery in China still face many difficulties. Some
of the main problems are the following:
Disparity is huge in China. Although national poli-
cies are quite comprehensive and instructive, a wide dis-
parity exists among provinces and cities in terms of social,
economical, and developmental levels. In some rich and
reform-driven coastal or eastern areas, the mental health
service system is being quickly reformed within whole prov-
inces or cities. However, in some under-developed western
areas, the reform process is slowed down by poor under-
standing, and lack of resources and skills. In those areas,
the existing national mental health policies become just
Resources are not properly allocated between the com-
munity and psychiatric hospitals. Though community
mental health is strongly encouraged as part of the equaliza-
tion of public health service, and national funding has been
given to each province to cover registration and following
up of the patients at community level, general physicians
lack basic knowledge and skills for these tasks. In the next
two or three years, CNY 15 billion will go to the construc-
tion of 550 psychiatric hospitals that are often located in
less populous suburban areas, and the funding structure still
remains primarily based on psychiatric hospital beds rather
than care received from personnel and treatment programs.
This will discourage hospitals to be involved in community
services. In addition, social insurance policy only subsidiz-
es the expenses of hospitalization, leading more patients to
use unnecessary in-patient services.
Some important outcomes are unclear about psycho-
ses. It is understandable that, from the social stability point
of view, psychosis treatment and management is always the
top priority of the government. However, due to the lack
of relevant laws and regulations, involuntary admission is
undertaken under the name of “caring about mentally ill”.
Social mobilization and resources re-allocation do increase
the treatment rate of patients with psychoses. However,
whether duration of untreated psychosis is shortened, or
patients’ functional levels are improved, are yet to be an-
Psychiatry is being made less attractive. The focus on
psychosis management makes psychiatry less attractive.
Fewer medical graduates are willing to be trained as psychia-
trists, and psychiatric hospitals continuously lose profession-
als with higher levels of education, training and expertise.
The government, therefore, is considering to transform psy-
chiatric facilities into “public health institutions” in which
staff are regarded as “paracivil servants”. This may further
discourage graduates from entry training in psychiatry.
Partnership with other sectors is unsatisfactory. Al-
though the responsibility of each relevant ministry or sector
has been stated in various documents, inter-organizational
cooperation and collaboration is still not fully or firmly es-
tablished, with the health and mental health sectors work-
ing in isolation in many areas.
suggesTions for fuTure PoliCy
In a country with highly centralized government struc-
tures such as China, mental health development needs
strong and continuous support from government at all lev-
els. Without this support, the mental health sector will find
it hard to fulfill the management of psychoses by itself. In
addition, China needs to develop awareness of the impor-
tance of non-governmental organizations and their poten-
tial role in integrating various social resources and provid-
ing valuable supplementary services for mentally ill patients
living in the community to enhance their recovery.
Community physicians in urban areas and village physi-
cians in rural areas will require training in order to under-
stand and develop individual care plans for four types of
psychotic patients (similar to the 686 Program) at the pri-
mary care level, and to follow up stable patients at least four
times per year.
Given the large number of patients with chronic mental
disorders in China, community and home-based care for
most patients needs to be encouraged and promoted. Fam-
ily members should be supported to provide ongoing care in
the community for their mentally ill relatives.
The limited amount of funding could only support the
basic administration and transportation of staff in the na-
tional program, but the mental health facilities that employ
these professionals have to make a profit in order to pay
their salary. Mental health service fee for psychoses should
be provided by the government as either salary of the ser-
vice providers or insurance for the patients.
Government support and investment in clinical stud-
ies and health policy research are necessary to establish
evidence-based treatment strategies and policy that are
relevant in a Chinese context. Moreover, economic evalua-
tions from the perspective of functional recovery and long-
term outcomes and benefits for patients with mental dis-
orders are needed to inform policies and reimbursement
provided by the Social Security Department.
Chinese exPerienCes as resPonse
To inTernaTional advoCaCy
This reform program in China is consistent with policy
recommendations issued in recent years by the WHO and
supported by other international authorities. In 2001, the
WHO recommended that countries develop community-
based services for people with mental disorders (15). This
recommendation has been recently strengthened by a call
for action to scale up services for people with mental disor-
ders (16), the development of the Mental Health Gap Ac-
tion Programme (mhGAP) (17), the activities of the WPA
(18-20), and the guidelines published recently in World
The work on the 686 Program and other developments in
China are important steps in moving towards internation-
ally agreed and accepted standards in mental health service
provision. However, mental health services in China, as in
many low- and middle-income countries (LAMIC), have a
long way to go to meet the target of providing mental health
care in the community.
Locally driven research provides relevant information to
guide policy makers in the expansion of cost effective and
culturally adapted health services (16). However, dissemi-
nation of this work to national and international audiences
is hampered by the poor representation of publications from
LAMIC in mainstream psychiatric journals (23,24). Recent
work by WPA has demonstrated that, despite a significant
level of scientific activity shown by China (as well as India,
South Africa and South Korea), none of these countries,
and indeed, no LAMIC in the African and Asian regions,
is so far represented by a psychiatric journal in the main
international databases (25,26). Internationally supported
action to improve indexation of journals and research dis-
semination will aid the publication of data from this and
similar projects. The WPA journal, World Psychiatry, and
the recently indexed Asia Pacific Psychiatry, the journal of
the Pacific Rim College of Psychiatrists, have the opportu-
nity to bridge this gap.
Although China’s mental health service reform has fo-
cused only on psychoses so far, the scale of the reform, and
the sheer numbers of psychiatric patients involved, repre-
sent a massive and ambitious program, which has had to
overcome huge challenges. The reform began earlier than
the reform of general health care in China, and is consistent
with the Chinese public health strategy and the framework
for country directions according to the WHO mhGAP.
With continued political commitment, timely assessment
of needs and matching resources, development of appropri-
ate public health policies, delivery of effective interventions,
strengthening of human capacity, efficient mobilization of
financial resources, rigorous monitoring and evaluation,
China will be in a favorable position to build and strengthen
a national sustainable community mental health system and
service for the benefit of the mental health of its population.
Jin Liu and Hong Ma contributed equally to this paper
and Xin Yu is the corresponding author. The authors thank
N. Sartorius, B. Saraceno and S. Saxena for their continu-
ing advice and support to mental health reform in China,
and M.L. Belfer for helping to edit the paper, and making
suggestions as to content. They also thank all those who
have participated or helped in the establishment and/or
implementation of the 686 Program.
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