Spotlight on Mental Health: Mental health in China

Helena Wang, Asia Executive Editor at The Lancet, is joined by three guests to discuss the trajectory of mental health services in China, culturally-adapted mental health interventions for Chinese populations, and self-harm and suicide prevention approaches for children and adolescents in China.

Guests on this podcast:
Michael Phillips - the Director of Suicide Research and Prevention Center, Shanghai Mental Health Center,  Shanghai Jiao Tong University School of Medicine
Siying Li - PhD candidate, Department of Clinical, Educational and Health Psychology, University College London
Lu Niu - Associate Professor of Xiangya School of Public Health, Central South University

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Helena: Welcome to The Lancet Voice for our 200th Anniversary Mental Health Full Light. Today is June the 1st. I'm Helena Wang, Asia Executive Editor of The Lancet. I'm very happy today to discuss mental health in China with three guests. I will ask them to introduce themselves to you later. We have been working on a commission on mental health in China during the past few years with our Chinese colleagues, which is a comprehensive report on the current status and the future trajectory of mental health and mental health services in China.

In this podcast, I have invited a co chair of the commission to give you a heads up of the highlights of the commission. In addition, I also invited two mental health experts. To discuss culturally adapted interventions for Chinese and self harm and suicide prevention for child and adolescent in China.

Michael: My name's Michael Phillips. I'm a Canadian psychiatrist who's lived in China and worked in China for more than 35 years now in different parts of the country. Currently, I'm a professor at Shanghai J University. and head of the Suicide Prevention Center in the China Mental Health Center. I'm also Executive Director of the WHO Suicide Center in the Beijing Guilin Hospital and a professor in Psychiatry and Epidemiology at Columbia University in New York.

And I'm honored to be one of the co directors of the China Lancet series on mental health, along with Professor Xiao Chebian from South China University. 

Helena: I'm happy to learn that you will lead one of the major China commission on mental health. So can you give us some introduction of the mental health commission you are currently working with Chinese colleagues?

Michael: We have about 15 experts around the country who are commissioners on this project, and it's been going for a year. It's a really Massive undertaking. One of the take home messages is we're looking at primarily from 1990 to 2020. 30 year period. And over that period, China has, like many other countries in the world, committed huge resources to mental health.

They've had a mental health law. They've tried to ensure the insurance coverage for mental health, and they provide a huge community services for mentally ill. When you look at the prevalence and burden of mental disorders over that 30 year period, they're largely unmoved and unchanged. Other than the suicide rate, which has actually dropped quite quickly, but that's largely because of urbanization.

So there are a lot of people, about 200 to 300 million people don't have access to pesticides, which is the most common method of suicide. So that's a primary driver of the drop in suicide rates. But other than that, the other disorders have been basically stable over 30 years, despite this huge commitment of resources.

When we look at the international recommendations, because there's now been several international commissions, and one in Lancet, and WHO, and other organizations, their recommendations for the promotion of global mental health is one to focus on the individual rights of patients. That's really the core focus of theirs.

And another is to, to the extent possible, close down these specialized psychiatric hospitals and provide service from the community. So the community will generate supportive networks that can help the mental health in the community. The problem is that in China, one. The idea, the family is responsible for people of serious mental illnesses.

The idea that the family would just like a psychotic patient be on the street and then be in a tent city is just unthinkable in China. And the other element is that, especially in rural areas, there's simply no resources, mental health or otherwise, that could generate bottoms up. And so, that is a little, it doesn't, this general trend in the global recommendations really doesn't seem to fit with what's happening in China.

And the other element of this is, if China does, and it's tending to follow the Western standard of just committing more resources, financial and personal resources, bring more and more resources, but the outcomes in the high end countries haven't been that good either. Over those 30 years, the high end countries, they haven't improved the rates of mental illness.

And in fact, in substance abuse, they got worse. So does China and other developing countries really want to follow that pattern? We want to follow this pattern. And so, and kind of their recommendation, just do more of what we're doing and things will get better. We've been doing that for 30 years and I haven't.

And so the question the commission has is, do we promote what's following the Western model or do we think of doing something different? That's the takeoff point for the commission or one of the kind of highlights. We say, just do more of what we're doing and things will get better. Our concern is that 30 years from now, we're going to be looking at the same picture, we're putting more resources and still there's no real substantial change in mental health.

So the question is, why, what is the problem here? Why is, globally, mental health continues to be a huge, substantial problem that really isn't, other than some minor fluctuation, really isn't changing? The metaphor that I think of is that it's a two sided coin. And one side of the coin is identifying and treating individuals with mental illnesses.

The other side of the coin is promoting commuting mental health. And right now, in China and globally, the vast majority of resources Are committed into the side of identifying, treating, and managing people with mental illnesses, and very little is going to the promotion of mental health, community mental health.

And of course, these are related because if you have good community mental health, that's going to prevent mental illnesses from evolving, or will decrease that. And we, especially in research, we can see this vast amount of resources in mental health research are focused on neuroscience, which is very exciting, and it improves genetic studies about genetic risk factors for depression and other things, biomarkers.

And it gets high impact journals, people get their careers based on this. There's not much evidence that this is really changing the mental health picture, but that's where most of the resources go. The other big source of resource consumption is for new medications and new kind of treatments for different disorders.

And yes, it improves the treatment outcomes for some patients. It also generates huge profits for drug companies and insurance companies, so that's one of the reasons there's lots of emphasis on that. But then look, how much is spent on preventing these illnesses? Where is the prevention side? And it's minuscule in comparison in terms of funding, in terms of personnel, in terms of policies.

And so that, we think, is a, it's a fundamental problem. And there's great examples in health where the change of focus has improved things. Think of heart disease. Now, when we were talking about new drugs for hearts. valve operations, heart transplants, that didn't really change the problem of heart disease.

What it did was the Framingham study. Diet, exercise, stress, so cross sexual things really improved heart disease. Similarly, traffic accidents. Yes, there's better crisis surgeries and more rapid responses, but where it really decreased the crowd was changing the roads, seatbelts, airbags, and controlling drinking and driving.

And we haven't moved there in the mental health area, we're still on the, let's get more treatments, let's do this, we haven't moved to the cross sexual preventive elements, that's really where we need to move, and that's, we're trying to think of how we can change the direction of thinking about this to get a better balance of resources.

Helena: Yeah, I really like your point about promotion of community mental health, and that we, change the direction towards the prevention side. So can you be a little more specific on how we can further improve promotion and prevention in terms of different settings? 

Michael: First, we're looking at a public health model.

First, you've got to say, what are the causes of the condition? And we've been focusing on genes and biomarkers. But COVID has really opened our eyes. COVID happened and globally, the prevalence of depression and anxiety increased 25%. That's not genes. That's not biomarkers. That's a major social disruptive factor.

And these types of disruptive social factors are becoming more. common, more frequent, the internet, the isolation related to the internet, AI, and how is that going to affect work, crisis change, crisis climate change, resulting in huge waves of refugees, all these sort of things, then rapid urbanization that destabilizes a social network that affects psychological stressors.

So the first you got to think What are the things that are really driving mental illnesses, and it isn't biology, unfortunately. There might be a, one of the examples is we're now looking at how air pollution reduces the, can lead to more depression because it affects the immune system. So there is some biological marker there, but we really need to be thinking of first causes, not intermediate causes.

So given that's the reality and the reality that's facing young people today, they're thinking. What am I learning at school? Is that going to help me 20 years from now when AOR takes over all jobs? That's one of the rationales here. So in order to address that, we've got to one, have government intervention.

For example, when we find out that the internet is producing suicide packs on the internet, the government should intervene and stop that. So there may, and in the West, that would be unacceptable, but in China, yeah, that's what you got to do. When you find there's clear negative outcomes of these social changes, AI or other social network, then you intervene and you restrict that, the negative side effects.

Then you've got to build up individual resistance and community level resilience and adaptability because these stressors are going to keep coming. And if we always are, we're doing what's called whack a mole. When a person gets a mental illness, we try and treat it. We gotta stop them from getting to the point where they're mentally ill.

And this is a, a full society work, but you, like, how do we Improve adaptability and resilience in children. And that should be the ministry of education that deals with that. That has nothing to do with the health sector. The major, how do you do that? And there's no research about that. And the research that's available in this area is very poor.

So we got to put resources on what are the mechanisms that can improve the psychological quality of our children. So they're more resilient and it's not only on children, of course, but that's where we want to start in the schools and how you do this, I have ideas. There's no good quality evidence based research.

You've got to have substantial resources. People got to work on this to figure out what works. And it'll be different age groups. It'll be different in urban and rural settings. So you got to have adaptable models. But it's also needed in the workplace. How do you decrease workplace stress? You know, how do you provide individual resilience and adaptability to elders?

What do they need to know? How can they manage their own, one, identify and manage their own psychological stress? That's one component. And then the other is community resilience. And community resilience means developing the social infrastructure that promote social support groups, because we know for sure that people who are engaged in all sorts of social networks, be it with their school mates, in a book club, in an exercise group, this provides an outlet for them if they have any psychological stress and an ear to listen to them.

So how do you encourage and ensure that everybody Gets invested in one of these or multiple social support networks. What are the mechanisms that government or other institutions or private NGOs can support the generation of the social infrastructure that will encourage all sorts of social support networks and everybody, you don't get an isolated elderly doesn't talk to anybody.

Everybody's engaged in these networks. How do you do that? What's the way you do? That's affected. And doing that is really essential. However, this sort of refocus of energies, which is one of the recommendations we'll hope to make from the commission, refocus of energy resources to the prevention side, it clearly is going to involve the schools, it's going to involve the police, it's going to involve, for example, restricting pesticide, involves the administrative agriculture.

The work industry, employment, how do you get work sites to deal with the mental health of their employees? And it's got to get widespread community buy in. So you've got to get people saying, yes, it's worth committing social resources. Like parents have to be willing to have their kids spend less time studying algebra and more time in psychological training sessions.

And that's, you gotta get community buy in to do this. But that's, we need research. How does that work? That has to be flexible enough and it has to be monitored in detail because it will be changing over time and that obviously requires a top down approach. Because all of these institutions, the schools, the police, the work ministries, they have different priorities, they have different methods of organ, of doing things.

So if we want to get them all on the same page, it's not going to be bottoms up approach. It's going to be tops down. And China already has some experience in this area. For example, many years ago, they banned lead in gasoline. And you think, what does that have with mental health? A lot, because the lead in gasoline created a lot of mental illness in young children, because air pollution with lead.

And so they reduced within a year and a half. That would be unthinkable in the West, but in a year and a half. It cut lead from all gasoline sold in the country. That was a major improvement in the mental health of the country, but it had nothing to do with the health side. The current emphasis, the government is trying to get schools to reduce homework load of children, because the homework load of children has severely limited their sleep.

And clearly, chronic sleep deprivation has very serious long term effects on mental health. So there, that's another intervention. The government, the central government, said schools got to reduce homework, and they went down to the minimum education. And now they got to work with the parents who want, still want the kids to study to get, so they can get into high schools.

But there's got to be social buy in to this. But that's something the government has done. So it's trying to be more systematic about this and having As part of the moving resources so we get the schools and all these other agencies involved and that's a top down approach. The idea that bottoms up, that simply would not work to generate that type of preventive efforts.

Helena: So I wonder any other recommendations the commission will come out for to overcome all the barriers and problems in mental health in China? 

Michael: I got a list of 50. I guess I'll try and think of the top two or three. China has its mental health law. Really was very forward thinking. I was really very progressive and had a lot of good ideas.

And the problem is the monitoring of those, those were good ideas, but then you have to have specific programs and it got a month, there's got to be a degree of transparency. Ideally, I think there should be. NGOs are external expert groups who monitor the progress of certain plans and programs. And if they're not working, then change them to have a, so there's got to be regular monitoring of the outcomes of the, cause there's lots of ideas, but you got to monitor them in a rigorous way.

And also I work in suicide a lot and the WHO and UN has promoted national suicide plans for decades. And many countries have done this, but China has yet to do this. And so I think having a national suicide plan is another thing that would be really beneficial to structures. That too is an area that requires multi sector collaboration.

And if you don't have a national plan, it's very hard for me as a psychiatrist to talk to the Ministry of Agriculture saying, we'll just restrict access to this pesticide. But if you've got a national plan, then I could do it. So having follow up on the plans and rigorous scientific assessment of the effectiveness of the plans and being flexible enough to change the plans as times change.

And there's all these new stresses that are happening, like COVID was out of the blue and we waited till COVID had mental illness before we started doing something about it. We got to think proactively. The Environmental Protection Agency, if you want to construct a structure, you've got to think what are the potential damages before you permit the structure to occur.

The Food and Drug Administration. You've got to say, what are the negative effects of this drug before you allow it to be sold? We should think of the negative psychological effects of the things that we're doing and say preventively and put them in before the thing happens and all the bad stuff happens.

We've got to call whack a mole, get, treat the mental illnesses that we could have predicted before. Now, some of these times you can't predict them. But you should at least have a mechanism that say these major social change, like we allow AI in the job plate, okay, what are the potential negative effects there, psychological effects, and do some preventive stuff at the front end before we allow these technologies, these innovative technologies to be promulgated.

And that requires forward thinking, which is rather than responsive to the illness side. 

Helena: Thank you so much. 

Michael: My pleasure.

Siying: I am Xiang Li, I'm a Ph. D. student of clinical psychology at University College London. I'm from China and has been brought up in China. I then came to study in the UK since high school and was trained at UCL for both my undergrad and Ph. D. I'm really interested in the cultural adaptations of psychological interventions and in particular, mental How interventions can be delivered in China for the Chinese population at the moment.

I'm just approaching this from my largely academic and technical perspective, but I would just hope to go on and see some more clinical implications of it. 

Helena: Yeah, thank you so much for your introduction. So could you please also tell me a little bit about the paper you recently published in the Lawrence Psychiatry?

Siying: Of course. So as you might be aware of, there has been a long standing debate about whether mental disorders are culturally defined. that the development and experience of mental disorders are in part shaped by culture. And as you might know already, Chinese culture is shaped by the long history of China and many philosophical notions like Confucianism and Taoism.

And it is characterized by strong collectivism and have this emphasis on social hierarchy and filial piety and the way that family and society operates. So you might just see that the way that development and manifestation of depression in Chinese culture could be really different from. For example, within the culture of London where I currently live.

And if that's the case, it would just suggest that we need very different kind of treatment to treat in different cultural groups. So you would bring a treatment developed in the West and want to apply that in the Chinese context, then you would need to significantly modify that treatment so they are congruent with the culture that You want to treat in, and this just leads us to the question of whether we can make sufficient modification of the treatment so that it is still effective, or do we need to develop new treatments very much rooted in Chinese culture traditions that understand how mental disorder is seen and treated within China.

And in our review, we have built on work that we have done with other colleagues at UCL, where we started to look at what we can do to better understand the process of culture adaptation. And what was so helpful about the Chinese literature was that there were both the culturally modified interventions, which were essentially Western models of treatment, for example, cognitive behavior therapy, and adapted often through changes in language or understanding of the cultural beliefs.

And in addition to that, there is also culturally specific interventions, which were models. emerged from the Chinese culture and informed by the Chinese culture traditions like Confucianism and Taoism. So this kind of provides us a great opportunity for almost like a natural experiment to test out whether the idea about the culturally determined nature of mental disorders and its implication for treatment holds true.

Fortunately, we find that there is no significant differences between culturally modified and culturally specific interventions. So it could just be that one's individual experience of mental disorders might be culturally defined, but some of the underlying mechanisms might be much the same across culture.

So we'd expect that the underlying structure of treatment to also be same. And this is just very good news because it means that existing evidence based interventions, which we have. readily training programs and developed materials for can be applied in China and potentially transported across to other cultures as well.

Thank 

Helena: you. That's quite interesting. So you have consistently indicated that psychological interventions can be transported across cultures with appropriate modifications. So, could you please provide us some specific examples of such appropriate modifications? 

Siying: So in the previous review at UCL by our colleagues Arundel and other colleagues, we identified three main areas of modification to improve treatment effectiveness when treating ethnic minority groups.

And these are changes to the way that therapists deliver the treatment. the nature and content of the treatment, and then there is the service level design delivery of treatment. So to give some more specific examples of one of each of the three areas, to start by the first one, therapist related adaptations.

So these were adaptations to ensure that people who provide the treatment are familiar with the culture and with the language. So some specific example could be ethnic matching the therapist with the patients. And there is also content related adaptations, so these were essentially changes to the content and structure of the intervention to improve acceptability and appropriateness.

So, this could be, try to use culturally relevant terms of reference, considering the cultural norms and social expectations when delivering, and more specifically, you could provide additional psychoeducation, pre treatment, or remove jargons and explain in plain language for population with perhaps a lower education level, and you could also have some specific Consideration of culturally specific issues like community dwelling adults, where we call them empty nest, elderlies in China.

Families who lost child, which could be quite prevalent because of the one child policy earlier in China, there could also be some considerations of what can be lost in translation, for example, assertiveness is quite important concept and culture and CBT, but there is just no direct translation of that in Chinese.

So these were considerations we can make in terms of content. And then finally it comes up to organizational adaptation. So these were essentially. A lot of effective get into care, and that could be really important because no matter how effective a treatment is, if people cannot effectively get into care and access the care, then they wouldn't be able to benefit from it.

And this could be considerations for specific communities within China, perhaps more minoritized communities and. For example, it could be more rural communities and also other ethnic minorities within China. So this change is to promote access really needs to understand the social context, the beliefs and structures of that society or community.

To be more specific, this could be changes to location of treatment, whether it would be more accessible if it's delivered at home or community center or other non healthcare settings, so people feel less stigmatized if they have to come into care, and also be changes to medium used to provide treatment, so it could be online or community center.

By telephone or delivered in a group and also could be changes to what time of the day the therapy is delivered or the time length of the intervention itself. 

Helena: Thank you. So my last question is that what do you think might be the challenge facing you with regard to cultural adapted interventions?

Despite 

Siying: all the effort and work people have put in into this area, there are some limitations and challenges we have at the moment. The first one is that in previous literature, culture adaptation is often done in migrant population or ethnic minorities in the society that they live in. This is, as you can tell, quite a different population from, for example, Chinese and China, where they are living in.

native and indigenous community. So we kind of lack research in this area and need to address this further in future research. And another challenge that we have is that for culture adaptations so far, it's been really rooted in individual treatment. And we don't really have a good enough way to standardize, systematically, properly understand and describe the underlying mechanism for us to evaluate their effectiveness.

So we need better understanding to make sure that in a culture adaptation, we don't lose the focus of the underlying mechanism of the disorder that might inform treatment while we make all the changes to adapt to that culture group. So if we have a better system to describe, develop, and evaluate culture adaptations, we can learn much more from it about how we can better implement treatment, how we can better train people to deliver the treatment, and ensure that these bring about better outcomes for people.

So yeah, this is just some challenges and barriers that we find out during our research. And yeah, I'm just at the beginning of my career and I've learned quite a lot so far and still got a lot to learn, but I look forward to facing that challenge in the future. 

Helena: Wow, thank you so much for accepting my interview, and it's a great pleasure to talk with 

Siying: you, and thank you again.

Thank you very much, Helena, for inviting me. It's my pleasure to join this conversation.

Lu: Hello, my name is Niu Lu. I'm an associate professor of Shanghai School of Public Health. Central South University of China, working with Professor . Aha. Been doing research in suicide prevention for 10 years. Currently I focus on self harm and suicide in depressive adolescence. I'm so excited to talk to you today about our works.

Helena: Thank you for your introduction. I'm rather impressed that you have done a great deal of research on self harm and suicide prevention in children and adolescents. Could you please tell me a little bit about your research and the China situation in this area? Oh, of course. 

Lu: Originally, in the past 20 years, the suicide rate in China has decreased significantly.

However, there are concerns of a rebound. In recent years, especially, there are growing concerns about the increase of self harm and suicide among adolescents in China. We know that it is common for suicidal thoughts and behaviors to emerge during the transition from childhood to adolescence and show a significant increase during this developmental phase.

They have found global version of disease study shows that sepsis or suicide is the most leading cause of death among Chinese adolescents aged 10 to 19. The mortality rate was around 2 to 3 per 100, 000 persons. And the data from GBD in China has statistics, but the actual number or actual mortality is likely to be much higher because of under reporting.

Helena: Yeah, thank you for sharing the figures. So what might be the best way to scale up mental health services in China with regard to suicide and self harm prevention for children and adolescents? 

Lu: Well, I have some suggestions. The first will be school based gatekeeper training programs for both teachers and parents.

They need to have the ability to identify at risk teenagers and how to respond to them. Recently, the Ministry of Education of China proposed regular depression screening for in school adolescents. It is a big mood and it's wonderful. But still, screening programs might be not enough, yet no doubt that it can help detect adverse adolescence, but it is not enough.

The screening is processional, but the status of teenagers are constantly changing, as well as suicidal thoughts. It fluctuates quickly and is affected by acute life stress and acute emotional response. So we need parents and teachers to serve as a gatekeeper to identify abnormal signs or behaviors as they have so many opportunities to contact and interact with teenagers.

However, mental health problems is often overlooked as parents, schools, and even the whole society place too much emphasis on academic achievements. Most teachers and parents learn the skills to respond properly. Sometimes they can recognize something goes wrong with the teenager and their academic performance might be getting poorer.

But some might still think that the psychosocial distress, abnormal behaviors must be excused, but not to study hard. We always hear depressive adolescents say that they have difficulties in discussing problems. or expressing their emotions with their parents. They tend to conceal their emotional disturbance from their parents because they think their parents won't understand and might even start a big argument.

On the other hand, there is personnel shortage issues in schools as there are no enough qualified psychological teachers available. And schools often have limited resources to address these problems. There's also fears about, fears of being blamed by parents. So, if they notice some students might have mental health issues, they always suggest parents to take them to hospital, maybe let them have a long time break.

Sometimes school teachers still find it is difficult to cooperate with parents, as some parents don't perceive mental health as a serious issue, and some of them are worried that visiting a psychologist could help. have a negative impact on their child's future. Insufficient knowledge and stigma are major barriers to overcoming suicide and self harm in youth.

Thus, it is essential to provide gatekeeper training programs and tackle these issues. Meanwhile, psychosocial skill training programs are also needed for children and adolescents. People need to know that improving mental health is a key to preventing self harm and suicide. Currently, many adolescents feel unheard and overprotected, and many of them land the skills necessary to deal with difficulties and frustrations in their daily life.

In our research, we ask depressive adolescents when they feel depressed or overwhelmed by negative thoughts, how they respond to COVID staff. It is sad that it is common for them to say that they don't know how to deal with it. They have no friends to talk to and they don't want to talk with their parents as they, their parents won't understand how they feel.

As a result, some tend choose sub home and suicide. As a solution to escape from pain or just want to gain the attention of their parents. So it's crucial to develop psychosocial skill training programs that help adolescents improve their skills in communication. problem solving, emotional regulation, and most importantly, they need to have the ability to recognize when to ask for help.

With these skills, teenagers can build good self esteem and develop meaningful relationships, and they can handle challenging situations better. In addiction, more research, more evidence are needed to support the effectiveness of these programs. In the past, we spent too much effort on what needs to be done.

However, we know too little about how to make it work. For example, let's still talk about the depression screening program. The government has given us a clear roadmap. On what to do next, right? However, we still don't know the details of how to actually execute the program. The skills we need to use and how can we treat those children who had got a positive results kind of things.

It is the same situation for other programs like The gatekeeper training and psychosocial skill training we talked about. So further research is needed to understand how these programs can be conducted effectively and efficiently. Finally, I would like to address the key role of social media in suicide prevention.

Now the internet and social media have really changed the way we look and receive information. And this provides. a novel approach to reach young people and educate the public, reduce stigma, and facilitate achievement seeking. However, information on websites and social media are overwhelming. We can find lots of inaccurate information, or even worse, we can find prior suicide discussion, which can be really harmful.

To address this, we need targeted solutions and policies to ensure responsible reporting, responsible discussion of mental health and suicide on social media. 

Helena: Thank you so much for sharing so many insightful recommendations. It's my honor.

Gavin: Thanks so much for joining us for this episode of the Lancet Voice. This podcast will be marking the Lancet's 200th anniversary throughout 2023 by focusing on the spotlights with lots of different guest Lancet group. Remember to subscribe if you haven't already and we'll see you back here soon. Thanks so much for listening.