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Mental health in China is a growing issue, with experts estimating that 173 million people live with a mental disorder. Social stigma related to religious and cultural beliefs of upholding social harmony and maintaining personal reputation contribute to a lack of desire to seek treatment. While the Chinese government has committed to expanding mental health care services and legislation, the country struggles with a lack of mental health professionals and access to specialists in rural areas.
China's first mental institutions were introduced before 1849 by Western missionaries. Missionary and doctor John G. Kerr opened the first psychiatric hospital in 1898, with the goal of providing care to people with mental disorders and treating them in a more humane way.
In 1949, the country began developing its mental health resources by building psychiatric hospitals and facilities for training mental health professionals. However, many community programs were discontinued during the Cultural Revolution.
In a 1999 meeting jointly held by Chinese ministries and the World Health Organization, the Chinese government committed to creating a mental health action plan and a national mental health law, among other measures to expand and improve care. The action plan, adopted in 2002, outlined China's priorities of enacting legislation, educating its people on mental illness and mental health resources, and developing a stable and comprehensive system of care.
In 2000, the Minority Health Disparities Research and Education Act was enacted. This act helped raised national awareness to health issues through research, health education, and data collection.
Since 2006, the government's 686 Program has worked to redevelop community mental health programs and make these centers the primary resource, instead of psychiatric hospitals, for people with mental illness. These community programs make it possible for mental health care to reach rural areas and for people in these areas to become mental health professionals, though specialists are still relatively inaccessible to rural populations. The program also emphasizes rehabilitation rather than management of symptoms.
In 2011, the legal institution of China's State Council published a draft for a new mental health law, which includes new regulations concerning the right of patients not to be hospitalized against their will. The draft law also promotes the transparency of patient treatment management, as many hospitals were driven by financial motives and disregarded patients' rights. The law, adopted in 2012, stipulates that a qualified psychiatrist must make the determination of mental illness; that patients can choose whether to receive treatment in most cases; and that only those at risk of harming themselves or others are eligible for compulsory inpatient treatment. However, Human Rights Watch has criticized the law. For example, although it creates some rights for detained patients to request a second opinion from another state psychiatrist and then an independent psychiatrist, there is no right to a legal hearing such as a mental health tribunal and no guarantee of legal representation.
Though China continues to develop its mental health services, it continues to have a large number of untreated people with mental illness. Intense stigma associated with mental illness, a lack of mental health professionals and specialists, and culturally-specific expressions of mental illness may play a role in the disparity.
Prevalence of mental disorders
Researchers estimate that roughly 173 million people in China have a mental disorder. Over 90 percent of people with a mental disorder have never been treated.
A lack of government data on mental disorders makes it difficult to estimate the prevalence of specific mental disorders, as China has not conducted a national psychiatric survey since 1993.
Conducted between 2001 and 2005, a non-governmental survey of 63,000 Chinese adults found that 16 percent of the population had a mood disorder, including 6 percent of people with major depressive disorder. Thirteen percent of the population had an anxiety disorder and 9 percent had an alcohol use disorder. Women were more likely to have a mood or anxiety disorder compared to men, but men were significantly more likely to have an alcohol use disorder. People living in rural areas were more likely to have major depressive disorder or alcohol dependence.
In 2007, the Chief of China's National Centre for Mental Health, Liu Jin, estimated that approximately 50 percent of outpatient admissions were due to depression.
The suicide rate in China was approximately 23 per 100,000 between 1995 and 1999. Since then, the rate is thought to have fallen to roughly 7 per 100,000, according to government data. WHO states that the rate of suicide is thought to be three to four times higher in rural areas than in urban areas. The most common method, poisoning by pesticides, accounts for 62 percent of incidences.
It is estimated that 18 percent of the Chinese population or over 244 million people believe in Buddhism. Another 22 percent of the population, roughly 294 million people believe in folk religions  which are a group of beliefs that share characteristics with Confucianism, Buddhism, Taoism, and shamanism. Common between all of these philosophical and religious beliefs is an emphasis on acting harmoniously with nature, with strong morals, and with a duty to family. Followers of these religions perceive behavior as being tightly connected with health; illnesses are often thought to be a result of a moral failure or insufficiently honoring one's family in a current or past life. Furthermore, an emphasis on social harmony may discourage people with mental illness from bringing attention to themselves and seeking help. They may also refuse to speak about their mental illness because of the shame it would bring upon themselves and their family members, who could also be held responsible and experience social isolation.
Also reputations might be a factor that prevent individuals from seeking for professional help. Good reputations are highly valued. Especially in a Chinese household, every individual is responsible to keep the family's reputation high. It's believed that mental health will hinder individuals from achieving the academic standards and goals expected from parents. Without reaching the expectations, individuals are anticipated to bring shame to the family, which will affect the family's overall reputation. Therefore, mental health is a weakness that's unacceptable. This perception of mental health cause individuals to internalize their mental health problems. Eventually, it become ignored and overlooked by families.
In addition, many of these philosophies teach followers to accept one's fate. Consequently, people with mental disorders may be less inclined to seek medical treatment because they believe they should not actively try to prevent any symptoms that may manifest. They may also be less likely to question the stereotypes associated with people with mental illness, instead agreeing with others that they deserve to be ostracized.
Lack of qualified staff
China has 17,000 certified psychiatrists, which is 10 percent of that of other developed countries per capita. China averages one psychologist for every 83,000 people, and some of these psychologists are not board-licensed or certified to diagnose illness. Individuals without any academic background in mental health can obtain a license to counsel following several month of training through the National Exam for Psychological Counselors, even if most of them study psychology for personal use and do not intend to pursue a career in counseling. Patients leave the clinics with false diagnoses and often do not return for follow-up treatments, which is detrimental to the degenerative nature of many psychiatric disorders.
The disparity between psychiatric services available between rural and urban areas partially contributes to this statistic, as rural areas have traditionally relied on barefoot doctors since the 1970s for medical advice. These doctors, one of the few modes of healthcare able to reach isolated parts of rural China, are unable to obtain modern medical equipment, and therefore, reliable diagnoses for psychiatric illness. Furthermore, the nearest psychiatric clinic may be hundreds of kilometers away, and families may be unable to afford professional psychiatric treatment for the afflicted.
Multiple studies have found that Chinese patients with mental illness report more physical symptoms compared to Western patients, who tend to report more psychological symptoms. For example, Chinese patients with depression are more likely to report feelings of fatigue and muscle aches instead of feelings of depression. However, it is unclear whether this occurs because they feel more comfortable reporting physical symptoms or if depression manifests in a more physical way among Chinese people.
Chinese Military Mental Health
Military mental health has been an area of focus, particularly in Western countries. For example, in the United States, it is estimated that about twenty-five percent of active military members suffer from a mental health problem, such as PTSD, Traumatic Brain Injury and depression. Although China's progress has been slow compared to their Western counterparts, the government has increased their efforts the address the mental health issues of their people. China has also been focusing more resources to helping those with psychiatric problems, to promote both social order and harmony with the growing population and rising economy. Currently, there are no clear initiatives from the government about mental health treatment towards military personnel in China. Specifically, China has been investing in resources towards researching and understanding how the mental health needs of military members and producing policies to reinforce the research results.
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Research on the mental health status of active Chinese military men began in the 1980s, where psychologists began by investigating soldier's experiences out in the plateaus. The change of emphasis from physical health to mental health can be seen in the four dominant military academic journals; First Military Journal, Second Military Journal, Third Military Journal, and Fourth Military Journal. In the 1980s, researchers mostly focused on physical health of soldiers, but as troop's ability to perform their services and the longevity of their services was declining, the government began looking towards mental health to provide an explanation for this trend. In the 1990s, research in mental health increased in hopes that by improving mental health of soldiers, combat effectiveness may also increase.
In addition to affecting active military member's work ethics, it can create lasting effects that continue to affect them after they leave the military. For example, researchers compiled all of the research articles from 1997 to 2007, with a sample size of 103,245 military members, about how working in the plateaus have affected soldiers when they resumed civilian life. Plateaus were an area of interest because the environmental conditions are harsh with low atmospheric pressure and intense UV radiation, but it was critical to place military there to stabilize the outskirts and protect the Chinese citizens who live near there. The plateaus not only affect the body physically, like the arteries, lungs, and back pain, but they also show high levels of depression because they are away from their family members with limited communication methods. They found that this may impact their lives as they saw that this population had higher rates of divorce and lower rates of employment.
However, assessing the mental health status of the People's Liberation Army (PLA) is difficult because military members work a diverse array of duties over a large landscape. For example, in addition to combat, military members also play an active part in disaster relief, peacekeeping in foreign lands, protecting borders, domestic riot control, and more. In a study of 11,324 soldiers, researchers found that those who work as peacekeepers have higher levels of depression compared to those who work in the engineering and medical departments. Not to mention, the environment plays a factor in the manifestations of mental health symptoms. Most research has concentrated mainly on plateaus, high altitudes, and other countries . With such a diverse military roles over an area of 3.25 million miles, it is difficult to gauge its impacts on soldiers’ psyche and provide a single method to address mental health problems
Although research has increased over the last two decades, there still lacks a sense of comprehensiveness and reliability in their studies. Furthermore, in over 73 studies that together included 53,424 military members, some research shows that there is gradual improvement in mental health at high altitudes, such as mountain tops, but other researchers found that at higher altitudes, depressive symptoms can worsen. These research studies demonstrate how difficult it is to assess and treat the mental illness that occurs in the army and how there are inconsistent results. Furthermore, studies of the military population focus on the men of the military and exclude women in their studies, even though the number of women that are joining the military has increased in the last two decades.
Chinese researchers try to provide solutions that are preventative and reactive, such as implementing early mental health training or mental health assessments to help service members understand their mental health state and how to combat these feelings themselves. In addition, researchers suggest that in order to improve the mental health of the military members, programs should include: psychoeducation, psychological training, and attention to physical health to employ timely intervention.
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In 2006, the Ministry of National Defense of People's Republic began vetting the people who can join the military at the beginning of recruitment. In a study consisting of 2500 military men, the findings show that there are community members who are more predisposed to mental illness measuring interpersonal elements such as: levels of anxious behaviors, depression symptoms, sensitivity to events, resiliency, and emotional intelligence. Researchers have also been looking at external factors that could impact a person's mental fortitude, such as: single-child status, urban or rural environment, and education level. The government even incorporated about how soldiers can address their mental illness in their training manual. In 2013, the Tibetan Center for Human Rights and Democracy (TCHRD) leaked out small portion of the People's Liberation Army's (PLA) training manual from 2008 on how to combat PTSD and depression while Chinese soldiers act as peacekeepers in Tibet. The manual suggested that soldiers should
“close [their] eyes and imagine zooming in on the scene like a camera [when experiencing PTSD]. It may feel uncomfortable. Then zoom all the way out until you cannot see anything. Then tell yourself the flashback is gone” .
In 2012, the government specifically addressed military mental health in a legal document for the first time. In article 84 of the Mental Health Law of the People's Republic of China, it states “The State Council and the Central Military Committee will formulate regulations based on this law to manage mental health work in the military”.
Besides vetting, assessments, and an excerpt of the manual, not much is known about the services that are provided to active military members and veterans. In a research analysis with 45 different studies with a sample size of 15,000, the level of anxiety has increased due to sociocultural pressures like economic conditions, lack of social connections, and the feelings of threat to the livelihood of military members. This manifested both in 2016 and 2018, when Chinese veterans have demonstrating their unhappiness by organizing protests and showcasing it in the streets of China. In both instances, veterans advocated for better benefits, resources for better job prospects, and justice for those veterans who were treated unfairly by the government. As a way to combat the dissatisfaction of veterans, the government established the Ministry of Veteran Affairs in 2018 to alleviate the tension that veterans feel. At the same time, Xi Jinping, General Secretary of the Communist Party of China, promised to enact laws that protect the welfare of veterans.
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