Dr. Arthur Kleinman is a professor of psychiatry and medical anthropology and Director of the Harvard University Asia Center. He is an expert on global mental health and has conducted extensive research in China. Dr. Kleinman sat with Beijing Review reporter Chen Wen in Boston and shared his opinions on the state of mental health in China.
Beijing Review: Can we say the mental health problem in China is a byproduct of rapid economic and social changes?
Arthur Kleinman: There is definitely a relationship between the very, very rapid social change and the kind of things that people have gone through and the greater rates of depression and anxiety. But I don't think you can say the same thing for severe chronic psychosis, like schizophrenia and bipolar disease. These are more fixed in their biological underpinnings, and much less responsive to the changing times.
Depression and anxiety, which are the most common disorders, are increasing in part because of the times people are living through and in part because standards are different. When I first went to China in 1978, almost no one was diagnosed with depression, because the standards used for diagnosis were extremely narrow. To be diagnosed you had to be psychotically depressed, you had to be so depressed that you had delusions or hallucinations, or you just literally couldn't function. Very few people who have depression present that degree of severity. So the standards have loosened over time, that accounts for part of the increase we've seen.
We also see the social contribution to anxiety and depression disorders increasing. So it's both things: the real increase and the change of standards.
What positive developments have you seen in China's treatment of mental illness?
With regard to depression and anxiety, I think there is a fundamental change in the young generation of urban Chinese. They are well-educated and much more willing to talk about psychological issues. They're quite capable of expressing the fact that they're sad or they feel anxious, or they feel upset in some way. I think familiarity with psychological language is a part of globalization. So this is the generation that's most thoroughly globalized. They're also more introspective and able to talk about themselves.
This growing middle class is more willing to entertain diversity, to tolerate and accept differences. I believe this is changing people's attitudes with regard to depression and anxiety. Over time, we're seeing these terms becoming more acceptable and people are using them more widely, reducing the stigma.
However, I think the situation with psychosis (schizophrenia, bipolar disease and other psychotic disorders) is totally different. Psychosis continues to hold an enormous stigma in China. It's a stigma that not just affects people who are ill but extends to their families as well. They are not treated with dignity and respect. And also they're seen as frightening because they may be violent in some way. In cases of psychosis, the whole idea of treatment in China is to protect society from sufferers, rather than to serve their rights as patients. This attitude really hasn't changed from the first time I visited China in 1978.
How will this change over time? I think this will take a real effort from the government and from communities. It's necessary to transform the way people think of the chronically mentally ill. Instead of thinking of them as dangerous to society, they need to be seen as human beings suffering from a certain kind of disability. Care giving has to be seen as essential, this is going to be China's great challenge. I'm very optimistic about China. China has been remarkably successful in reducing poverty, raising standards of living and building a middle class. This is something that China now has to work on, changing the treatment for and stigma toward psychosis.
For depression and anxiety, things are changing tremendously. China is doing very well in these areas. In the field of psychosis, which is what I'm concerned about, I don't think it's enough to just have social education. I think you have to start with the profession itself. The psychiatrists, particularly those dealing with the chronically mentally ill, need to become more effective advocates for the rights of the mentally ill.
It sounds like the new mental health law is about to be implemented. That's a great development for China to have legislation at actual statement concerning how the mentally ill should be treated.
What impacts do you think the new legislation will have?
The only thing I would say is it could have happened 20 years ago. But the fact that it's happening now is very important. Better late than never.
The government must make sure this legislation is comprehensive and that it protects the mentally ill and their humanity so they cannot be taken advantage of. They cannot simply be committed to asylums as if they were stored in a warehouse. They have to be treated like people with the opportunity for treatment and rehabilitation. I think the government can play a role in this.
However, at present I don't think the government's response is sufficient, it's necessary but not sufficient. To really change the stigma, you have to see societal change related to values, to people's understanding of the importance of these individuals as human beings. I think this change will start with China's youth. They're an incredibly interesting group. They are globally aware, interested in improving China's environmental situation and health situation, and they are committed to building a more sophisticated, developed society. I really believe they're going to change China. This is the great transformation of China that's going to happen in the next 20 or 30 years, I'm optimistic about this. But you have to take a long-term view.
What steps can be taken to improve the situation? What's the best place to start?
First of all, the government must give a clear signal that the matter of mental health is really important, and that change is necessary. Second, psychiatrists need to get the resources they need to be able to make some changes. Third, psychiatrists and psychologists need to receive ethical training that changes their value orientation toward the mentally ill and makes them advocates, more strongly committed to changing the situation of the mentally ill. Finally, training and education on the rights of the mentally ill must be given to nurses, patient's families and local communities. It will take some time to effect the necessary changes.
Dr. Arthur Kleinman made a speech titled Mental Health Challenges Facing the World and China at the inaugural Harvard America-China Health Summit in Boston on September 21-22. As part of an official agreement under the auspices of the China-U.S. Strategic and Economic Dialogue, the summit was hosted by the Harvard School of Public Health China Initiative with the support of the Chinese Ministry of Health and the U.S. Department of Health and Human Services. Here are some key points:
About 10 percent of adults suffer from a mental disorder globally. Up to 30 percent of primary care receivers have a mental disorder. Depression, anxiety disorders and substance abuse are most common. Between 0.5 and 2 percent of all adults suffer from a chronic, severe mental disorder. About 1 in 10 children suffer from a childhood mental disorder.
Globally, especially in developing and poor countries, appropriate pharmacological agents for the treatment of mental illness remain in short supply and are rarely used. While in urban areas, even in poor countries, there has been a rapid move to the over-diagnosis of conditions and the prescription of inappropriate treatment.
Globally mental health is so seriously defined by stigma that an international effort must be made to change attitudes. Discrimination places tremendous burdens on individuals and families. Stigma is not uncommon in medical institutions and stigmatizing assumptions are common in patient care. There is no example from anywhere in the world of a single adequately effective method for reducing the stigma against mental illness.