What India can learn from China on tackling mental health

After the outbreak of Severe Acute Respiratory Syndrome or SARS in 2003, China decided to overhaul its under-funded public health system. The one non-communicable that the country decided to spend public money on was mental health. In 2004, it launched the 686 program, so named because of the initial investment of 6.86 million yuan.

“China launched the largest publicly financed programme for mental health problems having more than 4 million patients already in a completely digitised electronic registry,” said Vikram Patel, mental health expert with the Public Health Foundation of India. “This could only be done with very strong leadership in the government, with technically sophisticated managers who are both clinicians and public health professionals and a very firm governance monitoring progress of the system.”

In comparison to China’s dramatic action on mental health, India’s response to its similar mental health burden has been non-existent.

Now, mental health professionals in the two countries have formed a new collaboration to find solutions to this shared problem. The China-India Mental Health Alliance aims to bring senior and mid-level researchers from both countries together to assess and address the mental health crises. As a first step, the alliance has published a set of three papers in the journals The Lancet and Lancet Psychiatry that take stock of the disease burden, treatment gaps and the possible role of alternative medicine in mental illness in both countries.

According to the papers the number of disability-adjusted life years or DALYs for mental illness grew by 28% in China between 1993 and 2013. A DALY can be thought of as a year of healthy life lost and the sum of DALYs across a population is a measurement of its health against a yardstick of an ideal disease-free population. In India, the number of DALYS grew by 61% in the same period.

The similarities

India and China together have 38% of the world’s population and one-third of its burden of mental illness – that’s more than all the mental illness in all developed countries combined.

Common ailments like depressive and anxiety disorders make up the lion’s share of mental illness in both countries but most resources are aimed at severe illnesses like schizophrenia and bipolar disorder.

“Severe mental disorders need to be taken care of but we have to focus on common mental disorders like depressive and anxiety disorders because of the sheer burden,” said Rahul Shidhaye, researcher with the Public Health Foundation of India and author of the paper on mental health burdens. “Secondly, we need to shift our focus from tertiary to general primary care because that is where depression is detected and can be treated. The third thing is that we have to our attention away from specialists to lay health workers and general medical personnel.”

China is similar to India also in its poor access to treatment for common mental illness like depression, anxiety and alcohol abuse. In rural parts of India and China access to all health interventions remain sketchy but are the worst for mental healthcare. In rural treatment even for serious illness like psychosis and epilepsy are largely unavailable. For example, the second paper finds that contact coverage, which is the extent to which a health service is used, for epilepsy is as low as six percent among tribal populations of India but 92% in urban areas.

However, while contact coverage for schizophrenia is 77% in urban parts of China and 70% in rural China, it is below 50% in India. There are also far fewer psychiatrists and mental hospital beds in India than in China

“In the absence of professionals people are already seeking help from alternative sources,” said Jagadish Thirthalli of the National Institute of Mental Health and Neurosciences or NIMHANS in Bengaluru. In the third of the Lancet papers, Thirthalli and his collaborators explores the role of alternative medicine in China in India. Both societies have traditional systems like acuputure, qigong and taichi in China and ayurveda, unani and yoga in India.

The paper assesses the efficacy of some of these alternative medicines in treating mental illnesses. “There are some studies that show treatments like yoga can help with conditions like depression,” said Thirthalli. "But there hundreds of alternative treatment sand hundreds of other psychiatric conditions to be treated. We have very little evidence-based research to show which alternative treatments are useful." He issued the caveat that looking at alternative medicine through the lens of allopathic science may not give a true assessment of the help or harm done by the treatments.

The differences

India’s burden of mental illness will grow much faster than China’s in the coming decade, the research finds. In 2013, 36 million years of healthy life were lost to mental illness in China, and 31 million in India. By 2025, the number of years people in India would have lost will increase by 23% compared to 10% lost by people in China. That’s because China, with its ageing society and low birth rate, mimics developed nations in its trajectory of mental illness incidence.

Dementia will grow in both countries but China will have a much higher proportion of dementia cases among its mentally ill because of its ageing population.

The researchers point out that a major difference in between the two countries is in the centralised governance of health in China as opposed to the systems overseen by the states in India. "The public sector in China is the major provider of mental health-care, and 86% of the psychiatric beds and close to 70% of all health facilities that provide mental health-care are directly funded by the government," the study on treatment gaps finds. "In India, however, the rapidly growing and mostly unregulated private sector is the largest service provider, accounting for more than 70% of general outpatient and 60% of general inpatient care; data specifically for mental health care were not available."

Patel sees the impact of China’s investment in mental health in show up in the rates of suicides. “Suicide rates in China in the '90s were much higher than in India,” he said. "Ever since the Chinese government has been investing in social determinants in healthcare, the suicide rate has dropped by more than 50% in the last decade. Now it is much lower than India. In India it has only risen and plateaued out."

But according to Patel, one lesson that India can teach China the innovation led by NGOs in the mental health space to change attitudes, reduce stigma, address human rights abuses, improve access to care through community health workers.