Abstract
Background
A goal of China’s 2012 National Mental Health Law is to improve access to services and decrease urban versus rural disparities in services. However, pre-reform data is needed for objective evaluation of these reforms’ effectiveness. Accordingly, this study compares the pre-reform utilization of medical services for the treatment of schizophrenia in rural and urban communities in China.
Methods
In a large community-based study in four provinces representing 12% of China’s population conducted from 2001 to 2005, we identified 326 individuals with schizophrenia (78 never treated). Comparing those living in urban (n = 86) versus rural (n = 240) contexts, we used adjusted Poisson regression models to assess the relationship of ‘never treated’ status with family-level factors (marital status, family income, and number of co-resident family members) and illness severity factors (age of onset, symptom severity and functional impairment).
Results
Despite similar impairments due to symptoms, rural patients were less likely to have received intensive mental health services (i.e., use psychiatric inpatient services), and appeared more likely to be ‘never treated’ or to only have received outpatient care. Among rural patients, only having more than four co-resident family members was independently associated with ‘never-treated’ status (RR = 0.34; 95% CI, 0.12–0.94; p = 0.039). Among urban patients, only older age of onset was independently associated with ‘never-treated’ status (RR = 1.06; 95% CI 1.02–1.10, p = 0.003).
Conclusions
Identifying differential drivers of service utilization in urban and rural communities is needed before implementing policies to improve the utilization and equity of services and to define metrics of program success.
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Background
Schizophrenia is a severe psychiatric illness that contributed to an estimated 12.66 million disability-adjusted life years (DALYs) lost across 20 million global cases according to the 2017 Global Burden of Disease study [1, 2]. In low- and middle-income countries, schizophrenia is ranked the 3rd leading cause of DALYs, accounting for over 15 million DALYs [3]. In China, relative to common mental disorders (e.g., anxiety, depression), schizophrenia in particular is marked by severe stigmatization [4] and, in rural areas especially, people with schizophrenia are especially vulnerable to high mortality and suicide rates [12]. However, despite conducting a national mental health epidemiological study from 2013 to 2015 [13], there has been no systematic effort to clarify the reasons for the persistent (and increasing) gap in urban versus rural services.
Assessment of the effect of China’s mental health reforms on urban versus rural access to care should be based on a comparison of the situation before and after instituting the reforms. This report provides a pre-reform baseline to which subsequent findings can be compared by assessing factors affecting urban versus rural access to care for schizophrenia – one of the mental disorders most likely to be treated– based on data from a large (n = 63,004) representative mental health epidemiological study in China conducted from 2001 to 2005 [14]. The findings support that individuals with psychotic disorders overall are more likely to seek treatment (12%) compared to other diagnostic groups including mood, anxiety, and substance use disorders (4.9, 3.2%. 0.8%, respectively) [14]. Individuals with severe psychotic disorders are even more likely to seek treatment (63.5%) compared to severe mood, anxiety, and substance use disorders (6.7, 8.5, 2.8%) [14]. The authors posit numerous factors that contribute to low treatment seeking in non-psychotic disorders in China including low awareness that the illness is treatable or perceived ineffectiveness of treatment, fear of stigmatization, and lack of access to treatment [14]. Importantly, there are notable differences in treatment rates for schizophrenia between urban and rural locales in China; in rural China, data to date indicates that cases are significantly more likely to be untreated (35.4%) compared to their urban counterparts (17.5%) [54];) that could precipitate care-seeking.
Conclusions
These results for China in 2001 to 2005 provide a snapshot of an evolving mental health service network that can be used to assess the effects on mental health services of subsequent rapid urbanization and major changes resulting from important mental health policy initiatives such as China’s 2012 national mental health law [9]. Distinguishing the independent effects of economic development, migration to cities, improvements in public health, and mental health policy initiatives on national mental health will be difficult, and the effects of these factors probably differ in different parts of the country. However, in the absence of a baseline against which current conditions can be compared, this difficult task will be rendered nearly impossible. A clear understanding of the current trajectory of mental health services and of the factors that affect this trajectory is essential to develo**, evaluating, and regularly revising effective mental health policies and programs.
These findings may also be relevant for other LMIC that are planning to implement community-based mental health reforms. Such projects need to be preceded by community-specific situation analyses that compare the urban versus rural characteristics and treatment of mental illnesses. The subsequent reforms should be flexible enough to include community- and cohort-specific adaptations that will effectively decrease disparities in the provision of mental health services between urban and rural communities. Such situation analyses should – based on our findings – include assessment of the potential differential effect of family-level factors and illness-severity factors on care-seeking for schizophrenia (and other mental disorders) in urban and rural communities. Clarification of the factors that drive the utilization of services in different subgroups of the population will help facilitate community-specific scale-up efforts to alleviate the global burden of mental disorders [33].
Availability of data and materials
The datasets used and analyzed during the current study are available from the corresponding author (Dr. Michael Phillips) on reasonable request.
Abbreviations
- LMIC:
-
Low- and middle-income countries
- GHQ:
-
General Health Questionnaire
- SCID-IV:
-
Structured Clinical Interview for DSM-IV -TR psychiatric diagnoses
- GAF:
-
Global Assessment of Functioning
- TCM:
-
Traditional Chinese Medicine
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Acknowledgements
Dr. Yang, Dr. Phillips, and Dr. Li, are shared first authors for this manuscript. The authors would like to thank Zhuozhi Lin, Ruoxuan Wang, Jamie Lee, Elliott Golden, Karen Choe and Howard Bi for their administrative assistance in formatting the paper.
Funding
This work was supported by the National Institutes of Mental Health (LHY, MRP, ES, grant number R03MH092666), (LHY, MRP, ES, grant number R01 MH108385), (LHY, MRP, ES, grant number, R01 MH127631); and the Fogarty International Center (LHY, MRP, ES, grant number R01 MH108385), (LHY, MRP, ES, grant number, R01 MH127631), the Li Ka Shing Foundation Initiative for Global Mental Health and Wellness (LHY) and the Global Alliance of Chronic Diseases/Chinese National Natural Science Foundation of China (MRP, NSFC grant number 81761128031). The Funders had no role in the design of the study, the collection, analysis, and interpretation of data, or in the writing of this manuscript.
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LHY, MRP and ES conceptualized the project. MRP, XL, JZ, QS, ZD, and SP formulated data collection procedures and collected the data. GY and LHY conducted the analysis. LHY, MMG and ES wrote the first draft; MRP, ES and LHY provided final edits to the submitted manuscript. LHY, MRP, MMG and GY revised the manuscript. All authors have seen and approved the final version of the report.
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All research involving human participants or data was conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from all subjects and/or their legal guardian(s). This study was approved by the ethics committee of Bei**g Hui Long Guan Hospital (Bei**g, China); Shandong Provincial Mental Health Centre (**an City, Shandong, China); Li Tong De Hospital (Hangzhou City, Zhejiang, China); 3rd People’s Hospital (**ning City, Qinghai, China); Tianshui City Psychiatric Hospital (Tianshui City, Gansu, China), and Qingdao Mental Health Centre (Qingdao City, Shandong, China).
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Yang, L.H., Phillips, M.R., Li, X. et al. Determinants of never-treated status in rural versus urban contexts for individuals with schizophrenia in a population-based study in China. BMC Psychiatry 22, 128 (2022). https://doi.org/10.1186/s12888-021-03651-y
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DOI: https://doi.org/10.1186/s12888-021-03651-y