Foreign report Mental health delivery system in Shanghai, China

John Kerr in Guangzhou (in South China) in 1897 (Xia &Zhang, 1981). From then until 1949,only a few mental hospitals and institutions were set up in eight cities. However, since 1949, Chinese psychiatry has de veloped rapidly under government support, particu larly during the last 15 years. Three research and training centres in mental health have been set up in collaboration with the World Health Organisation in Shanghai, Peking and Nanjing since 1980. This article describes the development of the mental health service in Shanghai in recent years.

John Kerr in Guangzhou (in South China) in 1897 (Xia & Zhang, 1981). From then until 1949,only a few mental hospitals and institutions were set up in eight cities.
However, since 1949, Chinese psychiatry has de veloped rapidly under government support, particu larly during the last 15 years. Three research and training centres in mental health have been set up in collaboration with the World Health Organisation in Shanghai, Peking and Nanjing since 1980. This article describes the development of the mental health service in Shanghai in recent years.

Background
Shanghai is one of the greatest cities in China, with a population of over 12 million people and 12districts and 10 counties. bed capacity of 6,500, or an average of 54/10,000 population, it still cannot meet the needs of many mental patients. The main reasons are due to the increase in the prevalence rate of mental disorders and the huge population in Shanghai. Comparing the surveys of 1958 and 1982,it was found that the aver age prevalence rate of total mental disorders and schizophrenia had increased respectively from 3.02 per 1000 and 0.98 per 1000 in 1958 to 7.28 per 1000 and 4.75 per 1000 in 1982 (Shen, 1987). That is, the total prevalence rate has increased 1.43 times, with schizophrenia rising 3.85 times during this period.
How can we solve the problem of so many mental patients? How can we improve this difficult situation? What measures will be simple, economic, practical, and also effective? The mental health service in Shanghai must develop in accordance with its special situation.

The three-level scheme of organisation
Using the theory and experience of community psychiatry in Western Europe for reference, a threelevel (municipal, district/county and community) mental health network was established in Shanghai in the early 1980s and has been progressively con tinued since. The organisation at the municipal level, for example, comprises representatives of the Shanghai Health Bureau, Civil Welfare Agency and Police Department, and its main tasks are to: (a) draw up a coordinated programme for mental health care in the whole municipality (b) coordinate the methods and strategies of the professional and all social agencies carrying out mental health work (c) mobilise and organise medical staff and social agencies to push forward the development of mental health work (d) advise and supervise the district and county facilities to carry out various programmes of primary mental health care.

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The primary mental health care service The primary mental health care services (PMHCSs) in Shanghai get support from various levels of administrative organs as well as all social agencies. The main forms of PMHCSs have four aspects.

(a) Occupational therapy groups (or stations)
The occupational therapy (OT) groups in Shanghai are more or less the same as day hospitals, halfway stations or sheltered workshops in North America and Europe. However, there are four points which characterise OT groups in Shanghai: (i) they are run by the community, neighbour hood committees and districts (ii) most of the staff are volunteers and nonprofessional paramedicals with short-term training in clinical psychiatry (iii) they serve not only as psychiatric treatment and rehabilitation units, but also as units of patients' self-supportive organisations and (iv) they chiefly lay emphasis on OT combined with psychotropic drugs, behavioural modifi cation, social skill training, re-education, and recreational treatments. OT groups admit patients who have partially re covered but are not quite capable of taking up definite jobs and those who were unemployed before their illness. The administrations are composed of district officers, paramedicals and retired workers, among which retired workers play a main role in community mental health care work. They often keep in contact with the regional psychiatrists and psychiatric nurses. The psychiatric family care unit is another important form of mental health care service in Shanghai. It consists of the patient's neighbours, retired workers and family members to assist in the care of mental patients with a couple of people devoting their time to the care of each patient. Their duty is to observe the patient's mental condition and report to the health personnel concerned if abnormal behaviour occurs. Meanwhile, they help to guide and advise the patients, solve their related social or psychological problems and administer drugs as prescribed.
(c) Care of mental patients in big factories There are many big factories and companies in Shanghai, since it is one of the main industrial and commercial cities in China. For this reason, in factor ies and other work places, especially those with over 2000 employees, the mental health service is inte grated into the factory general health care system (parallel to their administrative organisation), under the supervision of district mental health staff.

(d) Training of primary mental health workers
Clinical psychiatric training for medical staff work ing at the grass-roots level in neighbourhoods, dis trict or county hospitals, and the factory health stations has been provided. The training course often lasts six weeks, two weeks of which are devoted to theoretical lectures which are followed by four weeks of clinical practice. The object of such training is to provide the trainee with basic and practical knowl edge about psychopathology, diagnostic criteria for common mental disorders, psychopharmacology, and mental care and prevention so that the medical staff can provide an effective mental health care service at their neighbourhood or factory level.

Comment
Although the achievements made since the network of mental health care was established in Shanghai Ji are quite encouraging, there is plenty of room for improvement. In the near future we are going to strengthen the systematic training of mental health workers (including residents, nurses, social workers and clinical psychologists, etc.), helping them to pay more attention to psycho-social factors and to master the professional knowledge of psychiatry together with the modern bio-psycho-social medical model.