|Year : 2017 | Volume
| Issue : 1 | Page : 36-41
Evaluation of attitudes to integration of mental health service in the chinese population of nonpsychiatric health-care providers
Chunyan Zhu1, Qingshan Geng2, Li Chen3, Lan Guo1
1 Department of Prevention Medicine, School of Public Health, Guangzhou Medical University, Guangzhou, Guangdong 510182, P. R. China
2 Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Science, Guangzhou, Guangdong 510182, P. R. China
3 Department of Health of Guangdong Province, Bureau of Health Care, Guangzhou, Guangdong 510182, P. R. China
|Date of Web Publication||24-May-2017|
No. 106, Zhongshan Road, Yuexiu District, Guangzhou 510080
P. R. China
Source of Support: None, Conflict of Interest: None
Objectives: The objective of this study was designed to assess the attitudes of Chinese nonpsychiatric health-care providers in Guangdong to mental health services (MHSs) integrated into the system of health care. Methods: A cross-sectional study was conducted to evaluate the attitudes of nonpsychiartric health-care providers to integrated MHS in 16 tertiary general hospitals from December 2012 to March 2013. A multiple regression model was used to analyze the impact factors of the subjects' attitudes to integrated MHS. Results: Of all the 2574 subjects, 1842 (71.6%) subjects strongly supported integrated MHS in general hospitals while only 4.3% (111) of subjects disagreed/strongly disagreed with integrated MHS. The rest of subjects (621/24.1%) remained neutral. The multiple regression model analyses presented that those male subjects with postgraduate diplomas who agreed with integrated MHS were interested in training on MHS. Approximately, more than 30% of subjects who were diagnosed with mental disorders and worked for 8–10 h/day were prone to obtain MHS and own a positive attitude to MHS in clinical practice. Conclusions: Most subjects owned positive attitudes to MHS in clinical practice. Lack of MHS knowledge is the major obstacle to those subjects who disagreed with integrated MHS.
Keywords: China, clinical practice, mental health service, nonpsychiatric health-care provider
|How to cite this article:|
Zhu C, Geng Q, Chen L, Guo L. Evaluation of attitudes to integration of mental health service in the chinese population of nonpsychiatric health-care providers. Heart Mind 2017;1:36-41
|How to cite this URL:|
Zhu C, Geng Q, Chen L, Guo L. Evaluation of attitudes to integration of mental health service in the chinese population of nonpsychiatric health-care providers. Heart Mind [serial online] 2017 [cited 2022 May 24];1:36-41. Available from: http://www.heartmindjournal.org/text.asp?2017/1/1/36/206965
| Introduction|| |
Mental and drug misconducts are the leading reasons of disabilities worldwide as reported by the updates of the global burden of disease in 2010. The economic burdens of mental and drug misconducts were increased with a percentage of 37.6% from 1990 to 2010. In 2010, the number of patients with mental and drug misconducts was 183.9 million (95% confidential interval [CI]: 153.3–216.7 millions) and accounted for 7.4% of patients worldwide (95% CI: 6.2%–8.6%). Of all the patients, the percentage of the patients with depression was 40.5% (95% CI: 31.7%–49.2%). Even though the number of patients with depression enrolled in the general hospitals was reported to be completely more than that in the psychiatric hospitals, lack of knowledge, and treatment regimens of patients with mental health disorders are common among nonpsychiatric practitioners.,, In China, the incidence of patients with mental health disorders increases and has already been important health and social issues. Approximately, 173 million patients suffered from mental health disorders in 2009 as reported in a survey conducted in four Chinese cities. By 2020, the percentage of the costs spent by the patients with mental health disorders was estimated to account for 20% of the total disease burdens in China. However, the system of health care in China has not been well-developed yet that leads to the misdiagnosis of nonpsychiatric health-care providers. Compared to that of the industrialized countries, the percentage of illness recognition (e.g., depression and anxiety) remains low in the Chinese general hospitals  given that the integration of mental health service (MHS) in the general hospitals has not been endorsed by the Chinese health-care providers yet.
By 2020, mental disorders are estimated to account for 20% of the total disease burdens in China. Meanwhile, the health-care system in China is not well developed, and a great number of patients with mental illness are misdiagnosed by the nonpsychiatric health-care providers. The recognition rate of mental illnesses, such as depression and anxiety, remained low in the nonpsychiatric settings of the Chinese general hospitals compared to that of the industrialized countries as reported by Jianlin  and the concept of MHS integrated into general health care in the general hospitals has not been widely endorsed by the Chinese health-care providers.
This study was to evaluate the attitudes of the health-care providers and administrators to the integration of MHS to better understand the current statuses of MHS in the general hospitals and the feasibility of continuing medical educations among Chinese health-care providers in Guangdong.
| Methods|| |
A cross-sectional survey was conducted from December 2012 to March 2013. A total of sixteen tertiary general hospitals that follow global clinical practice in Guangdong were randomly screened, and the questionnaires were distributed to 3410 health-care providers, including nonpsychiatric physicians, nurses, and administrators. The study protocol was approved by the Ethics Committee of the Guangdong General Hospital. Informed consents were obtained from all the subjects who were enrolled in the study.
Self-evaluation questionnaires were developed by WJ and QG. Demographic items included sex, ages, marital statuses, education levels, occupation, institution, professional titles, and mean of working hours. The marital statuses were grouped as “never married,” “married,” and “widowed/separated/divorced.” The education levels were grouped as “secondary,” “university,” and “postgraduate.” The occupations were grouped as “physician,” “nurse,” “administrative staff,” and “others.” The institutions were grouped as “hospitals affiliated to universities,” and “nonuniversity affiliated hospitals.” The professional titles were grouped as “junior and below,” “intermediate,” and “senior.” The means of working hours were grouped as “<8 h/day,” “8–10 h/day,” and “>10 h/day.” The subject attitudes to MHS integrated into general health care was a self-evaluation test with answers as presented below: “Strongly agree,” “agree,” “neutral,” “disagree,” “strongly disagree,” and “do not care.” Those subjects who failed to complete the questionnaires or 90% of answers in the questionnaire were not completed were excluded from the final analyses.
All statistical analyses were performed with SPSS (Version 15.0, Chicago, IL; SPSS Inc). P < 0.05 (two-tailed) was considered to be statistically significant.
The data were presented as means ± standard deviations for those continuous variables or as frequencies (%) for those categorical variables. The answers to the attitudes to MHS integrated into general health care included “strongly disagree,” “disagree,” “neutral,” “do not care,” “strongly agree,” and “agree.” The Chi-square and multiple cumulative logits model were performed to evaluate the associations between the attitudes to integration of MHS and impact factors of demographic data.
| Results|| |
A total of 3410 questionnaires were prepared, and 2735 (80.2%) questionnaires were collected. Of all, 2574 (75.5%) questionnaires were eligible for the final analyses. The mean age of the subjects was 34.9 ± 9.2 years. The female and male subjects accounted for 66.3% and 33.7%, respectively. In all the subjects, 58.9% of subjects obtained higher education, including 38.8% of subjects with postgraduate education, 67.0% of subjects from the universities affiliated to the hospitals, 52.5% of physicians, and 45.9% of subjects with junior or below titles [Table 1].
Attitudes to mental health services integrated into general health care
Of all the subjects, 239 subjects (9.3%) strongly agreed, 1603 subjects (62.3%) agreed, 621 subjects (24.1%) neurally or did not agree, 92 subjects (3.6%) disagreed, and 19 subjects (0.7%) strongly disagreed with the concept of task shifts on MHSs, respectively [Table 1].
Relationship of mental health services and subject attitudes to mental health services integrated into general health care
The results showed that a total of 1058 subjects (41.1%) never obtained any schooling training on any psychiatry curriculum. Of all, 1712 subjects (66.5%) never took psychiatrist rotations in the period of clerkship and 1714 subjects (66.6%) never obtained MHSs as continuing medical education. Totally, 2417 subjects were prone to obtain training on MHSs. Those subjects who obtained MHSs as continuing medical education after graduation were prone to obtain training on MHSs and owned more positive attitudes to MHSs integrated into general health care in the general hospital [all P < 0.01, [Table 2].
|Table 2: Relationship of mental health services and subjects' attitudes to mental health care integrated into general health care|
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Relationship of mental health services in general practice and subject attitudes to mental health services integrated into general health care
As showed in [Table 3], a total of 1156 (44.9%) subjects reported that 30% of patients were observed with physical diseases complicated with mental disorders and only 6.9% of the patients were prone to obtain MHSs in daily work. Those patients who were reported with a higher percentage of the patients complicated with mental disorders were prone to obtain MHSs, and own positive attitudes to MHSs integrated into general health care in the general hospital (all P < 0.01).
|Table 3: Relationship of mental health services integrated into general health practice and subjects' attitudes to mental health care integrated into general health care (n=2574)|
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The multiple cumulative logistical model analysis was performed with the covariates of demographic variables [Table 4]. Compare to those female subjects, those subjects who did not obtain MHSs as continuing medical education after graduation, those subjects who were not prone to obtain training on MHSs, and worked for more than 10 h/day, higher percentages of male subjects, those subjects who obtained MHSs as continuing medical education after graduation, those subjects who were prone to obtain training on MHSs, and worked for 8–10 h/day owned positive attitudes to MHSs integrated into general health care. In those subjects who were well-prepared, needed to prepare further, and did no preparation for training on MHSs, a lower percentage of subjects who owned positive attitudes to MHSs integrated into general health care were observed in the populations who needed no training and needed systematic training. While those subjects who were postgraduated, those subjects who held a role of physician, and those subjects with an estimated percentage of 10% in mental disorders were observed with negative attitudes to MHSs integrated into general health services.
|Table 4: Multiple logistic regressions of subjects' attitudes to mental health care integrated into general health care after adjusted the parameters of demographic data, education levels, and mental health services|
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| Discussion|| |
The study was designed to evaluate the attitudes of nonpsychiatric health-care providers from the province of Guangzhou in China to MHSs integrated into general health care. The results showed that most subjects owned a positive attitude to MHSs integrated into general health care and most subjects needed to prepare MHSs further due to lack of education and knowledge on MHSs.
The prevalence of mental disease is increasing in China, and the prevalence of psychological disorders is higher in the outpatients from the general hospitals ,, who are at a higher risk to develop severe anxiety, depression, and potential mood disorders. Lack of professional resources on mental health was one of the major obstacles in advancing mental health care in China. Less than 15 psychiatrists per million population or per 10,000 patients with mental disorders could be allocated in contrast to a burgeoning need of MHSs in a population of 1.4 billion with <20,000 registered psychiatrists in China is estimated. Although the majority of health-care providers owned a positive attitude to mental health integrated into general health care, only a small proportion of subjects self-assessed to be qualified for the daily care of mental disorders that is consistent with a study conducted in China.
Lack of MHS education, training, and knowledge are common in the nonpsychiatric health care providers as a result of the Chinese medical education system. In the past decades, mental health was not emphasized by training on general public health or delivery of health services in China. Only a few universities provided curricula in the area of public mental health to train potential nonpsychiatric health-care providers, administrators, planners, and leaders. Psychiatric-related education and training are exceedingly limited in the nonpsychiatric physicians who completed high-level college education and beyond.,,
Lack of MHS education and training were related to recognition and treatment of mental health that is consistent with the results of those previous studies. Those nonpsychiatric health-care providers who obtained MHS education owned a higher-quality diagnosis and treatment of depression or anxiety in the general hospitals as reported by Shisheng et al. As Eaton et al. demonstrated, those psychiatric professionals, especially for nonspecialists, needed to be trained better and supported identification and management of mental disorders. Knowledge of physicians, attitudes, and confidences in the treatment of mental disorders such as depression  were demonstrated to be impacted through a brief educational program while others supported that only continual, longitudinal educational programs contributed to significant changes in clinical practice.
In our study, those physicians with a university diploma who were enrolled in the trial and worked for more than 10 h/day were observed to own a more negative attitude to MHS integrated into general health care compared to those administrative staff with a postgraduate diploma who worked for 8–10 h/day. The factors including patients, health-care providers, and the system of MHS could negatively influence improvement of MHS in the general hospitals., Lack of knowledge on diagnosis or treatment, psychological orientation, and time pressure bring the barriers of MHS to the health-care providers.,, An earlier study showed that subject attitudes to integration of MHS owned an impact on subject participation of training programs, and the treatments of patients in medical general practice., The education levels of the health-care providers, psychiatric-related schooling education, and continuing medical education were used for evaluation of knowledge and skill competencies. As Phillips et al. reported  the demands of nonpsychiatric working settings or the number of qualified general physicians increased after the Law of the Chinese Mental Health was launched in 2013.
Given the limitations of the study, the trial was designed as a cross-sectional study that was not powered for causal inferences. Second, selection bias led to a over-estimated positive response. Third, the possibilities of generalization in the health-care providers of the community settings needed to be confirmed since the subjects in the study were all nonpsychiatric health-care providers in the general hospitals. Finally, in clinical practice, the MHS in the general hospitals involved other stakeholders, such as decision-makers who supported and facilitated MHS, and those who were not investigated in the current study; therefore, the stakeholders' views on MHS were expected to explore further.
| Conclusions|| |
Until now, it is the largest study in China that explores the attitudes of nonpsychiatric health-care providers to mental health care integrated into general health care. Most the nonpsychiatric health-care providers owned a positive attitude to MHSs integrated into general health care while the majority of subjects needed to obtain MHSs further. Lack of knowledge on MHSs, education, and training led to negative attitudes to MHSs integrated into general health care that emphasized the necessities of MHSs education, schooling training, and those training for nonpsychiatric health-care providers after graduation.
We appreciate Dr Lu Shen and Dr Jinyao Zhang, Abbott, China, for their technical assistance on the research project that was funded by the Medical Scientific Research Funds in the province of Guangdong, China (C2013023), and by The Educational Scientific Planning Fund of Guangzhou, China (1201420504).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, et al.
Global burden of disease attributable to mental and substance use disorders: Findings from the Global Burden of Disease Study 2010. Lancet 2013;382:1575-86.
Tyrer P. Are general practitioners really unable to diagnose depression? Lancet 2009;374:589-90.
Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: Scarcity, inequity, and inefficiency. Lancet 2007;370:878-89.
Piek E, Nolen WA, van der Meer K, Joling KJ, Kollen BJ, Penninx BW, et al.
Determinants of (non-) recognition of depression by general practitioners: Results of the Netherlands Study of Depression and Anxiety. J Affect Disord 2012;138:397-404.
Lancet Global Mental Health Group, Chisholm D, Flisher AJ, Lund C, Patel V, Saxena S, et al.
Scale up services for mental disorders: A call for action. Lancet 2007;370:1241-52.
Phillips MR, Zhang J, Shi Q, Song Z, Ding Z, Pang S, et al.
Prevalence, treatment, and associated disability of mental disorders in four provinces in China during 2001-05: An epidemiological survey. Lancet 2009;373:2041-53.
Jianlin J. Depressive disorder in general hospital: Diagnosis, treatment and research thinking. Chin Ment Health J 2012;26:899-901.
Liu J, Ma H, He YL, Xie B, Xu YF, Tang HY, et al.
Mental health system in China: History, recent service reform and future challenges. World Psychiatry 2011;10:210-6.
Xu P, Ying Q, Yufei Y. Comparison of related factors of anxiety and depression in patients with different diseases in the internal medical department of polyclinic. Chin J Clin Rehabil 2006;10:1-3.
Li L, Wang HM, Ye XJ, Jiang MM, Lou QY, Hesketh T. The mental health status of Chinese rural-urban migrant workers: Comparison with permanent urban and rural dwellers. Soc Psychiatry Psychiatr Epidemiol 2007;42:716-22.
Liming O, Ruifang Y, Jian C, Meilan Z, Chunyan Z, Qingshan G. An epidemiological survey on depression/anxiety in clinical patients of general hospitals in Guangzhou. Chin J Clin Psychol 2009;17:61-3.
Zhu C, Ou L, Geng Q, Zhang M, Ye R, Chen J, et al.
Association of somatic symptoms with depression and anxiety in clinical patients of general hospitals in Guangzhou, China. Gen Hosp Psychiatry 2012;34:113-20.
Yue-Qin H. Status quo and challenge of mental health in China. Chin J Health Policy 2011;4:5-9.
Rong F, Chunyan Z, Li C, Qingshan G. Analysis of influencing factors for attitude shifting to mental health work among non-psychiatric doctors in general hospitals. Chin Med Ethics 2015;3:369-73.
Shui-Yuan X. The challenges of mental health service in China. Chin Ment Health J 2009;23:844-7.
Phillips MR. Mental health in China: Challenges and options for the 21st
century Michael. Chin J Nerv Ment Dis 2004;30:1-10.
Chunyan Z, Li C, Qingshan G, Guihao L, Rong F, Yanhua O. A cross-sectional study on the mental education among non-psychiatric medical workers of the general hospitals in Guangzhou. Chin J Behav Med Brain Sci 2013;22:932-4.
Shisheng H, Ling X, Huiling W, Zhongchun L, Gaohua W. Survey on the non-psychiatric physician's ability of diagnosis and treatment of depression/anxiety disorders in general hospital. Chin J Behav Med Brain Sci 2015;24:1037-40.
Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, Araya R, et al.
Scale up of services for mental health in low-income and middle-income countries. Lancet 2011;378:1592-603.
Wang YH, Huang HC, Liu SI, Lu RB. Assessment of changes in confidence, attitude, and knowledge of non-psychiatric physicians undergoing a depression training program in Taiwan. Int J Psychiatry Med 2012;43:293-308.
Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA 1999;282:867-74.
Saraceno B, van Ommeren M, Batniji R, Cohen A, Gureje O, Mahoney J, et al.
Barriers to improvement of mental health services in low-income and middle-income countries. Lancet 2007;370:1164-74.
Goldman LS, Nielsen NH, Champion HC. Awareness, diagnosis, and treatment of depression. J Gen Intern Med 1999;14:569-80.
Cooper LA, Brown C, Vu HT, Palenchar DR, Gonzales JJ, Ford DE, et al.
Primary care patients' opinions regarding the importance of various aspects of care for depression. Gen Hosp Psychiatry 2000;22:163-73.
Kirmayer LJ. Cultural variations in the clinical presentation of depression and anxiety: Implications for diagnosis and treatment. J Clin Psychiatry 2001;62 Suppl 13:22-8.
Dowrick C, Gask L, Perry R, Dixon C, Usherwood T. Do general practitioners' attitudes towards depression predict their clinical behaviour? Psychol Med 2000;30:413-9.
Botega NJ, Silveira GM. General practitioners attitudes towards depression: A study in primary care setting in Brazil. Int J Soc Psychiatry 1996;42:230-7.
Phillips MR, Chen H, Diesfeld K, Xie B, Cheng HG, Mellsop G, et al.
China's new mental health law: Reframing involuntary treatment. Am J Psychiatry 2013;170:588-91.
[Table 1], [Table 2], [Table 3], [Table 4]