Significance of the 686 Program for China and for global mental health

Quietly, with little apparent notice from even the strongest advocates for global mental health, China is undertaking the world's largest – and arguably most important – mental health services demonstration project, a project focused on providing comprehensive care for persons with severe mental illnesses. As Professor Ma indicates in her short report,[1] the ‘686 Project’ was launched as part of China's commitment to rebuild its public health infrastructure following the SARS epidemic, and has now moved beyond the initial pilot phase into a process of scaling up community mental health services throughout the country. China is currently moving toward passage of its first national mental health law, so the project has profound implications for mental health policy in the country. It will also provide useful models for the development of mental health policies in other countries with limited mental health personnel.

Several critical features of the 686 Program should be stressed. First, as Professor Ma indicates, the program has developed an increasingly clear model of services that move mental health care out of the specialty mental hospital into community settings, linking provincial and district hospitals to township or neighborhood level health clinics which provide outreach services into the community. Of particular importance to the model is that in many sites multifunctional treatment teams practice mental health care full-time or near full-time, carrying the services directly into villages and urban communities. This model is quite different than older models for providing mental health services in primary care settings, which rely on training primary care doctors and nurses to recognize and respond to the subset of persons who suffer mental illnesses who appear in their clinics. Building multifunctional teams and sending them into the community constitutes a greater commitment of resources. And, unlike the traditional model, it makes it possible for team members to develop real competence as mental health specialists and to provide community-based care in reality rather than in name alone.

Second, the program has made rehabilitation and recovery central to the clinical activities of the core multifunctional teams, ‘leap-frogging’ older models focused more narrowly on the management of psychotic symptoms. The whole program has required an enormous effort of training the different stakeholders: leaders of the program throughout the country, hospital clinicians and administrators, team members in primary care settings, and so forth. AusAID played an important role, providing educational experiences for program leaders in Australia and Hong Kong. Professor Ma's team at the Peking University Institute of Mental Health has run annual workshops focused on ‘balanced rehabilitation.’ At the workshops specialists from Beijing and Shanghai and experts in recovery-oriented mental health services from the United States and Australia spark the imagination of program leaders from around the country and strengthen their clinical skills to help convert their ideas and enthusiasm into practical services. The program continues to develop training materials and to build a cadre of teachers to run a wide variety of courses for all types of personnel who manage or provide services for the mentally ill.

Third, as reported by Professor Ma, the program has played an important role in helping build a ‘rich database of experiences in community-based health reform.’ Many of the extraordinary initiatives – some initiated centrally and some initiated provincially or locally – remain even more hidden from view than the overall 686 Program. In our roles as Program Directors (along with Professor Arthur Kleinman) of a Fogarty International Center collaborative training program focused on implementation sciences and on mental health services and policy research (see Note), we have had the opportunity to participate in training activities, meet with leaders of the program from around China, visit several local program sites, and consult in the development of implementation research projects and data analysis. We have had the opportunity to see first-hand several of the innovative programs that are being undertaken, many of them beyond the scope of the original 686 Program. For example, the ‘unlocking project’ developed out of early experiences in the 686 Program when it was found that some individuals with severe mental illnesses were being locked up and often restrained with ropes or chains by their families because of episodes of violence (usually directed at other family members) or self-harm; some provinces have used their own resources to expand the 686 Program's model unlocking project throughout the province. In some settings the basic 686 Program has been augmented with early psychosis programs, social skills training projects, family psychoeducation programs, or special post-hospitalization behavioral and psychosocial interventions. Other locations have expanded the scope of community services beyond those for persons with psychotic illnesses to include services for elders with depression or dementia, consultation-liaison programs in general hospitals, school interventions for children, and drug treatment programs. Obviously, not all of these services are a direct result of the 686 Program, but it is clear that the public mental health programs launched in 2005 and the increased exposure of Chinese mental health leaders to community-based programs in Australia, the United States and Europe are leading to a broad reform movement of mental health care in China.

In the initial years of the 686 Program, one notable weakness was the lack of sustained evaluation studies or a broader program of implementation research. There are signs that this is changing. In collaboration with colleagues at Harvard and with support of the Fogarty International Center training program, both the Peking University Institute of Mental Health and the Shanghai Mental Health Center are making substantial commitments to developing programs in what the U.S. National Institutes of Health currently calls ‘Implementation and Dissemination’ (I & D) research. In the Peking University Institute a substantial focus of the Fogarty program is on linking evaluation research of the 686 Program with more basic research in biological psychiatry and genetics. Professor Ma and her colleagues at the Institute recently held a training workshop for a new Implementation Research Leadership Program linked to the Fogarty program which is intended to bring together leaders of the 686 Program from around China to build programs of collaborative research. We believe that the development of research in the 686 network, supported by local resources and carried out by local mental health teams, may have as great a potential for improving the implementation of mental health care throughout China as any projects developed in more academic settings. Several of the studies being developed are related to retrospective and prospective evaluations of the unlocking program: trying to identify factors associated with the variable success of the program (in some locations ‘re-locking’ was common) and the relative importance of the intensity of the follow-up services in the success of the program. Other planned studies include a) a multi-site prospective comparison of injectable haloperidol, oral first-generation medications, and oral second generation medication; b) a randomized controlled trial to formally evaluate a social skills intervention; and c) a province-wide comparison of the 686 Program with another community intervention model. These are all extremely positive developments, suggesting that the 686 Program may have long-term effects well beyond the original goals of developing a model for the community-based treatment of persons with severe and persisting mental illness.

Enormous challenges remain for the development of mental health services throughout China.[2] Well trained generalist mental health specialists are extremely limited and subspecialists – for example in geriatric psychiatry or child psychiatry – are largely limited to academic centers in large cities. Even when health insurance or special programs such as the 686 Program subsidize the cost of medication and hospitalization, many families impoverished by the mental illness of a family member cannot afford care. Nonetheless, the importance of the 686 Program and the network of administrators, policy makers, and clinicians it has developed cannot be over-emphasized. This is a critical time to formally evaluate and document the overall effectiveness of the 686 Program and of the many innovative add-on projects that have grown out of the 686 Program. The huge scope of the projects makes it feasible to demonstrate the role of mental health care in reducing impoverishment while improving the lives of those suffering from mental illnesses and of their family members. The results of such studies would make important contributions both to improving the quality of care and to the policy debates now underway in China.

Models relevant for the development of mental health services in low-resource settings are unlikely to come from North America, Europe or Australia. China is currently developing and testing a wide range of service models, some of which deserve to be adapted and tested in the many other countries with few mental health professionals and small mental health budgets. However, these Chinese models will only be internationally accessible if their operational characteristics are described in sufficient detail to enable replication in other countries and if the process and outcome measures for the projects are rigorously monitored and evaluated. This should be a primary goal of the mental health community in China; achieving this goal would provide sustained evidence-based support for the development of community mental health services in China and, at the same time, make a very substantial contribution to global mental health.

Note

The Fogarty International Center grant, 1D43TW009081, Building Research Capacity to Improve Mental Health in China across the Lifespan, directed by Byron Good, Mary-Jo DelVecchio Good, and Arthur Kleinman, links the Department of Global Health and Social Medicine at Harvard University to the Shanghai Mental Health Center and the Peking University Institute of Mental Health, with the aim of training new researchers and supporting the development of implementation research for mental health services in China.