Approaches to involuntary admission of the mentally ill in the People’s Republic of China: Changes in legislation from 2002 to 2012

Abstract

Because a systematic analysis of laws on involuntary admission of the mentally ill in China does not exist, this paper explored the trajectory of the legislation on involuntary admission of the mentally ill in China; the social and cultural factors underlying these changes are also discussed. By describing and analyzing the differences or similarities of current legal frameworks and procedures for involuntary admission of the mentally ill across the seven local mental health regulations and the National Mental Health Act, one can see a trajectory of gradually more stringent legislation for involuntary admission during the past 10 years of China. The compromise, reversals, and circuitous paths during the legislation process reflect the difficulty the government faces in balancing the benefits between society and individuals, and explores the transformation of the mode of mental health services. The approach in the 2012 National Mental Health Act, despite some weaknesses, is an important step to standardize the diverse practices in involuntary admission of the mentally ill in China. Further research on the influence of the National Act on mental health services is clearly needed.

Introduction

The involuntary admission of the mentally ill is a controversial issue in mental health care worldwide, and it is no exception in the People’s Republic of China (PRC). During the past decade, in reports of some events receiving much attention in society, such as serious and fatal attacks on adults and children by mentally ill patients or human rights violations in psychiatric hospitals, the lack of a national mental health law, especially legislation on involuntary admission, is always viewed as the root cause [1–4].

Problems relevant to involuntary admission of the mentally ill have been addressed in various articles and sections of China’s legal statutes since the early 1980s, such as Criminal Law (1980), the Criminal Procedure Law (1980), and Regulations on Penalties for Administration of Public Security (1986). The scope of these laws, however, is too narrow, and only detention of patients with illegal behaviors was covered.

It was not until 2002 that involuntary admission of the mentally ill was fully addressed in the “Shanghai Municipality Regulations on Mental Health,” the first local legislation on mental health in China. By defining the conditions that must be met when the mentally ill should be involuntarily admitted, the regulation became an important measure to protect the human rights of mental patients and prevent abuse. Since that time, several other cities (Ningbo [2006], Beijing [2007], Hangzhou [2007], Wuxi [2007], Wuhan [2012], and Shenzhen 2012]) have enacted regulations on mental health to address the legal issues related to involuntary admission of the mentally ill. All of these legislations at the local level served as models for the national mental health legislation [5].

In 2011, after more than a quarter century process of formulation, revision, and re-revision by numerous psychiatrists, jurists, government administrators, and legislators, the draft of the National Mental Health Law was released for public consultation and comment by the Legislative Affairs Office of the State Council and by the Standing Committee of the National People’s Congress. Then, a revised draft was approved on 26 October 2012. According to the new law, an entirely new approach to involuntary admission of the mentally ill went into effect on 1 May 2013¹.

Our previous work summarized the legislation on involuntary admission of the mentally ill in China before 2008 [5]. As the first study to attempt to collect data on this issue in China, the study showed that despite some defects, the local mental health regulations in five cities covered the basic principles needed to meet international standards of mental health legislation. In addition, under a similar legislation structure, the application of these measures differed widely across these cities, which shows that legislation on involuntary admission of the mentally ill is gradually changing in China.

Until now, there have been few systematic reviews which have addressed the changes in legislation on involuntary admission of the mentally ill. Indeed, reviews on the changes from local regulations to a national law are rare. The same situation exists regarding analyses of the social and cultural factors underlying these changes. In this paper we have attempted to explore the trajectory of the legislation on involuntary admission of the mentally ill in China by describing and analyzing the differences or similarities of current legal frameworks and procedures for involuntary admission of the mentally ill across the seven local mental health regulations, two drafts (June and October 2011), and the final version of the National Mental Health Law, thus contributing basic information that is essential to any discussion on this issue in China.

The following qualitative data on legal frameworks for involuntary admission of the mentally ill was gathered in our study: criteria for involuntary admission; procedures of initial assessment and decision-making; periods of detention; discharge procedures; and complaint procedures. These data was gathered by a group of psychiatrists who have been trained in evaluating mental health care systems. All of these psychiatrists were involved in our previous study, which was published in 2010 [5]. Because procedures governing forensic psychiatry in China are regulated by criminal law and criminal procedure law, and not considered part of the mental health care system proper², involuntary admission of the mentally ill in this context did not include the admission of mentally ill offenders or any other aspect of forensic psychiatry.

Diversity in Legislation on Involuntary Admission of the Mentally Ill in China

In addition to the “Compulsive Admission” for mentally ill offenders, there are two kinds of involuntary admissions in China. The “Medical Protective Admission” is executed by the family member of the mentally ill who are unable to give informed consent, and the “Emergency Admission” is executed by the police or other government authorities for patients with dangerous behavior, while the seriousness of the behavior does not constitute a criminal offense. The legal regulations on detaining the mentally ill in the seven jurisdictions are similar en masse, but with some subtle difference in detail.

Criteria for Involuntary Admission of the Mentally Ill

While all these local regulations stipulate a given and confirmed mental illness/disorder as a major condition for detaining a person, the additional criteria are heterogeneous across the seven jurisdictions (Table 1). In the procedure of “Medical Protective Admission,” Shanghai uses “totally or partially lose the competence of insight” and “hospitalization beneficial to treatment and recovery of the persons;” Beijing and Wuxi use “grave impairment in mental activities that lead self health conditions or external reality cannot be fully identified or self behavior cannot be controlled;” Hangzhou, Ningbo, Wuhan, and Shenzhen use “cannot (entirely) recognize or control one’s own behavior” and “hospitalization is necessary.” The mentally ill with dangerous behavior to others or society can be detained according to the “Emergency Admission” procedure in four cities. Shanghai and Shenzhen also allow a patient with dangerous behavior to oneself to be detained.

Table 1.

Criteria for involuntary admission

	Date of publication	Diagnoses legally defined	Medical Protective Admission			Emergency Admission
			Need to treatment	Danger to self	Impairment of judgment	Risk to self	Risk to other	Risk to society/public order
Shanghai	2002	Mental illness	Yes	n. d.	Competence of insight	Yes	Yes	Yes
Ningbo*	2006	Mental illness	Yes	n. d.	Recognize or control behavior	-	-	-
Hangzhou*	2007	Mental illness	Yes	n. d.	do.	-	-	-
Beijing	2007	Severe mental illness	n. d.	n. d.	Identify health conditions or external reality, control behavior	No	Yes	Yes
Wuxi	2007	Severe mental illness	n. d.	n. d.	do.	No	Yes	Yes
Wuhan*	2010	Mental illness	Yes	n. d.	Recognize or control behavior	-	-	-
Shenzhen	2012	Mental illness	Yes	n. d.	do.	Yes	Yes	Yes
Draft 1	Jun 2011	Mental illness	No	Yes	do.	No	Yes	Yes
Draft 2	Oct 2001	Severe mental illness	Yes	Yes	Identify health conditions or external reality, manage personal affairs	No	Yes	No
National Law	2012	Severe mental illness	No	Yes	do.	No	Yes	No
Draft 1	Jun 2011	Mental illness	No	Yes	do.	No	Yes	Yes
Draft 2	Oct 2001	Severe mental illness	Yes	Yes	Identify health conditions or external reality, manage personal affairs	No	Yes	No
National Law	2012	Severe mental illness	No	Yes	do.	No	Yes	No

^*In Ningbo, Hangzhou and Wuhan, there have no clearly legal regulations on Emergency Admission. Mental illness patients with danger to others or society can only be detained as a “Compulsory Admission” patient if his/her danger behavior constitute a criminal offense. In such situation, the use of “Compulsory Admission” will be decided by police after a forensic psychiatry evaluation.

Abbreviations:

n. d. not defined;

do. Ditto

In the process of drafting the National law, “need for treatment” criterion was canceled in the 10 June 2011 draft and added to the 26 August 2011 draft with the formulation as “without admission will do harm to the treatment of patient.” In the finalized law, “Medical Protective Admission” can only be used for a patient suffering from a severe mental disorder who exhibited “self-harm in the immediate past or current risk of self-harm” (Article 30.2.1). Another change in the National law is the abolishment of the “danger to society” criterion, which was used in the seven cities for many years. The National law only allows a severely mentally disordered patient who is a danger to others to be detained in emergency situations. The “danger to other” criterion not only means a behavior that has occurred, but also a possible behavior. Thus, in the final law it is stated as a behavior that “harmed others or endangered the safety of others in the immediate past or current risk to the safety of others” (Article 30.2.2).

Procedures of Initial Assessment and Decision-making

With respect to the expertise for assessing the medical criteria for involuntary placement, all seven local jurisdictions require that initial psychiatric assessments must be performed by trained psychiatrists (Table 2). In Shanghai and Shenzhen, the evaluator should have the title of “attending psychiatrist,” which usually means >5 years of clinical experience, while in Beijing the psychiatrist should have >2 years of experience. Just like most local jurisdictions, the National law also requires a registered psychiatrist for the initial assessment (Article 29.1). In most cities, the number and qualification for experts in “Emergency Admission” is much stricter than “Medical Protective Admission.” Usually, two attending psychiatrists or psychiatrists with higher qualification are needed (Shanghai requires two psychiatrists and at least one shall be an attending psychiatrist). According to the National law, a registered psychiatrist will be eligible to do the evaluation in both situations, and there is no specific provision on the number of assessment experts that is needed.

Table 2.

Procedure for involuntary admission

	Shanghai	Ningbo	Hangzhou	Beijing	Wuxi	Wuhan	Shenzhen	Draft 1	Draft 2	National Law
Review Process
Stage I
recheck for diagnoses	Yes	Yes	Yes	Yes	Yes	Yes	n. d.	n. d.	n. d.	n. d.
recheck for admission	n. d.	n. d.	n. d.	n. d.	n. d.	n. d.	Yes	Yes	Yes	Yes*
recheck by another mental health institute	n. d.	n. d.	n. d.	n. d.	n. d.	n. d.	Yes	Yes	Yes*	Yes*
maximum waiting for review	6 months	6 months	1 month	3 months	3 months	1 month	5 days	5 days	5 days	n. d.
Stage II
review by forensic psychiatrist	Yes	n. d.	n. d.	n. d.	n. d.	n. d.	Yes	Yes	Yes	Yes*
assessment again	n. d.	n. d.	n. d.	n. d.	n. d.	n. d.	n. d.	n. d.	Yes	n. d.
maximum waiting for review	n. d.	n. d.	n. d.	n. d.	n. d.	n. d.	n. d.	7 days	5 days	n. d.

^*For patient with risk to others

Abbreviations:

n. d. not defined;

The difference can also be seen in the deciding authority of “Emergency Admission.” In most cities, if the guardian of a patient with dangerous behavior refuses to detain the patient, only police can start the “Emergency Admission” procedure. In Shanghai, however, the procedure can start by “affiliated units, neighborhood committees, or villagers’ committees where the patient resides.” Wuxi also allows the “affiliated units” of the patient with dangerous behavior to make decisions regarding hospitalization. The decision power of the police was repealed in the draft of the National law. In the National law that was finally adopted, only “affiliated units (employer), neighborhood committees, or villagers’ committees where the patient resides” can make decisions on admission for the patient who is a danger to others (Article 36.2), and the role of the police is only to “take measures to assist the medical institutions for the implementation of the patient’s admission if the guardian refuses admission” (Article 35.2).

Periods of Detention

Neither the seven local regulations nor the National law have clear provisions on the maximum length of involuntary admission for the mentally ill. Only Shanghai regulations state that the institute should review the initial placement monthly for involuntary-admitted patients. Shanghai also states that “Emergency Admission” should be accomplished in 72 hours. If such people are not suffering from a mental disorder, they can only be discharged within 72 hours (Table 2).

Discharge Procedure

The discharge procedures among the seven cities are similar. While patients under “Medical Protective Admission” can be discharged at any time after the request from their guardians, patients under “Emergency Admission” can only be discharged after the recommendation from a psychiatrist and the deciding authority that makes the decision on admission.

The National Act also uses such modes. For a patient who is a danger to self, the guardian “may request discharge at any time and the hospital shall comply with such requests” (Article 44.2), and for patients who are a danger to others, the hospital “shall promptly arrange for registered psychiatrists to conduct an evaluation,” if “the evaluation finds that the patient no longer requires inpatient treatment, the medical facility shall immediately inform the patient and the guardians” (Article 44.4).

Complaint Procedures

A review system for involuntary admission of the mentally ill is an important approach to prevent improper detention. Although most local regulations formulate that hospitals should reassess the diagnoses from patients and their guardians who apply, only Shenzhen specifically states that patients and their guardians can apply for review of the decision on involuntary admission (Table 2). All of these reviews are done by the institute where the patient stays; only Shenzhen enables patients and guardians to request another mental health hospital to review an involuntary admission. Shanghai and Shenzhen allow independent forensic psychiatrists to re-check the review conclusions. Other cities do not clearly specify how to establish independent oversight and review mechanisms for involuntary admission of the mentally ill. Across the seven cities, the legally stipulated period of time awaiting a review is very heterogeneous, ranging from 5 days to 6 months. In 2011 when the draft of the National law was released for public comment, a two-stage review system was designed (Table 2). According to this system, patients under the “Medical Protective Admission” procedure have the right to apply for a review within the original hospital, and patients or their guardians under the “Emergency Admission” procedure can request another psychiatric hospital for an independent medical assessment. If the review conclusion is not satisfied by patients or their guardians, they can request a forensic psychiatry assessment institution to arrange an independent evaluation in stage two; such an evaluation can be rechecked within the institution. Such a system was finally simplified; according to the finalized law, only when a patient who is a danger to others is admitted, the patient and his/her guardian can apply for a medical assessment. The assessment can be performed by the hospital where the patient stays or another psychiatric hospital (Article 32.2). If the patient and his/her guardian are not satisfied with the results of the reassessment, they “may commission a legally accredited certification agency to conduct an independent, legally-binding medical certification for mental disorders” (Article 32.3).

Discussion

The nature of involuntary admission for the mentally ill involves restricting the liberty of certain individuals for the benefit of the individual and society at large. Involuntary admission for the mentally ill must weigh the rights of the public and the rights of the mentally ill, and balance the rights of the patient to receive treatment with the right of autonomy. The different approaches to regulating the application of involuntary admission for the mentally ill are largely dependent on a variety of social values, cultural or legal traditions, as well as different concepts and structures of mental health care delivery worldwide [7]. In China, these factors have also led to the increasingly stringent legislation of involuntary admission in the past 10 years.

Over the last 50 years, the lack of community-based services has been a key problem in mental health care in China. Usually, community mental health services might only be available to the wealthy, rather than the poor and deprived [8]. To make matters worse, even the community-based mental health systems in large cities have also been eliminated with the introduction of the market economy. Using Shanghai as an example, prior to 1990 there was at least one community-level rehabilitation facility in each district or town. By June 2004, the number of these facilities had decreased by 62% [9]. Due to the lack of community services, hospitalization becomes the only viable option despite the heavy financial burden it places on patients and their families [10]. Because there are no national guidelines on involuntary admissions for the mentally ill, people who are suspected of having psychiatric disorders are usually sent to psychiatric hospitals with consent forms signed by relatives [3].

For these reasons, when Shanghai began to draft its local mental health legislation, one important aim was to make the mental health service, especially the inpatient service, more accessible. This made the long-standing practice of family supervision of hospitalization of the mentally ill with help from the community being accepted by legislators and turned into a clear legal framework. Thus, the Shanghai regulation makes it possible for patients are unable to give informed consent because of “lack of insight,” but who will get benefit from admission and treatment, to be detained under the request from the guardians of patients, even if the patient poses no risk to themselves or others. The regulation also empowers not only the police, but also the “affiliated units, neighborhood committees, or villagers’ committees” to render decisions on detaining a patient with dangerous behavior.

Such a combined mode, where either the dangerousness or the need-for-treatment criterion for being detained is fulfilled, received support at the government public health policy level. According to two official documents, the first National Mental Health Plan (2002–2010) in 2002 and the Proposal on Further Strengthening Mental Health Work in 2004, the proposed mental health service model in China is led by psychiatric hospitals and supported by departments of psychiatry in general hospitals, community-based health facilities and rehabilitation centers [9]. The emphasis of the responsibility of the psychiatric hospital in mental health service at the policy level facilitated the model in Shanghai being adopted by other jurisdictions that began to legislate on involuntary admission of the mentally ill. Of course, such kinds of learning were not an intact copy, but with some adjustments partly driven by the competing interests of the various stakeholders, including patients, family members of patients, community members, mental health care providers, human rights activists, governmental agencies, and legislators [26].

For a long period of time, some critical opinions were raised throughout the development of the mental health service in the PRC, the human rights of individual mental patients were not properly respected, and the involuntary admission of the mentally ill was abused [11–13]. After the Shanghai regulations took effect, such criticism from some judicial and legal professionals intensified [14]. The criticism focused in the use of “lose the competence of insight” as a criterion to determine whether or not mental patients have no capacity to give informed consent and an involuntary admission procedure should be started. To the opinion of these critics, the medical term “insight” replaces the legal term of capacity for action. Thus, psychiatrists who have the right to determine “insight” replaced the court judge and determined whether or not a person has the capacity for action. Psychiatrists also suggested that it is a very dangerous practice to identify a mental patient to be a person incapable of disposing merely on the basis of a medical diagnosis because too much power is given to the psychiatrist. In addition, the provision that “hospitalization beneficial to treatment and recovery of the person” is also too vague because “admission beneficial to someone” does not mean it is the only or best choice for the patient. Thus, the provision used in Shanghai cannot effectively prevent the abuses of compulsory psychiatric treatment and unnecessary hospitalization.

In contrast, the importance of community mental health services has been increasingly emphasized by the government in the past 10 years. Policies that fund community mental health services, promote regular mental health training for community-based primary care providers, and reduce the financial burden on patients and their families began to be adopted by central and local governments [16,17]. In 2006, the National Continuing Management and Intervention Program for Psychoses was implemented by the central government to provide an integrated hospital and community treatment model for psychoses [9].

Such a shift in the government mental health policy, combined with the opponents of medical paternalism used in involuntary admission legislation, promoted the 2006 local regulations that modified the details in the involuntary admission procedures. First, the term “insight” is no longer used and two different kinds of threshold for involuntary admission are used. Two cities (Beijing and Wuxi) emphasize the severity of the disease, and limit involuntary admission to “severe psychoses” or conditions of similar severity. The other four cities (Hangzhou, Ningbo, Wuhan, and Shenzhen) emphasize that “hospitalization is necessary,” which is more rigorous compared to the word “beneficial” used in Shanghai. Furthermore, in these cities the condition for a patient who cannot give informed consent is based on “impairment of judgment,” which is more similar to the legal criterion used in the civil capacity. The criterion in Emergency Admission was limited to patients with danger to others or society (except Shenzhen) and only police can make decisions on admission in this procedure (except Wuxi and Shenzhen).

All these modification show the efforts of legislators to shift from a traditional model that only cares about how to manage mental illness by legislation to balancing the interests between these persons and the entire society. However, such transformation cannot be accomplished at one stroke because the traditional concepts that benefit society are higher than the interests of the individual, and the protection of patients’ rights to receive treatment is a higher priority than the protection of his/her right to autonomy. Thus, most of these local regulations lack effective oversight and review mechanisms for involuntary admission of the mentally ill, clear time limitations for involuntary admission, and specific discharge procedures [5]. Due to the vast, multi-ethnic, and diverse population in China, social harmony and stability is a well-recognized concern for the Chinese government [9]. Thus, the “danger to society” and “disturbance of public order” criteria for “Emergency Admission” have been used in several cities.

In drafting the National Mental Health Law, the legislators faced multiple pressures from the community. While the public and government want to ensure the safety of community members from potential risks of having mentally ill individuals living in the community, some legal experts expressed their dissatisfaction to the local legislation. The legal experts were critical that the legislation process in these jurisdictions were led by local health administrators, and most expert participants were government staff and psychiatrists [14]. Some further argued that the “need for treatment criterion” in involuntary admission creates the possibility that any person can be put in institutions against his/her will by local authorities and psychiatrists, diagnosed with mental disorders they do not have, and given drugs and electroshock treatments they do not need [14]. The government should invite more lawyers, sociologists, and other stakeholders involved in the national legislative process, because involuntary admission is not purely a medical issue, but a legal issue. Thus, the government suggested that a “risk criterion” alone should be used and all involuntary admissions need to be reviewed by a third party, such as civil courts. These adverse opinions from the legal community reflect the different concerns between legal and mental health practitioners. Both communities have the common objective of preventing individuals with mental illness; however, communities have divergent opinions about how to achieve those aims [15]. While the primary concern of mental health practitioners is the need of treating patients and preventing them from harm to themselves and others, the priority of law practitioners is the protection of the personal freedom and rights of autonomy of the mentally ill and the general public. In the beginning, these views from the legal community did not arouse much response in the public. The situation has undergone significant changes since 2010 after a series of cases about people who were misdiagnosed as mentally ill and were sent into psychiatric hospitals improperly have been reported by the media [1,2,14]. Although these “misused” cases are not a pervasive phenomenon [3] and some of them were just based on the testimony from one side of interested parties, these reports attracted the attention of the public and aroused fervent arguments on ethical and legal issues on involuntary admission. In the opinion of some critics, psychiatrists exhibited a lack of intention to protect the interests of mental patients, and the guardian is endowed with unlimited power in the current involuntary admission system [14]. These arguments divided the different groups in mental health services, such as mental health professionals, patients, family members, and the general public, who share a common interest in protecting the rights of mentally ill patients, and created opposition among them. In this round of the debate, how to protect the interests of patients and promote mental health services had become the topic that received the least amount of attention.

Such a change in values and attitudes in the community finally influenced the drafting of the National Mental Health Law. Thus, the national legislation on involuntary admission turns to focusing the limited hospital-based mental health services on patients with dangerous behaviors and emphasizing the autonomy of patients. When the draft was publicized on 10 June 2011, the draft aroused continuous debates and concerns about its potential negative effects on mental health services in China. One issue that received a harsh attack was the “danger to society/disturbance of public order” criteria. With the gradual shift in general societal values towards individual freedom, more and more people fear that the “disturbing of public order” clause can be easily abused because it is quite broad and ambiguous, and call on the government to turn the emphasis on protecting society from the potential dangers posed by people with mental illnesses to the protection of the rights and responsibilities of patients [18].

Some mental health professionals expressed their concern about the canceling of the “need for treatment” criterion [10]. Mental health professionals feared that the law raises the threshold for involuntary admission too high and may lead to a number of undesirable consequences because experience in some Western countries has shown commitment criteria do not strongly influence involuntary admission rates [19]. In contrast, mental health laws that require the patient to be assessed as dangerous before they can receive involuntary treatment are associated with a significantly longer duration of untreated psychoses and may also foster a strong public perception of mentally ill persons as being generally uncontrollable or dangerous, thus contributing to stigmatization [7, 19]. The two-stage review system was also thought to be too complex and would hinder patients from receiving treatment in a timely fashion.

The final text of the law seems like the result of a compromise between the civil liberties approach that highlights the importance of individual freedom and autonomy, and the medical model that emphasizes the need for treatment as a sufficient prerequisite for the involuntary. The law finally shifted to the dangerousness criterion as the standard for involuntary admission of the mentally ill, and the “danger to society or disturbance of public order” criterion that had been widely challenged was abolished. Such human rights orientation approaches have included legal restrictions on the clinical practice of psychiatry that exceed those in some high-income countries and is considered to be an important step to provide appropriate protection of patients’ human rights during the process of involuntary admission by some people [17]. The law takes into account the central role of the family in Chinese culture by restricting the use of an independent supervisory mechanism alone to a patient who is admitted based on a risk to others. Thus, the family members continue to have an important role in making decisions on admission and treatment for those at risk to self. In addition, the law also makes concessions to the unequal regional growth and imbalanced urban and rural economies in China. Because there are only about 20,000 psychiatrists in China, most of whom work in specialized psychiatric hospitals in urban areas [20], the qualification of psychiatrists who are eligible to perform admission evaluation in the National law is lower than the requirements by most local regulations.

Overall, the National law intends to protect Chinese citizens from possible abuses of involuntary admission [21], promote transformation of the mental health service system [21], and improve services for people who are mentally ill [22]. Optimistic experts even believe that there will be a rapid shift from hospital-based psychiatric care to community-based psychiatric care after the passing of the law, and individuals with mental health problems who are not willing to be hospitalized will be able to receive appropriate care in the community because the law actively promotes the goal of increasing community-based services in China [17, 21].

Some weaknesses in the law may be obstacles to the realization of the above goals. First, there is no clear definition regarding “current risk” in the criterion of involuntary admission, which may leave a loophole to the abuse of this clause because different people (psychiatrists, family members, and lawyers representing the patient) may have different understandings of the coverage of such clauses and practices, or litigate based on what they believed to be the status quo [23].

Second, just like most local regulations, the National law does not have a specific duration for involuntary admission. The intention of the legislator is to let the various jurisdictions to develop specific rules according to their own situations. But without a national guideline, the implementation of the national law will be quite diverse throughout the country, and let the most troublesome issue in China currently, that patients (and their family members) will be unwilling to leave inpatient wards, even though their condition meets the criteria of discharge, is still not resolved.

Finally, the National law does not mention whether or not the patient who is a “danger to others” can self-apply for discharge. Because the law presumed that the hospital would be responsible for the patient’s illness and potential danger in the future, the problem of some patients being detained in the psychiatric hospital for years has yet to be resolved. Even though the national legislation on involuntary admission is far from perfect, it is still exciting news for persons with mental disorders, their caregivers, and mental health professionals [24]. Experiences in Shanghai show that to standardize the diverse practices in involuntary admission through legislation can achieve great success in reducing medical disputes and balancing the needs of patients, families, and the public [10].

Because mental health legislation in China is still in its infancy, there remains a lot of work to do. For example, some more comprehensive and practical guidelines should be developed for psychiatrists to strengthen protection of mental illness patients’ rights vis-à-vis admission, discharge, and treatment procedures [25]. At the same time, an educational series and promotion program for the National law needs to be implemented. Furthermore, for those jurisdictions that already have legislation on involuntary admission, the revisions of the local regulations are also necessary

Conclusion

The trajectory of gradually more stringent legislation for involuntary admission of the mentally ill in the past 10 years in China, along with the compromise, reversals, and circuitous paths during the process reflect the difficulty for the government to balance the benefits between society and the individual, and explore the transformation of the mode of mental health services. The articles in the final National law, as the combination of the different perspectives of the community, mirror the fierce collision between traditional cultural values that emphasize the community and family and the modern concept involving the pursuit of personal freedom and autonomy in contemporary China. Because the possible effect of such legislation is still unclear, continued research on the influence of the law on both the consumer and provider of mental health services may contribute to possible legal amendments in the future.