China ends its zero-COVID-19 policy: New challenges facing mental health services

Since the outbreak of COVID-19 in late 2019, China has adopted a community-based, dynamic, zero-COVID-19 policy. However, the cost of implementing the zero-COVID-19 policy is increasing as the highly transmissible omicron variant becomes dominant (Chen and Chen, 2022). In view of the declining mortality rate in COVID-19, the increasing popularity of vaccination, and the development of herd immunity, China announced in December 2022 that it would relax restrictions to alleviate the negative impact of mass lockdowns. Besides, the effects of long COVID on human physical and mental health have attracted researchers' attention. The existing research showed that the prevalence of Post-COVID-19 was 72.6% in people admitted to hospital and 46.2% in those not admitted to hospital (Förster et al., 2022). The most common long-term symptoms were fatigue, physical exhaustion, difficulty concentrating, and loss of smell or taste. The patients with Post-COVID-19 perceived their quality of life as notably reduced.

Psychiatry and mental health services in China have been traditionally marginalized with limited resources allocated, however, some positive progress has been noticed. By the end of 2021, there were 506,637 psychiatric beds (36.3 per 100,000 population, same units hereafter unless otherwise specified) and about 36,000 psychiatrists (2.58), which are slightly above the average (or median) levels in upper middle-income countries (24.3 and 2.11, respectively) (Xia et al., 2021). Of note, the number of psychiatrists and psychiatric nurses relative to beds was small in top-tier psychiatric hospitals, although these numbers have increased over the past few years on a national scale. There was also a very limited number of psychologists in these hospitals (0.03 per bed, one psychologist for 30 beds), and there were virtually no psychologists in some hospitals, or psychologists working on inpatient units (Xia et al., 2021). Besides, 43.9% of the hospitals did not have a single social worker, and only 9.8% had more than 10 social workers in their workforce (Xia et al., 2021). This is extraordinary and it also means that the psychiatrists in these hospitals often need to take on the role of therapist and social worker at times, in addition to their traditional responsibilities.

Previously, one of the largest community mental health projects globally is the mental health care model in China entitled the "Management and treatment program for severe mental illness" (Xiang et al., 2020). In order to establish community-based mental health services nationwide, this project integrated the resources in psychiatric hospitals and existing community psychiatric services and trained mental health professionals in the development of individual service plans. Regular outreach psychiatric treatment, rehabilitation and prevention services are provided under this national program (Xiang et al., 2018). Of note, this program was initially developed as part of the national effort to rebuild the community health system following the 2003 severe acute respiratory syndrome (SARS) outbreak in China.

Nowadays, based on the current situation of mental health in China, the government is promoting a "Top-down and Bottom-up" mental health care system (Li et al., 2022). It is a four-level model. The top-level is one National Center for Mental Health, which are mainly responsible for the involvement of China in international research, formulation of national clinical guidelines, the establishment of a national training system for psychiatry, and mental health policies. The second level consists of five National Regional Health Centers and 34 Provincial Mental Health Centers. Centers within this second level mainly break down and execute relevant policies and guidelines for mental health issues at the top level, thereby establishing an effective working system to train the associated professionals and addressing mental health services in regional provinces. A total of 879 municipal medical institutions will serve as the third level's basic framework, mainly responsible for the diagnosis and treatment of mental disorders in local regions. A great number of primary medical care centers (including township health centers or community health service centers) and mental health centers in the primary/middle schools form this system's fourth level. The fourth level's main function is to screen high-risk groups and evaluate patients with mental disorders. The referral system for patients with mental disorders follows the bottom-up strategy. In brief, patients can get their mental health services from the fourth level as a start to the end of the top-level corresponding to varying degrees of demand (Li et al., 2022). This framework mainly shows the following two characteristics: On the one hand, government-led national strategies and supports are crucial to ensure adequate medical resources based on China's existing hierarchical health care system. On the other hand, screening, diagnosis, intervention, and referral can be achieved at different levels of this system by a bottom-up strategy.

As we can see, China has put much effort into improving public mental health, including offering mental health support and building a network to provide these services, training psychologists and psychiatrists, and improving the quality of services provided by community centers and schools (Cui et al., 2020). However, the end of the zero-COVID-19 policy will bring new challenges to patients with mental illness. First, there is no data about the vaccination rate of patients with mental disorders in China. A study involving 1853 patients with severe mental illness in China found that 45% of the patients were reluctant to be vaccinated (Bai et al., 2021). According to the estimated lifetime prevalence rates of schizophrenia (0.6%), bipolar disorder (0.6%), and major depressive disorder (3.4%) in China, and the reported vaccine hesitation rate, as many as 29 million patients with severe mental illness could be reluctant to get vaccinated (Huang et al., 2019). Additionally, the side effects of psychotropic drugs and the unhealthy lifestyle related to mental illness may make patients more vulnerable to COVID-19 and its complications (Xiao et al., 2022). The increased risk of infection may lead to the increased possibility of severe COVID-19 and mortality in this population. Therefore, after relaxing public health measures, patients with mental disorders should be strongly encouraged to take vaccines.

Second, compared with the general population, the general physical health of patients with mental illness is usually poor, and they seldom use physical health services to meet their health needs. Many infected people may not be willing to seek help from health institutions. Therefore, free COVID-19 antigen and nucleic acid tests should be regularly provided to patients with psychiatric illnesses and their caregivers. Third, there is a serious shortage of mental health services for children and the elderly in China. A recent report showed that child and geriatric beds accounted for 3.3% and 12.6% of all beds in tertiary mental hospitals, respectively, and many hospitals had no specialized child or geriatric units (Xia et al., 2021). The greatest challenge of moving away from the zero-COVID approach in China is that SARS-CoV-2 cases would surge rapidly, which could overwhelm healthcare systems and greatly increase the case fatality rate of COVID-19. What's worse, there are fewer than 500 full-time child psychiatrists in China, and the distribution is uneven (Wu and Pan, 2019). It is known that many children with mental disorders are rejected from hospitals or hospitalized with adults, causing safety and other concerns (Xia et al., 2021). Another problem is that there are no national guidelines covering interventions for major public health crises affecting children. In addition, the vaccination rates of these two groups are lower than those of other age groups (Guan and Zhong, 2022). These sub-groups would face the risk of being neglected due to poor medical service provision and might be highly exposed to the adverse effects of the COVID-19 epidemic. Therefore, the government should allocate sufficient public and mental health resources to serve these high-risk groups. Fourth, the way COVID-19 interacts with mental illness is still unknown, but immune system dysfunction is common in patients with psychiatric disorders (Cullen et al., 2019). A recent study shows that COVID-19 survivors were more likely to have symptoms of anxiety, depression and pain than those who were not infected with COVID-19 (Huang et al., 2022). Therefore, it is necessary to study the long-term prognosis of patients with mental illness infected with COVID-19. Finally, the previous psychiatric service guidelines and expert consensus were formulated in the context of the zero-COVID-19 policy, and might not be applicable to the reopening stage of the pandemic. These documents are in urgent need of updating.

In short, the reopening policy will bring new challenges to China's mental health services. We must be prepared for this. Clearly, preventive measures such as the provision of adequate protective equipment and medical supplies, and public education on the risks of COVID-19 for patients and hospital staff, are essential to reduce the possibility of disease transmission (Xiao et al., 2022). We suggest developing online medical services widely and rapidly, which can prevent hospitals from being overwhelmed and reduce the risk of nosocomial infections. This strategy can also be used to monitor patients' mental state, provide drug management, and ensure the prevention and control of epidemics. Besides, building a national service network system might be a suitable goal for the future.

Funding

The authors received no grant from any funding agency in the public, commercial or not-for-profit sectors.

CRediT authorship contribution statement

YX: Conceptualization,Writing – original draft preparation. T-tC: Writing – review & editing. LL: Formal analysis. LZ: Investigation. All authors have approved the final manuscript.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.