This is the third and final article in a series on the challenges and promise of mental health care in China. Part one can be found here, and part two here.

Disasters, humanitarian crises, and medical emergencies affect the health and well-being of populations globally. These calamities are most often connected with the loss of economic and material resources and the loss of life, but they are also associated with a substantial increase in the burden of mental disorders in affected populations.

These mental health burdens typically come in the form of common mental disorders including depression, generalized anxiety, and post-traumatic stress disorder (PTSD). Importantly, these disorders are associated with functional impairments that limit engagement in social and occupational roles, and therefore can lead to long-term consequences such as the loss of relationships, livelihoods, and productive work — all things that imbue our lives with meaning.

The field of mental health and psychosocial support (MHPSS) is concerned with responding to the unique psychological and psychosocial needs of populations who are stressed by disaster, humanitarian crisis, or medical emergencies, including infectious outbreaks like SARS and COVID-19. In addition to providing material aid, MHPSS interventions provide what is commonly known as psychological first aid, which involves non-directive support to people, such as normalizing reactions, reflective and active listening, links to needed services, and the provision of accurate and timely information. These programs may also involve counseling support and more intensive psychological interventions after critical safety needs are met.

The first documented MHPSS intervention in China was in response to the 2003 SARS epidemic, but it was not until the 2008 Wenchuan earthquake in the southwestern Sichuan province that broader recognition and support for the development of MHPSS really took shape.

The Wenchuan earthquake exacted a devastating loss of life with more than 69,000 fatalities and another 400,000 people injured. According to the then-Ministry of Health, more than 39,000 medical personnel were trained and dispatched to the region to provide MHPSS interventions. This coordinated effort also included community-based health centers and hospitals. Over 140,000 people received front-line psychological counseling support, and 55,959 received more intensive treatment.

The COVID-19 pandemic provided another opportunity to apply the lessons of the 2003 SARS epidemic and 2008 earthquake. National guidance on mental health intervention was rapidly deployed following the outbreak in Wuhan, and hundreds of mental health professionals provided MHPSS interventions to front-line hospital care workers and patients in the central city. In addition, numerous tools were developed and deployed to educate the general population around mental health and over 300 mental health hotlines were set up by the government, associations, and universities.

These hotlines are especially tailored for crisis intervention and support, and since they are anonymous, people may feel more comfortable using them without the shame of revealing their vulnerabilities to others in person.

Now in its third year, the COVID-19 pandemic and the challenge of reaching populations in need have caused the field of digital mental health to grow exponentially. Digital mental health is the application of remote methods to deliver psychological interventions. These can include telehealth visits with a provider or the use of smartphone apps. Digital mental health is especially promising as it is a scalable alternative to face-to-face treatment — scalable meaning that, because it is not as human resource-intensive as in-person care, many more people can potentially benefit from the program.

Since the stigma about mental health treatment is high in China, and culturally, seeking support from mental health professionals is still uncommon for most people, evidence-based mobile applications offer an excellent alternative to traditional forms of treatment. They also overcome a key barrier to mental health care globally: the absence of a professional workforce capable of delivering mental health interventions to the people who need these services — what is commonly referred to as the treatment gap.

In the context of the global pandemic, the Center for Global Health Equity at NYU Shanghai partnered with the World Health Organization to conduct the first cultural adaptation and randomized trials of Step-by-Step in China. The first digital mental health intervention program developed by the WHO, Step-by-Step aims to reduce depressive symptoms and is delivered via mobile phones with minimal support from mental health workers. The results of the trials were positive, and we are now working on expanding the program in order to reach a multitude of populations and across the life course, from young people to elders.

In the meantime, while the field of MHPSS continues to mature in China, additional research is needed to determine its future direction. In a broad sense, much of the programming that has been evaluated to date relies heavily on Western conceptualizations of mental health and interventions that have been developed for non-Chinese populations. This issue of cultural fit and relevance can largely be overcome through rigorous cultural adaptation, in which an evidence-based intervention program is modified to accommodate more relevant language, cultural idioms, and illness conceptualizations. There remains an opportunity to develop illness definitions and models which better fit Chinese culture and context, and to evaluate these programs with the same rigor applied to existing interventions.

Digital interventions in particular present an opportunity to rapidly prototype and adapt content that highlights cultural features. Since culture is rapidly developing, we need to continue to modify our interventions to remain current and enhance engagement.

We also need to ensure that our interventions can and will be used. That requires engagement at multiple stakeholder levels, including direct beneficiaries, clinicians, hospitals, and government departments that can strengthen policy support. Additional research is likewise needed to broaden our knowledge about optimal content, delivery mechanisms, and user experiences to ensure people will use these services as intended.

Finally, we must ensure the equitable distribution of MHPSS interventions and tailor them for diverse populations, whether they be youth, elders, members of the LGBTQ+ community, migrants, or people living with serious mental illness. Each population has their own unique needs, vulnerabilities, and strengths. These must be taken into account to close the treatment gap and ensure that MHPSS interventions can serve the needs of the public.

Editors: Cai Yineng and Kilian O’Donnell; portrait artist: Zhou Zhen.

(Header image: DrAfter123/VCG)