Chinese perspectives on primary care for common mental disorders: Barriers and policy implications

Abstract

Background:

The World Health Organization (WHO) has called for integration of mental health into primary care for a decade. In Western countries, around 15% to 25% of patients with common mental disorders including mood and anxiety disorders seek help from primary care physicians (PCPs). The rate is only about 5% in China.

Aims:

This article reviews the Chinese findings on the barriers to primary care for common mental disorders and how they compared with Western findings.

Methods:

A narrative literature review was conducted, focusing on literature published from mid-1990s in English or Chinese. Patient, PCP and health system factors were reviewed.

Results:

Although Chinese and Western findings show similar themes of barriers, the Chinese have stronger barriers in most aspects, including under-recognition of the need for treatment, stigma on mental illness, somatization, worries about taking psychiatric drugs, uncertainties in the role, competency and legitimacy of PCPs in mental health care and short consultation time.

Conclusion:

Current policies in China emphasize enhancement of mental health facilities and workforce in the community. Our review suggests that patients’ intention to seek help and PCPs’ competency in mental health care are other fundamental factors to be addressed.

Keywords

Barriers Chinese common mental disorder help-seeking primary care Western

Introduction

The need to increase awareness of mental health problems in primary care settings originated from Western countries in 1960s. One major reason was that some psychiatrists, especially David Goldberg and his colleagues in the United Kingdom, recognized the potential advantages of primary care physicians (PCPs) in managing patients with mental health conditions compared with psychiatrists. These included firsthand knowledge of the patients’ personal and family background, provision of continuing care and frequent contacts with patients presenting psychosomatic symptoms (Blackwell & Goldberg, 1968). On the other side of the world, George Engel, an American psychiatrist, suggested a revolutionary biopsychosocial model which challenged the conventional biomedical model in clinical care (Engel, 1977). Moreover, the psychiatrists had developed psychiatric screening questionnaires for primary care settings (Goldberg & Blackwell, 1970; Johnstone & Goldberg, 1976). They began to investigate the diagnostic accuracy of the PCPs and propose the need for training (Goldberg, Steele, Smith, & Spivey, 1980). Subsequent studies showed that over half of primary care attenders with mental health problems were not recognized (Freeling, Rao, Paykel, Sireling, & Burton, 1985; Tylee, Freeling, & Kerry, 1993). These led to further research on mental health care in primary care settings.

The international study conducted by the World Health Organization (WHO) in primary care settings across 15 cities reported that the overall prevalence of current mental disorders was 24%. The most common mental disorders were depression (10.4%) and generalized anxiety disorders (7.9%) (Sartorius, Ustün, & WHO, 1995). In 2008, the WHO called for integration of mental health into primary care (WHO, 2008). Western studies found that only around one-third of adult patients with a common mental disorder including mood and anxiety disorders had sought professional help. The 12-month help-seeking rates reported in the United Kingdom, United States and Australia were 39%, 29% and 35%, respectively (McManus, Brugha, Bebbington, & Jenkins, 2009; Pratt & Brody, 2008; Slade, Johnston, Oakley Browne, Andrews, & Whiteford, 2009). Various Western studies showed that among patients who had sought help, over half of them consulted PCPs (Kovess-Masfety et al., 2007; McManus et al., 2009; Thompson, Hunt, & Issakidis, 2004). Compared with Western findings, the help-seeking rates were lower among Chinese. A large-scale study in four provinces of China reported that the 1-month prevalence of mood disorders was 6.1%. The overall help-seeking rate and the specific rate for PCPs were 8% and 5%, respectively (Phillips et al., 2009).

This narrative literature review article aims to discuss Chinese findings on the barriers to primary care for common mental disorders and how they compared with Western findings. An extensive literature search was performed on PubMed and MEDLINE using different combination of the following terms: primary care, general practice/family medicine/family practice, mental health, common mental disorder, depression, anxiety, psychological distress, help-seeking, management, treatment and stigma. The terms Chinese and China were added to specify Chinese studies. Besides, local journals in Chinese were reviewed. Forward and backward searches of reference lists were made to further identify articles. We focus on literature published from mid-1990s because they are more relevant to the current context of mental health care and help-seeking characteristics.

Chinese trends in mental health research and policy development

Most of the help-seeking studies on common mental disorders came from Western countries, despite a few on Chinese immigrants (Chen, Hung, Parkin, Fava, & Yeung, 2015; Ho, Hunt, & Li, 2008; Kung, 2004; Parker, Chan, Tully, & Eisenbruch, 2005). European countries (especially the United Kingdom), the United States, Canada and Australia are the major sources of relevant Western findings. Studies in China tended to focus on psychosis in specialist psychiatric settings (Boey, 1998; Tang, Sevigny, Mao, Jiang, & Cai, 2007; Zhang et al., 2013). The review by Liu et al. (2011) highlighted that national mental health service reform had started in China since 2004. In that year, mental health was officially included into the public health program. The Chinese government included both specialist care and primary care services in the mental health reform program which focused on the management of psychosis. Common mental disorders have been called neurotic disorders (Ni et al., 2014). Depression has also been classified as a chronic disease. In 2006, the Chinese Government published guidelines emphasizing community-based management of chronic diseases including depression of the elderly patients (Chen, Conwell, He, Lu, & Wu, 2015). In 2015, the Government published the 2015–2020 National Mental Health Work Plan which stated the importance of prevention and treatment of depression and anxiety disorders (Xiong & Phillips, 2016).

There have been many local studies on the prevalence and clinical factors of common mental disorders in China, especially on the elderly patients. However, there is a relatively small number of help-seeking and health service studies in primary care settings, which were conducted in major urban cities including Beijing (Chen, 2012; Du et al., 2011), Shanghai (Wong, Xuesong, Poon, & Lam, 2012; Wong & Li, 2014; Wu et al., 2007; Zhou, Huang, Jin, Guo, & Chen, 2012), Hangzhou (Chen, Conwell, et al., 2015), Shenzhen (Deng et al., 2014) and Hong Kong (Chin, Chan, Lam, Lam, & Wan, 2015; Chin et al., 2014; Lam, Lam, Lam, & Ku, 2013; Lam & Sun, 2014; Sun, Lam, Lam, & Lo, 2015b; Sun et al., 2016). The findings from these major cities as well as other cities are highlighted in this article. Some studies on Chinese immigrants in Western countries are also included.

Regarding terminology, the term ‘mental health problem’ is commonly used by medical professionals. In primary care studies, it mainly refers to common mental disorders (Rickwood, Thomas, & Bradford, 2012). On the other hand, the term ‘psychological problem/distress’ is often used in patient studies. These terms are used in this article to preserve the original contexts of the studies on PCPs or patients. The barriers to mental health care including patient, PCP and health system factors are discussed below. For comparison purpose, under each theme, we describe the international or Western findings first, followed by specific Chinese studies.

Patient factors

Under-recognition of the need for treatment

A systematic review on international data (Prins, Verhaak, Bensing, & van der Meer, 2008) concluded that between 49% and 84% of the patients with depression or anxiety perceived a need for treatment. The latest WHO World Mental Health Survey found that on average 57% respondents with major depressive disorders in 21 countries recognized the need of treatment. The rate was only 39% in Beijing/Shanghai, China (Thornicroft et al., 2017). Inadequate mental health literacy is one factor for under-recognition of the need for treatment. A comparative study found that the Shanghai Chinese had lower mental health literacy than the Chinese in Australia and Hong Kong (Wong et al., 2012). Another important factor is the preference for self-coping to professional treatment. When self-coping did not work, the distressed would then consider professional help (Doblyte & Jimenez-Mejias, 2017). Un-guided self-coping strategies could be ineffective, delay treatment or even counterproductive. Reported in both Western and Chinese studies, patients used various coping strategies, such as avoidance, withdrawal, minimizing the problem, suppressing the symptoms, wishing the condition to go away and resignation to fate (Del Valle, Belloch, & Carrio, 2017; Kung, 2004). Some of these strategies might be in opposite to the approaches used in cognitive behavioral therapy (CBT), which emphasizes correcting biased thoughts based on evidence, exposure to situations and symptoms and behavioral changes in a structured approach (Arch & Craske, 2009). A study in Jiangyin analyzed the initial help-seeking behaviors of distressed patients attending a community psychology clinic. It revealed that 8% of patients had self-medicated for their distress by buying drugs/health care products over the counter, or having self-(mental) training, and 6% used lay religious practice (Shen, Qian, Du, & Feng, 2006). A study in Hong Kong found that 13% of the primary care patients with distress experience used informal sources of help only, such as family members/friends, exercise and religious support. Besides, 52% had not sought any formal or informal help (Sun et al., 2017).

Stigma on mental illness

Around 15%–30% of patients in Western studies regarded stigma or embarrassment as a barrier to seeking professional help (Bushnell et al., 2005; Meltzer et al., 2003). To avoid social stigma, patients often preferred self-coping strategies (Doblyte & Jimenez-Mejias, 2017; Rickwood, Deane, Wilson, & Ciarrochi, 2005). Higher stigmatizing attitudes were associated with lower rates of help seeking (Evans-Lacko, Brohan, Mojtabai, & Thornicroft, 2012). The degree of stigma was affected by cultural factors. Comparative studies showed that Chinese had higher stigma toward mental illnesses than the Westerners (Furnham & Chan, 2004; Yang et al., 2007). The stigma might be increased by the serious concern about shame and loss of ‘face’ in Chinese culture, which could also be projected to the patients’ family (Kung, 2004). Yang et al. (2013) argues that stereotypes of dangerousness and unpredictability toward mental health patients challenge Chinese cultural norms of restrained and moderate behavior. However, different from psychotic disorders, depression and anxiety disorders are often seen by the Chinese as common problems encountered in life (Kolstad & Gjesvik, 2014; Lam & Sun, 2014). The viewpoints from Kung (2004) may be more relevant to conditions of common mental disorders. She points out that Chinese see the causes as having bad thoughts and personality weakness. Besides, psychological treatments require examination of thoughts and feelings associated with distress, which Chinese tend to avoid.

Psychosomatic presentations

It is well known that many patients present with psychosomatic symptoms only (Cape & McCulloch, 1999; Tylee, Freeling, Kerry, & Burns, 1995), such as headache, dizziness, fatigue/weakness, palpitations and sleep problems (Matalon, Kotliroff, Blumberg, Yaphe, & Kitai, 2011). Patients may not link their symptoms to psychological causes (Murray, Toussaint, Althaus, & Lowe, 2016). Besides, somatization is considered as a way for some patients to avoid expression of mental health problems which are subject to social stigma (Murray et al., 2016; Simon, VonKorff, Piccinelli, Fullerton, & Ormel, 1999). Some patients may be treated as having functional, non-specific or medically unexplained symptoms without a formal diagnosis of mental disorder (Matalon et al., 2011). Unnecessary somatic treatments may be prescribed (Walters, Tylee, Fisher, & Goldberg, 2007). An international study conducted in 14 countries found that 45%–95% (overall 69%) of depressed patients presented only somatic symptoms to their PCP. A high somatization rate of 87% was reported in Shanghai, China (Simon et al., 1999). Parker, Gladstone, and Chee (2001) argue that Chinese often express depression in somatic terms like ‘heartache’ (means sadness) and ‘fatigue’ (means emotionally hurt or despair). The Chinese might understand the emotional meanings of these terms. However, research studies found that the issue was not just about usage of terms. In Hong Kong, the PCPs reported that many patients did not realize the psychological causes of their somatic symptoms, especially at the early stage of consultations (Sun, Lam, Lam, & Lo, 2015a; Sun et al., 2015b). The study in Jiangyin found that 35% of the patients of a community psychology clinic had initially consulted specialists in neurology, cardiology, gastroenterology, pulmonology and emergency medicine, and 10% had initially consulted PCPs (Shen et al., 2006). A study in Shanghai found that the top 10 reasons for distressed patients to consult PCPs were as follows: weakness (9.4%), sleep disorder (9.0%), abdominal pain (5.6%), chest distress (4.7%), dizziness (4.3%), chest pain (3.8%), headache (3.4%), anxiety (3.0%), depression (3.0%) and cough (2.6%) (Zhou, Huang, Jin, et al., 2012).

Patients’ uncertainties in the role of PCPs in mental health care

Related to somatic presentations, Western studies found that many patients believed PCPs dealt with physical illnesses only and suspected their ability in managing psychological problems (Bushnell et al., 2005; Murray et al., 2016; Peters et al., 2009). Some patients also felt that their PCPs were not interested in discussing psychological problems (Cape & McCulloch, 1999). Patients might simplify their problems and focus on their somatic complaint (Peters et al., 2009). In an Australian survey, 34% of the patients perceived that PCPs were not the right persons to be consulted for psychological problems (Bushnell et al., 2005). A much higher rate was reported in Hong Kong that 64% of the Chinese patients did not expect PCPs to manage psychological problems (Sun et al., 2016).

Worries about taking psychiatric drugs

Antidepressants are the most commonly prescribed medications for depression and anxiety disorders (Bandelow et al., 2015; Coupland et al., 2011). Benzodiazepines are sometimes prescribed to patients for temporary relief of symptoms (Sjostedt, Ohlsson, Li, & Sundquist, 2017). Systematic review and meta-analysis studies concluded that patients usually preferred psychotherapy to medication (76% vs 49%) (Angermeyer, van der Auwera, Carta, & Schomerus, 2017; Prins et al., 2008). Both general public and diagnosed patients expressed in qualitative studies that drugs relieved the distress symptoms rather than solving the problem, and they might become addicted to the drugs (Kadam, Croft, McLeod, & Hutchinson, 2001; Priest, Vize, Roberts, Roberts, & Tylee, 1996). Besides, some patients assumed that PCPs were unable to give ‘talking’ therapy. They thought antidepressant prescription was the most likely outcome which they wanted to avoid (Biddle, Donovan, Gunnell, & Sharp, 2006). A comparative study found that the Chinese schizophrenic patients had lower acceptance toward psychiatric medications than the American patients (Mohamed, Rosenheck, He, & Yuping, 2014). The worries about medications generalize to conditions of common mental disorders. The study in Hong Kong found that worries about side effects of psychiatric drugs (80%) and drug dependency (75%) were rated as the top barriers by the Chinese primary care attenders (Sun et al., 2016).

PCP factors

Difficulty in recognizing and handling patients with somatic presentations

Western studies showed that PCPs’ recognition of mental health problems was significantly lower among somatic presenters (Bridges & Goldberg, 1985; Hickie et al., 2001; Weich, Lewis, Donmall, & Mann, 1995). Somatic presentations increase diagnostic difficulty as they are often incomplete, implicit and without psychosocial cues provided (Murray et al., 2016). Another problem is that patients may feel intrusive to be asked about psychosocial issues if they do not realize the relation with their physical problems (Peters et al., 2009). A qualitative study found that some patients with unexplained somatic complaints felt dissatisfied when the PCP concluded that they had depression (Gask, Rogers, Oliver, May, & Roland, 2003). The difficulty appears to be stronger in a Chinese context. In Hong Kong, the PCPs highlighted in qualitative interviews about patients’ expectation for an explanation in physical terms and patients’ reluctance to discuss psychological problems. In the survey, 72% of the PCPs perceived the difficulty in managing their patients’ reluctance to accept the diagnosis of mental health problems (Sun et al., 2015b). Similarly, a study in Shanghai found that two-thirds of the PCPs perceived patients’ reluctance to accept the diagnosis of depression. Besides, over half of them thought that they should treat physical problems ahead of depression (Wu et al., 2007).

Competency in mental health care

Mitchell, Vaze, and Rao (2009) conducted a meta-analysis of studies which assessed the accuracy of diagnoses of depression by PCPs. This study found that only 47.3% of depression cases were correctly identified. An Australian survey found that PCPs without mental health training were more likely to perceive incomplete knowledge about depression as a management barrier (Richards, Ryan, McCabe, Groom, & Hickie, 2004). Indeed, many PCPs had little or no formal mental health training in medical schools (Lam et al., 2011). Even in the United Kingdom, less than half of PCPs have received mental health training (England, Nash, & Hawthorne, 2017). PCPs were also found to be less confident about using psychotherapy than medication for the treatment (Oakley Browne, Lee, & Prabhu, 2007). A study in Ireland reported that only one-third of PCPs had received postgraduate training in psychotherapy (Copty & Whitford, 2005). The overall percentage of trained PCPs is unknown in China where training programs tended to be on management of psychosis (Liu et al., 2011). A study in Hangzhou reported that 17% of the PCPs had received short period of mental health training (Chen et al., 2010). A study in Shanghai found that 71% of the PCPs without mental health training answered wrongly for all five questions about geriatric depression, compared to 30% of those with a specific training intervention (Wu et al., 2007). A study in Beijing found that only 18%, 13% and 30% of the PCPs correctly selected the symptoms, screening methods and therapeutic principles of depression, respectively. Only 30%–40% of the PCPs recognized the following as common symptoms of depression: loss in appetite or significant weight loss (31%), psychomotor agitation or retardation (38%), poor concentration (38%) and fatigue or loss of energy (39%) (Du et al., 2011). Another Beijing study found that 70% of elderly patients with delayed treatment for depression in psychiatric hospitals reported inability of PCPs to identify depression as the reason, which ranked second among all reasons (Lyu, Li, Han, Cheng, & An, 2015).

Attitudes toward mental health care

Some PCPs have limited interest and motivation to manage mental health problems (Garcia-Campayo, Sanz-Carrillo, Yoldi-Elcid, Lopez-Aylon, & Monton, 1998; Oopik, Aluoja, Kalda, & Maaroos, 2006). Mental health care may be seen as only one of a number of priorities (McDermott et al., 2012). There have been debates between psychiatrists and PCPs about the definitions of cases with depression or anxiety (caseness) in primary care settings (Earnshaw, 2000; Goldberg, 2000; Middleton & Shaw, 2000). In practice, PCPs may not treat cases which they consider as being ‘subthreshold’ or mild conditions. Many do not stick to the diagnostic criteria used by psychiatrists and researchers (McDermott et al., 2012; Mental Health and General Practice Investigation Research Group, 2004). Apart from a lack of proactive attitude in management, some PCPs may hold negative views toward mental health patients. Western studies showed that, similar to the general public, some health professionals including PCPs held stigmatizing opinions on mental health patients (Caldwell & Jorm, 2001; Lawrie et al., 1998; Reavley, Mackinnon, Morgan, & Jorm, 2014). Despite this, they had better attitudes toward non-psychotic disorders. In Hong Kong, 72% of the PCP survey respondents expressed their willingness to manage depression, compared to 40% for schizophrenia (Lam et al., 2013). Nonetheless, lacking of skills could lower the willingness. The Hangzhou study found that most PCPs were uncomfortable in managing depression and they preferred psychiatrists/psychologists to handle it (Chen, et al., 2010). The Shanghai study found that 59% of the PCPs without mental health training would refer depression cases to psychiatrists, compared to 32% of those with training (Wu et al., 2007).

Health system factors

Law and policies

Western countries generally allow PCPs to diagnose common mental disorders. The situation is the same in Hong Kong. However, under the mental health law for Mainland China issued in 2013, only psychiatrists can diagnose mental disorders (Li et al., 2015; Phillips et al., 2013; Standing Committee of the National People’s Congress, 2012). Thus, most PCPs can only recognize patients with potential mental health problems and refer them to psychiatrists for a formal diagnosis. Afterward, the PCPs may follow-up and manage the diagnosed patients. Under this policy, the legitimacy of PCPs in mental health care is rather uncertain and the management depends on the psychiatrists’ decisions.

Accessibility and affordability of services

The WHO Mental Health Survey found that the treatment rate showed a downward gradient across high- to low-income countries (Thornicroft et al., 2017). Unequal access to mental health services was also observed within countries. Australians living in areas of lower socioeconomic status were found to have poorer access to mental health care sources including PCPs (Meadows, Enticott, Inder, Russell, & Gurr, 2015). Similarly, the study by Juan Chen (2012) in Beijing reported that patients with lower socioeconomic status were less likely to utilize mental health services. However, the barriers regarding accessibility (22%) and affordability (27%) of services were considered less important by the patients. Instead, refusal to recognize the need of treatment (66%) was the major barrier (Chen, 2012). In most cities of China, costs of antidepressants including selective serotonin reuptake inhibitors (SSRIs) have been partially covered by national health insurance (Tao, Wang, & Cui, 2015). The reimbursement rate varies by region (Liang, Mays, & Hwang, 2017), and the national reimbursement rate for all types of medical expenditure (including physical and mental) was 26.4% in 2011 (Zhang, Tang, Zhang, Zhang, & Zhang, 2015). On the other hand, Hong Kong, being a special administrative region, runs a different system where 71% of the primary care attenders perceived treatment cost of psychological distress as a barrier (Sun et al., 2016). The fee charged by private PCPs in Hong Kong can be tripled for consultations specially arranged for treating mental health problems to compensate for the extra time cost.

Consultation time constraints

A review study by Hutton and Gunn (2007) showed that consultations with a recorded diagnosis of mental health problem were longer than other consultations. Some PCPs expressed that short consultation time limited their chance to care for mental health problems. Treating these problems might lengthen the consultations and lead to increased waiting time of other patients. PCPs working in private sector might need to subsidize these longer consultations if there is no extra charge (MaGPIe Research Group, 2005). There are opinions that fee-for-service systems tend to favor short consultations and procedural practice rather than long mental health consultations (McDermott et al., 2012). In Hong Kong, consultation time constraints were perceived by 85% of PCP survey respondents as a barrier to mental health care (Sun et al., 2015b). This is due to the fact that the usual consultation time in primary care clinics of Hong Kong is only around 5–8 minutes (Yu et al., 2015), compared to an average of 9.4 minutes reported in the United Kingdom, 10.2 minutes in the Netherlands, 14.6 minutes in Australia and 17.5 minutes in the United States (Hutton and Gunn, 2007). Studies in Beijing also reported a short average consultation time in general practice, ranging from 3 to 8 minutes (Jin et al., 2015; Peng, Su, & He, 2012). Time constraints (50%) ranked middle among different barriers to mental health care perceived by PCPs in Beijing. Other barriers regarding limited knowledge in diagnosis/management (84%) and consultations dominated by physical complaints (62%) ranked higher (Du et al., 2011).

Implications to mental health care in urban China

Western and Chinese findings show similarity in the barriers encountered by the patients and PCPs. However, the Chinese have stronger barriers in most aspects, including under-recognition of the need for treatment, stigma on mental illness, somatization, worries about taking psychiatric drugs, uncertainties in the role, competency and legitimacy of PCPs in mental health care and short consultation time. In this section, we discuss the possible strategies and interventions to overcome the barriers. As China has a huge population of 1.4 billion, a 6.1% prevalence of mood disorder (Phillips et al., 2009) means 85 million patients. Despite low help-seeking rates, depression and anxiety disorders/state still ranked fifth (3.4%) and seventh (3.0%), respectively, among all diagnoses in a general practice study of Shanghai (Zhou, Huang, Chen, Guo, & Jin, 2012). Our discussion focuses on policy implications to major urban cities of China, which take a piloting and leading role in mental health reform (Ji et al., 2008).

Patient factors

While policies in China emphasize enhancement of mental health services in hospital and primary care settings (Li et al., 2017), one fundamental problem is the patients’ low intention to seek help, which should be the first barrier to be tackled. Public education to promote mental health literacy may reduce under-recognition of the need for treatment and stigma on mental illness (Yap, Reavley, & Jorm, 2012). In a Chinese context, public education programs should target worries about taking psychiatric drugs (Sun et al., 2016) apart from mental health literacy (Wong et al., 2012). A significant proportion of the public would still prefer self-coping to professional treatment for mild to moderate distress. Proper self-coping skills may be delivered by websites using evidence-based materials developed by mental health professionals (Andrews, Cuijpers, Craske, McEvoy, & Titov, 2010; Rosso et al., 2017). Apart from providing self-help materials, the websites can also be the connection points to access professional services from PCPs and mental health professionals. The beyondblue and Headspace websites in Australia are well-established examples. A recent survey in Beijing found that nearly 20% of residents had searched for mental health information online. Younger age and higher socioeconomic status were significant predictors (Chen & Zhu, 2016). For the majority of patients who have less health literacy, the formal health care system remains the entry point to mental health care. Public education should enhance the image of PCPs as a source of mental health care and referral (Sun et al., 2016).

PCP and health system factors

Lack of workforce for mental health care is commonly acknowledged as a barrier in China (Li, Sun, Zhang, & Kolstad, 2014; Li et al., 2017). The rate of psychiatrists per 100,000 population is 1.7 in China, compared with the international average level of around 4.0 (Li et al., 2014; WHO, 2015). While the number of clinical psychologists is unknown in China, the number of psychotherapists is estimated to be over 5,000, and about 40,000 licensed counselors participate in mental health–related work (Hu et al., 2017). There are over 1.7 million PCPs in China (Li et al., 2017), but the mental health workforce contributed by them is unknown. The competency of PCPs in mental health care is a critical factor as shown in our review. Indeed, the workforce for mental health care would multiply if a significant proportion of the huge group of PCPs possesses the skills, which can be enhanced by training (Walters et al., 2007). Successful experiences have been reported in Hong Kong (Lam et al., 2011), Shanghai (Wu et al., 2007), Hangzhou (Chen et al., 2004) and Shanxi (Jia & Wang, 2015). Training programs should target recognition and management of common mental disorders, especially for the skills in handling psychosomatic complaints, which are the top reasons for consultation (Zhou, Huang, Jin, et al., 2012). Besides, trainings can improve motivation in providing mental health care in daily practice as well as attitudes toward mental health patients (Lam et al., 2011; Lam, Lam, Lam, & Sun, 2015). Moreover, trainings along with policy development may help to enhance the legitimacy of PCPs in mental health care in Mainland China. Relevant trainings can be provided by psychiatrists, psychologists and experienced PCPs. To deal with consultation time constraints, the PCPs can arrange follow-up consultations to focus on the patients’ mental health problems and this will also allow the patients be better prepared for discussing their problems (Sun et al., 2015a). Furthermore, collaboration with other health professionals such as clinical psychologists, social workers, nurses and occupational therapists can provide longer sessions of counseling and psychosocial support to the distressed patients. A cluster-randomized trial in 16 primary care clinics of Hangzhou city showed positive outcomes of collaborative care to elderly patients with depression (Chen, Conwell, et al., 2015). The program involved trained PCPs, primary care nurses as care managers and psychiatrists for expertise support. Service coverage among the population is likely to be limited at the beginning stage. A recent survey in Guangdong still reported a shortage of mental health workforce, of which only 28% were for community settings (Li et al., 2015). Despite this, we believe service development can build on successful experiences and the coverage can expand gradually to a larger proportion of the population of China. The number of PCPs trained in mental health care as well as other mental health staff is expected to increase significantly when relevant national policies are successfully implemented. Manpower and skills should complement each other to maximize the effect.

Footnotes

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Kai Sing Sun

References

Andrews

Cuijpers

Craske

M. G.

McEvoy

Titov

(2010). Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: A meta-analysis. PLoS ONE, 5, e13196.

Angermeyer

M. C.

van der Auwera

Carta

M. G.

Schomerus

(2017). Public attitudes towards psychiatry and psychiatric treatment at the beginning of the 21st century: A systematic review and meta-analysis of population surveys. World Psychiatry, 16, 50–61.

Arch

J. J.

Craske

M. G.

(2009). First-line treatment: A critical appraisal of cognitive behavioral therapy developments and alternatives. Psychiatric Clinics of North America, 32, 525–547.

Bandelow

Reitt

Rover

Michaelis

Gorlich

Wedekind

(2015). Efficacy of treatments for anxiety disorders: A meta-analysis. International Clinical Psychopharmacology, 30, 183–192.

Biddle

Donovan

J. L.

Gunnell

Sharp

(2006). Young adults’ perceptions of GPs as a help source for mental distress: A qualitative study. British Journal of General Practice, 56, 924–931.

Blackwell

Goldberg

D. P.

(1968). Psychiatric interviews in general practice. British Medical Journal, 4, 99–101.

Boey

K. W.

(1998). Help-seeking pattern of psychiatric outpatients in urban China. The International Journal of Psychiatric Nursing Research, 4, 433–443.

Bridges

K. W.

Goldberg

D. P.

(1985). Somatic presentation of DSM III psychiatric disorders in primary care. Journal of Psychosomatic Research, 29, 563–569.

Bushnell

McLeod

Dowell

Salmond

Ramage

Collings

, … MaGPIe. (2005). Do patients want to disclose psychological problems to GPs? Family Practice, 22, 631–637.

10.

Caldwell

T. M.

Jorm

A. F.

(2001). Mental health nurses’ beliefs about likely outcomes for people with schizophrenia or depression: A comparison with the public and other healthcare professionals. The Australian and New Zealand Journal of Mental Health Nursing, 10, 42–54.

11.

Cape

McCulloch

(1999). Patients’ reasons for not presenting emotional problems in general practice consultations. British Journal of General Practice, 49, 875–879.

12.

Chen

Ren

Shi

Zhang

Huang

Ren

(2004). The effect of the training of general practitioner psychology medicine on family medicine practice [in Chinese]. Chinese General Practice, 7, 950–951.

13.

Chen

(2012). Seeking help for psychological distress in urban China. Journal of Community Psychology, 40, 319–341.

14.

Chen

Zhu

(2016). Online information searches and help seeking for mental health problems in Urban China. Administration and Policy in Mental Health, 43, 535–545.

15.

Chen

J. A.

Hung

G. C.

Parkin

Fava

Yeung

A. S.

(2015). Illness beliefs of Chinese American immigrants with major depressive disorder in a primary care setting. Asian Journal of Psychiatry, 13, 16–22.

16.

Chen

Conwell

(2015). Depression care management for adults older than 60 years in primary care clinics in urban China: A cluster-randomised trial. Lancet Psychiatry, 2, 332–339.

17.

Chen

S-l.

B-h.

Cheng

Jin

M-h.

(2010). General physicians’ attitude and clinical practice toward depression patients in primary care [in Chinese]. Chinese Journal of Public Health, 26, 114–115.

18.

Chin

W. Y.

Chan

K. T.

Lam

C. L.

Lam

T. P.

Wan

E. Y.

(2015). Help-seeking intentions and subsequent 12-month mental health service use in Chinese primary care patients with depressive symptoms. British Medical Journal Open, 5, e006730.

19.

Chin

W. Y.

Chan

K. T.

Lam

C. L.

Wong

S. Y.

Fong

D. Y.

Y. Y.

… Chiu

B. C. F.

(2014). Detection and management of depression in adult primary care patients in Hong Kong: A cross-sectional survey conducted by a primary care practice-based research network. BMC Family Practice, 15, 30.

20.

Copty

Whitford

D. L.

(2005). Mental health in general practice: Assessment of current state and future needs. Irish Journal of Psychological Medicine, 22, 83–86.

21.

Coupland

Dhiman

Morriss

Arthur

Barton

Hippisley-Cox

(2011). Antidepressant use and risk of adverse outcomes in older people: Population based cohort study. British Medical Journal, 343, d4551.

22.

Del Valle

Belloch

Carrio

. (2017). The long and complex road in the search for treatment for mental disorders: An analysis of the process in five groups of patients. Psychiatry Research, 253, 1–8.

23.

Deng

X. L.

Zhang

H. Y.

Zhang

Q. S.

Tang

J. J.

Hou

Y. H.

(2014). Mental health knowledge of community general practitioners in Bao’an District of Shenzhen [in Chinese]. Practical Preventive Medicine, 750–752.

24.

Doblyte

Jimenez-Mejias

(2017). Understanding help-seeking behavior in depression: A qualitative synthesis of patients’ experiences. Qualitative Health Research, 27, 100–113.

25.

C-y.

Zhao

Y-l.

Zhang

Cui

S-q.

(2011). Demand of general practitioner in Beijing for training on depression and the strategy. Chinese General Practice, 14, 6–9.

26.

Earnshaw

(2000). Distinguishing mental illness in primary care: Nature of psychological illness in primary care needs to be defined. British Medical Journal, 321, 1412–1413.

27.

Engel

G. L.

(1977). The need for a new medical model: A challenge for biomedicine. British Medical Journal, 196, 129–136.

28.

England

Nash

Hawthorne

(2017). GP training in mental health needs urgent reform. British Medical Journal, 356, j1311.

29.

Evans-Lacko

Brohan

Mojtabai

Thornicroft

(2012). Association between public views of mental illness and self-stigma among individuals with mental illness in 14 European countries. Psychological Medicine, 42, 1741–1752.

30.

Freeling

Rao

B. M.

Paykel

E. S.

Sireling

L. I.

Burton

R. H.

(1985). Unrecognised depression in general practice. British Medical Journal, 290, 1880–1883.

31.

Furnham

Chan

(2004). Lay theories of schizophrenia: A cross-cultural comparison of British and Hong Kong Chinese attitudes, attributions and beliefs. Social Psychiatry and Psychiatric Epidemiology, 39, 543–552.

32.

Garcia-Campayo

Sanz-Carrillo

Yoldi-Elcid

Lopez-Aylon

Monton

(1998). Management of somatisers in primary care: Are family doctors motivated? Australian & New Zealand Journal of Psychiatry, 32, 528–533.

33.

Gask

Rogers

Oliver

May

Roland

(2003). Qualitative study of patients’ perceptions of the quality of care for depression in general practice. British Journal of General Practice, 53, 278–283.

34.

Goldberg

(2000). Distinguishing mental illness in primary care: Mental illness or mental distress? British Medical Journal, 321, 1412.

35.

Goldberg

D. P.

Blackwell

(1970). Psychiatric illness in general practice: A detailed study using a new method of case identification. British Medical Journal, 1, 439–443.

36.

Goldberg

D. P.

Steele

J. J.

Smith

Spivey

(1980). Training family doctors to recognise psychiatric illness with increased accuracy. Lancet, 2, 521–523.

37.

Hickie

I. B.

Davenport

T. A.

Scott

E. M.

Hadzi-Pavlovic

Naismith

S. L.

Koschera

(2001). Unmet need for recognition of common mental disorders in Australian general practice. The Medical Journal of Australia, 175, S18–24.

38.

K. P.

Hunt

(2008). Patterns of help-seeking behavior for anxiety disorders among the Chinese speaking Australian community. Social Psychiatry and Psychiatric Epidemiology, 43, 872–877.

39.

Rohrbaugh

Deng

Munger

K. F.

Liu

(2017). Expanding the mental health workforce in China: Narrowing the mental health service gap. Psychiatric Services, 68, 987–989.

40.

Hutton

Gunn

(2007). Do longer consultations improve the management of psychological problems in general practice? A systematic literature review. BMC Health Services Research, 7, 71.

41.

W. D.

Chang

H. F.

Fang

W. L.

M. Z.

Gao

Y. Q.

Zheng

et al . (2008). Views on implementation of community mental health system with Chinese characteristics [in Chinese]. Journal of Clinical Psychosomatic Diseases, 14, 543–545.

42.

Jia

Wang

(2015). The analysis of the intervention diagnosis effect on detection rate for mental disorder at general outpatient in community health service center [in Chinese]. Journal of Shanxi Medical College For Continuing Education, 25, 5–8.

43.

Jin

Zhao

Chen

Wang

(2015). The length and content of general practice consultation in two urban districts of Beijing: A preliminary observation study. PLoS ONE, 10, e0135121.

44.

Johnstone

Goldberg

(1976). Psychiatric screening in general practice: A controlled trial. Lancet, 1, 605–608.

45.

Kadam

U. T.

Croft

McLeod

Hutchinson

(2001). A qualitative study of patients’ views on anxiety and depression. British Journal of General Practice, 51, 375–380.

46.

Kolstad

Gjesvik

(2014). Collectivism, individualism, and pragmatism in China: Implications for perceptions of mental health. Transcultural Psychiatry, 51, 264–285.

47.

Kovess-Masfety

Saragoussi

Sevilla-Dedieu

Gilbert

Suchocka

Arveiller

Hardy-Bayle

M.-C.

(2007). What makes people decide who to turn to when faced with a mental health problem? Results from a French survey. BMC Public Health, 7, 188.

48.

Kung

W. W.

(2004). Cultural and practical barriers to seeking mental health treatment for Chinese Americans. Journal of Community Psychology, 32, 27–43.

49.

Lam

T. P.

Goldberg

Tse

E. Y.

Lam

K. F.

Mak

K. Y.

Lam

E. W.

(2011). What do primary care doctors get out of a year-long postgraduate course in community psychological medicine? The International Journal of Psychiatry in Medicine, 42, 133–149.

50.

Lam

T. P.

Lam

K. F.

Lam

E. W.

Y. S.

(2013). Attitudes of primary care physicians towards patients with mental illness in Hong Kong. Asia-Pacific Psychiatry, 5, E19–28.

51.

Lam

T. P.

Lam

K. F.

Lam

E. W.

Sun

K. S.

(2015). Does postgraduate training in community mental health make a difference to primary care physicians’ attitudes to depression and Schizophrenia? Community Mental Health Journal, 51, 641–646.

52.

Lam

T. P.

Sun

K. S.

(2014). Stigmatizing opinions of Chinese toward different types of mental illnesses: A qualitative study in Hong Kong. The International Journal of Psychiatry in Medicine, 48, 217–228.

53.

Lawrie

S. M.

Martin

McNeill

Drife

Chrystie

Reid

… Ball

(1998). General practitioners’ attitudes to psychiatric and medical illness. Psychological Medicine, 28, 1463–1467.

54.

Sun

Zhang

Kolstad

(2014). Mental health care in China: Review on the delivery and policy issues in 1949–2009 and the outlook for the next decade. Acta Neuropsychiatrica, 26, 134–145.

55.

Cheng

K. K.

De Maeseneer

Meng

… Hu

. (2017). The primary health-care system in China. Lancet, 390, 2584–2594.

56.

Jia

Hou

Ryan

Blashki

Everall

(2015). A survey of the mental health workforce in Guangdong: Implications for policy and workforce planning. Australasian Psychiatry, 23, 675–678.

57.

Liang

Mays

V. M.

Hwang

W. C.

(2017). Integrated mental health services in China: Challenges and planning for the future. Health Policy and Planning, 33, 107–122.

58.

Liu

Y. L.

Xie

Y. F.

Tang

H. Y.

… Xin

Y. U.

(2011). Mental health system in China: History, recent service reform and future challenges. World Psychiatry, 10, 210–216.

59.

Lyu

Han

Cheng

(2015). Reasons for delay in seeking for mental health care among Chinese elderly people with depressive disorder [in Chinese]. Chinese Nursing Management, 15, 433–436.

60.

MaGPIe Research Group. (2005). General practitioners’ perceptions of barriers to their provision of mental healthcare: A report on mental health and general practice investigation (MaGPIe). The New Zealand Medical Journal, 118, U1654.

61.

Matalon

Kotliroff

Blumberg

Yaphe

Kitai

(2011). Non-specific symptoms as clues to changes in emotional well-being. BMC Family Practice, 12, 77.

62.

McDermott

Huppert

Blashki

Stone

Epstein

Olsen

… Singh

(2012). The active participants in mental health services. In Meadows

Farhall

Fossey

Grigg

McDermott

Singh

(Eds.), Mental health in Australia: Collaborative community practice (3rd ed.) (pp. 267–318). South Melbourne, Victoria, Australia: Oxford University Press.

63.

McManus

S. M. H.

Brugha

Bebbington

Jenkins

(2009). Adult psychiatric morbidity in England, 2007: Results of a household survey. Leeds, UK: The NHS Information Centre.

64.

Meadows

G. N.

Enticott

J. C.

Inder

Russell

G. M.

Gurr

(2015). Better access to mental health care and the failure of the Medicare principle of universality. The Medical Journal of Australia, 202, 190–194.

65.

Meltzer

Bebbington

Brugha

Farrell

Jenkins

Lewis

(2003). The reluctance to seek treatment for neurotic disorders. International Review of Psychiatry, 15, 123–128.

66.

Mental Health and General Practice Investigation Research Group. (2004). General practitioner recognition of mental illness in the absence of a ‘gold standard’. Australian & New Zealand Journal of Psychiatry, 38, 789–794.

67.

Middleton

Shaw

(2000). Distinguishing mental illness in primary care: We need to separate proper syndromes from generalised distress. British Medical Journal, 320, 1420–1421.

68.

Mitchell

A. J.

Vaze

Rao

(2009). Clinical diagnosis of depression in primary care: A meta-analysis. Lancet, 374, 609–619.

69.

Mohamed

Rosenheck

Yuping

(2014). Insight and attitudes towards medication among inpatients with chronic schizophrenia in the US and China. Social Psychiatry and Psychiatric Epidemiology, 49, 1063–1070.

70.

Murray

A. M.

Toussaint

Althaus

Lowe

(2016). The challenge of diagnosing non-specific, functional, and somatoform disorders: A systematic review of barriers to diagnosis in primary care. Journal of Psychosomatic Research, 80, 1–10.

71.

Wang

Yan

Huang

Wallen

G. R.

… Hua

(2014). Neurotic disorders of general medical outpatients in Xi’an, China: Knowledge, attitudes, and help-seeking preferences. Psychiatric Services, 65, 1047–1053.

72.

Oakley Browne

Lee

Prabhu

. (2007). Self-reported confidence and skills of general practitioners in management of mental health disorders. Australian Journal of Rural Health, 15, 321–326.

73.

Oopik

Aluoja

Kalda

Maaroos

H. I.

(2006). Family doctors’ problems and motivating factors in management of depression. BMC Family Practice, 7, 64.

74.

Parker

Chan

Tully

Eisenbruch

(2005). Depression in the Chinese: The impact of acculturation. Psychological Medicine, 35, 1475–1483.

75.

Parker

Gladstone

Chee

K. T.

(2001). Depression in the planet’s largest ethnic group: the Chinese. American Journal of Psychiatry, 158, 857–864.

76.

Peng

Y. C.

Y. J.

(2012). Work content of key posts in community health services: A non-participant observation [in Chinese]. Chinese Journal of General Practitioners, 15, 726–728.

77.

Peters

Rogers

Salmon

Gask

Dowrick

Towey

… Morriss

(2009). What do patients choose to tell their doctors? Qualitative analysis of potential barriers to reattributing medically unexplained symptoms. Journal of General Internal Medicine, 24, 443–449.

78.

Phillips

M. R.

Chen

Diesfeld

Xie

Cheng

H. G.

Mellsop

… Liu

(2013). China’s new mental health law: Reframing involuntary treatment. American Journal of Psychiatry, 170, 588–591.

79.

Phillips

M. R.

Zhang

Shi

Song

Ding

Pang

… Wang

(2009). Prevalence, treatment, and associated disability of mental disorders in four provinces in China during 2001–05: An epidemiological survey. Lancet, 373, 2041–2053.

80.

Pratt

L. A.

Brody

D. J.

(2008). Depression in the United States household population, 2005–2006. NCHS Data Brief, 1–8.

81.

Priest

R. G.

Vize

Roberts

Tylee

(1996). Lay people’s attitudes to treatment of depression: Results of opinion poll for defeat depression campaign just before its launch. British Medical Journal, 313, 858–859.

82.

Prins

M. A.

Verhaak

P. F.

Bensing

J. M.

van der Meer

(2008). Health beliefs and perceived need for mental health care of anxiety and depression – the patients’ perspective explored. Clinical Psychology Review, 28, 1038–1058.

83.

Reavley

N. J.

Mackinnon

A. J.

Morgan

A. J.

Jorm

A. F.

(2014). Stigmatising attitudes towards people with mental disorders: A comparison of Australian health professionals with the general community. Australian & New Zealand Journal of Psychiatry, 48, 433–441.

84.

Richards

J. C.

Ryan

McCabe

M. P.

Groom

Hickie

I. B.

(2004). Barriers to the effective management of depression in general practice. Australian & New Zealand Journal of Psychiatry, 38, 795–803.

85.

Rickwood

Deane

F. P.

Wilson

C. J.

Ciarrochi

(2005). Young people’s help-seeking for mental health problems. Australian E-Journal for the Advancement of Mental Health, 4, 218–251.

86.

Rickwood

Thomas

Bradford

(2012). Review of help-seeking measures in mental health: An evidence check rapid review brokered by the Sax Institute for beyond blue. Ultimo, New South Wales, Australia: The Sax Institute.

87.

Rosso

I. M.

Killgore

W. D.

Olson

E. A.

Webb

C. A.

Fukunaga

Auerbach

R. P.

… Rauch

S. L.

(2017). Internet-based cognitive behavior therapy for major depressive disorder: A randomized controlled trial. Depression and Anxiety, 34, 236–245.

88.

Sartorius

Ustün

T. B.

, & WHO. (1995). Mental illness in general health care: An international study. Chichester, UK: John Wiley & Sons.

89.

Shen

Qian

Feng

(2006). Data analysis of 1570 new cases o f community psychological clinic [in Chinese]. China Journal of Health Psychology, 14, 716–717.

90.

Simon

G. E.

VonKorff

Piccinelli

Fullerton

Ormel

(1999). An international study of the relation between somatic symptoms and depression. The New England Journal of Medicine, 341, 1329–1335.

91.

Sjostedt

Ohlsson

Sundquist

(2017). Socio-demographic factors and long-term use of benzodiazepines in patients with depression, anxiety or insomnia. Psychiatry Research, 249, 221–225.

92.

Slade

Johnston

Oakley Browne

M. A.

Andrews

Whiteford

(2009). 2007 national survey of mental health and wellbeing: Methods and key findings. Australian & New Zealand Journal of Psychiatry, 43, 594–605.

93.

Standing Committee of the National People’s Congress. (2012). Mental health law of the people’s republic of China [in Chinese]. Retrieved from http://www.gov.cn/jrzg/2012-10/26/content_2252122.htm

94.

Sun

K. S.

Lam

T. P.

Lam

K. F.

T. L.

(2015a). Managing common mental health problems: Contrasting views of primary care physicians and psychiatrists. Family Practice, 32, 538–544.

95.

Sun

K. S.

Lam

T. P.

Lam

K. F.

T. L.

(2015b). Obstacles in managing mental health problems for primary care physicians in Hong Kong. Administration and Policy in Mental Health, 42, 714–722.

96.

Sun

K. S.

Lam

T. P.

Lam

K. F.

T. L.

Chao

D. V.

Lam

E. W.

(2016). Barriers of Chinese primary care attenders to seeking help for psychological distress in Hong Kong. Journal of Affective Disorders, 196, 164–170.

97.

Sun

K. S.

Lam

T. P.

Lam

K. F.

Piterman

T. L.

Chao

D. V. K.

… Lam

E. W. W.

(2017). Help-seeking behaviours for psychological distress amongst Chinese patients. PLoS ONE, 12, e0185831.

98.

Tang

Y. L.

Sevigny

Mao

P. X.

Jiang

Cai

(2007). Help-seeking behaviors of Chinese patients with schizophrenia admitted to a psychiatric hospital. Administration and Policy in Mental Health, 34, 101–107.

99.

Tao

X. J.

Wang

L. P.

Cui

G. Y.

(2015). Use of antidepressants in enterprise-affiliated hospital before and after national health insurance reform [in Chinese]. China Pharmaceuticals, 24, 169–170.

100.

Thompson

Hunt

Issakidis

(2004). Why wait? Reasons for delay and prompts to seek help for mental health problems in an Australian clinical sample. Social Psychiatry and Psychiatric Epidemiology, 39, 810–817.

101.

Thornicroft

Chatterji

Evans-Lacko

Gruber

Sampson

Aguilar-Gaxiola

… Kessler

R. C.

(2017). Undertreatment of people with major depressive disorder in 21 countries. British Journal of Psychiatry, 210, 119–124.

102.

Tylee

Freeling

Kerry

Burns

(1995). How does the content of consultations affect the recognition by general practitioners of major depression in women? British Journal of General Practice, 45, 575–578.

103.

Tylee

A. T.

Freeling

Kerry

(1993). Why do general practitioners recognize major depression in one woman patient yet miss it in another? British Journal of General Practice, 43, 327–330.

104.

Walters

Tylee

Fisher

Goldberg

(2007). Teaching junior doctors to manage patients who somatise: Is it possible in an afternoon? Medical Education, 41, 995–1001.

105.

Weich

Lewis

Donmall

Mann

(1995). Somatic presentation of psychiatric morbidity in general practice. British Journal of General Practice, 45, 143–147.

106.

Wong

D. F.

Xuesong

Poon

Lam

A. Y.

(2012). Depression literacy among Chinese in Shanghai, China: A comparison with Chinese-speaking Australians in Melbourne and Chinese in Hong Kong. Social Psychiatry and Psychiatric Epidemiology, 47, 1235–1242.

107.

Wong

D. F. K.

J. C. M.

(2014). Cultural influence on shanghai Chinese people’s help-seeking for mental health problems: Implications for social work practice. The British Journal of Social Work, 44, 868–885.

108.

WHO. (2008). Integrating mental health into primary care: A global perspective. Geneva, Switzerland: Author.

109.

WHO. (2015). Mental health Atlas country profile 2014. Geneva, Switzerland: Author.

110.

Song

Zhu

(2007). Doctors’ knowledge and attitudes towards geriatic depression in community health center in Shanghai [in Chinese]. Shanghai Archives of Psychiatry, 19, 341–344.

111.

Xiong

Phillips

M. R.

(2016). Translated and annotated version of the 2015–2020 National Mental Health Work Plan of the People’s Republic of China. Shanghai Archives of Psychiatry, 28, 4–17.

112.

Yang

L. H.

Kleinman

Link

B. G.

Phelan

J. C.

Lee

Good

(2007). Culture and stigma: Adding moral experience to stigma theory. Social Science & Medicine, 64, 1524–1535.

113.

Yang

L. H.

Purdie-Vaughns

Kotabe

Link

B. G.

Saw

Wong

Phelan

J. C.

(2013). Culture, threat, and mental illness stigma: Identifying culture-specific threat among Chinese-American groups. Social Science & Medicine, 88, 56–67.

114.

Yap

M. B.

Reavley

N. J.

Jorm

A. F.

(2012). Associations between awareness of beyondblue and mental health literacy in Australian youth: Results from a national survey. Australian & New Zealand Journal of Psychiatry, 46, 541–552.

115.

F. S.

Yip

B. H.

Kung

Fung

C. S.

Wong

C. K.

Lam

A. T.

… Wong

S. Y. S.

(2015). The association of types of training and practice settings with doctors’ empathy and patient enablement among patients with chronic illness in Hong Kong. PLoS ONE, 10, e0144492.

116.

Zhang

Lin

Zhang

Wang

… Tian

(2013). Pathways to psychiatric care in urban north China: A general hospital based study. International Journal of Mental Health Systems, 7, 22.

117.

Zhang

Tang

Zhang

(2015). National health insurance development in China from 2004 to 2011: Coverage versus Benefits. PLoS ONE, 10, e0124995.

118.

Zhou

Z.-h.

Huang

W.-j.

Chen

S.-y.

Guo

J.-z.

Jin

S.-h.

(2012). Patient reasons for encounter and problems managed at a general practice clinic affiliated to a tertiary hospital [in Chinese]. Chinese General Practice, 15, 2652–2655.

119.

Zhou

Z.-h.

Huang

W.-j.

Jin

S.-h.

Guo

J.-z.

Chen

S.-y.

(2012). Prevalence and management of mental disorders in general practice clinic of general hospital [in Chinese]. Chinese General Practice, 15, 2942–2945.