The first national action plan on depression in China: Progress and challenges.

Depressive disorders (depression hereafter) are a group of common mental disorders which contribute greatly to the global burden of disease and disability. In China, a 2013 epidemiological survey in the general population found that the prevalence of depression was 6.8% (95%CI: 5.8%−7.8%) [1]. However, the majority of people with depression in China were not diagnosed, and the treatment gap in depression was unacceptably high. For instance, only 19.5% of patients with major depression received any treatment [2]. Considering the adverse impact of depression, such as impaired socio-occupational functioning, increased risk of suicide, and growing global burden as measured by disability-adjusted life years [3], developing and implementing appropriate preventive measures and effective treatments for depression in different populations are critical. Consequently, on September 11, 2020, the National Health Commission of China released the first action plan for the prevention and control of depression, entitled “The Action Plan to Develop Specialized Services for the Prevention and Treatment of Depressive Disorders” (Action Plan hereafter) [4], which included the rolling out of regular routine screening for depression across the nation. Given the extensive and profound long-term impact of this national Action Plan, we therefore outline in this paper an overview of the key aspects, progress and challenges of the Action Plan.

The Action Plan addresses six key aspects at the national level, including 1) public education on the prevention and control of depression, 2) routine screening and assessment of depression; 3) early diagnosis and standardized treatment for depression; 4) depression in vulnerable subpopulations, including adolescents, pregnant women, older persons, and those in occupations with high stress level; 5) establishment of psychological assistance hotlines; and 6) psychological interventions. All these measures are vital in targeting individuals with high risk of depression and those with pre-existing depression but at risk of relapse. Early identification of depression would ensure timely treatment, and substantially decrease the treatment gap, illness progression and suicide risk in those with depression.

However, several challenges in the Action Plan need to be addressed. First, the mass screening of depression incorporated in routine physical examinations across the population including subgroups such as secondary school and university students, perinatal women and older persons, is deemed useful in early identification of depression. However, protecting the confidentiality and privacy of individuals, particularly for those with identified depression, may be difficult in routine large-scale assessment. Severe stigmatization and discrimination towards patients with mental disorders are common in China, and individuals with identified depression may have concerns about how their assessment results will be shared with others that could lead to negative consequences. As such, some individuals may conceal their symptoms in the assessment process. Of note, the mental health policy regarding the confidentiality and information sharing is highly complex which may lead to misunderstanding between professionals and those living with depression.

Second, the Patients Health Questionnaire - 9 (PHQ-9) is recommended in the Action Plan as the screening tool for depression. However, the PHQ-9 is only a generic scale which is not sufficiently sensitive to detect depression in all subpopulations. Instead, specific tools for measuring depression for different sub-populations may be more appropriate, e.g., the Edinburgh Postnatal Depression Scale (EPDS) for peripartum women and the Geriatric Depression Scale (GDS) for the older persons. In addition, as the PHQ-9 is a self-report scale, those with cognitive impairment may be unable to complete the assessment, even though they are at a high risk of depression [5]. Additionally, the cut-off values of the PHQ-9 for depression are not the same in different subpopulations [6], which needs to be considered to ensure screening accuracy.

Third, the Action Plan recommends that persons identified as having depression should visit mental health professionals. However, there is a lack of relevant guidelines/consensuses on the criteria for referral to mental health services according the level of illness severity. For instance, the PHQ-9 is sensitive enough to identify those with mild depressive symptoms using the widely used cutoff value of 5. However, the majority of people with transient mild depressive symptoms do not require specialized mental health services and can be provided with self-management strategies or low-intensity interventions in primary care. Hence, inappropriate referral to mental health services could create confusion among those identified as having depression and mental health professionals, and could result in inefficient use of resources.

Fourth, previous studies using the PHQ-9 have found high prevalence of depression in different populations. For instance, a study using the PHQ-9 cutoff value of 10 found 9.2% (95% CI=7.2%–11.2%) of pregnant women in late pregnancy suffered from depression in China [7]. Therefore, nationwide screening would lead to a large number of depressed persons being identified which could very likely overwhelm the already inadequate mental health resources in China. Across China, mental health resources remain insufficient. Most of available resources are concentrated in psychiatric hospitals and mental health units of general hospitals located in urban and economically-developed areas [8] Further, primary mental health services are still under-developed in most areas due to various reasons such as the lack of trained professionals and effective cross-referral systems [9].

Fifth, the Action Plan also recommends psychological interventions for persons identified as having depression. However, there is an acute shortage of qualified psychological counsellors and psychotherapists in China, especially in remote, rural, and economically under-developed areas. In 2017, there were only 6000 licensed psychotherapists in China [10] which would be grossly inadequate to meet the demand for timely psychological interventions for the entire population.

In conclusion, the Action Plan for depression is a significant milestone in the progress of mental health services in China, but several major challenges need to be addressed in the implementation of the Action Plan.

Author contribution

Yu-tao Xiang and Chee H Ng developed the initial idea. Wen Li and Yuan Yang developed the first draft. Zi-Han Liu, Yan-Jie Zhao, and Ling Zhang provided extensive comments to the first and subsequent drafts. Teris Cheung and Chee H Ng provided extensive comments to subsequent drafts.

Declaration of Competing Interest

The authors declare no conflicts of interest.