The Serious Mental Illness Management System in China: concerns to be addressed
Authors: Yi‐Lang Tang, Xiao‐Nian Luo, Xiang‐Dong Wang
Journal: World Psychiatry (2024)

The Serious Mental Illness Management System (SMIMS) in China is a national government program designed to address the needs of individuals with severe mental illness in the community. The guiding document, Standards for the Management and Treatment of Serious Mental Illness, was updated in 20181. The system aims to provide community-based care to individuals diagnosed with one of the following six mental disorders: schizophrenia, schizoaffective disorder, delusional disorder, bipolar disorder, epilepsy-associated mental disorder, and intellectual disability1. It reflects a multifaceted approach, by involving mental health professionals, police, social welfare workers, and volunteers to form community teams. As of 2020, there were at least 6.4 million patients registered in the system2. However, considering the actual number of individuals with severe mental illness in China, the system is likely to have been markedly underutilized. A study found that >50% of people with the above diagnoses were not registered in the system3. The SMIMS intends to provide a range of community-based services, including outpatient follow-up, family visits, free medication, and financial assistance. A recent study4 showed that, among discharged patients with schizophrenia, 88.9% accepted the follow-up management. A few other studies reported that patients in the SMIMS had more favorable outcomes, including fewer rehospitalizations, better medication adherence, and greater improvement in symptoms2, 5, 6. The SMIMS project is probably the largest and most comprehensive in the world, involving multiple levels of government and disciplines. It has benefited millions of patients, including improved treatment accessibility and availability. However, some concerns have emerged over the years regarding the balance between control and treatment, the lack of an exit mechanism, and the possible restrictions on individuals once they are registered in the system. One of the primary concerns raised about SMIMS is its perceived emphasis on control rather than treatment. Once an individual is diagnosed with one of the above six conditions, clinicians are required to report the patient's information to the SMIMS database. Once registered, patients and their families can theoretically opt out of the community follow-up, but it has been found that more than 95% of the registered cases participate in the follow-up management2, suggesting possible pressure to enroll all registered patients. Moreover, patients' information in SMIMS is shared with police departments and local resident committees, which has caused concerns about confidentiality and privacy. While the objective of preventing violence and crimes and ensuring social stability is important and valid, it is also important to note that individuals with severe mental illness have a much higher risk of becoming victims than perpetrators of violence7, and control measures should not undermine the essence of patient-centered care. A reasonable balance between control and treatment is essential to avoid further stigmatizing and alienating individuals with severe mental illness, and to foster an environment where patients feel supported and empowered in their journey toward recovery8. The absence of an exit mechanism in SMIMS raises ethical concerns. Currently, once an individual is registered in the system, the information remains indefinitely, irrespective of whether the condition has improved, achieved remission, or was initially misdiagnosed. This practice disregards the dynamic nature of mental disorders, and the possibility of recovery or improved functioning over time. An exit mechanism would not only ensure that those who no longer meet the criteria for severe mental illness are not unnecessarily burdened, but also allow for the efficient allocation of resources to those who need them most. The fact that the government has access to patients' information has raised concerns about patients' rights being infringed. Possible restrictions for individuals within SMIMS include denial of driver's license applications, according to the current vaguely worded regulations9. When patients' information is entered into the SMIMS, they are typically informed about the benefits but not the potential risks. It is not uncommon for patients and their families to question psychiatrists who made these diagnoses, leading to disputes. As a result, many psychiatrists, particularly those in outpatient settings, may hesitate to make certain diagnoses or may resort to diagnoses outside the listed six categories, such as unspecified mood disorder instead of bipolar disorder. It is worth reflecting on why a well-intentioned system has not only dissuaded many patients from participating, but has also become a source of patient-doctor conflicts. Moreover, there is no established system to challenge or appeal the above-mentioned restrictions. Any restrictions should be carefully considered, well defined and regularly re-assessed, with a focus on protecting both the rights of individuals and the well-being of the community. To address the challenges and improve the SMIMS, several steps are necessary. First, rigorous, independent research is needed to evaluate the effectiveness and acceptability of the system compared to historical data and parallel community-based programs. Studies need to focus on how the system impacts patients, professionals and communities. Second, the system needs to shift its focus from control to a patient-centered approach that prioritizes individual well-being, treatment and recovery. Third, SMIMS should incorporate an exit mechanism to accommodate patients who no longer meet the criteria for a severe mental illness or who have been misdiagnosed. Regular reviews of individuals' status will ensure that resources are allocated efficiently and that patients are not unnecessarily burdened by the system. Finally, any potential restrictions or limitations on individuals within SMIMS must be transparent, clearly defined, and communicated to patients and their families, and patients need to have a mechanism to challenge or appeal the restrictions. In conclusion, we believe that the SMIMS in China represents a historically significant effort to address the challenges of managing severe mental illness within the community. However, a comprehensive, independent evaluation of the system is required, and this evaluation should inform evidence-based changes that prioritize patient-centered care, individual rights, and the overarching goal of improving the lives of patients and their communities. In particular, there is a need to address concerns regarding the balance between control and treatment, the absence of an exit mechanism, and potential restrictions on individuals' rights.