Professor Michael Phillips, MD, MPH, MA, is Director of the Suicide Research and Prevention Center at the Shanghai Mental Health Center of the Shanghai Jiao Tong University School of Medicine, Professor of Psychiatry and Global Health at Emory University, Executive Director of the World Health Organization (WHO) Collaborating Center for Research and Training in Suicide Prevention at Beijing Hui Long Guan Hospital, co-Editor-in Chief of the Shanghai Archives of Psychiatry, editorial consultant for The Lancet and a former International Clinical Epidemiology Network (INCLEN) liaison officer for China.
费立鹏教授简介：加拿大籍，医学博士，流行病学及人类学硕士，现任上海交通大学医学院上海市精神卫生中心危机干预研究室主任，研究方法咨询中心主任，美国艾默里大学精神卫生学与全球卫生学教授。费立鹏教授是世界卫生组织精神卫生处顾问，北京回龙观医院临床流行病学研究室主任，上海精神医学杂志共同主编， Lancet中文版协调人，British Journal of Psychiatry等国际一线杂志编委。费立鹏教授曾是国际临床流行病学发展中心的中国代表。
The interview with Dr. Phillips was conducted during Westlake Youth Forum held in Hangzhou, China on August 5th, 2012. Dr. Phillips was an invited speaker for the conference.
25 Years in China
但是我觉得我的专业能力当时不够强，于是我去美国华盛顿大学做精神科住院医师。在那里我遇到了Arthur Kleinman教授，他做关于台湾的医疗体系及精神卫生研究。他后来到哈佛大学，担任社会医学系主任， 后来担任人类学系主任。 他也是中国研究方面的专家，与中国长沙也有合作。于是我选择跟他学习。在华盛顿大学期间，我完成了精神科的住院医师培训，同时在Robert Wood Johnson Fellowship的支持下，获得两个硕士学位，分别是流行病学和人类学。我毕业后1985年回到大陆，在湖南医科大学做访问学者两年。在此期间给精神科医生做方法学培训。两年结束后我找了全职工作，在80年代对一个外国人来说也并不好找，不过我很幸运的在湖北沙市（现荆州）精神病医院找到机会，在那里从1987年工作到1994年，一开始是做精神分裂症家庭医生，同时在很多地方讲研究方法学。在此期间，我也成为国际临床流行病学发展中心的国内代表，在成都的华西医科大和上海第一医科大（现上海复旦大学医学院）帮他们建立临床流行病学中心，并带研究生。接下来1994年到2010年我在北京回龙观医院工作。再后来来到我现在工作的地方—上海交大医学院精神卫生中心。回到你的问题说我为什么来到中国，我在1978年完成两年留学生生活时已经定了要在中国做精神卫生方面的研究，当我于1985年完成了精神科医师培训之后我就回到中国并一直在这里工作生活。
Jing: What motivated or attracted you, a Canadian scholar, to come to study and work in China decades ago and since then have lived in China for the past 25 years?
Dr. Phillips: I visited China for the first time in 1976 during my internship in New Zealand, after I received my MD degree in Canada. I was considering a career in public health. A friend of mine happened to be planning for a visit to China, so I tagged along with the group and came to China. I spent 3 weeks in China. It was quite impressive to me that even though the country was under-developed, the government paid a lot attention to public health and did a great job. I believe the efforts in public health at this early stage built a great foundation for the health system of the country in later years. I was especially impressed by the speed and intensity of public health communication. Once a public health directive was released, even the most remote rural areas would receive it within a very short period. I believed I could learn something about how the public health system worked in China and then apply it in other developing countries, because I had always planned to pursue my career in the developing world, such as African countries.
After finishing my internship in New Zealand, I returned to China as an international student in a two-year program — first year for language training and second year studying public health in a medical school. I spent my first year in Beijing studying Chinese, which turned out to be very difficult and I spent a lot of time learning the language. But in the second year I wasn’t permitted to go to a School of Public Health because I was coming from a ‘Second World’ country (New Zealand). So I was quite disappointed. Instead I continued to study the language at Nanjing University in my second year, during which I was able to visit some medical centers. It was in the two years of studying in China that I made the decision to pursue my career here in China, because I knew I could do something and contribute.
However, I felt I was not ready professionally at that time, so I went to the University of Washington in the United States to further my professional training. I chose psychiatry as my specialty and enrolled in a psychiatry residency program. I met Professor Arthur Kleinman during this period. He was an expert in mental health research and had conducted research on the health care system in Taiwan. He later moved to Harvard University and became the chair of the Department of Social Medicine and, later, chair of the Department of Anthropology. I learnt a lot from him. While at the University of Washington, I completed my residency in psychiatry and subsequently finished two additional degrees – a Masters in Epidemiology and a Masters in Anthropology – with support from the Robert Wood Johnson Fellowship.
After I graduated in 1985, I came back to mainland China and became a visiting scholar in Hunan Medical University, providing research methodology training to mental health physicians. Two years later, I accepted a full-time job offer in a psychiatric hospital in Jingzhou, Hubei. It was not easy for a foreigner to find a job in China at that time, but I was lucky. I worked there from 1987 till 1994, as a physician doing research in schizophrenia and as a national trainer in research methodology. During this time period, I also served as the liaison officer for China in the International Clinical Epidemiology Network (INCLEN) and worked with Huaxi Medical University in Chengdu and Shanghai First Medical University (now Fudan University Shanghai School of Medicine) helping them develop their centers for Clinical Epidemiology. I subsequently worked at the Beijing Hui Long Guan Hospital from 1994 to 2010 and then moved to Shanghai where I now work in the Shanghai Mental Health Center in the Shanghai Jiao Tong University School of Medicine. Back to your question on why I came to China. I decided to pursue metal health research in China when I finished my two-year exchange-fellow study in China in 1978. After receiving additional training in psychiatry I came back to China in 1985 and have stayed here since.
Mental Health in China
后来情况也逐步改善，特别是最近几年。跟其他国家相比，其他国家卫生部有一大批人专门做心理卫生相关的事情，而中国直到大概2006年时卫生部才有全职管理心理卫生的官员，推动精神卫生研究的发展并逐步提高精神卫生研究的重要性，当然这也和疾病负担相关。1999年，世界卫生总干事布伦特兰博士来中国做了关于心理卫生工作的专题报告 ， 他的报告强调了精神卫生在公共卫生领域的重要性。也是从那时起人们开始谈论自杀的问题，在中国，精神疾病及自杀占疾病总负担的20％，比传染病，癌症，糖尿病，呼吸道疾病的负担都要重。之后，卫生部对精神卫生逐步重视起来，特别是2009年医改，精神卫生问题还是很被重视。总体来说，目前的情况是很乐观的。虽然精神卫生的地位仍不能跟外科，内科相比，但差距在明显缩小。现在有人自愿成为精神科大夫。
Jing: Being an expert in the field of mental health in China, could you tell us about the recent development of mental health in China?
Dr. Phillips: When I came to China in 1985, the research on mental health in China was very limited. There were many reasons for this. Mental health received little attention and there were no usable curriculums. Psychiatry was a subfield under Neurology and didn’t become a separate discipline until 1994. At that time, medical school graduates were not willing to work in psychiatry. Psychiatry was not a priority so the quality of psychiatric research was poor and funding for Psychiatry very limited.
Mental health later received more attention, especially in recent years. Although there is still a substantial gap in this area between China and other countries. The Ministries of Health (MOH) in other countries have a group of people who specifically work on mental health. But in China, we didn’t have a full-time mental health official in the Ministry of Health until 2006. In 1999, the Director-General of WHO visited China and gave a major presentation on mental health. This highlighted the public health importance of mental health to the Chinese MOH. People started to talk about suicide since then. In China, mental health and suicide accounts for 20% of the total disease burden which is higher than infectious diseases, cancer, diabetes and respiratory diseases. The MOH gradually put more efforts on mental health, especially since the health care reform in 2009. Therefore, although psychiatry still does not enjoy a status comparable with internal medicine or surgery, but the gap has been much narrowed. Some medical students now prepare themselves to be psychiatrists, which is a sign of improvement in the field of mental health in China.
China’s Health Care Reform and Mental Health
Jing: You mentioned that the Health Care Reform of China in 2009 paid a lot of attention to mental health. Could you elaborate on this?
Dr. Phillips: In China’s Health Care Reform in 2009, the central government and MoH emphasized on mental health issues. Specifically, the reform encourages the treatments of hypertension, diabetes and mental illness in community-based health centers. Thus, it is important to develop urban and rural community-based clinics that have general physicians who are capable of providing mental health services. A critical challenge of this reform is that China still has a severe shortage of physicians who can treat patients with mental illnesses, because there is very limited systematic training in mental health in Chinese medical schools and few doctors choose psychiatry as their specialty. In a large epidemiological study of 63,000 community members from four provinces we found that 17% of the Chinese population have current mental health problems but only 5% of them had ever sought help for these problems. The MOH has given clear guidelines in the reform: invest on developing Community Health Service Centers and especially on controlling severe mental illnesses which could affect social stability. The 686 program has especially emphasized the availability of treatment or free treatment for people with schizophrenia or other severe mental illnesses who may pose a danger to others or to the community. The future efforts will focus on individuals who lost some degree of social functionality, such as those who have severe depression and anxiety. China has 170 million people who have mental disorders, one fourth of whom are moderately to severely disabled because of their mental health problems. Among these who cannot work, only 20% are receiving services. Therefore, the next step is to focus on providing treatment for the remaining 80%. These people are often unwilling to visit psychiatric services, so they will need to be treated in community health service centers. Hence, it is important to develop the capability to treat mental health patients in community-based health services. This will be a huge challenge, but the good thing is that the MOH is determined to achieve this goal and has indicated willingness to provide the required funds.
Mental Health Legislation in China
Jing: During the past 20 years, what were the major policies or legislations in the field of mental health in China?
Dr. Phillips: The development of mental health policies and legislations was initially focused on criminal law enforcement. For example, if a patient with severe mental illness killed someone, the law determines if he/she is legally responsible, and if not, under what circumstances he/she needs to carry partial or full responsibility. However, the development of regulations on the management of non-criminal general mental problems was relatively slow. Some big cities, including Beijing, Shanghai, and Guangzhou, have their local policies on when patients are eligible for treatment, when they can receive free treatment, and employer’s responsibility to protect employees with mental health problems. In western countries, health insurance normally provides restricted coverage for mental illnesses, because of the concern of wasting health resource by providing treatment for the ‘worried well’. But in China, health insurance systems treat mental illness the same way as other diseases. So Chinese patients with mental illnesses are not excluded from receiving psychiatric treatment if they decide to do so.
费立鹏：今年，在经历20年后，中国的精神卫生法或将出台[编者注：在与Michael Phillips 教授的采访两个多月后，中国精神卫生法已于2012年10月26号正式被全国人大常委表决通过]，正在进行第三次征求意见，如果通过就出台。这个法律出台后，原先有自己精神卫生管理条例的城市将取消原有条例，都将遵循此法。这个法律将很有意义，现在精神病院的病人大多是强制住院，一般被家人推荐入院。出于伦理的考虑，新的法律将要求大多数情况下自愿住院。除非对社会及他人有危害的情况下才可以由公安系统带走强制住院。
Jing: What do you think the direction of mental health policy and legislation in China?
Dr. Phillips: It will be very exciting this year if the National Mental Health Act is passed into law [Note: Few months after the interview, China's National Congress passed the National Mental Health Act on Oct 26, 2012]. Now the proposal is under the third round of public consultations. If it passes this round, it will become legislation. If this happens, cities that previously had their own local regulations will repeal their own versions and adopt the new national law. The law is quite meaningful; it is the result of over 20 years of hard work. Currently, patients admitted to psychiatric hospitals are primarily admitted involuntarily, usually on the recommendation of family members. Based on ethical considerations, the new law will require voluntary hospitalization in most cases. Involuntary hospitalization will only be allowed if the individual is a danger to others or to the community.
Mental Health Research in China
Jing: Please give us an overview of the focus and achievements of the mental health research in China.
Dr. Phillips: The focus of mental health research in China, similar to that in the United States, is on basic research, especially research on the genetic bases of mental illnesses. Because of the influence of international research communities, and the advantage of large sample sizes in China, there is a great interest in conducting large-scale genetic studies. The need for graduate students to rapidly complete their research and publish it in SCI journals also leads to an over-emphasis on biological, lab-based mental health research. In contrast, mental health research from the public health and community health point of view, a field in which I am interested, receives little funding and few high-level graduate students are willing to work in the area. About 80% of the research funding for mental health in China goes to basic research and psychopharmacological research; relatively very little is available for community-based studies on public mental health.
Jing: What are the challenges for mental health research in China? What is the future direction?
Dr. Phillips: Mental health research has many similar challenges as for other disciplines. Currently, a lot of graduate students and faculty have limited time and funding for research, so they are not motivated to do long-term research, and thus focus their attention to short-term projects that can produce deliverables within a short timeline. Similar to other fields, research on mental health needs multi-disciplinary collaboration and also needs long-term cohort study. Long-term longitudinal research in mental health is important to identify the underlying factors that result in violent behaviors, suicide, addiction, etc. These studies need to start at the early stage and then follow the individuals for many years to understand the complex factors that contribute to mental health problems. Similarly, interventions also need to start from an early stage. Long-term follow-up studies are critical.
Interviewer: Jing Hao, MPH, PhD student, University of Massachusetts at Amherst