A Conversation with Professor Michael Phillips

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.

1.     中国25年职业生涯

25 Years in China

郝静:您作为一个加拿大籍学者,在中国一呆就是25年,是什么吸引您来到中国并学习和工作了这么久?

费立鹏:我最初来中国是在加拿大医学博士毕业后,在新西兰做住院医师期间。当时有考虑过转到公共卫生的方向,正好有朋友想去中国看看,于是我就随代表团来到中国。那是1976年,当时呆了3个星期。我第一次的中国经历让我印象深刻的是,虽然国家很穷,但是在毛泽东主席的带领下,公共卫生很受重视,也做得非常好,我认为这种早期的基础对后来整个国家的健康水平有很大好处。特别是中国公共卫生宣传工作的速度和力度,一有文件发出去,很快就连最偏远的地方都能收到信息。所以我想在这里可以学到一些关于公共卫生体系的东西,应用于其他的发展中国家,因为我本来就打算去发展中国家,比如非洲。

在回到新西兰后,也和同事交流了这次经历。在我完成了住院医生后,还没有完全决定要去哪个专业,有意向想去中国。我有个朋友在新西兰政府工作,他建议可以以新西兰 学生身份去中国学习。这个机会让我可以在中国呆两年,第一年学中文,第二年去公共卫生学校学习。我第一年在北京学中文,这个学习过程对我来说很困难,我花了很多功夫学习语言。但是第二年不能让我去医学院学习,因为我来自于第二世界国家(新西兰)。我很失望。于是第二年我在南京大学继续学习语言,期间找到些机会去一些医院看看。这两年的时间让我改变了原本去非洲发展的计划,并决定要来中国,因为我觉得在这里我可以做出些贡献。

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.

2.     中国精神卫生的发展和现状

Mental Health in China

郝静:您是中国精神卫生领域的专家,能否给我们介绍一下中国精神卫生的发展及现状?

费立鹏:当我1985年来到中国,那时中国的精神卫生研究还很落后,原因是复杂的。精神方面的研究并不受到重视和尊重,也没有相关课程。精神科是属于神经科下的学科,一直到了1994年,精神科才成为独立的学科,然而,当时的医学院学生毕业后不愿意分配去精神科,即使分配去精神科,也要想办法转到其它科,没有人愿意留下,当时精神科并不受到重视,研究水平低,研究经费少。

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.

3.     医改对精神卫生的具体影响

China’s Health Care Reform and Mental Health

郝静:您刚才提到2009年的医改对精神卫生也有很多的关注,请为我们解释一下其中具体的影响。

费立鹏: 在2009年的医改中,政府及卫生部都很重视支持精神卫生的工作。特别是医改对包括糖尿病,高血压及精神卫生等大病提倡社区化服务。因此,发展城市及农村社区卫生诊所并有能够提供精神卫生服务的全科医师非常重要。所面临的巨大挑战是中国缺乏精神科医生,中国的医学院并没有系统的关于精神卫生的教育,而且目前仍然较少人愿意选择精神科。基于四个省,63000多样本的大型流行病学研究显示中国17%的人群有精神卫生方面的问题,而但只有其中5%的人看过精神科大夫。卫生部在医改中给了很明确的方向:把钱放在社区卫生发展上,尤其是着重控制影响社会稳定的严重精神病。686项目重点强调了严重精神分裂症,及其他威胁他人及影响社会稳定的严重精神病人进行治疗或免费治疗,提高该人群接受服务的比例。下一步重点将放在严重抑郁症,焦虑症等,即个人社会功能有障碍的人。中国有1.7亿人有精神障碍,其中四分之一中等或严重社会功能缺失,不能工作。这四分之一的人群中只有20%接受服务,使另外的80%能够接受治疗是下一步的改革重点。这些病人通常不愿意看专科大夫,因此需要在社区卫生服务中心治疗。所以培训社区卫生服务能力非常重要。能不能很好的实施精神卫生服务社区化是个大问题,但是卫生部有决心实现这一目标,并表示愿意支持需要的经费。

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.

4.     中国精神卫生政策发展

Mental Health Legislation in China

郝静:在过去的20年,中国关于精神卫生的法律及政策有什么重大的发展和改变?

费立鹏:中国关于精神卫生的政策及法律发展大部分是在司法方面,关注犯罪的问题,比如精神病患者杀人,有没有责任,在什么情况下需要负担部分或全部责任,发展比较快。但是其他关于普通精神病管理的条例发展很慢,中国没有这方面的法律。只有北京,上海,广州等城市有出台地方条例,比如在什么情况下接受治疗,什么情况下可以免费治疗,工作单位有责任保护有精神问题的工作人员等。与国外作个比较,国外很多医保对精神病治疗的报销有严格限制,因为国外担心不必要的医疗资源的浪费。但中国的将精神病和其他疾病给予相同对待,所以如果中国患者愿意,他们并不会受限制来接受精神病方面的治疗。

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.

郝静:您认为中国的精神卫生政策发展方向是什么?

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.

5.     中国精神卫生研究的重点,成就及前景

Mental Health Research in China

郝静:请您介绍一下目前中国精神卫生研究的重点及取得的成就。

费立鹏:精神卫生的研究重点与美国相似,还是在基础研究,尤其是在基因上的研究。原因有受国外研究趋势影响,再加上国内样本量大,在基因上容易有新发现的优势。另外高等院校的毕业要求学生在有限时间完成研究并要求SCI文章发表也促使基因研究成为精神卫生的研究焦点。相反,我感兴趣的精神卫生在公共卫生,社区卫生方面的研究,比例很低。研究经费绝大多数投入生物学,药理等基础研究方面,而在公共卫生领域很少。

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. 

郝静:您认为精神卫生在公共卫生领域研究面临的的挑战是什么?前景在哪里?

费立鹏:与很多学科面临的挑战相似,目前很多研究生,教授,考虑到研究时间有限,经费不足,对于长期研究项目积极性不够,研究人员及研究经费支持者更需要短期有效,马上出成果的项目,所以很多研究仅限于短期的研究。与其他领域研究相似,精神卫生的研究需要扩大多学科合作,也需要做长期随访研究。我认为长期随访研究很重要,我们也可以做。研究例如暴力行为,自杀,成瘾性等原因,要从早期开始,长期随访,这样的研究可以解释很多复杂因素之间的影响。同样,干预也要从早期开始。这将是周期很长的过程。

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
采访者:郝静,MPH,麻州大学博士生

   
  
 
 
  
    Dr. Michael Phillips

Dr. Michael Phillips