Adult psychiatric epidemiology in China in the 80s

PETER CHEUNG

A D U L T P S Y C H I A T R I C E P I D E M I O L O G Y IN C H I N A IN THE 80s

ABSTRACT. This paper presents the prevalence rates of the main adult psychiatric disorders as determined by seven community surveys conducted in China in the 1980s. The prevalence rates are compared with previous findings in China and those from Taiwan and the West.

INTRODUCTION

Kleinman and Mechanic (1979) observed that very few psychiatric epidemiological studies had been done in China. During a visit to China, they were told by

health personnel that very few mentally ill patients were seen in China. Reported cases of schizophrenia were very much lower than the lowest prevalence estimates by the World Health Organization (WHO) of two cases per thousand population. They cautioned, however, that the prevalence of mental illness may not be less than in Western countries. It may be, for example, that the prevalence is underestimated because of differences in illness expression and behaviour and

containment of very disturbed behaviour by a close-knit social system. Neverthe- less, the true prevalence may be lower because available support and control systems help to shorten the acute course of psychiatric disorders.

Liu et al. (1987) stated that between 1958 and 1981 a total of sixty-one psychiatric epidemiological studies were conducted in China. The populations studied included as many as fifty-four million people. Forty-two studies used 'key-informants' for case identification. Only six of the sixty-one surveys had

been published by 1981. Lin and Kleinman (1981) reviewed the methodologies and findings of these six surveys. These surveys only studied those syndromes with significant, visible impact on the community and health services. Thus data

on the functional psychoses, organic mental disorders and obsessive-compulsive neurosis were collected. There were no data on other forms of neurosis, especially depression. During these surveys, local health personnel and neighbourhood cadres were instructed to report on all persons suspected of suffering from psychiatric problems. Probable cases were then assessed individually to establish the final diagnosis. The prevalence of the main syndromes studied

were as follows:

Culture, Medicine and Psychiatry 15: 479-496, 1991. © 1991 Kluwer Academic Publishers. Printed in the Netherlands.

480 PETER CHEUNG

- Schizophrenia 0.77-4.80 per thousand. - Mental retardation 1.13-2.90 per thousand. - Manic-depressive illness 0.03-0.09 per thousand. - Hysteria 0.29-0.83 per thousand.

- Obsessive compulsive n. 0.03 per thousand.

Lin and Kleinman (1981) commented that many of the less disturbed or impaired patients might not be noticed by the neighbourhood cadres or health personnel responsible for reporting. That was suggested to be the major reason why the prevalence rates reported in these studies were lower than those reported in other societies, including Taiwan. Variation in diagnostic criteria was thought to be responsible for the marked differences of prevalence rates among these studies.

A number of more recent psychiatric epidemiological surveys have been conducted in China since 1981 and reported in Chinese in the Chinese Journal of Neurology and Psychiatry (see Appendix). There were seven community surveys excluding those focusing primarily on intellectual handicap, children, and the elderly (see Table I). Of these, the Yehsieng Survey studied only

TABLE I Summary of the surveys: population and methodology

Survey Population Methodology

Chang Shan Islands 33,683 (1) Clue investigation (3/81-8/82) (2) Two stage method

Yehsieng (1982) 61,794 Two stage method Tientsin (9/81-6/82) 75,498 Two stage method National Two stage method

(Twelve Region) 80,000- (6/80-6/84) 100,000 per area

(cluster sampling followed by random sampling to obtain samples) 1,732 (sample size) 16,111 (sampling same as in National Survey) 4,974 (sample size)

Pingwu (1982)

Chiehyang (1984)

Xinjiang (1985)

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482 PETER CHEUNG

psychotic disorders and hysteria, the Chiehyang Survey studied only manic depressive illnesses and the Tientsin Survey studied only neuroses. The Chang Shan Islands and National (also known as the Twelve Region) Surveys studied a range of psychotic and neurotic disorders. The Xinjiang and Pingwu Surveys studied psychiatric disorders among two Chinese ethnic minorities, i.e., the Urgurs and Baima Tibetans, respectively.

In this paper the methodologies of and the main findings (excluding those on children and the elderly) from these surveys are reviewed.

SUMMARY OF THE SURVEYS

Methodologies

The methodologies of these surveys are summarized in Table I. All the surveys used the two stage method for case identification. In the first stage, a large number of individuals were screened with questionnaire(s) (screening instruments) in order to identify probable cases; these, in the second stage were examined by a psychiatrist or trained doctor to confirm (or otherwise) their caseness status, using standard diagnostic schedules and diagnostic criteria. The various measuring instruments and the diagnostic criteria used in the surveys are shown in Table II. Some of the instruments were translated from well established ones used internationally, in particular the Present State Examination (PSE) (Wing et al. 1974), while others were designed by the survey teams themselves. Apart from using a screening questionnaire, the Chang Shan Survey also used, in the first stage, "clue investigation" in which village doctors and leaders of production brigades provided a list of suspected cases. The National Survey produced, with the assistance of WHO experts such as Professors J. Cooper and N. Sartorius, its own handbook on its methodology and diagnostic criteria, and these were used by some of the other surveys (see Tables I and II). Full details of the National Survey will be published by the WHO soon (Cooper, J.E., personal communication 1990).

Each survey typically started with a promotion and education campaign, enabling the surveyed populations to understand the nature and importance of the surveys and ensuring a high response rate. All the research personnel underwent training before the field work. The inter-rater reliability of the instruments used were established by pilot studies and reported in the original papers (see Appendix).

The Chang Shan, Yehsieng and Tientsin surveys were whole population surveys, while the National, Pingwu, Chiehyang and Xinjiang surveys used proper sampling techniques to obtain samples of the populations for study. The

PSYCHIATRIC EPIDEMIOLOGY IN CHINA 483

National Survey involved twelve psychiatric epidemiological units in six of the major administrative regions in China. Each unit chose an urban and a rural area, each with a population of 80,000 to 100,000, which were representative in terms of socioeconomic conditions of the other areas of the region in which the research unit was situated. Cluster sampling was first used to determine the primary sampling units in each of the urban and rural areas. Random sampling was then used in each sampling unit to select fifty households for survey.

The vast majority of the populations surveyed in the Chang Shan, Yehsieng, Tientsin and National surveys comprised the Hans, the largest ethnic group among the Chinese. The Pingyu Survey studied specifically the Baima Tibetans in Pingwu County in Sichuan Province. The Baima Tibetans lived in hilly locations two to three thousand metres above sea level, and were geographically and culturally isolated from other ethnic groups. They were a primitive group without any written language. The Xinjiang Survey studied specifically the Uygurs who have socio-cultural norms different from the Hans and are forbid- den to marry people outside their own group. However their culture has been much influenced by the Hans, and they are comparable in their educational standards to the Hans.

All the surveys also studied the sociodemographic characteristics of their subjects, and analysed their prevalence rates in relation to such characteristics. However it is beyond the scope of this paper to discuss such findings.

Prevalence Rates

The prevalence rates of the main psychiatric syndromes studied are shown in Table III. The National Survey showed a range of prevalence rates in the twelve regions surveyed, and these are also shown in Table 111.

Among the neuroses, the Chan Shan Survey found the rate of hysteria to be 2.85 per thousand and other neurotic disorders 0.27 per thousand. The Yehsieng Survey found the rate of hysteria to be 0.65 per thousand. The relative fre- quencies and prevalence rates of the various neurotic disorders found by the other surveys are shown in Table IV. Only the Tientsin and National surveys reported on the rates of obsessive compulsive neurosis which were estimated to be 0.13 and 0.3 per thousand, respectively.

The National Survey, which was the only one among the surveys reviewed which studied the prevalence rates of alcoholism and drug dependence in the community, found the total prevalence rate of alcoholism to be 0.18 per thousand, drug dependence 0.39 per thousand and analgesic dependence was 0.37 per thousand.

The National Survey, which was the only survey that had estimated the rate of personality disorders, found it to be 0.13 per thousand (5/38,136).

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TABLE III Summary of the surveys: prevalence rates

Surveys Schizophrenia Manic-depressive Neurosis

Chang Shan 1.93/I000(p) 0 . 5 9 1 1 0 0 0 ( p ) 3.12/1000(p) Islands 7.2/1000(e)

Yehsieng 2.62/I000(p) 0.89/1000(p) (not studied) 5.21/1000(e)

Tientsin (not studied) (not studied) 13.39/1000(p) 28.81/1000(e)

National 4.75/1000(p) 0.37/1000(p) 22.21/1000(p) (Twelve 5.69/1000(1) 0.76/1000(I) Region) (2.25-10.23/1000) (0-2.4/1000) (6.85--40.08/1000)

Pingwu nil(p) 0.66/1000(p) 16.47/1000(p)

Chiehyang (not studied) 0.56/1000(p) (not studied) 1.37/1000(1)

Xinjiang 2.21/1000(p) 0.4/1000(p) 5.17/1000(p)

(p) Stands for period prevalence rates. (e) Stands for life expectancy or lifetime risk. (1) Stands for lifetime prevalence rates.

TABLE IV Summary of the surveys: composition of neurotic disorders

Surveys Neurasthenia Hysteria Depression Others

Tientsin 68%(9.10) 14.5%(1.95) (not included) 18%(2.41) National 58%(12.8) 16 .0%(3.55) 1 4 % ( 3 . 1 1 ) 12%(2.67) Pingwu 1 6 % ( 2 . 6 4 ) 40.0%(6.59) 1 2 %(1 .9 7 ) 32%(5.27) Xinjiang 50%(2.58) 7.1%(0.36) 21.4%(1.71) 21.5%(1.11)

Figures in brackets refer to period prevalence rates (per thousand).

DISCUSSION

Methodologies

The methodologies of the surveys reviewed here certainly were much more sound than the ones reported in the past (Lin and Kleinman 1981). Instead of using the "key informant" or the "clue investigation" method, all the surveys utilized the two-stage method which is the most widely accepted research


strategy for obtaining a complete picture of the psychiatric morbidity of a population (Eastwood 1971; Goldberg 1972 and Williams 1980). The prevalence rates obtained by these surveys can thus be regarded as much more reliable than the ones used by previous surveys in China.

The National (Twelve Region) Survey is one of the few recent psychiatric epidemiological surveys which have utilized the same methodology and diagnostic criteria to study simultaneously a large number of centres located over a vast geographical area (Robins et al. 1984), providing the opportunity to study how prevalence rates could be affected by different socio-economic and socio-cultural conditions.

No studies, to the best of the author's knowledge, have been published to describe the processes, problems and issues involved in the translation and design of measuring instruments used in the surveys reviewed. No detailed validity and reliability studies of these instruments were published. It is desirable to have such studies published in future to enable cross-cultural workers in other countries to evaluate and learn from the use of instruments involved in these surveys.

As mentioned above, the Chinese version of the PSE/ICD-9 was used in these surveys reviewed. The DIS/DSM-III system (Diagnostic Interview Schedule/Diagnosis and Statistical Manual of the American Psychiatric Association Version 3) was, however, used in other surveys in China (Liu et al. 1987) and in Taiwan (Hwu et al. 1981). Zhang (1985) and Yan (1985) suggest that the DIS/DSM-I/I diagnostic system is more consistent with Chinese clinical diagnoses than the PSE/ICD-9 and SADS/RDC (Schedule for Affective Disorders and Schizophrenia/Research Diagnostic Criteria) systems. Zheng et al. (1988) found the Adult Diagnostic Interview Schedule-Present (ADIS-P), based on a selection of items adapted from DIS and SADS, has a concurrent validity as good as the DIS. Further studies are needed to determine which diagnostic system would be most suitable in epidemiological studies in China.

There was no discussion of the refusal rates in the surveys reviewed. In China, it was probably regarded to be the duty of every citizen to participate in the surveys reviewed because the knowledge gained in these surveys would be of significant benefit to the state. This could mean that the refusal rates were almost non-existent because most people regarded that it was socially desirable to take part in the surveys. However, it is possible, because of the strong stigma attached to mental illness in China (Lin 1982), that some participants might consider it socially undesirable to disclose their current symptoms or past psychiatric history to the research workers, and this would result in an under- reporting of symptoms.

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TABLE V Comparison of prevalence rates

China a Taiwan West

Schizo- phrenia

Affective disorder

Neuroses

Alcoholism

1.93-4.75/1000 2.2/1000 0.77-1.13/1000 (Lin 1953) (Lin and Kleinman 1.5/1000 1981) (Lin et al. 1969)

2-9/1000 (Hare 1982; Cooper 1987)

0.37-0.89/1000 0.6/1000 4--12/1000 0.03-0.09/1000 (Rin and Lin 1962) (Lin and Klein- (Lin and Kleinman 9.8/1000 b man 1981) 1981) (Yeh et al. 1987)

3.12-22.21/1000 26% (Cheng 1985) 2.84% b (Liu et 39.1%b (Yeh al. 1987) et al. 1984)

6.1% men, 14.9% women (Bebbin-

ton 1981) 13.5% men, 18.7% women (Hender- son et al. 1979, 1981) 28.8 %--31%b (Robins et al. 1984)

0.18/1000 0.5/1000 1.4-19/1000 (Lin et al. 1953) (Mellor 1975)

4.5/1000 b 9.2% men, 0.5% women b 19.1-28.9% men, (Liu et al. 1987) (Yeh et al. 1984) 4.2-4.8% women b

(Robins et al. 1984)

Personality 0.13/1000 1-1.5% b 5-15% (Vaill- disorder (Yet et al. 1984) ant and Percy

1980) 2.1-3.3% b (Robins et al. 1984)

a Rates in China are ranges derived from surveys reviewed here unless specified otherwise. b Rates based on DSM/DIS system.

Prevalence Rates

It is informative to compare the estimated prevalence rates from these surveys

with those from previous findings in China as well as those from Taiwan and

Western countries.


Schizophrenia

The rates in the surveys reviewed range from 1.93 to 4.75 and are thus similar to the rates reported in Westem countries and in Taiwan (see Table V). However these rates are certainly higher than those reported in the 1950s in China when the range reported was from 0.77 to 1.13 per thousand. The higher rates found in the 1980s are likely due to more stringent and reliable ways of case identification. The rate of schizophrenia among the Uygurs was similar to those of other surveys reviewed which involved mainly the Hans. This is in keeping with the finding of a recent WHO study that schizophrenia (defined narrowly by the presence of Schneider's first rank symptoms) has a similar incidence across a variety of cultures, suggesting that the aetiological factors are common to all the cultures studied (Sartorius et al. 1986). The absence of any cases of schizophrenia among the Baima Tibetans surveyed could be a special characteris- tic of that ethnic group which deserves further research.

The National Survey showed an almost five-fold variation in rates. One of the possible reasons for this variation is the unreliability of the diagnoses made across regions. Further study appears warranted to ascertain whether such variations in different regions in China can be explained by differences in diagnostic practices or simply reflect the differences in clinical prognosis in different regions with different degrees of development.

Affective Disorder

The prevalence rates in the surveys reviewed here ranged from 0.37 to 0.89 per thousand and were much higher than the 0.03 to 0.09 per thousand reported in China previously (Lin and Kleinman 1981). However, they were still much lower as compared with the rates found in Westem countries and recently in Taiwan (Yeh et al. 1987) (see Table V). Schizophrenia was more prevalent than affective disorders by seven-fold in China according to the Twelve Region (National) Psychiatric Epidemiology Collaborative Unit (T.R.P.E.C,U.) (1986), while world-wide the rates of schizophrenia and manic-depressive disorder are quite similar. The T.R.P.E.C.U. believed that the diagnostic criteria for manic- depressive disorder in China were probably much too narrow as compared with the West. Also in some instances, manic depressive disorders have been misdiagnosed to be schizophrenia. Yan (1985) and Zheng et al. (1988) found that schizophrenia has been overdiagnosed by Chinese psychiatrists. Affective symptoms were often disregarded when psychotic symptoms were prominent.

488 PETER CHEUNG

Neuroses

The prevalence rates of neurotic disorders in the surveys reviewed ranged from 3.12 to 22.21 per thousand. However, as only prevalence rates of hysteria and obsessive compulsive disorders have been reported in the past, it is not possible to compare these figures with previous findings in China. The prevalence rates reported in Taiwan (Cheng 1985) and the West (Bebbington et al. 1981; Henderson et al. 1979, 1981) are much higher than those reported in these surveys (see Table V). Liu et al. (1987), using the Chinese version of the Diagnostic Interview Schedule Version IN (DIS) found a lifetime prevalence rate of 2.84% of any DIS disorders if tobacco-related disorder was not included. These rates were much lower than those reported in the three sites in the Epidemiologic Catchment Area (ECA) study in the United States (Robins et al. 1984) and in Taiwan by Yeh et al. (1984) using the Chinese Modified Version of the Diagnostic Interview Schedule (DIS-CM-II) (see Table V). Thus, the prevalence rate of neurotic disorders appears to be much lower in China than in Taiwan and the West irrespective of whether the PSE/ICD-9 or DIS/DSM-III system was used. This is certainly one of the most remarkable findings of these surveys.

Xiang (1986) believed that the low rate of neuroses in China was likely to be related to the traditional cultural values in China. Most people in China have strong support from their extended families. Family structures are usually stable, the family atmosphere is usually harmonious and divorce rates are low. The good family and social support systems have probably served as protective factors against the development of neurotic disorders. Study of possible cultural and other factors in China that are protective against neuroses appear warranted.

All the recent community surveys, apart from the Pingwu Survey, have found neurasthenia to be by far the commonest neurotic disorder in China (Table IV). The term neurasthenia was coined by Beard (1881) in the U.S. Lin (1989) has traced the history of how the term has fallen into disuse in the U.S. and has become an important diagnostic entity in four Eastern cultures - China, Japan, Taiwan and Hong Kong. The term neurasthenia means weakness of the nervous system in Chinese, and both laymen and many health professionals believe it has an organic or physical basis. There are also culturally determined expectations, shared by laymen and health workers alike, of what being ill with neurasthenia is really like, and those suffering from it are usually relieved of their respon- sibilities and duties (Kleinman 1982). Kleinman (1982) studied 100 patients with neurasthenia in the Psychiatry Outpatient Clinic at the Hunan Medical College. He found eighty-seven of them met the DSM-III criteria for Major Depression. Although a substantial number of those with Major Depression improved significantly with antidepressant medication, the amount of help seeking only decreased slightly and most of them did not see any improvement


in their social functioning and coping ability. Based on these findings, Kleinman concluded that neurasthenia is most useful to be regarded as a culturally patterned illness experience related to depression, other neurotic disorders or to culturally sanctioned ways of coping with distress and difficulties. Kleinman's findings and concepts have created some controversy among psychiatrists in and out of China (Lin 1989). Young (1989) and Yan (1989) have argued for the necessity of retaining the diagnostic concept of neurasthenia.

Hysteria was found to be the commonest neurotic disorder among the Baima Tibetans and second most prevalent neurotic disorder in the other surveys reviewed here (Table IV). The present rates are slightly higher than those reported earlier in China (Lin and Kleinman 1981). The estimated lifetime prevalence rate of hysteria in the West is around 3--6 per thousand for women, and substantially lower for men (Carey et al. 1980). Thus, the rate of hysteria in the West is much lower as compared with anxiety, depressive or phobic neuroses which are the commonest neurotic disorders. The prevalence of hysteria has declined in the West during this century. For example, hysterical neurosis (conversion reactions and dissociative states) accounted for 6% of annual admissions to the Bethlem Royal and Maudsley Hospitals from the mid- nineteenth century up to the 1950s, but since then the annual rate has dropped to 3% (Hare 1965). The high rate of hysteria reported in China is probably not surprising for two reasons. In hysteria there is, according to Freudian theory, the conversion of psychological conflicts into somatic complaints, and Chinese are well known for their somatization of emotional difficulties (Lin 1982). Also, some authors suggest that hysteria is a non-verbal communication that arises in the doctor-patient relationship (Pilowsky 1969) and those who lack effective verbal communication skills such as those who are illiterate are mostly likely to use hysterical symptoms to express themselves and gain their ends. There was a substantial minority of the surveyed populations who were illiterate. The Baima Tibetans, who had the highest rate of illiteracy among the surveyed populations, also had the highest rate of hysteria.

The rates of depressive neurosis reported in these surveys (see Table IV) are certainly much lower than the rates of 0.95 to 10.8 per cent reported in the West (Boyd and Weissman 1982). Lin and Kleinman (1981) pointed out that the prominent discrepancy between Chinese and Western findings could not be explained entirely by variations in diagnostic practice and case identification methods. They suggested that depressed Chinese patients tended to somatize their complaints and were more likely to be under the care of physicians than psychiatrists. Furthermore, during the Cultural Revolution it was considered ideologically undesirable to be depressed.

Yeh et al. (1984) found the lifetime prevalence rate of major depression in Taiwan to be 0.9% for males and 1.4% for females. For dysthmic disorders the corresponding figures were 0.08 and 0.4% respectively. These figures are

490 PETER CHEUNG

certainly much lower than those reported in the E.C.A. Study in the States (Robins et al. 1984). For instance, in New Haven, the rate of major depression in males was 4.4% and females 8.7%. The corresponding figures for dysthymic disorders were 2.6% and 3.7%. Liu et al. (1987) commented on the consistently low rate of depression reported in China and other East Asian countries and called for a careful examination of the concept of depression across cultures. They suggested that the overall low rate might be due to biological variations of East Asian people or to the fact that depressive symptomatologies form unstable clusters and overlap with other neurotic disorders in East Asian people. Further studies into the rate of depresssion in China and among Chinese communities in other countries appear warranted to clarify the possible cultural, social or biological basis of the low occurrence.

The rate of obsessive compulsive neurosis reported by the National Survey was ten times higher than the figure of 0.03 per thousand reported in China in the past (Lin and Kleinman 1981). This increase in rate is more likely due to improved ways of case finding. The present figure is similar to those reported in the West. For example, Carey et al. (1980) stated that the one year prevalence rate varies from 0.1 to 2.3 per thousand. Yeh et al. (1984) also found a rate similar to those in the States. These findings suggest that the rate of obsessive compulsive neurosis among Chinese is not lower than in the West, as has been suggested in the past (Lin 1953; Rin 1959; Tseng 1973) when the assumed rarity of obsessive compulsive neurosis was attributed to the pragmatism and lack of compulsion in Chinese culture.

Alcoholism

The rate of alcoholism found by the National Survey was much lower than those reported in the West (Mellor 1975). The rates found by Liu et al. (1987) in Shanghai and Yeh et al. (1984) in Taiwan are much lower than the figures reported in the E.C.A. survey employing the same methodology (Robins et al. 1984) (see Table V). These recent findings are in keeping with previous findings of a much lower rate of alcoholism among Chinese than Westerners (Wang 1968; Lin et al. 1969; Chu 1972; Singer 1972, 1974). Wang (1968) and Lin et al. (1982) have discussed various biological and cultural reasons to explain this phenomenon.

Other Psychiatric Disorders

The National Survey found a very low rate of personality disorders, which is quite out of keeping with the findings in the West (Vaillant and Perry 1980;


Robins et al. 1984) and also in Taiwan (Yeh et al. 1987). The very low rate of personality disorder found in China is likely to be at least partly due to different diagnostic practices in China. Further studies seem necessary to ascertain whether China in fact has a lower rate of personality disorders as compared with the West and other Chinese communities.

None of the common culture bound syndromes among Chinese such as koro, amok and latah, were studied in the surveys. Lin et al. (1981) stressed that it is important to study these syndromes because they can contribute significantly to the understanding of how Chinese culture influences deviance and psychopathology. They reviewed the literature and found that no epidemiological studies had been done in this area. More recently an epidemic of koro in southern China has been reported (Guangdong Transcultural Research Group 1987).

Psychosexual disorders and eating disorders were also not studied in these or past surveys in China. Liu et al. (1987) in their Shanghai Survey have not included anorexia nervosa, psychosexual dysfunction, antisocial behaviour and drug abuse in their survey because these disorders were considered to be extremely rare or the questions designed (DIS, Version III instrument) to elicit

the presence of symptoms for these disorders were not culturally appropriate in China. There is a need to develop culturally appropriate questions and diagnostic criteria to be used in China in order to study the eating disorders as well as the

other disorders which have been considered to be rare in China. The apparent rarity of these disorders might be due to the inadequacy or irrelevance of

diagnostic criteria based on Western norms and concepts to detect their presence among the Chinese.

SUMMARY AND CONCLUSIONS

The methodologies of the surveys studied here have advanced tremendously as compared with previous surveys in China, especially in terms of much more reliable and valid ways of case identification and use of standardized diagnostic criteria. However, more information is needed about the screening instruments used in the surveys so that workers in other countries, especially those in

overseas Chinese communities, can evaluate and apply them in future surveys.

There is also a need to ascertain which diagnostic system - PSE-ICD-9 or DIS- DSM-III or others - would be most appropriate in future epidemiological research in China. Culturally appropriate diagnostic criteria and definitions for research (and also clinical use) are also needed in China.

The rate of schizophrenia in China appeared to be similar to the West and Taiwan. The lower rate of manic-depressive disorder as compared with findings

in the West and Taiwan was most likely due to an underdiagnosis of the disorder and overdiagnosis of schizophrenia in China.

492 PETER CHEUNG

One of the most remarkable findings of these surveys was the much lower rate of neurotic disorder as compared with the West and Taiwan irrespective of whether the PSE-ICD-9 or DIS-DSM-M diagnostic system was used. This was attributed to the stable family and social support systems. Most people in China were part of such systems, and it is hypothesized that they offer protective influence against the development of psychiatric disorders. It is desirable to replicate this finding in future surveys in China and to pursue further research on the factors that are protective against the development of neuroses in China.

Among the neurotic disorders, neurasthenia was found to be the commonest. It is, according to Kleinman (1982), most usefully conceptualized as a culturally determined illness experience related to depression, anxiety and other neurotic conditions. The significance of neurasthenia as a diagnostic entity in East Asian cultures has recently been reviewed by Lin (1989). The high rate of hysteria was certainly contradictory to findings in the West, where hysteria is seldom encountered in clinical practice or community surveys and the validity of the term as a disease has been challenged. It would be interesting to follow up the cases found in these surveys to learn more about their nature. The rate of depression was found to be much lower than those reported in the West. This might be due to the underdiagnosis of depression; many might have been diagnosed to be suffering from neurasthenia instead. It has also been suggested that this could not be exlained on the basis of differences in diagnostic criteria or practices, and various mechanisms have been advanced to explain this phenomenon. The rate of obsessive compulsive neurosis was found to be similar to those reported in the West and Taiwan and was not as low as had been

postulated in the past. A very low rate of alcoholism and drug dependence, which has been reported

in China and overseas Chinese communities in the past, was again found in the National Survey. With the open policy and modernization programmes going on in China, the mainland Chinese are likely to be more open to Westem in-

fluences. It remains to be seen whether this will increase the rate of alcoholism

in China. Personality disorders were found to be rare in China, and this was likely at

least partly due to different diagnostic practices between China and the West and Taiwan. Eating disorders, psychosexual disorders and culture bound syndromes were not covered in these surveys. It would be of importance to include these disorders, using culturally relevant and acceptable diagnostic criteria, in future community studies in China.

Department of Psychological Medicine Dunedin Hospital New Zealand


ACKNOWLEDGEMENTS

Thanks are due to Professor J.E. Cooper for his valuable comments on an earlier

draft of this paper and to Drs. S. Lee and H.G. Hwu for supplying me with some

of the references from China and Taiwan quoted in this paper.

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APPENDIX

There are ten published papers in Chinese which depict the seven surveys discussed in this review of psychiatric epidemiology in China in the 1980s. No Author.

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and Psychiatry 19(2):97-98.

Adult psychiatric epidemiology in China in the 80s

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