A doctor checks the situation of patients with mental illness while they eat in a hospital in Yuncheng, Shanxi Province. Photo: CFP

Liu Shuangrui, 55, suffers from chronic schizophrenia. On Monday he shot and killed four people, including two police officers, in Fuzuo township, Hebei Province, and injured three others with a hunting rifle, according to a statement from the township government.

It has been the latest high profile attack by people with mental illness.

On May 4, a 29-year-old man surnamed Wang, who has a history of mental illness, brutally beat a 2-year-old boy in the street in Luochuan county, Shaanxi Province. The boy suffered a skull fracture. Surveillance video footage shows that Wang suddenly kicked the toddler down while Wang was sweeping the floor in front of a restaurant. Wang then repeatedly stepped on the child's head and beat him with the broom and dustpan.

A spade of incidents involving people with mental illness has triggered public doubts as to why they were not hospitalized or kept under control by their relatives.

Discrimination, a lack of doctors and psychiatric wards, and a complete absence of community-based rehabilitation restrict access to timely and necessary treatment, according to social workers and experts.

Lack of services

"Discrimination against the patients has strongly discouraged them and their relatives from admitting their illness and seeking medical treatment," said Dong Wentian, deputy head of Peking University Sixth Hospital, a top mental health institution in China.

For Shenzhen, Guangdong Province alone, the authorities estimated that there are 150,000 patients with serious mental illness while only about 16,000 people are registered in the citywide management system. This is because many families are reluctant to expose the patients to public ridicule and fears, Guangdong-based Nandu Daily reported on April 10.

Jia Fujun, director of the Guangdong Mental Health Center, said almost no family voluntarily registered until the patients were known to hurt others or themselves, Guangzhou Daily reported in 2014.

Huang Xuetao, founder of the Shenzhen-based NGO Equity and Justice Initiative, dedicated to fighting discriminations against people with mental illness, said the more we feel hostile toward them, the less knowledge we have about their actual condition and the less we can do to reduce the incidence of violent attacks.

"What they need is to be heard, instead of being isolated," she said.

"Besides, huge medical expenses, be it in the hospital or at home, daunted the families," Liang Shuji, director of the Guangzhou Richmond Mental Health Social Work Resource Center, which is devoted to mental health recovery, told the Global Times.

Health insurance currently reimburses people with mental illness for about 40 percent of overall expenses, with many imported medicines that produce fewer side effects than domestic ones being excluded from the insurance scheme. A one-month course of therapy is estimated to cost about 15,000 yuan ($2,418), according to the Guangzhou Daily.

"Even if they are willing to be hospitalized, China is short of mental hospitals and professionals," Dong said.

According to statistics provided by the World Health Organization in 2014, there were 0.1 psychiatrists for per 10,000 people in China, one third of the global average. In addition, only 1.4 psychiatric beds are provided per 10,000 people, accounting for about half of the world average level. Both figures lagged far behind Europe.

"Students in medical and nursing schools are reluctant to major in psychiatry. Being a psychiatrist or a psychiatric nurse makes them feel inferior to other doctors because their patients - people with mental illness - experience widespread discrimination," said Liu Jitong, an associate professor of medical sociology and social welfare in Peking University, adding that students were afraid of being attacked by their violent patients.

Wang Mingzhong, head of the Qinglongshan psychiatric hospital in Nanjing, Jiangsu Province, was quoted by the Modern Express in 2013 as saying, "My hospital is overcrowded since a large number of patients deem it a nursing home."

Although the majority of them have homes and guardians, they refused to be discharged, due to their families' incapability of taking care of them, and public bias against people with mental illness, said Wang.

Among the 1,270 inpatients, 20 percent have lived in the hospital for 21 years, 16 percent for 11 to 20 years, and 61 percent for 5 to 10 years, according to Wang.

Community-based rehabilitation

Dong said that community-based rehabilitation is the key for recovery after the hospital helped relieve their symptoms.

"Mental illness is not a simple disease and cannot be cured in hospital in a short period of time," Liu explained.

"If patients are confined in an enclosed environment for a long time, their social functions will deteriorate," Liang said.

He added that it is not feasible to leave the patients in hospital for long since the recovery process may last for years. For example, he said one of his patients spent one year gaining trust in him before opening up.

Liang said that patients need to interact with the people in their real lives and be in a familiar environment before they come back from hallucinations to reality.

Social workers frequent patients' houses, listening attentively to their anxiety, worries and happiness and giving feedback as well as guidance to modify the patients' behaviors, he said.

Social workers also gather the patients' relatives, friends and neighbors to chat with the patients in a community, instead of talking with them alone, according to Liang.

Liu pointed out that considering the limited medical approaches to mental illness and side effects of some medicine, the development of mental illness treatment will follow the example of the US, shifting its focus from medical treatment to community-based rehabilitation in the long run, which requires a large number of professional social workers.

In the US, professional social workers constitute the largest group of mental health services providers. There are 200,000 more clinically trained social workers than psychiatrists, psychologists and psychiatric nurses combined, according to the US' National Association of Social Workers.

He cited a guideline on treating mental illness issued by the National Health and Family Planning Commission this year, which stresses the importance of psychotherapeutic intervention.

Liu said he expects more financial investment in mental illness to go to communities.