Some good news about the chaining of mentally ill patients in China, from the 686 Program

by Michael Woodhead
In recent years there have been several media articles about mentally ill people in China being chained up - usually by families - because there are no mental health services. 

The impression given by the articles is that this is a widespread practice and is going unchallenged. "This is an example of how mental disorders are dealt with in rural China" said The Independent. It is enlightening, therefore, to read that such practices are rare and have been targeted for elimination for more than a decade. In a sobering paper published in PLOS One this week, Dr Lili Guan and colleagues at the Peking University Institute of Mental Health talk abut the so-called 686 program that has been running since 2005 to provide basic mental health services and ensure human rights are upheld for people with severe mental disorders.

In their article they describe how they recruited village health workers across China to seek out and identify mentally ill people who had been chained up by families. Their program found 271 such people - some of whom had been in chains for 28 years, but most had been chained for shorter periods and intermittently as circumstances arose, rather than continuously. Cases of chaining were rare - accounting for only 0.2% of mental health patients reviewed in the program.

Most of the chained people had schizophrenia and none of them were receiving care from mental health institutions, usually because there were no such community services in their area, or the families could not afford it. The patients were restrained mostly because they were violent and abusive, causing harm to people and property.

The program of 'unlocking' was focused on providing free antipsychotic medications. Patients were first admitted to psychiatric units and assessed, and then families were provided with free medications and a treatment plan. The 'unlocked' patients were then returned home to live in the community.
The good news from the program is that regular treatment rates went from 1% to 75% and most patients complied with treatment and showed great improvements. Their functioning improved and the family burden also lightened significantly. Relapse into ''locking' occurred with only 21 patients (8%), with families citing lack of adherence to medication and return to violence or harmful behaviour and lack of caretaker/financial resources to access help.

"The finding that more than 92% of those unlocked and entered into continuous treatment by the 686 Program remained free of restraints by 2012 demonstrates the feasibility of improving the human rights of persons with severe mental illness by increasing access to mental health care in the community, even with limited societal resources," the researchers said.

"Nevertheless, the failure to prevent relocking for 21 individuals suggests that considerable room for improvement of our mental health care practice still exists."

The researchers also noted that their program covered less than 1% of the population of mentally ill people in China, and said it would require more resources to allow it to cover the whole country.

"There is obviously much to be done in China to scale up the 686 Program for the whole nation and to improve quality of care. This will require substantially increased investment in mental health services. However, the success of the program in maintaining the severely ill individuals in treatment over three to seven years, and the benefits of the intervention for those who have lived for years with untreated psychosis and for their families, attests to the feasibility and social value of the “686” model."

Authors note: Restraint for people with mental illness is not uncommon practice in  western countries, particularly for elderly people in nursing homes. Medical groups in countries such as Australia have expressed concern that patients who are agitated and have challenging behaviour are sometimes restrained due to lack of staff and for convenience, rather than for their own wellbeing.

China medical news headlines for Wednesday 29th January

Tuberculosis rates fall by 80%
Rates of tuberculosis in Shandong have fallen by 80% in the last decade, a study of 55,000 adults has shown.The prevalence rate of bacteriologically confirmed TB ases was 34 per 100,000 for adults in 2010. However, diagnosis of TB is now more difficult as half of bacteriologically confirmed cases did not present persistent cough, researchers said in BMC Infectious Diseases.

Man arrested for spreading H7N9 rumours
China's internet is full of stories of doctors and medical staff who have died of H7N9 influenza. Social networks such as Sina Weibo, QQ and WeChat have stories circulated by netizens of deaths of medical staff in Shanghai, Tianjing, Shenzhen and Nantong, according to CRI. However, health authorities have branded the stories as rumours and have arrested one man for spreading false information. In one case, a doctor who was named as having died of H7N9 influenza has startled patients by being on duty at hospital.

Shanghai life expectancy is 82
Life expectancy in Shangahi is 82 and a half years old, the Shanghai Health and Family Planning Commission has said. Women have a life expectancy four and a half years longer than, a report in ECMS said. LIfe expectancy in the city is on a par with developed countries but infant mortality including migrant families, rose from 5.04 per 1,000 in 2013 to 5.73 per 1,000.

High alert as H7N9 cases increase
China has gone on to high alert for H7N9 influenza as the number of cases continues to increase. Bird markets have been shut down in Shanghai and quarantine authorities have stepped up monitoring at airports. However, health authorities have played down the risk of a pandemic, saying the infection is not spread by human-to-human transmission. A vaccine against the H7N9 virus is being developed but is not ready for use in humans yet, authorities have reported.

China's can't cope with dementia
People in China are ill prepared to cope with the huge number of elderly people with dementia and Alzheimers disease, according to an article in SCMP. China has almost six million patients with Alzheimer's, 50% higher than a decade ago and twice as many as earlier estimated by the international health community. However, caring for dementia sufferers in China is left to family members with limited or no training and no support from the state.

Red Cross resuscitation ads are wrong
An advertising campaign by the Red Cross that urges Chinese to help those who have collapsed and need resuscitation is technically inaccurate, according to emergency specialists The picture on the ad shows a woman pressing the soft tissue of the patient's neck, which will lead to obstruction of the airway. First-aid practitioners should place their index finger and middle finger on the patient's chin bone, a doctor has pointed out.

China study links dementia to passive smoking

A study by scientists in China has found a link between passive smoking and syndromes of dementia.
The study of nearly 6,000 people in five provinces in China reveals that people exposed to passive smoking have a significantly increased risk of severe dementia syndromes.
Passive smoking, also known as 'second-hand' smoke or environmental tobacco smoke (ETS), is known to cause serious cardiovascular and respiratory diseases, including coronary heart disease and lung cancer. However, until now it has been uncertain whether ETS increases the risk of dementia, mainly due to lack of research. Previous studies have shown an association between ETS and cognitive impairment, but this is the first to find a significant link with dementia syndromes.
The study, published in Occupational and Environmental Medicine, is a collaboration between scientists at King's College London and Anhui Medical University, China, along with colleagues in the UK and USA.
According to the World Health Organization (WHO), nearly 80 percent of the more than one billion smokers worldwide live in low- and middle-income countries, where the burden of tobacco-related illness and death is heaviest; but only 11 percent of the world's population are protected by comprehensive smoke-free laws.
China is the largest consumer of tobacco in the world, with 350 million smokers. Since 2006, the Chinese government has actively promoted the introduction of smoke-free environments in hospitals, schools, on public transport and in other public places, but implementation has not been widespread.
Recent data show that the prevalence of passive smoking is still high, with over 50 percent of people exposed to environmental tobacco smoke on a daily basis. China also has the highest number of dementia sufferers in the world, with increasing rates of new cases as the population ages.
Dr Ruoling Chen, senior lecturer in public health from King's College London, and colleagues interviewed 5,921 people aged over 60 in the rural and urban communities of Anhui, Guangdong, Heilongjiang, Shanghai and Shanxi to characterise their levels of ETS exposure, smoking habits and assess levels of dementia syndromes.
They found that 10 percent of the group had severe dementia syndromes. This was significantly related to exposure level and duration of passive smoking. The associations with severe syndromes were found in people who had never smoked and in former and current smokers.
The data from the Anhui cohort, which were collected at baseline in 2001-03 for dementia syndromes and in the follow up in 2007-08 for ETS exposure and dementia, further excluded the possibility that dementia syndromes caused people to be more exposed to environmental tobacco smoke.
Dr Ruoling Chen, also a visiting professor at Anhui Medical University said: 'Passive smoking should be considered an important risk factor for severe dementia syndromes, as this study in China shows. Avoiding exposure to ETS may reduce the risk of severe dementia syndromes.
'China, along with many other countries, now has a significantly ageing population, so dementia has a significant impact not only on the patients but on their families and carers. It's a huge burden on society.'
The findings from this study, together with a second recent study by Chen and colleagues published in Alzheimer's & Dementia on the links between passive smoking and Alzheimer's disease, strengthen the case for public health measures to protect people from exposure to environmental tobacco smoke.
'At present, we know that about 90 percent of the world's population live in countries without smoke-free public areas. More campaigns against tobacco exposure in the general population will help decrease the risk of severe dementia syndromes and reduce the dementia epidemic worldwide.'
He added: 'The increased risk of severe dementia syndromes in those exposed to passive smoking is similar to increased risk of coronary heart disease -- suggesting that urgent preventive measures should be taken, not just in China but many other countries.'
Source: Science Daily

Dementia drugs shown to be effective in Chinese clinical trial

Donepezil and galantamine improved cognitive function

 by Michael Woodhead
Acetylcholinesterase inhibitors such as galantine and donepezil are effective in improving cognitive function in Chinese patients, a new study has shown.
The drugs are already considered standard of care for Alzheimer’s disease in western countries. Galantamine is an acetylcholinesterase inhibitor that may also act via allosteric modulation of nicotinic acetylcholine receptors. Therefore, it may provide benefits compared with other acetylcholinesterase inhibitors. Therefore, researchers at the Department of Neurology of Peking Union Medical College Hospital compared galantamine with donepezil in a double-blind trial involving 233 patients at nine hospitals in China.
The patients with mild to moderate Alzheimer’s disease were treated with either galantamine or donepezil for 16 weeks.
 Alzheimer’s cognitive symptoms  scores improved significantly from baseline in both groups of patients, with a significant difference in favour of galantamine in the “language”  area. Significantly more galantamine-treated patients responded to treatment and showed better cognitive scores. Both treatments were well tolerated, although fewer galantamine-treated patients experienced gastrointestinal adverse events compared with donepezil (30% versus 48%).
The researchers conclude that cognitive function improved significantly in subjects with mild to moderate Alzheimer’s disease treated with galantamine or donepezil, and both treatments were generally well tolerated. Significant benefits for galantamine over donepezil were observed for language and response to treatment."
Source:  Neuropsychiatric Disease and Treatment