|Year : 2020 | Volume
| Issue : 3 | Page : 59-66
Mental health challenges raised by rapid socioeconomic transformations in China: Lessons learned and prevention strategies
Yankun Sun1, Yanping Bao2, Arun Ravindran3, Yan Sun1, Jie Shi4, Lin Lu5
1 Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China
2 National Institute on Drug Dependence, Peking University, Beijing, China
3 Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
4 National Institute on Drug Dependence; Beijing Key Laboratory on Drug Dependence Research, Peking University, Beijing, China
5 Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital); National Institute on Drug Dependence; Beijing Key Laboratory on Drug Dependence Research; National Clinical Research Center for Mental Disorders, Key Laboratory of Mental Health, Ministry of Health, Peking University, Beijing, China
|Date of Submission||24-May-2020|
|Date of Acceptance||10-Aug-2020|
|Date of Web Publication||29-Sep-2020|
National Institute on Drug Dependence, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing 100191
Prof. Lin Lu
Peking University Sixth Hospital (Institute of Mental Health), Peking University, No. 51 Huayuan Road, Haidian District, Beijing 100191
Source of Support: None, Conflict of Interest: None
China's rapid economic development has contributed to health improvement, such as increasing life expectancy, reducing communicable diseases, and mortality rate. However, the sustainable social and economic transformations, including industrialization, urbanization, globalization, and informatization, have triggered huge challenges to population health in China, particularly to mental health. This review discussed the mental health problems due to socioeconomic changes such as population, life-style, and environment changes, as well both the economic and disease burden of mental disorders. With awareness of these challenges, the following three possible responses are proposed: identify social and economic impact on mental health based on high-quality qualitative and quantitative analysis; improve mental health awareness and literacy; and enhance mental health-care system and promote implementation research. Lessons from China can be a great reference for other low- and middle-income countries. With efforts overcoming the current and potential challenges on mental health, the Sustainable Development Goals on mental health can be possibly achieved by 2030.
Keywords: Globalization, industrialization, mental health, socioeconomic transformations, urbanization
|How to cite this article:|
Sun Y, Bao Y, Ravindran A, Sun Y, Shi J, Lu L. Mental health challenges raised by rapid socioeconomic transformations in China: Lessons learned and prevention strategies. Heart Mind 2020;4:59-66
|How to cite this URL:|
Sun Y, Bao Y, Ravindran A, Sun Y, Shi J, Lu L. Mental health challenges raised by rapid socioeconomic transformations in China: Lessons learned and prevention strategies. Heart Mind [serial online] 2020 [cited 2022 May 17];4:59-66. Available from: http://www.heartmindjournal.org/text.asp?2020/4/3/59/296560
| Introduction|| |
Since the economic reform launched in late 1970s, China has experienced rapid economic growth. Indeed, China has also undergone major societal changes, including industrialization, urbanization, globalization, and informatization, as well as demographic, environmental, and lifestyle changes. China has also witnessed a shift in disease pattern from communicable to noncommunicable diseases (NCDs), including mental and substance use disorders, which account for a large percentage of the disease burden. In order to effectively address health concerns, China has designed a blueprint named “Healthy China 2030” at the national level to promote health over the next 15 years. Such strategy focuses on the promotion of mental health and the prevention and treatment of substance abuse. The strategies also fulfill the UN Sustainable Development Goals (SDGs) agenda. To better understand the current status in mental health in China, this review discussed the challenges in the field of mental health raised by economic and social transformations. We also proposed some possible responses to the current mental health system in order to improve mental health, and thus achieve the goals of both Healthy China 2030 and UN SDGs, which can also serve as references for other low- and middle-income countries (LMICs) with comparable trajectories of social and economic transformations.
| Socioeconomic Transformations and Mental Health in China|| |
Following the foundation of the People's Republic of China in 1949, China has transformed from an agriculture-based society into an industry-dominated economy. Industrialization is undoubtedly the major driver of China's economic development, however, it has also introduced health risks, such as processed foods, outdoor air, light, and sound pollution, and industrial waste, which are deleterious, not only to physical, but also to mental health. Along with rapid industrialization, China has also experienced a surprising phase of urbanization, which has contributed to better access to health-care services and increased popularity of health knowledge [Figure 1]. While, it has also led to rural–urban lifestyle changes, including poor diet, increased alcohol consumption, and tobacco use, as well as increased exposure to environmental pollution, chronic stress, and violence. These changes are anticipated to have a deleterious effect on the population's mental health. Indeed, China is currently involved in globalization, especially after joining the World Trade Organization in 2001, which has not only introduced innovative drugs and treatment procedures, but also introduced health-related risk factors, such as fast food, cultural shock, and tobacco and alcohol imports, as well as an influx of illicit drugs into the domestic market. Moreover, with the emergence of new communication technologies, such as tele-technology, computerization, and the Internet, China has experienced some informatization-based technologies, such as electronic medical records, tele-health or e-health services, and internet-based cognitive-behavioral therapy, which have allowed for the provision of better patient management services. However, the dramatic increase in the Internet and smartphone use has also raised concerns about potential mental problems, such as internet addiction (IA), internet violence, erosion of face-to-face interaction, and even access to illicit drugs via the Internet.
|Figure 1: Percentage of urban citizens and number of floating population (million)|
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The effects of urbanization, industrialization, globalization, and informatization on public health have generated great attention, but little attention has been directed at their effect specifically on mental health in China. Therefore, in the following sections, we will detail the trend of pandemic of mental disorders and the possible impact on mental illness of contributing factors resulting from rapid economic development and social changes.
| Increasing Disease Burden of Mental Disorders|| |
With China's rapid development, mental disorders have become major NCDs in China. The lifetime prevalence of any disorder (excluding dementia) was 16.6%. Mental and substance use disorders were accounting for 8.21% of the total disability-adjusted life years, and rank fifth among the leading causes of disease burden. Within the domain, disease burden in males is much higher than that in females. Depressive disorders, schizophrenia, anxiety disorders, and drug and alcohol use disorders (AUDs) are responsible for the majority of disease burden of mental and substance use disorders, as well as eating disorders are with highest increased disease burden from 1990 to 2017 [Figure 2]. The expenditure on mental disorders accounts for >15% of the total health expenditure and 1.1% of China's gross domestic product. The annual costs for an individual patient with mental disorders in China increased from $1,094.8 in 2005 to $3,665.4 in 2013, and the total cost for the whole society was increased by three times from $21.0 to $88.8 billion. Indeed, with strong social stigma on mental illness, only 8% had ever sought for mental health care. Therefore, if all patients with mental disorders had sought professional care services, the economic cost would have been reached to $484.1 billion.
|Figure 2: Rate of disability-adjusted life years under the domain of mental and substance use disorders in China (per 100,000)*|
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| Changes in Demographic Structure|| |
About 244.5 million people (also called floating population), accounting for 18% of the total population, migrated from rural to urban areas seeking jobs, better income, and lives [Figure 1]. Due to China's household registration system, also called hukou, migrants who work outside of their registered regions or geographical areas may have restricted access to education, health care, and social welfare services. Although the physical health in migrants seems to be better than their peers as sick migrants return to the countryside or region of origin, a number of studies indicate that migrants, particularly rural-to-urban migrants, suffer from poorer mental health than urban residents and rural counterparts. The prevalence of common mental health problems assessed by General Health Questionnaire-12 was 34.4% in Chinese migrant workers. Higher prevalence of psychological and depressive symptoms, nicotine dependence, risky alcohol use, and suicidality has been reported. The possible factors include perceived social stigma, daily discriminatory experiences, interpersonal tensions and conflicts, financial and employment difficulties, occupational hazards, higher work stress, separation from families, homesickness, living conditions, and social status., Moreover, particular groups, such as youth migrant workers, female migrants, and children with migrant parents, also experience more serious mental health problems than their counterparts. It is estimated that about 24% of female migrant workers with poor mental health suffer from cultural differences, gender-specific stressors, and financial and employment difficulties.
Despite significant problems with mental health in internal migrants, utilization of mental health services is quite limited in this population. Only 3.25% of the migrants with lifetime major depressive disorder have ever accessed professional mental health services, which is much lower than that in the general population.
Along with large-scale internal migration, an increasing number of family members are left behind in the hometowns, including wives, elderly, and children, most of whom are facing mental health challenges.
First, nearly 80% of the migrant workers choose to leave their children at their hometown as they cannot afford to raise their children in urban settings. Several studies indicate that the quality of life of left-behind children and adolescents is significantly lower than that of their peers in terms of psychological, emotional, social, and academic function. As well, higher rates of depression and anxiety symptoms and higher rates of IA and sleep problems have been indicated among left-behind children compared to same-aged counterparts.
Second, with large-scale migration of younger populations to urban or metropolitan cities, there has been a dramatic increase in left-behind elderly and empty nesters both in rural and urban areas, especially in families with only one child. Studies indicate that mental health in left-behind elderly is significantly poorer than in the general population, particularly in women. Indeed, there are more anxiety symptoms and poorer mental health among empty-nester elderly adults, especially those in rural areas. The mental problems in both left-behind elderly and empty nesters are mainly influenced by lack of social support, loneliness, marital status, parent–child relationship, life satisfaction, economy satisfaction, living situation, physical activity, and number of chronic diseases.
Third, as rural–urban migration in China is a largely male-dominated, left-behind women make up 6.1% of the total rural married women. Most of the left-behind wives must take on the responsibilities of intensive work. Along with sparse sex life, lack of communication with husbands and lack of social support are likely to contribute to more negative emotions such as psychological distress, symptoms of depression, and poor coping styles.
The number of inhabitants aged 65 years and over increased from 49.9 million to over 158 million between 1982 and 2017, and currently accounts for 11.4% of the total population. Mental and neurological disorders, including dementia and depression, are common in the elderly, and their prevalence has increased markedly in recent years. The prevalence of dementia in people over 65 was 5.6% in 2013. Depression is also common in the elderly, and is often neglected and underdiagnosed, as the elderly are less likely to seek help for mental health due to stigma and low mental health literacy. Currently, mental and neurological disorders account for 7% of the total burden of disease among those over 70 years of age in China, right after cardiovascular disease, neoplasm, and chronic respiratory disease.
| Changes in Lifestyle|| |
In recent decades, the structure of nutrition intake has shifted to increased consumption of high-quality protein (dairy, eggs, fish, and seafood) and fats (edible oils and meat particularly pork) and decreased intake of coarse grains, vegetables, and fruits; this may be characterized as an unhealthy type of diet. The modern unhealthy diet adopted by Chinese can affect mental health both directly and indirectly. Epidemiological studies have shown that healthy diets are associated with lower risk of anxiety, depression, cognitive impairment, and even suicide. On the other hand, high-fat diets have been shown to negatively affect cognitive function in tasks such as simple reaction time, symbol-digit substitution, and serial digit learning, as well as to increase the risk for dementia. The evidence on the impact of unhealthy diets on mental disorders is more conflicting, as some studies found correlations between unhealthy diets and mental health problems, but most found no significant links. Nevertheless, unhealthy diets can also indirectly affect mental health by inducing obesity, Type 2 diabetes, cardiovascular diseases, and other NCDs, which are highly comorbid with mental disorders. While there is high-quality evidence on the correlation between diet and mental health in high-income countries, there is an urgent need to evaluate the relationship of diet and mental health in the context of China and other LMICs.
Along with rapid growth in economic development and disposable income, alcohol consumption of the Chinese population has changed noticeably. Although alcohol has been accepted as part of the culture for thousands of years, harmful drinking patterns and AUDs have become an epidemic risk factor influencing both mental and physical health in China. Consumption per capita has been increased considerably in recent years, from 2.5 L in 1978 to 6.7 L in 2010. The 12-month prevalence of AUDs was estimated at 1.2%, with significant differences in prevalence between men (3.5%) and women, (0.1%). Moreover, the current and lifetime prevalence of alcohol dependence are with an increasing trend with age up to 60, and with slightly higher prevalence in rural than in urban populations.
With a growing tobacco industry in the past 30 years, smoking remains one of the most common behavioral risk factors in China, particularly in the male population. In 2010, an estimated 28.1% of adults in China (52.9% of men and 2.4% of women) were current smokers. In 2015, there were an estimated 316 million current smokers in China, making this country the largest consumer of tobacco in the world. Smoking is commonly considered a risk factor for mental and substance use disorders. It not only induces nicotine dependence and addiction, but is also believed to be a gateway to illicit drug use. For instance, tobacco smoking has been reported to be associated with about four times increased risk for cannabis use and opiates addiction. As well, cigarette smoking has been linked to increased risk for completed suicide.
| Internet and Social Media Exposure|| |
Widespread use of the Internet and social media is evident. Up to June 2016, China had 710 million internet users, of whom 656 million were mobile internet users, accounting for 92.5% of the total citizen population. Large number of people access social and internet media with mobile devices via apps such as WeChat, Weibo, and BBS. However, heavy use and dependence indicates a risk factor for IA, which can be broadly conceptualized as an inability to control one's use of the Internet, and comprises the problematic use of internet/video gaming, mobile handheld devices, and other forms of addictive internet usage. The negative consequences of IA include emotional, social, and mental dysfunction in a wide range of areas of daily activities. The estimated prevalence of IA among adolescents in mainland China is with large variations from 2.0% to 17.1%. Adolescents with IA have higher rates of attention deficit hyperactivity disorder, depression, hostility, and aggressive behaviors, in addition to impaired inhibition and working memory and disturbed circadian rhythms indicative of sleep problems. Furthermore, IA and internet exposure to suicidal thoughts are both significantly associated with increased risk of self-harm. Finally, it has been reported that heavy internet use can be a risk factor for the development of alcohol consumption, tobacco use disorders, and risky substance use.
| Changes in Environment|| |
The rapid pace of industrialization in China has led to significant air, water, and soil pollution, while growing urbanization with an increasing volume of population, vehicles, and nightlife activities has caused noise and light pollution.
In China, even though most cities have plans to eliminate the use of coal in households, many urban and rural communities continue to rely on the combustion of biomass and coal, which is the dominant source of air pollution in the country. Indeed, more fossil fuel combustion, pollutants from transportation, and burning of agricultural wastes are produced, resulting in more hazardous air quality. Air pollution is currently a significant issue in China, especially in metropolitan cities, such as Beijing and Shanghai. Air pollution has been proposed to be associated with an increased risk of mental and neurological disorders. A recent study indicate that both PM2.5 and PM10 levels were positively associated with the number of hospital admissions for depression in China. Indeed, a research with a sample size of nearly 32,000, examined the relationship between cognitive test scores, taken from the nationally representative China Family Panel Studies longitudinal survey conducted in 2010 and 2014, with short- and long-term air pollution exposure calculated from official air pollution index values. It indicated that the effect of air pollution on verbal tests becomes more pronounced as people age, especially for men and the less educated. Moreover, postnatal exposure to air pollutants, such as NOx, CO, O3, and SOx, especially with PM2.5 pollution, as well as exposure to other toxic compounds, such as lead, diesel particulate, manganese, and nickel, during pregnancy have been reported to be associated with increased odds of autism spectrum disorder and attention deficit hyperactivity disorder. However, the relationship and neurological mechanisms underlying the impact of air pollutants on mental and neurological health are not well identified.
Light and noise pollution
The development of electric lighting in the 20th century contributed greatly to the economic development in China. However, people are exposed to artificial light and excessive light both outside and inside homes. Urban light pollution, shift work, transmeridian travel, and exposure to artificial light emanating from televisions and computers have dramatically altered the timing of light exposure that the body uses to entrain biological rhythms. It has been demonstrated that exposure to high-intensity or chronic light, particularly during night time, can affect the endogenous circadian rhythmicity leading to disturbances, such as phase shifts of the entire circadian system, displacement of sleep, and acute suppression of nocturnal melatonin production. This, in turn, can induce increased incidence of headaches, worker fatigue, medically defined stress, and anxiety. In addition, exposure to artificial light at night time can lead to significant changes in sleep architecture, including increases in sleep-onset latency, arousal index, shallow sleep, and rapid eye movement sleep, as well as changes in brain oscillations associated with sleep depth and stability. Indeed, a study showed that when compared with dim light, both intermittent light and continuous bright light significantly increased subjective alertness and decreased sleep efficiency and total sleep time.
Another unwanted effect of urban development and industrialization is that of noise pollution. Noise pollution has been demonstrated to be associated with mental health and sleep quality. Studies investigating short-term exposure to noise indicated that occupational and environmental noise was related to annoyance, disturbance of normal human activity, and somatic and psychosomatic health effects. A health survey was conducted in Beijing in 2017, which for the first time investigated the spatial distributions of multiple noise pollution perceived by residents in Beijing, including road traffic noise, railway (or subway) noise, commercial noise, and housing renovation (or construction) noise. The results show that perceived higher noise pollution exposure is significantly associated with worse mental health. Moreover, traffic, neighborhood, and leisure noises have also been reported to induce disturbances in sleep, such as increased awakenings and decreased slow wave sleep time, and lead to increased use of sleep medication.
| Discussion|| |
Mental health issues related to economic and social transformations
With rapid economic growth and social development in the past few decades, China has undergone significant industrialization, urbanization, globalization, and informatization. These changes have induced demographic, lifestyle, and environmental changes, which in turn may have significant impacts on physical and psychological health [Figure 3]. This review identified some of the mental health issues associated with these changes.
|Figure 3: Mental and neurological disorders triggered by economic and social transformations|
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From a demographic perspective, one particular phenomenon of significance is the increasing floating population, as an increasing number of migrant workers and left-behind families are facing mental and psychological problems. Moreover, the growing aging population and accompanying increases in the prevalence of mental and neurological disorders is likely to add significantly to the community's burden of disease. Although issues of left-behind children and the elderly are increasingly being brought to light, the issues surrounding mental health problems in left-behind women remain largely unaddressed.
Other issues of concern are changes in lifestyle, including increases in alcohol and tobacco use, as well as illicit substance abuse. Moreover, the adoption of unhealthy diets has resulted in increased prevalence of obesity, which is a risk factor for depression and other mental illnesses, especially among children and adolescents. In addition, the growth of informatization and globalization, as well as the widespread use of the Internet and social media, which are permeating the nation, are risk factors, not only for the development of behavioral addictions, such as internet or gaming addictions, but also for risky substance use.
From an environmental perspective, economic development has been accompanied by air, light, and noise pollution that can exacerbate mental problems, including depression, anxiety, and sleep disturbances. Indeed, the rate and disease burden of mental illnesses is rapidly growing in China, despite low identification and treatment rates. Nevertheless, there is a lack of quantitative research on this subject in China, highlighting the need for more studies to better understand and predict the impact of rapid economic development on mental health in China and other LMICs.
Strategies to deal with mental health challenges
To enhance mental health-care system
There were 2.38 psychiatrists and 31 mental hospital beds per 100,000 people in China in 2017 [Figure 4]. Though this is better than the availability in neighboring countries and middle-income countries, mental health-care resources and services are not distributed evenly across the country. Most of the services and resources are located in urban areas, while two-thirds of rural counties remain without any mental hospital beds. There are a great proportion of individuals with mental illness that are unable or unwilling to receive government-funded community-based treatments, indicating a large treatment gap. In 2015, the Chinese government issued the Mental Health Work Plan 2015–2020. The primary goal of this initiative is to establish, by the year 2020, a universal integrated service and management network for mental health, led by governmental departments, with active participation from health-care sectors, community organizations, patients, and families. In this regard, development and expansion of a mental health system of prevention, treatment, and rehabilitation would be in line with the national goals of socioeconomic development and would meet the needs of the public. More inputs or resources need to be allocated in enhancing mental health services and promoting public mental health from both governmental and institutional levels.
|Figure 4: The density of mental health workforce and beds in psychiatric hospitals in 2017 (per 100,000)|
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To improve mental health awareness and literacy
Numerous studies indicate that social disapproval and family shame regarding mental illness is widespread in China, and such stigma has emerged as a significant barrier to accessing appropriate treatment. Lack of knowledge about mental illness was one of the most common reasons cited by the patients of Chinese cultural backgrounds and their parents for their delay in seeking psychiatric help. Therefore, poor mental health literacy and stigma contribute to low illness recognition and treatment rates in China. In order to effectively address this issue, it is necessary to understand the obstacles that patients, families, and mental health providers face in receiving and providing optimal clinical services. Enhancing mental health literacy and proposing anti-stigma for mental disorders campaign are not only effective ways of reducing stigma and discrimination, but also strategies to facilitate early intervention for mental disorders and thus, improve health outcomes.
To facilitate prevention and treatment strategies
Mental illness prevention strategies that aim to reduce the incidence, prevalence, and recurrence of mental disorders; reduce risk factors and increase protective factors; and reduce the impact of mental illness on affected people, families, and society, need to be set as priority. Although evidence for the effectiveness of prevention strategies is robust, most of it has been derived from high-income countries. Moreover, while many mental health programs have applied such evidence and achieved local success, few programs have been systematically scaled up to regional- or national-levels, and prevention programs targeting the general public or at-risk individuals are rarely implemented. In this regard, mental health-care sectors need to re-evaluate the effectiveness of the current prevention strategies, as well as invest in the development of more effective prevention programs that consider changes of risk and protective factors and implement effective programs at local or national levels.
In addition, beside the standard and hospital-based treatment strategies, more cost-effective therapies need to be implemented in order to improve access to mental health services across regions, particularly in light of the wide disparity that exists between rural and urban regions in terms of social and economic development levels, as well as access to mental health-care resources. Due to advances in digital technology, the use of mobile, Internet, and other remote technologies is widespread. Such technology could be applied to the health-care system to improve access. There is promising evidence on the effectiveness of online, text-messaging, and telephone support interventions for mental disorders including: technology for supporting clinical care and educating health workers, mobile tools for facilitating diagnosis and detection of mental disorders, technologies for promoting treatment adherence and supporting recovery, online self-help programs for individuals with mental disorders, and programs for substance misuse prevention and treatment. However, further research is needed to confirm the effectiveness of these strategies in China.
To encourage mental health research
Although increasing efforts have been directed to identify the social correlates of mental disorders at an individual level, there is a scarcity of high-quality national-level evidence on the impact of macro-level socioeconomic changes, such as rapid urbanization and globalization and demographic, environment, and lifestyle changes, on mental disorders. Locally driven studies need to be conducted to examine China's specific situation. As with rapid social and economic transition, prospective and longitudinal research is necessary in order to better understand how these changes impact mental health, to identify risk and protective factors, and to establish effective prevention and intervention strategies to promote mental health.
Government support and investment in biological and clinical studies, as well as health policy research, are necessary to elucidate physiological mechanisms of mental disorders, create innovative treatment strategies, and establish evidence-based mental health policy in a Chinese context. Moreover, health economics research in China's mental health-care system is urgently needed to determine the long-term cost-effectiveness of prevention, intervention, and treatment programs, and to re-evaluate allocation of funds to achieve better and more uniform distribution of mental health-care resources across the country.
| Conclusion|| |
China's rapid economic development has undoubtedly led to improvements in general health. However, NCDs have progressively become the dominant causes of disability and death in China, with dramatic increases in the burden of mental, neurological, and substance use disorders. Along with substantial urbanization, industrialization, globalization, and informatization, some challenges concerning mental health have emerged. Although considerable research has been conducted to identify the social and economic changes in China, there is a paucity of qualitative and quantitative research on the effect of these changes on mental health in China and other LMICs. Given the growing prevalence of mental health issues, efforts are needed to address the scarcity of social and mental health-care services. More studies are needed to identify the impact of economic and social developments on mental health, and to guide the development of effective interventions and policies applicable to China and other developing countries undergoing similar economic and social changes.
- Rapid urbanization and industrialization have resulted in increasing internal migration and left-behind families, who have poorer mental health status than their peers
- Increased alcohol intake and smoking can induce increased alcohol and nicotine dependence, and even illicit drug abuse
- Internet and social media use can not only increase internet or gaming addiction, but also facilitate exposure and delivery channels via the Internet
- The growth of urbanization and manufactories has also increased air, light, and noise pollution that can further induce mental problems
- China needs to put the mental health issue into priority to these challenges: identify social and economic effects on mental health on the basis of high-quality qualitative and quantitative analysis, improve mental health awareness and literacy, and enhance the mental health-care system and promote implementation research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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