A Western psychiatrist visiting a ward, out-patient department, or sheltered workshop in China would find much that was familiar, not only in terms of clinical syndromes and medication usage but also in the paucity of resources, problems with administrative hierarchies, and lack of status accorded by medical colleagues to psychiatry. Chinese psychiatric patients able to converse with their Western counterparts would discover that they shared much of the experience in common: stigma, problems with employment, and difficulties in finding a marital partner. Patients' relatives from East and West, likewise, would be able to recite a litany of similar concerns and complaints: the need for guidance and advice in handling disturbed behaviour at home, the gossip of neighbours, and the fear of another relapse.

In pre-revolutionary China most disabled persons had no opportunity to receive education or obtain employment, and many of them experienced social discrimination. After the founding of the People's Republic, the government adopted a number of measures aimed at guaranteeing their livelihood. Efforts were made to give those who maintained the ability to work the opportunity to do so; those who were unable to work were provided with emergency relief or, if they had no family members who could support them, placed in orphanages, long-term psychiatric hospitals, and other types of welfare institution. Once the basic livelihood needs of the disabled were met, the next objective was to provide rehabilitative services. The evolution of these services has depended on three separate but related developments: the maturation of an organisational structure for the co-ordination of the services; the promulgation of laws that safeguard the rights and privileges of disabled persons; and the formation of academic societies of medical rehabilitation. This paper first considers these three developments and then examines how they have influenced the evolution of psychiatric rehabilitation in China.

This paper discusses the effectiveness of an in-patient rehabilitation programme administered by nurses that combines life skills training, active encouragement, and a token economy. Fifty-two chronic schizophrenic patients with prominent negative symptoms who had been continuously in hospital for at least a year were randomly assigned to the experimental or control group. The training and associated reinforcement schedule were administered daily to experimental subjects by two specially trained rehabilitation nurses. Control subjects did not receive training or reinforcement but were individually asked to perform the same daily tasks and participate in the same activities as the experimental-group subjects. Patients in both groups received their previous dosage of medication throughout the trial. After three months the severity of negative symptoms, as assessed by blind evaluators, decreased in both groups of subjects, but the improvement in the experimental group was much greater than that in the control group. These findings demonstrate the efficacy of behavioural interventions for chronic schizophrenic in-patients in China and highlight the importance of changing the role of Chinese psychiatric nurses from that of custodians who control patients' behaviour to that of therapists who provide psychological and behavioural treatment.

Seventy-six in-patients who had the residual subtype of schizophrenia were randomly assigned to a treatment group or a control group. Both groups received standard medication as prescribed by their treating physicians, but the treatment group also received a one-month course of music therapy that included both passive listening to music and active participation in the singing of popular songs with other patients. Outcome was evaluated by four nurses using Chinese versions of the Scale for Assessment of Negative Symptoms and the in-patient version of the World Health Organization's Disability Assessment Scale. Music therapy significantly diminished patients' negative symptoms, increased their ability to converse with others, reduced their social isolation, and increased their level of interest in external events. As music therapy has no side-effects and is relatively inexpensive, it merits further evaluation and wider application.

A priority for psychiatric rehabilitation workers in China is to develop less-restrictive methods for managing the estimated 2500 chronically institutionalised patients who are symptomatically stable and have adequate psychosocial functioning but have no family members who are able or willing to take them home. We transferred 45 chronic schizophrenic male in-patients to an open-door rehabilitation ward where they were given as much freedom as possible and encouraged to take part in occupational, social, and recreational activities. The Nurses Observation Scale for Inpatient Evaluation (NOSIE) was used to compare the psychosocial functioning of the 43 patients who completed the year-long trial with that of 43 similar patients who received standard in-patient treatment on a locked ward. Over the year, the experimental group showed a significant improvement in overall functioning, whereas the control group showed no improvement. These findings suggest that open-door rehabilitation wards situated within the hospital can mobilise latent psychosocial functioning and may be a good method for re-introducing chronic schizophrenic patients in China back into the community.

Fifty female schizophrenic patients on the same locked ward were randomly assigned to experimental and control groups. Experimental group subjects were given as much autonomy and freedom as possible (they were permitted to leave the ward at will) and were encouraged to take part in collective activities. The control group were not permitted to leave the ward and did not take part in these activities. All patients were evaluated at enrolment and after six months – using Chinese versions of the Scale for Assessment of Negative Symptoms and the Brief Psychiatric Rating Scale – by psychiatrists who were blind to patients' treatment status. After the six-month intervention the severity of all types of both negative and positive symptoms and the mean dosage of medication in the experimental group were significantly less than in the control group.

To objectively evaluate in-patient rehabilitation programmes in China, we developed a new rating scale: the Inpatient Psychiatric Rehabilitation Outcome Scale (IPROS). The scale has five subscales: performance in occupational therapy, daily activities, socialisation, personal hygiene, and level of interest in external events. Evaluators (physicians or nurses) observe patients for one week before coding items on a five-point scale. Comparison of four independent evaluators' results for 32 schizophrenic patients assessed on two separate occasions indicated that the inter-rater and test-retest reliability for the overall IPROS score and for the five subscale scores was excellent (all ICC values ≥0.973). Validity was evaluated by comparing IPROS results with those of five other independently assessed clinical measures for 101 chronic schizophrenic patients before and after a six-month rehabilitation programme; concurrent validity and longitudinal validity were satisfactory (correlation coefficients 0.37–0.81, all P values <0.01).

This paper describes the community mental health services in Shanghai, analyses the effectiveness of these services, and discusses their culture-specific characteristics. It reports on a prospective, matched-control study of the three most important types of service: a community follow-up programme in psychiatric out-patient clinics at primary-level general hospitals, ‘guardianship networks’ operated by non-professional volunteers, and work therapy stations. In total 308 pairs of subjects completed the study. Using Chinese versions of the Disability Assessment Schedule to assess impairment in psychosocial functioning and the Present State Examination to assess the levels of positive and negative symptoms, ten blind evaluators who had excellent inter-rater reliability assessed the functioning of subjects at enrolment and every six months for the next two years. Over the two years, symptoms and social functioning improved in the treatment groups and deteriorated in the control groups. Thus these community psychiatric services have the dual benefit of promoting rehabilitation and preventing psychosocial deterioration.

The evolution of the Zhengyang Community Mental Health Rehabilitation Centre described in this paper proves that community-based mental health services initiated and developed by enthusiastic and committed community members can be successful in the Chinese setting. The most important step is to utilise community resources to secure a stable source of income, preferably by establishing a profitable welfare enterprise that can both finance the provision of other services and provide work for mentally ill clients who cannot obtain regular employment. The ultimate goal is to reintroduce as many clients back into the community as possible, so a range of services is needed: supervision of medication, social skills training, occupational rehabilitation, and, most importantly, work placement. The vitality of the organisation depends on its flexibility and responsiveness to the changing needs of patients; it must use its experience to guide policy decisions about the development of new services and the alteration or termination of existing services.

This paper describes the development of community mental health services in Nanjing and reports on a retrospective study that compared the two-year outcome for 78 schizophrenic patients who attended four enterprise-based sheltered workshops (experimental group) with that of 78 schizophrenic patients who attended an out-patient clinic (control group). Despite having a longer course of illness and more prior hospital admissions than patients in the control group, at the end of the two years patients treated in enterprise-based sheltered workshops had significantly less psychosocial dysfunction (mean Social Dysfunction Screening Schedule score 3.4 (s.d. 0.2) v. 7.4 (s.d. 0.7), t = 49.2, d.f. 154, P<0.001) and less severe psychiatric symptomatology (mean Brief Psychiatric Rating Scale score 33.1 (s.d. 2.7) v. 54.1 (s.d. 2.9), t = 47.0, d.f. 1 54, P<0.001). Moreover, compared with the control group, over the two year period a smaller proportion of the experimental group experienced a clinical relapse (14.1% v. 38.5%, χ2 = 5.10, d.f. 1, P<0.05) or hospital readmission (7.7% v. 21.8%, χ2= 10.7, d.f. 1, P<0.01). We conclude that the organisation of on-site sheltered workshops for mentally ill factory workers is an effective model for promoting community mental health that merits widespread application in China.

At the time of discharge from their first stay in psychiatric hospital, 78 male schizophrenic patients were randomly assigned to a family intervention (experimental) group or a ‘standard care’ control group and were followed for the next 18 months. The family intervention consisted of both group and individual counselling sessions every 1–3 months that focused on education about the illness and on methods of dealing with the patient. There was a significantly lower rate of hospital readmission in the family intervention group than in the control group (15.4% versus 53.8%, χ2= 12.75, P<0.01), and the mean hospital-free period for those who were readmitted was significantly longer in the experimental group than in the control group (245 days versus 130 days, t =2.91, P<0.01). Moreover, the clinical status and overall level of functioning in patients who were not readmitted were significantly better in experimental subjects than in control subjects. Stratified analysis showed that family intervention and regular use of medication had independent and additive effects on the outcome. During the 18 months after the index discharge patients who did not take medication regularly and who did not receive family intervention were 7.9 times as likely to be readmitted to hospital as patients who took medication regularly and received family intervention.

The main characteristics of the Yantai model are (a) a three-tier (county, township, village) management structure; (b) the vertical integration of community mental health workers, including a professional advisory group of psychiatrists from the central psychiatric hospital, groups of community psychiatrists at small county psychiatric hospitals, non-psychiatric physicians who run psychiatric out-patient clinics at township general hospitals, and village paramedics (‘village doctors’) who supervise patients in the community; (c) ongoing training of all community mental health workers; (d) registration and yearly follow-up of all patients with mental illnesses in the community; (e) provision of home-care services to a proportion of acutely ill patients; and (f) most of the cost of the service is borne by the state. The network of services provided by this model makes it convenient for patients to obtain treatment and, if necessary, go into hospital; it reduces the economic burden on the family and the community; it combines treatment, prevention, rehabilitation, and supervision under one administrative network; and it decreases the overall level of psychopathology and psychosocial dysfunction in the community.

This paper describes the ‘rural guardianship network’ method of managing persons with severe mental illnesses and reports on a retrospective case–control study that compares the outcome of 561 schizophrenic patients from townships with guardianship networks to that of 103 schizophrenic patients from a township without guardianship networks. Each patient enrolled in a guardianship network is assigned a guardian – usually a family member – who ensures that the patient takes medication and gets medical follow-up, and reports any changes in the patient's condition to the village health worker or the township doctor who is responsible for psychiatric care. These guardians are supported and supervised by management groups at the village and township levels composed of government officials, medical administrators, physicians from township hospitals, and village health workers. Compared with patients who are not enrolled in guardianship networks, enrolled patients have significantly lower rates of hospital admission, lower rates of socially disruptive behaviour, and lower levels of psychopathological symptoms. The rural guardianship network is an effective and economical means of providing close supervision of mentally ill patients in their homes.

In 1983 the branch hospital of the Yanbian Community Psychiatric Hospital, a rural residential centre for 120 chronic psychiatric patients who have no means of financial support, adopted a new treatment philosophy that emphasised psychosocial rehabilitation and made the protection of patients' human rights and respect for their personal dignity the central organising principles for the hospital's treatment programme. From being a boarding facility for chronic psychiatric patients, the hospital became a thriving community. Comparison of the status of the 81 continuously resident schizophrenic patients before and after the policy change showed that (a) the proportion who actively participated in agricultural labour increased from 10% in 1982 to 38% in 1990; (b) the proportion who worked at non-agricultural jobs increased from 7% in 1982 to 22% in 1990; and (c) their mean yearly income increased from 1.67 Rmb in 1982 to 246.70 Rmb in 1990. Moreover, the number of successful suicides among all the patients in the hospital dropped from 13 in 1975–1982 to 1 in 1983–1990. We conclude that the success of psychiatric rehabilitation programmes depends on the extent to which they address the core issues of personal dignity and basic human rights.