The Effects of Social Reforms on Mental Disability in China

Abstract

Few studies have explored how mental disabilities have changed with the waves of Chinese social reforms that occurred between 1912 and 2006. The present study evaluated population-based data from the Second China National Sample Survey on Disability to investigate these trends and their effects on mental disabilities. The Cox proportional hazards model was used to estimate the association between social reforms and mental disabilities. The confounding variables considered were as follows: survey age, gender, residence in 2006, ethnicity, and living arrangements in 2006. The highest risks of mental disabilities were observed in subjects born during the Mao Zedong era. Subjects who experienced social turbulence during their early development may have increased risks of mental disabilities in adulthood. The results and discussion herein contribute to our understanding of mental disabilities in China within the context of changing political, socioeconomic, and health system conditions and a developing mental health system.

Keywords

disability mental social reforms population studies China

Introduction

Good mental health is essential to well-being.¹ China is currently undergoing profound socioeconomic transitions, and the prevalence of mental disorders has increased rapidly. A recent study conducted in China^2,3 reported mental disorders in approximately 17% of the population. Many people with mental disorders also experience long-term personal and social disabilities. The national prevalence of mental disabilities in China has tripled in recent decades.⁴ The estimated total disability-adjusted life years (DALYs) for 10 mental conditions was reported at 253, 851, 896 years, which equates to a gross domestic product (GDP) amounting to a country-wide total of CNY 2, 681 billion lost.⁵ According to research regarding the global burden of disease, the DALYs of mental and behavioral disorders increased from 24, 450, 500 in 1990 to 29, 954, 100 in 2010,⁶ changing aggressively during a period of rapid health transition in China.

In China, the social milieu, including political and socioeconomic environments, health care conditions, and the mental health system, changed aggressively during the 20th century and continues to change. The Republic of China, founded in 1912, represented a new era of Chinese history, which was preceded by the last imperial dynasty of China, the Qing dynasty.⁷ After a relatively stable period (1912-1930), China was involved in a long period of war. This war period began with the Japanese occupation of various parts of the country. China officially opposed the Japanese occupation in 1937 during the second Sino-Japanese War (1937-1945), which became part of World War II.⁷ Following the defeat of Japan in 1945, the Chinese Civil War began, lasting until 1949.⁷ During this time period, China was under the control of Kuomingtang (KMT), an authoritarian single-party state. Psychiatric hospitals were built very slowly, and the number of psychiatrists and beds gradually increased to 100 and 1000, respectively, in 1948.⁵

The People’s Republic of China was founded in 1949, and Chinese society was profoundly transformed over the subsequent 3 decades.⁷ Chinese socialist transformation was aggressive from 1949 to 1976 under Mao Zedong’s leadership. During the same period, special psychiatric hospitals were gradually built in every province in Mainland China, and community mental health work was initiated in Beijing, Shanghai, Hunan, Sichuan and Jiangsu in 1958.⁵ Facilities were established in these areas to train professionals and to develop work plans for the prevention and treatment of psychoses, including early detection and treatment and relapse prevention.⁸ However, this community mental health work almost ceased during the Cultural Revolution. From 1976 to 1989, China initiated economic reforms and opened its borders to greater international trade under Deng Xiaoping’s leadership. In the 1980s, the health, civil affairs and public security sectors set up a 3-tier network for the prevention and treatment of psychoses. Between 1990 and 2006, a period of aggressive economic reforms, for-profit hospitals were encouraged as part of the market economy, while financially dependent mental health rehabilitation facilities were closed or transformed into small-scale psychiatric hospitals.⁹

Over the past 100 years, China has experienced intense social change. However, we have identified no published studies exploring the relationship between the accumulation of social reforms and the development/incidence of mental disabilities in China. The present study investigated the association between social reforms and the development of mental disabilities using nationally representative, population-based data from the Second China National Sample Survey on Disability conducted in 2006.¹⁰

Materials and Methods

Data Source

The second China National Sample Survey on Disability employed a multistage, stratified, random cluster sampling approach, in which probability was proportional to size, to derive a nationally representative sample. The survey protocol and questions were reviewed by leading national and international experts, and the sampling plan was reviewed by experts from the Division of Statistics of the United Nations.¹⁰ This survey, conducted from April 1, 2006, to May 31, 2006, sought to describe the prevalence and causes of different types of disabilities and to explore the socioeconomic and demographic characteristics of people with these disabilities in China. The survey covered all provincial administrative areas in Mainland China, excluding Hong Kong, Macau, and Chinese Taipei. The final sample size represented 1.9 per 1000 noninstitutionalized inhabitants of China in 2006. The Chinese government received consent from all survey respondents to participate in the survey. The survey captured data regarding visual, aural, physical, verbal, intellectual, and mental disabilities.¹⁰ The present study included data from people with and without mental disabilities.

Ethics

The survey was approved by the State Council and was conducted in all province-level administrative regions of Mainland China by the Leading Group of China National Sample Survey on Disability and the National Bureau of Statistics. The Leading Group of China National Sample Survey on Disability and the National Bureau of Statistics worked within the legal framework provided by the statistical law in China. Therefore, the project was exempted from submission to an ethical committee, but all survey respondents provided consent to participate in the survey and to receive clinical diagnoses.

Data Collection Procedures and Data Quality

Pilot studies were conducted in different provinces prior to the survey period.¹⁰ More than 20, 000 interviewers, 6000 doctors of various specialties, and 50, 000 survey assistants were involved in the delivery of this survey. Trained field interviewers used a structured interview questionnaire to inquire about mental disabilities. Subjects who gave a positive response to questions regarding a specific disability and all children were referred to designated physicians for further disability screening and confirmation. The designated physicians performed medical examinations, made final diagnoses, assessed the severities of the disabilities (if any) following the guidelines of diagnostic manuals, and confirmed the primary causes of the disabilities.¹⁰ Respondents who gave multiple positive answers were examined by multiple specialists (a specific doctor for each disability). Strict quality control measures were implemented during every step of the survey process.¹⁰

Identification of People With Mental Disabilities

Mental disabilities referred to mental disorders lasting more than 1 year, which manifested in cognitive and affective behaviors that limited the subject’s daily life and restricted his/her social participation. Mental disabilities were defined and classified by the expert committee of the Second China National Sample Survey on Disability, based on the World Health Organization (WHO) International Classification of Functioning, Disability and Health (WHO-ICF).¹¹ Mental disabilities were diagnosed by psychiatrists according to the International Statistical Classification of Diseases, 10th Revision (ICD-10), and the WHO-ICF.^11,12 The types of mental disabilities were further classified as follows: organic mental disorders; mental disorders caused by psychoactive substance use; schizophrenia, schizotypal, and delusional disorders; mood disorders; neurotic stress–related and somatoform disorders; behavior syndromes; disorders of adult personality and behavior; epilepsy; and “others” (ie, undefined types of mental disabilities). Psychiatrists used the World Health Organization Disability Assessment Schedule Phase II (WHODAS II) as a scoring tool to assess the severities of mental disabilities, and mental disabilities were classified, based on their severities, into 4 categories (mild, moderate, severe, or extremely severe).¹³ All classifications and grading standards, screening methods, methods of diagnosis, and relevant scales of disabilities were pretested in pilot studies and demonstrated good reliability and validity.¹⁰

Definitions of Study Variables

In the present study, mental disabilities were categorized as binary (yes or no), whereas the subjects’ ages at the time of the survey, their ages at the onset of their mental disabilities, and the durations of their mental disabilities (i.e., the difference between their ages at the onset of their mental disability and at the time the survey was conducted) were categorized as continuous. Social reforms were categorized by the subjects’ birth years, as follows: 1912-1930: Republic of China founded; 1931-1949: War period; 1950-1976: the People’s Republic of China founded (Mao Zedong era); 1977-1989: economic reforms process (Deng Xiaoping era); and 1990-2006: aggressive economic reforms. The following study variables were also assessed: marital status (never married, divorced/widowed, or married); ethnicity (Han or other); education level (never attended school, primary school, junior high school or above); current employment status (employed or unemployed); residential area (urban or rural); sex (male or female); and living arrangement (living with others or living alone).

Statistical Methods

The Mantel-Haenszel chi-square test was used to evaluate categorical variables. Cox proportional regression analysis was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) for each birth year’s association with the corresponding mental disability. Potentially confounding variables, including survey age, sex, ethnicity, residential area, and living arrangements in 2006, were included as covariates. Statistical significance was indicated by a 2-tailed P value <.05. Statistical analyses were performed using SAS version 9.2 (SAS Institute, Inc, Cary, NC, USA).

Results

The characteristics (of the study population) selected for study are summarized by birth year in Table 1. The prevalence of mental disabilities in 2006 differed according to birth year, with prevalence rates of 1.42% for 1912–1930 (Republic of China founded), 0.99% for 1931-1949 (War period), 0.80% for 1950-1976 (Mao era), 0.44% for 1977-1989 (Deng era), and 0.12% for 1990-2006 (aggressive economic reforms). In the present study, the majority of subjects pertaining to each birth year were male participants who resided in rural areas, lived with others, and were of Han nationality. Furthermore, we observed that the educational status of the population of China has changed dramatically over the past 100 years.

Table 1.

Characteristic of Chinese Population According to Birth Year in 2006.

	1912-1930: Republic of China Founded	1931-1949: War Period	1950-1976: Mao Zedong Era	1977-1989: Deng Xiaoping Era	1990-2006: Aggressive Economic Reforms
Sample size, n	74, 304	358, 746	1, 097, 667	419, 758	575, 104
No. of mental disability cases	1058	3547	8791	1834	679
Survey age, mean (years)	80.5	64.8	42.3	22.8	8.9
Age of mental disability onset, mean (years)	70.0	47.8	27.7	13.5	3.5
Duration of mental disability, mean (years)	11.2	17.2	15.5	10.4	6.4
Male, %	43.1	50.1	50.1	50.2	53.5
Marital status, %
Never married	0.7	1.6	2.8	55.2	NA
Divorced/widowed	58.8	20.1	3.7	0.5	NA
Married	40.5	78.3	93.5	44.3	NA
Urban, %	34.2	34.2	36.5	33.9	27.0
Han ethnicity, %	91.7	90.4	89.9	85.8	85.0
Education, %
Never attended school	64.6	35.4	10.5	3.0	NA
Primary school	24.2	38.4	30.0	14.7	NA
Junior high school and above	11.2	26.2	59.5	82.3	NA
Living alone, %	13.1	6.5	2.0	1.6	0.2
Currently employed, %	4.3	38.9	85.0	72.9	2.8

Abbreviation: NA, not available.

The present study revealed different distributions of the types and severities of mental disabilities corresponding to different birth years (Tables 2 and 3, respectively). The most common type of mental disability in China also changed between 1912 and 2006. During the early 20th century, the most common mental disabilities were organic mental disorders. Subsequently, schizophrenia became the most prevalent mental disorder and remained so until the late 1980s. Over the following decades, the most common mental disorder changed again, this time to epilepsy.

Table 2.

Mental Disability Types and Severities According to Birth Year in 2006.

	1912-1930: Republic of China Founded	1931-1949: War Period	1950-1976: Mao Zedong Era	1977-1989: Deng Xiaoping Era	1990-2006: Aggressive Economic Reforms	P _tend ^a
Types of mental disabilities, %
Organic mental disorders	68.9	26.1	10.3	13.9	19.4	<.01
Mental disorders caused by psychoactive substance use	1.4	3.5	3.0	0.4	0.2	<.01
Schizophrenia	23.6	49.3	60.9	56.1	8.8	<.01
Mood disorders	2.3	6.5	6.3	3.0	0.9	.002
Neurotic stress–related and somatoform disorders	1.0	6.3	5.6	1.4	NA	<.01
Behavior syndromes	0.2	0.7	0.6	0.2	1.0	.85
Disorder of adult personality and behavior	0.5	0.6	0.8	2.1	17.5	<.01
Epilepsy	0.5	3.6	8.7	16.3	29.9	<.01
Other mental disorders	1.6	3.4	3.8	6.7	22.2	<.01
P	<.01
Different severity of mental disabilities, %
Mild	17.2	37.9	44.1	37.1	31.4	<.01
Moderate	9.4	15.7	16.0	15.4	19.0	<.01
Severe	12.8	14.1	14.1	13.3	22.1	.001
Extremely severe	60.7	32.4	25.7	34.1	27.5	<.01
P	<.01

Abbreviation: NA, not available.

The Mantel-Haenszel chi-square test was used for categorical variables

Table 3.

Mental Disability Types According to Mental Disability Severity in 2006.

	Mental Disability Severity
	Mild	Moderate	Severe	Extremely Severe
1912-1930 (Republic of China founded), %
Organic mental disorders	56.6	53.5	64.4	75.7
Mental disorders caused by psychoactive substance use	5.5	1.0	1.5	0.3
Schizophrenia	29.1	35.4	28.2	19.3
Mood disorders	5.0	4.0	1.5	1.5
Neurotic stress–related and somatoform disorders	0.6	1.0	2.2	0.9
Behavior syndromes	0.0	0.0	0.7	0.2
Disorder of adult personality and behavior	0.6	1.0	0.0	0.5
Epilepsy	1.1	1.0	0.7	0.2
Others	1.7	3.0	0.7	1.6
1931-1949 (War period), %
Organic mental disorders	16.1	20.0	25.1	41.3
Mental disorders caused by psychoactive substance use	6.7	2.9	2.4	0.5
Schizophrenia	42.8	57.3	58.3	49.0
Mood disorders	10.5	6.5	4.2	2.7
Neurotic stress–related and somatoform disorders	12.9	4.1	2.2	1.5
Behavior syndromes	1.0	0.9	0.4	0.4
Disorder of adult personality and behavior	0.7	0.7	0.6	0.4
Epilepsy	5.4	3.8	2.8	1.8
Others	3.8	3.8	4.0	2.4
1950-1976 (Mao Zedong era), %
Organic mental disorders	7.2	9.1	11.2	15.9
Mental disorders caused by psychoactive substance use	5.0	1.9	1.7	0.8
Schizophrenia	52.0	68.3	66.9	68.4
Mood disorders	9.9	5.0	4.6	2.0
Neurotic stress–related and somatoform disorders	10.1	3.1	2.7	1.2
Behavior syndromes	0.8	0.4	0.6	0.2
Disorder of adult personality and behavior	1.2	0.6	0.4	0.6
Epilepsy	10.4	8.0	8.1	6.7
Others	3.5	3.6	4.0	4.3
1977-1989 (Deng Xiaoping era), %
Organic mental disorders	7.5	10.3	11.9	23.3
Mental disorders caused by psychoactive substance use	0.7	0.4	0.4	0.0
Schizophrenia	56.1	62.2	62.3	50.8
Mood disorders	5.0	3.5	1.6	1.1
Neurotic stress–related and somatoform disorders	2.8	0.7	0.8	0.3
Behavior syndromes	0.2	0.0	0.4	0.3
Disorder of adult personality and behavior	2.1	0.7	3.7	2.2
Epilepsy	19.7	15.6	13.5	13.9
Others	6.0	6.7	5.3	8.0
1990-2006 (Aggressive economic reforms), %
Organic mental disorders	8.0	10.1	26.0	33.7
Mental disorders caused by psychoactive substance use	0.0	0.0	0.0	0.5
Schizophrenia	7.5	13.2	9.3	7.0
Mood disorders	1.9	0.8	0.7	0.0
Behavior syndromes	2.4	1.6	0.0	0.0
Disorder of adult personality and behavior	13.2	19.4	26.0	14.4
Epilepsy	48.8	28.7	16.0	20.3
Others	18.3	26.4	22.0	24.1

The HR values for mental disabilities presented an approximately normal distribution (Table 4). Compared with those who were born between 1912 and 1930 (Republic of China founded) and those born between 1990 and 2006 (aggressive economic reforms), those born between 1950 and 1976 (Mao Zedong era) exhibited 96% and 85% increased risks of mental disabilities, respectively. In addition, the risk of contracting mental disabilities decreased after the People’s Republic of China was founded (P < .01).

Table 4.

Accumulation of Social Reforms Effects on Mental Disabilities Development.^a

	1912-1930: Republic of China Founded, HR (95% CI)	1931-1949: War Period, HR (95% CI)	1950-1976: Mao Zedong Era, HR (95% CI)	1977-1989: Deng Xiaoping Era, HR (95% CI)	1990-2006: Aggressive Economic Reforms, HR (95% CI)	P _tend
Total
Model 1	1.00 (reference)	1.67 (1.50-1.85)	1.85 (1.61-2.11)	1.52 (1.28-1.81)	1.00 (0.81-1.24)	.07
Model 2	1.00 (reference)	1.73 (1.56-1.92)	1.96 (1.72-2.24)	1.56 (1.32-1.86)	1.00 (0.81-1.24)	.05
Before 1949
Model 1	1.00 (reference)	1.16 (1.02-1.32)	—	—	—	.02
Model 2	1.00 (reference)	1.16 (1.03-1.32)	—	—	—	.02
After 1949
Model 1	—	—	1.74 (1.57-1.92)	1.49 (1.34-1.65)	1.00 (reference)	<.01
Model 2	—	—	1.85 (1.67-2.05)	1.54 (1.38-1.70)	1.00 (reference)	<.01

Abbreviations: HR, hazard ratio; CI, confidence interval.

Model 1: adjustment for survey age and gender. Model 2: adjustment for survey age, gender, residence area at 2006, ethnicity, and living arrangement in 2006.

Discussion

It is interesting that the HR distribution pertaining to mental disabilities was normal in the present study. This result suggests that social reforms may be related to the incidences of mental disabilities. Additionally, social traumas that occur early in life may be associated with the development of mental disabilities.

Our findings clearly show that the point prevalence of mental disabilities decreased from 1.42% for 1912-1930 (Republic of China founded) to 0.12% for 1990-2006 (aggressive economic reforms), which appears to correlate with the development of China’s mental health system. The first psychiatric hospital in China was established in 1898, and, over the next 50 years, psychiatric hospitals were gradually established in a limited number of large cities.⁸ In addition, the number of psychiatrists’ in China gradually increased to 100, and the number of beds available for psychiatric patients increased to 1000.¹⁴ After the People’s Republic of China was founded in 1949, more specialist psychiatric hospitals were established, and these early provincial hospitals played a role in social security and stability.⁸ Community mental health care programs started in some provinces, and facilities were established in these areas to train professionals and develop plans to prevent and treat psychoses.^8,9,14 However, community mental health programs largely disappeared during the Cultural Revolution (1966-1976) of the Mao era, and work rehabilitation centers for patients with psychoses and caring networks were organized by neighborhood committees (the lowest level of government).⁵ This slow development of the mental health system may be why the prevalence of mental disabilities did not decrease significantly during the Mao era. However, the prevalence of mental disabilities decreased dramatically over subsequent decades, as the mental health care system improved and economic reforms occurred during the Deng era. Furthermore, the Deng era saw the collectivization of agriculture, the opening of Chinese borders to foreign investment, and permission for entrepreneurs to start businesses in China. Subsequently, the privatization and contracting of large portions of state-owned industries and the lifting of price controls, protectionist policies, and regulations were implemented, although state monopolies in sectors such as banking and petroleum remained. The health, civil affairs, and public security sectors set up a 3-tier network for the prevention and treatment of psychoses. Financially dependent mental health rehabilitation facilities were closed or transformed into small-scale psychiatric hospitals.⁸ Before aggressive economic reforms (1990-2006), there was at least one community-level rehabilitation facility in every district or town; however, the numbers of these facilities subsequently decreased, and nearly half of people with mental disabilities never accessed mental health services, such as medical services, or rehabilitation services.^16,17 Although the prevalence of mental disabilities has gradually decreased over the past 100 years, the challenges facing the current mental health system may reverse this decrease.

That the HR parameter pertaining to mental disabilities exhibited a normal distribution with respect to social reform is an interesting finding. China was involved in 40 years of war, so it was thought that children born during these years would exhibit increased risks of mental disabilities during their lifetimes. This is consistent with the findings of previous studies, which have shown that wars are harmful to the mental health development of children.^18,19 Moreover, the risk of mental disabilities reached a maximum for those born between 1950 and 1976 (Mao Zedong era), after the founding of the People’s Republic of China. In addition, socioeconomic developments and improvements to the health care system were largely suspended during the Cultural Revolution,⁸ during which millions of people were involuntarily involved in violent struggles across the country and suffered a wide range of abuses, including public humiliation, arbitrary imprisonment, torture, sustained harassment, and seizure of property.^20,21 Childhood trauma, including emotional and physical abuse, as well as psychiatric stressors in adulthood have been reported in several studies investigating this time period.^22-25 In the present study, those born between 1950 and 1976 were aged 0 to 26 years during the Cultural Revolution, such that exposure to this trauma may have resulted in mental disabilities during their lifetimes, particularly for those who were children during the Mao Zedong era.

Limitations with regard to some of the information related to the prevalence of mental disabilities, such as personal characteristics and mortalities, prevented consideration of these factors in the present study. Furthermore, the historical link between various birth years and mental disabilities should be treated with caution in further studies. Additionally, we did not consider every potential confounder, such as marital status, education, and so on, because these factors were not available for the period from 1990 to 2006, another limitation that should be treated with caution in future studies. Other confounding factors, such as famine, natural disasters, economic crises, and so on, were not considered; these should be considered in future research. Finally, the present study was designed as an ecological study, with all of the limitations and assumptions of causality contained therein. The primary strengths of the present study are the large size and representativeness of the sample, which included all provincial administrative areas in Mainland China. In addition, all subjects selected were interviewed face-to-face at the time of data collection. Furthermore, standardized quality control measures were in place during field interviews and included training of the interviewers and crosschecking of the returned surveys (by contacting survey participants), rendering response bias of little concern.

Conclusions

China is currently undergoing social and economic reforms, such that the present study is very pertinent. The results reported herein benefit our understanding of mental disabilities within the context of political, socioeconomic, and health care conditions. Thus, our findings should help policy makers understand the association between social contexts and mental disorders/disabilities so that strategies for individuals, communities, and the mental health care system can be improved with regard to preventing and treating mental disabilities.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by State Key Development Program of Basic Research of China (973No. 2007CB511901), Yang Zi Program of MOE, State Key Funds of Social Science Project (Research on Disability Prevention Measurement in China, No. 09&ZD072) as well as China Postdoctoral Science Foundation (Grant No. 2015M570004) and the Scientific Research Foundation for the Returned Overseas Chinese Scholars, State Education Ministry.

References

Prince

Patel

Saxena

. No health without mental health. Lancet. 2007;70:859-877.

Phillips

Zhang

Shi

. Prevalence, treatment, and associated disability of mental disorders in four provinces in China during 2001-05: an epidemiological survey. Lancet. 2009;373:2041-2053.

Zhang

Chen

. Epidemiological investigation on mental disorders in 7 areas of China [in Chinese]. Chin J Psychiatry. 1998;2:69-71.

Zheng

Chen

Song

. Twenty-year trends in the prevalence of disability in China. Bull World Health Organ. 2011;89:788-797.

Liu

. Mental health system in China: history, recent service reform and future challenges. World Psychiatry. 2011;10:210-216.

Yang

Wang

Zeng

. Rapid health transition in China, 1990-2010: findings from the Global Burden of Disease Study 2010. Lancet. 2013;381:1987-2015.

Fairbank

Goldman

. China: A New History. 2nd ed. Boston, MA: Harvard University Press; 2006.

Shen

. Psychiatry. 4th ed. Beijing, China: People’s Medical Publishing House; 2001.

Yao

Zhang

. Investigation and suggestion on community rehabilitation facilities for psychotic patients in Shanghai. Shanghai Arch Psychiatry. 2005;17:35-37.

10.

National Bureau of Statistics of the People’s Republic of China. Communique on Major Statistics of the Second China National Sample Survey on Disability. Beijing: China Statistics Press; 2006.

11.

World Health Organization. International Classification of Functioning, Disability, and Health (ICF). Geneva, Switzerland: World Health Organization; 2001.

12.

World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders: Diagnostic Criteria for Research. Geneva, Switzerland: World Health Organization; 1993.

13.

World Health Organization. The World Health Organization Disability Assessment Schedule Phase II Field Trial Instrument. Geneva, Switzerland: World Health Organization; 1999.

14.

Zhang

Yan

. Community rehabilitation, and prevention and treatment work for psychoses in Shanghai [in Chinese]. Shanghai Arch Psychiatry. 1990;2:114-118.

15.

Shen

Zhang

Chen

. Familial and social prevention and treatment, and social rehabilitation of psychotic patients [in Chinese]. Shanghai Arch Psychiatry. 1990;2:108-111.

16.

Chen

Song

Zheng

. Mental health service use among Chinese adults with mental disabilities: a national survey. Psychiatr Serv. 2013;64:638-644.

17.

Santavirta

Betancourt

Gilman

. Long term mental health outcomes of Finnish children evacuated to Swedish families during the Second World War and their non-evacuated siblings: cohort study. BMJ. 2015;350:g7753.

18.

Feldman

Vengrober

. Posttraumatic stress disorder in infants and young children exposed to war-related trauma. J Am Acad Child Adolesc Psychiatry. 2011;50:645-658.

19.

“Wu Dou” in the Chinese Cultural Revolution [in Chinese]. China Youth Study. 1994;5:22-23.

20.

Ding

. Personal “Wu Dou” experience [in Chinese]. Yan Huang Chun Qiu. 2014;14:37-41.

21.

Kounou

Bui

Dassa

. Childhood trauma, personality disorders symptoms and current major depressive disorder in Togo. Soc Psychiatry Psychiatr Epidemiol. 2013;48:1095-1103.

22.

Grover

Carpenter

Price

Gagne

Mello

Tyrka

. The relationship between childhood abuse and adult personality disorder symptoms. J Pers Disord. 2007;21:442-447.

23.

Pirkola

Isomets

Aro

. Childhood adversities as risk factors for adult mental disorders: results from the Health 2000 study. Soc Psychiatry Psychiatr Epidemiol. 2005;40:769-777.

24.

Schilling

Aseltine

Jr Gore

. Adverse childhood experiences and mental health in young adults: a longitudinal survey. BMC Public Health. 2007;7:30.

25.

Slopen

Williams

Seedat

Moomal

Herman

Stein

. Adversities in childhood and adult psychopathology in the South Africa Stress and Health Study: associations with first onset DSM-IV disorders. Soc Sci Med. 2010;71:1847-1854.