The Mental Health Section has thus far set up seven core psychiatric service centers as part of a national network. Each center is responsible for the design of the psychiatric service delivery system and the mental health manpower training program in its geographic area of responsibility. In addition, two major steps were taken to improve the quality of psychiatric services: the biannual accreditation of all psychiatric hospitals, and the passage of a mental heath law, a cornerstone for future development. These steps are essential to the development of psychiatric services in the 1990s. Public health professionals are hoping that by the 21st Century psychiatry will be the equal of the other branches of medicine in Taiwan.
Psychiatry as an academic field has been actively developed over the past 40 years under the leadership of the Department of Psychiatry in National Taiwan University's College of Medicine. Other psychiatric centers have also been established, and they all have a busy agenda of research and service. These include the psychiatry departments set up in the following institutions: National Taiwan University Hospital, the Tri-Service General Hospital, the Chung Ho Memorial Hospital, affiliated with Kaohsiung Medical College, and Taipei Veterans General Hospital. In addition, there are public mental hospitals scattered throughout the island.
The Society of Psychiatrists has been very active in academic affairs and in setting up training courses for its members. The Society also shoulders the entire responsibility for giving the board examinations for the certification of psychiatric specialists. There are currently about 200 board-certified psychiatrists, a grossly inadequate number for Taiwan's population of 20 million. The number of board-certified psychiatrists increases by 25 physicians each year. There is a total of 58 psychiatric hospitals providing 11,066 psychiatric beds for inpatient service, an average of six beds per 10,000 population. In contrast, in Western countries the average number of psychiatric beds is about 25 beds per 10,000 population.
Several points deserve special attention when analyzing the data on the incidence of psychiatric disorders. First, there are several disorders that occur frequently in the community. All these cases are identified with a significant degree of dysfunction requiring psychiatric care. Some of them, such as psychophysiological and depressive disorders, can cause multiple physical complaints that bring these cases to general practitioners, who are usually not fully capable of handling psychiatric cases and often overemphasize prescription drugs in the therapeutic mix.
The same misplaced emphasis on drugs occurs in the various public insurance policies such as government employee health insurance, and labor and farmer health insurance. They all ignore the use of psychological therapy and incur high costs without corresponding therapeutic benefits. Depressive disorders account for some of the suicides in the community. Alcohol-related disorders result in high medical costs because of the serious harmful effects of alcohol on the various organ systems and the severe social dysfunction which accompanies these disorders. For example, with the high traffic density in Taiwan's cities, drivers under the influence of alcohol cause accidents that drive up insurance costs because of the higher traffic accident rate. Family problems and physical violence are also frequent complications arising from alcohol-related disorders.
Life in a sea of tension—Taipei traffic congestion is but one cause of the increased incidence of alcoholism and other mental and physical disorders.
Studies of community samples and findings from clinical cases indicate that the incidence of alcoholism has increased in Taiwan over the past 40 years. Studies of Han Chinese 40 years ago showed that the cases of severe alcoholism were rare, and the incidence was at the level of 0.01 percent. In the 1980s, the incidence of alcohol dependence among Han Chinese was around 1.0-2.0 percent. In studies of Taiwan aborigines in the 1950s, the incidence of severe alcoholism was about 0.1 percent. But today the incidence of alcohol dependence among the aborigines (again not including alcohol abuse) is about 10 percent.
Clinically, alcoholism was rarely seen in either an outpatient or inpatient setting in Taiwan in the 1950s. At pre sent, cases of alcoholism with associated medical or psychiatric problems are common. The Provincial Taoyuan Mental Hospital has 72 beds for acute psychiatric cases, and every week there is a constant inflow of alcohol-related new admissions to this facility. Clearly the increasing incidence of alcoholism deserves the serious attention of the public and of health officials, if only because of the social costs incurred in the medical system and in the family context. Taiwan has a serious need for an effective preventive campaign program to combat increasing alcoholism.
The incidence of schizophrenia is around 0.3 percent and about 0.2 percent for bipolar (manic-depressive) affective disorders. These figures are at the same level as recorded 40 years ago, most likely because they are probably associated with strong biological etiology rather than being determined by social factors. Schizophrenic and manic-depressive patients (especially the former) are usually chronic cases requiring clinical treatment, and they are characterized by severely diminished capacity. As a rule, the schizophrenic patients are unable to function independently in the community, and their families must spend a considerable amount of time and economic resources to support them.
Schizophrenic and manic-depressive patients require continuous medication to prevent a recurrence of acute psychotic breakdown. The prophylactic effects of antipsychotic medications for schizophrenics and mood stabilizers for manic-depressives are rarely understood by either the general public or health officials. These cases require strong community support and well designed rehabilitative programs, including shelters and workshops, halfway houses, social skills training programs, and housing service for patients whose families are unable to afford the intensive care and support they need. An effective community psychiatric service system providing such care and support is a dire need in Taiwan.
The psychiatric manpower needed to handle community outpatient cases satisfactorily should include three basic disciplines: the psychiatrist, the general practioner (the family physicians), and various categories of counseling personnel. The latter includes people with disciplines in psychiatric services such as clinical psychologists, psychiatric social workers, and occupational and recreational therapists. Some proportion of the cases with physical symptoms will initially seek the help of general practioners. If satisfactory improvement does not occur, then psychiatric referral is necessary.
There are about 56,000 schizophrenic and manic-depressive patients in Taiwan, of whom 9,937 are in psychiatric hospital beds. Patients with these two disorders require extensive care from the family and from society at large because of the chronic nature and guarded prognosis of both illnesses. There is a great shortage of psychiatric beds for such patients, as forcefully demonstrated by the long waiting lists for admission to acute care beds in the active treatment centers.
At the same time, there is a lack of systematic rehabilitation facilities in the community. All the chronic cases stagnate in the psychiatric beds, and there are no available outlets in the community. This situation escalates the medical costs for these cases. In addition, the patients' families cannot afford the medical costs and are unable to bear the social stigma imposed on the family. As a consequence, a significant proportion of these cases is sent to religious-related settings for long-term housing, such as the Home of Lung-fa-tang which, unfortunately, refuses necessary medical care.
It is urgently necessary to set up an effective monitoring system for evaluating the psychiatric cases in the chronic psychiatric wards and reclassifying these cases based on their psychopathological status. At the same time, the community rehabilitation facilities such as halfway houses, day-care and night-care settings, shelters and workshops, and outreach services for the family have to be set up. Social welfare also needs to be arranged by the government, and the public must be much better educated about psychiatric health.
The contemporary theoretical underpinnings of psychiatry in Taiwan mainly follow holistic system theory, emphasizing the concept of the biological and psychosocial integrity of an individual. The psychopathological factors considered include genetics, the nature of the disease, brain damage, biology of the brain, chronic and acute psychological stress, personality traits, family pathology, and social and cultural factors. This theoretical approach causes psychiatry in Taiwan to be a medical discipline which integrates technology and humanity.
Psychiatric research has been extremely active and is characterized by being distinctly Chinese and at the same time having the honor of achieving an international level of excellence. In the 1940s and 1950s, Taiwan's psychiatric epidemiological studies were known worldwide, and the data from these studies are often cited in the current literature. In recent decades, psychiatric research has included descriptive studies of psychiatric disorders, nationwide epidemiological studies on the incidence of disorders, and risk factors of various disorders. There have also been numerous studies in advanced scientific-technical aspects of psychiatric medical science. Research on suitable psychotherapeutic techniques for individuals, families, and group psychotherapy has also been very prolific and productive.
Based on the theoretical framework and the extensive first-class scientific research data, clinical services for psychiatric patients in Taiwan have adopted a team approach which incorporates the special disciplines of psychiatrists, clinical psychologists, psychiatric social workers, and psychiatric occupational therapists, with the psychiatrist acting as the team leader. The therapeutic strategy is formulated by the psychiatrist, and the therapeutic team members work on their areas of expertise as indicated by the patient's psychopathological profile.
All treatment modalities, such as various kinds of psychotherapies and somatic treatments, are considered in choosing the most efficient course of treatment to improve the patient's psychopathological condition. The therapeutic techniques used in somatic treatment include psychotropic drugs and electric convulsive therapy as medically indicated for the given psychopathological stage of the disorder.
In addition to mental health services in purely psychiatric settings, patients with other types of afflictions also receive such services in the general hospital through the consultation-liaison psychiatric service.
A sound administrative system is essential in insuring good psychiatric ser vice. At present, the mental health law is being reviewed by the Legislative Yuan. It is hoped that this key law will be put into action in the near future. The ROC on Taiwan is one of the few remaining nations in the 19908 without a mental health law for establishing an administrative system to serve the mentally ill.
Traditional cultural attitudes often impede the treatment of mental illness. People refuse to admit that a family member needs professional care and instead try to cope behind closed door at home.
The ROC's mental health law is expected to emphasize the preventive approach in addition to providing for an adequate quantity and quality of psychiatric facilities and services. The draft law pays special attention to the rights of the patient, including detailed commitment procedures for patients with severe mental illnesses. A special department responsible for psychiatric service and a special mental health consulting committee are required at every level of health administration. The draft law has many other features for setting up an administrative and operational network for mental health.
The movement towards good psychiatric service has also been promoted by the Chinese Mental Health Association and the Society of Psychiatry, ROC (Taiwan). These two organizations have been active in propagandizing mental health concepts and healthy lifestyles among the public. The Society of Psychiatry has promoted high standards of psychiatric service and training for specialists of all psychiatric disciplines. But the supply of psychiatric manpower still falls seriously short of the numbers required to meet public needs. All relevant professionals in the educational system and health administration must work closely with each other to solve this problem, and the success of their efforts will greatly aided by the forthcoming mental health law. —Hai-Gwo Hwu, M.D. is superintendent of the Taoyuan Provincial Mental Hospital and concurrently an associate professor in the Psychiatry Department of National Taiwan University's College of Medicine.