At least three of six men whose attacks near schoolyards this year left 21 people dead had earlier appeared deranged or suicidal, according to news reports. But in the highest-level statement on the killings, Prime Minister Wen Jiabao said only that China needed to resolve “social tensions” underlying the attacks.

Yan Jun, director of the mental health division of the Ministry of Health, refused repeated requests for an interview. The ministry said in a written statement that the government was “continuously strengthening” both its resources and professionals to provide mental health care.

A Dearth of Care

It has far to go. Only 1 in 12 Chinese needing psychiatric care ever sees a professional, according to a study last year in The Lancet, a British medical journal. China has no national mental health law, little insurance coverage for psychiatric care, almost no care in rural communities, too few inpatient beds, too few professionals and a weak government mental health bureaucracy, Chinese experts in the field say.

The Health Ministry’s own mental health bureau, established four years ago, consists of three people. Dr. Yan, the director, is a public health specialist, not a psychiatrist.

Every few years, China’s news media declare that a national mental health law is speeding toward adoption. The first draft was written half a century ago. Asked how many revisions it has undergone, Dr. Ma Hong of the Peking University Institute of Mental Health said, “Countless.”

Most psychiatric hospitals are financially unviable, said Yu Xin, who directs the Peking University Institute of Mental Health. One, in Hubei Province, opened a box factory in the 1990s to stay afloat. The fee structure is so absurd, he said, that hospitals can charge patients more for computer-generated diagnoses based on filled-out forms than for sessions with actual psychiatrists.

The Lancet study estimated that roughly 173 million Chinese suffer from a mental disorder. Despite government efforts to expand insurance coverage, a senior Health Ministry official said last June that in recent years, only 45,000 people had been covered for free outpatient treatment and only 7,000 for free inpatient care because they were either dangerous to society or too impoverished to pay.

The dearth of care is most evident when it comes to individuals who commit violent crimes. For example, after Liu Yalin killed and dismembered an elderly couple cutting firewood in a Guangdong Province forest, he was judged to be schizophrenic and released to his brother. Unable to afford treatment, the brother flew Mr. Liu to the island province of Hainan, in the South China Sea, and abandoned him, a Chinese nongovernment organization, Shenzhen Hengping, said in a recent report.

Last year, Mr. Liu killed and dismembered an 8-year-old Hainan girl.

“The government doesn’t want to cough up the money to treat these people, so they just give them back to their families,” said Huang Xuetao, a mental health lawyer and one of the authors of the report.

Left to their own devices, some relatives resort to heartbreaking solutions. In 2007, He Jiyue, a government psychiatrist, discovered a 46-year-old man locked behind a metal door in a stinking room in a rural Hebei Province home. The man was mentally ill, his aged parents told Dr. He. They had locked him up after he attacked his uncle.

That was 28 years earlier. The man, a high school graduate, could no longer speak. “I said to the parents: ‘How could you do this to somebody?’ ” Dr. He recalled. They replied, “We had no choice.”

In the past three years, Chinese mental health workers have rescued 339 other people whose relatives were too poor, ignorant or ashamed to seek treatment. Some, shackled in outdoor sheds, were “treated just like animals,” said Dr. Liu Jin, of the Peking University mental health institute.

Chronic shortages of both doctors and facilities ensure that what care exists is limited. China averages just one psychiatrist for every 83,000 people — one-twelfth the ratio in the United States — and most lack a university degree in any subject, much less mental health, Dr. Ma said.

“Professional psychiatrists in China are like pandas,” said Zhang Yalin, assistant director of the mental health research institute at Central South University’s medical school. “There are only a few thousand of us.”

A Profession Lacks Respect

Psychiatry’s bottom-of-the-barrel image in the medical community deters students from joining the profession. Dai Jun, a 24-year-old medical student in Wuhan, in central China, said he studied psychiatry when he enrolled at Nanjing Medical University six years ago because it was the only specialty with an opening. As an intern, he noticed that psychiatrists were not treated or rewarded like other doctors.

Patients often give surgeons and other specialists “hongbao” — envelopes of cash that can make up a third of a doctor’s income — in exchange for better treatment. Psychiatrists get neither hongbao nor respect.

“People think, ‘Oh, you are constantly locked up with crazy people. Maybe you are going to go crazy yourself, or you are already crazy. That is why you want to do this,’ ” Mr. Dai said. At his first opportunity, he switched to orthopedics.

Although research is scanty, a recent Health Ministry survey suggests that the need for more specialists is growing fast. The study found that the incidence of mental disorders had climbed more than 50 percent from 2003 to 2008. Although some of the increase was because of greater awareness and reporting, Dr. Ma argues that the incidence of stress-related disorders like depression and anxiety has shot up.

“Chinese society is just changing too fast for people to adjust to it,” she said.

The government recently pledged to invest more in mental health care, mostly by pouring billions of dollars into new and renovated psychiatric hospitals. Many psychiatric hospitals are more than half a century old and located — by design — far from cities. China added 50,000 psychiatric hospital beds from 2003 to 2008. But it needs more: Tibet, a region nearly three times as big as California, lacks a single psychiatric institution, the Peking University mental health institute says.

The Downward Spiral

Like much of rural China, Xizhen, in southern Guangxi, one of China’s poorest provinces, is isolated from services. Here, several hundred villagers tend fields of towering green sugar cane and cassava plants, sinking wells for water and chopping wood for fuel. Untrained practitioners who call themselves doctors handle most medical needs. The nearest hospital is an hour away by car.

Yang Jiaqin was a local health care worker. Although neither he nor his wife, Wen Zhaoying, had medical training beyond high school, the two dispensed care for years from a tiny clinic opposite Xizhen’s primary school. Five years ago, Ms. Wen said, it became obvious that her husband was the one who needed treatment. Always excitable and easily frightened, she said, he became obsessed with the notion that people were after him.

One night that autumn, he fled his house during a raging storm. Relatives found him the next day pacing near a pond, covered with scratches, shaking violently, she said. “It was very scary,” he told her. “People were chasing me all night.”

Relatives ferried Mr. Yang to the Hepu County Psychiatric Hospital, a sprawling, ramshackle collection of one-story buildings outside Beihai, the closest city. Administrators say the hospital’s five doctors serve a region of more than one million people.

There, Ms. Wen said, a psychiatrist prescribed medication that helped calm her husband. Still, his episodes grew more severe. In 2007, she said, Mr. Yang leaped from a third-floor window to escape imaginary pursuers, breaking his leg. In 2008, he fled Shenzhen, where he had become a migrant worker, and called the police from a Shanghai television tower, threatening suicide.

Doctors at a Shanghai psychiatric hospital diagnosed his condition as schizophrenia, administered antipsychotic drugs and, a month later, set him free.

Family members say that was Mr. Yang’s last encounter with a mental health professional. Mr. Yang refused doctors’ advice to return to his local psychiatric hospital, his wife said, so she went alone, Shanghai prescription in hand. Without examining her husband, she said, a psychiatrist decided that he was not psychotic and changed his medication.

By last spring, Mr. Yang, 40, was afraid to leave his dim mud-clay house. “All he did was stay home and cry,” Ms. Wen said. Last April 9, the demons inside him took control.

That evening, Mr. Yang smashed through the wooden door of his 63-year- old neighbor, Wu Wenguang, and struck him in the head with an ax. At the hospital where doctors stitched his wound, Mr. Wu said, the local police chief told him: “When crazy people hurt somebody, there is nothing we can do.”

Ms. Wen said the police found her husband at home that Friday night but told her the matter was best settled privately. “None of this would have happened” had they arrested him, she said. In a statement, the police insisted that they had searched fruitlessly for Mr. Yang, then told his wife he should turn himself in.

Ms. Wen said she began arrangements that weekend to admit her husband to a hospital. Mr. Yang’s 74-year-old mother, Pei Renyuan, said her son warned that he would kill himself and “take all of you with me.” Mr. Yang’s younger brother was assigned to watch him.

The following Monday afternoon, Wu Junpei, a spirited 8-year-old who loved to draw, sing and practice gymnastics, left school with friends, taking his usual shortcut past the Yang house toward his home 10 minutes away. Mr. Yang jumped onto the path with a cleaver and slashed a first grader, who fled. Then he turned on Junpei, slicing his arm and neck in quick succession.

Wu Zunwei, the boy’s 14-year-old cousin, was next. “I fell to my knees and begged him, ‘Please don’t hurt me,’ ” Zunwei recalled. Mr. Yang slashed his shoulder. “He didn’t say anything,” Zunwei said. “He was crying.”

Wu Huanglong, 43, raced over on his motorcycle to find his son lying, face up, on his blood-soaked navy backpack. “When I saw his eyes were staring up at me,” he said, “I thought to myself: ‘This is it. I am finished. I have lost everything.’ ”

Running from house to house, Mr. Yang killed a 70-year-old woman who was making firecrackers, and a man who was watching a television drama on his sofa. He slashed the man’s wife and a girl drawing well water.

The police, who seemed so quick to dismiss Mr. Yang’s earlier attack, were suddenly energized. Junpei’s 20-year-old sister said riot police officers descended on the hospital that night, wrapped Junpei’s corpse in a sheet and drove off with it, ignoring her screams of protest.

The county government has yet to release the body, Mr. Wu said. Villagers say that is probably because Mr. Wu refuses to sign a declaration that no one is to blame for his son’s death in exchange for about $19,000 in compensation.

Dr. Chen, the psychiatric hospital’s chief doctor, said Mr. Yang’s rampage occurred because “he has never been under systematic care.” His family, he said, “did not take his illness seriously enough.”

But he also said that his own hospital sometimes released mental patients purely because families could not afford treatment.

“The government has to invest more so that we can take care of all the patients who need treatment, regardless of whether or not the family can pay for it,” he said.

Dr. Chen and another hospital doctor say Mr. Yang’s condition has now stabilized. Their goal is to send him home. But Ms. Wen said she could neither care for him nor cover the cost of continued treatment.

If she does not pay, she said, hospital officials have warned that her husband will be released to her custody.

Zhang Xue, the hospital’s president, denies that. “I have never heard of such a thing,” she said. “The government takes this case very seriously and is devoting resources to it,” she said.

Autumn is still warm in Xizhen. Farmers harvest peanuts in their undershirts. Schoolchildren shoot marbles outside. After dinner, Mr. Yang’s aged parents like to leave their double wooden door open for air.

Junpei’s mother often shows up to burn incense on their doorsill, wailing in the gathering dark. She and her husband say Mr. Yang’s family is pretending that he is mentally ill to protect him.

Ms. Pei, Mr. Yang’s mother, said she could not face the woman’s grief or her own shame. As soon as she sees her, she shuts the doors.

Dan Levin and Xiyun Yang contributed reporting from Beijing. Research was contributed by Helen Gao, Benjamin Haas and Ashley Li from Beijing, and Wang Xiao from Xizhen.