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Objective: Severe mental illness (SMI) represents major social and public health problem in China, especially in low- or middle-income regions. We aim to assess the prevalence and distribution of SMI in Hunan province in central China. Methods: Multistage stratified random sampling methods were used to select qualified subjects in 123 districts and counties in Hunan province. 89465 individuals were randomly identified, and 72999 (81.6%) completed the supplemental 12-Item General Health Questionnaire (GHQ-12) and Cue questionnaire of psychiatric abnormal behaviors. 6082 suspected individuals having high or moderate risk, or psychiatric cues, were administered the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I) by psychiatrists. Results: 720 respondents were definitely diagnosed as SMI. The 1-month and lifetime prevalence was 9.35‰ and 10.10‰, respectively. The most frequent SMI was schizophrenia, followed by bipolar disorder, intellectual disability, epileptic mental disorder, paranoid psychosis and schizoaffective disorders, with 1-month prevalence ranging from 0.11‰ to 6.50‰ and lifetime prevalence ranging from 0.24‰ to 6.86‰. Multivariate logistic regression analysis revealed that lower education, farmer occupation, retirees or jobless/unemployed, unmarried or divorced and age of 30–64 years old were major factors that associated with the increased risk of SMI. In addition, only 33.3% of 528 patients who completed questionnaire sought help in psychiatric institutions, and up to 51.7% of 720 patients were not referred to the SMI management system in Hunan province. Conclusions: These findings provided a large-scale prevalence data of SMI in a provincial sample of China. The psychiatric disorders brought economical and psychological burden for family and society, which may shed light on the significance of scaling up province-wide mental health service and strengthening the SMI management. [ABSTRACT FROM AUTHOR]