Depression and shenjingshuairuo in China
by Dr Jianan Bao, MSc Global Mental Health candidate, Psychiatry trainee starting August 2017
The evolving perception of depression in China can be understood through historical, cultural and epidemiological perspectives. It is far too complex to sum up in one snapshot, but I will try.
During the Cultural Revolution in the 1960-70s, systematic persecution and humiliation of people considered to be intellectuals and capitalists, often by other citizens through mutual surveillance, led to a state of paranoia and repressed psychological distress. Some have argued that this suffering was expressed through neurasthenia, or shenjingshuairuo (神经衰弱), a condition characterised by persistent weakness and fatigue. The prevalence of shenjingshuairuo was as high as 1 in 10 in some studies, whereas the prevalence of depression was very low[1]. The physical symptoms of this condition were socially sanctioned and less stigmatizing than the symptoms of depression. However, the stigmatization of psychological symptoms is not unique to China and has been described throughout the world. The cultural practices around outward expression of emotions has a role to play as well in creating the condition of shenjingshuairuo. Emotions are expressed more indirectly in Chinese culture. The Chinese social psychiatrist Sing Lee gives an example of a Chinese parent communicating affection through cooking a child’s favourite food, asking if they are warm enough, or giving them pocket money, rather than direct expressions of affection such as hugging or telling them that they love them[2]. This resonated strongly with myself.
I was born in China but had not lived there for many years. I went to Shanghai for my elective and spent my time at a psychiatric outpatient clinic in a large hospital. I did not see anyone diagnosed with shenjingshuairuo. Everyone did however present with a somatic complaint, most often that of insomnia, and nearly everyone left with a prescription, sometimes one for traditional Chinese medications. Perhaps this was due to the lack of confidentiality during the consultations. Sometimes the door would be left open, a long queue of patients standing outside. Most people came with a family member, who would sometimes answer most of the questions asked about the patient’s mental state in lieu of the patients themselves. It was easier for anyone to talk about somatic symptoms in that setting. No doubt another contributing factor was that doctors’ salaries were directly associated with drug sales.
It seems to me unlikely that the symptoms of psychological distress had changed much. It is more likely that the questions asked guided the answers one received. As one psychiatrist in Lee’s paper told him, “since we had little understanding of depression in the past, we rarely asked patients about depressed mood”1. Indeed, the anthropologist-physician Kleinman found that he could elicit symptoms of persistent low mood from patients presenting initially with symptoms of shenjinghshuairuo, eventually diagnosing 87% of these patients with major depressive episodes2. Regardless of how one interprets a patients’ symptoms (and, as clinicians, we are always interpreting symptoms), depression is a condition of the mind and of the body. The character used for psychotherapy in China is the same as that used to mean heart: 心. Perhaps the mind and the body have always been more connected in Chinese culture.
110 is the national emergency number in mainland China.
Beijing Suicide Research and Prevention Center (http://www.crisis.org.cn), a World Health Organization Collaborating Centre for Research and Training in Suicide Prevention, available 24/7 at 800-810-1117 (for landline callers) or 010-8295-1332 (for mobile and VoIP callers)
Lifeline Shanghai (https://www.lifeline-shanghai.com/) available 10am to 10pm every day at 021-6279-8990
Shanghai Mental Health Center (http://www.smhc.org.cn) serves as a mental health clinic as well as teaching, researching and planning mental health prevention throughout China. They can be reached at 021-64387250.
Shenzhen Mental Health Center (http://www.psyonline.com.cn/) free professional counseling available 24/7 at 0755-25629459
Guangzhou Crisis Research and Intervention Center (http://www.gzcrisis.com/) available 24/7 at 020-81899120 or 020-12320-5, online counseling is also available with QQ messenger at 1661042151
Mental Health Center of School of Medicine of Zhejiang University (http://www.hz7hospital.com/) available 24/7 at 0571-85029595
References
[1] Lee, S. (1999). Diagnosis postponed: shenjing shuairuo and the transformation of psychiatry in post-mao China. Cult Med Psychiatry, 23(3): p. 349-80; discussion 381-99.
[2] Kleinman, A. (2011) Deep China: the moral life of the person: what anthropology and psychiatry tell us about China today. Berkeley, Calif.; London: University of California Press