How 2020 Kicked Off a Nationwide Discussion about China’s Hidden Epidemic

2020 has been a watershed year in China when it comes to national attention for depression.

As a nationwide lockdown swept mainland China at the start of the Covid-19 pandemic, the isolation, stress, and uncertainty put people at an increased risk of depression. According to data from China’s leading search engine Baidu, searches for mental health related keywords such as “psychological help” reached a 10-year high at the beginning of 2020.

A study conducted by one of China’s biggest online counseling platforms similarly showed that across the country, anxiety and depression among respondents largely correlated with the severity of the Covid-19 outbreak in that region. In response, mainstream Chinese media outlets also began to give the pandemic’s toll on mental health more attention.

The pandemic kicked off a national discussion about mental health and aggravated mental health issues that were below the surface, which continued throughout the year even after lockdown measures were widely relaxed.

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The responses have ranged from top-down policy prescriptions to intriguing initiatives from the country’s leading technology companies.

For example, in response to an increasing trend of negative and unhappy comments on the site, music streaming app Netease launched a campaign in August to employ mental health professionals and volunteers to reach out and provide free online consultations for users.

More recently, the National Health Commission of China published a new policy plan that added screening for depression as part of the annual physical exams for high school and college students, as well as for “high risk” groups such as pregnant women and the elderly. The plan specifies that schools are required to take “necessary measures” when cases are identified.

While the guidelines raised concerns about students’ privacy, particularly for minors, many praised the move as a needed step towards more dialogue around mental health. Yet in order to reach this goal, China will have to overcome several major hurdles — one of which is inadequate services dedicated to mental health.

A Long Overdue Conversation

In China, the number of psychiatrists per 100,000 people is 2.02 — below the world average of 3.96, and well below the average rate of 20 among developed countries. This nationwide lack of specialists, as well as a low depression recognition rate of 21%, means that China’s treatment rate of depression is only about 10%.

On Chinese microblogging platform Weibo, heated discussions about how depression is seen and treated have become some of the most frequently trending topics in recent months. When a female passenger was rejected from boarding a domestic airline due to shaking hands triggered by her depression medication, it sparked an intense debate about social acceptance of depression. The hashtag #Female University Student Rejected from Boarding Flight# quickly attracted 150 million views.

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Similarly, the hashtags #The Depression Rate in China is 2.1%# — based on a 2019 government report that used statistics from 2014 — and #There are an Estimated 300 Million Depression Patients Globally# garnered over 300 million and 470 million views respectively.

This discussion arrives at a time when there are an estimated 95 million people living with depression in China, while the outpatient rate of depression nationwide is increasing 20% annually, implying that more people are coming forward and being diagnosed with depression. Meanwhile, nearly one in four Chinese university students is estimated to suffer from depression.

The silver lining, however, is that tech-savvy Chinese youth are becoming more proactive in acknowledging, navigating, and combatting depression through the internet.

Finding Sanctuary Online

“I believe young people in China, especially people born in and after the ‘90s, have a higher awareness of depression in recent years, thanks to discussion on social media — official accounts on Weibo and [China’s Quora] Zhihu, in particular,” says Gegeda, who previously worked in mental health and declined to give her real name for privacy purposes.

While it has been well-documented that social media can negatively impact mental health, platforms such as Weibo and messaging app WeChat are playing an increasingly important role in creating a safe space to share experiences and recognize symptoms of depression.

Know Yourself, a psychology company that runs an official WeChat account with 2.8 million followers, uses language that young people find relevant in its messaging. In publishing daily content drawing from a wide range of subjects such as “academic psychology, pop-psychology, social science, and pop culture” and running accessible yet professional online psychological assessments, counseling and psychology courses, the company is a great example of how emerging media platforms can join the fight against depression.

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Meanwhile, Weibo account “Depression” (抑欝症), which has more than three million followers, has shared dozens of people’s stories daily to the platform over the past four years. “90% of posts are too negative to even publish,” says the account’s creator, Nuanjun, who declined to give her real name for privacy reasons.

Nuanjun suffers from depression herself, which is what motivated her to create a platform for people to share personal struggles with the illness. “Most people just need someone to listen, which they might not necessarily get in daily life,” the blogger says.

“Hello everybody. I am a tree hollow [树洞, meaning a ‘good listener’],” reads a post pinned to the top of the account on Weibo. “If you would like to share any of your thoughts, please DM me (if you want to remain anonymous, please make a note). A lot of things get better after sharing. Come on!”

A pinned post on social media account “Depression” (source: Weibo)

The account also shares resources for its followers, such as depression self-assessment charts and contact information for regional mental health centers around the country.

By spreading awareness, platforms such as Know Yourself and Depression help lay the foundations for professional treatment. China’s biggest online counseling services, Yixinli and Yidianling, have 22 million and 10 million registered users respectively. Yet while the number of users on Yixinli has surged in the past few years — 54% in 2019 alone — there are still only about 20,000 in-house psychologists on the platform.

What’s more, though in theory such platforms make mental health resources available nationwide, sign-ups still lag in China’s third-tier cities and beyond. About 61% of users on Yixinli are from first-tier cities such as Shanghai and Beijing. Know Yourself founder Qian Zhuang said in a 2019 interview that the platform’s average user is someone from a first- or second-tier city in China, while 80% of users have an undergraduate degree or higher.

“Since there are no physical boundaries on the internet, people in smaller cities can actually enjoy the benefits of increasing availability in depression-related information online,” Gegeda says. “The problem here is how to get them started.”

Generational Divides

What stops some people from seeking help is a both historical and cultural stigma around mental health. In traditional Chinese culture, having mental health issues was seen as a sign of weakness or of being incapable, while seeing a therapist was largely unheard of until recently.

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Xiao Mengyuan, a 27-year-old woman based in the upper tier city of Hangzhou who has struggled with depression since 2016, thinks the previous generation’s lack of understanding is the biggest challenge facing people her age. “[My parents’ generation] thinks depression is just people moaning and complaining,” says Xiao, her voice breaking. “My mom ignores it, and tells me to just ‘take it easy.’ Sorry, but it is so, so hard to chill.”

Nuanjun shares her sentiment, saying that she has noticed a clear gap in the views towards depression across generations.

But with a state-level acknowledgment of depression through the new screenings mandate, that may soon have to change. Along with the compulsory assessments, China’s new guidelines state that by 2022, the recognition rate of depression nationwide should be 80%, while the outpatient and treatment rates must increase by 50% and 30% respectively.

Reaching these goals not only depends on government-led efforts to make systemic changes to the current mental health sector. For people like Xiao, it will also take support and dialogue among family and friends, as well as from online communities.

“There is still a long way to go,” says Xiao. “But about this, at least, I am optimistic.”