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Global psychiatry, ‘shenjing shuairuo’ and cultural understandings of depressive disorders in China

A section of the DSM-V (Diagnostic and Statistical Manual of Mental Disorders V), the principal authority for psychiatric diagnosis, lists various “cultural concepts of distress”: among these is shenjing shuairuo, a depressive-like syndrome linked to Chinesecommunities and explained primarily as an imbalance of Qi (vital energy). Shenjin shuairuo is described as “a cultural syndrome that integrates conceptual categories of traditional Chinese medicine with the Western diagnosis of neurasthenia”. Unlike Western understandings of depression that are rooted in the mind and in brain biochemistry, shenjing shuairuo literally translates from Chinese to “weakness of the nervous system”. It is constituted through somatic symptoms such as insomnia, weakness, tiredness and dizziness, alongside mental irritability and distress typical of other disorders such as Major Depressive Disorder.


The history of shenjing shuairuo illustrates how, over the 1900s, notions of mental illness in China integrated Western and traditional elements whilst also remaining distinct from Western psychiatry. Up to the 1970s, mental illness as understood by the West was rare in China. However, as modern “Americanised” psychiatry became globalised, Western understandings of depression, anorexia and other disorders took hold. At the same time, patients’ presentation of mental diseases themselves began to mimic American symptomatology – primarily in urban and globalised locations such as Hong Kong.


Several factors have helped change cultural notions of mental illness in China. These include market forces of American pharmacopsychiatry; increasing economic development, urbanisation and globalisation; and changes in drug advertisement and prescription practices. Nowadays, traditional and somatised notions of mental illness in China coexist with biomedical Western understandings of psychiatry.


The pharmaceutical sector and its associated activities – namely drug advertisement, prescription and even the publication of the DSM itself – have been important in shaping social notions of mental illness. Medical practitioners communicating with and treating patients can quietly shape how people understand depression, for example, and its associated medications. The same goes for broader advertisement practices in newspapers and new media. It is not without reason that the global pharmaceutical industry spends far more on marketing (targeting both physicians and consumers) than on Research & Development. Payton and Thoits write that the advertisement of psychiatric drugs has successfully constructed experiences like that of depression as a biomedical phenomenon to be treated through medication. Hence, an understanding of how psychiatric drugs have been developed and marketed in China is important to track shifts in mental illness concepts over time.


The history of neurasthenia, depression and shenjin shuairuo in China


One of the earliest concepts of mental illness in China was that of shenjin shuairuo, often referred to in the West as neurasthenia. The term “neurasthenia” was coined in America in 1869 to refer to an exhaustion of the nervous system; it was introduced in China in the early 1900s, translated as shengjin shuairuo and integrated into the logic of Traditional Chinese Medicine. As Lee (1994) explains:


“Shen is emblematic of vitality, the capacity of the mind to form ideas, and the desire of the personality to live life. Jing originally refers to the meridians or channels which carry qi (“vital energy”) and xue (“blood”) through the body. Conceptually, shen and jing are treated by Chinese people as one term (shenjing) that means “nerve” or “nervous system.” When shenjing becomes shuai (degenerate) and ruo (weak) following undue nervous excitement, a variety of psychic and somatic symptoms may reasonably ensue.”


This Sinicised notion of psychiatric illness went hand-in-hand with the sale of pharmaceuticals to address it, Chinese and Western alike. Already in 1911, advertisements for zhongjiang tang – a Chinese-manufactured drug for “melancholia” – appeared in newspapers. Western-manufactured drugs also started appearing in the Chinese market in the 1920’s, and texts from Japanese psychiatrists were translated into Chinese around the same time. Indeed, Japan had already begun integrating some Western notions of depression into its East Asian cosmology, thus providing a model for China to do the same. Constructions of depression in China increasingly took on a hybrid form that integrated the role of Qi imbalances, nervous system malfunctions and brain malfunctions.



Fang Huichun Chinese Pharmacy in Hangzhou - Avel-breizh


Beyond integrating Western and Traditional Chinese understandings of depression, the diagnosis of shenjin shuairuo also reflected specific social functions of mental illness in China. Studying the ‘cultural life’ of shenjin shuairuo, Arthur Kleinman found that it served as a social protective factor in Communist China. In general, bodily complaints have more accepted in China than displays of emotional distress. Yet in the Mao era, showing depressive symptoms such as social withdrawal was also ideologically unacceptable as this would indicate “a lack of faith in the revolution”. However, shenjin shuairuo was often somatised: its primary symptoms included pain, insomnia, dizziness and weakness, making it a socially-sanctioned form of mental illness. For this reason among others, shenjin shuairup became the primary non-psychotic diagnosis in 1960s to 1980s China: in 1986, Kleinman found that during a one-week period at a clinic in Hunan, 30% of patients were diagnosed at neurasthenic whereas only 1% were diagnosed as depressed.


From the 1980s, however, diagnoses of shenjin shuairuo in China declined significantly in favour of today’s better-known diagnoses of schizophrenia, depression and anxiety. Deng Xiaoping’s post-Mao open-door policy had introduced international standards of medicine to China. The popularity of American psychiatry and the 1980 publication of the DSM-III had great influence because the scientific perspective of Western psychiatry fit with contemporary narratives of modernisation and “scientism”. Significantly, the DSM-III did not include the diagnosis of shenjin shuairuo. Patients who would have previously been diagnosed with this affliction were re-categorised using Western labels for depressive disorders. This signalled a shift toward universalism and commercialism in mental illness diagnosis; global pharmaceutical companies began seeing the Chinese market as an opportunity.



The rise of “depression” and antidepressants in China


When foreign psychiatric medications were introduced to China in the late 20th century, they were met with trepidation from society. The Western phenomenology of depression was poorly understood and did not seem to fit with traditional notions relating to Qi or somatic concerns. There remained a mismatch between the Chinese psychiatric industry and popular understandings of mental illness. This mismatch arguably continues to this day – a 2019 study found that in Chinese primary care settings, only 3% of elderly patients diagnosed with Major Depressive Disorder received treatment from a mental healthcare professional and less than 1% took antidepressants.


Despite these low psychiatric treatment figures, rates of depression seem to have risen in China. Modern China is a stressful place to live in, with high economic competition and social expectations. Estimates reveal that China makes up 20% of global Disability-Adjusted Life Years attributed to mental disorders as defined by the DSM – placing it as first in the world. A 2013-2015 survey found that the lifetime prevalence of mental illness in China is 16.6% - translating to a significant burden – yet only 9.5% received treatment. This crisis became especially pronounced during the COVID-19 pandemic, when 35% of respondents to a national survey reported psychological distress including depression or anxiety.



Walking in Shanghai – Nuno Alberto, Unsplash


Social awareness of mental illness has also increased. The government passed a “Mental Health Law” in 2013 and has launched various mental health awareness campaigns since then. The pandemic sparked mass online discussion of depression and is helping reduce stigma further. As stigma reduces, both physicians and patients become more comfortable with prescribing and taking antidepressants – corresponding to shifting understandings of mental illness among the Chinese population. The notion of depression as a biochemical condition has taken root. Analysing narratives of depression in Chinese newspapers over the past three decades, Geyer and Wang found that that since 2009, the depiction of depression as a chemical condition has appeared exponentially. Indeed, China may be particularly suited to biomedical models of depression: unlike in the West, cognitive forms of treatment such as talk therapy are not widely accepted.


Accordingly, the use of antidepressants in China has risen considerably. Sales of antidepressants rose from 25.1 to 56.74 billion yuan between 2011 and 2016, and hospital visits for antidepressants increased significantly between 2013 and 2018 for all age groups. Between 2018 and 2021, psychotropic medicine sales increased by 42.2% in Chinese hospitals, primarily driven by the increased use of antidepressants. Nowadays, Prozac (translated as Baiyoujie) is on the Essential Drug List of many Chinese cities.



Prozac (Baiyoujie, 百憂解) packaging - Wu Dongyue Photography


Pharmaceutical advertising


This rise in antidepressant consumption is, in part, the outcome of decades of intentional efforts from the psychiatric industry. Pharmaceutical companies have long taken steps to market their drugs according to cultural understandings of mental illness (intended to increase their social acceptability), and have paid significant attention to China due to its market size. The diagnosis of depression has intentionally been coupled with the well-accepted, traditional concept of shenjin shuairuo. An advertisement for fluoxetine in 1996, for example, stated: “In one study in China, 50–87% of patients diagnosed as SJSR (the common symptoms of which are headache, insomnia, dizziness, forgetfulness, anxiety, and loss of energy) fulfilled the criteria for depression”. For decades, pharmaceutical companies have sponsored Chinese psychiatrists to attend international conferences, introducing them to the American psychiatric “medical-industrial complex”. Young medical graduates were also recruited as “detail persons” and offered high salaries to promote pharmaceutical products directly to doctors.


This push for psychiatric drugs has given rise to ethical concerns. Geyer and Wang’s 2019 study of modern Chinese antidepressant advertisements found that adverse effects, overdosage and drug interactions are often underemphasised, whilst information tends to be oversimplified to focus on effectiveness and convenience rather than safety. The overprescription of antidepressants and the earning of “grey income” from pharmaceutical sales is also prevalent among doctors. A step toward greater regulation was taken in 2015 when China’s Advertising Law was updated to mandate the listing of contraindications. Nonetheless, pharmaceutical companies could still be using vague terms in their leaflets to avoid disturbing the precarious social acceptance of antidepressants.


Conclusion


In 2022, China’s first domestically-produced antidepressant – Ruoxinlin – was approved for market sale. Until this point, most antidepressants in the Chinese market were developed by multinational pharmaceuticals. This is a symbolic turning point, as biochemical models of depression are no longer purely a Western import. Yet, it is important to contextualise that the use of psychiatric medication in China remains lower than in other countries. Understandings of depression in China are still linked to traditional notions of somatisation, vital energy and mind-body unity.


As China’s pharmaceutical industry grows, there will be a need to balance between stigma- increased pharmaceutical regulation. The answer should not be, however, to simply mimic Western biomedical models. Traditional notions of mental illness remain important. They serve Chinese communities by giving them socially-sanctioned ways to understand their distress. Acknowledging depression as an issue of mind-body ‘imbalance’ can help remove the stigma associated with global psychiatric labels. Similarly, somatic understandings of mental illness allow people to ask for help in contexts where talk therapy is constrained by stigma.



Hu Qing Yu Chinese Pharmacy - Siyuwj


More broadly - traditional, hybrid notions of depressive conditions in China are a reminder of the non-universality of Western biomedical models. Indeed, mental illness is as culturally shaped in the West as it is in China – but this happens to be framed within biomedicine. Globalisation has caused non-Western societies like that of China to, to some extent, adopt this same framing. China and other countries (primarily in the Global South) should be careful not to accept this without challenge or due consideration, particularly when financial incentives are involved. Instead, localised understanding of distress should be integrated into modern treatment. For example, there have been advances (1, 2, 3) in testing Traditional Chinese Medicine scientifically to treat depression. These present an important alternative or addition to Western pharmaceuticals for Chinese communities – and perhaps even beyond – as forces of globalisation continue and China grows as a financial and biomedical power.


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