'I suffer from depression, and just choose to die. I did not die for any important reason.' These were the final words of college student 'Zoufan', who set this note to post itself on Weibo the morning after she hung herself, alone in her dormitory.
Zoufan's death in 2012 prompted huge outpourings and discussion on Weibo. According to China's Center for Disease Control and Prevention, suicide is the top cause of death among Chinese youth, with at least 500 school children killing themselves every year. In total, roughly 250,000 people commit suicide annually in China, while another two million attempt to.
Zoufan's death came at a key turning point in China’s debate over mental health, a melting pot of pressure for the government to act over the country's growing mental health crisis. The following year, the country's long-awaited first national mental health law came into effect.
As is the case with many countries around the world, estimates vary as to how many people suffer mental illness in China. According to a 2012 study by The Lancet, roughly 173 million Chinese people suffer from a mental health disorder, of which a mere 15 million sought treatment. In other words, over 90 percent of the affected population, 158 million people, did not seek or receive any professional help. In 2017, The World Health Organisation estimated that 54 million Chinese suffered with depression, specifically.
A study by Caixin in 2015 suggested that depression cost the nation an estimated 52 billion RMB every year in lost work days, medical expenses and, often, funeral expenses. Some projections say depression-related deaths, such as suicides, now even exceed traffic fatalities in China. WHO figures say that suicides in China account for a quarter of suicides worldwide and that, contrary to Western populations, more women than men kill themselves.
Even though awareness of mental health problems is growing, many still fail to get necessary help, in part because China has a severe undersupply of trained mental health staff. The Lancet study found that China averaged only one psychiatrist for every 83,000 people – approximately one-twelfth of the ratio in the US.
'The public health system is not able to tackle this problem at all, and very few people can afford other help'
And according to Professor Samson Tse, associate dean for the Faculty of Social Studies at the University of Hong Kong, those that do work in the public system are often not properly trained. Even if you get to see a counsellor, says Tse, the chance of them being equipped adequately is quite slim.
'It's very, very difficult to get help. The public health system is not able to tackle this problem at all, and very few people can afford other help. People don't know how to access these services, and often the beds are too expensive even in the public system. So for someone who is not wealthy, and not very educated, to access these services is very difficult,' he says.
Tackling depression is a challenge for many countries in the world. But there are a number of conditions which increase the burden in China. Firstly, huge demographic changes increase the likelihood of mental illness – urbanisation has cast many young or vulnerable people miles from their family and hometowns, or left children at home without parents, and the ageing population makes dementia a widespread problem. According to Tse, his research has shown depression and suicide rates among older people in China are 'skyrocketing'.
'Isolation is the first killer. The rapid urbanisation and modernisation in most of China has made life difficult for older people, especially combined with all kinds of ageing problems,' Tse says.
The second factor that has held back mental health provision in China is the need to play catch-up after years of neglected services. It was only in 2004 that mental health started to get its own dedicated place in the country's health system; for many years it was largely ignored. Rural poverty and a lack of access to medical resources has been coupled with a lack of education about neurological conditions. Suicide is up to five times more likely in rural China, says the WHO, with most people drinking easily available pesticide.
And this lack of provision has been compounded by a lingering ideological factor. Although mental hospitals existed before the founding of the People's Republic in 1949, most were established and run by Christian missionaries, and later closed. In Mao's Communist society, any form of mental health issue was seen as bourgeois and capitalist.
The ideology-driven vision of society simply made no allowance for mental illness, and these attitudes have been slow to change, even in a rapidly developing country. Many are also just starting to deal with traumas from the past, such as those arising from the Cultural Revolution, the one-child policy and political upheavals.
Given the lack of facilities, those who can afford it seek help in the private sector. The Wenzhou Kangning Hospital is China's biggest private psychiatric hospital, founded by doctor-turned-entrepreneur, Guan Weili. Guan says he was inspired to start the hospital after seeing failings in the public health system in the 1990s.
'At the time, China's economy was just beginning to develop,' he says. 'The hospitals that the government provided at the time could not meet the needs of the patients. So, as a psychiatrist, I decided to establish this hospital because I saw the same situation every day. It was a big problem.' Now there are seven such centres across the Mainland, along with affiliations with another six hospitals, providing beds for around 2,000 patients and treating mental health conditions from schizophrenia to insomnia.
The hospital in Wenzhou is in the process (2016) of being redeveloped into a vast, towering facility, one which Guan says will be more like a five-star hotel than a hospital. On our visit, we tour rooms of patients in pyjamas, with the higher risk wards behind locked doors. Patients who are able to move around under supervision are encouraged to use the replica kitchen and living room, read the newspaper and participate in art classes, all of which help them to re-adjust to life outside the hospital. One, wearing half-buttoned-up pyjamas and a slightly bemused expression, grasps both our hands and welcomes us to Wenzhou.
This type of care costs more than the public health system. A night in a bed at Kangning Hospital ranges from 400-800RMB per night, and the average cost of a stay is between 12,000-15,000RMB. But unlike Professor Tse, Guan rejects the idea that mental health care is expensive in China. When he started out, he says only 30 percent of the population had medical insurance, and it was reserved mostly for civil servants.
'In 1996, society's coverage ratio for basic medical treatments was very low, but now, 95 percent have access to medical insurance,' says Guan. 'It's a huge and fast improvement. The man on the street would not have had medical insurance back then.'
Private psychiatric care in China grew by 20 percent in the last few years as China's middle class increasingly prioritises spending on health. Private employers are also expanding their services in this area, with companies such as Foxconn reportedly offering 24-hour hotlines and suicide prevention counselling, though of course, that is partly due to their history of such cases.
But, while the cost of staying in a private hospital such as Kangning is prohibitively high for most people, sometimes just normal one-on-one counselling can be too expensive as well. With single sessions ranging from around 200 to 700RMB per hour, investment in what should be a longer-term solution does not seem like a feasible option for those without health insurance.
So, for those who can't access private or state care, responsibility all too often falls to ill-prepared relatives. Yuyang Liu, a Beijing-based photographer, has been documenting the lives of those caring for mentally ill people at home. 'The idea of photographing mental illness issues first came up when I received a newsletter from a Chronic Disease Prevention Center in Gaoyao town, Guangdong, where I worked as a photojournalist,' Liu says. 'The letter mentioned its effort in helping those struggling with mental illness and their families. I was curious about their real lives and conditions, so this is how I started.
'Some of the [people with mental illness] went to hospital, but more were staying at home. I found there were some families who were ashamed of them and abandoned them. But more families will try and look after them and try to give them a better life. This is also why I chose to do such a project: to see the relationship between patients and family members, and the humanity in their life.'
Liu says one of the most shocking cases he came across was 83-year old Mei Lin, who lives with four mentally ill patients who she cares for by herself. 'She does everything to support this family without the ability to live independently,' says Liu. 'Mei Lin tells me she often feels hopeless and cries a lot. For her, it's an endless road.'
Inevitably, it's difficult to quantify the numbers of mentally ill people kept at home. A report in Chinese newspaper Xinjing Bao in 2013 said as many as 100,000 mentally ill people were kept locked up in Hebei province alone, with the reporter finding people confined to cages, often naked.
The government’s '686 Program' was set up to provide better links between hospitals and community health care, and work to 'unlock' those mentally ill patients who are restrained by relatives who often don't know how else to cope.
Private health care will continue to play an important role in China's growing mental health sector, and the Kangning Hospital has ambitious plans to expand. By 2019, it is intending to have 30 medical centres and 8,000 beds in China.
'We do need more professionals, but the challenge is also cultural – we need to bring about ways that will work in the context of urban China'
But the key challenge, Professor Tse says, is raising the knowledge and education of mental health to allow more acceptance in China. 'We do need more professionals, but the challenge is also cultural. We need to bring about ways that will work in the context of urban China,' he concludes. 'For example, we need to focus more on the family's involvement. Plus, many people will still turn to herbal medicine and traditional doctors for help first, so we need to equip this community and this layer of the workforce so they are able to do some simple diagnosis and intervention too. We need to focus on cultural values and beliefs and find the way that works for China.'
This article first appeared in our October 2016 issue; updates have since been made to reflect changes and new figures.
By Helen Roxburgh