In Western psychiatry, depression is considered a major cause of suicide. But research from China calls that assumption into question. More than 300,000 suicides occur annually in China, nearly 10 times the number of suicides in the United States.
"While China has the world's largest number of suicides, this is not just due to its large population. It also has a very high suicide rate, two to three times higher than that of the U.S.," said Arthur Kleinman, M.D., chair of the department of social medicine at Harvard University and professor of psychiatry at Cambridge Hospital. "What's surprising is that many researchers do not point to depression as the major cause of suicide. Even though the rate of depression is going up in China, it is still much lower than it is in the West. So, given that rate, it is unlikely depression would be the cause of suicide. Also, the Chinese have emphasized the social dimensions of suicide and have shown that it correlates with social problems."
This data from China presents a fundamental challenge to Western psychiatrists, Kleinman said, "to rethink suicide" and "to examine to what degree depression associated with suicide is not the cause of suicide, but simply is an outcome of social-psychological conditions, just like the suicide is."
Kleinman, who is the Maude and Lillian Presley Professor of Medical Anthropology, has lived in East Asia for more than five of the last 30 years. He is director of the World Mental Health Project, which produced the book, World Mental Health: Problems and Priorities in Low-Income Countries, and chair of the Technical Advisory Committee of the World Health Organization's Nations for Mental Health Program.
Long interested in the problem of depression in China, Kleinman noted in this exclusive interview that he is planning to collaborate on a study of suicide with psychiatrist Michael Phillips, M.D., a Harvard Medical School colleague who is in China full-time conducting research at a collaborating center.
In a prior study, Phillips found that 40% of all suicides in the world occur in China, but depression there is three to five times less common than in the West, and substance abuse, often viewed as another cause of suicide, is much less common in China than in the West (Kleinman and Cohen, 1997).
The pattern of suicide in China is different from that of the West, where suicide is more common in men and in urban areas, Kleinman said. In China, suicide is more common in women than in men and, since 70% of China's 1.2 billion people live in rural areas, 90% of the suicides occur there. Fifty percent of all suicides in women in the world occur in China, which can partly be accounted for by the accurate reporting system of the Chinese. Among Chinese women ages 16 to 26, the suicide rate is particularly high.
"They probably always have been at high risk for suicide in Chinese society, but their suicide today seems to be related to social changes, as well as continuing social problems," Kleinman said. "For example, the paternalism in Chinese families has often led to abuse of women, especially young women. They have been forced into marriages, or had their futures cut off. Additionally, there is the classic difficulty of relationships between daughters-in-law and mothers-in-law, but that has been intensified by economic developments of the last two decades which, if anything, have sort of worsened the situation of rural women."
Another factor could be the one-child-per-couple policy in China. Kleinman and colleague Sing Lee, M.D., at the Chinese University of Hong Kong, wrote in an article, "Although it reduces the risk of population explosion and is accepted by urban dwellers, it may constitute a major blow to disempowered young women in many rural areas. Having more sons and grandsons is essential for raising these women's inferior status in a social world that is still largely ruled by patriarchal values" (Lee and Kleinman, 1997).
A surprising element of the suicide story in China is that women and men 55 years and older are at increasing risk, even though Chinese society has always been thought of as valuing the elderly, Kleinman added.
"This is a highly complex problem that people are just beginning to look into. Part of it may be that the elderly themselves, in a very Confucian way, respond to the burden that they are on younger people by committing suicide as a way of controlling resources that are scarce," he said. Additionally, as economic and social forces change, some elderly people in China are being isolated and uncared for.
Kleinman has been studying health issues in Taiwan since 1968, and in China since 1978. His first research project in China involved untangling a very complex relationship between depression and neurasthenia, a term quite popular at that time in Chinese psychiatry, although no longer used in American psychiatry.
"My early research raised questions as to what degree neurasthenia could be rediagnosed as depression. This led to a very big controversy in Chinese psychiatry because that was a time when depression was almost undiagnosed in China. It was diagnosed only for people who had psychotic depression and in very small numbers of cases in clinics, whereas neurasthenia, along with schizophrenia, was the first or second most common diagnosis in psychiatric clinics."
Since that research was conducted, epidemiological studies have indicated that the rates of depression are increasing in China.
"But still, in those epidemiological studies, their rates of depression are much lower than in the West," he said. "The real question is, and this is an ongoing question, does China have much less depression or does it simply diagnose depression less frequently?"
Kleinman's other areas of research have included somatization, an area of high interest to the Chinese "because they see a lot of that," changes in the Chinese psychiatric profession, the treatment and cost of treatment of epilepsy in rural China (epilepsy is widely treated by psychiatrists as well as neurologists in China), and the social course of schizophrenia and the influence of family therapy on schizophrenia outcome.
In 1994, Kleinman was co-author of an article on family-based intervention for schizophrenic patients in China (Xiong et al., 1994). For that study, Harvard and Chinese researchers developed and evaluated a comprehensive, ongoing intervention for families of schizophrenia patients appropriate for China's complex family relationships and unique social environment.
Following their admission to a hospital, 63 patients with schizophrenia were enrolled in the study. They were randomly assigned to receive standard care or a family-based intervention that included monthly 45-minute counseling sessions focused on the management of social and occupational problems, medication management, family education, family group meetings, and crisis intervention. At six-, 12- and 18-month follow-ups by blind evaluators, the proportion of subjects rehospitalized was lower, the duration of the rehospitalization was shorter and the duration of employment was longer in the experimental group than in the control group.
There are several changes and programs going on in China that are quite interesting, Kleinman said. For example, during market reforms, the former socialist health care system was allowed to disintegrate. China is now recasting its rural health care system.
The way that Chinese psychiatry has dealt with issues such as depression has as much to teach Western psychiatry as Western psychiatry has to teach Chinese psychiatry, according to Kleinman.
"We can teach them about the importance of being attentive to minor forms of depression that may be going undiagnosed and untreated, and they can teach us about the dangers of medicalizing forms of suffering as depression, which may not deserve to be called depression," Kleinman said.
"For example, the DSM-IV makes the extraordinarily absurd point that after eight weeks of bereavement for a spouse, child or parent, one can make the diagnosis of major depressive disorder of a bereaved person. That is total nonsense. There is no empirical data for that, and indeed it flies in the face of almost everything we know internationally about bereavement. For the Chinese, no one who is bereaved for only two months after a loss is diagnosed as having major depressive disorder, and that sort of caution on their side is a good caution for us."
Kleinman went on to point out that much of what is going on in China is representative of other parts of the world. "Eighty percent of the world's population is in societies like those of China, India, Indonesia, South America and sub-Saharan Africa. These are large, impoverished societies in the developing world, some of which are changing very rapidly. China is a very good example of that as it moves from a very poor society to a middle-income society," he said.
With those economic changes come mental health problems. In the last 10 years or so, the tremendous economic development of global capitalism and free markets in Asia, Latin America and even in Africa has been associated with a negative set of mental health outcomes, according to Kleinman.
"The substance abuse epidemic, the epidemic of sexually transmitted diseases, suicide, depression, and anxiety disorders, and violence are problems that are increasing all over the world and have something to do with our political economy and the way culture is changing worldwide," he said, warning of increasing problems.
"In 1998 and into 1999, we are seeing another change, and that is societies which had rapidly improved their economic situation from the standpoint of globalization of markets are now in economic crisis, a crisis that may very well spread to the United States. And economic crises have often been associated with a deepening of mental health problems."
Kleinman urged American psychiatrists to become much more involved in global psychiatry and the social aspects of psychiatry. He noted that in many areas outside North America and Western Europe, schizophrenia, dementia and other forms of mental illness are on the rise. For example, due to an increased population at risk, schizophrenia is expected to afflict 24.4 million people in low-income societies by the year 2000, a 45% increase over the number afflicted in 1985 (Kleinman and Cohen, 1997).
"Profound poverty, refugees associated with the disintegration of communities, the breakup of whole societies, radical changes in social environments owing to the development of megacities, huge shifts in urban/rural populations, exploding population growth and the aging of populations" are all profound social changes that impact psychiatry and the prevalence and treatment of such disorders as Alzheimer's disease, posttraumatic stress disorder and depression Kleinman said.
"In an era of profound globalization in just about every aspect of life, it is important that American psychiatry also define itself in a global manner, which we haven't. In my view of psychiatry, American psychiatry has been extraordinarily ethnocentric," Kleinman said.
With the one exception of cultural psychiatry, the social side of psychiatry, according to Kleinman, has particularly been in decline. For example, he said, American psychiatry has limited its view to Latinos in America rather than thinking of Mexicans, Central Americans or South Americans, or to African-Americans without thinking of Africa, or to Russian-Americans without being concerned about Eastern Europe.
"I would say that American psychiatry has failed utterly to engage seriously the international setting, and this has led to a marginalization of American psychiatry in international health. American psychiatry and psychiatry in other developed nations, such as those in Europe, are very small players in international health compared with fields like internal medicine. Even the other specialty areas, from ophthalmology to obstetrics, have a much greater stake in the international agenda than we do," he said.
"It is a scandal that American psychiatrists are so ethnocentric. And it reflects an extraordinary blindness in our time to the social side of psychiatric disorders and the almost total absorption of the profession either with biology or with managed care. I don't mean managed care as a social issue to study, but managed care as a reality of practice. My sense is that this is a moment in which psychiatry will either come to engage in these problems internationally as it should, and strengthen itself vis--vis engagement with social problems, or this side of psychiatry will disappear entirely, and psychiatry will be left as a rather marginal specialty that no longer addresses the agenda that psychiatrists have traditionally regarded their discipline to be engaged in."
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Kleinman A, Cohen A (1997), Psychiatry's global challenge. Scientific American March: 86-89.
Lee S, Kleinman A (1997), Mental illness and social change in China. Harvard Rev Psychiatry 5(1):43-46.
Xiong W, Phillips MR, Hu X et al. (1994), Family-based intervention for schizophrenic patients in China. A randomized controlled trial. Br J Psychiatry 165(2):239-247.