Dr. Gu Xiuling mentioned that in clinical practice, the first contact with depressed patients may not be with the psychiatry department of a specialist hospital, but with doctors in community hospitals or general hospitals, but their poor recognition of depression or little training in psychiatry leads to patients often being missed or misdiagnosed.17 Moreover, in many places there are only primary care physicians without psychiatry, and doctors do not deal with psychological problems (Phillips et al., 2009). In addition, the ability of counsellors and social workers to recognise the symptoms of depression is still at a stage where training is still needed. Many people find psychotherapy very expensive and turn to Chinese medicine, such as acupuncture and herbal medicine, while others refuse treatment altogether.18 All of these conditions make the number of depressed people seem small on the 'surface'.
An interesting cultural phenomenon is that many Chinese patients present to psychiatry with somatic symptoms rather than psychological complaints, and the rate of somatization reporting is much higher in China than in the West, particularly in clinical reports of depression (Nikelly, 1988; Yen et al., 2000). Chinese psychiatric patients have consistently high rates of somatization reporting, with upwards of 70% of patients with somatization symptoms as the main complaint (Chen, L., 2007; Ji et al., 2005). There are several explanations for the somatization complaints of depression.
TCM views illness as a manifestation of an imbalance in the whole; the body and the mind work for each other, and emotional illness cannot be separated from a holistic view and is therefore related to the imbalance of the five internal organs. This view of Chinese medicine takes somatisation for granted. For Chinese patients, the body is considered to be interpenetrating with the mind, with dysfunctional emotions or thoughts being directly related to the functioning of the physical body and vice versa. Chinese medicine considers mental problems to be due to imbalances or blockages in the body's internal organs and meridians, so depression is often defined as liver qi stagnation, spleen and stomach deficiency, kidney essence deficiency or heart and lung meridian disorders. Once the internal organs are out of balance or the meridians are blocked, depressive symptoms can spread. In this way, the concept of 'neurasthenia', a disorder of the nervous system, is in line with the traditional epistemology of Chinese medicine. However, in Western culture, the body and mind are seen as dichotomous entities, a distinction further exemplified by the DSM (Ying, 2002).
Secondly, Chinese people tend to minimise positive self-expression and are more repressed in their emotional expression, but Western cultures are more likely to express both positive or negative emotions. Hsu Longguang (Hsu, 1981) observed that in the West, the human being is defined as unique and distinct from others; but in the East, the human being is defined in terms of relationships with others. Thus, the Chinese conceptualise the self as social, as Confucianism teaches that one should not flaunt one's emotions in order to maintain the harmony of the whole. This would then explain the possible bias in the Chinese representation of depressive symptoms.
There is a stigmatization of mental illness in Chinese society. In 2012, the World Psychiatry Association interviewed nearly 13,000 people (aged 26-45) in China and found that more than 45% of people chose not to receive treatment, even if they were depressed; even among those who were willing to receive treatment, only Only 18% of those who would like to receive treatment would choose specialist psychiatric care. The stigma of being diagnosed with depression, or even wishing that doctors would not diagnose depression, is still prevalent.19 This factor also contributes to the underestimation of the number of people with depression.
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