Exploring the association between depression and shenjing shuairuo in a population representative epidemiological study of Chinese adults in Guangzhou,China

Abstract

Traditional mental illness concepts remain prevalent in China. Shenjing shuairuo (i.e., neurasthenia), a depressive-like syndrome less favored in Western psychiatric nosology, has a long tradition of acceptance among Chinese lay people. The concept may be more easily accepted in China due to the culturally informed view of the importance of harmony between mind and body and is consistent with Traditional Chinese Medicine. The goals of this study were to estimate the prevalence of shenjing shuairuo, the overlap between shenjing shuairuo and depression, and whether these two disorders share correlates. Data was obtained from 751 Chinese adults using stratified random sampling. Spatial epidemiological methods were utilized with face-to-face interviews conducted in Guangzhou, China. The Patient Health Questionnaire (PHQ-9) and the neurasthenia criteria from ICD-10 measured depression and shenjing shuairuo. The prevalence of depression and shenjing shuairuo were 5.3% and 15.4%, respectively. Participants with depression were nearly six times more likely to have shenjing shuairuo. Women were more likely than men to have comorbid depression and shenjing shuairuo. Poorer health was reported across disorders. Those with shenjing shuairuo were more likely to report medical diagnoses. Longer sleep latency was reported for those with shenjing shuairuo and those with depression reported fewer hours of sleep and lower sleep quality. Those with depression alone reported the poorest sleep. Significant diagnostic overlap and few distinct correlates were observed. Nevertheless, the difference in prevalence and acceptance among non-professionals suggests that shenjing shuairuo is a useful category of distress among Chinese adults in Southern China.

Keywords

Chinese culture bound syndrome depression neurasthenia

Studies in global mental health highlight the importance of identifying culturally specific signs and symptoms of mental disorders (Betancourt, Speelman, Onyango, & Bolton, 2009; Rasmussen, Katoni, Keller, & Wilkinson, 2011). Identifying the role of culture in shaping the manifestation and presentation of mental illness is of critical importance as the field continues to mature. Further research on culturally appropriate intervention targets is needed (Hall et al., 2014; Rasmussen et al., 2015) among Chinese populations.

Shenjing shuairuo (i.e., neurasthenia) is a cultural syndrome within Chinese populations and is closely related to illness concepts found within Traditional Chinese Medicine (TCM) (Lin, 1981). Few investigations have attempted to identify whether shenjing shuairuo is a distinct mental illness concept or if it shares features with other common mental disorders that are represented in the Western psychiatric nomenclature. The importance of this distinction arises in part due to claims of the universality of Western diagnostic constructs within diverse global communities. For example, the World Mental Health surveys presuppose that common mental disorders like depression can be universally applied, quantified, and compared within diverse populations (Kessler et al., 2015). This approach does not take into consideration the burden of disease associated with more widely accepted illness concepts that may already exist in a local population (e.g., Rasmussen et al., 2011).

The current study explored patterns of comorbidity between shenjing shuairuo and major depressive disorder to determine whether depression contributes uniquely to our understanding of mental health within Southern China. We further identified correlates of these comorbidity patterns to differentiate whether they may have a shared etiology. For the purpose of our study, we define comorbidity as the diagnostic co-occurrence between shenjing shuairuo and depression. Additionally, we would expect a pattern of three diagnostic categories to emerge: shenjing shuairuo alone, depression alone, and no disorder.

According to the ICD-10, shenjing shuairuo is listed as a primary diagnosis that is comprised of two core symptoms of either persistence of fatigue after mental effort, or body weakness after minimal effort. Additional symptoms include aches and pains, dizziness, headache, sleep disturbance, inability to relax, irritability, and dyspepsia (ICD-10; Neurasthenia (F48.0). The concept is also featured within the Chinese Classification of Mental Disorders (CCMD-3; Chinese Society of Psychiatry, 2001) as a syndrome comprised of neurosis accompanied by brain and bodily symptoms organized similarly to the ICD-10, such that there is persistent mental and physical fatigue following effort accompanied by at least two additional symptoms of worry, anxiety, depression (not dominant), excitement, muscle tension, sleep disturbance, physical manifestations including dizziness, indigestion, chest tightness. Unlike the ICD-10, fatigue is not a core feature of shenjing shuairuo in the CCMD-3. At present, shenjing shuairuo does not appear in the DSM-5 (American Psychiatric Association, 2013), but was included as a culturally bound syndrome in the DSM-IV (American Psychiatric Association, 1994) (Chang et al., 2005). The revised Chinese mental health law, enacted in 2013, requires mental health professionals to use the ICD-10 as the international standard, and few Chinese psychiatrists utilize the DSM-IV in their regular practice (Dai et al., 2014; The Central People's Government of The People's Republic of China, 2012). Therefore, the ICD-10 diagnostic classification system was used in the present study.

The popular use of shenjing shuairuo as a diagnosis has historic roots within the Cultural Revolution in China, but the diagnosis is not indigenous to China (Gamma, Angst, Ajdacic, Eich, & Rossler, 2007). After gaining popularity in the United States, neurasthenia was imported to Russia (Shapiro, 2000), and finally to China (Shapiro, 2000), when in the early 1900s (Shapiro, 2000), it was translated into Chinese as “weakness of nerves” or shenjing shuairuo (神经衰弱). The popularity of neurasthenia in China was partly politically driven. When the Chinese Communist Party assumed control in Mainland China, people found it impossible to disagree with the party's order and would utilize shenjing shuairuo to avoid carrying out party demands (Shapiro, 2000). From a biocultural perspective, the acceptability of this diagnosis was supported by the compatibility between the mind–body connection (Cheung & Lin, 1997; Kleinman, 1982; Parker, Cheah, & Roy, 2001), and disruptions to energy (qi), which can lead to weakness and impairment in role function. Shenjing shuairuo is a locally relevant illness concept among lay people in Mainland China (Kleinman, 1982).

Shenjing shuairuo was the most common non-psychotic diagnosis in China during the 1980s (Zhang et al., 2007), but since this time, somatization and major depressive disorder have gained prominence (Zhang et al., 2007). There have been few investigations into the prevalence and diagnostic comorbidity between shenjing shuairuo and depression. In 1994, the World Health Organization's (WHO) transcultural study across four WHO general health centers indicated a 1.7% prevalence for neurasthenia using ICD-10 criteria (Gamma et al., 2007), whereas a study in the United States reported a 3.61% prevalence among the Chinese American population (Zheng et al., 1997). The prevalence of shenjing shuairuo may be lower than the estimates of depression and other psychiatric illnesses in Chinese populations. For example, the prevalence of any psychiatric illness is estimated to be 17.5%, with depression being 6%, in Mainland China (Phillips et al., 2009). However, psychiatric epidemiological studies have largely ignored shenjing shuairuo in favor of Western psychiatric diagnoses, so the population prevalence and patterns of comorbidity for shenjing shuairuo in Mainland China is unknown.

The majority of studies that have addressed comorbidity between shenjing shuairuo and depression have been conducted in Western countries among Chinese immigrant populations. One foundational and notable exception was Kleinman's study in Hunan, China, where he found 87% comorbidity with major depressive disorder among neurasthenia patients (Kleinman, 1982). Zheng and colleagues' population-level study in Los Angeles reported a 3.61% prevalence of “pure” neurasthenia; a 13.4% prevalence of neurasthenia comorbid with depression; and a 8.9% prevalence of comorbidity with some forms of anxiety disorders (Zheng et al., 1997). Shi-Fu and colleagues' review of WHO data of 14 countries produced a high (44.8%) comorbidity between shenjing shuairuo and depression (Shi-Fu, He-Qin, Linden, Korten, & Sartorius, 1998). More recently, a longitudinal population-level study conducted in Zurich showed that among those who reported shenjing shuairuo, 68.5% also had a major depressive episode (Gamma et al., 2007). In another epidemiological study sampling Asian American ethnic groups in the United States, the prevalence of lifetime and 12 months of “pure neurasthenia” (with no overlapping major psychiatric disorders) was 2.22% and 1.19%, respectively. If inclusive of concurrent diagnoses, the prevalence for lifetime and 12-month neurasthenia significantly increased to 4.89% and 2.80%, respectively (Molina, Chen, Alegría, & Li, 2012).

Several correlates consistently related to depression may also be associated with shenjing shuairuo. In order to better understand whether these disorder categories are distinct, we primarily focus on sleep dysfunction, medical conditions, and potentially traumatic life events. We believe that if depression and shenjing shuairuo are distinct disorders, they will occur without comorbidity and demonstrate a different pattern of association with measured correlates.

Sleep dysfunction or sleep impairment is a defining characteristic of shenjing shuairuo. In one study, 20 participants with neurasthenia (chronic fatigue syndrome; CFS) who did not have co-morbid depression, anxiety, or sleep disorder were compared with 20 healthy matched controls on their sleep characteristics. Participants with CFS complained of poor quality and unrefreshing sleep, daytime napping, and greater night-time awakenings than controls (Sharpley, Clements, Hawton, & Sharpe, 1997). A separate study found that CFS patients had less total sleep time, lower sleep efficiency, and less rapid eye movement sleep than healthy controls (Togo et al., 2008).

Kleinman (1982) found a 75% co-occurrence between shenjing shuairuo and work-related illness along with a high frequency of chronic pain conditions. Shi-Fu et al. (1998) reported that patients meeting criteria for shenjing shuairuo minimized their poor health status. Recent investigations of neurasthenia and other overlapping conditions, mostly health-related, are notably diverse, including Burn-Out Syndrome (Freudenberger, 1974), Chronic Fatigue Syndrome (Abbey & Garfinkel, 1991; Greenberg, 1990; Lin, Lin, & Zheng, 2001; Luthra and Wessely, 2004; Schäfer, 2002; Starcevic, 1999; Ware & Kleinman, 1992), Fibromyalgia (Schäfer, 2002), Multiple Chemical Sensitivities (Schäfer, 2002), and Atypical Depression (Angst, Gamma, Sellaro, Zhang, & Merikangas, 2002).

The link between traumatic experiences and shenjing shuairuo reaching a threshold of clinical concern and impairment has long been recognized. Terms such as “combat neurasthenia,” “traumatic neurasthenia” and “traumatic neurosis” predate the modern concept of posttraumatic stress disorder (PTSD) (Crocq & Crocq, 2000; Jones & Wessely, 2006). Zhang et al. (2007) demonstrated that Taiwanese earthquake survivors with neurasthenia reported greater severity of intrusive and avoidant/numbing PTSD symptoms and less resilience when compared with survivors without shenjing shuairuo (Zhang et al., 2007).

The current study reports the prevalence of shenjing shuairuo and its association with major depression. The purpose is to characterize the unique disease burden of this condition and to clarify the need for treatment protocols for people suffering from shenjing shuairuo as opposed to general depression. As far as we are aware, this is the first epidemiological study of shenjing shuairuo and depression in Mainland China. We made the following hypotheses: 1) The prevalence of shenjing shuairuo will be higher in Mainland China compared with estimates reported for Chinese diaspora communities in the United States and other Western countries; 2) A high degree of overlap (greater than 40%) will be found between depression and shenjing shuairuo; 3) Age will be significantly associated with the two disorders such that younger people would report depressive symptoms more often than older people and that shenjing shuairuo will be more frequently reported by older adults due to potential age and cohort effects. No hypotheses were made about the correlates of the two disorders as this analysis is exploratory and descriptive.

Methods

Sample and procedure

Data collection occurred between April and November 2014 in the Yuexiu district and the Tianhe district of the South China city of Guangzhou, Guangdong. Stratified cluster sampling was used to select eligible participants in the two districts who were adults aged 18 to 59 years. The sampling followed a two-step process. Guangzhou consists of 12 districts and we first selected Yuexiu and Tianhe based on the high proportion of migrants living in these districts (one of the original aims of the data collection was to compare the health of migrant and non-migrant populations, see Chen et al., 2016; Hoi, Chen, Zhou, Sou, & Hall, 2015).

Spatial methods were utilized to identify participants. Within each district, we selected 700 households using Geographical Information Systems (GIS). Random geographic coordinates chosen were then overlaid on Google Earth images to find the nearest building to the randomly chosen points. If it was not a residential building, then the closest residential building was chosen. Only one household was selected within each building and only one eligible participant per household. If there was more than one eligible participant in the household we used the earliest birthday date method to choose the participant. We randomly selected a floor and randomly selected a household per floor for multistory buildings.

A mobile phone random number generator was used to choose the random floor and household. In households where an individual refused, we replaced that household within the same building by the same procedure as described above. If we were refused three times within one building, we moved to another building. If the household did not have the selected individual at home, we moved to another one. In addition, if nobody was at home during the first visit, we visited the same household two more times. We concluded that no one lives in the household we selected if there was no response during any of the three visits.

Pairs of Chinese interviewers using tablet devices conducted household face-to-face interviews. Interviewers asked questions about socio-demographic characteristics and health behaviors, and participants answered the sensitive portion of the questionnaire themselves, with assistance from interviewers if necessary. After finishing the study, participants were debriefed and received a 50RMB mobile phone prepaid card as a token of appreciation for their participation. All interviews were conducted in the participants' Chinese language, either Mandarin or Cantonese. All interviewers received extensive training in interview methods, research ethics, and the study protocol. The Institutional Review Board at Guangdong Provincial Skin Diseases and STIs Control Center and University of North Carolina approved the study protocol.

In total, there were 1215 attempted surveys, with 14 partial completions, 368 refusals, and 82 uninhabited locations, resulting in a sample of 751 complete surveys. This yields a total response rate of 66.20%, which is favorable for household surveys conducted in Mainland China.

Instruments

Shenjing shuairuo was measured using neurasthenia symptoms from the ICD-10 diagnostic system. Symptoms were translated from English to Chinese, translated back into English, and then compared for conceptual equivalence (Van Ommeren et al., 1999). Items were administered via tablet devices. A diagnosis of shenjing shuairuo was made if either of the two core symptoms were present: 1) Persistent increased fatigue after mental effort or 2) Bodily weakness and exhaustion after minimal effort and accompanied by two additional symptoms (e.g., muscular aches, irritability). Each item was scored as present or absent (coded as 0 absent and 1 present). Internal consistency reliability based on Kuder–Richardson Formula 20 was .72.

Depressive symptoms

The Chinese version of the 9-item Patient Health Questionnaire (PHQ-9; Yeung et al., 2008) was used to assess depressive symptoms. Participants indicated their level of depressive symptoms during the past two weeks on a 4-point scale (0 = not at all, 1 = on several days, 2 = on more than half of the days, and 3 = nearly every day). Higher scores indicated higher depressive symptoms (range = 0–27). The Chinese version previously evidenced high internal consistency (α > .80; Yeung et al., 2008; Yu, Tam, Wong, Lam, & Stewart, 2012). Depression diagnosis was indicated using a cut score of 10 or higher, which was based on population-based studies of Chinese samples (Hou et al., 2015; Nan, Lee, Ni, Chan, & Lam, 2013; Yu et al., 2012). Internal reliability was .88, in the current sample.

Participant characteristics

Age, sex, education level, marital and employment status, and migrant status were included. Age was dichotomized for analysis as being at or below age 35 and 36 or older, education level was dichotomized as junior high school and below versus senior high school and above, marital status was trichotomized as never married, married or cohabiting, or divorced/widowed, and employment was defined as employed, unemployed, student, and retired.

Sleep problems

The Chinese version of the Pittsburgh Sleep Quality Index (PSQI) (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989) was used to measure sleep latency (minutes it takes to fall asleep), average sleep duration per night (in hours), overall sleep quality (rated on a 4-point scale from very bad to very good) and two items measuring impairment in maintaining social relationships and impairment in occupational functioning related to poor sleep (rated on a 4-point scale from none to cannot do).

Self-rated health

Self-rated health status was assessed using a commonly used and validated (DeSalvo, Bloser, Reynolds, He, & Muntner, 2006) single item indicator with responses ranging from 1 = excellent to 5 = poor. This variable was categorized into poor/fair, good/very good/excellent.

Physical illness

Participants were asked to report whether they had been diagnosed by a doctor or other health professional with 1) any physical illness, 2) a backache lasting longer than 3 months, 3) any muscle or bone disease, or 4) any additional illness.

Exposure to potentially traumatic life events

The Life Event Checklist (Weathers, Marx, Friedman, & Schnurr, 2014) was utilized to measure the respondents' personal exposure to 17 life events. Exposure items included natural disaster, fire, and interpersonal violence (e.g., physical assault, rape). Affirmative responses were grouped into 0 = no exposure, 1 = one exposure, and 2 = two or more exposures.

Analysis

The prevalence of shenjing shuairuo, depression, and comorbid shenjing shuairuo and depression was estimated with 95% confidence intervals. Logistic regression analysis estimated unadjusted log odds of having depression if participants met criteria for shenjing shuairuo. Chi-square tests were used to assess whether participant demographic characteristics, self-rated health, physical illness diagnoses, and potentially traumatic event exposures were associated with shenjing shuairuo alone, depression alone, and comorbid shenjing shuairuo and depression. ANOVAs with post-hoc Bonferroni corrections were used to evaluate the association between each diagnostic category and sleep problems (sleep quality, sleep duration, sleep latency, and sleep-related impairment). Additional chi-square analyses evaluated differences between shenjing shuairuo only and depression only to further test the predicative validity of the depression diagnostic category. All analyses were conducted using STATA Version 12.1MP (StataCorp, 2011).

Results

Prevalence and comorbidity

The prevalence of depression, shenjing shuairuo, and comorbid depression and shenjing shuairuo was 5.32% (95% CI [3.7%, 6.9%]), 15.3% (95% CI [12.7%, 17.9%]), and 2.5% (95% CI [1.4%, 3.7%]) respectively. The odds of participants with depression having shenjing shuairuo were nearly 6 times those of participants without depression, OR = 5.80, 95% CI [3.00, 11.17], p < .001. The patterns of observed comorbidity were 81.62% with neither condition, 13.09% with shenjing shuairuo without depression, 2.79% depression without shenjing shuairuo, and 2.5% with both disorders.

Participant characteristics

Table 1 displays the sample characteristics and their associations with each diagnostic category. Participant sex was associated with comorbid shenjing shuairuo and depression, X² (df = 1) = 6.78, p=.009, with women being more likely to have comorbid conditions than men (4.78% versus 1.25%). No statistically significant associations were noted for any other participant characteristic with the diagnostic categories (p > .10).

Table 1.

Bivariate associations between participant characteristics and depression, shenjing shuairuo, and comorbid disorders.

	Total N (%)	Depression only (n = 21) %	X ²	df	p	Shenjing shuairuo only (n = 96) %	X ²	df	p	Shenjing shuairou and Depression (n = 19) %	X ²	df	p
Total	751	2.80				12.78				2.53
Sex			.269	1	.603		1.93	1	.164		6.78	1	.009
Female	377 (50.20)	42.86				56.25				78.95
Male	374 (49.89)	57.14				43.75				21.05
Age			1.21	1	.272		0.64	1	.422		0.12	1	.728
18–35	490 (65.25)	76.19				87.90				68.42
36+	261 (34.75)	23.81				12.10				31.58
Education			0.05	1	.826		0.00	1	.985		1.03	1	.744
Junior HS or less	165 (22.00)	23.81				21.88				31.58
Senior HS or higher	585 (78.00)	76.19				78.12				68.42
Income			0.27		.603		0.00	1	.951		0.63	1	.426
3200 RMB or less	365 (48.60)	42.86				46.70				57.14
Greater than 3200 RMB	386 (51.40)	57.14				49.30				42.10
Marital status			4.26	2	.119		3.03	2	.220		0.71	2	.701
Never married	276 (37.25)	57.89				30.85				42.11
Marred/cohabitating	276 (37.25)	42.11				69.15				57.89
Divorced/widowed	465 (62.75)	0.00				0.00				0.00
Migrant			0.64	1	.422		0.01	1	.934		1.88	1	.171
Yes	318 (42.34)	66.67				58.33				42.11
No	433 (57.66)	33.33				41.67				57.89
Employment status			1.09	3	.781		0.29	1	.962		6.64	3	.084
Employed	580 (85.67)	10.53				12.09				33.33
Unemployed	97 (14.33)	89.47				83.52				61.11
Student	97 (14.33)	0.00				2.02				0.00
Retired	97 (14.33)	0.00				2.02				5.56

Sleep problems

Results showed differences between diagnostic categories for sleep latency F(3, 741) = 6.12, p = .0004. Compared with participants with neither disorder (M = 19.20, SD = 15.94), those with shenjing shuairuo alone (M = 25.01, SD = 20.95, p = .011), and comorbid shenjing shuairuo and depression (M = 31.05, SD = 27.25, p = .016), reported an average of over 5 minutes and 11 minutes longer sleep latency, respectively. No significant differences were observed for the depression alone category (M = 23.33, SD = 9.66) when compared with other diagnostic categories.

The average amount of sleep per night differed by diagnostic category F(3, 741) = 6.71, p = .0002. Compared with participants with neither disorder (M = 7.53, SD = 1.16), participants with depression alone (M = 6.71, SD = 1.31, p = .009), and comorbid shenjing shuairuo and depression (M = 6.69, SD = 0.89, p = .016), reported an average of nearly one hour less sleep per night. No significant differences were observed for the shenjing shuairuo alone category (M = 7.32, SD = 1.19) when compared with other diagnostic categories.

Overall sleep quality differed by diagnostic category, F(3, 746) = 25.98, p < .0001. Compared with participants with neither disorder (M = 1.88, SD = 0.67), depression alone (M = 2.76, SD = 0.89, p < .001), shenjing shuairuo alone (M = 2.25, SD = 0.74, p < .001), and comorbid shenjing shuairuo and depression (M = 2.79, SD = 0.92, p < .001), all reported poorer sleep. Participants with depression alone reported worse sleep quality than participants with shenjing shuairuo alone (p = .014). The comorbid shenjing shuairuo and depression group reported worse sleep quality than the shenjing shuairuo alone group (p = .013).

Sleep-related impairment in social, F(3, 745) = 19.38, p < .0001, and occupational functioning, F(3, 742) = 23.22, p < .0001, was significantly different across diagnostic categories. Compared with the participants with neither disorder (M = 1.43, SD = 0.70), participants with depression alone (M = 2.43, SD = 1.12, p < .0001), shenjing shuairuo alone (M = 1.78, SD = 0.85, p < .0001), and comorbid shenjing shuairuo and depression (M = 1.94, SD = 0.99, p = .023), all reported greater social impairment. Participants with depression alone reported greater impairment in social functioning than participants with shenjing shuairuo alone (p = .002).

Compared with the participants with neither disorder (M = 1.59, SD = 0.77), those with shenjing shuairuo alone (M = 1.83, SD = 0.84, p = .033), depression alone (M = 2.81, SD = 1.03, p < .0001), and comorbid shenjing shuairuo and depression (M = 2.44, SD = 1.29, p < .0001) all reported greater occupational impairment. Participants with depression alone reported greater impairment in occupational functioning than participants with shenjing shuairuo alone (p < .0001), and participants with comorbid shenjing shuairuo and depression reported greater occupational impairment than those with shenjing shuairuo alone (p = .018).

Health status

Self-reported health

Increasingly poor self-reported health was associated with shenjing shuairuo alone, X² (df = 2) = 14.01, p = .001, depression alone, X² (df = 2) = 17.79, p < .0001, and comorbid depression and shenjing shuairuo, Fisher's exact test, p < .0001.

Physical illness

Self-reported medical diagnosis was associated with shenjing shuairuo, X² (1) = 14.28, p < .0001, and comorbid shenjing shuairuo and depression, X² (2) = 9.28, p = .002, but not with depression alone (p = .093). The same pattern of results was found for chronic back pain and bone and muscle disease. However only shenjing shuairuo alone also statistically significantly associated with reporting “other” medical diagnoses, X² (1) = 12.47, p < .0001 (see Table 2).

Table 2.

Bivariate associations between health status and trauma exposure and depression, shenjing shuairuo, and comorbid disorders.

	Total N (%)	Depression only (n = 21) %	X ²	df	p	Shenjing shuairuo only (n = 96) %	X ²	df	p	Shenjing shuairou and Depression (n = 19) %	X ²	df	p
Self Reported Health			17.79	2	<.001		14.02	2	.001				<.001
Very good/Excellent	459 (61.12)	47.62				8.33				21.05
Good	247 (32.89)	28.57				45.83				42.11
Poor/fair	45 (5.99)	23.81				45.83				36.84
Diagnosed with illness			2.82	1	.093		14.28	1	<.001		9.28	1	.002
No	428 (57.07)	42.86				40.62				26.32
Yes	322 (42.93)	57.14				59.38				73.68
Backache			2.90	1	.088		4.66	1	.031				.444
No	723 (96.27)	90.48				92.71				94.74
Yes	28 (3.73)	9.52				7.29				5.26
Muscle or bone disease			0.45	1	.501		5.46	1	.019		39.14	1	<.001
No	727 (96.80)	100.00				93.75				73.68
Yes	24 (3.20)	0.00				6.25				26.32
Other disease?			1.07	1	.301		12.47	1	<.001		2.08	1	.150
No	474 (63.12)	52.38				46.88				47.37
Yes	277 (36.88)	47.62				53.12				52.63
Potentially traumatic events			8.44	2	.015		6.01	2	.049		8.32	2	.016
None	504 (67.92)	47.62				60.64				42.11
1	130 (17.52)	19.05				18.09				26.32
2 or more	108 (14.56)	33.33				21.28				31.58

Exposure to potentially traumatic life events

Increasing exposure to potentially traumatic events was associated with shenjing shuairuo alone, X² (2) = 6.01, p = .049, depression alone, Fisher's exact test, p = .020, and comorbid depression and shenjing shuairuo, X² (2) = 8.32, p = .016 (see Table 2).

Additional chi-square analyses (see Table 3) focused on differences between the shenjing shuairuo only and depression only groups for health outcomes (health status, physical diagnosis). Results demonstrated that, compared to depression alone, a higher proportion of participants with shenjing shuairuo alone reported poor self-reported health, but this was not significant, X² (2) = 4.93, p = .08. No differences were noted for physical illness diagnosis between groups (all p's > .10).

Table 3.

Bivariate differences between shenjing shuairuo only and depression only on health status.

	Total N (%)	Depression only (n = 21) %	Shenjing shuairuo only (n = 96) %	X ²	df	p
Self Reported Health				4.93	2	.08
Very good/Excellent	13 (11.11)	23.8	8.8
Good	50 (42.74)	28.6	45.8
Poor/fair	54 (46.15)	47.6	45.8
Diagnosed with illness				.04	1	.85
No	48 (41.03)	42.9	40.6
Yes	69 (58.97)	57.1	59.4
Backache				.12		.73
No	108 (92.31)	90.48	92.71
Yes	9 (7.69)	9.52	7.29
Muscle or bone disease				1.38		.25
No	111 (94.87)	100	93.8
Yes	6 (5.13)	0.00	6.3
Other disease?				.21	1	.65
No	56 (47.86)	52.3	46.9
Yes	61 (52.14)	47.6	53.1

Discussion

Compared with previous studies conducted in Western settings, findings from this random population-level study demonstrated a higher prevalence of shenjing shuairuo. The current estimated prevalence was 15.4%, almost four times greater than Zheng's estimate of 3.61% among Chinese Americans (Zheng et al., 1997) and considerably higher than the 1.7% prevalence by the WHO study (Shi-Fu et al., 1998). This could be in part due to the sampling procedures employed and the influence of cultural and contextual factors. Ours was a population and not clinical sample, and stringent impairment criteria were not applied to either of the present diagnoses. The current study suggests that in Mainland China more than 1 in every 10 people may have shenjing shuairuo. This prevalence suggests that the illness concept shenjing shuairuo may be an important public mental health priority, which requires future study.

The 2.5% comorbidity of shenjing shuairuo and depression is significantly lower than expected from Zheng and colleagues' (1997) study, which documented a 13.4% comorbidity among Chinese Americans and 44.8% across 14 countries (Shi-Fu et al., 1998). Unlike Chinese diaspora communities living in Western contexts, shenjing shuairuo overlaps with depression to a much lesser degree. This suggests symptoms of shenjing shuairuo are more commonly reported than depression among community samples in Mainland China. But again, our present effort was conducted within a non-clinical population.

Associations between shenjing shuairuo and demographic, trauma, and physical health indicators provide further clarity about the diagnostic specificity of the disorder. Participants with comorbid shenjing shuairuo and depression were more likely to be women than men. This is generally consistent with literature supporting roughly 20% higher levels of internalizing conditions among women than men, conditions such as depression, anxiety, and somatic complaints (Eaton et al., 2012). Choi and Chen (2006) found Chinese women perceived a higher stress level related to family demands than Chinese men (Choi & Chen, 2006). Age was not found to be associated with differential endorsement of symptoms related to either depression or shenjing shuairuo, contrary to our predictions.

Poorer self-reported physical health was not specific to any disorder category. This is broadly consistent with literature reporting associations between mental health and physical health (Prince et al., 2007). Participants with shenjing shuairuo received a greater number of diagnoses by medical professionals. This may be due to greater somatic symptom involvement, as shenjing shuairuo is associated with elevated somatization (Zheng et al., 1997). Participants with shenjing shuairuo may therefore interact with medical professionals with greater frequency, which may increase the opportunity for screening for psychiatric disorders, within primary care medical clinics.

The present study provided a comprehensive analysis about sleep quality. Longer sleep latency was highest among participants with shenjing shuairuo and specific to this disorder. Worry, linked to delayed sleep onset, might be related to shenjing shuairuo (Pillai, Steenburg, Ciesla, Roth, & Drake, 2014), or lower pain tolerance (Sivertsen et al., 2015) may account for longer sleep latency. Depression and shenjing shuairuo share poor sleep quality, and this was associated with social and occupational impairment within the shenjing shuairuo group. Sleep appears to be an important correlate for both disorders.

Potentially traumatic life events were not specific to shenjing shuairuo. There was a dose–response relationship between the number of exposures and each disorder category. The association between depression and stressful life events is commonly supported in the literature and a high comorbidity between depression and posttraumatic stress disorder is often reported (Campbell et al., 2007).

Shenjing shuairuo may not be a popular diagnosis among mental health professionals in China as the concept was largely replaced by depression. The ICD-10 is now used more than the CCMD-3. Western biomedical conceptualizations are prevalent in China, as psychiatry is the dominant model, which tends to focus more on serious mental illnesses rather than common mental disorders and their treatment. However, greater integration of Western and Chinese concepts of distress may be needed. A recent survey revealed that the majority of psychiatrists believe there are some difficulties in applying universal diagnostic categorizations in China (Dai et al., 2014).

Illness concepts derived from Traditional Chinese Medicine (TCM), which emphasizes balancing qi, yin–yang imbalance, dietary therapy, and environmental influences on health, are more common health beliefs in China (Thirthalli et al., 2016). Shenjing shuairuo, although not born from TCM, emphasizes physical and psychological integration and is more widely accepted. Stigma around Western mental health concepts is an important barrier to service use among Chinese (Yang et al., 2007), and the acceptance of physical causes and treatments following TCM are more culturally acceptable (Thirthalli et al., 2016). This may account for the durability of this condition among community samples in South China.

Despite rapid industrialization, urbanization, and development, Chinese cultural illness beliefs remain. Given the overlap with depression, shenjing shuairuo may be a sufficient diagnostic category to capture distress among a large population of Mainland Chinese. Future research can assess the difference in acceptability of depression and shenjing shuairuo as diagnostic categories among patients and the general public. Moreover, research is needed to understand whether patients with shenjing shuairuo respond better to psychological, pharmacological, or TCM treatments. Traditional treatments include healthy diet, regular exercise, massage, medication, rest, and lifestyle adjustment to reduce stress (Kleinman, 1986). At present, little systematic evidence regarding the efficacy of shenjing shuairuo treatment exists.

The present study has several important limitations. We were unable to measure all possible psychiatric comorbidities. Anxiety disorders are the second most common psychiatric comorbidity with shenjing shuairuo, ranging from 8.9% to 11.4% (Molina et al., 2012; Ormel et al., 1994; Shi-Fu et al., 1998; Zheng et al., 1997). We also did not measure occupational stress and fatigue. Although we measured potentially traumatic life events, daily stressors might be more associated with depression and provide greater specificity regarding disorder etiology. This was not a clinical sample and although this increases the generalizability of our findings to the adult community-dwelling Chinese population, it may not provide information related to clinical presentation. We also utilized the PHQ-9 for case recognition. This instrument was designed for depression screening and not for diagnosis. However, the instrument has evidenced excellent sensitivity and specificity, and can serve as a good proxy as a diagnostic instrument.

This population-level study found evidence of a high prevalence of shenjing shuairuo in the general adult Chinese population in Guangzhou, China. The movement away from this diagnostic category by Chinese health professionals may mean that a large proportion of individuals will go undiagnosed and be untreated, further perpetuating a treatment gap. Findings from this study imply that the presentation and expression of shenjing shuairuo in China is similar to depressive disorders, but future research is needed to better understand the etiology, correlates, and treatment of this condition.

Footnotes

Acknowledgment

The authors wish to thank Mr. Tat Leong Wu for his assistance in manuscript preparation. We also thank all study participants and the team of interviewers from the University of Macau and Sun Yat-sen University.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this study was funded by Fogarty Global Health Fellows Program Consortium comprised of the University of North Carolina, Johns Hopkins Bloomberg School of Public Health, Morehouse and Tulane (5R25TW009340-02, 1R25TW009340-01). Professor Hall received additional support from grants SRG2014-00001-FSS, MYRG2015-00124-FSS and MYRG2015-00109-FSS awarded by the University of Macau.

Brian J. Hall, PhD, is the Director of the Global and Community Mental Health Research Group and an associate professor of psychology in the Department of Psychology at The University of Macau. He also holds a faculty appointment in the Department of Health, Behavior, and Society at the Johns Hopkins Bloomberg School of Public Health. Dr. Hall’s research is focused on the social determinants of population health, health disparities, the consequences of adversity and traumatic stress, cultural beliefs about health, and developing and evaluating scalable interventions for marginalized populations globally.

Kay Sio–Ngã Chang, PsyD, is a Faculty Collaborator in the Global and Community Mental Health Research Group and an associate professor of psychology at the University of Macau. She actively applies the scientist–practitioner framework in both her academic and clinical work since her graduation from the California School of Professional Psychology, San Francisco. She is a US licensed psychologist and a UK Chartered Clinical Psychologist who has a noticeably diverse clinical experience base for having practiced in the US, China, Hong Kong and Macau. She also volunteers for ongoing consultations in abuse cases and disaster trauma work. Her research interests include the applied aspects of positive psychology, medical anthropology, trauma work, professional development issues, addictive behaviors, creativity factors and resilient capacities.

Wen Chen, PhD, is an associate professor of medical statistics and epidemiology in the School of Public Health at Sun Yat–sen University. Dr. Chen researches public health services for migrants and refugees. She is currently the Project Manager of the Sun Yat–sen Center for Migrant Health Policy and the Hornor Researcher of Humanitarian and Development Research Initiative at Western Sydney University. Her published works focus on public health services research with migrants and refugees, including disparities in service delivery, risk behaviors, social determinants of health, and interventions.

Ka Lon Sou, MSc, is a PhD student in the Division of Psychology at Nanyang Technological University. Mr. Sou studies emotion perception and how it is affected by psychological disorders. He is a former research staff member of the Global and Community Mental Health Research Group at the University of Macau.

Carl Latkin, PhD, is a professor in the Departments of Health, Behavior, and Society and Epidemiology at the Johns Hopkins Bloomberg School of Public Health. He is co–director of the Prevention Core at the Johns Hopkins University Center for AIDS Research. His work examines social, environmental, and social network characteristics to address health behaviors in novel interventions for disadvantaged populations, in the USA, and globally (e.g., China, Thailand, and Vietnam).

Albert Yeung, MD, ScD, is Director of Primary Care Research at the Depression Clinical and Research Program at Massachusetts General Hospital (MGH) and Associate Professor of Psychiatry at Harvard Medical School. Dr. Yeung obtained his medical degree from National Taiwan University. He also obtained a Doctor of Science degree with a major in epidemiology from Harvard School of Public Health. He completed residency training in psychiatry at MGH. Dr. Yeung’s major research interests include integrating primary care and mental health services to improve treatment of depression, mental health issues of under–served populations, and the use of complementary and alternative methods including acupuncture, tai chi, qigong, and mind body group intervention in treating anxiety and depressive disorders.

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