China Wants to Screen Students for Depression. What Then?
On Sept. 11, China’s National Health Commission published long-awaited new guidelines for the prevention and treatment of depression. Although generally well received, one of the plan’s provisions provoked widespread concern: a rule calling for secondary and postsecondary students, pregnant women, the elderly, and other high-risk groups to be screened for depression, and for high schools and colleges to establish mental health files for students, with special emphasis on those with “abnormal” assessment results.
According to the state-organized China Mental Health Survey, there are about 50 million people living with depression in China. Other surveys have shown incidences of depression among Chinese college students could be as high as 24%, or one in four. More recent studies suggest this number may be skyrocketing amid the coronavirus pandemic.
Done correctly, screening can be a powerful weapon in the fight against depression. But screening methods are controversial, and no substitute for effective treatment techniques. Without carefully weighing the pros and cons, there’s a chance increased screening could end up compounding the problem rather than fixing it.
In the past five years, Chinese society and the Chinese government alike have both paid increasing attention to mental health issues, including depression. For example, last year’s “Healthy China Initiative (2019-2030)” government guideline lists “promoting psychological health” as one of its major objectives.
But awareness of mental health problems in the country remains low, while prejudice and stigma are widespread. Even in major cities like Shanghai, less than 42% of residents are able to correctly identify the symptoms of depression. As a result, many people with mental health illnesses do not consider themselves unwell, and even if they do eventually recognize they have a problem, they are often unwilling to consult mental health professionals. According to the China Mental Health Survey, the consultation rate for depression and other mood disorders in China is as low as 9.5%.
Since we can’t rely on people to come to us, we must go to them. In this context, screening is an important means of identifying individuals who could benefit from mental health care and providing them with the help they need. Yet international attitudes toward screening programs are very much divided, with some experts arguing depression screening harms just as much as it helps.
In particular, screenings can hurt respondents by producing false positives. Screening is different from a clinical diagnosis in that it casts a wide net to detect as many potential cases as possible. When it comes to other diseases, false positives can easily be rectified by going to the hospital and receiving a second examination. That’s harder in the case of depression, and considering the social stigma attached to mental health issues in China, we must carefully consider the potential consequences of false positives before carrying out screening programs.
Meanwhile, if mental health professionals wish to realize the positive benefits of screening, we must ensure they are accompanied by effective intervention services. Unfortunately, many colleges and universities have not yet established adequate systems for providing such services.
First, many schools don’t recognize the importance of maintaining students’ mental health. I personally know of school administrators who call students with mental health illnesses in for meetings, not to provide them with appropriate psychological support, but rather to persuade them to take leaves of absence, or at least not to do anything “stupid” that would “damage the school’s reputation.”
At present, most schools offer professional mental health services only through their psychological consultation centers, which are often severely understaffed. The scant staff members available are typically undertrained. If large-scale screening programs for depression and other mental health issues become a reality on Chinese campuses, these are the people who will play a crucial role in ensuring their safety and effectiveness. If they themselves are prejudiced against depression, or haven’t been trained to provide ethical, effective services, it could result in violations of confidentiality or privacy that would be absolutely disastrous for students’ well-being.
Indeed, it is not uncommon nowadays for students to say that on-campus psychological counseling has not only failed to improve their condition, but actually caused additional trauma. Carrying out screenings and providing follow-up services are not simple endeavors — they require us to continually investigate students’ needs and seek their opinions. Before carrying out on-campus screening for mental health issues, we should first consider the degree to which students approve of such initiatives and ask them what can be done to improve current consultation services.
It’s likely that, over the next two years, governments at all levels are going to start issuing colleges and universities in their jurisdictions new criteria for the construction of on-campus mental health systems. The criteria must go beyond detection rates. Our ultimate goal should not merely be detecting mental illness, but rather treating it effectively and improving the overall well-being of students. We need to see whether students with mental health illnesses really get the help they need, whether their symptoms have improved, and whether they are satisfied with their school’s mental health services. If colleges solely focus on detection rates to the detriment of follow-up services, students will simply do their best to fly under the radar during screenings, and the pressure these screenings create may actually cause their mental health to deteriorate.
In short, we should not screen for the sake of screening. Screening programs must be accompanied by the development of mental health frameworks that include counseling services, staff training programs, as well as awareness and education initiatives. These frameworks must then be continually evaluated and refined, and we must carefully study their viability in different regions throughout China — that is, whether or not they have the potential to improve the clinical outcome of local people with depression, rather than exacerbating their condition.
In many cases, it is possible to measure the benefits of mental health screenings, but much more difficult to measure their harm. Minimizing the latter means implementing better mental health education to combat public prejudices and discrimination, creating a tolerant and friendly social atmosphere, and preventing the stigmatization that extensive screening may engender.
In China, the Beijing Suicide Research and Prevention Center can be reached for free at 800-810-1117 or 010-8295-1332. In the United States, the National Suicide Prevention Lifeline can be reached for free at 1-800-273-8255. A more complete list of prevention services by country can be found here.
Translator: Lewis Wright; editors: Cai Yiwen and Kilian O’Donnell; portrait artist: Wang Zhenhao.
(Header image: E+/People Visual)