Prevalence of mental disorders in China

The Article published by Jin Lu, Xiufeng Xu, and colleagues1Lu J Xu X Huang Y et al.Prevalence of depressive disorders and treatment in China: a cross-sectional epidemiological study.Lancet Psychiatry. 2021; 8: 981-990Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar in The Lancet Psychiatry on the prevalence of depressive disorders in China has attracted much interest. Due to several methodological issues, we believe that the findings should be interpreted with caution. First, although the structured Composite International Diagnostic Interview (CIDI) 3.0 can generate point, 1-year, and lifetime prevalence of depressive disorders, only 1-year and lifetime figures were reported. The omission of point prevalence could hinder understanding of the full profile of the epidemiology of depression in China. Compared with 1-year and lifetime prevalence, the point prevalence of depressive disorder might have more important implications for the provision of timely interventions and resources across national programmes. Furthermore, because of the limitations of structured interviews administered by lay interviewers, the accuracy of psychiatric diagnoses might be unreliable. For example, in the validation study of the CIDI 3.0 in China,2Huang YQ Xie SF Lu J et al.Community-based evaluation of the reliability and validity of Chinese version of Composite International Diagnostic Interview-3.0.Chin Ment Health J. 2010; 24 (in Chinese).: 21-24Google Scholar the specificity of the CIDI 3.0 for major depressive disorder was only 68·6% and for dysthymia was only 72·3%, suggesting that up to 31·4% of people without depression could be misdiagnosed as having depressive disorders, which could explain the low treatment rate found in this survey. Second, the survey only included people who had resided in the selected households for at least 6 months during the past year. In China there are millions of migrant workers, with many who frequently relocate across different regions to find work and other opportunities. Considering that migrant workers are a subpopulation at high risk of depressive disorders,3Qiu P Caine E Yang Y Chen Q Li J Ma X Depression and associated factors in internal migrant workers in China.J Affect Disord. 2011; 134: 198-207Crossref PubMed Scopus (116) Google Scholar the exclusion of those who lived in the selected households for less than 6 months might underestimate the prevalence of depressive disorders. Third, in this survey, the participants who had depressive disorders within the past year completed a self-report version of the Quick Inventory of Depressive Symptomatology (QIDS-SR) assessment. However, the validation study of the QIDS-SR was published in 2016,4Feng Y Huang W Tian T-F et al.The psychometric properties of the Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR) and the Patient Health Questionnaire-9 (PHQ-9) in depressed inpatients in China.Psychiatry Res. 2016; 243: 92-96Crossref PubMed Scopus (23) Google Scholar and so it is unclear how the authors used the QIDS-SR Chinese version in this survey, which was conducted between 2012 and 2015. Importantly, QIDS-SR can only assess depressive symptoms in the past week, rather than symptoms in the worst month during the past 12 months, as claimed by Lu and colleagues.1Lu J Xu X Huang Y et al.Prevalence of depressive disorders and treatment in China: a cross-sectional epidemiological study.Lancet Psychiatry. 2021; 8: 981-990Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar Moreover, QIDS-SR Chinese version is a self-report scale validated only in Mandarin, rather than in other dialects found in many regions in China.4Feng Y Huang W Tian T-F et al.The psychometric properties of the Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR) and the Patient Health Questionnaire-9 (PHQ-9) in depressed inpatients in China.Psychiatry Res. 2016; 243: 92-96Crossref PubMed Scopus (23) Google Scholar It is unclear what proportion of the illiterate or poorly educated participants who spoke different regional dialects were able to fully understand, let alone complete, the QIDS-SR items, or how much training lay interviewers had on the correct use of QIDS-SR in these circumstances where it might only have been possible to use the structured CIDI 3.0. Fourth, to estimate treatment rate, participants with depressive disorders within the past year were asked if they "received any treatment for their depressive symptoms during the past 12 months".1Lu J Xu X Huang Y et al.Prevalence of depressive disorders and treatment in China: a cross-sectional epidemiological study.Lancet Psychiatry. 2021; 8: 981-990Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar However, it is incorrect to assume that illiterate or poorly educated individuals, or even those with low mental health literacy, could adequately understand the meaning of depressive symptoms, particularly with the use of lay interviewers who might not be able to explain the meaning fully. Furthermore, individuals in China tend to somatise their depressive symptoms.5Kleinman A Culture and depression.N Engl J Med. 2004; 351: 951-953Crossref PubMed Scopus (358) Google Scholar Many participants with depression who mainly have somatic symptoms are likely to have under-reported both depressive symptoms and the treatment sought for their depression-related somatic symptoms. Additionally, in defining treatment with any antidepressant or mood stabiliser for 30 days or more, it is unclear whether this referred to 30 consecutive days of treatment or 30 cumulative days of treatment. Fifth, the prevalence of depressive disorders in the whole study sample was not mentioned, and comparison with prevalence data from other surveys in China and other countries were not done. Finally, key factors closely associated with the prevalence of depression and treatment rate in China, such as stigma, were not measured. We declare no competing interests. Y-TX, HC, and H-LS contributed equally to this work. Prevalence of depressive disorders and treatment in China: a cross-sectional epidemiological studyDepressive disorders in China were more prevalent in women than men, unemployed people than employed, and those who were separated, widowed, or divorced than people who were married or cohabiting. Most people with depressive disorders reported social impairment. Treatment rates were very low, and few people received adequate treatment. National programmes are needed to remove barriers to availability, accessibility, and acceptability of care for depression in China. Full-Text PDF Prevalence of mental disorders in China – Author's replyOn behalf of my coauthors, I thank Yu-Tao Xiang and colleagues and Chuanyuan Kang and Jianzhong Yang and colleagues for their comments on our Article.1 Full-Text PDF Prevalence of mental disorders in ChinaJin Lu, Xiufeng Xu and colleagues described the socioeconomic characteristics and use of mental health services in people with depressive disorders in China, using data from the China Mental Health Survey (2012–15).1 These are the first nationwide data on the epidemiology, clinical severity, functional impairment, and treatment of depressive disorders in the general population in China, which can be used to plan the prevention and treatment of depressive disorders. Full-Text PDF