By GU Jiaqi, ZHAO Lanxi, YANG Shuhongji
In a 2019 online survey of more than 300,000 college students in China, over 20 percent of them reported “sadness and depression,” a problem that colleges, parents and the medical community are coming to terms with, but the response is slow. Colleges cannot find enough qualified counselors for students in need. And those seeking help can be further traumatized by incompetent care, social stigma, and bureaucratic red lines.
Zihua locked herself in her room and tied a noose to a rod in the wardrobe, and put her head through it. She had been planning for this moment since she started her sophomore year three weeks before. Then she changed her mind and collapsed on the floor. Calling her parents, oblivious to anything but her grades, would not help.
Her coursework was difficult and she didn’t even like her major, biology, that much. She was devastated when she failed to achieve a perfect GPA, but quitting biology was never an option.
“I don’t really know what to do other than studying harder,” she said. She stopped eating and was diagnosed with moderate depression. She wasn’t the first in the family to receive a diagnosis of depression, but neither she nor her parents considered doing anything about it.
Depression is a common and serious medical condition. The Health Organization estimates that more than 350 million people are affected. It is given as a major cause of suicide.
Trying to be a ‘good’ student
Many who suffer depression in college trace it back to high school. Many thought things would get better, but college often turns out to be even more stressful — the race for internships, countless exams, and never-ending application cycles for scholarships and awards.
Yinxue studies computer science. She is a good, but not an outstanding student. Some of her close friends have scholarships, research grants, and better 4.0 GPAs. Feeling that she is not as smart as her peers, she tries to work harder, never leaving the library before it closes. Her free time is spent on learning another coding language or preparing for another certificate — anything that might be useful when she looks for a job. “I can’t slow down. Otherwise, I’d feel so guilty, to my mom and to myself,” she said.
During lockdown this year, confined to her childhood bedroom, she suddenly found herself unmotivated, which made her even more guilty, frustrated, and discouraged. She lost all appetite and developed an irregular heartbeat and shortness of breath. Diagnosed with depression and prescribed medication, her symptoms didn’t improve until school resumed and her life went back to normal.
For sophomore Wenyin, depression is part of her daily routine, and sometimes, death seems to be a better option than carrying on, but Wenyin tries to tame those frightening ideas.
“I’ve been dealing with depression for five years,” Wenyin said. “It’s like having lice, you know. Is it bothersome? Yes, it is. But I’ve learned to live with it.”
Weyin is not ashamed of her “mental illness”. On the contrary, she is more than willing to share her story. She is forever cracking jokes and full of energy, the epitome of positivity. But only she knows what it is like to be constantly on an emotional roller coaster between exhilaration and despair. “I’d have a thousand plans for life in the morning, and want to kill myself at night,” she said.
Wenyin and her mother were kicked out from her family when she was only three. Mental illness runs in her family, but no one talks about it. The family has long given up on a cousin who has schizophrenia. When Wenyin was diagnosed with severe depression, anxiety disorder, and obsessive-compulsive disorder, everyone, including her father, simply pretended that she was fine.
Then in college, she was also diagnosed with bipolar disorder, marked by extreme mood swings. Anything may trigger an avalanche of anger, guilt, and sadness. She once had “a full meltdown” on seeing an ad for luxury goods. “How can people waste money on such meaningless things when millions of people are starving?” she recalled thinking.
Suicide is constantly on her mind. But she can’t bear the thought of her leaving her mom. She cannot decide whether she wants to make a huge amount of money and die, or buy life insurance and die by accident. She can’t be close to anyone, for fear of being unable to abandon them. She is torn between the urge to end the agony and her self-imposed obligation not to hurt anyone. (“Even if I jump off a building, I’ll make sure I don’t hit anyone passing by.”)
Last November, she tried to hang herself in the dorm room, but the belt she used snapped, leaving her bawling on the floor. She calmed down and decided to shelve the suicide plan until after an English test she had promised to take with a friend. “I can’t leave her alone,” she reasoned with herself.
When Zihua finally mustered up the courage to seek help at the campus counseling center. The counselor immediately informed her “mentor”, a graduate student assigned to oversee the well-being of undergraduate students, who, most likely out of good intentions, asked Zihua’s roommates and friends to “watch out for her”. Soon, everyone knew that she was “mentally ill.” Others started to dodge her.
College students often refrain from seeking professional help for depression, deterred by the social stigma associated with mental illness, as well as the practical repercussions after the diagnosis. Zihua was rejected in her application to switch majors, blatantly on the basis of her mental health. “They want ‘good’ students,” she reasoned with herself.
Go home, get better
WANG Chao, a counselor at a university in Shanghai, told Jiemian News that many students delayed treatment, but even if they sought mental health support, mismanagement of their depression could exacerbate and prolong their suffering.
Zihua took some time off college and went home. Her parents, unaware of the risks of sudden discontinuation of antidepressants, didn’t intervene when Zihua stopped taking her pills. On returning to school a few months later, towards the end of her freshman year, Zihua seemed to have turned into another person. She shopped obsessively, partied with abandon, and was prone to excitement. Mistaking these for her effort to be sociable, her parents were relieved that she was finally getting better. Little did they know that her depression had proceeded to bipolar disorder, which led to her attempted suicide.
Wenyin recalled being dragged away from her high school classroom in front of all her friends by her parents, afraid that her headache and trembling hands would reveal her “craziness” and embarrass the family. The teacher simply looked on, and told her to “recover at home”.
The counseling service at college was hardly any more helpful. The counselor, after knowing of Wenyin’s suicidal thoughts, referred her to a local hospital. Her mentor reported her case to the dean of the department, who invited Wenyin to a “tete-a-tete”. After some awkward exchange of pleasantries, the dean, in a sudden burst of warmth, grabbed Wenyin’s hand and raved, “We are all with you. Do you feel loved?”
"We lean an ear to your heart, tell us what is bothering you," reads on the wall of a counselling room in a university. Photo by Gu Jiaqi
“I was so uncomfortable and embarrassed,” she recalled. “I don’t need love or care from them, or kindness expressed in this manner. Anyone with any basic knowledge would know that.”
Awkward inquiries from her mentor, counselor, and dean become another inconvenience she has to deal with. If the weather suddenly turns cold, for example, the mentor texts her “It’s getting cold. Are you ok? Don’t be sad.” If she doesn’t reply, he asks, “You are taking medication on time, aren’t you?”
The blame game
In 2018, the Ministry of Education issued guidelines on “timely and effective” counseling for students. Each school must have at least two professional counselors and the counselor to student ratio should be no lower than 1: 4000. In certain cities such as Shanghai, the minimum ratio is 1: 3000. In 2020, the National Health Commission also published a set of measures requiring colleges to establish mechanisms to assess, treat, and manage mental health conditions among students.
The reality is a far cry from what the guidelines had hoped. Colleges are grappling with severe shortages of well-qualified and certified counselors. This is partly due to a chaotic reshuffling of the national certification system, which in essence suspended certification for professional counselors in 2017. But the real reason is economics, according to Wang Chao. “The hourly rate for a therapist is in the high hundreds at a private clinic. At a college counseling center, they make tens. It’s very hard for schools to attract and retain good counselors.” Wang said.
With the number of students in need soaring and the supply of qualified on-campus counselors stagnating, colleges are facing enormous pressure from media, parents, and lawmakers. If a student kills himself, the social media backlash and sometimes legal liabilities all fall on the school.
CHEN Jun, director of Shanghai Mental Health Center, told Jiemian News that destigmatization and privacy protection are two imperatives in managing depression on campus. Students often hesitate to seek professional help, deterred by the social stigma associated with “mental illness”. On the other hand, the already sensitive matter of privacy protection is further complicated by the delicate dynamics among family, school, and medical professionals, all crucial to students’ mental well-being.
The 2018 guidelines mentioned that schools should “take measures to protect sensitive private information of students.” But in practice, this is a fine line to walk. When should a counselor, concerned about the safety of the student, alert the school or other medical professionals even without the patient’s consent? How much of a student’s medical information should be disclosed to her parents, who are sometimes the root cause of her mental health issues? Who makes the decision on whether to continue with her study or focus on treatment? And what if the school requires a written “proof of mental stability” from the counselor for the patient to go back to the classroom, while in actuality such proof is both scientifically unsound and ethically wrong?
Chen said schools should establish clear protocols and processes in assessing, treating, and monitoring mental health on campus, which requires close collaboration between schools and healthcare institutions. Professional institutions should not only serve as psychology specialists to whom the school counselors refer students for treatment, but also can play an active role in mental health initiatives on campus, such as training social workers.
The challenges in dealing with depression on campus reflect systemic shortcomings in managing and treating mental health in the entire country. Data from the National Health Commission suggested that by the end of 2015, only 29 universities had full-time undergraduate psychological medicine courses. And by 2017, the year when the test for certification for professional counselors was suspended, there were a little more than 30,000 certificated psychiatrists.
"China currently ranks among the lowest in the world in the number of professional psychotherapists on a per capita basis," said Chen. "Mental health has been overlooked by the public for a long time, one of many reasons why medic students to want to be a therapist."
But as society becomes more aware of mental health, Chen expects the shortage would be alleviated.
Where do we go from here?
Zihua went through over forty therapy sessions after her attempted suicide. For her, these sessions, albeit “not immediately helpful,” provided a cathartic outlet for her dark thoughts. She remembered crying in one of the first meetings with the therapist and feeling relieved. “The next day, I began to notice the sky, the bird songs. I was gradually able to feel things.” Her parents no longer push her to “grind it out” in school, and Zihua is able to, at least temporarily, let go of her obsession with “a perfect GPA”. “First I got to recover. I can't die, or try to die again.”
Finally, Zihua was able to switch out of the biology department to study social work in 2017, something she has grown passionate about out of her own struggle with depression. She started an intervention group to advocate for mental health awareness on campus. During her clinical internships, she found herself easily empathizing with teenagers suffering from depression.
“I had wanted to excel at everything. But now I have come to be at peace with just being an ordinary person. In fact, it’s good to be ordinary, and be happy about the ordinary things in life,” she said. But knowing of her own tendency she is still extremely careful, even paranoid sometimes, in fear of a relapse.
Yinxue is only getting busier. In fact, studying hard is her way to escape from darker thoughts. She struggles to sleep and shuns social occasions. Her friends suggested she go to the school counselor for help, but she always says no. She is too busy.
Wenyin's condition is not getting better. Depression became so unbearable for her this fall that she had to take a leave of school to receive full-time care at the hospital. There, she made friends with other patients, some extremely well-educated and successful in the eyes of unknowing outsiders.
She is recovering at home, waiting for her “proof of mental stability.” But even with this, it’s still uncertain whether she would ever be allowed back to school – to resume her studies, she needs “proof of recovery”, which theoretically is impossible to obtain since one can never “fully recover from” bipolar disorder. Before the “system” figures out what to do in such cases, Wenyin, as well as thousands of other students, are just coping.
The list of Wenyin's expanse of her stay at Shanghai Mental Health Center. Altogether it costs her 23,302 yuan, 17,932 yuan of it are covered by social insurance. Photo provided to Jiemian News by Wenyin
(Except for Chen Jun, the names of other interviewees have been changed to protect privacy.)