Narrated experiences of depression and suicidality among Chinese inpatients

Suicide in China accounts for one-sixth of deaths by suicide worldwide and has drawn recent international attention (Yu et al., 2021). Studies have identified depression to be a major risk factor in suicidal behavior and estimate that up to 70% of Chinese people who die by suicide are depressed (Phillips et al., 2002; Lee, 2011; Wu, 2011). However, few studies have investigated experiences and meanings of suicidal behavior among people with depression in China.
Moreover, understandings of depression are changing rapidly in China (Lee, Kleinman, and Kleinman, 2007), and experiences of depression are culturally and contextually specific (Foucault, 1980; Lee, 1999). How do modern-day Chinese people with depression understand and experience their illness, what does it mean to them, and how does this relate to suicidal behavior?
This thesis seeks to understand experiences of depression and suicidal behavior (suicidal ideation and attempt) among psychiatric inpatients in Nanjing, China. I conducted and analyzed 142 qualitative interviews with adult inpatients diagnosed with a depressive disorder at Nanjing Brain Hospital. Interview transcripts were coded using an integrated approach that allowed for both inductive emergence and deductive organization of codes (Bradley, Curry, and Devers, 2007), and a high degree of inter-rater agreement was established among three coders. Based on participants’ interview responses, I engaged theoretical frameworks regarding the social course and moral experience of illness and the role of culture in experiences of depression (Ware and Kleinman, 1992; Yang et al., 2014; Ryder and Chentsova-Dutton, 2012).
The data chapters (Chapters 3 to 6) are organized around participants’ sociopsychosomatic experiences, moral experiences, somatic symptoms, and suicidality in the context of depression. Chapter 3 elucidates how participants’ understanding and experience of depression interacted with their interpersonal relationships and societal conditions. Chapter 4 identifies that “what mattered most” to participants was maintaining their roles within their families and discusses how depression threatened participants’ “moral status” within their social contexts (Yang et al., 2014). Chapter 5 explores why participants tended to emphasize somatic symptoms and how this somatic emphasis interacted with stigma and medical help-seeking. Chapter 6 demonstrates how participants’ motivations for suicidal behavior responded to experiences of suffering and impairment related to depression symptoms, their perceived inability to lead a moral life, structural factors that made mental healthcare difficult to afford and access (particularly for rural residents), and societal stigma and misinformation regarding disability, chronic illness, and mental illness.
This thesis furthers understanding of the complex interrelationships between social, moral, psychological, and somatic experiences of depression among Chinese inpatients, how these experiences are informed by cultural values and structural barriers to care, and how these experiences influence suicidal behavior. While the study offers one window into a specific set of experiences, it also presents implications for targets for depression treatment, anti-stigma intervention, and suicidal behavior prevention; highlights how structural issues with mental health service delivery interact with moral values in China; and informs future research on the intersection of depression, disability, and suicidal behavior.

Keywords: China
somatization
depression
chronic illness
cultural context
moral experience
lived experience
qualitative
mental illness
social context
disability
stigma
psychiatry
suicidal behavior
Advisor: Singh, I