Psychiatry Research 269 (2018) 1–8

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Primary care patient beliefs and help-seeking preferences regarding T

depression in China
Jiang Yuxinga, Hillary R. Bognerb, Wang Xiaoqingc, Wang Jiayua, Zhu Tingfeia, Yeates Conwelld,
⁎
Chen Shunlina,
a
Department of Psychology and Behavioral Sciences, Zhejiang University, Hangzhou, Zhejiang Province, PR China
b
Department of Family Medicine and Community Health, University of Pennsylvania Health System, Philadelphia, PA, USA
c
School of Mathematics and Statistics, Southwest University, Chongqing, PR China
d
Department of Psychiatry, University of Rochester Medical Centre, Rochester, NY, USA

A R T I C LE I N FO A B S T R A C T

Keywords: Patient beliefs about depression and its treatment in primary care clinics in China influence the delivery of care.
Depression Our objective was to investigate primary care patients’ beliefs about depression and its treatment as well as help-
Belief seeking preferences regarding depression in China to aid in the development and promotion of interventions that
Help seeking are acceptable to patients with depression. 100 primary care nurses used the Public Knowledge and Beliefs
Primary care
Survey Package (PKBSP) to assess patients in the primary care clinic waiting rooms. Of the 2639 patients, 15.5%
China
were depressed. Patients with higher education level were less likely to be depressed. Differences in beliefs were
significantly associated with age, education level and depression status, but no significant differences were found
on gender. Help-seeking preferences were also significantly associated with age, education level and depression
status. Patients screened with PHQ-9 positive depression were less willing to endorse “take antidepressants” and
“consult a non-medical practitioner” than non-depressed patients. However, they were more willing to endorse
“consult a psychotherapist”. Patient beliefs about depression and its treatment highlight a need for modification
of current paradigms, practices, and approaches to improve the acceptability of depression care provision.
Efforts to increase collaboration between primary care physicians and mental health professionals are needed.

1. Introduction
Depressive disorder represents a major public health issue inter-
nationally. The prevalence of depression among global population is
4.4% in 2015, with a total of 322 million patients (WHO, 2017). Ac-
cording to the National Health and Family Planning Commission, the
prevalence of mood disorders was 4.06% in China and depressive dis-
order was 3.59% (National Health and Family Planning Commission
PRC, 2017). Major depressive disorder was the second leading global
cause of years lived with disability (YLDs) in 2010, accounting for
12.1% of the total YLDs and 2.5% of the total disability-adjusted life-
years (DALYs) (Ferrari et al., 2013). Moreover, depression is often
complicated by comorbid physical illness, functional disability, and
suicide risk. The prevalence of major depression approaches 80%
among patients with chronic diseases, such as cardiovascular disease,
diabetes, and chronic pulmonary heart disease, which are the leading
causes of death in the world (Zhang et al., 2008). A meta-analysis
showed that in China the pooled lifetime prevalence of suicidal
ideation, suicide plan, suicide attempt were 53.1%, 17.5% and 23.7%
respectively (Dong et al., 2018).
Because depression has several different treatment options, patient
beliefs are important and have implications for acceptability of treat-
ment, adherence to treatment and subsequent recovery. Patient help-
seeking preferences may help to explain why certain patients accept
medications for depression or mental health referrals or fail to follow
through on clinical recommendations for treatment. According to the
Theory of Planned Behavior (TPB) (Ajzen, 1991), individuals are more
likely to engage in a behavior if they have favorable attitudes towards
it, believe that people whose views they value think that they should
carry out the behavior, and feel that they have the necessary resources
and opportunities to engage in the behavior.
While effective treatments, including medication and psy-
chotherapy, exist (Mitchell, 1997), a majority of people with depression
do not receive appropriate care (Kohn et al., 2004; Organization, 2001).
In Canada, 63.1% of 12-month major depressive patients sought
treatment and 33.1% were taking an antidepressant in 2012

⁎
Corresponding author.
E-mail address: chenshulin@zju.edu.cn (S. Chen).

https://doi.org/10.1016/j.psychres.2018.08.031
Received 12 October 2017; Received in revised form 9 August 2018; Accepted 12 August 2018
Available online 13 August 2018
0165-1781/ © 2018 Elsevier B.V. All rights reserved.
Y. Jiang et al.
(Patten et al., 2015). In China, 91.7% of patients with mood disorders
were not aware of the need to seek treatment (Phillips et al., 2009), and
only 22.7% of patients with major depression received treatment over
one year (Lee et al., 2009). This low treatment rate was probably due to
several factors, including stigmatization of mental illness, a lack of
awareness that they need care, misunderstanding about treatment, in-
accessibility of services due to cost or distance, improper dosing of
medications by primary care physicians, or other factors (Endo et al.,
2008; Greenberg et al., 2003; Kohn et al., 2004; Phillips et al., 2009;
Richards et al., 2004).
At the patient level, one barrier contributing to the under-treatment
of depression is related to their knowledge and attitudes about de-
pression. To date studies focusing on attitudes towards mental illnesses
have shown that stigma is associated with decreased quality of life
(Alonso et al., 2009), greater depression severity (Pyne et al., 2004;
Sirey et al., 2001), increased number of unmet mental healthcare needs
(Roeloffs et al., 2003), reduced medication adherence (Sirey et al.,
2001), more negative attitudes towards seeking a treatment
(Conner et al., 2010) and lower treatment compliance (Fung et al.,
2007). In addition, negative attitudes or beliefs would hinder effective
help-seeking for depression (Halter, 2004; Vega et al., 2010). However,
patients with more knowledge about antidepressant medication and
counseling are more likely to seek treatments (Dwight-Johnson et al.,
2000). If the public's mental health literacy is not improved, public
acceptance of mental health care may be hindered and many in-
dividuals with mental disorders may not receive appropriate help
(Jorm, 2000).
Another factor affecting depression treatment and management may
be the patients’ attitudes towards help-seeking, such as preference for
types of providers and treatments. For instance, some depressed pa-
tients prefer psychotherapy, others prefer antidepressant medicine or a
combination of both (Churchill et al., 2000; Dwight-Johnson et al.,
2004; Gum et al., 2006; Kwan et al., 2010; Raue et al., 2009). There is
also evidence that addressing patients’ preferences helps will improve
treatment quality and outcomes. Preference strength is significantly
associated with treatment initiation and 12-week adherence rate
(Raue et al., 2009), and patients who receive preferred treatments
improve more rapidly than those who do not (Chilvers et al., 2001; Lin
et al., 2005). The possible explanation may be that preference will
enhance the likelihood of treatment adherence (Dwight-Johnson et al.,
2001; Kwan et al., 2010; Schaik et al., 2004).
Studies in Hongkong have shown that primary care patients pre-
ferred to seek help from family and friends when they were depressed
(Chin et al., 2015; Sun et al., 2017). The help-seeking behavior was
found to be related to age, education and income (Sun et al., 2017).
Chinese immigrants in American and Canada were less likely to use
mental health services than local people (Abe-Kim et al., 2007; Tiwari
and Wang, 2008).
Currently, there is increased interest in targeting primary care set-
tings for the treatment of depression, because most depressed in-
dividuals visit their primary care physicians during the course of their
depressive episode (Coyne et al., 1994). In Western countries, over one-
half of all depression is treated in primary care clinics (Oxman et al.,
2002), and integrated pharmacologic and psychosocial interventions
currently available to primary care physicians have been shown to ef-
fectively treat patients with depression in primary care (Gensichen
et al., 2006; Gilbody et al., 2006).
In China, there are potential advantages for primary care clinics to
be the settings for depression care delivery. First, they are convenient
for patients to seek help because residents in most urban areas can find
a primary care clinic within a half-mile of their homes. Second, gov-
ernment-sponsored health insurance covers a greater proportion of care
when delivered through the primary care system (90–100%) compared
to that delivered in hospitals (70–100%). Third, Chinese are known to
have a tendency to express depression somatically (Kleinman, 2004;
Parker et al., 2001) so individuals may be more likely to seek a
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Psychiatry Research 269 (2018) 1–8
treatment for mental health problems in the primary care setting than
in mental health care clinics (Roeloffs et al., 2003).
Given the role of beliefs and preferences in help seeking behavior
and treatment effectiveness, it is important to learn about the beliefs
and preferences of Chinese primary care patients. To our knowledge, no
such research has been conducted in China. The purposes of this de-
scriptive study were to explore (1) the beliefs about depression and its
treatment, and (2) help-seeking preferences for depression among
Chinese primary care patients. And on the basis of findings from pre-
vious studies, we hypothesized that primary care patients were more
likely to be depressed than general population. We also predicted that
the beliefs and help-seeking preferences varied by gender, age, educa-
tional level, and depression status.
2. Methods
2.1. Sample
The sample included patients of primary care clinics in Hangzhou
City, China. According to previous researches, the prevalence of de-
pression was 15–20% among primary care patients (Gili et al., 2013;
Yeung et al., 2002). The sample size should be 2266, which was cal-
culated according to the simplification formula of Cross sectional study.
In consideration of the response rate, we tried to invite 3000 patients. A
two stage sampling method was employed. First, twenty primary care
clinics were randomly selected from each of the 5 districts in Hangzhou
City. A total of 100 clinics were selected as the study sites. Second, 30
consecutive patients visiting each clinic who met the following criteria
were recruited: (1) age ≥ 18 years; (2) residence in the neighborhood
served by the primary care clinic (and hence registered as a patient of
the clinic); (3) ability to communicate orally; and (4) capacity to pro-
vide informed consent. Patients who had cognitive impairment docu-
mented in their medical records were excluded. The Human Study
Committee of Zhejiang University approved the study.
Among the 3000 eligible patients who were invited to participate in
the study, 208 (6.93%) refused and 153 (5.1%) were excluded from
analyses because of incomplete data. In all, 2639 (87.97%) participants
were available for the present analysis.
2.2. Data collection
During the period from December 2009 to April 2010, one nurse
practitioner in each selected clinic was recruited and trained for three
hours to help with sample recruitment and data collection. These nurses
were asked to administer a questionnaire to 30 consecutive patients
visiting their clinics who met the inclusion and exclusion criteria. After
the nurse verified eligibility and obtained informed consent from the
patient, she gave the questionnaire to the patient to self-administer.
Nurses interviewed patients who were unable to read the questionnaire
(either due to illiteracy or low vision).
The questionnaire consisted of three sections, each contained
closed-ended questions requiring mainly single tick box or categorical
responses. The questions in each of the five sections are outlined below:
1. Gender, age (years), educational level (years of education).
2. The nine-item Patient Health Questionnaire (PHQ-9), which has
been validated in a primary care sample of the Chinese population
as well as in the general Chinese population (Chen et al., 2006;
Wang et al., 2014). A total score of ≥ 10 on the PHQ-9 was used to
classify the patient as depressed.
3. Attitude and knowledge questionnaire about depression, which was
developed according to the attitude and knowledge questionnaire of
European Alliance Against Depression (EAAD). It included three
parts:
a. Agree/disagree responses to the knowledge or belief statements
about depression (1 = “Agree”, 0 = “Disagree”), including the
Y. Jiang et al. Psychiatry Research 269 (2018) 1–8

following 6 statements: “depression is not a real disease,” “if Table 2

somebody is suffering from depression, it is his/her own fault,” Knowledge and beliefs about depression among primary care patients in China.
“anybody could suffer from depression,” “depression is a disease, Statement Agree/appropriate n
such as asthma or diabetes, which ought to be treated by a doctor (%)
or psychotherapist,” “If you are suffering from depression, you
Attitudes about depression
have to pull yourself together to get over it,” “Without external
1. Depression is not a real disease. 831 (31.5%)
support you are at the mercy of depression.”; 2. If somebody is suffering from depression, it is his/ 844 (32.0%)
b. Appropriateness ratings of 12 intervention options (1 = “appro- her own fault.
priate”, 0 = “not appropriate”) including the following inter- 3. Anybody could suffer from depression. 755 (28.6%)
ventions (European Alliance Against Depression, 2008): “take 4. Depression is a disease, such as asthma or diabetes, 198 (7.5%)
which ought to be treated by a doctor or
antidepressants,” “consult a non-medical practitioner,” “pull
psychotherapist.
yourself together,” “consult a doctor,” “do sports,” “take barbi- 5. If you are suffering from depression, you have to 1591(60.3%)
turates and sedatives,” “autogenic training,” “consult a Chinese pull yourself together to get over it.
Medicine doctor,” “go on holiday,” “eat sweet things,” “consult a 6. Without external support you are at the mercy of 364(13.8%)
depression.
psychotherapist,” and “talk to friends”;
Appropriate intervention
c. Ratings of preferred persons to ask for help with depression 1. Take antidepressants 1214 (46.0%)
(1 = “yes”, 0 = “no”) including the following persons 2. Consult a non-medical practitioner 1079 (40.9%)
(European Alliance Against Depression, 2008): “psychiatrists,” 3. Pull yourself together 860 (32.6%)
“psychologists,” “Chinese medicine doctors,” “colleagues,” 4. Consult a doctor 800 (30.3%)
5. Do sports 723 (27.4%)
“physicians,” “relatives,” “social workers,” “parents,” “friends,”
6. Take barbiturates and sedatives 517 (19.6%)
and “spouse/boyfriend/girlfriend.” 7. Autogenic training 380 (14.4%)
8. Consult a Chinese medicine doctor 375 (14.2%)
9. Go on holiday 224 (8.5%)
2.3. Data analysis
10. Eat sweet things 203 (7.7%)
11. Consult a psychotherapist 79 (3%)
Descriptive statistics, percentage (%), were used to summarize the 12. Talk to friends 66 (2.5%)
demographic characteristics, general beliefs regarding depression and Preferred helper
its treatment, and help-seeking preferences. Differences in different 1. Psychiatrists 1264 (47.9%)
2. Psychologists 1174 (44.5%)
groups were examined using the Chi-square test for categorical vari- 3. Chinese Medicine doctors 974 (36.9%)
ables. A multivariate logistic regression was used to control for the 4. Colleagues 905 (34.3%)
various variables. A p-value of < 0.05 was considered to indicate sta- 5. Physicians 860 (32.6%)
tistical significance. All data were analyzed with the Statistical Package 6. Relatives 792 (30%)
7. Social workers 728 (27.6%)
for Social Science (SPSS, Version 23.0).
8. Parents 362 (13.7%)
9. Friends 177 (6.7%)
3. Results 10. Spouse/boyfriend/girlfriend 153 (5.8%)

3.1. Demographic characteristics

Of the 2639 patients, 44.0% were male and ages ranged from 18 to
69 years (mean age = 43.98 ± 14.36). In all, 32.3% patients were
young adult (age = 18–34), 47.9% were middle aged (age = 35–60),
and 19.8% aged > 60 years. About one third (33.6%) of the sample
received an education over 12 years, and 27.0% had been educated for
about 9 to 11 years. There were 16.4% who were educated no more
than 5 years. According to the data of the 6th national population
census in Hangzhou city, the sample had a little greater proportion of
female and old people compared to the general population. According
to the score of PHQ-9, 84.5% of the total sample were non-depressed
(PHQ-9 score < 10), and 15.5% were PHQ-9 positive depressed.
3.2. Variations by social-demographic characteristics in depression status
Table1 displays that gender and age were not significantly different
in patients with or without PHQ-9 positive depression. However, edu-
cation level was significantly associated with depression status
(χ2 = 31.896, p < 0.01). Further analyses with partitions of χ2 method
found that a higher education level they have, participants were less
likely to be depressed.
3.3. Knowledge and belief about depression among primary care patients in
China
Table 2 illustrates general beliefs concerning depression and its
treatment and help-seeking preferences.
Less than one-third of patients (31.5%) agreed with the statement
“depression is not a real disease.” However, only a small minority
(7.5%) agreed with the statement “depression is a disease, such as
asthma or diabetes, which ought to be treated by a doctor or psy-
chotherapist.” In all, 13.8% of patients agreed with the statement
“without external support you are at the mercy of depression” and, over
half (60.3%) agreed with the statement “if you are suffering from de-
pression, you have to pull yourself together to get over it.” In addition,
nearly one third (32.0%) agreed with the statement “if somebody is
suffering from depression, it is his/her own fault.” Only 28.6% of pa-
tients agreed with the statement “anybody could suffer from depres-
sion.”
When being asked whether some interventions were appropriate for

Table 1
Variations by social-demographic characteristics according to depression status.
Group (n) Gender Age(years) Education (years)

Male Female χ2
18–34 35–59 ≥ 60 χ 2
0–5 6–8 9–11 ≥ 12 χ2
(1160) (1479) (852) (1264) (523) (4330) (608) (712) (886)
Depression 16.10% 14.90% 0.690 15.10% 15.30% 16.30% 0.330 22.20% 18.40% 14.00% 11.30% 31.896⁎⁎

⁎⁎
p < 0.01.

3
Y. Jiang et al.
depression, more than half of the patients endorsed none of the 12
listed interventions. The largest percentage of patients endorsed “take
antidepressants” (46.0%), followed by “contact a non-medical practi-
tioner” (40.9%), “pull yourself together” (32.6%), “consult a doctor”
(30.0%), “do sports” (27.4%), “take barbiturates and sedatives”
(19.6%), “autogenic training” (14.4%), and “consult a Chinese
Medicine doctor” (14.2%). Some interventions were endorsed by only a
small percentage of patients, such as “eat sweet things” (7.7%), “go on
holiday” (8.5%) and “talk to friends” (2.5%). Notably, “contact a psy-
chotherapist” was endorsed by only 3.0% of patients.
In questions inquiring about preferred persons to ask for help with
depression, less than half of the patients gave an affirmative response to
any of the10 listed helpers. The largest percentages of patients pre-
ferred to ask professionals for help, such as “psychiatrists” (47.9%),
“psychologists” (44.5%), “Chinese medicine doctors” (36.9%), and
“physicians” (32.6%). In addition, “colleagues” (34.3%), “relatives”
(30.0%), and “social workers” (27.6%) were also endorsed as preferred
persons to ask for help by nearly one third. The closest persons to pa-
tients, including “parents” (13.7%), “friends” (6.7%), and “spouse/
girlfriend/boyfriend” (5.8%), were the last to be asked for help.
3.4. Variations by socio-demographic characteristics and depression status
in knowledge and beliefs about depression
Table 3 displays the proportion of agreements on knowledge and
beliefs about depression in groups differed by socio-demographic
characteristics (gender, age, education level) and depression status.
Table 4 displays the result of Chi-square tests which indicate the var-
iations by social demographic characteristics and depression status in
beliefs regarding depression and its treatment and help-seeking pre-
ferences.
Gender distributions were not significantly different between any of
the groups. However, age, education, and depression status were sig-
nificantly related to beliefs about depression and its treatment.
Compared with older patients, younger patients were more likely to
endorse the statements “depression is not a real disease” (χ2 = 6.766,
p < 0.05) and “if somebody is suffering from depression, it is his/her
own fault” (χ2 = 18.765, p < 0.01). Patients with higher levels of
education were more likely to endorse the statement “depression is not
a real disease” (χ2 = 59.453, p < 0.01), “if somebody is suffering from
depression, it is his/her own fault” (χ2 = 69.033, p < 0.01), and
“without external support you are at the mercy of depression”
(χ2 = 11.985, p < 0.01). More non-depressed patients endorsed the
statement “depression is not a real disease” (χ2 = 41.359, p < 0.01),
“anybody could suffer from depression” (χ2 = 37.783, p < 0.01), “if
somebody is suffering from depression, it is his/her own fault”
(χ2 = 18.782, p < 0.01), and “without external support you are at the
mercy of depression” (χ2 = 6.352, p < 0.05).
Only one significant difference was found by gender on the appro-
priateness ratings of the 12 intervention options; more men endorsed
“consult a Chinese medicine doctor” as appropriate (χ2 = 5.408,
p < 0.05). Compared to the older patients, younger patients were more
willing to endorse as appropriate “pull yourself together” (χ2 = 8.983,
p < 0.05), “consult a doctor” (χ2 = 14.204, p < 0.01), “take barbitu-
rates and sedatives” (χ2 = 17.995, p < 0.01), and “autogenic training”
(χ2 = 15.492, p < 0.01), and to endorse as not appropriate “take an-
tidepressants” (χ2 = 7.439, p < 0.05), “do sports” (χ2 = 8.988,
p < 0.05), “go on holiday” (χ2 = 18.286, p < 0.01), and “talk to
friends” (χ2 = 11.413, p < 0.01). Education level also was significantly
related to appropriateness ratings of the intervention options. Patients
with a higher education level were more likely to endorse as appro-
priate “consult a non-medical practitioner” (χ2 = 7.841, p < 0.05) and
“consult a doctor” (χ2 = 15.288, p < 0.01), but they were less likely to
endorse as appropriate “go on holiday” (χ2 = 13.674, p < 0.01), “eat
sweet things” (χ2 = 10.938, p < 0.05), and “talk to friends”
(χ2 = 27.617, p < 0.01). Interestingly, although patients with PHQ-9
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Psychiatry Research 269 (2018) 1–8
positive depression were less willing to endorse as appropriate “take
antidepressants” (χ2 = 11.721, p < 0.01) and “consult a non-medical
practitioner” (χ2 = 7.891, p < 0.01) compared to non-depressed pa-
tients, they were more willing to endorse as appropriate “consult a
psychotherapist” (χ2 = 16.927, p < 0.01), as well as “eat sweet things”
(χ2 = 3.915, p < 0.05) and “talk to friends” (χ2 = 7.629, p < 0.01).
A similar pattern was seen in our examination of the ratings of
preferred persons to ask for help with depression. Compared to older
patients, younger patients preferred to ask “Chinese medicine doctors”
(χ2 = 23.316, p < 0.01), “physicians” (χ2 = 12.679, p < 0.01) and
“relatives” (χ2 = 9.750, p < 0.01) when they were depressed, and not
“parents” (χ2 = 15.247, p < 0.01). In addition, patients with a higher
education level preferred to ask “psychologists” (χ2 = 30.519,
p < 0.01), “colleagues” (χ2 = 9.821, p < 0.05), “relatives”
(χ2 = 30.290, p < 0.01) and “social workers” (χ2 = 9.247, p < 0.05)
compared with patients with a lower education level, but not “parents”
(χ2 = 13.587, p < 0.01) and “friends” (χ2 = 11.465, p < 0.01).
Similarly, the non-depressed patients preferred to ask “psychiatrists”
(χ2 = 26.123, p < 0.01), “psychologists” (χ2 = 33.608, p < 0.01),
“colleagues” (χ2 = 4.532, p < 0.05) and “relatives” (χ2 = 4.772,
p < 0.05) compared with PHQ-9 positive depressed patients, but not
“friends” (χ2 = 11.046, p < 0.01).
Further, a multivariate logistic regression was performed to identify
factors associated with different attitudes and preferred helper, which
was shown in Table 5. The results were almost the same as the chi-
square test previously showed, except that there was no significant
difference of age on the agreement of “depression is not a real disease”
and “if somebody is suffering from depression, it is his/her own fault”,
as well as the intention to ask help form psychologists. Also there was
no significant difference of depression status on the preference of help
from colleague and relatives, which was shown in Table 6.
3.5. Variations by attitudes towards depression in preferred professional
helpers
Patients who endorsed the belief “depression is not a real disease”
preferred to seek help from “psychologists” (χ2 = 29.421, p < 0.01)
and “psychiatrists” (χ2 = 88.252, p < 0.01). However, patients who
endorsed the belief “depression is a disease, such as asthma or diabetes,
which ought to be treated by a doctor or psychotherapist” preferred to
seek help from “physicians” (χ2 = 16.026, p < 0.01) and “Chinese
medicine doctors” (χ2 = 5.276, p < 0.05). Patients who endorsed the
belief that “if somebody is suffering from depression, it is his/her own
fault,” and “anybody could suffer from depression” preferred to seek
help from all four professional helpers.
4. Discussion
Our study revealed significant differences in beliefs about depres-
sion and its treatment as well as help-seeking preferences regarding
depression among Chinese primary care patients. Slightly less than one-
third of the sample believed that depression is not a real disease.
However, only 7.5% agreed that depression ought to be treated pro-
fessionally (by a doctor or a psychotherapist). Differences in beliefs and
help-seeking preferences were significantly associated with age, edu-
cation level and depression status, but no significant differences were
found by gender. Patients were less willing to endorse “take anti-
depressants” and “consult a non-medical practitioner” than non-de-
pressed patients. However, interestingly, depressed patients were more
willing to endorse “consult a psychotherapist” than non-depressed pa-
tients.
4.1. General depressive status
Of the 2639 patients in our sample, the overall PHQ-9 positive de-
pression rate was 15.5%, which was much higher than the depression
 Y. Jiang et al.

Table 3
Proportion of agreements on knowledge and beliefs about depression in groups of socio-demographic characteristics and depression status.
Group Gender Age (years) Education (years) Depression
n (%) Male Female 18–34 35–59 Over 60 0–5 6–8 9–11 Over 12 Non-depressed Depressed
1160 1479 852 1264 523 433 608 712 886 2231 408

Attitudes about depression

1. Depression is not a real disease. 365(31.5%) 466(31.5%) 280(32.9%) 411(32.5%) 140(26.8%) 86(19.9%) 163(26.8%) 233(32.7%) 349(39.4%) 759(34.0%) 73(17.9%)
2. Suffering from depression is his/her own fault. 350(30.2%) 494(33.4%) 321(37.7%) 369(29.2%) 154(29.4%) 91(21.0%) 156(25.7%) 233(32.7%) 364(41.1%) 752(33.7%) 93(22.8%)
3. Anybody could suffer from depression. 331(28.5%) 423(28.6%) 232(27.2%) 368(29.1%) 154(29.4%) 102(23.6%) 185(30.4%) 213(29.9%) 254(28.7%) 689(30.9%) 65(15.9%)
4. Depression is a disease ought to be treated by a doctor or 96(8.3%) 102(6.9%) 74(8.7%) 90(7.1%) 34(6.5%) 30(6.9%) 43(7.1%) 59(8.3%) 66(7.4%) 165(7.4%) 34(8.3%)
psychotherapist.
5. You have to pull yourself together to get over depression. 693(59.7%) 901(60.9%) 514(60.3%) 763(60.4%) 314(60.0%) 244(56.4%) 371(61.0%) 450(63.2%) 527(59.5%) 1345(60.3%) 247(60.5%)
6. Without external support you are at the mercy of depression. 161(13.9%) 203(13.7%) 121(14.2%) 166(13.1%) 77(14.7%) 41(9.5%) 83(13.7%) 94(13.2%) 145(16.4%) 323(14.5%) 40(9.8%)
Appropriate intervention
1. Take antidepressants 553(47.7%) 661(44.7%) 361(42.4%) 595(47.1%) 258(49.3%) 189(43.6%) 297(48.8%) 313(44.0%) 415(46.8%) 852(38.2%) 193(47.4%)
2. Consult a non-medical practitioner 467(40.3%) 612(41.4%) 331(38.8%) 525(41.5%) 225(43.0%) 154(35.6%) 268(44.1%) 297(41.7%) 361(40.7%) 781(35.0%) 171(42.0%)
3. Pull yourself together 385(33.2%) 473(32.0%) 311(36.5%) 386(30.5%) 162(31.0%) 126(29.1%) 192(31.6%) 240(33.7%) 301(34.0%) 701(31.4%) 134(32.8%)
4. Consult a doctor 348(30.0%) 453(30.6%) 298(35.0%) 365(28.9%) 137(26.2%) 116(26.8%) 166(27.3%) 207(29.1%) 311(35.7%) 640(28.7%) 125(30.6%)

5
5. Do sports 321(27.7%) 401(27.1%) 201(23.6%) 369(29.2%) 152(29.1%) 125(28.9%) 169(27.8%) 183(25.7%) 245(27.7%) 535(24.0%) 114(28.0%)
6. Take barbiturates and sedatives 219(18.9%) 297(20.1%) 207(24.3%) 215(17.0%) 95(18.2%) 76(17.6%) 111(18.3%) 150(21.1%) 180(20.3%) 448(20.1%) 80(19.5%)
7. Autogenic training 172(14.8%) 207(14.0%) 153(18.0%) 169(13.4%) 56(10,7%) 57(13.2%) 89(14.6%) 96(13.5%) 137(15.5%) 339(15.2%) 58(14.2%)
8. Consult a Chinese Medicine doctor 186(16.0%) 189(12.8%) 134(15.7%) 171(13.5%) 71(13.6%) 61(14.1%) 86(14.1%) 89(12.5%) 140(15.8%) 373(16.7%) 56(13.8%)
9. Go on holiday 101(8.7%) 124(8.4%) 51(6.0%) 107(8.5%) 66(12.6%) 54(12.5%) 52(8.6%) 62(8.7%) 57(6.4%) 241(10.8%) 33(8.1%)
10. Eat sweet things 100(8.6%) 102(6.9%) 51(6.0%) 104(8.2%) 47(9.0%) 46(10.6%) 51(8.4%) 55(7.7%) 50(5.6%) 223(10.0%) 29(7.2%)
11. Consult a psychotherapist 42(3.6%) 35(2.4%) 21(2.5%) 37(2.9%) 20(3.8%) 17(3.9%) 17(2.8%) 21(2.9%) 23(2.6%) 136(6.1%) 10(2.4%)
12. Talk to friends 26(2.2%) 38(2.6%) 13(1.5%) 29(2.3%) 23(4.4%) 25(5.8%) 15(2.5%) 16(2.2%) 9(1.0%) 98(4.4%) 9(2.1%)
Preferred helper
1. Psychiatrists 556(47.9%) 708(47.9%) 396(48.5%) 619(49.0%) 249(47.6%) 201(46.4%) 274(45.1%) 344(48.3%) 445(50.2%) 810(36.3%) 204(50.0%)
2. Psychologists 494(42.6%) 680(46.0%) 394(46.2%) 580(45.9%) 200(38.2%) 161(37.2%) 265(43.6%) 292(41.1%) 456(51.5%) 701(31.4%) 191(46.9%)
3. Chinese Medicine doctors 422(36.4%) 552(37.3%) 370(43.4%) 423(33.5%) 179(34.2%) 120(27.7%) 213(35.0%) 278(39.0%) 362(40.9%) 732(32.8%) 153(37.6%)
4. Colleagues 380(32.8%) 524(35.4%) 298(35.0%) 413(32.7%) 193(36.9%) 141(32.6%) 185(30.4%) 242(34.0%) 336(37.9%) 663(29.7%) 143(35.1%)
5. Physicians 371(32.0%) 490(33.1%) 318(37.3%) 386(30.5%) 157(30.0%) 123(28.4%) 188(30.9%) 240(33.7%) 310(35.0%) 672(30.1%) 135(33.1%)
6. Relatives 332(28.6%) 461(31.2%) 290(34.0%) 360(28.5%) 143(27.3%) 114(26.3%) 147(24.2%) 209(29.4%) 323(36.5%) 569(25.5%) 126(30.9%)
7. Social workers 327(28.2%) 401(27.1%) 256(30.0%) 346(27.4%) 126(24.1%) 101(23.3%) 177(29.1%) 182(25.6%) 268(30.2%) 573(25.7%) 114(27.9%)
8. Parents 172(6.8%) 189(12.8%) 89(10.4%) 179(14.2%) 93(17.8%) 78(18.0%) 64(10.5%) 89(12.5%) 130(14.7%) 323(14.5%) 55(13.5%)
9. Friends 79(6.8%) 99(6.7%) 46(5.4%) 90(7.1%) 42(8.0%) 44(10.2%) 44(7.2%) 39(5.5%) 51(5.8%) 234(10.5%) 25(6.1%)
10. Spouse/boyfriend/girlfriend 65(5.6%) 87(5.9%) 39(4.6%) 77(6.1%) 37(7.1%) 33(7.6%) 37(6.1%) 37(5.2%) 46(5.2%) 174(7.8%) 22(5.4%)
Psychiatry Research 269 (2018) 1–8
Y. Jiang et al. Psychiatry Research 269 (2018) 1–8

Table 4 Table 5
Variations by socio-demographic characteristics and depression status ac- Multivariate logistic regression on attitudes about depression and preferred
cording to knowledge and beliefs about depression. helper.
Group Gender Age Education Depression Group Gender Age Education Depression

Attitudes about depression Attitudes about depression

1. Depression is not a real 0.001 6.766* 59.453⁎⁎ 41.359⁎⁎ 1. Depression is not a real disease. ⁎⁎ ⁎⁎

⁎⁎ ⁎⁎
disease. 2. Suffering from depression is his/
2. Suffering from depression is 3.115 18.765⁎⁎ 69.033⁎⁎ 18.728⁎⁎ her own fault.
⁎⁎
his/her own fault. 3. Anybody could suffer from
3. Anybody could suffer from 0.001 1.129 6.997 37.783⁎⁎ depression.
depression. 4. Depression is a disease ought to be
4. Depression is a disease ought 1.782 2.74 1.002 0.48 treated by a doctor or
to be treated by a doctor or psychotherapist.
psychotherapist. 5. You have to pull yourself together
5. You have to pull yourself 0.389 0.025 5.706 0.009 to get over depression.
⁎⁎
together to get over 6. Without external support you are at *
depression. the mercy of depression.
⁎⁎
6. Without external support you 0.027 1.08 11.985 6.352* Preferred helper
⁎⁎
are at the mercy of depression. 1. Psychiatrists
⁎⁎ ⁎⁎
Appropriate intervention 2. Psychologists
1. Take antidepressants 2.324 7.439* 4.393 11.721⁎⁎ 3. Chinese Medicine doctors ⁎⁎ ⁎⁎

2. Consult a non-medical 0.380 2.615 7.841* 7.891⁎⁎ 4. Colleagues *

practitioner 5. Physicians *
⁎⁎
3. Pull yourself together 0.385 8.983* 3.861 0.305 6. Relatives *
4. Consult a doctor 0.097 14.204⁎⁎ 15.288⁎⁎ 0.613 7. Social workers *
⁎⁎ ⁎⁎
5. Do sports 0.102 8.988* 1.577 2.708 8. Parents
6. Take barbiturates and 0.665 17.995⁎⁎ 3.111 0.079 9. Friends ⁎⁎
*
sedatives 10. Spouse/boyfriend/girlfriend
7. Autogenic training 0.366 15.492⁎⁎ 1.863 0.273
8. Consult a Chinese Medicine 5.408* 2.256 3.545 2.311 *p < 0.05.
doctor ⁎⁎
p < 0.01.
⁎⁎ ⁎⁎
9. Go on holiday 0.087 18.286 13.674 3.156
10. Eat sweet things 2.734 5.257 10.938* 3.915*
11. Consult a psychotherapist 3.191 2.094 1.875 16.927⁎⁎ together to get over it. The emphasis on personal responsibility for the
12. Talk to friends 0.423 11.413⁎⁎ 27.617⁎⁎ 7.629⁎⁎ management of depression corresponds to the low perceived effec-
Preferred helper tiveness of depressive interventions and the remarkable unwillingness
1. Psychiatrists 0.001 1.289 4.306 26.123⁎⁎ to seek help. In addition, nearly one third of patients believed if
2. Psychologists 3.027 10.329⁎⁎ 30.519⁎⁎ 33.608⁎⁎
somebody is suffering from depression, it is his/her own fault. This
3. Chinese medicine doctors 0.214 23.316⁎⁎ 23.978⁎⁎ 3.362
4. Colleagues 2.059 3.227 9.821* 4.532* belief might be rooted in the cultural experiences of these patients and
5. Physicians 0.390 12.679⁎⁎ 6.94 1.349 had implications for their use of health services for depression. The
6. Relatives 2.01 9.750⁎⁎ 30.290⁎⁎ 4.772* beliefs about depression in our study were aligned with the somatiza-
7. Social workers 0.377 5.808 9.247* 0.828
tion pattern seen in Chinese patients with depression (Kleinman, 2004;
8. Parents 2.311 15.247⁎⁎ 13.587** 0.25
9. Friends 0.014 4.111 11.465⁎⁎ 11.046⁎⁎ Parker et al., 2001). The results in our study were also similar to pre-
10. Spouse/boyfriend/girlfriend 0.143 4.084 3.795 3.697 vious findings uncovered in studies done in other countries, which in-
dicated a moderate or low knowledge level of depression (Khan et al.,
*p < 0.05. 2010) or participants with little mental health literacy about depression
⁎⁎
p < 0.01. (Goldney et al., 2001). The beliefs about depression and emphasis on
self-help in our study suggested incorporating Chinese primary care
rate of 3.59% from the National Health and Family Planning patients’ beliefs about depression and its treatment into mental health
Commission. The higher rate of PHQ-9 positive depression in our study care services may lead to greater engagement and adherence to treat-
might be a result of sampling patients from primary care clinics. We did ment.
not find any age and gender differences between patients who were Approximately half of our sample preferred to seek help from psy-
depressed and patients who were not depressed. These findings differ chiatrists or psychologists. This result was quite different from previous
from previous studies on the higher rates of depression in women, for research that respondents would prefer to seek non-professional help
example one previous study which found that women were more likely (i.e. friends and family) over professional help (Mackenzie et al., 2006;
to suffer from depression than men in 23 European countries Oliver et al., 2005). The reason might be that patients were mostly from
(Velde et al., 2010). However, we did find patients with a higher urban areas and well-educated. Also, primary care patients had a higher
education level were less likely to be depressed. Our study found a depression rate, which might result from poor social support.
significant decrease in PHQ-9 positive depression among patients with Also, nearly half patients endorsed antidepressants as an appro-
higher levels of education, consist with the previous finding that more priate treatment. However, PHQ-9 positive depressed patients were less
years of education was associated with the risk of depression willing to endorse “take antidepressants” and “consult a non-medical
(Crespo et al., 2014). practitioner” than non-depressed patients. Interestingly, PHQ-9 positive
depressed patients were more willing to endorse “consult a psy-
4.2. General beliefs chotherapist” than non-depressed patients. These findings were similar
to previous western studies, in which psychotherapy was more pre-
Although over half of the patients believed that depression is a real ferred than antidepressants among persons with depression (Churchill
disease, very few patients believed that depression is a disease, just like et al., 2000; Gum et al., 2006; Raue et al., 2009).
asthma or diabetes are diseases, and should be treated by a doctor or In the present study, we found that the older age and being de-
psychotherapist. The reason might be that they believe they can heal for pressed were associated with higher likelihood to admit that depression
self or they have stigma on depression. In fact, over half of patients is a real disease but lower willingness to seek professional treatment.
believed that persons suffering from depression need to pull themselves

6
Y. Jiang et al. Psychiatry Research 269 (2018) 1–8

Table 6
Variations by attitudes toward depression in preferred professional helpers.
1. Depression is not a real disease. 2. Suffering from depression is one's 3. Anybody could suffer from 4. Depression is a disease ought to be
own fault. depression. treated professional.
Agree Disagree χ 2
Agree Disagree χ2 Agree Disagree χ2 Agree Disagree χ2
(n = 831) (n = 1808) (n = 844) (n = 1795) (n = 754) (n = 1885) (n = 198) (n = 2441)

Psychologists 52.2% 40.9% 29.421⁎⁎ 50.9% 41.4% 20.976⁎⁎ 53.7% 40.8% 36.391⁎⁎ 50.5% 44.0% 3.140
Psychiatrists 61.4% 41.7% 88.252⁎⁎ 54.0% 45.0% 18.693⁎⁎ 54.4% 45.3% 17.760⁎⁎ 48.0% 47.9% 0.001
Physicians 33.2% 32.4% 0.190 36.5% 30.8% 18.441⁎⁎ 37.8% 30.6% 12.848⁎⁎ 45.5% 31.6% 16.026⁎⁎
Chinese 38.5% 36.1% 1.398 39.8% 35.5% 4.609* 40.8% 35.3% 7.179⁎⁎ 44.4% 36.3% 5.276*
medicine
doctors

*p < 0.05.
⁎⁎
p < 0.01.

The possible explanation may be related to the stigma on depression in
China (Tsang et al., 2003; Yang and Pearson, 2002). Moreover, higher
educational level was associated with higher willingness to seek help,
especially from professionals, even though participants with higher
educational levels were more inclined to believe depression is not a real
disease. Given the general beliefs and help-seeking attitudes as well as
specific factors discussed above, in order to improve the acceptability
and uptake of interventions for depression, future efforts should focus
on increasing knowledge regarding depression and disseminating in-
formation about depressive interventions in addition to acknowledging
and incorporating cultural conceptions of depression as a part of care.
Furthermore, efforts to decrease stigma may increase the willingness to
seek help. All these efforts combined may foster the engagement and
adherence to mental health treatment and help to improve outcomes for
depression. Embedding mental health care in the primary care setting
and following other guidelines of collaborative care models have been
shown to be effective in Western studies (Gilbody et al., 2006; Katon
et al., 2010; Unützer et al., 2002). The same scheme could be suitably
adapted to the Chinese cultural context, thus paving the way to effec-
tively treating depression in a culturally sensitive manner.
One of our findings that a conception of depression as a disease such
as asthma or diabetes was associated with the preference to seek help
from physicians and Chinese medicine doctors whereas a conception of
depression as not a disease was associated with the preference to seek
help from psychiatrists or psychologists may help to explain why cer-
tain patients accept certain treatments. An enhanced understanding of
the relationship between beliefs regarding depression and help-seeking
preferences might be helpful to improve outcomes of the treatment on
depression. This is consistent with the Theory of Planned Behavior
(Ajzen, 1991), which underscores the importance of beliefs and atti-
tudes as an important predictor of behavioral intention. The Theory of
Planned Behavior has been applied in other settings and found to be
valid (Mak and Davis, 2014; Mo and Mak, 2009).
regarding depression and its treatment as well as help-seeking pre-
ferences among Chinese primary care patients. Hence, several study
limitations should be mentioned.
First, even we translated and adapted it, and let two psychologists to
help on the language of these items. The instrument has not been fully
validated in Chinese settings, so we still had some concern about the
implications of this questionnaire in our culture settings. As we know,
culture is also an important factor for people's beliefs and attitude to-
ward depression (Kleinman, 2004). Further studies to examine its
psychometric properties are needed to strengthen the validity of our
findings.
Second, use of questionnaires to measure general beliefs and per-
ceived help-seeking attitudes may be influenced by perceived social
desirability, biasing responses, especially with regard to stigmatized
topics.
Third, our sample was selected from primary care settings in
Hangzhou city; they should be different from the community general
population, which would be a limitation for the application of these
outcomes in the general population. Also, we do not have data from
other areas, the results cannot fully represent the whole country.
Forth, our method for sampling had some potential confounders for
bias. Some patients who refused to participant in the study may limit
the power of these outcomes; a consecutive sample may introduce se-
lection bias; the sample size unbalance in different age groups may also
limit the power of the implication in different population groups.
Finally, association of socio-demographic factors with knowledge
and attitudes was assessed only using univariable analysis, which might
result in confounding.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.

Conflict of interest
5. Conclusions
The authors declare no conflict of interest.
Depression remains a difficult clinical challenge in primary care
clinics in China. Patient beliefs about depression and its treatment may
Acknowledgment
dissuade treatment-seeking or the acceptance of certain treatments. Our
results highlight a need for modification of current paradigms, prac-
We would like to acknowledge nurse practitioners from all clinics
tices, and approaches to improve the acceptability of depression care
for collecting data. The project was supported by Fogarty International
services. Professional care providers such as psychiatrists and psy-
Center, the National Institutes of Health of United States of American
chologists were preferred persons to ask for help with depression and
grant R01TW008699.
approximately half of patients endorsed asking these professionals.
Efforts to increase collaboration between primary care physicians and
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