Psychological Reports, 2005,96,435-444.

O Psychological Reports 2005

ANXIETY AND DEPRESSION I N ADOLESCENTS

I N URBAN AND RURAL CHINA1

THERESE HESKETH AND QU JIAN DING

Centre for International Child Health Institute of Population Studies
Institute of Child Health Zhejiang University
University College London

Summay.-The goal was to assess rates of anxiety and depression in adolescents

in two areas of Zhejiang Province, China. A cross-sectional survey was carried-out us-
ing a self-report questionnaire developed for this study. Participants were middle
school students (age range 13-16 years) in an urban and a rural setting. There were
1576 completed questionnaires. Symptoms of anxiety sufficient to interfere with enjoy-
ment of life, relaxation, and sleep were common (48%, 40%, and 2776, respectively).
School-related problems were the predominant sources of worry. One third reported a
history of depression, 16% had at times felt life was not worth living, and 9% re-
ported that they had attempted suicide. Girls were more likely to report symptoms of
depression. Patterns of help-seeking showed reliance on friends and parents; only 1%
had sought professional help. There were no significant differences in anxiety and de-
pression between one-child and multisibling families.

There are sparse data on anxiety and depression for adolescents in most
developing countries (Nikapota, 1993; W H O , 1995). China is no exception.
Routine data, when available, are unhelpful because coverage of services is
low, especially in rural areas, as well as use of differing conceptualisations of
Illness and the stigmatisation of mental dlness (Jianlin, 2000). There have
been few studies of the psychological well-being of adolescents in mainland
China, and the under 16-year age group has been particularly neglected.
However, interest has grown recently for two major reasons. Firstly, massive
socioeconomic change has resulted from China's rapid transition to a market
economy. The previous system of job allocation and "jobs for life" has dis-
appeared, leading to unemployment and huge competition in education and
the workplace. Education is now regarded as the primary pathway of up-
ward mobility in Chinese society, and the pressures on young people to suc-
ceed are considerable. In Taiwan and Hong Kong these pressures have been
shown to lead to high rates of anxiety and depression (Crystal, Chen, Fulig-
ni, Stevenson, Hsu, KO, Kitamura, & Kimura, 1994), and there are indica-
tions that this may be true of the mainland (Dong, Yang, & Ollendick, 1994;
Liu, Oda, Peng, & Asai, 1997). Secondly, interest in the psychological well-
being of young Chinese has been stimulated by the One Child Family Poli-

'Address correspondence to Therese Hesketh, Centre for International Child Health, Institute
of Child Health, 30 Guilford Street, London WC1 N l E H or e-mail (t.hesketh@ich.ucl.ac.uk).
436 T. HESKETH & Q. J. DING

cy. This was introduced in 1979 and was expected by psychologists to have
detrimental effects on the mental well-being of Chinese children: only chil-
dren elsewhere have been depicted as more egocentric and maladjusted than
children with siblings (Hall, 1987). Studies examining the effect of the policy
on the psychological development of younger children, however, have yield-
ed equivocal results. For example, a study of 697 preschool children in Nan-
jing showed slightly higher scores for temper, moodiness, and depression
only in girls compared with those with siblings but no differences for boys
(Tseng, Kuotai, Hsu, Jinghua, Lian, & Kameoka, 1988). In a four-province
study of 1,000 8- to 17-yr.-olds no evidence was found that only children
had "undesirable personalities" as judged by self-report and by teachers and
mothers (Falbo, Poston, Ji, Jiao, Jing, Wang, Gu, Yin, & Liu, 1989; Falbo
& Poston, 1993). But there have been few studies examining- the influence
of the policy on the psychological well-being of adolescents.
This study was carried out at the request of the education authorities in
Zhejiang Province, eastern China, to provide rates of anxiety and depression
in middle school students, with a view to informing service developments in
the health and education sectors. It was carried out as part of a wider pro-
gramme of research into adolescent health in Zhejiang Province.

The study locations were the capital Hangzhou, one of the boom cities
of the east, and Chunan, a poor mountainous area 150 km to the southwest.
The average annual per capita income in 2000 was US$1,800 in Hangzhou
and $650 in Chunan. In each area, six middle schools were invited to partic-
ipate. The schools were selected to be representative of schools in rural and
urban areas of Zhejiang on the basis of an "academic score" on the percent-
age of students in the school who go on to mainstream higher education.
The academic scores of the schools ranged from 20% to 85%) which is
equivalent to the overall range for Zhejiang. No school refused to partici-
pate. In each year there are three to five classes, and one randomly selected
class in each year for each school was included.
Local authorities wanted to develop their own rapid appraisal tool, suit-
able for the Chinese setting, so a self-report questionnaire was developed.
Questions were developed by an advisory board of local experts (two psy-
chiatrists, a psychologist, an educationalist, and the authors). The equivalent
of local ethical approval was obtained from the provincial and local educa-
tion authorities. The survey was initially piloted among 40 children across
the age range at urban and rural sites, and minor amendments were made
according to feedback. Parents and children were informed one week in ad-
vance that the survey would occur and were told that there was the option
to refuse participation, although none did. The survey was carried out in De-
 ANXIETY AND DEPRESSION I N CHINESE ADOLESCENTS 437

cember 2001. The questionnaires were administered in the classroom by one

of the authors (QJD) and were completed anonymously under examination
conditions. Students were assured of the confidentiality of the questionnaire
information and were offered access to a counsellor should they require it.
Three students did avail themselves of this service.
Analysis
Initially crosstabulations (sex, urban/rural residence, age, parental edu-
cation, household income, one-child family) were carried-out to identify
significant associations (Pearson chi-squared with 95 % confidence intervals),
and then multiple logistic regression was used to assess which characteristics
were independently associated with the key psychological morbidity indices.
Analysis was carried out on SPSS Version 10. Values of p < .O1 were regard-
ed as significant.
RESULTS
Complete questionnaire data were obtained from 1,576 respondents in
total, 870 boys and 806 girls. Forty-five surveys were inadequately com-
pleted, i.e., more than 10% missing answers across key variables (see Table
1). In urban Hangzhou, family income was higher as was parental education.
The marked urban/rural difference in family size reflects the mode of imple-
mentation of family planning policy in China, which generally allows two
children in rural areas (Hesketh & Zhu, 1997).
TABLE 1
OF STUDYPOPULATION
CHARACTERISTICS BY AREA

Characteristic Urban (Hangzhou) Rural (Chunan)

Total N 784 792
Boys 369 401
Girls 4 15 391
Age, yr., M f SD 13.9f 1.1 14.4 f 1.2
Age range 12-17 12-18
One-child family, % 87 22
Monthly household income, %
High (>800 RMB)" 71 31
Low (< 800 RMB) 12 48
Education of parents, %
Neither completed middle school 11 26
One completed middle school 27 39
Both completed middle school 45 20
Note.-Not all groupings sum to 100% because data are missing. *1US$ = 8RMB.

Seventy percent of these young people claimed to worry a lot, nearly

half saying it interfered with their enjoyment of life, and over a quarter say-
ing it interfered with sleep (see Table 2). Boys are just as prone to anxiety as
girls, but in Chunan students suffered more from the more severe types of
43 8 T. HESKETH & Q. J. DING

worry leading to tension and sleep disturbance. In terms of sources of worry

school-related issues predominate with over two-thirds citing school perfor-
mance as a source of worry and significantly more in Chunan. Nearly half
worry a lot about homework and getting a job after school with no urban/
rural or sex differences. More traditional concerns of adolescents are cited
less frequently, only 15% were concerned about appearance, family quarrels
14%, and the break-up of the family just 4.4%. Nearly one-quarter (24%)
worried about family finances, but nearly five times as many in rural Chunan
(40% vs 8.5%, p < .001) did so.

TABLE 2
PSYCHOLOGICAL
MORBIDITY:
PERCENTAGE RESPONSES
AFFIRMATIVE BY SEXAND AREA

Parameter All Sex P Area P

Boys Girls Urban Rural
Anxiety
I worry a lot
Worr interferes with my enjoyment
of h e
Worry makes me tense and unable
to relax
Worry interferes with my sleep
Sources of Anxiety
School performance/grades
Finding work after leaving school
Homework
Family economic situation
Appearance
Family quarrels
Unpopularity
Parents separate/divorce
Depression
Are you often sad and tearful?
Have you been sad/tearful in the
past week
Have you ever been sad to the point
of having no desire to do things?
Have you ever felt life doesn't seem
worth living?
Have you ever tried to end your life?

Around one third of all respondents said they were often sad and tear-
ful, including significantly more girls (p < .OOI) and rural inhabitants ( p <
.OOl). Throughout the questions related to depression girls and rural dwell-
ers were significantly more at risk. Analysis by age, household income, and
parental education gave very inconsistent results, suggesting overall that
these are not important risk factors for anxiety or depression. There was also
 ANXIETY AND DEPRESSION I N CHINESE ADOLESCENTS 439

a strong association between anxiety and depression. Those who are depress-
ed are five times as likely to say they worry a lot (Odds Ratio: 5.18, 3.74-
7.18).
Patterns of help-seeking for psychological problems show that nearly a
third go to no one for help, and only a tiny minority seek help beyond their
social network of family and friends. Friends are the most important source
of support, followed by parents. Only 1 % had sought professional help. In
contrast, preferences for help-seeking show that many would like to seek
professionals, including counsellors and school-based professionals, suggest-
ing the existence of considerable unmet need.

TABLE 3
HELP-SEEKING
BEHAVIOUR
FORPSYCHOLOGICAL (N = 1,070)
PROBLEMS

Source Whom did you ask for he1 From whom would you like
when anxious or depresse& to receive help?
n YO n %
Friend(s)
Parents
Teacher
Other relative
Doctor
School nurse/doctor
Counsellor
Telephone helpline
No one

Analysis of all the variables was carried out, comparing adolescents in a

one-child family with those in families with siblings (see Table 4). Note that
in Hangzhou 94% are only children with equal numbers of girls and boys.
In Chunan 22% are only children, and of these 82% are boys. Unadjusted
odds ratios suggest that being an only child is protective against many of
these parameters of anxiety and depression. But after adjustment for resi-
dence and sex, only one item fell just short of statistical significance-chil-
dren with siblings were more likely to say that worry makes it hard for them
to relax.
DISCUSSION
In these young Chinese, anxiety and depression were common, with de-
bilitating symptoms in around one-third of the respondents. Comparison of
the prevalence of anxiety and depression across different populations is
fraught with problems mainly because so many different tools and sampling
methods were used. However, anxiety and depression have been commonly
reported in many studies involving young people (Roberts, Atkinson, &
Rosenblatt, 1998). For example, in a UK study of 14- to 16-yr.-olds, 8 % re-
 T. HESKETH & Q. J. DING

TABLE 4
SUMMARY
OF PSYCHOLOGICAL
MORBIDITYPARAMETERS
BY FAMILY
SIZE:
PERCENTAGES, AND ADJUSTED
UNADJUSTED, ODDSRATIOS

Item One Two+ Unadjusted 95% CI Adjusted" 95% CI

Child Children Odds Ratio Odds Ratio
Worry a lot 59 60 1.0 0.8, 1.3 1.0 0.7, 1.3
Worry interferes with life 37 45 1.4 1.1,1.7 1.1 0.8,1.7
Worry makes it hard to relax 29 40 1.6 1.3,2.0 1.6 1.1,2.3
Worry interferes with sleep 19 32 2.03 1.6,2.3 1.5t 1.1,2.0
Often sad and tearful 24 39 2.03 l.6,2.5 1.0 0.8, 1.5
Sad and tearful in past week 30 36 1.33- 1 . 1 1.6 0.9 0.7, 1.2
Sad to point of no interest
in life 25 35 1.63 1.3,2.0 1.2 0.9, 1.6
Life has felt not worth living 14 14 1.0 0.8, 1.4 1.0 0.8, 1.2
Have tried to end life 13 11 0.9 0.7, 1.2 1.3 0.8, 1.9
"Adjusted for sex and urbadrural residence. t p < .O3. 3p < .001.

ported they were depressed everyday and 28% at least once a week. Only
3 % of girls and 8 % of boys said they never felt depressed (Macfarlane, Mc-
Pherson, McPherson, & Ahmed, 1987). The rate of clinical depression in
the 11- to 18-yr.-olds studied in the U.S. National Longitudinal Study of
Adolescent Health was 9.3% with no significant difference between girls
and boys (Resnick, Bearmann, & Blum, 1997). Kasmini, Kyaw, Krishnaswa-
ny, Ramli, and Hassan (1993) found that 12% of young adolescents in rural
Malaysia had some form of mental disorder. Roberts, et al. (1998) analysed
50 epidemiological studies from 20 countries over four decades and found
the prevalence of adolescent psychiatric disorder to vary between 5 % and
50%, with a median of 15%.
We found that nearly one in six of the respondents had felt that "life
wasn't worth living", and 9% reported that they had tried to end their own
lives. This was much higher than anticipated, and it raised considerable con-
cern. There are no data on attempted suicide in China, on methods used,
recognition, follow-up (if any), or prognostic factors. Population-based data
for completed suicide have only recently been made available. Although the
rate for the whole population averages 30/100,000 (Phillips, Liu, & Zhang,
1999; Qin & Mortenson, 2001), rates for women in some rural areas are as
high as 50/100,000 with the 15- to 24-yr. age group only exceeded by per-
sons over 55 (Li & Baker, 1991). This contrasts with the usual situation in
the West where urban men have the highest suicide rates and where at-
tempted suicide is more common in young women (Platt, Bille-Brahe, &
Kerkhof, 1992). National comparisons of suicide data are difficult to inter-
pret in many countries. Underreporting is known to occur because suicide is
illegal in many countries, and it is highly stigmatised. Data for the USA are
thought to be among the most reliable; for 1996 a rate of 10.8 per 100,000
 ANXIETY AND DEPRESSION IN CHINESE ADOLESCENTS 44 1

is cited, 4.0 for women and 18.0 for men. Younger men (ages 15 to 24
years) had higher rates of 22 per 100,000, whereas women varied little over
the lifespan (National Centre for Health Statistics, 1998). In other countries
with majority ethnic Chinese populations llke Hong Kong and Singapore
male suicide predominates, although, as elsewhere (Platt, et al., 1992), this is
largely linked to mode of lethality rather than higher rates of severe depres-
sion (Cheung, 1986). But the whole question of suicide and attempted sui-
cide in this age group in China is a subject which requires urgent explora-
tion.
Although anxiety and depression are common in both sexes and areas,
there are quantitative differences worth noting. Rural adolescents appear to
be more vulnerable to symptoms of anxiety and depression. In a study of
adults, higher rates of depression in rural adults were attributed in which
the same difference was related to lower status and self-esteem (particularly
for women), a lower general satisfaction and comfort in everyday life, and
the virtual nonexistence of psychiatric or psychological support services
(Pritchard, 1996). In our study, girls were significantly more prone to de-
pression, but there were no significant sex differences for anxiety. Such sex
differences are well recognised in Western countries (Hayward & Sanborn,
2002) and have also been reported from China mainland, Hong Kong, and
Taiwan (Crystal, et al., 1994; H u , 1994). A number of commentators have
noted that Chinese child-rearing practices may be particularly likely to lead
to a higher incidence of neurotic disorders. The Chinese generally value
achievement, obedience, impulse control, good moral character, and control-
led temperament. These might be expected to lead to psychological prob-
lems related to overcontrolled behaviour, that is, depressed mood and anxi-
ety (Chen & Uttal, 1988; Crystal, et al., 1994). Furthermore, the cultural pro-
scription against open confrontation and displays of anger may lead to a
higher incidence of depressed mood (Bond & Huang, 1986).
The major sources of worry in this study were related to school stress
irrespective of sex, residence, and family size. School-related issues and con-
cerns about getting a job are the most commonly cited sources in both ur-
ban and rural areas. Success in the Chinese education system is measured
largely by passing examinations (Dong, et al., 1994). Examinations are par-
ticularly frequent in middle schools, and this may help explain the clear anx-
ieties about school performance among these young people. Concerns about
school-related issues far outweigh those more traditional concerns of adoles-
cence (appearance, family quarrels, and popularity) which are cited infre-
quently by these students.
The students reported a clear reluctance to seek help, together with high
unmet need. Only a very few had sought professional help; there are a num-
ber of possible explanations for this. They include habit and tradition (Che-
442 T. HESKETH & Q. J. DING

ung, 1984)) the tendency to somatise in Chinese populations (Kleinmann,

1987), and the lack of psychotherapeutic services (Boey, 1999). There are
few trained psychotherapists and counseUors in China, and almost none in
rural China. Primary care is easily accessible to the majority of the popula-
tion, but practitioners are not trained to deal with psychological problems.
Child and adolescent psychiatry as a subspeciality is just starting to be rec-
ognised, and there are now specialists in three cities in Zhejiang province,
including Hangzhou. But where psychiatric services are used, medication is
s t d the main form of treatment. In Boey7sstudy of college students in urban
China were reports of great reluctance to use mental health services, as con-
fidence in the professionals was lacking (Boey, 1999). The popularity of a
telephone helpline (14% said they would like to use one) dustrates the de-
sire for anonymity, and this was actually stated by 19 students.
After adjusting for confounding variables, our findings suggest that fam-
ily size has little influence on mental well-being. If anything, the one-child
family may have a marginal protective effect, so that only children may be
slightly less prone to symptoms of depression and anxiety. In younger chil-
dren, the evidence for the psychological effects of being an only child in the
Chinese setting is similarly inconclusive (Tseng, et al., 1988; Yang, Ollen-
dick, Dong, Xia, & Lin, 1995). Clearly our results are crude: in a situation
where 85% of all only children are urban residents and 90% of the only
children in the rural area are boys, the effects of confounding must be enor-
mous, and analysis alone will not remove the complex effects of such distor-
tion. One might expect that academic pressures would be greater for only
children. However, we found no evidence for this. Rather the majority of
children irrespective of family size were most concerned about school-related
issues.
The study was carried out as a rapid appraisal, and there are clear limi-
tations. Questions about lifetime (ever) symptoms are highly reliant on mem-
ory and varied interpretation of symptoms at different ages. The few ques-
tions we asked are inadequate to describe the psychological mechanisms and
coping processes which these adolescents are adopting. More qualitative ap-
proaches are planned to elucidate some of these questions. However, the
study provides information about a hitherto under-researched population,
and four major points have emerged: rates of self-reported anxiety and de-
pression are high, school-related issues predominate as a source of worry,
there is a high level of unmet need, and there are no significant differences
in rates of anxiety and depression between only children and those with sib-
lings.
To our knowledge it is the first time that a rapid needs assessment in
mental health leading to policy change has been carried out with a mainland
Chinese population. The findings of this study have contributed to four
444 T. HESKETH & Q. J. DING

KLEINMANN, A. (1987) Depression, somatisation and the new cross-cultural psychiatry. Social
Science and Medicine, 11, 3-10.
LI, G. H., &BAKER,S. P. (1991) A comparison of injury death rates in China and the United
States. American Journal of Public Health, 81, 605-609.
LIU, X. C., ODA,S., PENG,X., &ASAI,K. (1997) Life events and anxiety in Chinese medical
students. Social Psychiatry and Psychiatric Epidemiology, 32, 63-67.
MACFARLANE, A., MCPHERSON, A., MCPHERSON, K., & AHMED,L. (1987) Teenagers and their
health. Archives of Disease in Childhood, 62, 1125-1129.
NATIONAL CENTREFOR HEALTHSTATISTICS. (1998) Health, United States. Hyattsville, MD: Au-
thor.
NIKAPOTA, A. D. (1993) Child psychiatry in developing countries. British Journal of Psychiatry,
158, 743-751.
PHILLIPS, M. R., LIU, H., & ZHANG,Y. (1999) Suicide and social change in China. Culture,
Medicine and Psychiatry, 23, 25-50.
PLATT,S., BILLE-BRAHE, U., & KERKHOF, A. (1992) Parasuicide in Europe: the W H O Euro
multi-centre study of parasuicide. Acta Psychiatrica Scandinavica, 85, 97-104.
PRITCHARD, C. (1996) Suicide in the People's Republic of China categorised by a e and gen-
der: evidence of the influence of culture on suicide. Acta Psychiatrica ~can&zauica,93,
362-367.
QIN, P., &MORTENSON, I? B. (2001) Specific characteristics of suicide in China. Acta Psychiat-
rica Scandinavica, 103, 117-121.
RESNICK,M. D., BEARMANN, P. S., & BLUM,R. W. (1997) Protecting adolescents from harm:
findings from the National Longitudinal Study of Adolescent Health. Journal of the Amer-
ican Medical Assocation, 278, 823-832.
ROBERTS, R. E., ATKINSON, C. C., & ROSENBLATT, A. (1998) Prevalence of psychopathology
among children and adolescents. American Journal of Psychiatry, 155, 715-725.
TSENG,W., KUOTAI,T., HSU,J., JINGHUA, C., LIAN,Y., & KAMEOKA, V. (1988) Family planning
and child mental health in China: the Nanjing Survey. American Journal of Psychiatry,
145, 1396-1403.
WORLDHEALTHORGANISATION. (1995) A picture of health: a review and annotated bibliogra-
phy of the health of young people in developing countries. Geneva: WHO/FHE/ADH.
YANG,B., OLLENDICK, T. H., DONG,Q., XIA, Y., & LIN, L. (1995) Only children and children
with siblings in the People's Republic of China: levels of fear, anxiety and depression.
Child Development, 66, 1301-1311.

Accepted Februa y 21, 2005.