Old Version

Tortured Smiles

Smiling faces can hide deep depression, still stigmatized in China.

By Fu Yao Updated Jul.2

There’s an old joke. A man goes to the doctor. “I’m so depressed,’ he says. “Life seems pointless. I can’t go on.” “Listen, my friend,” says the doctor, “Tonight the great clown Grimaldi is performing. You’ve never seen anything as funny. You go to that show tonight, and you’ll laugh more than you’ve ever laughed before.”  

The man bursts into tears. “But doctor,” he says, “I am Grimaldi!”  

It’s a tale that might seem familiar to Xue Zhiqian, or Joker Xue, a popular Chinese celebrity who sings, acts and hosts TV shows. He’s famous for his sparkling sense of humor in front of the camera.   

But Xue recently spoke in public of suffering from chronic depression, with which he was recently diagnosed. And he’s not alone. There are other comedians or TV hosts in China who’ve covered their inner suffering with a happy mask, such as Cui Yongyuan and Wang Zijian. They all suffer from what people call “smiling depression.”  

“Smiling depression” is a term used for patients who are depressed, but who don’t exhibit the conventional outward symptoms such as tears or lethargy. These “smiling” patients might not actually be aware that they’re depressed – or they might have been diagnosed, but refuse to tell anyone. On the outside, they can seem all smiles, and even enjoy an active social life. But behind closed doors, they suffer from secret insomnia, crushingly low self-esteem and even suicidal thoughts.  

According to the latest statistics released by the World Health Organization, by 2015 over 320 million people were suffering from depression, accounting for some 4.3 percent of the total global population. That includes at least 90 million people in China. But although people are growing more aware of the disease, it’s rarely recognized in China, especially in this particular form.  

Invisible Torture 
Smiling depression is a state that Wang Yiqing, an 18-year-old high school student recognizes only too well. A passionate, optimistic and high-flying girl, she was diagnosed with severe chronic depression last summer. “I suddenly felt like I was trapped in a black hole, and no matter how much I struggled, I couldn’t escape the darkness.” But she hid her agitation from her classmates and family, sticking to her old routine and putting on a smiley face.  

When she could keep up the pretense no longer, she sought help from her school’s therapist. After she was evaluated, the counselor was shocked to find she was suffering from severe depression.  

It was no surprise to Wang, but her teachers and parents refused to believe it. They thought she was merely anxious about the upcoming college entrance examinations, and told her she should relax. She felt that nobody understood or supported her, and continued interacting with others with her usual smile. But she was surprised to find how quickly she went downhill. She began to lose control of her body. Her hands trembled, and she lost her appetite; when she climbed a single set of stairs her heart would beat unbearably fast.  

Ever smaller things would cause her to collapse. Once, she saw her father fumbling with his lighter, and it caused her to burst into tears. But most of the time, she tried to hold back from crying and squeeze out a smile. “I had no choice, because I did not want to worry my parents,” Wang told NewsChina in late March.  

“I wasn’t surprised that no one noticed, I was very good at covering it up,” Wang Yiqing says. “I didn’t want to let people know because I was afraid they would think I was mad or would laugh.” After a few months, Wang Yiqing went to hospital and was diagnosed with both anxiety and depression. Today she is mixing group therapy and medication.  

Social Stigma 
Because of the stigma attached to depression, there are huge numbers of people who cover their mental health problems with a smile.  

“Normally, people relate depression with overt sadness, but in reality, some depressed patients can smile well,” Dr Lu Yazhou, a psychiatrist from Beijing Anding Hospital told NewsChina: “Some patients put on a smile as a habitual cover up, even when they are in the dangerous situation of deep depression. But in most cases, there’s sadness in the smile.” The doctor is often the only person who is aware of how the patient is feeling on the inside.  

Dr Liu Qi, from Beijing No. 6 Hospital, told NewsChina that there was another risk. “When they’ve already decided they can’t be helped and are already planning suicide, they smile.” Typically, people who suffer with classic, severe depression might have suicidal thoughts, but not the willpower or energy to act on their feelings. However, those suffering from smiling depression have the energy to plan and follow through. This is why smiling depression can be more dangerous than the classic form of severe depression.  

According to Dina Goldstein Silverman, a US psychologist and assistant professor of psychiatry, there’s a troubling connection between smiling depression and suicide. In contrast with patients who have little energy to even get out of bed, chronically depressed patients who are suicidal and report a surge of energy might be more likely to initiate a suicide attempt.  

Overlooked Problem Talking about depression is becoming more common in China, but there’s still many who don’t come forward, especially those who keep smiling.  

Wu Zhe is a licensed psychologist in California, the US. Among his patients who suffer from smiling depression, most are adolescents. In her opinion, apart from professional treatment, family participation is equally important. “In most cases, Chinese-style education emphasizes that children should be obedient, and courageous in tackling obstacles. Children are taught not to bring trouble to the family, thus the young Chinese feel kind of guilty when talking about their misery,” Wu Zhe explained to the reporter.  

“But talking within the family is helpful in cultivating intimate relationships, and enables children to learn techniques to face outside pressure.” In the community where Wu works, each school employs a full-time therapist and teachers are very conscious about students’ mental health. If they see anything wrong, they talk with the student. “American parents know how important their kids’ mental health is, and if they see warning signs, they call me to consult.”   

The situation is sadly different in China. In 2006, Anding Hospital in Beijing set up its depression treatment center, the first of its kind inside China. Up until now, every day, there are around a couple of hundred patients seeking treatment in the center. Doctor Lu from Anding Hospital believes that in China most people remain ignorant about the treatment of depression as an illness. “In China, the treatment rate of depression is around 4.3 percent, even in megacities such as Beijing and Shanghai, the rate is no more than 5.1 percent.”  

On March 31, 2017, the China Social Welfare Foundation published the 2017 Depression Among Chinese Netizens Research Report. Only 5 percent of those studied said that they would seek psychotherapy or other professional help when they suffer from depression, and 47 percent said that if they suffered from depression they would choose to hide it from others. (Wang Yiqing is a pseudonym)