SHANGHAI — It took less than two months for menopausal depression to push Xu to the brink of killing herself.

The 55-year-old, a teacher from the southwestern Yunnan province, first began feeling unwell in May 2018. Initially, her only symptom was a loss of appetite, and she assumed she simply had a stomach problem. She took a few pills, and thought nothing more of it.

But over the next few weeks, Xu’s condition rapidly worsened. She started experiencing anxiety and insomnia. She stopped taking care of her appearance, preferring to go out wearing casual clothes and slippers. Trying to avoid social interaction, she took detours to avoid bumping into friends in the street.

By July, Xu was contemplating suicide. She told her brother she wanted to jump from his 27th-floor window.

The confession caught Xu’s family completely off guard. Zhou Ying, Xu’s daughter, who lives over 2,000 kilometers away in Shanghai, had been video chatting with Xu regularly and was aware she was struggling. But when she heard what her mother had said, she was shaken to her core.

“I burst into tears at the office,” Zhou tells Sixth Tone.

Many Chinese families have similar stories to tell. Depression among middle-aged women is a silent epidemic in the country, and since mental health largely remains a taboo topic in China, it makes the disease even more dangerous.

An estimated 95 million people are living with depression in China, with middle-aged women among the most at-risk groups. According to a national mental health survey published in 2019, 65% of those with depression are female, while 53% are aged over 50.

During menopause, which typically affects women aged 45-55, the likelihood of becoming depressed rises dramatically. According to a study by the Chinese Preventive Medicine Association published in 2016, the prevalence of depression among menopausal women is four times higher than among premenopausal women.

Triggers for middle-aged depression can include the unpredictable hormonal fluctuations caused by menopause, but also the transitions that commonly take place in people’s lives at this age, according to Wang Yong, chief psychiatrist at the Shanghai Mental Health Center.

“The emotional problems between husband and wife, as well as children moving out, may lead to a mental health crisis in middle-aged and elderly people,” says Wang.

But menopausal depression is notoriously difficult to treat. For one thing, both patients and their loved ones often fail to recognize the severity of the condition, says Wang.

“People often confuse menopausal syndrome with menopausal depression,” says Wang.

Social pressures, meanwhile, make Chinese women — and elderly and middle-aged women especially — less likely to acknowledge they have emotional problems. Having been raised in a society lauding stoicism and neglecting the mentally ill, many are unwilling to admit they need help — even to themselves.

“Many mothers and grandmothers, even if they know they’re in a ‘bad emotional state,’ don’t want to come and see the doctor,” says Wang. “It’s their children who force them to go to the hospital.” 

As Xu’s story shows, however, the effects of menopausal depression can be devastating. The suicide rate among those with depressive disorder in China is between 4% and 10.6%, according to the 2019 study. Though Xu would eventually recover, her daughter Zhou calls the disease an “invisible killer” that needs to be taken more seriously.

“Most people feel it’s not a disease and that it will go away with time,” Zhou says. “This has led to menopausal depression becoming more hidden and rarely diagnosed, making it a very dangerous disease.”

Zhou is doing what she can to raise awareness of the condition. In December, the 29-year-old took to Douban — a social platform popular among young Chinese — to share her mother’s story and urge others to keep a close eye on relatives going through menopause.

The post caused a sensation. China’s millennials are generally more attuned to mental health issues than their parents’ generation, and the COVID-19 pandemic has focused attention on the topic like never before. In a Chinese survey conducted in February 2020, during the height of China's coronavirus epidemic, 35% of respondents said they were experiencing psychological distress.

Zhou’s story received over 2 million views on Douban, with hundreds of users sharing their own tales of dealing with mothers affected by depression. Like Zhou, many said they’d moved across the country for work, which made it harder for them to recognize their family members were showing signs of the disease.

“My mother once mentioned she’d been sleeping poorly and had no strength, but I didn’t pay much attention to it,” wrote one user. “One day, she didn’t reply to my message and I thought she was working, but that morning she’d jumped off a bridge and killed herself.”

“Mom jumped from the 17th floor,” another commenter wrote. “The pandemic made it difficult for me to return home from overseas. My mother and all my friends and family kept (her depression) from me for a whole year.”

For Wang, however, the key to tackling menopausal depression will be changing attitudes toward mental health among China’s older generations. The psychiatrist says nearly one-third of his patients are middle-aged or elderly, and they tend to be the most difficult to treat. 

“The older they are, the more stigma the patients have,” he says. “They’re more likely to … have a long course of the disease.”

Stigma is often associated with negative emotions toward oneself generated by depression, Wang says. The lack of education on mental health issues among those with menopausal depression in China makes the stigma more difficult to counter.

Like many with depression, Xu initially struggled to accept her condition. She likes her job as a secondary school Chinese language teacher in Yunnan, and she has a good relationship with her husband, who works as a history teacher at the same school.

“My mom repeatedly said she really had no reason to get angry with anything,” Zhou recalls.

Fortunately, the teacher has a strong support network and was willing to accept help. After Zhou learned that Xu had said she wanted to kill herself, she immediately took leave from work and flew out to see her mother. She insisted Xu accompany her back to Shanghai for treatment, a proposal her mother reluctantly accepted.

Things didn’t go smoothly at first. In Shanghai, Xu was afraid to go out, and spent days pacing up and down Zhou’s small apartment. “If I was about 5 meters away from her outside, she didn’t dare come up to me alone,” says Zhou.

A few days after her arrival, Xu accidentally injured herself while cutting fruit. After getting five stitches at the hospital, she said she couldn’t stay in a strange city any longer. Xu flew to Luzhou, her hometown in the southwestern Sichuan province, to stay with relatives. There, she saw a doctor and started taking medication, which helped her insomnia but didn’t cure her feelings of “world-weariness,” Zhou says.

With the new school semester approaching, Xu wanted to take a long vacation to rest at home, but her daughter was against the idea. Instead, the family was able to arrange for the school to transfer Xu to an easier job, to help her maintain a relaxed state at work.

At the end of 2018, Xu said she wanted to check in to the hospital in Kunming, capital of Yunnan province, for further treatment. Some family members opposed this idea, saying Xu was already getting better. But Zhou supported her mother.

“It was a good sign that she proposed being hospitalized,” she says.

Xu spent two weeks in the hospital, accompanied by her husband. They shared meals, watched TV, and took walks in the park after dinner. After being discharged, the couple returned to Luzhou for Spring Festival. 

Since then, Xu’s condition has gradually improved. Her anxiety and restlessness have subsided, and she has become more sociable and started to take more care over her appearance, according to Zhou. 

But not everyone benefits from such support. There is still widespread ignorance about depression in China, and many of those who have it find even their own family less than understanding.

When Xu first showed symptoms of depression, Zhou asked a friend who works at a hospital for advice on what to do. The friend, a female medical worker, simply replied: “It’s like this for everyone during menopause. What’s so special about your mother?”

Chen Wan, a 53-year-old from Shanghai, has largely had to deal with her issues alone. She has struggled to keep control of her emotions since entering menopause, but her husband hasn’t been sympathetic, she says.

“In the past, when we argued, he’d say I was under great pressure at work, but now he’ll impatiently ask me if I’m menopausal,” Chen tells Sixth Tone. “I don’t understand … Puberty and pregnancy are considered normal physiological stages for women. Why has ‘menopause’ become such a negative word?”

Chen’s family situation often leaves her feeling isolated. She works full time at a bank, while her partner manages a company in Shanghai and often travels for business. Their 28-year-old son lives in Beijing and recently got divorced.

“I used to call my son to complain about my husband, but now I don’t want to bother him,” says Chen.

But the mother is well-informed about mental health, and she decided she needed to see someone. Last November, she went to the hospital, where she was diagnosed with mild menopausal depression. 

“The doctor said it’s normal and suggested I should be open with my family and seek their help and understanding,” says Chen.

Chen, however, doesn’t feel ready to tell her husband and son about her diagnosis yet. “As men, I don’t think they can empathize with me,” she says. “If I tell them, they’ll find me melodramatic.”

Instead, Chen relies on her weekly appointments with her psychiatrist for support. “It costs me a fortune, but I feel reborn after each session,” she says.

The situation can be even more complicated for men dealing with menopausal depression.

Although there are differing opinions within the medical profession regarding “male menopause,” studies have found that 30%-40% of men aged between 40 and 70 display one or more symptoms of menopause, with declining hormone levels a common cause.

In some cases, men also experience psychological problems related to the physiological changes they’re undergoing. Though the changes brought on by male menopause are less dramatic, Wang, the psychiatrist, says depression in older men is often more difficult to treat than in women.

“In Chinese culture, men — especially those in senior positions — are generally reluctant to show they’re depressed and are unwilling to accept their emotional problems,” says Wang. “They feel this is a shameful thing and a kind of mental illness that will make people prejudiced against them.”

For a long time, Wang, a 66-year-old retired technician who has no relation to psychiatrist Wang Yong, had no idea why he kept feeling so nervous and restless. Concerned he might have a cardiac issue, he went to the hospital, but the tests showed there was nothing wrong with his heart.

Wang Jing, his daughter, tells Sixth Tone her father — for whom she only gave a surname for privacy reasons — used to be shy and good-tempered. But over the past five years, he has become “irritable and often angry about insignificant things,” she says.

“If things don’t go his way, he gets very anxious,” says Wang Jing.

After discounting a physical ailment, Wang and his family began to realize his emotional changes may be related to male menopause. On a friend’s recommendation, he began taking a traditional Chinese remedy, which calmed him down a little and helped him sleep better.

Yet Wang remained anxious and irritable. Only after reading a few books about psychology at the community library did he started to understand what he was going through. “He told us he had depression,” Wang Jing recalls.

Since then, the retiree has been using exercise to fight his depression. He has formed the habit of taking a walk every day. On one of these strolls, he met a group of people doing tai chi, and he now also practices with them regularly.

For now, however, Wang’s family doesn’t consider it necessary for him to obtain psychiatric help, as his condition is relatively mild.

“My parents and I aren’t prejudiced against depression and other mental diseases,” says Wang Jing. “We simply feel that compared with other diagnosed patients, especially those with suicidal tendencies, his symptoms … aren’t so serious.”

Back in Yunnan, meanwhile, Xu is trying to move on with her life. She is still taking medication, but the dosage has been reduced to one-fourth of its original level.

Zhou considers her mother to have “basically recovered” at this point. Though the daughter still shudders to look back on what she calls Xu’s “dangerous experience,” Zhou knows things could have turned out so much worse.

“I feel lucky my mom is still alive,” she says. “I’m grateful my family was supportive and took my mother’s medical treatment seriously, and didn’t just regard her depression as part of menopause.”

In China, the Beijing Suicide Research and Prevention Center can be reached for free at 800-810-1117 or 010-8295-1332. In the United States, the National Suicide Prevention Lifeline can be reached for free at 1-800-273-8255. A more complete list of prevention services by country can be found here. 

Editor: Dominic Morgan.

(Header image: E+/People Visual)