Navigating stigma and somatization: a qualitative exploration of mental health experiences among middle-aged adults in rural China

Abstract

This study investigated the experiences of stigma and somatization among middle-aged adults with mental health issues. Using frameworks of public stigma, self-stigma, affiliate stigma, and somatization (both presenting and functional), the study explores how individuals navigate the stigma associated with mental health. Interviews were conducted with middle-aged adults in rural areas, and the data were analyzed using Interpretative Phenomenological Analysis (IPA) to gain insights into their lived experiences. The findings reveal that mental health stigma in rural China significantly influences how individuals express mental distress, often leading to somatization. Patients tend to frame their mental health issues in terms of physical symptoms, such as headaches or fatigue, to avoid stigma. The study also highlights the role of cultural norms in shaping these expressions, particularly within the context of close-knit rural communities where mental health issues is stigmatized. The implications for education and policy are discussed, emphasizing the need for improved public mental health education and more equitable distribution of healthcare resources between urban and rural areas. This study contributes to the understanding of mental health stigma in rural China and offers practical suggestions for addressing mental health challenges in underserved communities.

Introduction

The number of individuals with mental health issues in China has been steadily increasing [1]. According to the National Health Commission (NHC) of The People’s Republic of China, as of the end of 2018, there were 5.81 million registered patients with severe mental health issues nationwide [2], and the number of mental health patients in China is projected to reach approximately 350 million by 2023 [3]. However, the availability of mental health services remains limited [4], and rural residents often struggle to afford the high costs associated with mental healthcare [5]. Research indicates that rural doctors have a significant lack of understanding regarding mental health issues and that discrimination against mental health patients is prevalent [6]. This discrimination may exacerbate patients’ feelings of shame and hinder them from seeking timely medical treatment [6]. For middle-aged individuals, the situation is even more concerning. Compared to young adults, middle-aged individuals exhibit poorer mental health [7, 8], and are more likely to experience midlife crises [9]. However, to our knowledge, no previous studies have specifically examined the mental health experiences of middle-aged adults in rural China.

Mental health in rural China

Existing literature highlights significant disparities in China’s mental health system. China has two-thirds of its 1.3 billion citizens residing in rural areas, however, mental health care resources are predominantly concentrated in urban psychiatric hospitals [10]. Rural areas lack sufficient medical resources [11], and medical staff often lack specialized training and face substantial workloads with minimal compensation [12]. Consequently, rural mental health patients experience inadequate treatment and face substantial disadvantages in terms of service availability, scope, and quality [13]. For instance, a study estimated that 173 million Chinese individuals have diagnosable mental health issues, of whom 158 million have never received treatment [14]. This reflects a pronounced imbalance in the distribution of mental health resources, with most hospitals and professionals concentrated in more developed regions [15].

Some studies in rural China have explored mental health issues among adults, with a portion focusing on mental disorders and suicide, particularly in young and elderly adults [16, 17]. However, most research on adults does not classify participants by specific age groups [18], potentially overlooking the unique characteristics of middle adulthood. Middle adulthood is generally defined as individuals between the ages of 40 and 65 [19]. During this stage, people often undergo significant changes in physical health, psychological well-being, careers, and social roles [7]. Many studies indicate that middle-aged adults tend to experience poorer mental health and take on more family responsibilities compared to young adulthood and older age [7, 20, 21]. Furthermore, traditional Chinese culture associates mental health issues with deep-seated fear and stigma [22]. As a result, stigmatized mental health issues are frequently expressed through somatization [23]. This cultural perception places middle-aged adults, who typically bear greater family responsibilities, at particular risk of mental health challenges [8]. In Chinese society, family expectations place greater responsibility on middle-aged adults, requiring them to care for elderly parents and raise children [24]. In rural China, middle-aged adults with mental health issues face a higher risk of suicide compared to younger adults, particularly when they have access to means of self-harm [25]. For example, a study reported that pesticides and herbicides are commonly used among middle-aged adults, and suicide attempts are more prevalent among females [26]. Despite this, research on the mental health issues of middle-aged adults in rural China remains limited, and no studies have specifically examined the relationship between stigma and somatization in this population. This gap in the literature leaves a critical void in understanding their unique experiences.

Stigma and somatization

Stigma and somatization play a significant role in shaping individuals’ experiences with mental health. The stigma associated with mental health issues hinders patients’ access to mental health services [27], and serves as a major source of stress in their lives [28]. For instance, a review reported that the stigmatization of mental health issues is perpetuated by prejudicial attitudes and various acts of discrimination across multiple domains of life [29]. Moreover, mental health stigma has been linked to somatization [30]. For example, a study found that somatization is strongly associated with mental health conditions such as depressive and anxiety symptoms, resulting in significant distress [31]. Given the importance of stigma and somatization in the mental health experience, this study focuses on the experiences of stigma and somatization among middle-aged adults.

Stigma

Stigma is described as an attribute that is deeply discrediting, reducing the individual from being perceived as whole and “usual” to being viewed as tainted and discounted [32]. Stigma can be classified into many types, such as public stigma, self-stigma, and affiliate stigma. Public stigma refers to the endorsement of stereotypes, prejudice, and discrimination by society [33]. In China, public stigma is often perceived as a source of “family shame,” “hostility,” and “discrimination”, which can significantly hinder help-seeking behaviors [34]. Affiliate stigma describes the psychological responses and identification of individuals who are closely associated with the stigmatized individual, such as family members [35], it toward individuals with mental health conditions in China is linked to increased family burden, as well as feelings of inferiority, helplessness, and sadness among family members [36]. Self-stigma is the internalization of societal stigma by the individuals targeted, leading to feelings of shame and self-devaluation [33], individuals who experience self-stigma in China often exhibit alienation, stereotype endorsement, and social withdrawal [37]. Numerous studies in Western contexts have identified the existence of these forms of stigma among mental health patients, their families, and mental health service workers [38, 39]. These stigmas have been linked to negative mental health outcomes [40]. For instance, a meta-analysis of 49 studies reported a significant association between stigma and mental health issues [41].

Previous research on mental health stigma in China has predominantly focused on urban populations [42]. In contrast, studies addressing rural areas have primarily examined stigma from the perspective of healthcare providers [6, 12]. These studies highlight that stigma is often rooted in widespread biases and misunderstandings. However, to date, limited research has explored the experiences of stigma from the perspectives of patients, their families, and their communities. This study seeks to address this gap by examining the stigma experiences of middle-aged adults in rural China.

Somatization

Somatization can occur as a secondary phenomenon resulting from psychological distress (presenting somatization) or as a primary phenomenon characterized by medically unexplained symptoms (functional somatization) [43]. Functional somatization refers to symptoms that cannot be fully explained by physiological or anatomical abnormalities but nonetheless have a significant impact on an individual’ s functional ability [43]. In Chinese social context, some studies have reported an association between somatization and functional impairment in conditions such as heart failure and brain disorders [31, 44]. In contrast, presenting somatization refers to the expression of psychological or emotional distress through specific physical symptoms, which often serve as the primary reason for seeking medical attention [43]. In Chinese culture, presenting somatization is frequently expressed as neurasthenia, a practice intended to protect patients and their families from stigmatizing diagnoses [40, 45]. Numerous studies have reported that mental health issues are often expressed through somatization [46]. For example, a review reported that somatization disorder was often an outcome of mental health issues, and effective treatments include antidepressants, supportive psychotherapy, and cognitive-behavioral therapy [47]. Furthermore, somatization varies across cultures, reflecting the ethnomedical belief systems in which these expressions of distress are rooted [48].

In the context of Chinese culture, somatization has been closely linked to societal and cultural structures. Kleinman and Kleinman (1985) argued that neurasthenia, often regarded as a manifestation of somatization, serves as an example of the social construction of clinical reality [23, 49]. Other studies have also documented how somatization symptoms, such as sleep disturbances, general malaise, and physical pains, can prevent patients from seeking mental health services [50]. However, much of this research has been conducted in developed areas, such as Hong Kong [50] or urban hospitals [23]. In rural China, where mental health services are severely lacking [11], informal caregiving and social support networks play a critical role in addressing mental health issues [51]. This unique context suggests that the mechanisms and manifestations of somatization may differ from those observed in urban settings. However, existing studies have not fully explored the somatization processes and their specific characteristics in rural China, leaving an important gap in the literature.

The current study

Previous research has documented the importance of stigma and somatization in the context of mental health issues [27, 30]. However, limited attention has been given to rural areas in China, with insufficient exploration of the experiences of middle-aged adults facing mental health issues. Additionally, there is a lack of clarity regarding the interplay between stigma and the somatization process in rural China. This study aims to address these gaps by investigating the mental health experiences of stigma and somatization among middle-aged adults in rural China.

Methods

Participants

This study collected data from rural areas of Liaoning Province, Jilin Province, and Heilongjiang Province in Northeast China, regions characterized by relatively low levels of economic development. Participants (n = 20) were recruited from these provinces, including 12 individuals with self-reported mental health issues. Among these participants, 5 were diagnosed with dissociative disorders, 5 with depression-related illnesses, 1 with schizophrenia, and 1 with panic disorder.

Additionally, interviews were conducted with 8 community members of these patients, to explore the patients’ lived experiences. Most interviewees were females with mental health issues (n = 10). All participants were middle-aged, had an education level of junior high school or below, and had incomes lower than the rural per-capita average.

Regarding the duration of illness, the majority of patients (70%) had been ill for less than six months. Each interview lasted at least 30 min, with some extending to 60 min for those with extensive experience. Additionally, one interviewee participated in two sessions (pilot interview and formal interview), resulting in a total interview time of up to 120 min. The characteristics of participants are shown in Table 1.

Table 1 Main interviewee information

Procedures

This study recruited mental health patients residing in rural China using snowball sampling. Between June 2023 and October 2023, interviews were conducted with 12 patients diagnosed with mental health issues, along with their relatives and friends. Each patient participated in two or more in-depth interviews, each lasting no less than one hour. The interview was developed specifically for this study and can be found in the supplementary file. In May 2023, we developed an interview guide and invited Liu to conduct a pilot interview. Based on the results, we revised the guide to better align with the rural Northeast China context. A social worker then conducted the interviews following this revised guide. The interviews were conducted in Mandarin Chinese or the Northeast dialect with audio-recorded, following a semi-structured interview guide. The guide addressed four main topics: sociodemographic information, daily life prior to illness, quality of life during illness, and life post-recovery. Researchers completed training on the ethical aspects of human subjects research. Informed consent was obtained from all participants, including details on guidelines, potential risks, and benefits. Data collection involved recording interviews with a digital voice recorder, with participants’ permission.

Data analysis

This study analyzes experience with mental health issues using the frameworks of public stigma, affiliate stigma, and self-stigma [33, 35], as well as the frameworks of presenting somatization and functional somatization [43]. The interview data were analyzed using interpretative phenomenological analysis (IPA), a dynamic approach that aim to explore the participant’s view of the world and to adopt, as far as is possible, an insider’s perspective of the phenomenon under study [52]. First, the audio recordings of each interview were transcribed verbatim in Chinese, yielding over 60,000 words of text. The transcripts were then read multiple times to identify codes and organize them into initial themes. Second, initial notes were systematically transformed into emergent themes, ensuring that the analysis remained grounded in participants’ mental health experiences. Third, emergent themes were further integrated into superordinate themes, establishing logical relationships between themes to capture deeper patterns and meanings within the data. Two coders independently coded the data using Excel, collaboratively establishing coding rules during the process. Any inconsistencies in coding were discussed and resolved through biweekly meetings. Finally, an independent expert reviewed the coding results and provided further refinements to ensure accuracy and reliability. The entire coding process was conducted in Chinese to maintain the cultural and linguistic nuances of the discussions. Two researchers with doctoral-level knowledge in related research field and proficiency in both Chinese and English translated the data separately, which was then subjected to peer debriefing to ensure fidelity to the participants’ intended meanings.

Ethical considerations

We received ethical approval from Technology Ethics Committee in Qingdao University of Science and Technology (QKDDL-2024-50). All participants or their legal guardians provided informed consent to participate in the study. First, the participants self-reported their capability to participate the interview. Then, the investigators and a supervisor determined that all adult patients and participants were deemed capable of ethically and medically consenting to their involvement in the research. For sensitive issues such as suicide, researchers do not ask any additional follow-up questions. After the interview, the research team provided participants with access to mental health counseling resources, emphasizing that the services are completely free. The decision to use these resources was entirely up to the participants, and the research team were not involved in any follow-up treatment or services.

Results

Stigma and somatization represent distinctive challenges faced by mental health patients in rural China. Participants reported that stigma adversely impacts their self-esteem, familial relationships, and social interactions within the community. Patients with mental health issues often reject their psychiatric diagnosis and instead frame their conditions in somatic terms, describing them as physiological disorders such as headaches or chest tightness.

The experience of Sigma

Self-stigma: low self-worth and suicide

Most patients with mental health issues exhibited low self-efficacy and a diminished sense of self-worth. In daily life, many patients lost their ability to independently care for themselves and become reliant on family members for support. This dependency reinforced their belief in their own inadequacy. Experiencing low self-efficacy often leads patients to devalue themselves and feel disrespected. For instance, after Zhang fell ill, she depended entirely on her family for care, and her narrative revealed a sense of self-denial.

After getting sick, I couldn’t control myself and felt really disoriented. My mother-in-law and husband grew distant and didn’t like me. I felt powerless to do anything I wanted.

Many patients experienced a significant loss of their work capacity and income due to their illness, leading them to perceive themselves as worthless. This diminished ability to work and earn income often reinforces feelings of inadequacy. Respondents frequently expressed sentiments such as, “I am useless” or “I lack the ability to work and earn money.” For instance, after Xue fell ill, her inability to work externally led her to believe that:

I used to have a job and send money home, but later I got sick and couldn’t work anymore—I even needed to spend money. Who would still look up to me? No one! When I go out, no one respects me because I’m useless!

The decline in self-efficacy among patients often escalated into suicidal tendencies. As their illness progresses, patients may view their daily lives as “meaningless”. Some patients express such despair that they contemplate suicide, with statements like, “I wish I could die.“

I’m really tired of living. Every day, the pain is unbearable. I don’t even feel like a person anymore—maybe it’d be better if I were gone.

Affiliate stigma: family relationship disorder and power transition

Mental health issues significantly distort family relationships, particularly affecting parent-child dynamics. Many patients reported deterioration in their relationships with their parents, often leading to verbal conflicts. For example, Liu’s mother expressed severe frustration by saying, “You should die soon! Why are you still alive?” Similarly, Zhang experienced heightened tension with her mother-in-law after developing postpartum depression, illustrating the strain these conditions can place on familial interactions.

I get really frustrated when I hear my child crying. I feel like my husband doesn’t understand me, and my mother-in-law keeps making sarcastic remarks. Eventually, I lost my temper and ended up yelling at and hitting my husband and mother-in-law.

Participants also reported that their marital relationships have been disrupted. Among the patients interviewed, many of whom are female, there is a notable pattern of conflict with their spouses during illness. For instance, Zhang, who experienced postpartum depression, frequently argued with her husband due to a lack of understanding and support. In some cases, these conflicts escalate to the point of divorce. Liu, the patient with the longest duration of illness—spanning three years—reported that her husband openly engaged in infidelity and sought a divorce during her period of schizophrenia.

My husband and my mother both said that after trying many treatments, there’s nothing else that can be done. My husband considered leaving me.

Mental health issues often led to increased scrutiny and control by family members, who were concerned about the potential for shame or trouble caused by the patient’s condition. Many patients reported feeling “monitored” by their families. For instance, Jin remarked, “My family is constantly watching me and worries that I might go out and cause trouble.” Similarly, Liu’s husband noted:

We closely monitor her (Liu) and accommodate her demands as much as possible to avoid further issues. If we don’t, she might act independently and bring additional complications to the village.

Due to concerns about the potential embarrassment their behavior might bring to the family, family members often prioritize the needs and wishes of the patient. Consequently, mental health patients may gain significant influence within the family, effectively becoming the focal point of family dynamics. For example, Yang’s family members began to give greater weight to her opinions after her illness, with their actions increasingly requiring her consent. Similarly, Zhang’s family seeks her consent before taking any action, as they are concerned that it may worsen her condition.

“I didn’t want my in-laws to get married at that time, though I kept that to myself. After I became ill, I lost control and started speaking my mind. I told them that if they dared to get married, I’d come over and twist their heads off. This scared my in-laws a lot, and they eventually became worried that I would actually interfere with their plans.” (Yang).

“My family members are extremely cautious in everything they do, constantly watching my reactions and want to accept my consent. They are afraid that if they do something to upset me, it might worsen my condition.” (Zhang).

Perceived public stigma: community exclusion

Mental health issues were often linked to moral deficiencies, with many villagers attributing such conditions to personal misconduct or family moral failings. This association resulted in significant community exclusion for patients within rural communities. For example, Jin’s neighbor remarked on her situation as follows:

They believe this illness is a result of doing too many bad things—either because of something shameful their ancestors did or because of their own actions.

The cultural exclusion faced by mental health patients was pronounced, as they are often barred from participating in significant community events and cultural festivals. During important occasions, such as weddings and funerals, patients were frequently prohibited from attending. For instance, Xue was restricted by his family from participating in activities such as ancestor worship during the Qingming Festival and was also excluded from attending the weddings of relatives, friends, and neighbors.

My dad wouldn’t let me participate in ancestral worship, saying I had a depression and should stay home. I haven’t been to any weddings or events; who would invite me? Some people even question what kind of wedding someone with a condition like mine should attend.

Economic exclusion represented a significant challenge for patients with mental health issues, as they often face barriers in the labor market, finding employment both within and outside their villages. Even when they did secure jobs, their earnings were typically much lower compared to other villagers. Xue remarked, “With this illness, you can’t find any work at all. Who cares about you?” Similarly, Jin noted that her daily wage decreased by 20 yuan after she fell ill, stating, “They think I’m worth this price.”

Additionally, mental health patients encountered relationship exclusion, frequently finding themselves marginalized within their communities. Villagers often exhibit reluctance to engage with individuals suffering from schizophrenia, maintaining a deliberate distance. Liu’s neighbor conveyed her attitude towards Liu during that period:

When she appear sick, everyone thinks she’s just pretending. We all avoid her because we’re afraid of her. Since she’s not acting normally, we don’t want to socialize with her and tell our children to stay away.

In daily interpersonal interactions, patients with mental health issues were deprived of basic rights such as shopping and engaging in everyday social interactions. For instance, after Liu developed schizophrenia, she was treated differently by local stores, which perceived her as incapable of making purchases independently. Liu said:

I went to the store and said things like, ‘This is mine, that’s mine, everything is mine, and I’m just taking it without paying.’ They were too scared to confront me, so eventually, my family and the store started making sure I had someone with me when I shopped.

The experience of somatization

Presenting somatization

Some patients who expressed mental health issues through somatization struggled to differentiate between psychological and physiological pain. This resulted in complaints of symptoms such as headaches, chest pain, insomnia, and hypertension. Yang exhibited pronounced somatic symptoms, primarily experiencing acute somatization that lasted only a few days. Initially, she believed she was suffering from high blood pressure:

I don’t think I have dissociative disorders I believe that people with mental health issues are just crazy. I only feel discomfort in my head, with constant pain and nausea. I’ve always thought of it as hypertension.

Beyond hypertension, most participants interpreted their mental health issues as physical problems, such as headaches and dizziness, and sought diagnoses from neurology departments. Many doctors diagnosed their conditions as issues like cerebral blood flow deficiency. This led to repeated hospital visits without any identification of the root cause:

I kept feeling dizzy and confused, so I went to the hospital. The doctor said there was nothing wrong, just insufficient blood flow to the brain, and prescribed some medication, advising me not to keep my head down. But even after taking the medicine, my symptoms didn’t improve. It wasn’t until my condition became very severe that a doctor referred me to a psychiatric department.

Additionally, some participants reported somatization symptoms that made it difficult to interact with strangers. For instance, Hu experienced uncontrollable trembling whenever she met strangers. She initially attributed this to her inability to manage interpersonal relationships, but as her condition worsened, she eventually sought medical help:

I always thought I was just a timid person. Every time I saw strangers, I couldn’t stop shaking. My hands and feet would become icy cold, and I couldn’t speak. My husband and mother also thought I was just afraid of strangers. It wasn’t until after my suicide attempt that I realized I had depression.

Functional somatization

Many participants reported that functional somatization had a significant impact on their ability to work, often forcing them to quit their jobs. For example, Bai, who worked as a sanitation worker, had to stop working due to relentless pain caused by somatization:

“I used to be able to work, but after getting sick, I felt pain all over my body and couldn’t go to work anymore. I went to the hospital, but the doctors couldn’t figure out what was wrong with me—it was just pain. This caused me to lose my job. Even when I wasn’t working, I could still do housework, but now I can’t even clean the house. I rely entirely on my son and husband.”

In addition to work, some participants reported that somatization affected their ability to engage in social activities, isolating them from their social networks and increasing their sense of loneliness. For instance, Wu, who used to play mahjong with friends, found herself unable to participate due to her inability to concentrate:

I used to play mahjong all the time, but then I couldn’t play anymore because I always felt dizzy and couldn’t see the tiles clearly. After playing for a short while, I would feel lightheaded. Over time, I stopped playing with my friends altogether.

Somatization also affected participants’ interactions with family members and neighbors. For example, Li experienced speech loss as a manifestation of somatization, which caused her to withdraw from communication with her husband and mother-in-law. Her mother-in-law described her as “living in her own world, ignoring everyone.” Reflecting on her experience, Li stated:

At the time, I couldn’t speak and didn’t want to talk. I refused to communicate with my husband or my mother-in-law. Later, I realized it was depression. Back then, because of me, the atmosphere at home was very tense.

The relation between stigma and somatization

Stigma leads to somatization

As many participants reported, mental health issues carry a stigma, with many believing that “having a mental health issues is shameful” (Liu) or “is looked down upon by others” (Xue). This stigma leads to somatization, where many participants express their mental health issues through physical symptoms such as headaches and dizziness. Village doctor Chen identified the stigmatization underlying these somatic expressions:

Mental health issues carries a stigma. Patients and their families often face moral judgment. Even if there are genuine mental health issues, they are often expressed through physical symptoms to avoid moral condemnation from others.

Somatization thus becomes an important strategy for patients to cope with stigma. When sharing their experiences with others, they frequently substitute somatic symptoms for depression. For example, one patient told their neighbors:

I have headaches, dizziness, and nervous exhaustion. I don’t dare tell them I was diagnosed with depression, as that would lead to discrimination. People would look down on me and distance themselves from me.

Somatization worsens the condition

Somatization symptoms often mask the underlying mental health issues, which are frequently treated as physiological conditions such as hypertension or neurasthenia rather than being recognized as psychological problems. Many participants reported that their mental health issues initially manifested as physical symptoms, such as headaches and stomach pain. However, their decision to seek treatment in neurology departments instead of psychiatric ones delayed proper diagnosis and treatment. This delay worsened their conditions, resulting in low self-worth, suicidal thoughts, and strained family relationships:

At first, I just felt dizzy and had headaches. My son took me to the hospital, and I visited every hospital in the area. I even had a CT scan done, but nothing was found. The medication the doctors prescribed didn’t help either. After trying everything and not getting better, I went back home. My condition got worse, and I started yelling at my in-laws and causing trouble for my son and daughter-in-law.

Worsening condition heightens stigma

The prolonged lack of effective treatment for mental health issues increases the risk of social isolation among participants. They not only isolate themselves and avoid interacting with community members but also face rejection from the community. In some cases, functional somatization symptoms persisted for years, severely impacting participant’ work, social interactions, and daily lives. Many participants were forced to quit their jobs and isolate themselves at home. Most of them reported experiencing public stigma:

Since I was a child, I’ve had pain all over my body. Going to the hospital didn’t help, and the doctors said nothing was wrong. But I felt pain everywhere. I couldn’t leave the house and had to stay home. No other kids wanted to play with me, and no one respected me. Everyone thought there was something wrong with me and that I wasn’t a normal person.

In summary, stigma, somatization, and worsening condition form a vicious cycle. For many participants, stigma and somatization are mutually reinforcing, preventing accurate diagnosis and treatment of mental health issues while further exacerbating the condition. In turn, the worsening condition intensifies both stigma and somatization.

Discussion

This article presents results from a qualitative study investigating the experience of middle-aged adults with mental health issues in rural China. Our findings indicate that in the rural Chinese cultural setting, mental health issues are stigmatized, impacting patients’ self-perception, family dynamics, and community interactions. Furthermore, many patients experience somatization, expressing mental health issues as physical issues. Somatization can lead to self-stigma, affiliate stigma, and perceived public stigma; on the other hand, many patients use somatization to destigmatize.

The findings reveal that mental health patients face significant stigmatization, including discrimination from family, unfair treatment from the community, and self-stigmatization, which can increase their risk of suicide. These findings are consistent with existing literature, which indicates that family and community members often harbor biases against mental health patients [6, 12, 53, 54]. Our research further identifies that villagers often misattribute mental health issues to moral deficiencies, linking them to personal or familial moral failings. Consequently, there is a pressing need to enhance public health education in rural areas to improve understanding and reduce stigma [55].

This study focused on middle-aged adults and examined their experiences with mental health issues. Previous research primarily addressed mental health issues of older adults in rural China [16, 18], but did not specifically focus on middle-aged adults. Our findings revealed that the somatization of mental health issues prevented middle-aged adults from maintaining employment, lowered their self-esteem, and exposed them to significant mental health risks, which is consistent with the results of prior studies in western countries [41, 54]. However, our investigation further discovered that many participants experienced increased self-stigma [56] as a result of losing their jobs, and numerous middle-aged adults with mental health issues reported having suicidal thoughts due to unemployment. This may be due to the increased family responsibilities and life pressures experienced by middle-aged adults [21], which place them at greater risk for mental health issues [8]. It is crucial to enhance attention and intervention efforts targeted at the mental health of middle-aged populations in the future.

We identified unique forms of somatization in rural China, such as interpersonal difficulties, communication challenges, and speech disorders. Previous research has highlighted several forms of somatization, such as pain, fatigue, and dizziness [47]. Consistent with these findings, our study found that many participants in rural China reported somatic symptoms including headaches, blurred vision, and difficulty concentrating [50]. Additionally, earlier studies have pointed out cultural variations in somatization. For instance, Kleinman (1998) discussed the relationship between neurasthenia and depression in China [23]. However, in rural China, somatization also manifests as interpersonal difficulties, communication challenges, and speech disorders. This may be related to the cultural context of rural China, where communities are tight-knit and members are well acquainted with one another [57]. Mental health issues disrupt the daily interactions within the village, heightening feelings of isolation and making the exacerbation of psychological problems.

The study explored the relationship between the stigmatization of mental health issues and somatization. Previous research has indicated that the stigma surrounding mental health issues can lead to somatization [58]. Consistent with prior findings, our study revealed that many participants perceived mental health issues as a source of shame and chose to seek medical help through somatic complaints. Our research further deepens the understanding of the connection between somatization and stigmatization. Many patients avoid stigma through somatization, reframing their mental health issues as physical problems. Due to the limited healthcare resources in rural China [6, 11], mental health issues are often not effectively identified [6]. This exacerbates the progression of the illness and intensifies the problem of stigmatization. Patients, fearing the stigma associated with mental health issues, are often reluctant to acknowledge their condition and instead express their mental health issues through somatic symptoms, as they believe somatic symptoms carry less stigma than mental health issues. This creates a vicious cycle, further worsening the mental health crisis in rural China.

The stigma and somatization of mental health issues among middle-aged adults in rural China may be deeply rooted in broader sociocultural factors. Consistent with previous findings, many participants exhibited self-stigma and affiliate stigma, which manifested as family shame, feelings of inferiority, stereotype endorsement, and social withdrawal [34, 36, 37]. This self-stigma and affiliate stigma toward mental health issues may be linked to traditional Chinese values, such as family obligations, filial piety, and informal caregiving [59]. The filial culture places significant emphasis on meeting the needs of elders and avoiding family disgrace [60]. As a result, many middle-aged adults with mental health issues tend to deny their condition in an effort to avoid bringing shame to their families. Instead, they adopt somatization as a coping strategy, expressing psychological distress through physical symptoms, as they believed that the somatization brings less stigma than mental health issues. Second, middle-aged adults in rural China often bear greater family obligations, as they are responsible for supporting both older and younger generations [24]. Mental health issues can hinder their ability to fulfill these caregiving responsibilities, leading to heightened feelings of inferiority and, consequently, self-stigma. Additionally, informal caregiving is highly prevalent in rural China, often leading to the displacement of formal mental health services [34, 61]. Many participants reported seeking help not for their own mental health needs but rather for their family members, which prevents timely treatment and contributes to worsening symptoms. This dynamic ultimately perpetuates a vicious cycle of stigma and somatization.

Limitations and future directions

The scope of this study may be somewhat limited. Mental health issues encompass a wide range of disorders. This research specifically focused on patients with dissociative disorder, postpartum depression, panic disorder, depression, manic depression and schizophrenia in rural China, which may not fully represent the diversity of mental health issues. Furthermore, the majority of participants in this study were women, which may limit the generalizability of the findings and the potential impact on future policy. Women’s experiences with somatization and stigma often differ from those of men in the same sociocultural context [62, 63], largely due to differing family roles and societal expectations [64, 65]. As a result, this gender imbalance also constrains our understanding of how stigma and somatization affect men’s mental health. Future research should expand the sample size and consider employing mixed-method approaches to further explore differences in somatization across various mental health conditions between men and women. This study focuses on middle-aged adults with mental health issues, such as panic disorder, depression, and schizophrenia. However, the stigma and somatization associated with different mental health issues may vary. Future research should expand the sample to explore stigma and somatization across individuals with diverse mental health issues. Another limitation is the geographic focus, as the study was restricted to rural areas in Northeast China, which may limit the generalizability of the findings to other regions. Additionally, the study did not explore patients’ emotional experiences, such as fear, crying, and anxiety, which are important aspects of their experiences. Future research should address a broader range of mental health issues, increase the sample size, and incorporate an examination of patients’ emotional experiences. This would provide a more comprehensive understanding of mental health issues in rural China.

Implications

The findings from this study have several important implications for education, policy and interventions. In terms of education, this study highlights the need for enhanced public education in rural China to mitigate the stigmatization of mental health issues. Leveraging existing social work stations in China could be an effective means of promoting mental health awareness, ensuring that mental health issues are not mistakenly associated with moral failings or personal weakness. This could be done through community-based education programs, workshops, and campaigns that emphasize the biological, psychological, and social dimensions of mental health, thereby fostering a more supportive and understanding environment for those affected.

From a policy perspective, the study highlights several key recommendations. First, future efforts should prioritize achieving a more equitable distribution of medical resources between rural and urban areas, with a particular focus on mental health services. This includes facilitating the transfer of high-quality medical resources from urban centers to rural regions and integrating mental health screening into existing rural healthcare services. Second, increasing training for rural healthcare workers is crucial, such as equipping primary care physicians and nurses with basic mental health competencies. Third, it is also essential to increase government funding for rural healthcare. The government can enhance financial support for rural mental health services by increasing funding allocations and raising subsidy levels for mental health-related expenditures.

The findings from this study have important implications for intervention strategies. In Western societies, various approaches are commonly used to reduce stigma, such as education-based interventions, community-level programs, and interpersonal or intrapersonal strategies [66]. In developed urban areas of China, multiple intervention methods have been implemented, including anti-stigma training and peer-led interventions [67, 68]. However, in rural China, where mental health services are limited, most interventions focus on reducing stigma within healthcare settings rather than addressing self-stigma and stigma in the community [69, 70]. It is crucial to introduce more interventions aimed at reducing stigma associated with mental health issues in rural areas. First, drawing on international experiences, low-cost education-based interventions should be implemented to raise awareness about mental health conditions and correct common misconceptions. Additionally, social organizations and nonprofit institutions should be encouraged to provide services and launch rural mental health support programs to help mitigate self-stigma associated with mental health issues. Finally, community-based interventions should be implemented to reduce stigma. For instance, strategies such as home visits, one-on-one interactions, and collaborative efforts with local governing bodies have shown effectiveness in addressing mental health-related stigma in low- and middle-income countries, including rural India and the Busoga region [71, 72]. Given the success of such interventions in comparable international contexts, they offer valuable insights for application in rural China. However, it is essential to tailor these interventions to the local cultural context.