Online Support Groups for Depression in China: Culturally Shaped 
Interactions and Motivations 

 
Renwen Zhang, Jordan Eschler, Madhu Reddy 

Department of Communication Studies, Northwestern University 
 

 
ABSTRACT 
Online support groups have drawn considerable attention from scholars in the past decades. While prior 
research has explored the interactions and motivations of users, we know relatively little about how culture 
shapes the way people use and understand online support groups. Drawing on ethnographic research in a 
Chinese online depression community, we examine how online support groups function in the context of 
Chinese culture for people with depression. Through online observations and interviews, we uncover the 
unique interactions among users in this online support group, such as peer diagnosis, peer therapy, and 
public journaling. These activities were intertwined with Chinese cultural values and the scarcity of mental 
health resources in China. We also show that online support groups play an important role in fostering 
individual empowerment and improving public understanding of depression in China. This paper provides 
insights into the interweaving of culture and online health community use and contributes to a context-
rich understanding of online support groups. 
 

Keywords 
Mental health; depression; online support groups; culture; stigma; empowerment 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 



RUNNING HEAD: Online Support Groups for Depression in China 

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1. INTRODUCTION 
A third of the global burden of mental illness falls on China and India, where millions of people are 
untreated due to stigma and lack of resources (Charlson, Baxter, Cheng, Shidhaye, and Whiteford, 2016). 
An estimated over 100 million Chinese people have a diagnosable mental disorder, of whom 91% have 
never received any treatment (Phillips et al., 2009). This gap in treatment is partly due to the low level of 
national investment in mental health care, leading to limited mental health services and a lack of mental 
health professionals in China (Baxter et al., 2016). The lack of services is compounded by an intense 
stigma associated with mental illness (Yang, 2007; Yang et al., 2007). In China, mental health issues are 
often viewed in a negative light that threatens the ‘face’ or dignity of one’s family and ancestors (Yang, 
2007). Such traditional values stemming from Confucian ideologies reinforce the stigmatized status of 
people with mental illness in China (Yang and Kleinman, 2008), and hinder them from seeking treatment 
(Corrigan, Druss, and Perlick, 2014).    

Given the meager mental health resources in China, many people seek information and support online. 
Studies have shown that engagement in online support groups can lead to increased access to resources 
and a sense of empowerment (Barak, Boniel-Nissim, and Suler, 2008; van Uden-Kraan et al., 2008). Given 
the anonymity and lack of non-verbal cues of online communication, people perceive that there is less risk 
in disclosing their stigmatized issues to others and thus tend to be more open online (Bargh, McKenna, 
and Fitzsimons, 2002; Tidwell and Walther, 2002). Open online discussions often result in increased 
knowledge, better decisions, augmented social support, and a sense of control (Barak et al., 2008; Bartlett 
and Coulson, 2011). These positive consequences can generate individual empowerment which is key to 
improving health outcomes (Corrigan and Rao, 2012).  

Computer support cooperative work (CSCW) scholars have long been interested in online support 
groups. Prior work has focused on users’ needs, types of self-disclosure, social support exchanges among 
users (Andalibi, Öztürk, and Forte, 2017; De Choudhury and De, 2014; Eschler and Pratt, 2017; Wang, 
Kraut, and Levine, 2012). Despite a large body of literature on online support groups, the socio-cultural 
aspects of group engagement have been largely overlooked. Studies have shown that individuals’ use of 
online support groups is contingent on social and cultural contexts (Li, Zhou, Lu, Yang, and Gu, 2016). 
In particular, Chinese cultural values and health beliefs significantly affect people’s understanding of 
depression, illness management, and social interactions (Li et al., 2016). These cultural values may also 
influence how and why people participate in online support groups and affect how they benefit from the 
engagement.  

In this paper, we present a study about an online support group for depression in China. Based on 
online observations and semi-structured interviews, we examine the interactions among users in the group, 
as well as their motivations for use and benefits they receive from the engagement. Specifically, we focus 
on the unique aspects of Chinese culture that impact the use of online support groups. We also examine 
how online support groups are integrated into users’ depression management practices and at the same 
time create new possibilities for individual empowerment and destigmatization.   

This paper contributes to the existing body of literature in three ways. First, we describe the social 
interactions in a Chinese online support group that do not neatly fit previous observations of online health 
communities in the West. By examining the Chinese social and cultural contexts that shape the user 
engagement, we contribute to a context-rich understanding of online support groups. Second, we draw 
attention to the empowering effect of online support groups in places where mental health resources are 
scarce. This augments existing literature about patient empowerment and online health community 
engagement. Third, we discuss the potential for online support groups to improve public understanding of 
depression and reduce stigma at a societal level, which sheds light on the social implications of online 
health communities.  



RUNNING HEAD: Online Support Groups for Depression in China 

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In the sections that follow, we first present a literature review of prior work on mental illness in China, 
mental illness stigma, and online support groups, followed by a detailed account of our research methods. 
We then report our findings from the observations of the online support group and the interviews with its 
users. We particularly focus on users’ social interactions, motivations, and benefits in engaging in the 
online support group. Finally, we discuss how the findings of this study provide new insights into our 
understanding of online support groups.  

 
2. RELATED WORK 

2.1. Mental Illness in China 
China has experienced remarkable economic rise over the past decades. However, despite the rapid 
transformation, China's mental health care lags far behind other countries. In 2014, China had roughly 
23,000 psychiatrists – 1.7 for every 100,000 people, compared to the US with 12 for every 100,000 people 
(Organization, 2017). Among these psychiatrists, only about 4,000 are fully qualified (Xiang, Yu, 
Sartorius, Ungvari, and Chiu, 2012). Moreover, mental health care resources in China are concentrated in 
cities, whereas half of the country’s 1.4 billion people live in rural areas (Xiang et al., 2012). The scarce 
and uneven distribution of mental health services has resulted in a lack of treatment for people with mental 
illness in China. It is estimated that over 90% of Chinese people with depression have never received 
treatment (Phillips et al., 2009). 

This lack of treatment is compounded by an overall lack of knowledge and awareness of mental illness 
in China (Li et al., 2016). Depression has long been diagnosed as neurasthenia (shenjing shuairuo, a 
mechanical weakness of the nerves), rather than a mental health diagnosis, resulting in a low reported 
prevalence of depression over the past decades (Kleinman, 1986; Love, 2017). Neurasthenia is often 
treated with traditional Chinese medicine such as herbs and acupuncture (Kleinman, 1986). In addition, 
long-standing Confucian ideologies prompt Chinese people to neglect or hide their inner emotions and 
feelings, but be more sensitive to somatic symptoms such as fatigue, insomnia, headache, and muscle pain 
(Li et al., 2016). Therefore, Chinese people with depression often emphasize somatic symptoms as 
opposed to Western patients who stress emotional and psychological symptoms (Kleinman, 1986; Parker, 
Cheah, and Roy, 2001; Ryder et al., 2008). Even today, many Chinese still do not consider depression an 
illness. The lack of knowledge and awareness of depression perpetuates the low rate of treatment in China.  

Chinese people with mental illness often experience intense stigma, partly due to Chinese traditional 
values and the social norms of ‘face’ (mianzi) (Yang and Kleinman, 2008). Confucianism values self-
control and the ability to solve inner conflicts (Li et al., 2016). Chinese society tends to consider depression 
an excuse for failure and for an unwillingness to work hard. People with depression, therefore, are viewed 
as being weak (Li et al., 2016). Because the behavior of the individual often reflects on the family in 
Chinese collectivist culture, stigmatized illnesses such as depression are regarded as threatening the ‘face’ 
of one’s family. Moreover, traditional Chinese beliefs suggest mental illness is a punishment for the 
misconduct of one’s ancestors and, therefore, family members of the depressed may also find themselves 
stigmatized (Yang, 2007). Consequently, having a mental illness becomes a shame or guilt that threatens 
the ‘face’ (i.e. dignity) of one’s family and clan (Yang, 2007). This often compels Chinese people to 
conceal their depression to save face for their family.  

People with mental illness are stereotyped as insane and unpredictable with the potential to cause 
danger to others and to society (Rüsch, Angermeyer, and Corrigan, 2005). Some mental hospitals in China 
treat their patients as prisoners, locked behind metal doors and strapped to beds (Economist, 2017). Mental 
hospitals are also sometimes used to detain political dissidents who do not have mental health problems 
(Economist, 2017). For these reasons, it is unsurprising that the Chinese have significantly greater negative 
stereotypes towards people with mental illness compared to their Western counterparts (Knifton et al., 



RUNNING HEAD: Online Support Groups for Depression in China 

 3 

2010; Yang, 2007; Yang, Wonpat-Borja, Opler, and Corcoran, 2010). These stereotypes stem from the 
stigma attached to mental illness, which can be as disabling as the illness itself. In the following section, 
we will take a closer look at stigma and strategies to manage stigma. 

 

2.2. Mental Illness Stigma and Stigma Management  
The stigma of mental illness does not only exist in China. Goffman defines stigma as a mark of disgrace 
associated with any physical, social, or personal attribute that is deeply discrediting (Goffman, 1963). 
Stigmatized individuals are subject to prejudice and discrimination which diminishes their life chances 
(Goffman, 1963). Stigma undermines an individual’s dignity and self-esteem, leading to decreased well-
being and quality of life (Corrigan and Watson, 2002; Link, Struening, Rahav, Phelan, and Nuttbrock, 
1997). The desire to conceal stigmatized conditions often prevents individuals from seeking treatment 
(Link et al., 1997). Stigma also limits individuals’ access to material, social, and cultural resources, 
contributing to health disparities (Hatzenbuehler, Phelan, and Link, 2013). 

In making sense of the prejudice and discrimination experienced by people with mental illness, 
researchers have made a distinction between public stigma and self-stigma (Corrigan and Rao, 2012; 
Rüsch et al., 2005). Public stigma refers to the negative attitudes held by the general public towards a 
stigmatized group, while self-stigma occurs when individuals internalize these stigmatizing attitudes and 
suffer negative consequences (Corrigan and Watson, 2002; Rüsch et al., 2005). Public stigma often results 
in restricted opportunities of stigmatized groups (Link et al., 1997), and self-stigma engenders diminished 
self-esteem and self-efficacy, leading to isolation and poor health outcomes (Corrigan and Rao, 2012).  

Stigmatization has also been conceptualized as a socio-cultural process which operates to reproduce 
structural power relationships that exclude stigmatized individuals from the social world (Farrugia, 2009; 
Parker and Aggleton, 2003). People with mental illness are positioned as less powerful and thus subject 
to discriminatory consequences. As Parker and Aggleton argue (2003), ‘stigma and stigmatization 
function, quite literally, at the point of intersection between culture, power and difference’ (p.17). The 
construction and experience of stigma are constituted differently across social contexts and can shift over 
time (Toyoki and Brown, 2014).  

Individuals employ a variety of strategies to manage their stigmatized identities in ongoing social 
situations (Goffman, 1963; Toyoki and Brown, 2014). For example, stigmatized individuals strategically 
manage their identity through ‘techniques of information control’ (Goffman, 1963). They tend to share 
little with outsiders, but everything with insiders, such as others with similar conditions (Goffman, 1963). 
This can help them cope with the negative consequences of self-stigma (Corrigan and Rao, 2012). 
Furthermore, group identification has been shown to diminish the effects of self-stigma on people with 
mental illness (Jetten, Branscombe, Schmitt, and Spears, 2001). For example, individuals who belong to 
a group of people with mental illness are less likely to agree with the stereotypes and, consequently, less 
likely to experience decreased self-esteem and self-efficacy (Watson, Corrigan, Larson, and Sells, 2007). 
Individuals may develop positive self-perceptions via their interactions with peers from the stigmatized 
group (Watson et al., 2007). 
 

2.3. Online Support Groups for Mental Health 
Given the pivotal role of group identification in combating stigma, online support groups have opened up 
new possibilities for people with mental illness (Barak et al., 2008). Because of the anonymity and reduced 
non-verbal cues in online communication, the barriers to and risks of disclosing one’s stigmatized illness 
are greatly reduced (Walther, 1996). Individuals are less likely to face judgment or rejection from others 
in online settings than those in the offline world (Walther, 1996). Thus, individuals with mental illness 
often feel comfortable opening up online (Berger, Wagner, and Baker, 2005). Increased self-disclosure 



RUNNING HEAD: Online Support Groups for Depression in China 

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helps individuals to forge relationships that might not be possible offline, leading to increased social 
support and reduced feelings of isolation  (Barak et al., 2008; Berger et al., 2005).  

Studies have found empowerment to be the most salient benefit of support group attendance (Barak 
et al., 2008; Bartlett and Coulson, 2011; Ussher, Kirsten, Butow, and Sandoval, 2006). Empowerment 
refers to the individual ability to make personal decisions, to access relevant resources, and to experiencing 
personal growth as a results of developing skills and abilities (Staples, 1990; Wallerstein, 1992). 
Engagement in online support groups empowers patients through exchanging information, sharing 
experiences, and providing emotional support (van Uden-Kraan et al., 2008). Online discussions with 
peers not only help users make better treatment decisions (Barak et al., 2008), but also improve acceptance 
of the disease and facilitate patient-provider communication (van Uden-Kraan et al., 2008). Patient 
empowerment also generates improved health and social outcomes, such as enhanced self-esteem and 
reduced self-stigma (Bartlett and Coulson, 2011; Wright, 2000). In addition, online support groups serve 
as a place for people to enact a sense of being, to explore preferred, aspirational, and other alternate selves 
(Obodaru, 2012) 

Online support groups have been broadly studied in CSCW, HCI, and related fields over the past 
decades. Prior work has examined online communities for a wide range of health issues, such as mental 
illness (Andalibi et al., 2017; De Choudhury and De, 2014), diabetes (Huh and Pratt, 2014; Zhang, 2017), 
and breast cancer (Vlahovic, Wang, Kraut, and Levine, 2014; Yang, Yao, and Kraut, 2017). Much of the 
CSCW work on online health communities has used computational techniques to explore types of self-
disclosure, social support, and user interactions (De Choudhury and De, 2014; Wang et al., 2012; Yang et 
al., 2017). While these studies provide valuable insights into the social dynamics of online health 
communities, we know relatively little about the lived experience of users as well as their struggles and 
aspirations. It is also unclear how users integrate online health communities into their lives.   

Further, extant research on online mental health communities mainly focuses on English-speaking 
users (Andalibi et al., 2017; De Choudhury and De, 2014). Given the unique social and cultural context 
in China, as we mentioned earlier, China serves as an interesting case to study the interweaving of culture 
and online health community use. However, there has been scarce literature on online support groups in 
China. Li et al. (2016)’s study is among the very few to examine how Chinese people use online depression 
forums. Other studies of Chinese online health communities employed computational methods to explore 
the types of social support and user interactions (Wu, Hou, and Jin, 2017; Xu and Zhang, 2015), and thus 
lost out on the opportunity to gain specific insights into the socio-cultural aspect of online interactions.  

In this paper, we draw attention to the role of culture in influencing online support group use. In 
particular, we explore the online interactions, motivations, and benefits among users of an online 
depression community in China. By examining how people use online support groups to manage 
depression, we uncover the meaning of online health community in the lives of its users. Specifically, we 
address the following research questions: 

RQ1. How do people with depression in China use online support groups? 
RQ2. What motivates people with depression in China to engage in online support groups? 

 RQ3. What are the benefits and challenges of online support group engagement in China? 
 
 
3. METHODS 
We conducted a virtual ethnography of Sunshine, the largest and most popular online forum for people 
with mental illness in China. Virtual ethnography has been used to explore the communities and cultures 
created through computer-mediated interaction (Hine, 2000). We observed user interactions and 
discussion topics on Sunshine for four months. We also conducted semi-structured interviews with 15 



RUNNING HEAD: Online Support Groups for Depression in China 

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users to probe their motivations for using Sunshine and the perceived benefits. The research site, data 
collection, and analysis procedures are discussed in greater detail below.  

3.1. Research Site: Sunshine 
Launched in 2003, Sunshine is the first online forum for mental disorders in China. It had 161,211 
registered members and over 990,000 posts as of August 4, 2017. The forum contains six discussion 
sections, including Depression, Anxiety Disorder, Resources, Life, Religions, and Administrative Affairs. 
In this study, we focused on the Depression section, which is the largest and most active section.  

Sunshine is a publicly accessible forum. Anyone can browse the posts as a visitor, but only registered 
users are allowed to post and reply. Most of the registered users are people diagnosed with mental illness 
and their family members. Some are not diagnosed but suspect that they have mental health problems. 
Visitors who want to register are required to send an online request with appropriate reasons, which may 
be granted approval by administrators. Registered users each have a profile page displaying their personal 
information (e.g., pseudonym, gender, registration date), status updates, posts, friends, and albums. They 
can also send private messages to others via the chat channel.  

A peer-led support group, Sunshine is governed by several administrators and moderators, who are 
either veteran users or those who have recovered from depression. They manage different sections of the 
forum and can delete spammed, offensive, or inappropriate posts and ban users who do not follow the 
community norms from posting. A few psychologists occasionally participate in Sunshine, answering 
users’ questions and posting articles.  

Sunshine also has private chat groups that operate through QQ, an instant messaging service in China. 
Separate from the forum, QQ groups are places where users communicate with each other in a 
synchronous fashion. Only registered users of the forum are allowed to join the QQ groups. The QQ 
groups include a main QQ group with over 800 members, and 24 sub-groups featuring different provinces 
and different issues. There is also a WeChat official account of Sunshine, managed by forum 
administrators who post articles regarding knowledge about and treatment of depression. Anyone who 
follows the WeChat account can view the articles, but no interaction takes place on this platform. Given 
our interest in the dynamics of interactions in online support groups, this study primarily focuses on the 
forum and the main QQ group. 

 

3.2. Data Collection 
The first author conducted virtual ethnography in Sunshine for over four months in 2015 (Hine, 2000). 
The first author registered for an account by contacting a forum administrator and disclosing the identity 
as a researcher and the research objectives. All data collected in this phase was conducted in Mandarin 
Chinese. The first author, a native Mandarin speaker, observed the forum and its main QQ group to explore 
its culture and user interactions, without initiating or participating in any discussions. The author spent an 
hour per day on average in Sunshine, observing conversations and collecting publically-available posts 
illustrative of group interactions. A total of 562 posts were collected from more than 100 forum users, 
covering a wide array of topics.   

Given the public nature of the forum and the anonymity of the users, we did not perceive any potential 
risks to subjects in conducting observations and collecting posts. Excerpts of the collected posts used in 
this study were attributed to anonymized users, without disclosing their user names on the forum. We 
believed that it would be difficult to identify those users based on their posts because of the changes to 
the wording once they were translated to English. All data collection was conducted in accordance with 
the first author’s university policies at the time of collection.   

The first author conducted follow-up interviews with 15 users to understand their motivations for 
using Sunshine and the perceived consequences. The interviews were conducted via telephone or instant 



RUNNING HEAD: Online Support Groups for Depression in China 

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messaging application (i.e., QQ). Each interview lasted from one hour to two hours and followed a semi-
structured protocol. We used a maximum variation purposive sampling strategy by recruiting participants 
who had varied levels of depression and engagement in the forum during our observation period. 
Recruitment messages were sent to 33 users through the private chat channel of the forum, describing the 
purpose of this study and the voluntary nature of participation. Fifteen members agreed to participate in 
the study, including 7 females and 8 males (Table 1). All participants’ names used in this study are 
pseudonyms, different from their user names in the forum. The presentation of this research, and the steps 
taken to preserve user anonymity and confidentiality, are informed by the ACM Ethics guidelines (ACM, 
2018). 

 
ID Alias Gender Age Time with 

diagnosed 
depression 

Length of 
membership 

1 Lily Female 19 A few months 2 months 
2 Nikolas Male 28 Over 10 years 4 months 
3 Mars Male 40s 20 years; 

recovered 
4 months 

4 Frank Male 35 17 years 5 years 
5 Aaron Male 24 2 years 8 months 
6 Brian Male 27 5 years 4 months 
7 Catherine Female NA A few months 6 months 
8 Jack Male 30s 9 years 6 months 
9 Daisy Female 25 5 years 4 months 
10 Rachel Female 40s 6 years 6 years 
11 Stephen Male 40s 9 years 9 years 
12 Mary Female 20s 9 years 9 years 
13 Adam Male 63 15 years 3 years 
14 Julie Female 30s 8 years 6 years 
15 Elena Female NA 2 years 2 years 

Table 1. Participant demographics as of August 2015 
 

3.3. Data Analysis 
We first conducted a content analysis of the 562 posts collected to identify the themes of the online 
interactions among Sunshine users. All interviews were audio-recorded and transcribed in Chinese; 
illustrative quotes were translated from Chinese into English by the first author who is also fluent in 
English. Open coding was first conducted in Chinese, and then two of the authors iterated axial coding in 
English, identifying themes regarding engagement in Sunshine, as well as benefits that the participants 
received from the engagement (Strauss and Corbin, 1998). Extensive memos were written to document 
the analytical trajectory, which provided a basis for data analysis. The primary themes that emerged from 
the analysis are discussed in detail in the following section. 
 
 
4. FINDINGS 
The online observations captured the dynamics of the interactions among Sunshine users (RQ1). The 
interview participants offered nuanced accounts of why they participated in Sunshine (RQ2) and how they 
benefited from the engagement (RQ3). In this section, we first present the types of social interactions in 
Sunshine based on the observations, followed by users’ motivations for use and the impact of Sunshine on 



RUNNING HEAD: Online Support Groups for Depression in China 

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users. The combination of observational data and interview data offers us a holistic picture of the use of 
Sunshine and its meaning in the lives of its users.  
  

4.1. Social interactions in Sunshine 

4.1.1. Information exchange: medication and coping skills 
Information exchange was the most common practice among Sunshine users. Of the 562 posts we collected, 
almost half of them (48%) were related to medication. We observed myriad posts on the forum asking 
about the use and side effects of antidepressants. Some users expressed their mistrust towards the ‘Western 
medicine’ in their posts and asked if they should take the antidepressants prescribed by their doctors. 
Others experienced severe side effects after taking medicines and posted their symptoms on Sunshine to 
seek advice from their peers. For instance, a forum user posted her anxiety and despair after taking 
antidepressants: 

My brain functioning declined after taking Lexapro and Magnesium for three months. I had a hard time 
memorizing things and solving simple math problems. I’m going to take the College Entrance Exam soon 
and get so terrified about the side effects of the drugs. What should I do? Should I continue taking them? I 
feel hopeless and desperate. Please help me! (Anonymous forum user) 

In addition, users asked and shared experiences and strategies in coping with depression. Some mentioned 
that they took traditional Chinese medicine as a complement to antidepressants, and used acupuncture and 
practiced Tai Chi to relieve pain and anxiety. They described how they practiced these coping strategies, 
and what worked well and what failed. The information was either exchanged through Q&A, or shared in 
users’ public diaries and stories.    
 

4.1.2. Peer diagnosis and peer therapy 
We also observed many users posting messages describing their symptoms in great detail, asking others 
to assess their problems (32%). We labeled this type of interaction as peer diagnosis. Some of those who 
engaged in peer diagnosis had not obtained a formal diagnosis from a doctor, but suspected that they had 
depression. Others, however, posted their symptoms along with the diagnosis from doctors, asking their 
peers to help confirm the diagnosis. Often, they would receive comments from other users, who provided 
their own assessment and encouraged them to seek treatment from a trustworthy psychiatrist. Here is a 
post characteristic of this type of interaction: 

I feel like I am having depression but I am not sure. I took the PHQ-9 screening test on Sunshine and was 
scored as having moderate depression. Is it clinically validated? I have experienced insomnia, lack of 
energy, physical pain, and low mood for almost a month. Can anything tell me if I am depressed or not? 
Please!!! (Anonymized forum user)	

Sunshine users also practiced peer therapy by disclosing their thoughts and emotions. When a user 
posted his or her negative feelings, others would jump in and identify the problematic thinking that may 
contribute to the user’s problem, and offer ways to reframe negative thinking. Many participants 
mentioned that they did not feel comfortable talking about their personal issues with a therapist, who was 
considered a stranger. Some did not believe a therapist who had never gone through depression could 
understand their problems. Thus, they preferred to confide in their peers rather than therapists. 
 

4.1.3. Public journaling: self-tracking and storytelling 



RUNNING HEAD: Online Support Groups for Depression in China 

 8 

Sunshine users also kept a public journal of their activities and thoughts on this forum. 22% of the posts 
we collected fell into this category. Some users wrote diaries on the forum to record their treatment and 
daily progress, such as medication, symptoms, and feelings. Others, however, logged more mundane daily 
activities – hours slept, food consumed, exercise, and social interactions. Most users who did public 
journaling tracked both their daily activities and treatment. Below is an excerpt from a user’s diary: 

May 29th 

Today is the third day of taking medication. I slept at 12am and woke up at 4am, feeling something was 
stuck in my chest. I lied in bed until 8am and got up to make breakfast. I ate some cabbage and sausages, 
which were tasty. After taking medicines, I went to work. Lunch was bread and salad, same with yesterday. 
I love this type of food. 

Now is 3pm. Feeling sleepy, I am working while listening to music, A cool breeze brushes softly against 
my face. I feel like standing on the brink of a cliff – not knowing who I am, where I am going, and where I 
belong to. (Anonymized forum user)	

It was also not uncommon for users to engage in storytelling and narrate their struggles in fighting 
with depression with minute details and vivid descriptions. We observed a large volume of personal stories 
on the forum (24%). Some users disclosed what they have experienced in the past, expressing emotions, 
doing reflection, and making confessions. Others would respond with similar stories about themselves and 
offer positive explanations.  
 

4.1.4. Emotional support exchange 
As we observed online, many users revealed feelings of frustration and loneliness in their posts (28%). 
Other users who read these posts might not provide concrete solutions, but were able to recognize common 
experiences and offered empathy and encouragement. One example is from a Sunshine user who replied 
to another user on the forum: 

I know how desperate you are, as I have been there. I felt it was the end of the world but I survived. Just 
hang in there and take care of yourself. I know it’s hard to do so when we are mired in depression, but you 
have to know that you are not alone. We will always be there for you. Big hug J (Anonymized forum user) 

In referring to their own suffering, users tended to use inclusive pronouns such as ‘we’ and ‘us’ to 
express empathy towards each other. On the forum, users identified others as ‘brothers in arms (zhanyou)’ 
or ‘fellow patients (bingyou)’, and described depression as a ‘battle’ to be fought with ‘concerted efforts’. 
Some used emoji to liven up the text messages and to express their affection towards their peers.  

In the QQ chat group of Sunshine, hundreds of synchronized conversations took place every day. 
Compared to the forum, communications in the QQ group were more casual, covering topics from 
personal problems to jokes and funny stories. Members of the QQ group chatted with each other like 
siblings, calling each other ‘elder brother’, ‘second brother’, ‘little sister’, etc. When a group member – 
the ‘elder brother’, for instance – showed up in the group, others would greet him with great affection, 
saying ‘How you doing today, my dear brother?’ and ‘We’ve been waiting for you’. Daily issues such as 
bickering with partners were also discussed among group members.  
 
 



RUNNING HEAD: Online Support Groups for Depression in China 

 9 

4.2 Motivations for using Sunshine 
Users joined Sunshine for a wide variety of reasons, many were intertwined with the social and cultural 
contexts in China. The motivations for using Sunshine presented below were based on our interviews with 
the 15 users. 
 

4.2.1. Understanding depression  
A majority of the participants stated that Sunshine was their primary source of information about 
depression. Many encountered Sunshine when they searched for information about depression using 
Baidu, a Chinese search engine. They were tempted to join Sunshine in order to understand depression 
and find out if they had depression. Some participants had no idea what depression was before they joined 
Sunshine. Others viewed depression as the ‘emotional flu’ that would go away shortly and thus refused to 
seek treatment.  

In other cases, participants regarded their distress as neurasthenia (shenjing shuairuo) – or were 
diagnosed with neurasthenia – a result of weakness in the kidney and spleen. They used to receive 
treatment with traditional Chinese medicine, such as herbals, acupuncture, and exercise (qigong). As the 
63-year-old user, Adam, described: 

Depression was largely unknown in China when I first felt depressed in early 2000. I was then diagnosed 
with neurasthenia and treated with Chinese medicine for many years. But I felt something was wrong. After 
I got a computer at home, I actively searched my symptoms on the Internet and found Sunshine. It was the 
first time I heard depression. I was very intrigued and eager to find out what depression was and whether I 
was having depression. (Adam)	

Even for participants who knew depression, many had difficulty accurately describing their symptoms 
to doctors, leading to an inaccurate diagnosis and incorrect prescription of medicines. Taking 
inappropriate medicines often produced severe side effects, causing enormous pain to the them. Thus, 
participants said that they spent enormous time on Sunshine, reading the articles about depression and the 
experiences shared by other users.  

 

4.2.2. Seeking mental health care  
Participants were also prompted to use Sunshine for the purpose of seeking treatment. This was mostly 
because of the limited mental health resources in China and a lack of access to care. Many participants 
lived in rural areas or small cities, where mental hospitals and licensed therapists were scarce. They had 
to travel long distances to the nearest large city, spending extensive amounts of time, energy, and money. 
Rachel, for example, described her struggles in finding doctors:  

I had no idea where to find a psychiatrist when I first suspected I had depression. I lived in [a small county], 
where no mental hospital existed. I took a two-hour train to the best hospital in our province...However, the 
so-called ‘expert’ only asked me to fill out a survey and diagnosed me with depression within 10 minutes. 
It was too sloppy for me to believe in it. Hopelessly, I posted a message on Sunshine asking where to find 
a qualified psychiatrist. Many people encouraged me to see doctors in Beijing and recommended a couple 
prestigious hospitals. Following their instructions, I took an overnight train to Beijing Anding Hospital and 
was finally diagnosed with depression. (Rachel)	

Even for participants who had visited mental hospitals in big cities, many described receiving an 
inaccurate diagnosis, or being prescribed inappropriate medication. For example, four participants 
received treatment for depression for many years until they realized that they actually had bipolar disorder 



RUNNING HEAD: Online Support Groups for Depression in China 

 10 

after joining Sunshine. Furthermore, some complained that psychiatrists from different hospitals 
sometimes gave different or contradictory advice and prescriptions, prompting them to seek advice from 
their peers.  

Notably, many participants expressed a feeling of mistrust towards mental health professionals. They 
complained that good psychiatrists were extremely scarce, which corresponded to the fact that only 20% 
of the psychiatrists in China are fully qualified (Xiang, Yu, Sartorius, Ungvari, & Chiu, 2012). Negative 
interactions with unprofessional doctors dissuaded them from seeking treatment and propelled them to 
turn to Sunshine for advice. For instance, Aaron expressed his attitudes towards doctors: 

Doctors are profit-oriented; they always ask you to purchase expensive medicine even though you don’t 
need it. Peers are more reliable; they know what works and what doesn’t work. (Aaron)	

By describing other Sunshine users as “knowledgeable”, “experienced”, and “trustworthy”, our 
participants treated the online support group, to some extent, as a hospital or counseling center, with a 
great number of reliable therapists who had rich experience in managing mental illness. Although peer 
expertise was not equivalent to professional medical advice, many participants said that they trusted 
information from their peers more than from clinicians.  
 

4.2.3. Unburdening and self-expression 
Despite the need for information seeking, users also turned to Sunshine for self-expression. For those who 
wrote extensive personal stories, they described this behavior as a way to unburden themselves. Brian, for 
instance, posted more than 50 posts on the forum, most of which were personal experiences and feelings. 
He explained his motivation as follows:  

I was in great despair then. A number of factors such as work, relationship, and illness conspired to torture 
me, day in and day out. I found my life meaningless and I wanted to end my life. But I had no guts to do 
so. So I posted my thoughts and emotions on the forum, sometimes several times a day. I didn’t expect 
feedback from others; just wanted to get my feelings out there, to reduce stress. (Brian) 	

Brian’s narratives spoke to his need for venting negative feelings. He explained that the mere act of 
writing things down led to emotional catharsis, which gave him a sense of relief and reduced stress. Even 
though the cathartic effect was sometimes transient, our participants experienced decreased negative 
emotions after getting their feelings ‘out there’.  

Related to these feelings of relief, participants described online support groups as a ‘safe haven’, 
where they could open up without the fear of being judged or condemned by others. Because of the mental 
illness stigma, many have experienced negative treatment in the workplace or in social interactions, and 
therefore have chosen to conceal their emotions. The anonymity of Sunshine gave them the freedom of 
expression, the ability to self-disclose without being judged. As Frank described: 

No one knows who I am on the Internet. I can write down everything –  I mean those at the bottom of my 
heart – and reflect on my past behaviors and experiences. (Frank) 

 

4.2.4. Seeking acceptance and empathy 
Participants also joined Sunshine to seek understanding and acceptance from others. Given the lack of 
understanding of depression and stigma in the society, many described being rejected by their family and 
friends, who sometimes dismissed their feelings, or refused to talk about their illness. As Aaron described: 



RUNNING HEAD: Online Support Groups for Depression in China 

 11 

My parents are peasants, uneducated, without any knowledge about depression. They couldn’t understand 
my problem and blame me for being weak. I used to be very close to them but now we seldom talk. I don’t 
have any close friends, either. I don't know whom I should talk to…I feel so lonely. (Aaron)	

Some experienced a lack of offline social support because they worked far away from their 
hometown. Because of China’s rapid urbanization, some participants were migrant workers who took 
temporary jobs in faraway urban regions and returned home only during the Lunar New Year. They 
contended that the long distance isolated them from their family members and close friends and deprived 
them of the social support they used to have when at home.   

The social isolation of our participants was also associated with family ‘face’. Among Chinese people, 
because the behavior of the individual reflects on the family, those stigmatized illnesses such as depression 
were regarded as threatening the ‘face’ of one’s family. Therefore, some participants told us that their 
parents urged them to conceal their mental illness condition to protect family ‘face’ and even dissuaded 
them from seeking treatment. Some experienced rejection or distancing in the workplace and felt 
ostracized. For example, one interview participant, Brian, described being fired by his company after he 
took sick leave for mental health.  
 

4.2.5. Cultivating healthy habits 
For those participants who kept journaling on Sunshine, some undertook this behavior to build up healthy 
habits and cultivate coping skills. They believed that online support groups could promote healthy 
behavior. Mary, for example, logged her daily diet and exercise over a year and still kept a journal on the 
forum even after rehabilitation. She described her motives as holding herself accountable for regular 
exercise:  

I decided to stop taking the antidepressant in 2014. The psychiatrist suggested that I should do exercise 
every day to expedite rehabilitation. But it was so hard for me to do that. To motivate myself, I decided to 
keep a journal on the forum, documenting my daily activities, including exercise and healthy eating. I had 
the habit of journaling, but privately. Making it public motivated me to be persistent. Everyone was 
watching me. I had to keep my word. (Mary) 

In addition, some engaged in public journaling for the purpose of self-reflection. Since people with 
depression often experienced declined memory, participants described writing a diary as a way to remind 
them of what they did for the day and modified their behaviors accordingly.   
 
 

4.3. The Impact of Sunshine on Users 
In this section, we provide interview participants’ accounts regarding how they benefited from 
participating in Sunshine, as well as the negative experiences they had. 
 

4.3.1. Increased knowledge and better coping 
A major benefit of engaging in Sunshine, as many participants described, was to better understand 
depression and what it means to have depression. Obtaining information from peers enabled users to think 
through the nature of their distress and seek appropriate treatment. Some were encouraged to seek therapy, 
obtain a formal diagnosis, and take medicine. Participants also reported being exposed to a wide array of 
coping strategies by reading others’ posts on the forum, which helped them to make more informed 
choices regarding help-seeking and treatment.  



RUNNING HEAD: Online Support Groups for Depression in China 

 12 

With increased knowledge, participants felt more control over their illness and gained the confidence 
to communicate with psychiatrists. Some mentioned that they could describe their symptoms more 
accurately during the clinic visit and they were able to bring up their issues and concerns to their doctors, 
rather than blindly following what they suggested. Jack described his experience as follows:  

I learned a lot about the merits and side effects of different types of antidepressants [from Sunshine]. Once 
a psychiatrist prescribed an antidepressant about which I had heard horrible side effects from other users. 
Then I told the psychiatrist my concern and he prescribed another one that worked well for me. I felt like I 
saved my life! I would not have been able to communicate with doctors without the knowledge I acquired 
from Sunshine. (Jack) 

In addition, for those who wrote personal stories and diaries on the forum, they stated that the process 
of storytelling allowed them to make meaning of their experiences and to reframe negative thinking. Many 
said that this reframing process was in line with cognitive behavioral therapy and helped them to view 
things from a positive light.    

 

4.3.2. Reconstruction of normality 
Given the stigma associated with depression in China, many participants described feeling worthless, 
rejected, and abandoned. The online support group, however, became a ‘safe haven’, where they could 
open up without being judged or condemned by others. Daisy, 25, said that before she joined Sunshine, 
she often posted on Weibo – a Chinese version of Twitter – when feeling depressed. But she ended up 
being ‘unfriended (lahei)’ by her friends on Weibo who also shied away from her offline. The anonymous 
nature of online support groups, however, made her feel less vulnerable: 

I can say whatever I want in Sunshine. People understand me and never judge. I feel like I’m a normal 
person here, not inferior to anyone. (Daisy) 

A feeling of ‘being normal’ was constantly mentioned by our participants. The mutual experience of 
depression created a strong sense of identification within the group, which made participants feel accepted 
and normal, sometimes for the first time in years. In his post, Frank presented his story of struggling with 
depression for over ten years after a devastating breakup with his girlfriend. Frank described being treated 
as a ‘monster’ for a long time, and felt a sense of relief after sharing his story in Sunshine:  

The moment I posted it on Sunshine, I felt a sense of relief, a feeling of being forgiven by others and by 
myself. You can view it (the post) as a monolog or my confession. I wrote it to myself. I don’t have the 
guts to tell anyone around me, including my parents, in fear of being judged or criticized. I’ve had enough 
of being treated as a monster over the past 12 years. (Frank) 

Similarly, other participants who felt rejected by others in their lives also stressed the non-judgmental 
acceptance in Sunshine, which allowed them to vent, to cry, and to be vulnerable. By positioning 
themselves as part of this group, the participants constructed a normal self in spite of the social stigma. 

 
4.3.3. Enhanced self-efficacy and self-esteem 
Participants also benefited from sharing information and experiences with others. Although some reported 
helping others out of altruism and reciprocity, they all emphasized a sense of fulfillment gained from 
sharing information with others. In Sunshine, veteran users sometimes took on the role of mentor, through 
which they demonstrated expertise and strength. They felt empowered by acting as experts in this 
community as a result of self-learning and self-improvement. Mars, for instance, was in his 40s and had 



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 13 

recovered from depression after wrestling with it for almost 20 years. He frequently answered others’ 
questions on the forum and sometimes wrote articles about treatment. He told us: 

I love answering others’ questions. Young people on the forum respected me. They sought my advice and 
regarded me as an expert. This made me feel powerful…I am indeed an expert. I know much more than the 
doctors, who learned depression from textbooks rather than from experiences. (Mars)	

For those participants who kept a public journal on the forum, many commented that recording daily 
progress gave them a positive outlook based on control and strength. For instance, Catherine wrote diaries 
on the forum to record a wide variety of activates, such as medication, reading, yoga, and social activities. 
She described an elevated sense of self-control through the journaling practices: 

I felt increased self-discipline after posting diaries on Sunshine. I became more organized than before, 
thanks to others’ encouragement and follow-up. My mom always thought that I got depression because of 
a lack of self-control, but I’m not like that. (Catherine) 

Participants regarded this sense of control as important, given that they were viewed in society as 
unable to resolve their inner problems or conflicts. Engaging in public journaling gave group members 
the ability to exercise self-control and self-regulation. In this sense, the online diaries served as a 
demonstration of their strong will. For instance, a message posted on Sunshine says:  

People think of us as pessimistic and weak, but we are NOT! Most of us are fighting with depression with 
a strong will and optimistic attitude. We have to prove that we are not sore-losers. Write down your daily 
progress and share it with others. Although the society has abandoned us, we shouldn’t abandon ourselves! 
(Post by an anonymized forum user) 

By recording daily progress and posting optimistic messages, users were claiming a life they wanted 
to lead, a mindset they hoped to sustain. They presented themselves as people who proactively and 
positively wrestle with depression, rather than being “pessimistic and weak”. The post above also 
demonstrated a collective effort of users to challenge dominant views of depression and public stigma.  
 

4.3.4. Elevated sense of belonging 
Many participants thought of themselves as part of a larger collective, who were making ‘concerted 
efforts’ to fight depression. For them, the ‘enemy’ was not only depression, but also rejection from others 
and the society. Taking part in online support groups, however, provided them with a sense of belonging, 
affiliation, and social cohesion that they were longing for. Daisy, for instance, held a deep affection for 
Sunshine:  

When I was diagnosed with depression, I felt my life was screwed up and attempted to commit suicide 
twice. I felt extremely isolated since nobody could understand what it was like to have depression. So, you 
know, when I accidentally encountered Sunshine, I was so exhilarated that couldn’t help crying. It was then 
that I realized I was not alone. There were a lot of people who shared the same sufferings but held positive 
attitudes toward life and encouraged each other…We talk with each other like a family. (Lily)	

Similarly, other participants also positioned Sunshine as a “family”, full of their siblings who were 
“caring”, “empathic” and “supportive”. Some mentioned that they were the only child in their family, but 
other users whom they often talked to were like their brothers and sisters. They shared sorrows and 
happiness, and were always ready to provide help and support when others were in need.  



RUNNING HEAD: Online Support Groups for Depression in China 

 14 

As the bond among the users intensified, they felt the need to get together offline. Some users residing 
in the same city would go to dinner or bike together. For instance, Mary has joined several offline activities 
with other users. She described these events as ‘relaxing and heartening’ and providing her strength:  

Every time we gathered offline, hiking or biking together, we took a group photo. No one said “Cheese”. 
We cried “Fight depression! We are strong!” with our clenched fists. (Mary) 

In addition to offline gatherings, administrators of the forum and some veteran users also gave lectures 
to communities and universities, and participated in TV shows to talk about their experiences and spread 
knowledge about depression. Although none of our interview participants did this, they felt proud of these 
users who spoke up for them.  
 

4.3.5. Negative experiences – regulation and emotional contagion 
As much as the online support group fostered a sense of community, it also created tensions. As a 

well-regulated forum, Sunshine had its own norms, such as rules of speech, written in an eight-chapter 
document on the forum. Several administrators and moderators were in charge of regulating Sunshine and 
punishing users who did not follow the community norms. The most common punishment for users was 
being banned from posting (jinyan), from a week to indefinably. The case of Stephen was an exemplar. 
Stephen was with Sunshine for 8 years but ended up being indefinitely banned from posting because of 
his offensive messages. He expressed his frustration over this decision:  

I am very angry and disappointed about the decision. I couldn’t understand why they (admins) are so cruel 
to me. I came to Sunshine in seeking understanding and acceptance, yet was regarded as a madman to be 
regulated. Is there any difference between those administrators and the discriminatory public? (Stephen) 

In addition, some interview participants described being ‘infected’ by the negative emotions and 
thoughts of others. When users were in a depressive episode, they tended to post messages with intense 
emotions, which would be transferred to others who read the post. The transference of emotions sometimes 
aggravated users’ depression, and even triggered depressive episodes or suicidal ideation. Julie said her 
strategy to counteract the negative influence was to avoid using Sunshine when she was emotionally stable: 

There are so many negative emotions there. If I am in the process of recovery, I seldom look at the forum 
or interact with other members, for fear of being infected. I am too fragile to resist those negative effects. I 
only use Sunshine when I feel bad– usually when I go through a depressive episode. This is unburdening. 
(Julie) 

Despite the challenges faced by the users, most participants described benefiting from their 
engagement in Sunshine. In the next section, we will delve into the findings and analyze how Chinese 
cultural values influence the use of online support groups.   
 

 
5. DISCUSSION 
In this study, we provide an alternative story of online support group engagement, one that does not 
necessarily align with prior work in this field. Through our ethnographic research on an online depression 
community in China, we have described that this community has become the primary source of 
information for users, rather than a supplement to professional medical advice. Users engage in peer 
diagnosis and peer therapy and keep a journal on the platform. These behaviors are intertwined with 
Chinese cultural values and the lack of mental health resources. They also come from Chinese people’s 
health beliefs and health practices that are different from those of the American health care culture. These 



RUNNING HEAD: Online Support Groups for Depression in China 

 15 

findings shed light on the role of online support groups in fostering patient empowerment and improving 
public understanding of depression in China.  
 

5.1. Online Support Groups in Chinese Culture 
We have shown that the way people engage in online support groups in China differs from extant research 
on online support groups in three specific ways. First, online support groups are regarded as the primary 
source of information for Chinese users, sometimes in place of professional medical advice. Users rely 
heavily on their peers to obtain treatment advice and turn to the group for peer diagnosis and peer therapy. 
These findings contradict prior work in the U.S., where patients often use peer expertise to complement – 
rather than replace – expertise provided by health professionals (Hartzler and Pratt, 2011). The heavy 
reliance on peers is partly due to the scarcity of mental health resources in China, in particular a shortage 
of psychiatrists and therapists. Negative experiences of interacting with unqualified doctors further 
dissuade people from seeking treatment. Through online information exchange, however, users create a 
repository of mental health resources, from which they can easily retrieve the information they need. Such 
a repertoire of resources supplements the limited mental health resources in China.  

The reliance on peers may also stem from a mistrust towards Western medical care. Sunshine users 
in our study did not readily accept Western mental health counseling and interventions, particularly when 
self-disclosure was expected. Influenced by the long-standing Confucian ideologies, Chinese people tend 
to conceal their emotions and feelings, in particular when trust has not been gained (McLaughlin and 
Braun, 1998). The self-suppression tendency also explains why very few Chinese people see a therapist 
even when the resources are available (Ying, 2002). Online support groups, however, provide a safe space 
for the expression of emotion due to trust and non-judgmental acceptance among users. Therefore, Chinese 
people regard the online community as a counseling center and feel comfortable opening up. 

Second, the public journaling practice appears to be unique to Chinese online health communities. 
Many Sunshine users kept writing diaries about their life and illness on the site; some wrote lengthy 
personal stories. This behavior, to a large extent, is associated with a lack of support from their family and 
friends. For Chinese people, because the behavior of the individual reflects on the family, mental illness 
that indicates lack of self-control may produce shame and guilt that threaten family “face” (McLaughlin 
and Braun, 1998; Yang et al., 2007). As a result, Chinese people tend to be reluctant to discuss their 
stigmatized illness with their family (Leung, 2010). Online support groups, therefore, become the platform 
where users can share fears, hope, and progress on a daily basis, and get attention, caring, and empathy 
from their peers. 

Prior research on online health communities rarely reports the public journaling practice (Vlahovic et 
al., 2014; Zhang, 2017). Although self-tracking for mental wellness is well documented (Kelley, Lee, and 
Wilcox, 2017), most research focuses on the use of self-tracking technologies such as Fitbit rather than 
online health communities. The public journaling in online health communities, on the one hand, opens 
up opportunities for social computing scholars to examine depression discourse and patterns (De 
Choudhury and De, 2014; Wang et al., 2012). On the other hand, journaling as a traditional form of self-
tracking still deserves attention from researchers. Future research should further explore users’ needs and 
motivations of sharing personal diaries with others in online health communities. 

Third, Chinese users have come to recognize online support groups as a type of ‘family’, where they 
regard each other as siblings. As described in our study, Sunshine has become a venue where users fought 
together and shared sorrows and happiness. The rejection from family and friends in their lives prompted 
them to count on their peers. Based on centuries of Confucian thought and an agrarian lifestyle, traditional 
Chinese beliefs center around the unity and harmony (McLaughlin and Braun, 1998). The interests of the 



RUNNING HEAD: Online Support Groups for Depression in China 

 16 

individual often give way to the rights of the collective (Dien, 1983). This breeds an online community 
with strong bonds among its users.  

In addition, many participants in our study grew up under China’s one-child policy. Some of them 
recalled loneliness, isolation and imaginary friends during their childhood. The development of a ‘family’ 
in online support groups, therefore, satisfied people’s needs of interdependency and gave them courage, 
strength, and commitment to take action as a community. This leads to the emergence of group culture, 
which ‘acted as a collective defense mechanism, reducing member’s anxiety and buttressing their self-
esteem but also detaching them from awareness of the reality of their failures to accomplish their goals’ 
(Farrell, 1982, p. 468). 
 

5.2. Online Support Groups and Patient Empowerment 
Because of the unique aspects of Chinese culture, online support groups may also have distinct impact on 
users. To address RQ3, we examined the perceived benefits of online support group engagement. Similar 
to prior research (Bartlett and Coulson, 2011; Ussher et al., 2006), we found empowerment and agency to 
be the most salient consequence of using online support groups. Our findings suggest that online support 
groups can foster individual empowerment through information exchange, self-tracking, self-disclosure, 
and emotional support, which corroborate the empowering processes of online support groups (Van Uden-
Kraan, Drossaert, Taal, Seydel, and van de Laar, 2009; van Uden-Kraan et al., 2008). These empowering 
processes, however, are magnified in China because of traditional cultural values and the lack of mental 
health resources.  

The online information helps people to better understand what depression is and what it means to 
have depression. This has been of great importance in China where people have limited knowledge and 
understanding of depression. Through exchanging information and resources, users were able to think 
through the nature of their distress and seek appropriate and effective treatment. It is the reliance on oneself 
and peers to diagnose and assess treatment, rather than on professionals, that gave users a sense of personal 
competence. This sense of self-efficacy has been viewed as the most important contributing factor to 
personal empowerment (Barak et al., 2008).  

For those who record their daily progress, public journaling is a way to exercise self-control, one that 
is highly valued by Confucianism (Leung, 2010). Rather than using self-tracking services, users actively 
engaged with journaling, where they recorded daily progress and wrote optimistic messages. This behavior 
gave participants a positive outlook based on self-control and strength, despite being viewed by the 
broader society as weak and pessimistic. Through exercising self-control, users viewed themselves more 
positively – as individuals who had control over their illness, rather than as passive victims of depression. 
Such a positive self-definition not only gave users a sense of empowerment, but protected them from 
experiencing decreased self-esteem and self-efficacy as a result of internalized stigma (Corrigan, Kosyluk, 
and Rüsch, 2013). 

Moreover, users also felt empowered through self-disclosure and storytelling. Prior research has 
documented the power of writing for emotional catharsis and meaning-making (Barak et al., 2008). This 
has been repeatedly mentioned by our interview participants, who obtained a sense of relief by posting 
online. Intense negative feelings became less toxic after being posted online. Moreover, the process of 
writing allowed them to make meaning of their experiences and to reframe negative events and thoughts, 
a mechanism similar to cognitive behavioral therapy (Barak et al., 2008). Therefore, being able to 
communicate online and describe personal difficulties seemed to induce a sense of empowerment by 
bringing about emotional relief and freedom of expression (Barak et al., 2008). 

Engaging in online support groups can also reduce feelings of loneliness and social isolation. People 
with mental illness often find it difficult to confide in friends and family members, largely due to stigma 



RUNNING HEAD: Online Support Groups for Depression in China 

 17 

and social distance. In online communities, however, users actively interacted with others who shared a 
similar condition and were willing to provide social support. This prompted them to open up and express 
feelings, which was key to the development of interpersonal relationships among users (Bartlett and 
Coulson, 2011). Thus, users gained a sense of affiliation and social cohesion that they were longing for, 
which could subsequently translate into feelings of individual empowerment. 

Engaging in online support groups could also reduce self-stigma. First, information exchange and 
self-tracking increased users’ self-efficacy and enabled them to view themselves more positively – as 
individuals who were strong-willed rather than weak. Second, interacting with others who had similar 
conditions created a sense of normalcy, making individuals feel less inferior. Despite the public stigma 
and negative stereotypes, Sunshine users developed a positive self-perception that buttressed their self-
esteem and diminished self-stigma. This is in line with prior research suggesting that people with mental 
illness are empowered by technology to define themselves beyond traditional diagnostic labels (O'Leary, 
Bhattacharya, Munson, Wobbrock, and Pratt, 2017) and that social reinforcement for positive attitudes is 
key to combating self-stigma (Frohlich and Zmyslinski-Seelig, 2016). 

In this sense, online support groups function as a site for individual empowerment, resonating with 
what Foucault (1988) called ‘technologies of the self’, which ‘permit individuals to effect by their own 
means or with the help of others a certain number of operations on their own bodies and souls, thoughts, 
conduct, and way of being, so as to transform themselves in order to attain a certain state of happiness, 
purity, wisdom, perfection, or immortality’ (1988, p. 18). For people with depression in China, online 
support groups have become a means of moving toward new possibilities in achieving self-efficacy and 
self-worth. A feeling of ‘I am competent’ is the first step to gaining individual agency – the capacity to 
act independently and to make their own free choices (Barker, 2003).  

Despite the merits of online support groups, they are not a panacea for users. Our findings reveal that 
excessive self-disclosure might negatively affect others and impair collective goals, although they can 
empower individuals. The forum regulations can also create hierarchies and power relations, leading to 
further marginalization of some users. Given these costs of group participation, individuals need to 
develop strategies to balance the benefits and costs of their engagement. 
 

5.3. Online Support Groups and Destigmatization 
This study also shed light on the potential of online support groups to improve public understanding of 
depression and reduce stigma associated with mental illness. We have shown that Sunshine users have 
attempted to challenge public stigma through collective actions. For example, forum administrators and 
members gave lectures to communities and universities, and participated in TV shows to talk about 
depression. In addition, some users have publicly disclosed their stigmatized identities and shared 
experiences of treatment and recovery. Sunshine has organized members to write a book titled A Journey 
of Fighting Depression,	which contains 16 personal stories wrestling with depression. 

Studies suggest that destigmatization can be achieved in two ways: by removing misunderstanding of 
mental illness and by drawing equivalences between the stigmatized and normal groups (Clair, Daniel, 
and Lamont, 2016). In this sense, Sunshine is well positioned to create these two social conditions for 
destigmatization. First, disseminating knowledge about depression might challenge existing ideologies 
and misunderstanding of depression and remove blame for people with this condition (Clair et al., 2016). 
Personal stories of faith, hope, and success can also reconstruct the image of people with depression, 
portraying them in a more positive light. This can further promote public understanding of this stigmatized 
group.  

Second, demystifying depression and sharing personal stories could bridge group boundaries. 
According to Clair et al. (2016), “destigmatization is more likely when non-stigmatized individuals find 



RUNNING HEAD: Online Support Groups for Depression in China 

 18 

their own fate linked to the stigmatized group” (p. 229). In a similar vein, Sunshine users who publicly 
shared experiences in wrestling with depression could prompt the general public to view depression as 
relevant to – or not so different from – their own lives. Disclosing personal stories might also encourage 
other people with depression in China who have not sought help for mental health issues to open up online 
or offline.  

In addition, the affordances of social media (e.g., interactivity, anonymity, visibility) enable people 
with depression – who are stigmatized in offline interactions – easily expand the reach of their influence 
(Zheng and Yu, 2016). For example, the interactive features (e.g., comment, like, repost) of social media, 
in this case the forum and WeChat, can foster information dissemination, public education, and collective 
action in China (Rauchfleisch and Schäfer, 2015). An article or video will go viral if reposted many times, 
making it easier to draw public attention and to engage other social actors (Zheng and Yu, 2016). The 
anonymity of social media also allows group members to openly express their views, thereby promoting 
the public understanding of depression. With the aid of social media, people with depression could 
contribute to destigmatization of mental illness in the society, supplementary to organizational and 
governmental efforts.  
 

6. CONCLUSION 
The human experience of depression is culturally shaped. The way people use technology to manage 
depression is also influenced by social and cultural contexts. In this paper, we focus on an online support 
group for depression in China and examine user interactions, motivations, and benefits. We draw attention 
to the cultural values and limited mental health resources in China that shape how people use and 
understand online support groups. In particular, this study illustrates the user activities distinct from the 
extant research on online health communities, such as using peer expertise to replace doctors’ advice, 
engaging in public journaling, and viewing each other as siblings.  

We have also found that online support groups create new possibilities for empowering individual 
users and reducing stigma. Peer support and community building increase users’ knowledge, reduce 
loneliness, and buttress self-esteem. Users also make collective efforts aimed at improving public 
understanding of depression in China. Therefore, online support groups function as a site of individual 
empowerment and destigmatization for people with depression in China. This paper has deepened our 
understanding of online support groups in a non-Western context. It also sheds light on the social and 
psychological implications of online health communities. 
 

ACKNOWLEDGMENTS 
We thank the individuals who participated in this study. We also thank Gary Fine, Courtney Scherr, the 
reviewers and editors for their valuable insights and feedback.  
 
 
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