Both depression and diabetes are major global public health concerns. In China, the reported prevalence rates of these two illnesses have been drastically increasing. In terms of depression, a cross-sectional epidemiological survey of the prevalence of mental disorders among 32,552 respondents revealed that depressive disorders were the second most common class of disorders in China both in the 12 months before the interview (weighted prevalence 3.6%, 3.0–4.2%) and in a lifetime (6.8%, 5.8–7.8%) . Females (4.2%, 3.4–4.9%) had a higher prevalence than males (3.0%, 2.3–3.7%) in the 12 months before the interview; however, there was no significant difference between rural (3.7%, 3.0–4.5%) and urban (3.4%, 2.7–4.2%) areas . In terms of diabetes, a nationally representative sample of 75,880 participants found that the weighted prevalence of total diabetes, self-reported diabetes, newly diagnosed diabetes, and prediabetes were 12.8%, 6.0%, 6.8%, and 35.2%, respectively . However, few studies reported how a better understanding of depression and its health connections might lessen the public stigma toward health-associated depression. This study aims to use a set of vignettes to explore Chinese people’s perceptions toward families affected by depression and diabetes-associated depression.
Comorbidities of Diabetes and Depression
Depression and diabetes frequently occur together, and diabetes-associated depression can increase the risk of severe complications and mortality [3, 4, 5]. A recent meta-analysis found comorbid depression occurring in approximately one out of four adults with Type 2 diabetes . These increased rates of depressive disorders in adults with Type 1 and Type 2 diabetes range from 8-15% worldwide . In China, a meta-analysis found 27% of individuals with Type 2 diabetes also had depression, 20% had mild depression, and 10% had moderate to severe depression . A growing body of research indicates the relationship between depression and diabetes is bidirectional, wherein individuals with diabetes are twice as likely to develop depression and, conversely, those experiencing depression are at a heightened risk for diabetes [9, 10, 11, 12]. A prospective longitudinal study conducted with 17,708 participants across 28 provinces of China found that participants with depressive symptoms at the baseline were 33% more likely to develop Type 2 diabetes, and those with baseline diabetes were at a 35% increased risk of developing persistent depressive symptoms 
Other research examined gender differences in individuals with depression comorbid with diabetes. Sun and colleagues  studied rates of depression in 229,047 adults with diabetes in China and found a 4.8% prevalence of subthreshold depression (male, 3.6%; female, 5.5%) and 1.1% prevalence of probable depression (male, 0.8%; female, 1.3%). Five years later, high depression rates occurred among females (32%) and males (26%) with Type 2 diabetes . Those with both illnesses represent a population in need of mental and health care.
Why Studying Mental Health Stigma in China
In Shanghai, Wang et al  studied factors associated with depression and Type 2 diabetes in 865 Chinese older adults. Results found that individuals with employment, higher salary, and at least a college education exhibited more depressive symptoms than their less financially stable and lower educated counterparts . These findings may lead to research connecting depression and diabetes to job satisfaction and work-life balance in various working environments. In Hong Kong, Tung et al  examined psychological comorbidities among Chinese adults with Type 1 diabetes. They found that the higher rate of depression could be due to lifestyle adaptations to diabetes, lack of social interactions, and feelings of losing control of life events due to medical necessities. In Taiwan, Huang et al  compared treatment utilization between 1,209 patients with Type 2 diabetes (T2DM) and major depressive disorder (MDD) and 12,090 patients with T2DM but no MDD. They found that the MDD group had 23.43% more non-psychiatric outpatient visits than the non-MDD group. Additionally, they found that while women utilized healthcare services more often, men had 0.82 times more hospitalizations, indicating that more routine treatment-seeking behaviors can prevent hospitalizations . These studies demonstrated a need to study the comorbidity between mental health (depression) and health (diabetes), which often results in public stigma by the affected individual and their families.
The Chinese Lay Theory  is used as the explanation base to address the association between the fundamental Chinese values and three types of stigmatization.
The first type is self-stigmatization. Chinese beliefs emphasize the importance of whole-body harmony and self-support, but research on mental illness varies significantly in findings of etiology and stigma . Pan et al  analyzed the content in a popular social media site in China and found about 16,000 depression-related posts pointing to depression as a controllable disease by the patient. Ng et al  investigated Chinese mothers with adolescent children and found that these mothers placed high importance on children’s self-improvement, believing they could help their children fight against depression. This self-control concept is contrary to the expected images of the patients with depression that they cannot control themselves but may harm or threaten others. These images caused a conflict between weak and potential social threats [20, 21].
Second is the stigma against the family, which is a less examined stigma connecting to illness severity and caregiver stress. In Hong Kong, Lee et al  found that Chinese patients with schizophrenia were more likely to anticipate being stigmatized, conceal their health condition, and default on clinic visits than patients with diabetes. Their focus was not to compare depression with diabetes. Still, it brought about the unwelcome disclosure of a mental health illness, workplace difficulties, family rejection, and treatment non-adherence when patients dealt with life stress. The severity of the disease is also related to the use of psychotropic drugs. In a Hong Kong study, 83 practicing psychiatrists reported that people were wary of seeking help for depression because of medication side effects, such as confusion and being “muddleheaded” with high stress [23, p.1].
The third is public stigma. Depression is perceived as an uncontrollable disease that can cause shame and guilt, regardless of education, IQ, or income; thus, patients must undertake routine assessments for their health management [24, 25]. In a 2013 study when depression and diabetes were co-present, 89% of the public in China had a negative stigma of depression; in comparison, only 32% had a negative stigma of diabetes as measured by a devaluation instrument . Even though the patient’s physical symptoms are not as stigmatized as psychiatric symptoms, shame is a psychological barrier against help-seeking . Yeung et al  highlighted that Chinese men who lived with a ‘mentally ill’ label had a very high level of mental distress. In their study, common themes of a mental illness encounter included: mental health problems, shameful business, topics prohibited to discuss outside of the family, stress avoidance, refusal to seek outside help, the need to consult natural healers, reliance on family resources, seeking help from medical practitioners, and noticing sudden behavioral changes. Family members reported seeking help only when the patient was out of control . Social avoidance was a widely used family strategy to avoid stigma.
These three types of stigmatization can intersect with the labels used in medical diagnoses. To avoid being labeled, families prefer healthcare to other kinds of treatment. Wang et al  found that Chinese individuals who had a high perception of stigmatization had a higher likelihood of manifesting depression as a somatic complaint, which would be an acceptable reason to seek medical care. Additional Chinese studies focused on self-stigma toward depression as the illness is related to dysfunctional attitude and maladaptive cognitive coping , self-efficacy and social avoidance [31, 32], and stigma-reduction interventions . More negative stigma is associated with an illness when the patient shows severe psychiatric symptoms.
The above studies supported the current study for investigating public stigma toward the individuals who have been diagnosed with depression only or comorbid with diabetes. Study results will contribute to anti-stigma programs incorporated with cultural perspectives. Specifically, this study addressed three research questions:
- Does gender affect public stigma against a patient’s depression?
- Does depression comorbid with diabetes influence public stigma toward depression?
- Among Chinese individuals, what characteristics could predict a high public stigma toward a patient with depression?