A photo project about people with depression is helping to change the way Chinese view mental illness, Wang Qian reports.

He was having trouble falling asleep. He lacked appetite and energy. And he'd lost interest in everything. Zhang Nan knew what his sinking feeling meant. His depression was returning.

Zhang was first diagnosed with mild depression when he was in senior high.

This time, he decided to record the feeling using his camera. His photo project, Crinkled Fog, has lasted about three years. He has snapped shots of over 100 people, mostly female, ages 14 to 30, who struggle with mental health. Most are diagnosed with mild cases.

Zhang designed and photographed each shoot.

"At first, I just wanted to express myself," the 27-year-old says.

"Gradually, the project turned into a means of therapy and connection for me and my models to understand emotions, which are like fog that you can't grasp or get rid of."

He has since opened a photo studio in Wuhan, Hubei province.

He pinned the project on top of his Sina Weibo page and has looked for people struggling with depression across the country to share their stories and be his models since 2018.

Hundreds of people have contacted him.

The project has made national headlines and triggered discussions about mental illness.

Zhang has over 580,000 followers on the micro-blogging platform. A Weibo user comments that his images prove the idiom, "A picture is worth 1,000 words."

"Although things have been better with people talking openly about it nowadays, there are some misunderstandings about the mental illness," Zhang says.

"Through my images, I want the 'invisible' feelings to be seen and to tell people experiencing depression that you're not alone."

He adds that people, especially family members, should provide support and care for those who live with depression.

His photos were displayed at the Three Shadows Xiamen Photography Art Center in Fujian province last year. The curator, Wu Xihuang, says that Zhang uses photography to record the "collapse" and confusion of life.

"I know it won't be easy for anyone to open up to the public," Zhang says.

"I admire the courage of these people who come to me and share their stories without reservation."

World Health Organization figures show depression is a growing public health concern worldwide. About 264 million people around the world have depression, and more women are affected than men. In China, depression affects 54 million people and is one of the leading causes of suicide.

Unlike usual mood fluctuations and short-lived emotional responses to challenges in everyday life, depression may develop into a serious health condition. It can cause the affected person to suffer greatly and function poorly at work, at school and in the family. At its worst, depression can lead to suicide, the WHO says.

Beyond feeling blue

Zhang says depression feels like "being caught in a whirlpool or blanketed by a huge shadow". He tries to capture what this feels like in daily life.

According to Harvard Health Publishing, the onset of depression is more complex than a chemical imbalance. There are many possible causes, including faulty mood regulation in the brain, genetic vulnerability, stressful life events, medications and medical problems.

Every story behind Crinkled Fog proves how complex the mental illness is and shows the real damage it causes to people of all ages and from all walks of life.

Zhang usually starts his interview with people with depression using a camera or a smartphone. He sometimes puts on soothing music to relieve stress and nervousness.

He uses different settings or objects, such as fishbowls, beds and plush toys, to capture the mood with his lens.

But it's not easy to let the real mood flow and capture the moment.

Zhang says that most people smile and pretend to live happy and healthy lives when they first contact him. But this veneer disappears when they open up.

The 100th person Zhang shot for the series is a 23-year-old from Nanjing, Jiangsu province. The woman, nicknamed Yaya, was diagnosed during her first year in senior high school, when her grandfather passed away in 2013. Since then, she has been alone all the time, going to school, eating and sleeping by herself.

Her grandfather raised her, since her parents took her younger brother to do business in another city.

She only sees her parents several times a year. All they provide for her is money, she says.

During her darkest period, she received electroconvulsive therapy 10 times within six weeks.

Yaya told Zhang that her parents believe depression is just like a cold and will go away on its own.

She applied for the photo shoot when she got better this year because she wanted to record the moment.

"When I collapse next time, the image can remind me that I have felt good and can recover," Zhang quotes Yaya as saying.

Another woman who made an impression on Zhang is Xiao Meng (alias) from Hainan province, who participated in Crinkled Fog in 2018.She couldn't hold back her tears when telling her story. Zhang captured the moment they fell.

The psychology major can't overcome her illness, Zhang says.

Visibility to vulnerability

Although it's not the first project of its kind, Crinkle Fog has captured attention from the media and the public. And it has triggered discussions about mental illnesses, such as depression and anxiety, which have been on the rise, according to a national epidemiological survey on mental health.

Led by Huang Yueqin, director of the Division of Social Psychiatry and Behavioral Medicine at Peking University's Institute of Mental Health, the report was published in the journal, The Lancet Psychiatry, in February last year.

It indicates that, "mental disorders have become more common across China in the past 30 years".The researchers estimate that 16.6 percent of Chinese adults have experienced mental illness at some point in their lives.

The report says that "rapid social change is likely to bring about a general increase in psychological pressure and stress" and calls on authorities to "pay more attention to mental-health care".

Tsinghua University assistant professor of psychology Li Songwei says the findings mean a kind of improvement in that people are beginning to admit that depression is a real illness, according to an article on his official WeChat account.

"Just like your body, your moods can fall ill, too," he writes.

He quotes Social Origins of Distress and Disease: Depression, Neurasthenia, and Pain in Modern China by Arthur Kleinman, published in 1988. It says that, in the past, mental distress was much more likely to be expressed by Chinese patients in somatic forms, such as bodily ailments, than as psychological distress, such as feelings of sadness or loss of interest, as is commonly presented in the West.

"When depression can be diagnosed, no matter how terrible it is, there are effective treatments," Li writes.

A major obstacle is that some people don't see specialists, Lu Lin, director of Peking University Sixth Hospital and an academician at the China Academy of Sciences says at the recent Tencent Medical Enlightenment Summit.

"We must remove the stigma and the shame by actively and openly supporting our friends and family members who are experiencing depression," Bernhard Schwartlander, former WHO representative in China, told China Daily earlier.

There's a medical term called "smiling depression" that describes a person who appears happy to others and smiles through their pain, keeping their inner turmoil hidden. It's a major depressive disorder with atypical symptoms. Consequently, many people don't know they're depressed and don't seek help.

Taking action

The good news is that health authorities have noticed the alarming trend and have taken action.

In September, the National Health Commission released an action plan for depression prevention and treatment, particularly among vulnerable groups, including adolescents, pregnant women, seniors and people with high-stress jobs.

The plan requires secondary schools and universities to launch mandatory mental health courses to promote depression-prevention knowledge among young people.

The plan's target is that at least 30 percent of people with depression will have access to treatment by 2022, followed by 80 percent by 2030.

According to the US National Institute of Mental Health, depression is usually treated with medications, psychotherapy or a combination of the two. If these treatments do not reduce symptoms, electroconvulsive and other brain-stimulation therapies may be options. At least 70 percent of people with clinical depression can improve with treatment.

Various nongovernmental groups, including online communities, focusing on mental health have stepped in to play roles supplementary to hospitals and to raise public awareness.

Zhang is glad to see the change. He says such support, or even the smallest gesture, can make a difference to people with depression.

He's now writing a script for a documentary about depression to explore its complex terrain.

"Depression is not a weakness or a character flaw," Zhang says.

"It's like having a bad flu in your mind, which can be cured with proper treatment."