Anxiety, Depression and Other Mental Health Issues in North Korea

According to Barbara Demick’s book ‘Nothing to Envy: Ordinary Lives in North Korea‘, North Korea has a unique approach to mental health, influenced by Stalin and the rise of communism in the 20th century. Mental disorders are attributed to biological factors, genetics or injury to make them more socially and politically acceptable. Political dissent, “delusions of reform” and philosophical differences are often labelled as symptoms of schizophrenia.

In North Korea, people in need of mental health treatment are often sent to group centres in remote areas. The isolation and lack of resources in these centres can pose significant challenges to appropriate care and support. In addition, more than 60 years of separation between North and South Korea has resulted in dialect differences that contribute to discrimination, PTSD, social exclusion and difficulties in assimilation for North Korean refugees resettled in South Korea.

Soviet/Socialist/Communist Influence

Due to the closed nature of the North Korean socio-cultural system, it is difficult to obtain comprehensive first-hand knowledge of the current state of mental health in the country. However, insights can be gained from fleeing refugees, mental health researchers and practitioners who have interviewed defectors who have moved to South Korea, and by observing the influence of communist political ideologies on psychiatric thought and practice in other former socialist countries.

The rise of communism in the early 20th century, particularly in the USSR, shaped the approach to psychological thought. Freudian theory was suppressed and biological perspectives on mental health became prominent. Joseph Stalin’s Central Committee of the Communist Party rejected the notion of unconscious, irrational and uncontrollable aspects of the human psyche. Instead, the theories of Pavlov and Kraeplin, which focused on biological and physiological factors, were declared the primary basis of Soviet psychiatric thought. Mental disorders, including anxiety, were attributed to abnormalities or injuries in the central nervous system. Social factors such as poverty, level of education and socio-political pressures were largely ignored during the Stalin era. This approach influenced psychiatric methodology in countries with strong political ties to the USSR, including North Korea.

The review article by Park and colleagues highlights similarities between psychiatric practices during the Stalin era and contemporary methodologies in North Korea. An emphasis on dysfunction of the nervous system as the cause of mental illness and a focus on genetic predispositions, while dismissing unconscious or social processes, are evident in North Korean medical training circles.

Interestingly, psychiatric diagnosis and treatment in former and current socialist/communist countries, including North Korea, have been tailored within a political framework, intertwining psychiatric diagnosis with political ideas and terminology. Political dissent, “delusions of reform” and differences in philosophical beliefs were often incorporated into the pathology of schizophrenia. Depressive symptoms were seen as attempts to avoid collective labour, leading individuals to hide their symptoms to avoid political persecution. Chinese patients would sometimes ‘somatise’ their depressive symptoms, attributing them to biological causes in order to reduce social stigma and political backlash.

The approach to psychiatric illness and treatment in North Korea is thought to reflect practices in the former USSR and China. Biological explanations are emphasised, severe psychosis and schizophrenia receive more attention, and neurotic diagnoses and substance use disorders are often overlooked. When mood and anxiety disorders are treated clinically, a biological perspective is usually taken, and general practitioners or neurologists rather than psychiatrists or psychologists oversee treatment. Severe mental disorders are treated in large, isolated inpatient units known as ’49s’. Older generation antipsychotics, reliable tranquillisers and barbiturates are used instead of the more advanced psychopharmacological tools available in Western cultures. At present, talk-based psychotherapy is not practised in North Korea.

Clinical Presentations Observed in North Korean Refugees

A valuable source of clinical data on the mental health of the North Korean population comes from the reports of refugees who have defected to South Korea. The number of defectors increased significantly between 1998 and 2003, partly due to a perceived relaxation of communist rule following the death of Kim Il Sung. It is important to note that the estimated number of defectors may be underestimated, as official reports do not include those who left North Korea and entered China or other Asian countries en route to South Korea. Refugees who have attempted to enter South Korea via China provide valuable insights into the mental health of North Koreans due to the harsh treatment they experienced when captured and repatriated to North Korea.

Posttraumatic Stress Disorder (PTSD)

Post-traumatic stress disorder (PTSD) is a common mental health problem observed among North Korean refugees. The degree of traumatisation prior to emigration has been found to have a significant impact on the mental health of refugees. North Korean defectors report physical abuse, such as rape and assault, and psychological distress, including forced marriage and punishment of family members. Family mental health is particularly important in North Korean society, as the government often disciplines multiple family members as a result of dissent, leading to stronger family bonds and prolonged feelings of anxiety and worry.

Kim and Lee (2009) examined socio-cultural factors affecting post-traumatic recovery among North Korean refugees resettled in South Korea. They identified six central aspects: the struggle for survival and assimilation into a new society, unexpected stress and feelings of shock and chaos, reconsideration of the reasons for relocation, trauma recovery, reconstruction of personal meaning, and post-traumatic growth through the use of coping strategies. Transition to South Korean culture can be facilitated through training programmes that address language differences, reduce cultural discrimination, provide religious and spiritual education, and promote understanding of South Korean politics and ideology. Efforts to support family members across the border have also been associated with better psychological outcomes in refugee populations.

Mood and Anxiety Disorders in North Korean Defectors: Societal challenges and mental health implications

North Korean defectors face not only trauma and stress-related disorders, but also major depression and anxiety disorders. Studies have consistently shown that these refugees exhibit clinically significant depressive symptoms associated with a variety of factors, including feelings of loneliness, social exclusion, guilt about loved ones left behind, and difficulties adjusting to a competitive, capitalist society. In addition, the level of depressive symptoms experienced by North Korean refugees is related to their assimilation into a new culture and their perception of discrimination following resettlement.

The integration of North Korean defectors into South Korean society poses significant problems due to socio-cultural differences. Despite sharing a common ancestry and racial identity, there is a notable sense of contempt and discriminatory behaviour towards defectors from the North. This discrimination extends to the workplace, despite the South Korean government’s efforts to facilitate their transition. Linguistic differences resulting from six decades of separation between the two regions add to the difficulties faced by North Korean refugees. These challenges, combined with the difficulties of transitioning from a socialist to a capitalist economy, make them easily identifiable and potential targets of prejudicial behaviour.

Satellite images illustrate the stark contrast between North Korean society and the rest of the free world. While neighbouring areas such as China, South Korea and Japan are brightly lit and bustling with activity, North Korea remains shrouded in darkness. This stark contrast is likely to have a significant impact on the overall medical and mental well-being of North Koreans. The country’s leadership, history of communist/socialist influence, resistance to change and isolation exacerbate the challenges its citizens face in maintaining good physical and mental health.

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Seth Davin Norrholm, Ph.D.

Associate Professor, School of Medicine at Wayne State University

Seth D. Norrholm, Ph.D. (Twitter: @SethN12) is an Associate Professor of Psychiatry and Behavioral Neurosciences at Wayne State University School of Medicine. Dr. Norrholm has spent 20 years studying trauma-, stressor-, anxiety-, depressive-, and substance use-related disorders and has published over 100 peer-reviewed research articles and book chapters. The primary objective of his work is to develop “bench-to-bedside” clinical research methods to inform therapeutic interventions for fear and anxiety-related disorders and how they relate to human factors such as personality, genetics, and environmental influences.

Dr. Norrholm’s more recent work has focused on fear and anxiety in the community and how it is affected by the influence of mass media, social media outlets, and the sociopolitical environment. Dr. Norrholm has been featured on NBC, ABC, PBS, CNN.com, Politico.com, The Atlantic, Salon.com, The Huffington Post, Yahoo.com, USA Today, WebMD, The History Channel, and Scientific American. In 2019, Dr. Norrholm was recognized as an Expertscape world expert in Fear and Posttraumatic Stress Disorders.