Gaming Against Stigma: Enhancing Mental Health Literacy through Serious Games in the Chinese Context

Introduction

Depression is recognized as the leading cause of disability worldwide and continues to pose a growing public health challenge, particularly in China where its prevalence has markedly increased since the 1990s (Ren et al., 2020). This trend is especially pronounced among youth, with individuals aged 18 to 24 exhibiting the highest risk at 24.1% (National Mental Health Development Report, 2021–2022). Yet, despite the rising incidence, depression literacy remains critically low, and culturally responsive interventions are scarce. A majority of existing research adopts Western diagnostic paradigms, which often fail to capture culturally situated expressions of psychological distress (D. T. S. Lee et al., 2007).

My motivation to explore this topic stems from both academic and personal experiences. During my time working with young adults in China as a media researcher and educator, I encountered many students who expressed emotional distress in indirect ways—through references to physical symptoms or abstract metaphors in conversation. This echoed the silence and ambiguity I witnessed in my own extended family, where discussions of mental health were often avoided or framed as personal weakness. These experiences underscored for me how deeply cultural values influence the expression and reception of psychological suffering.

Understanding depression within China requires a nuanced examination of its sociocultural context. Traditional Chinese values such as collectivism and filial piety shape not only interpersonal relationships but also health-related behaviors, including mental health disclosure and help-seeking. Emotional suppression is often encouraged to maintain family harmony and uphold social obligations. Historical events, including the Cultural Revolution and the ideological emphasis on self-sacrifice, have further reinforced these stigmatizing norms, framing mental illness as a moral failing or personal weakness (Kleinman, 1986; Yang et al., 2020).

Stigma remains a formidable barrier, compounded by the cultural importance of "face" (mianzi)—a concept rooted in Confucian social order that ties personal identity and family reputation to external perception. Within this framework, mental illness is often seen as a source of shame, leading individuals and families to downplay or conceal psychological distress (Y. Yu et al., 2015). This results in a pervasive preference for somatic expressions, such as fatigue, insomnia, or gastrointestinal discomfort, over verbal articulation of emotional suffering. Traditional Chinese Medicine (TCM) reinforces this approach by interpreting mental health disorders as bodily imbalances in qi, emphasizing physical rather than emotional symptoms (Xu, 1987; S. Lee, 1994).

As a researcher interested in culturally grounded media interventions, I have long been drawn to interactive and narrative forms that can address social stigma in ways that conventional public health campaigns cannot. My previous work has explored the intersection of digital storytelling, affect, and identity, and I believe that serious games—particularly those developed within local cultural contexts—hold unique potential to bridge the gap between clinical knowledge and lived experience.

This review draws on interdisciplinary scholarship in educational theory, media studies, and health communication. It examines both scholarly literature and practical interventions, aiming to synthesize insights into how serious games can support culturally informed, emotionally resonant learning in mental health education.

Literature Review

Educational Theory / Concepts

At the theoretical level, this study is informed by five major frameworks. The first is mental health literacy, as defined by Jorm and colleagues in 1997(Jorm et al., 1997). This foundational concept identifies mental health literacy as the knowledge and beliefs that assist in the recognition, management, and prevention of mental disorders. Numerous studies, including those by Reavley et al., have shown that improved depression literacy correlates with greater help-seeking behavior and a reduction in stigma.

Secondly, constructivist learning theory underscores the role of active engagement in shaping understanding. Within serious games, players are required to make choices, observe consequences, and reflect on outcomes. This dynamic interaction simulates real-world problem-solving and facilitates a deeper understanding of complex topics such as mental illness.

The third relevant theory is narrative transportation. According to Green and Jenkins (2014), players who become emotionally and cognitively absorbed in a story are more likely to align with its values and internalize its messages. The Room of Depression employs visual storytelling, ambient sound, and dialogue choices to immerse players in Moon’s psychological world.

Fourth, Kolb’s experiential learning theory provides a framework for understanding how concrete experiences combined with reflective observation foster personal learning. The gameplay encourages reflection through narrative consequences, mirroring Kolb’s learning cycle.

Finally, stigma theory, particularly the framework developed by Link and Phelan(2001), elucidates how labeling, stereotyping, separation, and discrimination converge to produce social disadvantage for people with mental illness. Understanding these dynamics is crucial for designing effective educational interventions that not only raise awareness but challenge underlying prejudices.

However, critiques of game-based interventions for mental health point to potential pitfalls. Buday et al. (2022) highlight how popular games often portray mental illness through negative or sensationalized imagery. Others question the cultural appropriateness of mental health narratives developed in the West. Krath et al. (2021) argue for contextually grounded frameworks that consider the racial, gendered, and geopolitical nuances influencing game design and reception.

Depression Literacy

Depression represents a pervasive global health crisis, necessitating multidimensional responses that encompass both clinical treatment and proactive education. The concept of mental health literacy, first introduced by Jorm et al. (1997), serves as a foundational framework for these efforts, defined as "knowledge and beliefs about mental disorders which aid their recognition, management, or prevention."

Depression literacy, as a subdomain, refers to individuals’ understanding of depressive symptoms, etiologies, and treatment options. Higher levels of depression literacy are consistently associated with reduced stigma, increased help-seeking behaviors, and more accurate recognition of symptoms (Wang & Lai, 2008; Reavley et al., 2018; Tehrani et al., 2022). Svensson and Hansson (2016) note that depression literacy is instrumental in shaping public attitudes and diminishing discriminatory behaviors.

However, the interaction between depression literacy and stigma is not uniform across cultural contexts. Kulwicka and Gasiorowska (2023) argue that existing tools for measuring depression literacy often lack cultural sensitivity and risk misrepresenting mental health conceptions in non-Western societies. Pruksarungruang and Rhein’s (2022) study in Thailand highlighted the absence of religious and social context in prevalent diagnostic models, advocating for a grounded, qualitative investigation into culturally embedded beliefs about depression.

In China, depression literacy must be understood within a nexus of historical, familial, and institutional influences. Filial obligations and collective social identity often inhibit open acknowledgment of mental distress, framing it as a deviation from social responsibility. Yang et al. (2020) found that Chinese individuals with high depression literacy may still avoid help-seeking due to deep-rooted cultural stigmas tied to "face" and perceived familial dishonor. As such, effective educational interventions must disseminate biomedical knowledge and challenge entrenched normative beliefs through culturally resonant strategies.

Depression in China

Since the early 1990s, depression has emerged as a significant public health concern in China (Ren et al., 2020), where its framing and treatment are deeply influenced by historical legacies, philosophical traditions, and institutional practices. The diagnostic criteria and phenomenology commonly adopted are rooted in Western psychiatric paradigms, which may not adequately reflect Chinese cultural conceptions of mental illness (D. T. S. Lee et al., 2007).

Cultural values such as collectivism and filial piety have a profound effect on how psychological disorders are perceived and managed. In the Confucian framework, individuals are expected to maintain social harmony, fulfill family obligations, and suppress personal discomfort. Emotional restraint is seen as virtuous, while public acknowledgment of psychological distress is often stigmatized as disruptive or shameful. These pressures contribute to a culturally specific manifestation of depression in which somatic symptoms, such as dizziness, fatigue, or heart palpitations, become proxies for emotional pain (Parker et al., 2001; Xu, 1987).

Furthermore, historical developments such as the Cultural Revolution (1966–1976) discouraged open discussions about emotions and individuality, promoting collectivist ideals and self-sacrifice. These ideological underpinnings linger in contemporary mental health discourse, reinforcing avoidance, denial, and family-centric coping strategies (Kleinman, 1986; H. Li et al., 2019). Families often act as gatekeepers, suppressing disclosure and delaying access to formal mental health services to protect collective "face" (Yang et al., 2020).

The Traditional Chinese Medicine (TCM) model, which views depression as a disruption in the flow of qi (vital energy), contributes to a preference for somatic explanations and physical remedies. Expressions such as "heart panic" (xinhuang) or "brain swelling" (naozhang) illustrate how distress is linguistically and symbolically grounded in bodily metaphors (D. T. S. Lee et al., 2007). Despite increasing exposure to Western mental health paradigms in urban settings, this dual epistemology—TCM and biomedical—shapes how Chinese individuals conceptualize and seek treatment for depression.

The disjunction between high levels of psychological distress and low formal help-seeking behavior underscores a need for culturally grounded education strategies. Yu et al. (2015) highlighted that many Chinese individuals report high intention to seek help but limited awareness of available resources. Therefore, the development of mental health interventions must account for these cultural logics, communication practices, and trust structures.

Serious Games

Serious games, defined as digital or analog games designed for purposes beyond entertainment—such as education, behavioral training, and health communication—have gained traction as tools for public health interventions (Michael & Chen, 2005; Andrews, 2011). These games provide experiential, interactive environments that promote behavioral change and emotional engagement through narrative structures and gameplay mechanics. Plass, Homer, and Kinzer (2015) emphasize that effective game-based learning environments must integrate multiple theoretical perspectives, including cognitive, motivational, affective, and sociocultural dimensions. They argue that such integration facilitates deeper learning by aligning game mechanics with educational objectives.

As cognitive and affective learning tools, serious games offer immersive, goal-oriented simulations that reflect real-life decision-making scenarios (Lindgren, 2012). From a learning sciences perspective, Steinkuehler and Squire (2022) identify four primary functions of video games in educational settings: as content delivery mechanisms, as tools for engagement, as platforms for social interaction, and as environments for situated learning. They highlight that games can foster complex problem-solving skills and collaborative learning experiences. Empirical studies have examined the motivational aspects of gamification in educational contexts. Sailer et al. (2017) conducted an experimental study demonstrating that specific game design elements, such as badges, leaderboards, and performance graphs, positively influence learners' psychological need satisfaction, particularly in terms of competence and task meaningfulness.

In mental health contexts, serious games have shown promising outcomes. Lau et al. (2017) conducted a meta-analysis of ten studies and found that serious games reduced symptoms of anxiety and depression, although results varied across population groups. Fleming et al. (2014) echoed this in a systematic review, identifying the potential for these games to enhance emotional resilience and encourage treatment-seeking behavior. However, the majority of studies have focused on Western populations and clinical settings—such as training for healthcare professionals or support for military veterans (Andrews, 2011; Bhoopathi & Sheoran, 2006)—with limited research on the general public or culturally diverse populations.

One of the key pedagogical strengths of serious games lies in digital storytelling. Games that employ character-driven narratives, emotionally evocative scenarios, and branching dialogue trees encourage perspective-taking and increase empathy toward marginalized experiences, including mental illness (Green & Jenkins, 2014). Features such as avatar customization, journal entries, in-game choices, and consequences foster player identification and enhance cognitive elaboration (Schwarz et al., 2019).

Despite these affordances, serious games face criticism regarding superficial gamification, uneven player engagement, and risks of trivializing serious conditions. For instance, poorly designed mechanics may reinforce rather than dismantle stereotypes if they fail to critically engage with the complexities of mental illness (Buday et al., 2022). Furthermore, without cultural adaptation, game content may unintentionally exclude or alienate players from non-Western backgrounds.

In the Chinese context, there is growing interest in the application of serious games in education, but empirical work on mental health-specific titles remains sparse. Some efforts have explored the use of game-based platforms to teach psychological skills or stress management in schools and community centers. For example, studies by Yu et al. (2021) and Zhao et al. (2024) suggest that culturally relevant digital tools can enhance health literacy among young Chinese users. However, few serious games directly confront the stigmatization of depression or embed traditional cultural references into the narrative.

Depression Stigmatization and Serious Games

Stigma, as conceptualized by Link and Phelan (2001), refers to the process through which certain traits or behaviors are devalued, resulting in social exclusion, status loss, and discrimination. In mental health contexts, stigma manifests through stereotypes (cognitive generalizations), prejudice (emotional responses such as fear or anger), and discrimination (behavioral avoidance or mistreatment) (Rüsch et al., 2005).

These social mechanisms contribute to disparities in care access and exacerbate psychological distress among those affected. While numerous anti-stigma interventions have emerged—including face-to-face workshops, video-based campaigns, and online psychoeducation—serious games are uniquely positioned to address stigma by immersing players in empathetic and reflective experiences (Amsalem & Martin, 2022; Conceição et al., 2022).

Narrative-centered serious games can disrupt stigma by facilitating identification with characters who embody marginalized or misunderstood identities. Game-based interventions leverage identification (alignment with characters), transportation (cognitive and emotional immersion), and perceived realism to challenge cognitive biases and cultivate perspective-taking (Hinyard & Kreuter, 2007; Green & Jenkins, 2014). Well-constructed games evoke emotional dissonance and critical reflection, which may prompt attitude shifts toward mental illness.

Nevertheless, design challenges persist. If character portrayals lack psychological depth or rely on horror tropes—as seen in some Western titles that exploit mental illness for dramatic effect—then games risk reinforcing negative stereotypes (Buday et al., 2022). This risk is particularly salient in the Chinese market, where few games explicitly address mental health and many popular titles remain rooted in biomedical or supernatural framings.

Research examining the role of serious games in combating depression stigma within Chinese settings remains limited. However, growing digital literacy and gaming engagement among young adults suggest untapped potential. The Room of Depression offers a rare example: by focusing on an Asian female protagonist and her lived experiences with depression, the game invites culturally relevant engagement with mental illness. Through metaphorical scenes—such as oppressive architecture, visual decay, and muted dialogue—the game creates a symbolic landscape of emotional turmoil.

These design elements resonate with traditional Chinese expressions of distress while avoiding reductive or sensationalist representations. Moreover, the player's interaction with Moon’s internal monologue and fragmented memories fosters a narrative of vulnerability, not pathology—humanizing depression and fostering introspective empathy.

In summary, serious games, when thoughtfully designed and culturally adapted, represent a promising strategy for reducing stigma and promoting nuanced understandings of mental health. This study explores how such games can be used not only to convey biomedical information but to reshape emotional and social responses to mental illness.

Practice / Applications

One illustrative example of serious games being applied to mental health education is The Room of Depression, developed by the Hong Kong-based indie studio FirePillar2. Unlike conventional educational tools, this game invites players into the subdued, fragmented world of a young woman named Moon, whose daily life is shaped by her struggle with depression. Unlike traditional health education tools, The Room of Depression doesn’t rely on definitions or symptom lists. Instead, it creates a mood—quiet, heavy, often unsettling—through dim visuals, fragmented speech, and a slow pace. Players move through Moon’s day-to-day life, making small choices: whether to get out of bed, respond to someone, cook something. These tasks are deliberately ordinary, yet the game makes them feel burdensome. That’s the point—it’s trying to show what depression feels like, not what it clinically is.

This effective approach positions the game as more than just an educational product; it becomes a space for empathy and reflection. It doesn’t tell players what to think. Instead, it gives them a role in Moon’s experience, which can prompt a more personal response—especially among players who haven’t encountered mental illness up close. In some ways, this matches public health goals that go beyond information delivery: it’s about changing how people relate to these issues emotionally.

The game has circulated online, mainly via Steam, and has received positive responses for its emotional depth. Many players describe it as haunting or quietly powerful. But despite that praise, its presence in formal settings is minimal. In mainland China, for example, the game isn’t included in school curricula or broader mental health campaigns.

Several structural and logistical challenges limit its broader adoption. Access remains constrained by platform exclusivity, language limitations, and a lack of promotional infrastructure. Moreover, the game’s reliance on symbolic and non-linear storytelling may lead to interpretive ambiguity. Without guided reflection or contextual materials, players may struggle to derive accurate or constructive meanings from the experience. In some cases, the absence of scaffolding could result in misinterpretations that reinforce, rather than alleviate, harmful stereotypes or misinformation.

These challenges point to a wider tension in the deployment of serious games in educational and health-related contexts—namely, the difficulty of translating aesthetic or emotional experiences into measurable learning outcomes. While The Room of Depression offers a compelling entry point into discussions of mental health, its long-term impact on knowledge retention, stigma reduction, and behavioral change remains an open question, particularly in the absence of structured post-play engagement or empirical evaluation.

Potential Solutions or Improvements

Given the challenges outlined above, there are several practical directions worth exploring to increase the reach and educational value of The Room of Depression and similar titles. These suggestions are not exhaustive, but they reflect promising starting points drawn from both educational practice and media design.

A particularly feasible option is to integrate the game into formal curricula. Collaborations with secondary schools, universities, or vocational programs could enable the game to appear in courses related to health education, psychology, or digital storytelling. In such settings, the game would not stand alone. It could be paired with writing tasks, class discussions, or even group projects, allowing students to reflect on their experience and connect it with broader concepts. Framing the game within academic discourse might help move its impact beyond emotional response toward critical engagement and literacy-building.

Another possibility is to develop structured reflection tools that can accompany gameplay. These might take the form of facilitator guides, short worksheets, or digital discussion prompts. Used in classroom or therapeutic contexts, these materials would help players articulate their thoughts, recognize emotional patterns, and make connections to real-life concerns around mental health. Without some kind of follow-up mechanism, the emotional intensity of the game risks fading or being misunderstood.

Localization—especially in cultural and linguistic terms—remains an underdeveloped aspect of The Room of Depression. Although the game already strikes a chord with East Asian players, largely due to its minimalist aesthetic and subdued narrative tone, there is still considerable room for deeper regional adaptation. Introducing elements like local dialects, references to Traditional Chinese Medicine, or contextual links to nearby mental health services could help the game resonate more strongly with players in rural or underserved communities. In places where institutional support is scarce or stigmatized, these kinds of familiar cultural references might make the game feel less foreign, and more grounded in the everyday realities of its audience.

To expand the game’s reach beyond the gaming community, cross-media adaptations could be explored. Transforming the game’s narrative into short films, graphic novels, or podcasts would allow its core emotional themes to be experienced by broader audiences, including those less inclined to play digital games. These media forms could serve as alternative entry points into public conversations about depression and mental health.

Lastly, any serious effort to scale the impact of this kind of work needs to be grounded in feedback and iteration. Developers and researchers could work together to gather insights from players—not just through anonymous surveys, but through follow-up interviews, classroom observations, or embedded gameplay data. Understanding how different users interpret and emotionally respond to the game would help clarify what works and what doesn’t. This kind of collaborative reflection could shape not only future updates to The Room of Depression, but also inform the design of other games aimed at different mental health topics or demographic groups.

Taken together, these efforts could help position the game as more than a standalone experience. With the right partnerships and creative experimentation, it could become part of a wider, more durable infrastructure for mental health education—one that blends affect, accessibility, and cultural sensitivity.

Connecting Practice to Theory

The Room of Depression presents a particularly rich example of how serious games can embody key principles from educational theory. Most notably, its design reflects a constructivist approach to learning. Rather than conveying information through instruction, the game places players in emotionally charged scenarios that require interpretation and decision-making. Each seemingly simple choice—whether to get out of bed or reply to a message—carries emotional weight, subtly encouraging players to reflect on the psychological demands behind such tasks. These interactions simulate real-life learning processes, where understanding emerges through doing and reflecting, not just receiving facts.

Kolb’s experiential learning model is especially relevant here. The game provides a concrete experience: players navigate Moon’s day-to-day life, encountering the invisible burdens she carries. As they progress, they are prompted to observe and reflect—guided not by explicit instruction but by mood, pacing, and internal monologue. This reflection can give rise to abstract conceptualizations about depression and mental health, which may then inform players’ choices in future playthroughs—or even shift their perceptions in the real world.

The game also exemplifies narrative transportation theory. Many player reviews describe feeling emotionally immersed and “haunted” by the game’s atmosphere. This cognitive and emotional absorption enhances the likelihood that players internalize the game’s core messages, such as the importance of empathy, the hidden nature of mental suffering, and the stigma faced by those with depression.

In terms of mental health literacy, players often come away with a more nuanced understanding of depression’s symptoms and effects, even though the game avoids explicit terminology. It acts as an affective primer—provoking emotional insight that can motivate further learning or discussion.

However, the game’s impact is not universal. As some scholars note (Smith & Applegate, 2018), empathy-based media may not resonate with all audiences equally. Gender, socioeconomic status, and prior exposure to mental health issues can all influence how players relate to Moon’s story. Moreover, while awareness may increase, sustained behavioral change (e.g., seeking help, supporting others) is harder to measure and may require complementary interventions.

Critics of serious games argue that without built-in assessments or learning scaffolds, games like The Room of Depression risk being emotionally evocative but pedagogically ambiguous. To address these concerns, designers must embrace scaffolding frameworks (Anderson et al., 2022) and collaborate with educators and psychologists to ensure the experience supports not just emotional connection but durable learning.

In conclusion, The Room of Depression offers a powerful example of how narrative, design, and cultural sensitivity can converge to support mental health literacy. It demonstrates the promise of theory-informed serious game design while also revealing the practical gaps and unrealized potentials that future work must address.

 

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