Games that require social participation help to reduce symptoms of depression


When it comes to boosting mental health among older Chinese, it might be as simple as a game of mahjong, according to a new study from the University of Georgia.

Regularly playing the popular tile-based strategy game was one of several types of social participation linked to reduced rates of depression among middle-aged and older adults in China in the study appearing in Social Science & Medicine.

“Global economic and epidemiologic trends have led to significant increases in the burden of mental health among older adults, especially in the low- and middle-income countries,” said Adam Chen, an associate professor of health policy and management at UGA’s College of Public Health and study co-author.

Poor mental health is a major issue in China, which accounts for 17% of the global disease burden of mental disorders. On top of that, mental health issues related to social isolation and loneliness are on the rise as China’s number of older adults – as in other nations – continues to increase.

The benefits of participating in social activities to mental health have been widely acknowledged, and some work has been done in developed nations, including the U.S. and Japan, to better understand this relationship.

But little is known about the role of social interaction and mental health outside of these settings.

“Social participation manifests itself in different formats within different cultural contexts,” said Chen.

“Our paper provides evidence on the association between social participation and mental health in the context of a developing country.

We also examined the rural-urban difference, which has not been examined extensively in this line of literature.”

Chen and collaborators from China’s Huazhong University of Science and Technology analyzed survey data from nearly 11,000 residents aged 45 years and older from the nationally representative China Health and Retirement Longitudinal Study.

They looked at symptoms of depression and compared it to the type and frequency of social participation, including visiting with friends, playing mahjong, participating in a sport or social club, and volunteering in the community.

They found that, on the whole, participating in a wide variety of activities more frequently was associated with better mental health.

Specifically, urban residents who played mahjong, a popular strategy game, were less likely to feel depressed.

That wasn’t too surprising for Chen, as this finding was in line with other studies, but he was surprised to find that rural Chinese overall tended to report poor mental health compared to their urban counterparts.

“Traditionally, rural China featured tight-knit communities of close kinship, often with a limited number of extended large families in a village,” he said.

“We were expecting strong ties and communal bonds in rural China, but it appears that we were wrong.”

Chen suspects that the social structures in rural China were disrupted as many able-bodied adults moved into cities to find work. While family ties remained strong, community ties weakened in rural areas.

The benefits of participating in social activities to mental health have been widely acknowledged, and some work has been done in developed nations, including the U.S. and Japan, to better understand this relationship.

“What is more surprising is that mahjong playing does not associate with better mental health among rural elderly respondents,” added Chen.

“One hypothesis is that mahjong playing tends to be more competitive and at times become a means of gambling in rural China.”

The authors believe these findings may offer a guide to health practitioners designing policies and interventions to improve mental health among older Chinese.

The findings could also translate, said Chen, to Asian American communities.

“Older Asian Americans have a much higher proportion of suicidal thoughts than whites and African Americans,” he said.

“Improving social participation among older Asian Americans may help to address this burden to the U.S. population health that has not received due attention.”

Depression is one of the most common chronic mental health conditions among older adults in Chinese communities [1,2].

Symptoms of depression experienced in later life have serious implications for the health and functioning of older persons as emotional distress is consistently associated with higher levels of cognitive [3,4] and functional impairment [5,6], and the increased risk of physical illnesses such as heart disease and stroke.

Depressive symptoms also place older adults at the increased risk for suicide [710], which can devastate families and communities.

Growing evidence suggests that involvement in social activities improves the mental health of older adults. Research has demonstrated that socially active older adults have better health outcomes than their inactive counterparts, such as lower mortality rates [11,12], better physical functioning [13], and higher cognitive functioning [14,15]. Work in this area suggests that participation in social activities provides older adults with social support from informal social networks (i.e., relationships with other social group members and peers), which in turn benefits their emotional functioning [16,17].

Prior studies examining the relationship between social participation and mental health also suggest that various forms of social participation have psychological advantages for older adults. For example, religious participation [18] and volunteer work [19] increased individual social resources (measured by meeting attendance and informal social interaction), which, in turn, lowered depressive symptom levels. Research by Li and Ferraro [20], Musick and Wilson (2003) [19], and Thoits and Hewitt (2001) [21] used longitudinal data from the Americans’ Changing Lives study to explore the relationship between volunteering and depressive symptoms among older adults. These analyses each suggested that older adults psychologically benefited from sustained volunteering. Sugihara et al (2008) [22] examined the role of social participation in mitigating psychological distress in a nationally representative sample of Japanese adults aged 55 to 64. They found that volunteer work was significantly associated with fewer depressive symptoms for both males and females.

Although these studies involved analysis of longitudinal data and identified a relationship between a particular type of social participation and mental health, one of the outstanding questions raised by prior investigations was how change and duration of social participation affected the development of psychological distress in later life. That is, variations in exposure to a protective resource–such as the continuity, initiation, or cessation of social participation–may differentially increase or decrease the likelihood of experiencing psychological distress among older adults [23].

This study seeks to increase our understanding of the complex association between social participation and depressive symptoms by analyzing this relationship from a lifecourse perspective. Our analysis uses a nationally representative sample of older adults from Taiwan, as Asian nations are less frequently the focus of empirical investigations of protective effects in mental health outcomes.


Data are from a nationally representative sample of 1,388 adults aged 60-64 first surveyed in 1989 and followed over an 18-year time period for a total of six waves. Individual involvement in social activities was categorized into continuous participation, ceased participation before age 70, initiating participation in older adulthood, never participated, and dropped out before age 70. Two domains of depressive symptoms–negative affect and lack of positive affect–were measured using a 10-item version of the Center for Epidemiologic Studies-Depression Scale.


Analyses using growth curve modeling showed that continuously participating or initiating participation in social activities later life is significantly associated with fewer depressive symptoms among older Taiwanese adults, even after controlling for the confounding effects of aging, individual demographic differences, and health status.


These findings suggest that maintaining or initiating social participation in later life benefits the mental health of older adults. Facilitating social activities among older adults is a promising direction for programs intended to promote mental health and successful aging among older adults in Taiwan.

University of Georgia
Media Contacts:
Lauren Baggett – University of Georgia
Image Source:
The image is in the public domain.

Original Research: Closed access
“Melancholy or mahjong? Diversity, frequency, type, and rural-urban divide of social participation and depression in middle- and old-aged Chinese: A fixed-effects analysis”. Adam Chen et al.
Social Science & Medicine doi:10.1016/j.socscimed.2019.112518.


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