"Streets become too dark for people to walk, limiting social interactions outside of daytime work hours. No one can watch TV or consume the limited amount of media allowed by the government." - Barbara Demick in her book Nothing to Envy: Ordinary Lives in North Korea

In North Korea:

  • The approach to mental health has been highly influenced by Stalin and the rise of 20th century Communism
  • Mental disorders are a result of biological factors, genetics, or injury to make them more socially and politically acceptable
  • Political dissent, "delusions of reform", and philosophical differences are symptomatic of schizophrenia
  • Individuals requiring treatment are often shipped off to group centers in very remote locations
  • After 60 years of separation, dialects are different and contribute to discrimination, PTSD, social exclusion, and difficulty in assimilation for North Korean refugees in South Korea

Soviet/Socialist/Communist Influence

The current closed sociocultural system in North Korea prevents Western investigators from obtaining a great deal of first-hand knowledge regarding contemporary mental health status and practice in that country today. Information relevant to the characteristics of psychology and psychiatry in North Korea has been gathered from fleeing refugees, from mental health researchers and practitioners who interviewed defectors who transitioned to South Korea, and by observing the effects of Communist political influences (e.g., the former Soviet Union) on psychiatric thought and methods in other former socialist countries1.

Following the Russian revolution and the rise of Communism in the early 20th century, the approach to psychological thought in the newly formed Union of Soviet Socialist Republics (USSR) can be best described as a suppression of Freudian theory and the championing of biological approaches to mental health1. For example, the Central Committee of the Communist party, led by Joseph Stalin, did not allow for the presence of unconscious, irrational, and/or uncontrollable aspects of the human psyche2. Rather, the biologically- and physiologically-based theories of Pavlov and Kraeplin were "declared" as the principle foundations of Soviet psychiatric thinking3. Mental disorders - including anxiety disorders - were characterized as the result of central nervous system abnormalities or injuries4. In addition, the potential damaging influence of social factors such as poverty, level of education, and sociopolitical pressure were largely ignored during the Stalin era1. The cascade effect of this early Soviet approach to psychiatry infiltrated other countries with heavy political ties to the USSR including East Germany5, Lithuania6, Armenia7, Czechoslovakia8, and, of course, North Korea1.

In a recent review article, Park and colleagues (2014) reported many striking similarities between psychiatric practice during the Communist Stalin era and contemporary psychiatric methodologies employed in North Korea today. For example, the previously described Pavlovian approach, in which mental illness emerges as a result of impaired nervous system function, is accepted in North Korean medical education circles. Further, an emphasis is placed on the genetic predispositions that may lead to psychopathology with a concurrent dismissal of possible unconscious or social processes that may underlie altered behavior.

A fascinating revelation from the study of mental health in former and existing socialist/Communist countries, including North Korea, is the "tailoring" of psychiatric diagnosis and treatment within the political schema such that the resulting spectrum of psychiatric diagnosis is interwoven with political ideas and terminology. For example, Soviet and Chinese mental health providers working under Communist regimes would often include political dissent, "delusions of reform," and differences in philosophical beliefs as part of the underlying pathology of schizophrenia2,9,10. In addition, the expression of depressive symptoms was viewed as an attempt to avoid collective labor in China during their Cultural Revolution such that affected individuals would hide their symptoms to avoid political persecution11. Furthermore, many Chinese patients would "somatize," or place a biological emphasis on their depressive symptoms in order to deem them more socially acceptable and to reduce potential social stigma and political backlash12. Following the fall of many socialist regimes, rates of depression increased dramatically as a result of social factors such as unemployment and financial inequality as well as an internal concerns such as the inability to make autonomous decisions1. These psychological problems and maladjustment will be revisited below and also emerge in the face of defection in North Korean refugees.

As expected, the approach to psychiatric disease and treatment in North Korea is believed to mirror much of what was observed in the former USSR and China13. In general, biological explanations for mental problems are emphasized, schizophrenia and severe psychosis are given higher priority, and neurotic diagnoses and substance use disorders are largely ignored. When mood and anxiety disorders are treated clinically, it is usually from a biological perspective and often under the direction of general practitioners or neurologists rather than psychiatrists or psychologists13. Psychiatric treatment of severe mental disorders in North Korea proceeds in a manner very similar to what was seen in the mid-twentieth century in the United States. Treatment occurs in large, in-patient facilities (termed the 49th ward) that are situated in isolated regions of the country1,13. Older generation antipsychotic drugs (e.g., chlorpromazine), reliable sedatives (e.g., diazepam), and barbiturates are used to treat psychotic symptoms as opposed to the more novel and increasingly specialized psychopharmacological tools available in Western cultures. Finally, while it is believed that many mental health providers in North Korea are aware of the importance of emotional processing to therapy, talk-based psychotherapy is not used in North Korea as of this writing.

Clinical Presentations Observed in North Korean Refugees

A primary source of clinical data regarding the mental health of the North Korean population has been the reports collected from refugees who defected to South Korea from North Korea. According to Jeon and colleagues (2005), the number of defectors from North Korea increased exponentially between 1998 and 2003. This was in large part due to a perceived "softening" of the Communist rule following the death of Kim Il Sung in 199414. It is important to note that the estimated number of defectors may be underestimated as formal reports do not include those who left North Korea and entered China or surrounding Asian countries en route to South Korea14-16. The refugee population who attempted to enter South Korea via China is of particular interest to better understanding the mental health of North Koreans due to the harsh treatment they received when they were captured and sent back to North Korea; the consequences of which included severe punishment or execution17. In addition, North Korean refugees that remain in China un-captured are not recognized as political refugees, have limited access to food and water, and live in fear of being detected by Chinese and North Korean authorities14,18. Lastly, defection is typically characterized by sudden and forced departure, ill preparation for entry into a new society, and recovery from traumatic experiences including persecution, chronic stress, and interpersonal violence16.

Posttraumatic Stress Disorder (PTSD)

The mental health of North Korean refugees entering South Korea has been identified as a major factor influencing how well these individuals integrate into South Korean society19. Several reports from other refugee populations including Bosnians in Croatia20, Bhutanese refugees in Nepal21, and Kosovar Albanians22 have indicated that, as expected, the degree of traumatization prior to emigration has been shown to be a significant determining factor in refugees' mental health status23. For this reason, posttraumatic stress disorder is commonly observed in refugee populations following emigration16,24. Not surprisingly, North Korean defectors seeking refuge in China18 and South Korea14 report significant trauma exposure and PTSD symptoms as a result of both physical abuse (e.g., rape, assault) and mental anguish (e.g., forced marriage, loss or punishment of family members16). The role of family mental health is especially important in North Korean society as the government will typically discipline several family members as a result of dissent and, as such, family bonds tend to be stronger and feelings of anxiety and worry tend to extend beyond the individual14.

Kim and Lee (2009) investigated the sociocultural factors that have been shown to affect post-traumatic recovery in North Korean refugees that relocate to South Korea. The authors gathered information first hand from travel diaries, interviews, and emails from adult refugees and identified the following six central essences:

    1. the struggle for survival followed by assimilation into a new society
    2. unexpected stress including feelings of shock and chaos
    3. reconsidering the reasons for relocating
    4. trauma recovery
    5. rebuilding of [one's] meaning
    6. posttraumatic growth (e.g., employment of coping strategies; 16).

The transition into South Korean culture can be facilitated by training programs that assist with dialectical language differences, the reduction of cultural discrimination, an introduction to religious and spiritual education, and the development of an increased understanding of South Korean politics and ideology. In addition, individual efforts to assist other family members across the border have also been linked to better psychological outcomes in refugee populations25.

Mood and Anxiety Disorders

In addition to trauma- and stressor-related disorders26, North Korean defectors have also been reported to experience major depression and anxiety disorders. Previous studies have shown that North Korean refugees exhibit clinically significant depressive symptoms and that these symptoms are linked to feelings of loneliness, social exclusion, guilt related to loved ones left behind, and acclimation into a competitive, capitalistic society27-30. Further, Um and colleagues (2015) reported that increased depressive symptoms in North Korean refugees was associated with poorer assimilation into a new culture as well as an increased perception of discrimination upon relocation19.

The Problems of Korean Societal Integration

Despite sharing a common ancestry and racial identity, North Korean and South Korean citizens differ substantially at the sociocultural level and these differences have spurred a sense of contempt and discriminatory behaviors upon the arrival of defectors from the North into the South19,31-33. This type of discrimination extends into the workplace and despite efforts by the South Korean government to ease the transition of North Korean refugees into their society30,33,34. A marked contributing factor to discrimination and social exclusion is the linguistic difference between North Korean and South Korean dialects as a result of the six decades that have passed since the regions became separated30,33. The linguistic difficulties coupled with the often troublesome adaptation from a socialist economy to a capitalist market allow North Korean refugees to be identified with relative ease and as potential targets for prejudicial behavior (Jeon, 2000 #25797; Lankov, 2006 #25799).

By all available reports, North Korean society remains relatively stagnant in comparison to the rest of the free world. This is dramatically evident in satellite images of the Korean peninsula taken at night. The surrounding areas of China, South Korea, and Japan are teeming with lights and activity while North Korea lies quietly in darkness. This is very likely to affect the general medical and mental health of North Koreans especially given its leadership and history of communist/socialist influence, resistance to change and isolation.

Date of original publication:
Updated on: July 29, 2016

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