Depression and Suicide Ideation in Japanese Populations

5 Feb

Abstract

The World Health Organization (WHO) ranks depression as one of the most prevalent mental disorders and has identified depression as a leading risk factor for suicidal behaviors (WHO, 2009). Every year, an average of 340 people per 100,000 are diagnosed with depression (Takeuchi, Nakao, and Yano, 2008) and 30 people per 100,000 decide to commit suicide in Japan alone (Yamashita et al., 2005). Japan’s high suicide rate makes it the second highest out of the top 8 wealthiest countries (Great-Of-8 or G8 countries), with Russia being the highest (Beautrais, 2006). In the past decade, many researchers have examine depression and suicide and have found that depression prevalence may be greater than once expected. A cultural bias against mental disorders and expressing negative emotions may inhibit both the recognition of depression and depressed individuals’ help seeking behavior. The purpose of this literature review is to examine the depressive risk factors for suicidal ideation and the stigma associated with depression in the Japanese population.

Defining Depression

One essential aspect in classifying mood disorders and defining Major Depressive Disorder (MDD) is defining the duration and occurrence of Major Depressive Episodes (MDE). The DSM-IV defines a MDE as consisting of at least five symptoms that must be present during a continuous two-week cycle and one symptom must either be a depressed mood or anhedonia (a loss of pleasure or interest). The diagnostic criteria are:

1. Significant weight or appetite loss or gain (that is not due to dieting)
2. Insomnia or hypersomnia
3. Psychomotor agitation or retardation
4. Fatigue
5. Feelings of excessive worthlessness or guilt
6. Difficultly concentrating or deciding
7. Recurrent suicidal ideation

In order for these symptoms to be considered aspects of a MDE, they must be attributable to the MDE and not some external causes (e.g. substance use, bereavement, general medical condition). MDD is separated into two categories: single episode or recurrent MDD. Single episode MDD is classified as the presence of a single MDE, while recurrent MDD is defined by the presence of two or more MDE. In order to warrant a MDD diagnosis, there must have never been a manic, mixed, or hypomanic episode (American Psychiatric Association, 2000, Diagnostic and statistical manual of mental disorders text revision).

Prevalence of Depression and Suicide In Japan

Suicide is one of the top 20 leading causes of death worldwide, claiming about 850,000 lives globally every year (WHO, 2009). Suicide occurring in Asian countries account for 60% of all worldwide suicides, and 40% of all worldwide suicides occur in China, Japan, and India (Beautrais, 2006). While this statistic may seem misleading because a greater percentage of the world’s population are from these countries, it should also be noted that Japan has the second highest suicide rate out of the Group-Of-8 (G8) countries with about 25 suicides per 100,000 people (Beautrais, 2006). The G8 countries are the top 8 wealthiest countries and include: Canada, France, Germany, Italy, Japan, Russia, United Kingdom, and the United States. The suicide rate peaked in 1998 with 30,000 suicides per year, a 35% increase from 1997 due to economic problems. Since 1998 however, the suicide rate has remained relatively stable (Yamashita et al., 2005). For each suicide committed, an average of 5 to 6 people are affected, resulting in about 60 million people affected each year (Beautrais, 2006).
According to the WHO, mental illnesses, such as depression and substance use disorders, are among the leading risk factors for suicidal behaviors (WHO, 2009). Depression is also one of the leading causes of disability, affecting more than 121 million people worldwide, and the worst cases may lead to suicidal behavior (WHO, 2009). From 1984 to 1998, depression diagnoses in Japan increased from 83 to 340 per 100,000 (Takeuchi, Nakao, and Yano, 2008). This surge of depression cases was likely one of the contributing factors to rising suicide rates in Japan.
A study by Laser, Luster, and Oshio (2007) studied the prevalence of depressive symptoms in 802 Japanese adolescents in the Sapporo area of northern Japan. They found that the prevalence of depression in adolescents is surprisingly high. The authors reported that 17% felt depressed most of the time, 69% felt depressed sometimes, and a surprising 10% had frequent suicidal thoughts. While this finding may not be representative of adolescents nation-wide because meteorological factors may put adolescents from northern Japan at more risk, it suggests an at-risk age group that warrants further research.

Factors Affecting Suicidal Behaviors

Personal Factors
Who is more at risk for suicidal behaviors? According to a report by Yamashita et al. (2005), 70% of suicides are committed by men. The highest suicide rates for males occur from ages 55 to 59 and from 85 to 89, while the highest suicide rates for females occur from ages 85 to 89. This suggests that one of the highest risk groups of people are the elderly, with 4 to 5 times the suicide rates as individuals from Western countries (Oyama et al., 2006). People that successfully commit suicide tend to have histories of mental illness–generally depression, schizophrenia, and alcohol abuse–previous suicide attempts, and personality disorders. In a study of suicide note content reported by Yamashita et al. (2005), the most occurring problems were related to physical health, mental health, and family problems.

Environmental Factors
Suicide rates tend to be higher in more rural areas of Japan (Oyama et al. 2006). In 2002, the three prefectures with the highest suicide rates were: Akita with 42 suicides per 100,000, Aomori with 37, and Iwate with 36 (Yamashita et al. 2005). These three rural prefectures’ high suicide rates may be attributable to social and economic problems relating to more traditional industries or meteorological conditions. The location of these prefectures might also influence the prevalence of Seasonal Affective Disorder (SAD) with lower temperature, sunshine, and higher snowfall (Yamashita et al. 2005). This relates to Laser, Luster, and Oshio’s (2007) previously mentioned study and may indicate an important third variable affecting these adolescents’ high depression prevalence.

Societal and Cultural Factors
Yang & Lester (2004) performed an analysis on the natural suicide rates of various nations of the world. This study emerged from findings of their previous research which found a consistent positive suicide rate they labeled the “natural suicide rate”, even when predictor societal variables are ideal and have all been set to zero–a best case scenario. They found how much variance these predictor societal variables contributed to the suicide rates for the United States. In this study, they identified divorce and unemployment rates at two significant predictor social factors leading to suicide. They sets these rates to zero for 10 different countries and compared results to the 1980 suicide rate for each country. Japan’s 1980 suicide rate was 17.5/100,000, but when divorce and unemployment rates were set to zero, the natural suicide rate was only reduced to 17.0/100,000. Results were generally better for other nations of the world, but this study raises the question of how and which societal factors influence suicide rates of Japan and other nations of the world.
There are many stressors in Japan that are similar to Western countries, but the cultural and social context may lead to the greater suicide rate. This cultural and social context is critical when performing cross-cultural studies because there are many shared stressors between industrialized countries. Countries with religious sanctions against suicide and alcohol consumption tend to have lower suicide rates (Kelleher et al., 1998; Beautrais, 2006), but Japan possess neither and this may contribute to the high suicide rate. Mass media and publicized stories of suicides have also been shown to contribute a sense of familiarity and acceptance of suicidal behavior, condoning it as an acceptable response to life stress (Fekete et al. 2001). Japanese media also tends to present suicides less in terms of mental illness and more in terms of strong group affiliation, promoting a glorifying view of suicide (Fekete et al., 2001).

Prevention

One major world-wide method for suicide prevention is the use of prevention centers. Before 1970, Japan had no prevention centers, but by 1987, Japan had 31 and have been steadily growing since. Lester, Saito, and Abe (1997) analyzed the effects prevention centers had on suicide rates in terms of the number of centers per prefecture and the number of years it has been open. They found support for prevention effects with moderate negative correlations. The longer a center has been open and the number of centers have have been associated with lower increases in suicide rates. These two factors are important because the length of time a center has been open likely affects how reputable each center is and the number of centers likely affects how accessible care is to a number of people.
Oyama et al. (2006) evaluated a community-based program’s effect on preventing elderly suicide in rural Japan. This program focuses on health education, depression screening, and managing depression with community primary care and nursing resources. This population was chosen because both elderly people and those living in rural areas of Japan have been found to have higher rates of suicide and depression. The study was conducted over two 10 year periods (baseline and prevention implementation) in the towns of Matsudai, the intervention cohort, and Kawanishi, the reference cohort. This reference cohort was used to compare the treatment effects against the natural changes that may be occurring in a similar population. This study found gender differences in the programs effectiveness. The intervention was only effective in reducing suicide among the elderly female population. The researchers site other research supporting that programs focusing on improving depressive thought and suicidal ideation, as the present one proposed, only benefits females. Programs that focus on ameliorating suicide plans and impulsivity were shown to benefit both males and females. This suggests that males are typically more vulnerable to impulsivity related suicide, which must be accounted for in future prevention measures.
Japan uses a national three-tiered suicide prevention strategy consisting of primary, secondary, and teritiary methods that target varying levels of risk in order to increase effectiveness. Primary prevention is concerned with screening for high risk suicide people and increasing mental health and illness knowledge. Secondary prevention uses crisis intervention by medical and health professional, which includes managing depression and restricting access to suicide means. Tertiary prevention is mainly concerned with postvention psychological treatment and support for trauma survivors (Yamashita et al. 2005).
One suicide prevention method was developing a manual to support mental health and suicide prevention in the workplace for friends and family. This manual lists ten common suicidal signs that friends, family, co-workers must be aware of to help reduce suicidal behaviors. Because one of the association between mental health and suicide, several other manuals were developed to include information on how to work with people who are suffering from depression and were designed for health care providers and workers (Yamashita et al., 2005).

Depression Stigma

Jorm et al. (2005) conducted 3 related studies utilizing questionnaires to assess 2000 Japanese and 3998 Australian adults’ reactions to and beliefs about four mental disorder case vignettes, including: depression, depression with suicide ideation, early schizophrenia, and chronic schizophrenia. Items on the questionnaire assessed a wide range of knowledge about the underlying problem with each person. This study examined differing beliefs about treatment and outcome of the 4 different mental health vignettes. In Japan, they found that people are more reluctant to use psychiatric labels to describe mental disorders, unless they are the more extreme forms. The Japanese are also less likely to discuss mental health issues outside of the family and close friend and are more likely to endorse the helpfulness of private information sources, such as books and the internet. Despite the stigma associated with seeking outside help, there is a general belief that professional help is beneficial, especially psychotropic medication, but most likely believe that partial recovery is possible (Jorm et al., 2005).
Extending this study, Nakane et al. (2005) compared Japan and Australia’s public beliefs about the risk factors and causes of mental illness. This study used the same research sample and methods as the previous, but asked questions about beliefs of the causes and risk factors pertaining to the 4 vignettes. These researchers found that Japan and Australia share a common belief that personal vulnerability factors contribute to each disorder, but different kinds. In Australia, there is an emphasis on genetic predisposition as a risk factor for developing mental illness. The predominant view in Japan is that trait neuroticism is a major risk factor for depression, but this is seen as a sign of weakness of character and is therefore highly stigmatized. This stigma attached to depression decreases the chances that someone will openly discuss their depression and seek medical treatment (Nakane et al., 2005).
Griffiths et al (2006) conducted a third analysis comparing public attitudes on mental illness and social distance, while testing the prevalence of mental illness stigma in both countries. This study examined two types of stigma: perceived stigma, other people’s beliefs about mental illness, and personal stigma, one’s own attitudes about mental illness. This study also assessed perceived discrimination, the person’s belief that the person with a mental illness would be discriminated against by others in the community. Lastly, this study assessed attitudinal social distance, a person’s willingness to interact with a person with mental illness among situations with varying amounts of social distance. This study found that Japan was higher in personal stigma and social distance, while Australians were higher in perceived stigma and discrimination, although perceived stigma was generally higher than personal stigma in both countries. This also suggests that there are more negative attitudes in Japan, while there is a great perceived negative attitudes of the greater community in Australia.There are also little differences in attitudes between depression with and without suicidal thoughts (Griffiths et al., 2006).
The stigma attached to mental health may also be related to a stigma against expressing negative emotions and adds a difficulty in recognizing depression cases. Stewart et al. (2004) studied the relationship between cognition and depressive symptoms in 1,771 Hong Kong and 501 American adolescents. While the population being studied is not Japanese specifically, the two groups represent the larger populations of individualistic and collectivistic cultures. This study used surveys to assess depressive symptoms, cognitions, and stressful events over a 6 month period. Cognitions were further separated to included: self-efficacy, a belief in one’s capability to overcome a challenge and achieve; negative cognitive errors, a negative thought tendency to blame the self for negative events and external causes for positive events; and hopelessness, a tendency to view negative events as stable, and out of one’s control. Depressive symptoms and hopelessness were found to be higher in Hong Kong adolescents, while self-efficacy and negative cognitive errors were generally lower. This supports models of cognitions affecting depressive symptoms and the reverse, where depressive symptoms may cause “depressogenic” cognitions. This study also identifies an interesting cognition trend because there are weaker, but similar correlations between cognitions and mood in the Hong Kong group (Stewart et al., 2004). This supports the view that while a correlation exists, collectivistic cultures tend to focus less on their internal state and cognitions, which would affect Japan’s bias against expressing negative emotions because focusing on one’s negative emotions is asserting themselves over the importance of the group. This also suggests that
A study by Takeuchi, Nakao, and Yano (2008) examined the symptomatology of depressed workers over the course of 20 years. This study recruited 167 Japanese office workers to participate and assessed depressive symptoms through Zung’s Self-rating Depression Scale (SDS), which assesses 6 somatic and 14 psychological symptoms. It was found that sleep disturbances, fatigue, and total somantic-symptoms are related to future and long-term depression. This finding is significant because it suggests a method to measure depression even against a culture bias against expressing negative emotion as well as a means to predict future at-risk depressed individuals. It was alsoreported that people generally seek out internal medicine clinics rather than psychiatric clinics when they are experiencing depression related symptoms (Takeuchi, Nakao, & Yano, 2008).

Discussion

As stated earlier, the most extreme cases of depression can lead to suicidal behavior and in Japan, there are low rates of treatment (Beautrais, 2006). These low rates of treatment are due in part because of the stigma associated with expressing negative emotions and mental illnesses, which has been supported across many studies. This stigma prevents people from seeking treatment for depression and other psychological disorders (Jorm et al.,2005), thought to originate from personal weakness (Nakane et al., 2005), and creates negative attitudes (Griffiths et al., 2006). This stigma also influences the recognizable and diagnosable symptomatology by reducing the importance of cognitive elements (Stewart et al., 2004) and emphasizing the importance of somatic-symptoms (Takeuchi, Nakao, & Yano, 2008). If these at-risk depressed individuals do not receive the proper treatment when they need it most, there is a chance they will turn to suicidal ideation.
This surge in depression cases between 1984 and 1998 mentioned earlier may be due to improving depression recognition (Stewart et al., 2004; Takeuchi, Nakao, & Yano, 2008).The person may be even be unaware they are depressed and may have somatic complaints, such as sleep difficulties or body pains. These people are also more likely to seek out internal medicine clinics instead of psychiatric clinics (Takeuchi, Nakao, & Yano, 2008). Several researchers use Zung’s self-rating depression scale (SDS) in their studies of depression in Asian contexts, but based on Takeuchi, Nakao, & Yano’s (2008) findings, perhaps the scale should be looked at for a Japanese context. This scales uses 6 somatic and 14 psychological symptoms to assess the person’s depression. If more people experience somatic-symptoms more often than psychological symptoms, then I wonder if the scale is able to offset the cultural bias and still accurately diagnose depression in some individuals. Yamashita et al. (2005) discussed a series of depression manuals that were developed to aid people’s understanding of the disorder, one of which was developed for health care providers. These should help health care providers correctly identify and treat depression that may be somatically manifested.
What can be done to reduce this stigma? Griffiths et al. (2006) discussed that differences in public mental health education between Japan and Western countries may account for differences in public attitudes toward depression. Over the past decade, Australia began using many stigma reducing, mental health education programs (i.e. “Beyondblue”) that seemingly changed the overall public opinion on mental disorders (Griffiths et al., 2006). Currently, the Japanese government has included mental health education as a primary goal for suicide prevention and hopefully it will not only raise people’s attention toward the suicide problem, but also help reduce mental disorder stigma (Yamashita et al., 2005).
A large part of Japanese culture that may be strongly influencing the personal and perceived stigma is the “tatamae” and “honne” culture. “Tatamae” refers to things people say in order to maintain positive relationships, but may not actually believe, while “honne” refers to what the person is truthfully thinking and believing (Griffiths et al., 2006). While people still hold negative attitudes towards mental disorders (especially more mild cases), they overrate the attitudes of the community as being more negative they they actually. This may be reflective in this culture by people holding a different attitude toward mental illness then they present because of cultural influence. Griffiths et al. (2006) suggested that programs targeted at educating the public about realistic personal attitudes would help encourage people to seek treatment by showing them that people overrate the negative attitudes of the community and help dispel the negative public attitudes.
Yang and Lester’s (2004) study showed the influence of societal factors on the expression of suicide behaviors, but found divorce and unemployment had little effect on Japan’s natural suicide rate. It could be that these two factors have little effect on Japan’s suicide rate because of the positive economic context of the 1980’s in Japan and the societal expectations concerning marriage and divorce. While these two factors have substantial effects on some countries, it opens up the potential for other societal factors to be affecting the rates of suicide in Japan, such as general financial and economic stress instead of simply unemployment.
What about middle-aged men make them more susceptible to depression and suicide? I suspect that because of Japanese culture, these men are the main source of income for families, so there is a lot of pressure and stress to ensure their families success. Around this age, there is most likely a lot of change happening in the family because of children reaching adulthood and education-related financial problems. As stated earlier, financial problems are found to be one of the highest risk factors associated with depression and suicide. With the recent world-wide economic crisis, it might be expected that financial related depression and suicide would rise. If this number is large enough, it may mean that a greater focus needs to be place on prevention methods in Japan.
Laser, Luster, and Oshio (2007) identified adolescents as an understudied age group that may be at high risk for depression and suicide. This age group is going through many changes related to adolescence as well as many academic pressures to perform well. This is an important age group to study because many people develop depression during this time and if it goes untreated, it will likely exacerbate later in life.

Conclusion

Depression is one of the most prevalent mental illnesses world-wide and is one of the leading risk factors for suicide (WHO, 2009). Japan shares many stressors with other industrialized countries, but they have a unique cultural stigma against expressing negative emotions and mental illnesses that contributes to the development of depression. This stigma is thought to originate from personal weakness, creates negative beliefs, and ultimately prevents people from seeking treatment. When people do not seek out treatment and do not allow themselves to express and communicate strong feelings of depression, they are likely to ruminate and exacerbate their affective state. It is in this condition that it is the most dangerous and will likely lead to suicide. This literary review identified several recent studies that examined risk factors for depression and suicide as well as the effects of mental health stigma on the expression of depression in a Japan context.

References:

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.

Beautrais, A. L. (2006). Suicide in Asia. Crisis, 27(2), 55-57.

Fekete, S., Schmidtke, A., Takahashi, Y., Etzersdorfer, E., Upanne, M., and Osvath, P. (2001). Mass media, cultural attitudes, and suicide. Crisis, 22(4), 170-172.

Griffiths, K. M., Nakane, Y., Christensen, H., Yoshioka, K., Jorm, A. F., and Nakane, H. (2006). Stigma in response to mental disorders: A comparison of Australia and Japan. BMC Psychiatry, 6(21).

Jorm, A.F., Nakane, Y., Christensen, H., Yoshioka, K., Nakane, H., & Griffiths, K.M. (2005). Public beliefs about treatment and outcomes of mental disorders: A comparison of Japan and Australia. BMC Psychiatry, 5(33).

Kelleher, M. J., Chambers, D., Corcoran, P., Williamson, E., & Keeley, H. S. (1998). Religious sanctions and rates of suicide worldwide. Crisis, 19(2), 78-86.

Laser, J., Luster, T., & Oshio T. (2007). Risk and promotive factors related to depressive symptoms among Japanese youth. American Journal of Orthopsychiatry, 77(4), 523-533.

Lester, D., Saito, Y., & Abe, K. (1997). The effect of suicide prevention centers on suicide in Japan. Crisis, 18(1).

Nakane, Y., Jorm, A. F., Yoshioka, K., Christensen, H., Nakane, H., & Griffiths, K. M. (2005) Public beliefs about causes and risk factors for mental disorders: A comparison of Japan and Australia. BMC Psychiatry, 5(33).

Oyama, H., Goto, M., Fujita, M., Shibuya, H., & Sakashita, T. (2006). Preventing elderly suicide through primary care by community-based screening for depression in rural Japan. Crisis, 27(2), 58-65.

Stewart, S. M., Kennard, B. D., Lee, P. W. H., Hughes, C. W., Mayes, T. L., Emslie, G. J., & Lewinsohn, P. M. (2004). A cross-cultural investigation of cognitions and depressive symptoms in adolescents. Journal of Abnormal Psychology, 113(2), 248-257.

Takeuchi, T., Nakao, M., & Yano, E. (2008). Symptomatology of depressive state in workplace. Soc. Psychiatry Psychiatr. Epidemiol.. 43, 343-348.

World Health Organization. (2009, October 8). WHO | Depression. Retrieved from
http://www.who.int/mental_health/management/depression/definition/en/

World Health Organization. (2009, October 8). WHO | Suicide Prevention. Retrieved from
http://www.who.int/mental_health/prevention/en/

Yamashita, S., Takizawa, T., Sakamoto, S., Taguchi, M., Takenoshita, Y., Tanaka, E., Sugawara, I., & Watanabe, N. (2005). Suicide in Japan: Present conditions and prevention measures. Crisis, 26(1), 12-19.

Yang, B., & Lester, D. (2004). Natural suicide rates in nations of the world. Crisis, 25(4), 187-188.

3 Responses to “Depression and Suicide Ideation in Japanese Populations”

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  1. Why I just can’t get over it and be happy — Depression is an illness | julietjeske - February 9, 2013

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