- Email: [email protected]
Suicide in Japan
Comment
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Jewkes RK, Dunkle K, Nduna M, Shai N. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. Lancet 2010; 376: 41–48. McCoy SI, Kangwende RA, Padian NS. Behavior change interventions to prevent HIV infection among women living in low and middle income countries: a systematic review. AIDS Behav 2009; 14: 469–82. Padian NS, McCoy SI, Balkus JE, Wasserheit JN. Weighing the gold in the gold standard: challenges in HIV prevention research. AIDS 2010; 24: 621–35. Baird SJ, Garfein RS, McIntosh CT, Özler B. Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial. Lancet 2012; published online Feb 15. DOI:10.1016/S0140-6736(11)61709-1. Pettifor AE, Levandowski BA, Macphail C, Padian NS, Cohen MS, Rees HV. Keep them in school: the importance of education as a protective factor against HIV infection among young South African women. Int J Epidemiol 2008; 37: 1266–73. Hargreaves JR, Bonell CP, Boler T, et al. Systematic review exploring time trends in the association between educational attainment and risk of HIV infection in sub-Saharan Africa. AIDS 2008; 22: 403–14. Jukes M, Simmons S, Bundy D. Education and vulnerability: the role of schools in protecting young women and girls from HIV in southern Africa. AIDS 2008; 22(suppl 4): S41–56.
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Schultz T. The impact of PROGRESA on school enrollments. Washington, DC: International Food Policy Research Institute, 2000. World Bank. Education and HIV/AIDS a window of hope. Washington, DC: World Bank, 2002. Pronyk PM, Hargreaves JR, Kim JC, et al. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial. Lancet 2006; 368: 1973–83. Dunbar MS, Maternowska MC, Kang MS, Laver SM, Mudekunye-Mahaka I, Padian NS. Findings from SHAZ!: a feasibility study of a microcredit and life-skills HIV prevention intervention to reduce risk among adolescent female orphans in Zimbabwe. J Prev Interv Community 2010; 38: 147–61. Abdool-Karim Q. A proof of concept cluster randomised controlled trial to evaluate the impact of a cash incentivised prevention intervention to reduce HIV infection in high school learners in rural KwaZulu-Natal, South Africa. http://clinicaltrials.gov/ct2/show/NCT01187979 (accessed Feb 7, 2012). HPTN 068. Effects of cash transfer for the prevention of HIV in young South African women. http://www.hptn.org/research_studies.asp (accessed Feb 7, 2012).
Suicide in Japan Published Online September 1, 2011 DOI:10.1016/S01406736(11)61130-6 See Comment Lancet 2011; 378: 1051
Increase in 1998
Suicide rate Unemployment rate
6
25
5
20
4
15
3
10
2
5
1
0 1985
1987
1989
1991
1993
1995
1997 Year
1999
2001
2003
2005
Figure: Yearly change in suicide rate and unemployment rate from 1985 to 2009 in Japan
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2007
0 2009
Unemployment rate (%)
Suicide rate (per 100 000)
30
In 2009, according to the Japanese Ministry of Health, Labour, and Welfare, 30 707 people (24·4 per 100 000) committed suicide in Japan.1 Since 1998, when the suicide rate peaked at 31 755 (from 23 494 in 1997), the rate has remained higher than 30 000 per year, thus posing a serious and urgent challenge for Japanese society. Tellingly, the changes in the unemployment and suicide rates have been similar.2 The figure shows the change in suicide and unemployment rates from 1985 to 2009. Suicide rates were significantly correlated with unemployment rates (p<0·0001). The rising unemployment rate means that the number of people who had fallen into economic difficulties and had mental distress that was associated with
the continuing economic recession might have been increasing too. Additionally, the unwillingness of the banks to lend money to owners of small companies, and the increasing number of bankruptcies as a result of this unwillingness after 1998 might also have contributed to higher rates of suicides.3 It seems likely that this negative socioeconomic background is associated with the suicide trend in Japan. In response to this situation, the Japanese Government has introduced initiatives, such as counselling programmes and suicide-prevention education, and commissioned research and studies to assess the effect of these interventions. These are in addition to the government’s social initiatives to control access to dangerous places and drugs, and the dissemination of WHO media guidelines for responsible reporting of suicides. The initiatives were based on the success of community-based suicide-prevention programmes in local prefectures.4 Much of the academic research has been undertaken in municipalities in Japan to assess the effects of community intervention-based suicideprevention measures. For example, model projects for suicide prevention in six towns in Akita prefecture showed that comprehensive suicide-prevention efforts that combine primary, secondary, and tertiary prevention methods resulted in a steady reduction in the number of suicides in the community.5 In Akita prefecture, a health-promotion approach to address www.thelancet.com Vol 379 April 7, 2012
Comment
depression and mental ill health trained gatekeepers with an emphasis on civic participation, and they were used to raise public awareness about suicide. Furthermore, activities to prevent social isolation, such as the promotion of activities of mental welfare volunteers, were also stepped up. As a result of these efforts, the suicide rate in the intervention towns fell from 70·8 per 100 000 per year before the intervention (1999) to 34·1 per 100 000 per year after the intervention (2004) compared with little change in suicide rates in the control towns.5 In the absence of any downward trend in suicide rates in Japan, the government passed the Basic Law on Suicide Countermeasures in October, 2006, mandating comprehensive national suicide prevention measures and the provision of wide-ranging support for the relatives of individuals who have died by suicide.6 In June, 2007, the Comprehensive Suicide Prevention Principles7 specified six fundamental policies for suicide prevention and the Basic Law on Suicide Countermeasures8 specified nine. The campaigns by the Cabinet Office, Government of Japan, were undertaken in March and September, 2010, through nationwide television commercials and publicity campaigns. The number of suicides after the campaign in April and October, 2010, fell by 7·3% per month and 5·3% per month, respectively, compared with the numbers in April and October, 2009, when no campaign was undertaken.9 The drop in numbers was smaller in major cities than in rural prefectures. Prospective experimental intervention trials to assess the effectiveness of suicide prevention methods are thus needed in major cities to better understand the factors that contribute to these rural–urban differences. With respect to medical care for people who are at risk of suicide because of mental illness (including depression, schizophrenia, alcoholism, and drug dependency), in 2008, the Plan to Accelerate Suicide Prevention Measures,10 referred to the need for a framework of treatment provision. It also emphasised that
www.thelancet.com Vol 379 April 7, 2012
early and proper coordination is needed between psychiatrists and medical doctors because patients with depression will often present with physical symptoms. Additionally, better efforts to increase public knowledge about depression and progress towards elimination of prejudice would probably help to raise the consultation rate for depression, thereby leading to appropriate psychiatric treatment. Schemes are also needed for family doctors to refer their patients with depression to specialists. The key to successfully reduce the rate of suicides in Japan is thus the use of multidisciplinary and interprofessional approaches to develop comprehensive suicide prevention measures and implement them on a broader scale.11 Yutaka Motohashi Department of Public Health, Akita University Graduate School of Medicine, 1-1-1, Hndo, Akita City, Akita 010-8543, Japan [email protected] I declare that I have no conflicts of interest. 1 2 3
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Japan Ministry of Health, Labor, and Welfare. Vital statistics of Japan 2009. Tokyo: Health and Welfare Statistics Association, 2011. Kaga M, Takeshima T, Matsumoto T. Suicide and its prevention in Japan. Leg Med 2009; 11: S18–S21. Watanabe R, Ogura Y, Saito T, Furukawa M, Nakamura R. Research report on socioeconomic factors affecting suicide. Kyoto: Kyoto University, 2006. Motohashi Y, Kaneko Y, Sasaki H. Community-based suicide prevention programs in Japan using a health promotion approach. Environ Health Prev Med 2004; 9: 3–8. Motohashi Y, Kaneko Y, Sasaki H, Yamaji M. A decrease in suicide rates in Japanese rural towns after community-based intervention by the health promotion approach. Suicide Life Threat Behav 2007; 37: 593–99. Department of Public Health Akita University School of Medicine. Basic law on suicide countermeasures (law number 85 of 2006). Akita J Public Health 2006; 4: 83–86 (in Japanese). Cabinet Office, Government of Japan. Comprehensive suicide prevention principles. 2007 (in Japanese) http://www8.cao.go.jp/jisatsutaisaku/ taikou/pdf/20081031taikou.pdf (accessed July 21, 2011). Cabinet Office, Government of Japan. Basic law on suicide countermeasures. 2006 (in Japanese). http://www8.cao.go.jp/ jisatsutaisaku/bsc_law/index.html (accessed July 21, 2011) Cabinet Office, Government of Japan. The White paper on suicide prevention policy. 2011 (in Japanese). http://www8.cao.go.jp/ jisatsutaisaku/whitepaper/index-w.html (accessed July 21, 2011). Cabinet Office, Government of Japan. Plan to accelerate suicide prevention measures. 2008 (in Japanese). http://www8.cao.go.jp/jisatsutaisaku/ taikou/pdf/plan.pdf (accessed July 21, 2011). Motohashi Y, Watanabe N. Suicide can be prevented: planning and action of suicide prevention by health promotion approach. Saitama: Spika-Shobou, 2007 (in Japanese).
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Jewkes RK, Dunkle K, Nduna M, Shai N. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. Lancet 2010; 376: 41–48. McCoy SI, Kangwende RA, Padian NS. Behavior change interventions to prevent HIV infection among women living in low and middle income countries: a systematic review. AIDS Behav 2009; 14: 469–82. Padian NS, McCoy SI, Balkus JE, Wasserheit JN. Weighing the gold in the gold standard: challenges in HIV prevention research. AIDS 2010; 24: 621–35. Baird SJ, Garfein RS, McIntosh CT, Özler B. Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial. Lancet 2012; published online Feb 15. DOI:10.1016/S0140-6736(11)61709-1. Pettifor AE, Levandowski BA, Macphail C, Padian NS, Cohen MS, Rees HV. Keep them in school: the importance of education as a protective factor against HIV infection among young South African women. Int J Epidemiol 2008; 37: 1266–73. Hargreaves JR, Bonell CP, Boler T, et al. Systematic review exploring time trends in the association between educational attainment and risk of HIV infection in sub-Saharan Africa. AIDS 2008; 22: 403–14. Jukes M, Simmons S, Bundy D. Education and vulnerability: the role of schools in protecting young women and girls from HIV in southern Africa. AIDS 2008; 22(suppl 4): S41–56.
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Schultz T. The impact of PROGRESA on school enrollments. Washington, DC: International Food Policy Research Institute, 2000. World Bank. Education and HIV/AIDS a window of hope. Washington, DC: World Bank, 2002. Pronyk PM, Hargreaves JR, Kim JC, et al. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial. Lancet 2006; 368: 1973–83. Dunbar MS, Maternowska MC, Kang MS, Laver SM, Mudekunye-Mahaka I, Padian NS. Findings from SHAZ!: a feasibility study of a microcredit and life-skills HIV prevention intervention to reduce risk among adolescent female orphans in Zimbabwe. J Prev Interv Community 2010; 38: 147–61. Abdool-Karim Q. A proof of concept cluster randomised controlled trial to evaluate the impact of a cash incentivised prevention intervention to reduce HIV infection in high school learners in rural KwaZulu-Natal, South Africa. http://clinicaltrials.gov/ct2/show/NCT01187979 (accessed Feb 7, 2012). HPTN 068. Effects of cash transfer for the prevention of HIV in young South African women. http://www.hptn.org/research_studies.asp (accessed Feb 7, 2012).
Suicide in Japan Published Online September 1, 2011 DOI:10.1016/S01406736(11)61130-6 See Comment Lancet 2011; 378: 1051
Increase in 1998
Suicide rate Unemployment rate
6
25
5
20
4
15
3
10
2
5
1
0 1985
1987
1989
1991
1993
1995
1997 Year
1999
2001
2003
2005
Figure: Yearly change in suicide rate and unemployment rate from 1985 to 2009 in Japan
1282
2007
0 2009
Unemployment rate (%)
Suicide rate (per 100 000)
30
In 2009, according to the Japanese Ministry of Health, Labour, and Welfare, 30 707 people (24·4 per 100 000) committed suicide in Japan.1 Since 1998, when the suicide rate peaked at 31 755 (from 23 494 in 1997), the rate has remained higher than 30 000 per year, thus posing a serious and urgent challenge for Japanese society. Tellingly, the changes in the unemployment and suicide rates have been similar.2 The figure shows the change in suicide and unemployment rates from 1985 to 2009. Suicide rates were significantly correlated with unemployment rates (p<0·0001). The rising unemployment rate means that the number of people who had fallen into economic difficulties and had mental distress that was associated with
the continuing economic recession might have been increasing too. Additionally, the unwillingness of the banks to lend money to owners of small companies, and the increasing number of bankruptcies as a result of this unwillingness after 1998 might also have contributed to higher rates of suicides.3 It seems likely that this negative socioeconomic background is associated with the suicide trend in Japan. In response to this situation, the Japanese Government has introduced initiatives, such as counselling programmes and suicide-prevention education, and commissioned research and studies to assess the effect of these interventions. These are in addition to the government’s social initiatives to control access to dangerous places and drugs, and the dissemination of WHO media guidelines for responsible reporting of suicides. The initiatives were based on the success of community-based suicide-prevention programmes in local prefectures.4 Much of the academic research has been undertaken in municipalities in Japan to assess the effects of community intervention-based suicideprevention measures. For example, model projects for suicide prevention in six towns in Akita prefecture showed that comprehensive suicide-prevention efforts that combine primary, secondary, and tertiary prevention methods resulted in a steady reduction in the number of suicides in the community.5 In Akita prefecture, a health-promotion approach to address www.thelancet.com Vol 379 April 7, 2012
Comment
depression and mental ill health trained gatekeepers with an emphasis on civic participation, and they were used to raise public awareness about suicide. Furthermore, activities to prevent social isolation, such as the promotion of activities of mental welfare volunteers, were also stepped up. As a result of these efforts, the suicide rate in the intervention towns fell from 70·8 per 100 000 per year before the intervention (1999) to 34·1 per 100 000 per year after the intervention (2004) compared with little change in suicide rates in the control towns.5 In the absence of any downward trend in suicide rates in Japan, the government passed the Basic Law on Suicide Countermeasures in October, 2006, mandating comprehensive national suicide prevention measures and the provision of wide-ranging support for the relatives of individuals who have died by suicide.6 In June, 2007, the Comprehensive Suicide Prevention Principles7 specified six fundamental policies for suicide prevention and the Basic Law on Suicide Countermeasures8 specified nine. The campaigns by the Cabinet Office, Government of Japan, were undertaken in March and September, 2010, through nationwide television commercials and publicity campaigns. The number of suicides after the campaign in April and October, 2010, fell by 7·3% per month and 5·3% per month, respectively, compared with the numbers in April and October, 2009, when no campaign was undertaken.9 The drop in numbers was smaller in major cities than in rural prefectures. Prospective experimental intervention trials to assess the effectiveness of suicide prevention methods are thus needed in major cities to better understand the factors that contribute to these rural–urban differences. With respect to medical care for people who are at risk of suicide because of mental illness (including depression, schizophrenia, alcoholism, and drug dependency), in 2008, the Plan to Accelerate Suicide Prevention Measures,10 referred to the need for a framework of treatment provision. It also emphasised that
www.thelancet.com Vol 379 April 7, 2012
early and proper coordination is needed between psychiatrists and medical doctors because patients with depression will often present with physical symptoms. Additionally, better efforts to increase public knowledge about depression and progress towards elimination of prejudice would probably help to raise the consultation rate for depression, thereby leading to appropriate psychiatric treatment. Schemes are also needed for family doctors to refer their patients with depression to specialists. The key to successfully reduce the rate of suicides in Japan is thus the use of multidisciplinary and interprofessional approaches to develop comprehensive suicide prevention measures and implement them on a broader scale.11 Yutaka Motohashi Department of Public Health, Akita University Graduate School of Medicine, 1-1-1, Hndo, Akita City, Akita 010-8543, Japan [email protected] I declare that I have no conflicts of interest. 1 2 3
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8
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Japan Ministry of Health, Labor, and Welfare. Vital statistics of Japan 2009. Tokyo: Health and Welfare Statistics Association, 2011. Kaga M, Takeshima T, Matsumoto T. Suicide and its prevention in Japan. Leg Med 2009; 11: S18–S21. Watanabe R, Ogura Y, Saito T, Furukawa M, Nakamura R. Research report on socioeconomic factors affecting suicide. Kyoto: Kyoto University, 2006. Motohashi Y, Kaneko Y, Sasaki H. Community-based suicide prevention programs in Japan using a health promotion approach. Environ Health Prev Med 2004; 9: 3–8. Motohashi Y, Kaneko Y, Sasaki H, Yamaji M. A decrease in suicide rates in Japanese rural towns after community-based intervention by the health promotion approach. Suicide Life Threat Behav 2007; 37: 593–99. Department of Public Health Akita University School of Medicine. Basic law on suicide countermeasures (law number 85 of 2006). Akita J Public Health 2006; 4: 83–86 (in Japanese). Cabinet Office, Government of Japan. Comprehensive suicide prevention principles. 2007 (in Japanese) http://www8.cao.go.jp/jisatsutaisaku/ taikou/pdf/20081031taikou.pdf (accessed July 21, 2011). Cabinet Office, Government of Japan. Basic law on suicide countermeasures. 2006 (in Japanese). http://www8.cao.go.jp/ jisatsutaisaku/bsc_law/index.html (accessed July 21, 2011) Cabinet Office, Government of Japan. The White paper on suicide prevention policy. 2011 (in Japanese). http://www8.cao.go.jp/ jisatsutaisaku/whitepaper/index-w.html (accessed July 21, 2011). Cabinet Office, Government of Japan. Plan to accelerate suicide prevention measures. 2008 (in Japanese). http://www8.cao.go.jp/jisatsutaisaku/ taikou/pdf/plan.pdf (accessed July 21, 2011). Motohashi Y, Watanabe N. Suicide can be prevented: planning and action of suicide prevention by health promotion approach. Saitama: Spika-Shobou, 2007 (in Japanese).
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