A proposed approach to suicide prevention in Japan: the use of self-perceived symptoms as indicators of depression and suicidal ideation

Dysmenorrhea due to undiagnosed obstructed hemi-vagina and ipsilateral renal anomaly syndrome can become a cause of suicide

Background

A Japanese woman in her early twenties had committed suicide, jumped from a 25-meter high bridge into a lake. She had been suffering from severe dysmenorrhea and general fatigue monthly.

Results

A forensic autopsy revealed indications of a bicorporeal uterus, obstructed hemi-vagina, and ipsilateral renal agenesis, which lead to a diagnosis of obstructed hemi-vagina and ipsilateral renal anomaly (OHVIRA) syndrome. On the right side of the uterus, an enclosed cavity composed of black clots was observed. Histological findings suggested that her endometrium was in the early proliferative phase, implying that she was in the menstrual phase just before her death. She may have been suffering from severe lower abdominal pain from the increased pressure of the closed uterus cavity.

Conclusions

This case indicates that dysmenorrhea from undiagnosed OHVIRA syndrome can possibly lead to a suicide attempt. In Japan, because suicide was the leading cause of death for people aged 15 to 39 in 2019, preventive measures for suicide should be promoted. The present case also suggests that intervention for dysmenorrhea may prevent this in adolescent woman.

Relationship between menstruation status and work conditions in Japan

Background

Menstrual problems can significantly impact daily and work life. In reaction to a shrinking population, the Japanese government is encouraging more women to participate in the labor force. Actual success in achieving this aim, however, is limited. Specifically, participation in the workforce by women during their reproductive years is impacted by their health, which involves not only work conditions, but also traditional family circumstances. Therefore, it is important to further assess and gather more information about the health status of women who work during their reproductive years in Japan. Specifically, women’s health can be represented by menstruation status, which is a pivotal indicator. In this study, we assessed the association between short rest periods in work intervals and menstruation and other health status indicators among female workers in Japan.

Methods

Study participants were recruited from the alumnae of a university, which provided a uniform educational level. All 9864 female alumnae were asked to join the survey and 1630 (17%) accepted. The final sample of study participants (n = 505) were aged 23–43 years, had maintained the same job status for at least 1 year, and were not shift workers, had no maternal status, and did not lack any related information. The participants were divided into two groups according to interval time, with 11 h between end of work and resumption of daily work as a benchmark. This interval time was based on EU regulations and the goal set by the government of Japan. Health outcomes included: menstrual cycle, dysmenorrhoea symptoms, anxiety regarding health, and satisfaction in terms of health. Multiple logistic regression analyses were conducted to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for health indexes in association with interval time by adjusting for confounding variables that included both psychosocial and biological factors.

Results

We compared the health status of women in the workforce with and without a sufficient interval time of 11 h/day. Workers who had a short interval time had a significantly higher prevalence of anxiety about health and dissatisfaction with their health. For menstruation status, only abnormal menstruation cycles were observed more often among workers in the short interval group than those of the long interval group. However, this association disappeared when biological confounding factors were adjusted in a multivariable regression model. Dysmenorrhea symptoms did not show a statistically significant association with short interval time.

Conclusions

This study found a significant association between a short interval time of less than 11 h/day and subjective health indicators and the menstrual health status of women in the workforce. Menstrual health was more affected by biological factors than social psychological factors. A long work time and short interval time could increase worker anxiety and dissatisfaction and may deteriorate the menstrual cycle.

Community-based screening intervention for depression affects suicide rates among middle-aged Japanese adults

BACKGROUND

It has been suggested that screening interventions may be effective for suicide prevention. Few studies, however, have reported their effects on outcome measures, including death by suicide among middle-aged adults.

METHOD

We used a quasi-experimental parallel cluster design with matched community-based intervention and control municipalities (total eligible population: 90 000) in Japan. At-risk residents within the intervention area were invited for universal depression screening and subsequent care/support. We compared changes in suicide incidence of adults aged 40-64 years for the 4-year pre- and post-implementation periods in the intervention group with the control group and the whole country. Incidence rate ratios (IRRs) of the outcomes were adjusted for age group, gender and interaction terms, using mixed-effects negative binomial regression models. Suicide rates among intervention and control subgroups were compared.

RESULTS

The screening procedure was offered to 52% of the intervention group, and 61% of those contacted responded over the implementation period. Suicide rates decreased more in the intervention group [IRR 0.57, 95% (CI) 0.41-0.78; F 1,36 = 12.52, p = 0.001] than the control group (IRR proportion 1.63, 95% CI 1.06-2.48; F 1,82 = 5.20, p = 0.025) or the whole country (IRR proportion 1.64, 95% CI 1.16-2.34; F 1,42 = 8.21, p = 0.006). Sensitivity analyses confirmed the results from the primary analysis. There were lower suicide rates among both respondents and non-respondents to the screening than in the control group during the implementation period.

CONCLUSIONS

Prevention efforts involved in the depression screening intervention were probably successful in reducing suicide rates.

Long-Term Effects of a Screening Intervention for Depression on Suicide Rates among Japanese Community-Dwelling Older Adults

OBJECTIVES

To explore the long-term impact of a universal screening intervention for depression on suicide rates among older community-dwelling adults, with gender as an effect modifier.

DESIGN

Controlled cohort study reporting long-term follow-up of previous research.

SETTING

Two sets of three municipalities in Japan were assigned as intervention and control regions and compared with the surrounding zone and prefecture.

PARTICIPANTS

Intervention area residents aged 60 years and older (14,291) were invited to participate in a 2-year intervention (2005-2006). Four population-based dynamic cohorts of residents aged 65 years and older (1999-2010) were included as subjects, 6 years before and after the intervention started.

INTERVENTION

At-risk residents within the intervention region (4,918) were invited for a two-step screening program; 2,552 participated in the program linked with care/support services for 2 years. An education program open to the public was held.

MEASUREMENTS

Changes in suicide from a 6-year baseline to the 2-year intervention and a 4-year follow-up in the intervention region (11,700 adults ≥65 years) were compared with a matched control and two comparison areas using mixed-effects negative binomial regression models. Suicide rates among older adults exposed to screening were compared with those of the control region.

RESULTS

Suicide rates in the intervention region decreased by 48%, which was significantly greater than in the three comparison areas. The program's benefits lasted longer for women than men. Screening exposure may be associated with decreased suicide risk over the 4-year follow-up.

CONCLUSIONS

Universal screening may decrease suicide rates among older adults, with potential gender differences in treatment response.

Effects of universal screening for depression among middle-aged adults in a community with a high suicide rate

We examined the effect of a community-based screening program on depression in middle-aged individuals. Ten subdistricts constituting a rural township (2400 inhabitants aged 40-64 years) in northern Japan with a high suicide rate were randomly assigned to intervention (four) and control (six) groups. A 2-year depression-screening program entailing identification and subsequent care support was offered to adults aged 40 to 64 years in the intervention group, accompanied by 4-year ongoing dissemination of educational information in both groups. Change in depressive symptom prevalence was assessed through before-and-after cross-sectional surveys using the Center for Epidemiologic Studies-Depression Scale. Of the 900 targeted individuals, 49.2% participated in the screening. Comparison of data from these surveys after controlling for district-level clustering indicated a greater difference in prevalence between baseline and 5-year follow-up in the intervention group than that in the control. Universal screening and subsequent support seem effective to decrease depressive symptom prevalence among middle-aged individuals in a community setting.

Differences in specific depressive symptoms among community-dwelling middle-aged Japanese adults before and after a universal screening intervention

PURPOSE

This study investigated changes in depressive symptoms after the implementation of a universal screening for depression and subsequent care support.

METHODS

A cluster-randomized study design used 10 subdistricts (2,400 inhabitants aged 40-64 years) in northern Japan randomly assigned in a 2:3 ratio to intervention and control conditions. All 900 residents aged 40-64 in the intervention districts were invited to participate in a 2-year depressive screening program, with a participation rate of 49.2%. A 4-year ongoing education program occurred in both intervention and control districts. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to assess depressive symptomatology. Repeated cross-sectional samples were surveyed before (n = 1,516, response rate 63.6%) and after (n = 1,596, 66.4%) intervention, and the data, clustered according to district, were analyzed at the individual level using a mixed-effects model.

RESULTS

Significant changes in mean scores between baseline and 5-year follow-up in the intervention group were observed in the Depressive Affect, Somatic Symptoms, and Interpersonal Problems subscales. The difference between the changes over time in the two groups was significant for the three subscales and marginally for the CES-D total scale, but not for the Positive Affect subscale.

CONCLUSIONS

Universal depression screening and subsequent support can be effective in preventing general depressive symptoms, but may not influence psychological well-being, among middle-aged adults in a community setting.

The perspective of psychosomatic medicine on the effect of religion on the mind-body relationship in Japan

Shintoism, Buddhism, and Qi, which advocate the unity of mind and body, have contributed to the Japanese philosophy of life. The practice of psychosomatic medicine emphasizes the connection between mind and body and combines the psychotherapies (directed at the mind) and relaxation techniques (directed at the body), to achieve stress management. Participation in religious activities such as preaching, praying, meditating, and practicing Zen can also elicit relaxation responses. Thus, it is time for traditional religions to play an active role in helping those seeking psychological stability after the Great East Japan Earthquake and the ongoing crisis related to the nuclear accident in Fukushima, Japan, to maintain a healthy mind-body relationship.

Social and geographical inequalities in suicide in Japan from 1975 through 2005: a census-based longitudinal analysis

Background

Despite advances in our understanding of the countercyclical association between economic contraction and suicide, less is known about the levels of and changes in inequalities in suicide. The authors examined social and geographical inequalities in suicide in Japan from 1975 through 2005.

Methods

Based on quinquennial vital statistics and census data, the authors analyzed the entire population aged 25–64 years. The total number of suicides was 75,840 men and 30,487 women. For each sex, the authors estimated odds ratios (ORs) and 95% credible intervals (CIs) for suicide using multilevel logistic regression models with “cells” (cross-tabulated by age and occupation) at level 1, seven different years at level 2, and 47 prefectures at level 3. Prefecture-level variance was used as an estimate of geographical inequalities in suicide.

Results

Adjusting for age and time-trends, the lowest odds for suicide was observed among production process and related workers (the reference group) in both sexes. The highest OR for men was 2.52 (95% CI: 2.43, 2.61) among service workers, whereas the highest OR for women was 9.24 (95% CI: 7.03, 12.13) among security workers. The degree of occupational inequalities increased among men with a striking change in the pattern. Among women, we observed a steady decline in suicide risk across all occupations, except for administrative and managerial workers and transport and communication workers. After adjusting for individual age, occupation, and time-trends, prefecture-specific ORs ranged from 0.76 (Nara Prefecture) to 1.36 (Akita Prefecture) for men and from 0.79 (Kanagawa Prefecture) to 1.22 (Akita Prefecture) for women. Geographical inequalities have increased primarily among men since 1995.

Conclusions

The present findings demonstrate a striking temporal change in the pattern of social inequalities in suicide among men. Further, geographical inequalities in suicide have considerably increased across 47 prefectures, primarily among men, since 1995.

The possible absence of a healthy-worker effect: a cross-sectional survey among educated Japanese women

OBJECTIVES

Despite being highly educated in comparison with women in other member countries of the Organisation for Economic Cooperation and Development, Japanese women are expected to assume traditional gender roles, and many dedicate themselves to full-time housewifery. Women working outside the home do so under poor conditions, and their health may not be better than that of housewives. This study compared the self-rated health status and health behaviours of housewives and working women in Japan.

DESIGN

Cross-sectional survey.

SETTING

A national university in Tokyo with 9864 alumnae.

PARTICIPANTS

A total 1344 women who graduated since 1985 and completed questionnaires in an anonymous mail-based survey.

PRIMARY AND SECONDARY OUTCOME MEASURES

Health anxiety and satisfaction, receipt of health check-ups, eating breakfast, smoking, and sleep problems according to job status and family demands: housewives (n=247) and working women with (n=624) and without (n=436) family demands. ORs were used for risk assessment, with housewives as a reference.

RESULTS

After adjustment for satisfaction with present employment status and other confounding factors, working women were more likely than housewives to feel health anxiety (with family demands, OR: 1.68, 95% CI1.10 to 2.57; without family demands, OR: 3.57, 95% CI 2.19 to 4.50) and health dissatisfaction (without family demands, OR: 3.50, 95% CI 2.35 to 5.21); they were also more likely than housewives to eat an insufficient breakfast (with family demands, OR: 1.91, 95% CI 1.22 to 3.00; without family demands, OR: 4.02, 95% CI 2.47 to 6.57) and to have sleep problems (ORs: 2.08 to 4.03).

CONCLUSIONS

No healthy-worker effect was found among Japanese women. Housewives, at least those who are well educated, appear to have better health status and health-related behaviours than do working women with the same level of education.

Sleep, serotonin, and suicide in Japan

This article reviews evidence supporting the hypothesis that suicide rates in Japan could be reduced by elevating serotonin levels via increasing the average duration of sleep. Seven major relevant findings were apparent in the literature: 1) Sleep loss is associated with suicide, but the direction of causality is equivocal. 2) Decreased serotonergic activity may be involved in suicidal behavior. 3) Sleep debt may decrease serotonergic activity. 4) The suicide rate in Japan has remained at a heightened level for the past 12 years. 5) The average sleep duration in Japan has decreased over the past 40 years. 6) The average sleep duration in Japan is among the lowest in the world. 7) The average sleep duration in Japan plateaued in 1995 and has been relatively stable since. From the research reviewed, two major problematic issues were apparent: 1) Most people in Japan receive inadequate sleep. 2) Individuals whose sleep is inadequate are unlikely to be sufficiently physically active to stimulate serotonergic systems to a desirable level. I propose that public health initiatives encouraging a longer duration of sleep may provide a relatively simple way of addressing the disturbing current trend in Japan. The combination of actigraph and brain serotonin level measurement could allow large population-based cohort studies to be designed, to elucidate the causal links between sleep duration, serotonin levels, and suicide rates.