Analysing regional unemployment rates, GDP per capita and financial support for regional suicide prevention programme on suicide mortality in Japan using governmental statistical data

Suicide mortality rates in Japan before and beyond the COVID-19 pandemic era

Statistical analyses from Japan reported increasing suicides in 2020, first in the world, proving the severity of the public health crisis during the COVID-19 pandemic; however, so far, international suicides have not been shown to be objectively increasing at population level. Followed studies reported the existence of a substantial heterogeneity of suicides among subgroups and time-lag impacts. Against public health crisis in Japan, policymakers, psychiatrists and public health personnel should prioritize improving suicide prevention programs following evidence-based policymaking. Understanding how/what factors relate to the COVID-19 pandemic and what other factors have shaped the increasing suicide numbers since 2020 through objectively well-controlled/fine-grained analyses of high-quality longitudinal/cross-sectional data at the individual, regional, and national levels is important for identifying the reasons for the recent trend. For this purpose, this study examined suicide statistics, statistical analysis methods, and their interpretations. Recent analyses suggest an increased suicide risk among females <50 years and males <30 years in 2020-2022. Notably, time-series analyses revealed that adolescent suicides began increasing before the pandemic, while working-age female suicides sharply increased synchronously with the pandemic outbreak. Causality analyses suggest that social issues facing Japan and recent global psychosocial and socioeconomic transformations are risk factors for suicide in high-risk groups. Finally, this report demonstrates the importance of providing appropriate support based on an objective understanding of individuals who are at risk for suicide, without being bound by traditional established knowledges.

The association between economic uncertainty and suicide in Japan by age, sex, employment status, and population density: an observational study

Background

Suicide is one of the ten leading causes of death globally, and previous research has revealed a link between economic conditions and mental health. However, the literature has focused primarily on recessions and unemployment, i.e. actual economic developments, as opposed to uncertainty, which relates to economic developments that have not (yet) materialised. This study examines the differential association between economic uncertainty and suicide in Japan, depending on age, sex, employment status, and population density, in order to identify the groups that are affected the most.

Methods

Using monthly prefectural suicide mortality data from the Ministry of Health, Labour and Welfare and a monthly economic uncertainty index for the period 2009 to 2019, we employed a fixed effects panel data approach to examine the association between uncertainty and suicide by population group.

Findings

We found that a 1% increase in economic uncertainty is associated with a 0.061 increase in the monthly number of suicides per 100,000 people per prefecture, on average (coefficient: 6.08; 95% CI: 5.07-7.08), which constitutes a 3.62% increase. Self-employed people, as well as men in their 50s and unemployed men, experience the highest additional risk of suicide when uncertainty increases. The association was approximately three times stronger for males than for females, and a strong association was observed for self-employed males living in more densely-populated areas.

Interpretation

Uncertainty appears to relate to suicides for most groups, but self-employed people, males, and those living in more densely populated areas appear to be more at risk of suicide in periods of increased economic uncertainty. Our results provide an indication of which groups mental health services and prevention strategies can focus on in times of economic uncertainty.

Funding

None.

Female Labor-Force Participation as Suicide Prevention: A Population Study in Taiwan

OBJECTIVE

Female labor-force participation (FLFP) has been theorized as contributing to higher suicide rates, including among women. Evidence on this relationship, however, has been mixed. This study explored the association between FLFP and suicide in an understudied context, Taiwan, and across 40-years.

METHODS

Annual national labor-participation rates for women ages 25-64, and female and male suicide-rates, for 1980-2020, were obtained from Taiwan's Department of Statistics. The associations between FLFP rates and sex/age-stratified suicide-rates, and between FLFP rates and male-to-female suicide-rates ratios were assessed via time-series regression-analyses, accounting for autoregressive effects.

RESULTS

Higher FLFP rates were associated with lower female suicide-rates (ß = -0.06, 95% CI (Credibility Interval) = [-0.19, -0.01]) in the adjusted model. This association held in the age-stratified analyses. Associations for FLFP and lower male suicide-rates were observed in the ≥45 age-groups. FLFP rates were significantly and positively associated with widening male-to-female suicide-rates ratios in the adjusted model (ß = 0.24, 95% CI = [0.03, 0.59]).

CONCLUSION

This study's findings suggest that FLFP protects women from suicide, and point to the potential value of FLFP as a way of preventing suicide. In Taiwan, employed women carry a double-load of paid and family unpaid care-work. Child care-work is still done by mothers, often with grandmothers' support. Therefore, this study's findings contribute to evidence that doing both paid work and unpaid family care-work has more benefits than costs, including in terms of suicide-protection. Men's disengagement from family care-work may contribute to their high suicide rates, despite their substantial labor-force participation.

Temporal Fluctuations of Suicide Mortality in Japan from 2009 to 2023 Using Government Databases

In Japan, suicide mortalities consistently decreased before the COVID-19 pandemic (from 2009 to 2019) but, conversely, increased after the pandemic outbreak from 2020 to 2022. To provide up-to-date suicide statistics in Japan, this study determined the temporal fluctuations of standardized suicide mortalities (SMRs), disaggregated by sex and age, by joinpoint regression analysis using the government suicide database, named the "Basic Data on Suicide in Region". From January 2009 to December 2023, three temporal fluctuation patterns of SMRs pertaining to working age and older adults were detected, such as attenuations of decreasing trends before the COVID-19 pandemic (from around the mid-2010s), a sharply increasing trend that coincided with the pandemic outbreak, and gradually decreased during the pandemic, but no changes at the end of the COVID-19 pandemic. In particular, the SMRs of working-age females sharply increased concurrently with the pandemic outbreak, whereas those of males did not change. However, before the pandemic, decreasing trends of the SMRs of working-age males diminished in the mid-2010s, but those of females consistently decreased. The SMRs of working-age males indicated non-significant but sharply increasing trends in early 2022, a trend that was not observed for females. In contrast to working-age adults, the SMRs of adolescents already began to increase in the mid-2010s and also indicated consistently increasing trends between the periods during and after the pandemic. These results suggest, contrary to our expectations, that the impacts of both the outbreak and end of the COVID-19 pandemic were limited regarding the increase in SMRs from 2020. Therefore, when revising suicide prevention programs in the post-COVID-19 era, it should be noted that focusing on pandemic-associated factors alone is not sufficient.

Economic activity and suicides: Causal evidence from macroeconomic shocks in England and Wales

The relationship between economic activity and suicides has been the subject of much scrutiny, but the focus in the extant literature has been almost exclusively on estimating associations rather than causal effects. In this paper, using data from England and Wales between January 1, 1997 and December 31, 2017, we propose a plausible set of assumptions to estimate the causal impacts of well-known macroeconomic variables on the daily suicide rate. Our identification strategy relies on scheduled macroeconomic announcements and professional economic forecasts. An important advantage of using these variables to model suicide rates is that they can efficiently capture the elements of 'surprise or shock' via the observed difference between how the economy actually performed and how it was expected to perform. Provided that professional forecasts are unbiased and efficient, the estimated 'surprises or shocks' are 'as good as random', and therefore are exogenous. We employ time series regressions and present robust evidence that these exogenous macroeconomic shocks affect the suicide rate. Overall, our results are consistent with economic theory that shocks that reduce estimated permanent income, and therefore expected lifetime utility, can propel suicide rates. Specifically, at the population level, negative shocks to consumer confidence and house prices accelerate the suicide rate. However, there is evidence of behavioural heterogeneity between sexes, states of the economy, and levels of public trust in government. Negative shocks to the retail price index (RPI) raise the suicide rate for males. Negative shocks to the growth rate in gross domestic product (GDP) raise the population suicide rate when the economy is doing poorly. When public trust in government is low, increases in the unemployment rate increase the suicide rate for females.

Impact of the Japanese Government's 'General Principles of Suicide Prevention Policy' on youth suicide from 2007 to 2022

BACKGROUND

The Japanese Government programme 'General Principles of Suicide Prevention Policy' (GPSPP) contributed to decreasing suicide mortality rates (SMRs) before the COVID-19 pandemic, but they increased after the pandemic.

AIMS

To identify risk factors for youth suicide and the impact of GPSPP on youth suicide.

METHOD

Annual suicide numbers during 2007-2022 were obtained from government databases. SMRs of student and non-student youths were analysed with a linear mixed-effects model. Interrupted time-series analysis was conducted to investigate temporal relations between three GPSPP periods and SMRs with 52 suicide motives among high school, special vocational school and university students. Multiple regression analysis was conducted to investigate the influence of grade repetition on university student SMRs.

RESULTS

Non-student youth SMRs were higher than student SMRs. School-related (worrying about the future/underachievement), health-related (mainly mental illness) and family-related (conflict with parent and severe verbal reprimands) motives were major motives for student SMRs. During the first GPSPP period (2007-2012), no student SMRs decreased. During the second period (2012-2017), university and special vocational school student SMRs increased, but high school student SMRs were unchanged. In contrast, during the third period (2017-2022), with the exception of male special vocational school students, all SMRs increased. Unexpectedly, long-term grade repetition was negatively associated with health-related SMRs.

CONCLUSIONS

These findings suggest that GPSPP-supported programmes in schools partially contributed to student suicide prevention. To suppress increasing student SMRs, social/life support specialists should participate in in-school support services to bolster the social standing and lives of students who repeat grades or experience setbacks.

Trends in Suicidal Mortality and Motives among Working-Ages Individuals in Japan during 2007-2022

Suicides in Japan consistently decreased from 2009-2019, but increased during the COVID-19 pandemic. To identify causes of increasing suicides, age-dependent and temporal fluctuations of suicide mortality rate per 100,000 (SMRP) in working-age generations (20-59 years) disaggregated by suicidal motives (7-categories; 52-subcategories) and sex from 2007 to 2022, were analyzed by analysis of variance and joinpoint regression, respectively, using the government suicide database "Suicide Statistics". The SMRP of 20-29 year-old males and 20-49 year-old females began to increase in the late 2010s. SMRPs of these high-risk groups for suicides caused by depression (the leading suicidal motive for all groups) began increasing in the late 2010s. Economic-related, employment-related, and romance-related problems contributed to the increasing SMRPs in 20-29 males in the late 2010s. Romance-related and family-related problems contributed to the increasing SMRPs of 20-29 females in the late 2010s. Increasing SMRPs caused by child-raising stress in 20-39 year-old females from the late 2010s was a remarkable finding. In contrast, SMRPs of 30-59 year-old males consistently decreased until 2021; however, in these groups, SMRPs for suicides caused by various motives sharply increased in 2022. The consistent increase in SMRPs of high-risk groups from the late 2010s to the pandemic suggest recent socioeconomic and psychosocial problems in Japan possibly contributed to the increasing SMRPs in these high-risk groups independently of pandemic-associated factors, whereas the SMRPs of males of 30-59 years were probably associated with the ending of the pandemic rather than pandemic-associated factors.

Impacts of Complete Unemployment Rates Disaggregated by Reason and Duration on Suicide Mortality from 2009-2022 in Japan

In Japan, suicides had consistently decreased before the COVID-19 pandemic (from 2009-2019), but conversely increased after the pandemic outbreak (from 2020-2022). To identify the features of fluctuations of suicides in Japan, the standardized suicide mortality rates per 100,000 population (SMRP) disaggregated by gender (males/females) and age (10-year cohorts) from 2009-2022 were analyzed using interrupted time-series and joinpoint regression analyses. Temporal causalities from unemployment rate (CUR) disaggregated by unemployment duration and reasons for seeking work to SMRP were analyzed using vector autoregressive modelling with Granger causality analysis. SMRP fluctuations from 2009-2022 were composed of three patterns, such as positive discontinuity (increasing) synchronized with the pandemic outbreak, attenuations of decreasing trends before the pandemic, turning from decreasing before the pandemic to increasing/unchanging after the pandemic outbreak. Dismissal CUR positively related to SMRP of working-age generations, whereas voluntary CUR negatively related to SMRP of younger population (<30 years), which turned to persistently increasing before the pandemic (approximately 2016-2017). CUR shorter than 3 months positively related to SMRP of working-age females, which displayed promptly increasing synchronization with the pandemic outbreak. CUR longer than 12 months positively related to SMRP of working-age males, which contributed to persistently increasing SMRPs during the pandemic. These results suggest that increasing SMRP during 2020-2022 in Japan has been probably at-tributed to interactions among the pandemic-related factors, continuous vulnerabilities from before the pandemic and newly developing risk factors for suicides during the pandemic. Unexpectedly, increasing SMRPs of working-age males in 2022 suggest that either prolongation of the pandemic or the ending of the pandemic might positively affect suicides in Japan.

Suicidal Mortality and Motives Among Middle-School, High-School, and University Students

IMPORTANCE

The suicide mortality rate per 100 000 population (SMRP) consistently decreased before the COVID-19 pandemic outbreak in Japan and then unexpectedly increased during the pandemic. However, the underlying mechanisms remain poorly understood.

OBJECTIVE

To identify trends in and factors associated with suicidal mortality and motives among students in Japan from 2007 to 2022.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, data on SMRPs among Japanese middle-school, high-school, and university students were obtained from the government suicide database Suicide Statistics of the National Police Agency.

MAIN OUTCOMES AND MEASURES

Age-dependent and temporal fluctuations in annual SMRPs, disaggregated by suicidal motive (7 categories and 52 subcategories), sex, and school, were analyzed using linear mixed-effect and joinpoint regression models, respectively.

RESULTS

Total suicide numbers from 2007 to 2022 were as follows: 760 male middle-school students, 635 female middle-school students, 2376 male high-school students, 1566 female high-school students, 5179 male university students, and 1880 female university students. The mean (SD) student populations from 2007 to 2022 were as follows: 1 752 737 (81 334) male middle-school students, 1 675 572 (78 824) female middle-school students, 1 648 274 (67 520) male high-school students, 1 614 828 (60 032) female high-school students, 1 652 689 (32 724) male university students, and 1 229 142 (57 484) female university students. Among male students, the leading motives were school-related factors (underachievement and worrying about the future), followed by family-related and health-related motives. Among female students, school-related and family-related motives decreased, but health-related motives showed an age-dependent increase. The SMRPs of middle-school male students and female students were almost equal (mean [SD], 2.7 [1.0] vs 2.4 [1.4]), but the age-dependent increase in SMRPs among male students was pronounced (mean [SD], high-school vs university male students, 9.1 [2.4] vs 19.6 [3.0]; high-school vs university female students, 6.1 [2.4] vs 9.6 [1.8]). However, the incidence of suicide among high-school students associated with health-related motives was greater in female students. The majority of suicides associated with major impactable suicidal motives (school-related, health-related, and family-related motives) began increasing before the pandemic. Changes in SMRP associated with interpersonal relationships, such as conflict with classmates or parents, were not significant, but the rates increased greatly during the pandemic.

CONCLUSIONS AND RELEVANCE

School-related, health-related, and family-related problems were major motives, whereas the impacts of health-related and family-related motives increased and decreased with age, respectively. Notably, most SMRPs associated with major impactable motives (underachievement, conflict with a parent or classmate, and mental illnesses) had already begun increasing in the late 2010s, indicating that recent increasing SMRPs among school-aged individuals were associated with pandemic-related factors and other factors affecting this generation before the pandemic. It may be inappropriate to uniformly apply research findings based on school-aged individuals to school-based suicide prevention programs for students in middle school, high school, and university.

Variation in perceived health across gender, working status, educational level, and regional health care expenditure in Spain (2014-2017)

A gender perspective was used to analyze whether and how education, unemployment, and per capita public health expenditure were associated with perceived health among the Spanish population between the years 2014 and 2017. Using multilevel methodologies (looking at year, individual, and region) and linear and logistic specifications, we analyzed longitudinal microdata files from the Survey on Living Conditions. The results suggest that women with lower educational levels tend to report worse health than their more educated counterparts. On the other hand, women's bad health was not associated with unemployment, unlike men's. Regional per capita public health expenditure was not associated with perceived health in either men or women.

Is an increase in Japan's suicides caused by COVID-19 alone?

Similar to other countries, the Japanese government quickly undertook preventative measures against increasing suicides during the pandemic, but could not suppress the increase. Suicide mortality among both sexes under 20 and females aged 20-39 significantly increased during the pandemic, but unexpectedly had already slowed decreasing trends before the pandemic onset. Furthermore, before the pandemic, a higher complete unemployment rate contributed to increasing suicide mortality of both sexes, whereas during the pandemic, the positive relationship between females suicide mortalities and complete unemployment rates was not observed.

Analyzing the changing relationship between personal consumption and suicide mortality during COVID-19 pandemic in Japan, using governmental and personal consumption transaction databases

During the early stages of the ongoing COVID-19 pandemic, suicides did not increase in most countries/regions. Japan, however, was an exception to this, reporting increased numbers of female suicides with no changes in male suicide. To explore the trends of increasing suicides, the fluctuations of personal consumption (as an indicator of lifestyle) and standardized suicide death rate (SDR) disaggregated by age, sex, and prefecture, were determined using a linear mixed-effect model. Additionally, fixed effects of personal consumption on SDR during the pandemic were also analyzed using hierarchical linear regression models with robust standard errors. During the first wave of the pandemic, SDR for both sexes decreased slightly but increased during the second half of 2020. SDR of females younger than 70 years old and males younger than 40 years old continued to increase throughout 2021, whereas SDR for other ages of both sexes did not increase. Personal consumption expenditures on out-of-home recreations (travel agencies, pubs, and hotels) and internet/mobile communication expenses decreased, but expenditures on home-based recreations (contents distribution) increased during the pandemic. Increased expenditures on internet/mobile communication were related to increasing SDR of both sexes. Increasing expenditures on content distributions were related to increasing females' SDR without affecting that of males. Decreasing expenditures on pubs were related to increasing SDR of both sexes in the non-metropolitan region. These findings suggest that transformed individual lifestyles, extended time at home with a decreased outing for contact with others, contributed to the progression of isolation as a risk of suicide. Unexpectedly, increasing compensatory contact with others using internet/mobile communication enhanced isolation resulting in increased suicide risk.

Exploring characteristics of increased suicide during the COVID-19 pandemic in Japan using provisional governmental data

Background

The Japanese age-standardised death rate of suicide (SDR) had decreased during 2009-2019, but increased in 2020-2021, during the COVID-19 pandemic.

Methods

This study aimed to explain the trend change in the SDR during the pandemic, disaggregated by prefecture, gender, suicide method and household, as compared to predicted SDR derived from pre-pandemic data, using linear mixed-effect and hierarchical linear regression models with robust standard error analyses.

Findings

The SDR was lower during March-June 2020 (during the first wave of the pandemic), but higher during July-December 2020 than the predicted SDR. In 2021, males' SDR was nearly equal to the predicted SDR, whereas females' SDR in the metropolitan-region (17.5%: 95% confidence interval: 13.9-21.2%) and non-metropolitan-region (24.7%: 95% confidence interval: 22.8-26.7%) continued to be higher than the predicted SDR. These gender- and region-dependent temporal fluctuations of SDR were synchronised with those of SDRs caused by hanging, at home and single-person-households. Additionally, the rising number of infected patients with the SARS-CoV-2 and polymerase chain reaction (PCR) diagnostic examinations were positively (β = 0.024) and negatively (β =-0.002) related to the SDR during the pandemic, respectively.

Interpretation

Japanese suicide statistics have previously established that the predominant method and place of suicide were by hanging and at the individual's home, respectively. The present findings suggest that transformed lifestyles during the pandemic, increasing time spent at home, enhanced the suicide risk of Japanese people by hanging and at home.

Funding

Regional Suicide Countermeasures Emergency Enhancement Fund of Mie Prefecture (2021-40).

Relationships between Expenditure of Regional Governments and Suicide Mortalities Caused by Six Major Motives in Japan

Suicide mortality in Japan reduced in the period of 2009-2018. A number of studies identified the impact of financial governmental support for social welfare systems on suicide mortality; however, the detailed effects of specific regional policies, designed according to regional cultural, economic, education and welfare situations, on suicide mortality remain to be clarified. Therefore, the present study analyses the associations between the regional governmental expenditure of six major divisions, "public health", "public works", "police", "ambulance/fire services", "welfare" and "education", and suicide mortalities caused by six major suicidal motives, related to "family", "health", "economy", "employment", "romance" and "school", across the 47 prefectures in Japan during the period of 2009-2018, using fixed-effect analysis of hierarchal linear regression with robust standard error. The expenditure of "public works" displayed a positive relationship with suicide mortality of females caused by family-related motives but was not related to other suicide mortalities, whereas the expenditures in "public health", "police", "ambulance/fire services", "welfare" and "education" contributed to a reduction in suicide mortality, at least in some statistical indicators. The expenditures of both "ambulance/fire" and "education" were predominantly effective among the six major divisions of regional governmental expenditure in reducing suicide mortalities. In the education subdivisions, the expenditure of "kindergarten" was related to a reduction in suicide mortalities caused by a wide spectrum of motives. The amount of expenditure of welfare indicated the limited possibility of facilitating a reduction in suicide mortalities caused by only motives associated with economy or employment. However, in the welfare subdivisions, the expenditure of "child welfare" and "social welfare" was effective in reducing suicide mortalities, but the expenditure of "elderly welfare" was unexpectedly related to an increase in suicide mortalities. These results suggest that most Japanese people are struggling to bring up children even in the situation of an increasing elderly population with a decreasing birth rate. Therefore, it is important to enhance the investment welfare policy for the future to improve the childcare environment. Although the issue of an increasing elderly population and a decreasing birth rate in Japan has not yet improved, the obtained results suggest that evidence-based welfare expenditure redistributions of prefectures and municipalities could improve Japanese society and welfare systems.

Analysing the Impacts of Financial Expenditure of Prefectures on Methods of Suicide Completion in Japan

Recently, several studies reported that the governmental financial expenditures play important roles in the prevention of increasing suicide mortalities; however, the specific regional policies, designed dependent on regional cultural, economic, education and welfare backgrounds, affect suicide mortality by a specific suicidal means. Therefore, the present study determined the impacts of the regional governmental expenditure of six major divisions, “public health”, “public works”, “police”, “ambulance/fire services”, “welfare” and “education” on suicide mortalities by five major suicidal means, “hanging”, “poisoning”, “charcoal burning”, “jumping” and “throwing”, across the 47 prefectures in Japan during 2009–2018 using fixed-effect analysis of hierarchal linear regression with robust standard error. The expenditures of “ambulance/fire services” and “education” indicated the negative relation to suicide mortalities by wide-spectrum suicidal means, whereas expenditures of “public works” did not affect suicide mortalities. In the education subdivisions, expenditure of “kindergarten” and “elementary school” indicated the impacts of reduction of suicide mortalities, whereas the expenditures of “special school” for individuals with disabilities unexpectedly contribute to increasing suicide mortalities by poisoning, charcoal burning and throwing of females. Regarding subdivisions of welfare, expenditure of “child welfare” and “social welfare” contributed to a reduction in suicide mortalities, but expenditure of “elderly welfare” surprisingly contributed to increasing suicide mortalities. Furthermore, expenditures of welfare subdivision abolished the negative impacts of the expenditures of educational subdivisions, kindergarten and elementary school, but the positive impact of expenditure of special school on female suicide mortalities was not affected. These results suggest that most Japanese people are struggling to care for children even in the situation of an increasing elderly population with a decreasing birthrate. Therefore, it is important to enhance the investment welfare policy for the future to improve the childcare environment. The results demonstrated by this study suggest that the scientifically evidence-based redistributions of welfare expenditure in regional government, at least partially, provide improvement of Japanese society and welfare systems, under the continuous severe Japanese social concerns associated with increasing elderly population with a decreasing birthrate.

Determining What Changed Japanese Suicide Mortality in 2020 Using Governmental Database

The pandemic of 2019 novel coronavirus disease (COVID-19) caused both COVID-19-related health hazards and the deterioration of socioeconomic and sociopsychological status due to governmental restrictions. There were concerns that suicide mortality would increase during the COVID-19 pandemic; however, a recent study reported that suicide mortality did not increase in 21 countries during the early pandemic period. In Japan, suicide mortality was reduced from 2009 to 2019, but both the annual number of suicide victims and the national suicide mortality rates in 2020 increased compared to that in 2019. To clarify the discrepancy of suicide mortality between the first and second half of 2020 in Japan, the present study determines annual and monthly suicide mortality disaggregated by prefectures, gender, age, means, motive, and household factors during the COVID-19 pandemic and pre-pandemic periods using a linear mixed-effects model. Furthermore, the relationship between suicide mortality and COVID-19 data (the infection rate, mortality, and duration of the pandemic) was analysed using hierarchal linear regression with a robust standard error. The average of monthly suicide mortality of both males and females in all 47 prefectures decreased during the first stay-home order (April-May) (females: from 10.1-10.2 to 7.8-7.9; males: from 24.0-24.9 to 21.6 per 100,000 people), but increased after the end of the first stay-home order (July-December) (females: from 7.5-9.5 to 10.3-14.5; males: from 19.9-23.0 to 21.1-26.7 per 100,000 people). Increasing COVID-19-infected patients and victims indicated a tendency of suppression, but the prolongation of the pandemic indicated a tendency of increasing female suicide mortality without affecting that of males. Contrary to the national pattern, in metropolitan regions, decreasing suicide mortality during the first stay-home order was not observed. Decreasing suicide mortality during the first stay-home order was not observed in populations younger than 30 years old, whereas increasing suicide mortality of populations younger than 30 years old after the end of the first stay-home order was predominant. A decrease in suicide mortality of one-person household residents during the first stay-home order was not observed. The hanging suicide mortality of males and females was decreased and increased during and after the end of the first stay-home orders, respectively; however, there was no decrease in metropolitan regions. These results suggest that the suicide mortality in 2020 of females, younger populations, urban residents, and one-person household residents increased compared to those of males, the elderly, rural residents, and multiple-person household residents. Therefore, the unexpected drastic fluctuations of suicide mortality during the COVID-19 pandemic in Japan were probably composed of complicated reasons among various identified factors in this study, and other unknown factors.

Analysing effects of financial support for regional suicide prevention programmes on methods of suicide completion in Japan between 2009 and 2018 using governmental statistical data

OBJECTIVES

To explore the mechanisms of reduction of suicide mortality in Japan (from 25.7 to 16.5 per 100 000 population) between 2009 and 2018, the present study determined the effects of execution amounts of regional suicide prevention programmes (Emergency Fund to Enhance Community-Based Suicide Countermeasure: EFECBSC) on gender-specific trends of suicide mortality by disaggregated methods.

DESIGN AND SETTING

Stepwise multiple regression analysis was used to determine the effects of execution amounts of 10 subdivisions of execution amounts of financial support for regional suicide prevention programmes (EFECBSC) on suicide methods and gender disaggregated suicide mortalities in Japan between 2009 and 2018 using the statistical data obtained from national governmental database.

RESULTS

The suicide mortalities by the most common/frequent suicide methods, hanging, charcoal burning and jumping were significantly decreased between 2009 and 2018. Male hanging suicide was decreased by prefectural enlightenment, municipal development programmes, but female hanging suicide was decreased by municipal personal consultation programmes. Municipal development and enlightenment programmes decreased male and female charcoal-burning suicide mortalities, respectively. Jumping suicide was decreased by prefectural telephone consultation programmes but was unexpectedly increased by municipal personal consultation and enlightenment programmes.

CONCLUSIONS

This study revealed the contribution of ECEFBSC on reduction of suicide mortalities, especially hanging, charcoal-burning and jumping suicides, via enhancement of regional suicide prevention programmes in Japan; however, notably, the 'means substitution' from parts of hanging and charcoal burning to jumping is probably generated by EFECBSC. Therefore, these findings provide important aspects for planning evidence-based and cost-effective regional suicide prevention programmes.

Effects of Financial Expenditure of Prefectures/Municipalities on Regional Suicide Mortality in Japan

In Japan, suicide mortality has been improving from 2009; however, suicide remains one of the leading causes of death. Although previous studies identified solid relationships between governmental financial support for social welfare systems and suicide mortality, little attention is paid to how specific regional policies, designed according to regional cultural, economic, and social welfare situations, affect suicide mortality. Therefore, the present study analyses the relationships between the regional governmental expenditure of six major divisions and suicide mortality across the 47 prefectures in Japan from 2009 to 2018 using fixed-effect analysis of hierarchal linear regression with robust standard error. The expenditure in “public health”, “police”, “ambulance/fire services”, “welfare” and “education” is associated with reduction in suicide mortality, at least in some statistical indicators, whereas expenditure of “public works” indicated the influence of increasing suicide mortality or had no effect. Welfare expenditure was the most predominantly effective among the six major divisions of regional governmental expenditure. In the welfare subdivisions, expenditure of “child welfare” and “social welfare” was effective in a reduction in suicide mortality, but expenditure of “elderly welfare” surprisingly contributed to increasing suicide mortality. Child welfare expenditure negatively impacted suicide mortality in wide-ranging generations of both males and females; the positive effects of elderly welfare expenditure reached were limited as working-age populations increased, but unexpectedly did not affect the suicide mortality of elderly populations. The relatively increasing expenditure of elderly welfare with the relatively decreasing child welfare are unavoidable due to the Japanese social issues associated with a declining birth rate and ageing population. Furthermore, the budget of that regional government that can modify its expenditure structure by making its own policies is limited since most regional governmental expenditure is composed of essential expenditure for maintaining and operating regional social welfare systems. Although severe social situations in Japan are still unoptimised, the present results suggest that scientific-evidence-based redistributions of welfare expenditure in regional governments can at least partially improve Japanese society and welfare systems.

Impacts of Dual-Income Household Rate on Suicide Mortalities in Japan

To explore impact of enhancing social advancement of females in Japan, this study determined the effects of the dual-income household rate on suicide mortalities disaggregated by attributes of gender, age, and motives between 2009 and 2017 in Japan. This study analysed impact of dual-income household rate, other household-related factors (savings, liabilities and yearly incomes per household, minors and elderly rate per household), and social/employment factors (complete unemployment rate, employment rate, temporary male and female employment rates and certification rate of long-term care insurance) on suicide mortalities disaggregated by attributes of gender, age, and motives using hierarchical linear-regression model. Dual-income household rate was significantly/negatively related to suicide mortality of the working-age female population, but significantly/positively related to that of the elderly female population. Suicide mortalities of the working-age male population and the elderly male population were significantly/positively related to dual-income household rate. Male suicide mortalities caused by family-, health-, economy- and employment-related motives were significantly/positively related to dual-income household rate; however, the dual-income household rate was significantly/positively related to female suicide mortalities caused by family-, health-, economy- and school-related motives, but significantly/negatively related to suicide mortalities caused by romance-related motives. Dual-income households suppress social-isolation and develop economical/psychological independence of females, leading to reduced suicide mortality in working-age females. However, elderly and school-age populations, who are supported by the working-age female, suffer from isolation. Working-age males also suffer from inability to adapt from the traditional concept of work–life and work–family balances to the novel work–family balance concept adapted to dual-income households. These results suggest occurrence of new social/family problems in the 21st century due to vulnerability of traditional Japanese culture and life–working–family balance concepts as well as novel sociofamilial disturbances induced by declining birth rate and ageing population in Japan.

Impacts of Interaction of Mental Condition and Quality of Life between Donors and Recipients at Decision-Making of Preemptive and Post-Dialysis Living-Donor Kidney Transplantation

Pre-emptive kidney transplantation (PEKT) is considered one of the most effective types of kidney replacement therapies to improve the quality of life (QOL) and physical prognosis of patients with end-stage renal disease (ESRD). In Japan, living-donor kidney transplantation is a common therapeutic option for patients undergoing dialyses (PDKT). Moreover, during shared decision-making in kidney replacement therapy, the medical staff of the multidisciplinary kidney team often provide educational consultation programmes according to the QOL and sociopsychological status of the ESRD patient. In Japan, the majority of kidney donations are provided by living family members. However, neither the psychosocial status of donors associated with the decision-making of kidney donations nor the interactions of the psychosocial status between donors and recipients have been clarified in the literature. In response to this gap, the present study determined the QOL, mood and anxiety status of donors and recipients at kidney transplantation decision-making between PEKT and PDKT. Deterioration of the recipient's QOL associated with "role physical" shifted the decision-making to PEKT, whereas deterioration of QOL associated with "role emotional" and "social functioning" of the recipients shifted the decision-making to PDKT. Furthermore, increased tension/anxiety and depressive mood contributed to choosing PDKT, but increased confusion was dominantly observed in PEKT recipients. These direct impact factors for decision-making were secondarily regulated by the trait anxiety of the recipients. Unlike the recipients, the donors' QOL associated with vitality contributed to choosing PDKT, whereas the physical and mental health of the donors shifted the decision-making to PEKT. Interestingly, we also detected the typical features of PEKT donors, who showed higher tolerability against the trait anxiety of reactive tension/anxiety than PDKT donors. These results suggest that choosing between either PEKT or PDKT is likely achieved through the proactive support of family members as candidate donors, rather than the recipients. Furthermore, PDKT is possibly facilitated by an enrichment of the life-work-family balance of the donors. Therefore, multidisciplinary kidney teams should be aware of the familial psychodynamics between patients with ESRD and their family members during the shared decision-making process by continuing the educational consultation programmes for the kidney-replacement-therapy decision-making process.

Analysing the Impacts of Financial Support for Regional Suicide Prevention Programmes on Suicide Mortality Caused by Major Suicide Motives in Japan Using Statistical Government Data

To improve and plan regional suicide prevention programmes that utilise more cost-effective governmental financial support compared with previous programmes, the present study determined the effects of the amount of financial support provided for regional suicide prevention programmes, such as the Emergency Fund to Enhance Community-Based Suicide Countermeasures (EFECBSC), on the trends of suicide mortalities caused by six major suicide motives between 2009 and 2018, using forward multiple regression analysis. The ranking order of motives for male suicide was health, economy, family, employment, romance and school (in that order), whereas the ranking order for females was health, family, economy, romance, employment and school. Male suicide mortality caused by economy-related motives was significantly/inversely related to prefectural intervention programmes, whereas mortality caused by health-related motives was also significantly/inversely related to prefectural intervention programmes, but significantly/positively related to prefectural personal consultation support programmes. Contrary to males, female suicide mortality caused by health-related motives was significantly/inversely related to the municipal development programmes of leaders/listeners, whereas mortality caused by family- and school-related motives was significantly/positively related to prefectural and municipal telephone consultation support programmes, respectively. Contrary to our expectations, school-aged female suicide mortality caused by school-related motives was significantly/positively related to prefectural personal consultation support, enlightenment and municipal telephone consultation support programmes. These results indicate that Japanese regional suicide prevention programmes probably affect the suppression of male suicide mortality. However, these programmes are possibly ineffective, or at least partially, have an adverse effect, in regard to the suicide mortalities of female and school-aged populations. Therefore, we should work to improve regional suicide prevention programmes, making them more cost-effective and targeted towards female and school-aged populations in the future.