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

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.

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.

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.

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.

Bidirectional Causality between Spreading COVID-19 and Individual Mobilisation with Consumption Motives across Prefectural Borders in Japan

A combination of pharmaceutical and non-pharmaceutical interventions as well as social restrictions has been recommended to prevent the spread of coronavirus disease 2019 (COVID-19). Therefore, social contact surveys play an essential role as the basis for more effective measures. This study attempts to explore the fundamental basis of the expansion of COVID-19. Temporal bidirectional causalities between the numbers of newly confirmed COVID-19 cases (NCCC) and individual mobilisations with consumption motives across prefecture borders in three metropolitan regions in Japan were analysed using vector autoregression models. Mobilisation with consumption in pubs from Kanto to Tokai contributed to the spread of COVID-19 in both regions. Meanwhile, causal mobilisation with consumption motives in Kansai also contributed to the expansion of COVID-19; however, the pattern was dependent on the industrial characteristics of each prefecture in Kansai. Furthermore, the number of pub visitors in Kanto immediately decreased when NCCC increased in Kanto. In contrast, the causal mobilisations for the expansion of COVID-19 in the Tokai and Kansai regions were unaffected by the increasing NCCC. These findings partially proved the validity of the conventional governmental measures to suppress pub visitors across prefectural borders. Nevertheless, the individual causal mobilisations with consumption motives that contributed to the increasing COVID-19 cases are not identical nationwide, and thus, regional characteristics should be considered when devising preventive strategies.

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.