On June 18, 2013, the government released the White Paper on Suicide-Prevention Measures for 2013^[1] and reported that the number of people who committed suicide in 2012 fell below 30,000 for the first time in 15 years. However, this figure is still among the highest for developed countries^[2] and remains seven times greater than fatalities from traffic accidents, with an average of 70 people dying each day because of suicide. Suicides tend to increase with old age throughout the world, but Japan has a unique trend in which suicides peak among men in their forties to sixties. In fact, it is known that the number of attempted suicides is around ten times the number of suicides, and that for every person who commits suicide, there is an average of six or more family members who must deal with the loss.^[3] Despite this fact, however, reports on the current state of suicides and supportive intervention are extremely limited in Japan. Families of suicide victims are subjected to prejudice and tormented by shame and a sense of isolation.^[4] There was a class of Suicide Prevention and Control offered as a specialized academic course at the American school of public health where I studied.^[5] It was a very interesting course that analyzed initiatives from all over the world and the latest information, and introduced students to subjects like mental health care for surviving family members, especially children, of suicide victims. It is estimated that there are about three million bereaved family members of suicide victims in our country at present,^[6] but interventions on behalf of these family members are only done on a small scale, and their voices are not widely heard.

I spent five years and three months from July 2007 to October 2012 analyzing a part of the quantitative data portion of Listening to the Voices of the Voiceless: A Survey on Suicide (an interview survey of the family members of 523 suicide victims).^[7][8] A summary of the results was released in March 2013 as The 2013 Survey on Suicide (1st Edition).

People who meet the conditions for an interview survey of family members of suicide victims are what is called a hard-to-reach population, and therefore the survey had use respondent driven sampling (RDS) through the active cooperation of participants.

In terms of results, as there were over 500 respondents, an approach combining both quantitative analysis and qualitative analysis was attempted. Using the data to qualitatively clarify how much time there was to take preventative action, or make an intervention, and how urgent such action was for which people was one of the key tasks I set. Various occupations and ages were represented, but as we analyzed the data, we noticed characteristics that varied based on whether respondents were self-employed, company managers, female, students, and so on.^[9]

What the survey on suicide suggests

Even among the self-employed, the median time between business founders getting into debt or becoming responsible for debt as a cosigner and the point when half (50%) of them committed suicide was especially short—only two years. The median time for employees of companies was 4.5 years. One must admit that the time available for intervention between the occurrence of the trigger and suicide is, in fact, extremely limited. One of the characteristics seen in self-employed individuals is that they are less likely to talk about their problems with the people around them, so others do not realize that they have fallen into debt or are under pressure. When asked if they thought there were suicide warning signs, about 60% (58.2%) of all respondents said, “Yes, I think there were.” But the percentage of those who did not think that these were suicide warning signs at the time was actually as high as 90%. This indicates that even if warning signs are present, it’s actually difficult for people to recognize them.

At present, the task thought to be most urgent is coming up with prevention measures for the increasing number of suicides among young people. For those under 20, the median time between the occurrence of the trigger and the point when half of the group commits suicide is 3.2 years, according to this data. There are many instances in which the individual commits suicide within an extremely short period of time after the occurrence of the trigger. I think young people under 20 should also be treated as a high risk group for suicide in Japan today.

Problems facing the families of suicide victims

Comprehensive information about the families of suicide victims are rarely made public in Japan. The families also stay silent about the suicide, believing it is a type of death that must be concealed. This survey interviewed the family members of the suicide victims about the victims and threw light on even bigger challenges facing their families.

These include claims for compensation from the place where the suicide victim died, strained family finances due to the sudden loss of the primary breadwinner, efforts to avoid family-related topics out of a desire not to discuss the cause of death of the deceased, inconsiderate remarks from others, and regrets and feelings of guilt that do not fade with time. “How could you be so close to him/her and not realize what was going on?” was mentioned as an extremely difficult remark for surviving family members to hear. In addition, there has been very little change in the guilt felt by family members from immediately after the suicide up to the present. Approximately one half of the family members still answer, “I think the death of my family member was my fault,” even though several years have passed since the suicides.^[10] Only the feeling of “I want to die too,” measured at 32.5% right after the suicide, decreased slightly to 17.6% when the respondents were interviewed again several years later, while nearly half (45.6%) of respondents said that they still suffered from feelings of despair and dejection with a sense of uncertainty about the future. On the other hand, we found that remarks and messages such as “It’s okay to not be perfect,” “You haven’t done anything wrong,” and “He/she (the person who died) supported the people around him/her,” and close friends watching out for them and emailing them daily helped sustain the family members during this time.

Moving into the third year after the Great East Japan Earthquake

We have passed the two year mark since the 2011 Great East Japan Earthquake and entered the third year. The current situation and issues that need to be addressed have been pointed out several times in this Chuo Online column.^[11] The number of suicides are reported to have greatly decreased from pre-quake levels during the first and second years following the recent earthquake disasters we have experienced in Japan.^[12] However, this trend reversed when we moved into the third year, and the number of suicide victims increased. The Chuetsu Earthquake faithfully exhibited these phenomena.^[13] In the Great Hanshin Earthquake, the number of those who died alone also increased. It has been found throughout the world that the risk factors for suicide include sex (men are more at risk), age, health status (the sick are more at risk), hours of sunshine, low income, occupation, a lack of interpersonal relationships in the community, the death of a family member, and living on a slope. Several of these factors markedly change and emerge in a short period of time following a disaster.

At the beginning of July, I visited and interviewed local medical staff in disaster areas of Iwate prefecture. One individual told me, “We limit consultations to twenty-minutes, but we still don’t have any time to spare. One person who came in said, ‘I had that dream again. An old woman and her grandchild called out to me in the tsunami and asked me to save them. But even though I could see their faces, I couldn’t help them.’ There are actually still a lot of people who have trouble sleeping at night.” The psychological and physical strain that comes from staying long-term in temporary housing is actually nearing limits.

It has been pointed out how temporary housing after the Great Hanshin Earthquake was set up in such a way that it disrupted communities and interpersonal relationships. This led to an increase in the number of people who died alone, teaching us a valuable lesson. With the Great East Japan earthquake, a difference has be seen in the cohesiveness of districts and the comfort experienced by residents between districts that keep pre-earthquake communities together in temporary housing and districts that do not. The truth is that suicide is not nonexistent in temporary housing. This is the third year the risk of suicide is expected to increase.

There have been students who were victims of the Great East Japan Earthquake among the seminar students I supervise, and I have traveled to the disaster areas several times, starting right after the earthquake. Earthquake victims’ stay in temporary housing has dragged on, and there is no shortage of ways universities and students can contribute to improving the lives of people in areas where the future remains uncertain; even continuous efforts on a small scale help.

This August, I conduct a temporary housing survey in disaster areas of Iwate prefecture. As the member of a university, I think it is my duty not just to report survey results, but to stay close to the victims and convey a message that they are always in our thoughts, even when we are separated by long distances.^[14] With that goal in mind, I am getting a certain number of students to help me conduct the field survey.

Providing gentle interventions for environments and people at high risk for suicide is a difficult challenge, but it is not impossible. This is a year when the knowledge Japan has acquired from global-scale disasters like the Great Hanshin Earthquake and the Chuetsu Earthquake will once again be put to the test.

Kayako Sakisaka
Specially-Appointed Associate Professor, Chuo University Organization for Common Education Initiatives
Areas of Specialization: social epidemiology, global health, public health, international cooperation

Professor Sakisaka was born in Tokyo. She graduated from the School of International Health, Graduate School of Medicine, University of Tokyo with master of public health (MPH) and doctor of philosophy in health science (PhD) degrees. After serving as a Takemi Fellow at the Harvard School of Public Health (2009 - 2010), and an Assistant and Assistant Professor at the Graduate School of Medicine and the Faculty of Medicine, University of Tokyo, she became a Specially-Appointed Associate Professor on the Faculty of Policy Studies, Chuo University in 2011. She assumed her current position in April 2013. Her main publications and co-authored publications include: An Introduction to International Health Care Collaboration [kokusai hoken iryou kyouryoku nyuumon] (1998); The Sector-Wide Approach Trend in the Field of Health Care [hoken iryou bunya ni okeru sekutaa-waido apuroochi no doukou] (2001); Village Development and International Cooperation [sonraku kaihatsu to kokusai kyouryoku] (2002); Parteras and Community Health [paruteera totomoni chiiki hoken] (2005); and Our Work Connecting Local Sites with the World [genchi to sekai wo tsunagu watashitachi no shigoto] (2008). She has also authored numerous articles in English (Click here for more details).