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The following article was published by Japan Times contributor Roger Pulvers on Feb 12, 2012. Nearly five years later, the situation has not improved by much. Here’s the article in full:

The greatest public health issue facing the people of Japan today is not cancer. It is not vascular diseases than can cause heart attacks and strokes. It is not the prevalence of Alzheimer’s disease in the ever-rising number of the elderly.

It is depression in its many forms and guises.

Depression is the big gorilla on the basketball court, the one that’s stealing the ball but isn’t seen because everyone is willfully looking the other way.

The causes of depression can be biological, psychological, social or a combination of these. It affects young people to a much greater degree than they or their elders imagine. The elderly are particularly vulnerable. In fact, according to the Health and Consumer Protection Directorate-General of the European Commission, “depressive illness is the most frequent mental disorder among older people.”

Name any significant social problem — alcoholism and other drug-related illnesses, homelessness, teenage pregnancies, self-harm, domestic violence, child abuse, suicide — and you are more than likely to find some form of depression or serious mood disorder as a cause.

According to the World Health Organization, the international health burden brought on by clinical depression is enormous when measured by “cause of death, disability, incapacity to work and the use of medical resources.” And this does not take into account the hidden costs, such as those borne by unpaid caregivers, nor the heartrending toll on sufferers’ families.

Here in Japan, where a conservative estimate is that 1 in 5 people will experience one or another form of depression in their lifetime, the abiding societal postulate is: Keep it to yourself (KITY). In fact, this principle is applicable to the appearance of many social ills. If you don’t ask and you don’t tell, then it’s as if through such deceptions the problem will somehow slip below the tatami and disappear from

Whether you analyze this national trait as coming from an ancient Buddhist notion according to which victims and their family are “responsible” for a blight, or simply as a factor of garden-variety prejudice against anything smacking of “abnormality,” this society has long stigmatized anyone who might put a blot on the veneer of decorous harmony.

So, in actual fact, the working precept here is stigmatization. If you stigmatize someone in their milieu, they generally go away and hide (or die). Once they stigmatize themselves, you don’t need to bother anymore. You can even pretend to be tolerant. It works like a charm.

Kenzo Denda, of the Department of Psychiatry at Hokkaido University Graduate School of Medicine, has reported that 1 in 12 elementary school pupils suffers from depression, while at the middle-school level the figure may be as high as 1 in 4. Studies show that at least one-third of the prison population is made up of the clinically depressed.

Statistics on depression for Japan are very similar to those in the developed West. Statistics published by the Japan Committee for Prevention and Treatment of Depression (JCPTD) show that 6.6 percent of Japanese have depression, while every year the reported incidence is 2.1 percent. The breakdown by gender is also similar to that in the West: Women with depression outnumber male sufferers by about 3 to 1. In the West, the incidence of depression is particularly high in the young, while in Japan, says the JCPTD, it is spread among young and old.

But these comparative statistics can be misleading. A joint Japan-Australia survey on mental health conducted in 2003 and 2004 indicated that, in the case of Japan, a great many actual cases of depression were put in the category of “psychological problems and stress.”

Recognition is the crux of the problem. While big strides have been made in the treatment of depression in Japan over recent years, thanks in part to effective new drugs, the recognition of depression at the primary-care level is inadequate. General practitioners are not sufficiently trained to recognize depression. They too often attribute symptoms to other illnesses. The KITY meme exacerbates this. Japanese tend to be too reticent to divulge their true anxieties to anyone.

There has been an overemphasis in this country on male problems based on the stresses and strains of employment. Japanese women are traditionally told to grin and bear their suffering and not overburden others with their personal problems. Don’t nag. Don’t whine. Just pull yourself together, sigh a big sigh and get on with your tasks.

Active for the last 40 years, JCPTD has held countless conferences, meetings and forums for health professionals and the public. The organization is proactive in trying to train doctors to recognize depression when they see it. National broadcaster NHK’s educational channel has also had some amazingly frank shows about depression — including one in which female sufferers admitted to having sex with a great number of men in order to bolster their self-esteem. The courage of these women, who appeared under their own names, would be astounding in any country — let alone in Japan, where appearances count for so much.

But Japanese society will not come to terms with depression until very high-profile sufferers — whether royalty, movie stars or politicians — come out from behind the folding screen and openly talk about their illness. (Some people in show business have done this; and this has had a beneficial effect on public awareness.)

The task ahead for Japan is the total destigmatization of depression. This can only be achieved by opening the closet door and sharing the burden of illness throughout the entire society.

Writing in the February issue of the Japanese monthly news and current affairs magazine Wedge, freelance journalist Ryutaro Kaibe points out that every year between 800,000 and 1.2 million Japanese quit or stay away from work because of depression. The annual cost to the nation is an estimated ¥2.7 trillion.

To such costs must be added the human costs of suicides stemming from depression. Conservatively, 30 percent of the annual toll — more than 30,000 dead for 13 consecutive years — is due to depression. Most estimates indicate half, while some go as high as 80 percent to 90 percent.

It may be the sense of dignified self-restraint and prim respectability that compel Japanese people — particularly, as tradition has dictated, women — to de-emphasize their needs and display only the mildest forms of “proper” embarrassment. But when it comes to depression and the immense toll it is inflicting on individuals and society, it is time to abandon these shared virtues and go public.

Without mass public recognition of this ubiquitous problem, the good work being done by the psychiatric profession and NHK will prove ineffective.

As much as two-thirds of psychiatric disorders go untreated; and only one-fourth of sufferers receive some sort of medical help. This would imply that millions of people are still forced to suffer in silence.

All this makes depression the least prominent and most grave public health problem in the nation. Neglecting the people who need immediate treatment and care puts their lives in danger. It also imposes on all citizens an onus of silent guilt and widespread misfortune that can never be lifted.

Japan has marginalized those considered mentally ill for a long time and has developed a stigma against it.  Previously, mentally ill Japanese prisoners were ordered to be executed.  Today, the Japanese are taught to endure their mental issues privately, rather than to seek help from doctors.

Japan has one of the highest suicide rates in the world. In 2007, 33,093 people committed suicide, the second-highest number ever recorded, and it is the leading cause of death among people who are 20-49 years old and accounts for more than 30% of all deaths in Japan.  Primary causes for suicide include despair triggered by tragedy or a personal sense of failure and clinical depression caused by mental or emotional trauma or neurological factors.

Local doctors do not fully understand depression, its diagnosis and its treatment and are more likely to prescribe anxiety medications to relieve patients of their symptoms.  They most commonly prescribe anti-anxiety medications, sleep medications and antidepressants, resulting in a massive spike in the distribution of these drugs.

Although they effectively treat symptoms, addiction to these drugs has become a concern.  Withdrawal from them has been proven to be more difficult than withdrawal from heroin.  Professionals believe that long-term use of antidepressants can be much more harmful than their original condition.

Click here to view the full article

Many Japanese have a somewhat romanticized image of living in Britain. While for some those expectations may be fulfilled, the reality for others is that they struggle to adapt to a very different culture. A common complaint of those having difficulty adapting to British life is a feeling they cannot make themselves understood in English, and this leads to a sense of powerlessness, isolation, inferiority and frustration, says Nippoda. Unable to describe their true feelings, Japanese women may argue with their British partners and, on some occasions, turn violent, she said. In addition, some Japanese women may feel disappointed that British men do not match up to their expectations of a traditional English gentleman. Japanese students frequently find they are unable to follow lessons and, rather than seeking help, withdraw from life and become demotivated.
Go to the full article on Japan Times

Japan’s Mental Health Crisis
The Great East Japan Earthquake of 2011 affected the mental health of individuals in the regions directly impacted by the earthquake, tsunami and nuclear disasters and throughout Japan, spreading fear and concern to all Japanese living in and outside Japan. This further exacerbated the existing dearth of mental health services and practitioners. Both national experts and local authorities recognized the need for enhanced mental health services and reformation in mental health service delivery. In April 2013, the Japanese government announced the intention to make mental health a fifth national priority for national medical services, changing the balance of care from institutional services to community-based services. A December 2013 fact-finding trip to visit with officials from the Japan Red Cross, Japanese Association of Psychiatric Social Workers, and Miyagi Prefecture Department of Mental Health found a predominant spending in infrastructure using disaster relief funds, yet little has changed to increase the country’s capability to provide effective psychological counseling and psychotherapy. This is to be expected as the United States underwent a similar transformation beginning in the late 1950s with John F Kennedy’s Community Mental Health Act signed into law in 1963 and 40 years passed before achieving the level of arguable success we see today.

Where to Begin?
While Japan undertakes efforts to educate and transform societal opinions about mental illness and treatment and builds a new mental health infrastructure, the people living in Japan continue to go without adequate mental health services. In regards to disaster relief, the development of stress response syndromes, depression and an exacerbation of underlying psychopathology is a concern. Two years after the 2011 disaster, the main concern is about post-traumatic stress disorder (PTSD), which can be disabling. Our communications with disaster area relief agencies indicate the most impactful intervention from CJMH is to address their immediate need for psychological counseling for relief workers, social workers, and other caregivers who have persisted in providing long-term care to disaster victims. These individuals are more accepting of psychological counseling than the general public which they serve, and their mental well-being is critical to their ability to continue providing quality care to others. There is also an urgent need to better train medical and mental health practitioners, social workers, and caregivers in Japan on how to recognize symptoms of PTSD for referral to mental health specialists for treatment. Undiagnosed and untreated depression also remains a large problem as evidenced by Japan’s high suicide rate which remains higher than most other industrialized nations.

Who Can Best Help?
Sadly, Japanese psychologists and psychotherapists are not up to the task yet. The Japanese government does not regulate clinical psychologists or psychotherapists, and Japanese insurance companies do not cover their services. The certifications for the Japanese versions of these vocations only require a fraction of the training hours required by California’s Board of Behavioral Sciences. Not surprisingly, Japanese psychologists and psychotherapists are prohibited from making diagnoses, and that task is left for Japanese physicians and psychiatrists who are already overburdened and favor medication over psychotherapy. American mental health practitioners, particularly those trained and licensed in California, are arguably the best qualified professionals to provide training and counseling to their Japanese counterparts. Japan will need to undergo transformations in service delivery and insurance reform to effect a true, lasting solution to its mental/health crisis. In the meantime, its people need treatment. Effective knowledge transfer and service delivery can only be enacted by competent practitioners who are culturally astute and native Japanese speakers, i.e. organizations such as our Center for Japanese Mental Health. Our psychotherapists and clinical staff are multilingual, native Japanese speakers and are fluent in Japanese language and culture, enabling them to provide effective multi-ethnic, cross-cultural counseling to Japanese-speaking patients. Our cumulative expertise in effective, applied psychotherapy, understanding of English and Japanese language, cultures, and value systems, and professional relationships in the USA and Japan enable us to bridge the language, cultural, and institutional divides to facilitate knowledge sharing and innovation in the field of mental health for the benefit of both nations.