REVIEW
Suicide prevention program for the elderly:
the experience in Japan
Yutaka Ono
Health Center, Keio University, Kanagawa, Japan(Received for publication on July 22, 2003)

Abstract. In this article, the author describes a suicide prevention program for the elderly in Japan
carried out in a small town, Nagawamachi, Aomori. Because of the recent sharp increase in this town in
the rate of suicides, we started to develop a suicide prevention program with the goal of trying to detect
depression in its early stages. At ﬁrst we adopted various questionnaires and used structured interviews, and then developed a screener for depression. Screening is an important part of our suicide
prevention program, because elderly who are suicidal often do not recognize their distress is a treatable
medical condition, partly due to a negative image of mental illness, and most of them do not seek
medical help. The author underscores the importance of educational programs to address how to recognize the symptoms of depression and to develop a community network for the elderly to communicate with locals and support each other. It is also important to focus on a social schema to produce asociety that respects ‘‘being’’ and not just ‘‘doing’’. (Keio J Med 53 (1): 1–6, March 2004)
Key words: depression, suicide prevention, screener, psychoeducation

increases to 4 to 1 among the elderly, compared to100@200 to 1 among juveniles.1,2
The most consistently prevalent motive for suicide
among the elderly is illness – accounting for more than
60%, according to statistics from the National Police
Agency – followed by problems at home, alcoholism
and mental disorders. There are often family problems.
It has been reported that elderly individuals often
commit suicide in the homes where they live with theirfamilies, and not alone.
Within this context, we have been active since 1999
in creating a practical intervention program to identify
depression for the prevention of subsequent suicides,with the cooperation of Nagawamachi, Aomori Prefecture, which has a higher than average rate of suicide
among the elderly, as part of a national project.3,4 The
signiﬁcance of and procedures for suicide prevention
activities for the elderly are discussed in this paper.

Introduction
The annual number of suicides in Japan, which was
23,000 in 1997, increased markedly to 32,000 in 1998,
and leveled off at about 30,000 per year thereafter. This
precipitous increase was thought to have been a resultof an increase in the number of suicides by males intheir ﬁfties. While the suicide rate among teenagers and20 year-olds has been declining in Japan, a high suicide
rate among the elderly has become evident. The suicide
rate is known to increase with age, with a high rate observed among those 75 years and older.
The suicide rate among the elderly in Japan is alsohigh compared with that for other countries, and therate in rural Japan has increased more than in urban
areas. With regard to gender ratios, although there is ahigher rate among males than among females – a trend
similar to other countries – the gender difference is relatively small in Japan because the female suicide rate isso high. Moreover, there are few apparent predictive
indications for suicide among the elderly, and the rateof consummated suicides is extremely high. The ratioof attempted to consummated suicides among all age
groups is approximately 10 to 1. However, that ratio

Psychoeducation Activities
It has been claimed that more than most elderly individuals who commit suicide have had a prior mental
disorder, and that depression is often a signiﬁcant factor

Reprint requests to: Dr. Yutaka Ono, Health Center, Keio University, 4-1-1 Hiyoshi, Kohoku-ku, Yokohama-shi, Kanagawa-ken 223-8521,
Japan, telephone and facsimile: 81-45-566-1119, e-mail: yutakaon@sc.itc.keio.ac.jp
1

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in suicide, particularly among the elderly.5,6 It has beensuggested that early diagnosis and treatment of depression may be effective in preventing suicide.
Thus, although recognition and treatment of depression at an early stage are important in preventing suicide, the majority of people are unaware they are
depressed, and do not discuss it with others. For example, in our study4 of depression among individuals
65 years and older, 44 (12.3%) of 358 participants
responded that they had either ‘‘thoughts of death’’or ‘‘thoughts of suicide’’, and these thoughts had
continued for more than two weeks in 12 participants (3.4%). Only 15 of the 44 suicidal elderly
responded that they had consulted someone about theirproblems.
One reason that such a low percentage of elderlywith thoughts of death or suicide consulted others may
be their lack of awareness that depression can betreated. The other reason might be that depressive elderly tend to somatize and overlook depressive symptoms, or that a stigma against psychiatric disorders may
make it difﬁcult for them to seek help from others.
These results indicate the importance of community
networking through educational activities to increase
the possibility that people with depressive symptoms
will seek help, so that suicide may be prevented.
The importance of local public health activities has
been also advocated as a result of previous community
projects in Japan. In both Matsunoyamamachi, Niigata Prefecture, and J-town, Iwate Prefecture, suicide
among the elderly dramatically decreased through a
local intervention program.
For example, suicide prevention activities were conducted in Matsunoyamamachi from November 1986
to December 1996.7 For the elderly who were found to
be at a high risk of suicide, a primary care physician
provided psychiatric treatment and public health nurses
provided public health care and welfare. The high risk
group was identiﬁed using the Niigata University selfrating depression scale (NSDS), a revised Zung’s SDS,8
or through an interview by primary care physicians andpublic health nurses. The following groups were also
identiﬁed as high-risk: 1) elderly with a history of depression; 2) elderly hinting at suicide; 3) elderly who
had just experienced the death of a spouse; 4) elderly
who had just been released from a medical facility; and5) elderly whose relative or neighbor had recently committed suicide.
As a result of identiﬁcation of these high-risk groups
and subsequent intervention, there was a dramatic
decline in the suicide rate in the elderly: from 434.6
suicides/100,000 residents in the 17 years before thesuicide prevention activities, to 123.1 suicides/100,000
residents after the activities were introduced. A signiﬁcant decrease in mortality from suicide was found, es-

Ono Y: Suicide prevention program

pecially among people 65 years old and older. This result is thought to have been inﬂuenced by the primaryand secondary prevention activities undertaken. This
project demonstrated the importance of networking
between local governmental institutions, public healthnurses and physicians, and of creating an atmospherein which problems related to mental disorders can be
openly addressed.
After several years, welfare improvement and prevention activities were introduced, assistance for depressed elderly and conﬁned elderly was provided,and companion home visits were started for nonparticipants in these activities. These programs were
implemented because rebuilding relationships isthought to be a signiﬁcant aspect of suicide prevention,
based on the fact that psychological isolation, referred
to as a ‘‘reduced relation system condition’’, is a risk
factor for suicide among the elderly.
Oyama and associates9 recently reported the resultsof comparative studies of suicide intervention activities
for the elderly established in or around Matsunoyamamachi, Niigata Prefecture. They found that welfare
activities for the elderly, i.e. maintaining welfare services through visitations and facilities, play an important role in suicide prevention. The region where suicide rates had decreased had enhanced services, such as
welfare visits and group assistance for conﬁned elderly,and site visits to assisted living facilities, in addition toclose collaboration of professionals in the provision ofcare.
These results suggest the possibility that care introducing ‘‘relations’’ can be made available through existing home welfare services and improved welfare andprevention activities, in addition to positive treatment
for depression in suicide prevention.
Suicide Prevention Activities in Nagawamachi
Thus, to improve the results of regional suicide prevention, it is extremely important to identify depression
at an early stage and to provide treatment intervention through the cooperation of regional administration, healthcare professionals and local physicians. It isalso important to create an atmosphere in which frank
discussions of community problems can take place, including issues related to mental healthcare, such as depression and suicide.
Based on this awareness, and in conjunction withpublic welfare studies, we gained the cooperation of
Nagawamachi, Aomori Prefecture to conduct research
and a survey to create a manual of crisis intervention
and suicide prevention for use when early stage depression is discovered among the elderly. The following ﬁve items were used in screening for depression
and potential suicides, including two types of self-Keio J Med 2004; 53 (1): 1–6

administered questionnaires for evaluating depression:
the Japanese version of the Self-Rating Depression
Scale8,10 and the Hospital Anxiety and Depression
Scale.11,12 We then conducted a survey using a modiﬁed version of the Composite International Diagnostic
Interview (CIDI)13 section for Major Depression.
Using a Receiver Operating Characteristics analysis,
we identiﬁed ﬁve self-report items that differentiatedbetween the group who reported depressive symptoms
and the group who did not, as well as between thegroup who reported suicidal ideation in the CIDI andthe group who did not. We also modiﬁed the originalﬁve sentences to make them interrogative expressions,as listed below, and revised the rating method (4-point
scale) to a dichotomous scale (yes/no; score range 0–5),
to enable the elderly participants to respond to thescreening items more easily.
The questions were as follows.
(1) Is your life pretty full?
(2) Do you still enjoy the things you used to do?
(3) Do you think it too much trouble to do the things
you used to?
(4) Do you feel that you are useful and needed?
(5) Do you get tired for no reason?
By comparing with the Geriatric Depression Scale14,15
and the Japanese short version (GDS-S), we found that,when the cut-off score of this 5-item screening test was
set at 2, the test had a moderately reliable sensitivity
and speciﬁcity.
In the actual screening, we added two other questions inquiring about the existence of thoughts of suicide: ‘‘How many times have you thought of suicide?’’and ‘‘Do you think of suicide when you feel depressed?’’ We also asked if the respondent had experienced any difﬁcult life events recently: ‘‘Please write
anything down if you have had a recent problem or
difﬁculty’’. A total of eight items were used in thisscreening questionnaire.
This screening was intended for use in various situations. Residents identiﬁed through these questionnaires as possibly depressive were interviewed for adeﬁnitive diagnosis by a psychiatrist and healthcare
professional.
Cooperation of regional residents
Although administration of the activities is important
for the prevention of suicide, the active participation ofresidents in such activities is also vital for their effectiveness. In preventing suicide among the elderly, it isﬁrst of all important to create an environment to prevent depression. This can also be understood in relation
to the theories of the origins of depression.

3

According to the vulnerability model of mental disorders, psychiatric symptoms such as depression andanxiety manifest as the result of interactions of personality and environmental factors. For example, we haveconducted a genetic analysis of dimensions of temperament and symptoms of depression in about 201 pairs ofmonozygotic and dizygotic twins in order to evaluate
the hypothesis that one set of genetic risk factors may
be common to disorders and dimensions of temperament, whereas environmental risk factors are disorderspeciﬁc.16
Dimensions of temperament associated with novelty
seeking, harm avoidance, reward dependence and persistence were measured using the Temperament andCharacter Instruments developed by Cloninger,17,18
and depressive symptoms were measured using the
Hospital Anxiety and Depression Scale. Differencesamong individuals on these measures can be explainedby differences in their genes and in their environmental
experiences.
As a result, we found that each dimension of temperament is genetically dependent, and genetic variations in symptoms of depression are largely dependent
on the same factors that affect the temperament. There
are no differences between the sexes in gene action affecting the temperament. Furthermore, depression was
found to more likely occur in those predisposed to it ifthey obtained a high score on harm avoidance or reward dependence. These ﬁndings suggest that what isinherited in depression is a temperament proﬁle thatpredisposes an individual to the disorder. Thus, it might
be more heuristic to look for genetic markers for
dimensions of temperament rather than for depression
itself.
Whether or not the effect of stress on the personality
increases vulnerability or encourages resilience is unclear. It is clear, however, that anyone may feel strongly
stressed when placed in an environment unsuitable tohis or her own personality.
Accordingly, to effectively identify depression at an
early stage and prevent suicide, the environment must
be changed to make it easier for the elderly to live in,and this requires the cooperation of many people.
Therefore, it is helpful to actively promote psychoeducational activities such as town meetings, where
psychiatrists and/or public health nurses give talks on
depression and related disorders and on the various
effective psychiatric treatments currently available.
Another way to get this information to the public isthrough the use of town newspapers. For this study, we
also made a leaﬂet based on the 5-item questionnaire tolet people know about the symptoms of depression(Fig. 1).
Along with these activities, we distributed a leaﬂet
to all households of the town, illustrating depressive

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Ono Y: Suicide prevention program

Fig. 1

Psychoeducational leaﬂet of depression.

symptoms and where to obtain a consultation in case ofdepression. These brochures were intended to enable
the residents to identify their own depressive symptoms
and those of their family and friends, which might assist
them in seeking advice from public health nurses orother mental health professionals.

machi. At this meeting, the elderly gather and participate in group hobby activities, and listen to talks byvarious experts aimed to prevent them from losing theirsense of the value of living, which results from being
isolated from the community. At ‘‘the gathering’’, local
children also participate, and an opportunity is createdto have an exchange with the elderly. This meetingprovides the elderly with an opportunity to adopt an
important role in handing down their rich experiences
to children. It also provides support for the elderly, who
can lose sight of their role in society.
This activity is not only an opportunity for theelderly to participate in regional activities, but alsochanges their perspective on local values. The authors
have indicated the importance of changing the outlook
of communities regarding local values in a region – i.e.
the social schema – to create a mentally healthy region
and prevent suicide attempts. In general, Japanese aremethodical perfectionists, who tend to persevere to accomplish a set goal. This trait has been linked to postwar reconstruction and economic prosperity. However,this sense of values is also connected to the concept of
discarding people who are ‘‘unﬁt for use’’. Associatedwith this value system is the view that the elderly, who
cannot work due to physical failure, and middle aged
individuals who have lost employment, are simply
worthless. The recent increase in suicides is possibly
linked to this attitude.
Accordingly, to prevent suicide, it is important torevise this social schema, which places too much valueon ‘‘doing’’. To achieve this, it is necessary to recognizethat there is value in simple existence, and to respect avalue system that values the existence of the individual.
This will produce a society that respects ‘‘being’’ andnot just ‘‘doing’’ – a society that values competition, but
at the same time values symbiosis. Attaining this perspective is desirable in suicide prevention activities.

Modifying the attitudes of community populations

Cooperation of related organizations and improvementin the quality of healthcare activities

It has become clear that community activities aimed
at early detection and early treatment are important but
insufﬁcient. It is more important to apply a multimodal
approach19 to create a mentally healthy regional population and an environment in which depression does notoccur. Creating a space in which a community population can participate in local activities and feel humancontact is essential to ease hopelessness, which plays animportant role in geriatric suicidal ideation.20,21 Suchhuman contact is important not just on a regional basis,but also at work.
Based on this knowledge, a meeting for the elderly
called ‘‘the gathering’’ is regularly held in Nagawa-

The activities of disseminating information to residents and regional intervention, as typiﬁed by thescreening described up to now are, of course, indispensable. Also vital is the continuation of the effort toimprove the capabilities of healthcare professionals andadministrators, to provide higher quality service to assist local residents in identifying the condition of depression. Therefore, study and training are required for
healthcare professionals to learn interview techniques
and the appropriate manner to adopt when discussingthese topics.
One of the most useful strategies for such a purpose
is a modiﬁed cognitive technique.22,23 This approachKeio J Med 2004; 53 (1): 1–6

focuses on changing the cognition of the elderly that
their depression and distress is caused by their own
personal weaknesses. Because depressed individuals
and their relatives tend to feel ashamed of being depressed and try to hide it from other people, it is important to restructure this cognition. The goal is toassist the elderly to understand that depression is atreatable medical condition and that pharmacologicaltherapy and psychotherapy are helpful to relieve such
distress. These kind of interventions are useful not only
to prevent suicide, but also to improve quality of life in
the elderly, because depression in the later years of life
affects disability,24 the level of use of health services,25
and death rate.26
Moreover, there is a need for training in methods ofassistance and intervention, while managing the mental
condition of residents as necessary. Since such activities
cannot be accomplished without the cooperation of the
public health commission and health promotion commission, activities providing these people with information must occur simultaneously.
It is also important to establish close cooperation withpublic health professionals, primary care physicians, psychiatrists and other medical staff to effectively perform
initial interventions in a region. Cooperation with thepolice and other public ofﬁcials, and suitable assistancefor the person or family, are also necessary when a suicide plan is discovered, or when there is a high probability that an individual may harm himself or herself due
to depression. There is a strong tendency for the elderly
to visit a general practitioner just before committing
suicide. It is also reported that over 70% of elderly who
attempt suicide see a general practitioner within one
month prior to the event. However, the depressed person often hesitates to disclose suicidal ideation to aphysician, indicating that it is important that physicians
use caution in their consultations. Considering the factthat many elderly are examined by a physician soon
before they commit suicide, the importance of early intervention and treatment cannot be understated.
Considering that few older people disclose their suicidal ideation,4,27 there is a need for positive intervention by primary care physicians.
The importance of training general practitioners to
identify depression and risk of suicide has been demonstrated in previous research. A series of studies
in Gotland (Sweden) found that the introduction ofsuicide prevention training for general practitioners
resulted in a lower number of suicides.28–30
General practitioners should be aware that many
depressed patients may complain of various undeﬁned
physical ailments, masking a hidden depression. Caution should be taken in examining such individuals forthese undeﬁned physical complaints. In some cases it isdesirable to involve the family in the consultation.

5

However, there is still some doubt as to whether or
not appropriate intervention can be provided at the
primary care level. In a large study conducted in Europe, it was reported that depressed patients were notbeing treated with appropriate antidepressants. As yet,no such study has been conducted in Japan, however,there are indications from surveys of prescriptions forpsychotropic drugs that appropriate pharmacotherapy
is not being provided for individuals who may requireit.
Our data on the relationship of suicide rates and annual sales of anti-anxiety drugs by prefecture in theyear 2000 revealed a high correlation coefﬁcient of
0.566 (Ono, unpublished manuscript). Such a tendency
was not found with antidepressants. Although generalizations cannot be made from these ﬁndings alone, it
may be inferred that prescribing anti-anxiety drugs does
not prevent suicide attempts – it may even induce suicidal behavior, partly due to disinhibition. It may benecessary to conduct detailed surveys regarding prescription practices in clinics and to develop a treatment
manual of depression for primary care physicians.
Conclusions
In this paper we have discussed practical suicide prevention for the elderly in terms of the activities conducted by us based on past practical precedents, centered on screening and self-governing municipalities,
and the networking of residents and health professionals in a community. In conducting such activities, itis necessary to exercise adequate care regarding thereactions of local people and their personal privacy.
Psychiatric problems such as depression and suicide arevery private information, and care must be taken in
handling this conﬁdential information, obtaining consent and preserving privacy, so as to not unnecessarily
burden the individual.
Finally, considering that suicide cannot be prevented
completely, providing mental healthcare for a family
confronted by the suicide of a close relative is just as
important as undertaking prevention activities. We are
now planning to develop a manual to help individuals
deal with the extreme mental anguish of losing a closeone.
Acknowledgements: The authors wish to acknowledge the invaluableassistance provided by Shinji Sakamoto, Eriko Tanaka, and Keiko
Neichi in conducting the suicide prevention activities.

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