Practice for Suicide Prevention in Japan–Focusing on Varieties of Risks–

Project team of Suicide Prevention in GP at Doshisha University
Ritsu, YAMAMURA
Akiko ICHINOSE, Emi HIKITSUCHI, Ran TANABE
Takashi OKURA, Erino KANEKO, Katsunobu KIHARA

Introduction
Our research group, Suicide Prevention Research Project Team, had studied under
the theme of “Potential of Social Work in Suicide Prevention Practice", and carried out
the survey of social work practices in suicide prevention. This paper shows theinformation about situation of suicide and practice for prevention of it in Japan, which
has been under the base of above survey.
This paper, at first, shows summary of suicide and practice for prevention of it forthe past in Japan. Next, after introducing of concept of three steps in suicide
prevention, it shows recent practices especially on the point of views of risks and field.
And lastly, it presents three issues as future issues which we should address.
1. Suicide in Japan
Whenever we talk about suicide in our country, the explosion of suicide in 1998 ismentioned. The number of suicide in the yearly number, it’s about 23,000 previous year,
jump up to over 30,000. It was an increase of about 30% (Fig. 1). Also the suicide rate(the number of suicide per 100 thousand) increased from 19.4% in 1997 to 26.0% (Fig.
2), it was startling findings that Japan was ranked in the top 10 in the suicide rate by
WHO. In the latest findings by WHO, Japan is ranked 6th.
After that, although with some rise and fall, the number of suicide in the yearlyFig. 1: The Number of Suicide in Japan

Fig. 2: The Rate of Suicide in Japan

Source: “Jisatsu no Gaiyo Shiryo (Summary date of suicide)” (NPA)1“Jisatsu-Shibo-Tokei no Gaikyo: Jinko-Dotai-Tokei, Tokusyu-Hokoku (Summary ofnumber have kept over 30,000 in survey by Ministry of Health, Labour andWelfare(MHLW)1. And now, the word “30,000 people” became one of benchmark and a
key word of current suicide in Japan.
2．Past Practice for Suicide Prevention in Japan1)

Before 1998
Before the increase of suicide in 1998, suicide had been not a critical issue for Japan(MHLW 2008). Government referred to suicide in their various publications only a few
times during the decades, and no mention the necessity of specific action or seriousnessof issues.
At same time, however, suicide rate tended to be higher in specific areas, some
practices had been carried out by local governments in those areas. And some practiceby private organization were started, for example, practice of “Inochi-no-Denwa (Life
Line; 생명의 전화 or 정신건강상담전화)” in 1946, and “Jisatsu-boushi Center (Suicide
Prevention Center)” was opened at Osaka in 1978.
On the other hand, because of strong tendency to consider suicide as taboo, thosepractices were not brought to the fore and not carried out actively. It was centered on
only telephone counseling service.
2) After Suicide Increase in 1998
Due to increase of suicide in 1998, the strategies to prevent suicide have developed
rapidly on the initiative of central government. Leading them, “Kenko-Nihon 21(Health-Japan 21; Action for Health Promotion of Nation in 21 century)” was started.
In this plan, central government set target to reduce the number of suicide in the
yearly number to below 22,000 by 2010, as the one of goal for health promotion ofnation.
And, practices in the field of mental health for workers got active. Because it is said
that there were major economic depression, as we say “bubble economy burst”, andincreasing of the unemployed, worsening of work environment behind suicide increasein 1998. It’s explained by big increase of suicide in the age of especially 40s and 50s,
which is called the age of men in their prime (fig.3).
In the light of those circumstances, improvements of mental health for especiallyworkers have been developed as a part of suicide prevention. And, “Guideline forWorker’s Mental Health in Work Place”(2000/08/09) or “Manual for Suicide Prevention
and Support in Work Place ” (2001), those proposals published in sequence.

In Suicide Survey in Japan, there are 2 types of them by National Police Agency(NPA) and by MHLW. Those two different figures because difference of way to count. In
the survey by NPA, there were some years with less than 30,000 suicides after 1998.

1

2

Or, some practices was implemented by Ministry of Education, Culture, Sports,
Science and Technology (MEXT), for example, Education to value one’s life, staffing ofschool counselor, improvement of support system was implemented and so on. Those
are also as approach for bullying issues, which is recognized as one reason of children’ssuicide.
However,

despitethoseefforts,

thenumber of suicide in the yearly number
had not shown significant change. The oneof the reasons of it is that actions wereactually not by the whole national agency
but by each government agencies, local
governments, or private organizations suchas NPO in limited way, though there were
the guidelines or the recommendations by
central government.
Therefore, “Jisatsu Taisaku Kihon Ho(Basic Act for Suicide Prevention)” wasFig. 3: The Number of Suicide in Age Bracket

established. This Act is first low that has

in Japandefined

the

basic

policyinsuicideprevention at the national level andstipulate the responsibility of government
for it. In the background of this enactment,of course, there was recognition about
necessity of practice for suicide prevention
by the whole country. And more to say,there was big effect of strong appeals byconcerned person, many of them were
survival families of suicide (MHLW 2007).
By their action, more than ten thousand
signatures were collected, and Basic Act for
Suicide Prevention was established on Apr.

Fig. 4: The Rate of Suicide in Age Bracket inJapan

17th in 2006. And then, Broad Outline forComprehensive Suicide Prevention was

Source: “Jisatsu no Gaiyo Shiryo (Summary dateformulated on Jun. 8th in 2007, The whiteof suicide)” (NPA)

paper on Suicide Prevention was started to“Demographic Shifts” (Statistical Officepublish since 2007.
3. How to Prevent Suicide
1) Three Steps of Prevention
Before describing about actual suicide prevention practice in Japan, I’ll mention
3

about concept and construction “prevention”.
Just “prevention” is a concept that is very familiar in medical field. That isprevention of disease. The concept of disease prevention is said that there are 3 steps ofprevention, those are called first-prevention, secondary-prevention, and tertiaryprevention 2 . It is based on the prevention medicine, first-prevention is aimed at
general public rather than particular individuals. It is to provide knowledge orinformation to avoid disease by enlightenment or education and take action what iscalled “prevention”. Secondary-prevention is, for the persons who are diseased, early
detection and rapid cure, or prevention of complicating disease, it is “cure”. And
tertiary-prevention means rehabilitation or treatment for recovery. Those three levels
could be replaced with those three words, Prevention – Intervention – Postvention(Takahashi 2006).
Applying those words to suicide prevention, it could be considered thatfirst-prevention means the enlightenment activity about suicide and it’s prevention,
Secondary is actual preventive measures for person at risks of suicide and cure of
person attempted suicide, and tertiary is, when suicide is committed, care of survival
families of suicide3 or other relations (Takahashi 2006).
The difference between the case of disease and suicide is that, in the case of suicide,
there occurred “the suicide” between secondary and tertiary. And if it would becompleted, there is no way to approach –or support, care, help – to at least that person
committed suicide. At the same time, in the completed case, care or supports for thefamilies and relations have meaning accordingly the secondary-prevention for them.
Because, the suicides of family member or relations would bring forth the suicidal riskfor person who close to them4.
It means that, in suicide prevention, the secondary-prevention is very important.
And more, in the secondary-prevention, catching the person at risks is the key.
Because it is difficult for person at risks to call for help voluntarily and positively(Takahashi 2006). It is one of the trends of suicide prevention.
2) Catching the Person at Risks and Risk Factors
Then, how can we catch the person at risks? This can be achieved by understanding
the risks of suicide correctly, and the risks of suicide could be apprehended from the
There are other concepts that suggest “the 0(zero)-level prevention” before first or
smaller steps, recently. However, I refer to 3 step as the typical concept.
3 If we consider “getting disease” as “carrying out suicide”, construal of secondary andtertiary prevention in suicide prevention would be different. But in this case, I describe
as above because I consider the condition with risk of suicide as the condition withdisease.
4 It is known by previous research that the persons who have any suicide victim in
their family has higher risk of suicide (Fujiwara & Takahashi 2005).
2

4

reasons of suicide. The reasons of suicide are described as certain “issues” which force
someone to suicide, and then, those issues could be thought as the risks of suicide.
Confirming of reasons of suicide is essential factor of suicide prevention, therefore
many studies have been made on it.
However, it is very difficult to reveal completely the reasons of suicide. Because it is
impossible to hear their own account by suicide victims or to make a sweeping
judgment about what is reason for complex relationship among multiple reasons（Jisatsu Jittai Kaiseki Project Team 2008）. But, to figure out the reasons and risks ofsuicide is absolutely necessary. The importance of it is pointed in the Basic Act for
Suicide Prevention, as the importance of reality check of suicide.
Another dimension of catching the person at suicidal risks is that request for help
cannot be expected so much from the person themselves at risks. That is, it is not
sufficiently to be waiting them with hanging a signboard for help, we are needed theperspectives of outreach in suicide prevention. And, the important thing in outreach iswhere we go out, especially for suicide prevention. Because of not much appeal fromthe person at risks, it is needed to carry out in the field where we could expect
existence of such persons and we could take some positive (or mandatory)
interventions for them.
4. Practice for Suicide Prevention in Japan
In the practice for suicide prevention in Japan, one of the most focused factors as
risks of suicide is depression and depressive tendency. In the survey by LIFELINK5,
depression is pointed out as a factor with the highest crisis composite degree, and it
also accounts major share of “Issue of health” as reason of suicide in the survey by NPA.
In previous studies as well, it is said that most of people who committed suicide havetendency toward depression at least in some degrees (Nishikawa 2009). Depression isthought as the risk factor common to all suicide, so action against depression has
become the one of key points in suicide prevention practice.
On the other hand, it is recognized that suicide has age characteristics. Government
indicates a policy of different approach by ages. In the Broad Outline, the necessity ofdifferent approach for three ages – it’s juvenile, middle age and elderly - is pointed.
When we think about that suicides are very involved in people’s life, it is easy toassume those age characteristics. Because life has trends such as life-cycle orlife-pattern linked very much to age.
Those, “depression (or depressive tendency)” and “the risk of suicide by ages”, arewhat we catch in suicide prevention. On the other hand, about where we do it, our
LIFELINK is NPO in Japan. It is started as self-help group for survival families ofsuicide and has kept various practices for suicide prevention. It is said that they
contributed very much to establish of the Basic Act for Suicide Prevention, and now, it
is very influential for also national suicide prevention.

55

actual practices have carried out in the three main fields. Those are work place,community and school. And it can be thought that those three fields are fitted into
three ages indicated in the Broad Outline and be selected to catch effectively the
person at significant risk. Actually, two of the three field is very important for catch thetwo age groups with big number of suicide.
Thus, suicide prevention in Japan is summarized as the approach for depression andage characteristic risks of suicide in work place, community and school.
1) Work Place: the Risk Factor of 50s
Age group of 50s is the biggest group for the number of suicide6. It means that, in away, being 50s is possibly regarded as criterion of high risk of suicide especially formen. This group made the greatest contribution to suicide increase in 1998. Among
increase of about 8,000 in total, increase of 50s were about 2,400, it was 30% of thetotal, and 80% of it was men. And it made an impression that that suicide increase wasrelated deteriorating economy. However, on the other hand, this group is only one
group which has been decreasing the yearly number of suicide since 2003 (See Fig.3).
Life of 50s men is mostly occupied by work in term of time and mind, work iscentered in their life. At the same time, in late middle age represented by 50s, it is said
that people are likely to face the big challenge in the life-cycle (Takahashi 2000). Thatis, their life shifts gradually from upward trend of earlier age to stagnant or falling
trend, and they are made confront limitation of their own development or possibility inbody, mind, life, social relation and all aspects. Those changes in life, which is also thedevelopmental task for middle age people, are often brought up to them in work
environment.
Thus, work occupies an important place in 50s men’s life, and their risks of suicide
often occurs mainly in work place and others related work. For example, overwork,change of work environment, loss of job, and some issued resulted by those work issues.
And, the companies can take an important and effective role to catch quickly and toprovide appropriate response when the risks occur. That is, suicide prevention
practices in work place.
Though practices in work place is, of course, not aiming only 50s men. It is true that
50s suicide have made big impact on suicide of whole of the country and suicide
prevention in work place have needed to help them. So, it could be thought as thereason of the focusing on the mental health for workers by government and the reasonof the putting it first on the list of actual practice report in the first White Paper on
Suicide Prevention.
In sort of over 50, when it sorts them into two groups, 50s and over 60, the biggest
group is over 60, and when into three or more, 50s and 60s and over 70, for example,
50s is biggest. Now, MHLW uses smaller categories – 50s, 60s, 70s and Over 80 – from
2007.

6

6

And then, as above, suicide of 50s has decreased since 2003, the number of suicide in
the yearly number down by about 2,000 from the peak-year, 2003. And the majority ofsuch decrease is men’s suicide. It is hard to say that this situation could be unrelated tospreading of mental health for workers in recent years.
As a result, in recently, mental health care have been promoted in work place in thedaily work and the specific occasions – advancement, demotion, change of position ortask and so on - in which is considered possibility of rising risks. For example, building
up the check systems for health problems, like depression, in both of physical andmental of workers, education of supervisor workers, and using the outside agencies
specialized in EAP (Employment Assistance Program).
2) Community: The Risk Factors for Elderly
Elderly, same as adolescence, have been regarded as high-risk age of suicide(Takahashi 2006). Japan also has been no exception, and in both after and before 1988,
issues of elderly suicide have ever come up in social topic. But, in those cases, it had
been the issues mainly in certain areas. Some of those areas with high suicide rate
have had some characteristic, for example high population aging rate. So, it has beenthought that elderly suicide has regional characteristics.
It means, however, from the other view point, that there have been some practices
for suicide prevention for elderly since before in those areas. In that context, it isexpected that there have been a certain accumulated know-how on suicide preventionof elderly compared with of 50s men.
As the issues of elderly suicide had been focused in a certain areas, it has somecharacteristics matching to regional one. Besides the population aging rate as above, itis the income levels, with or without beneficial industry and so on. So, practices for
suicide prevention of elderly have been carrying out based on regions, that is,communities.
The reason of that elderly suicide prevention is based on community is not only
regional characteristics of it, but trends in life of elderly also make sense. Elderly is
generally have not so much object to which they belong, and community is last one towhich they could belong. Or else, one of the risk factor for elderly suicide is “isolation”
or “loneliness” (Takahashi 2006). It is thought that their suicide is influenced by thosefeelings which they felt during that they have been losing (or felt to be losing)gradually affiliations of social roles after golden age. In that point, it could be effective
to provide support as relationship with other people by network community.
Actually, the practice for suicide prevention in community is founded oncommunication or relationship during people in community. Watching-over activity
and visiting activity is main practice in those areas, especially elderly people who live
alone. And even if elderly people with family, some of them have risks. Isolation or
loneliness would occurred not only by being alone as real but also by losing the social
7role or meaningfulness. So enlightenment and education activities for people are also
important. Those could make people in community notice the risks of suicide withperson close to, and play a role of suicide prevention in community.
And, in some areas, collaboration with medical agencies such as hospital, clinic andhealth center have been carried out. Elderly people are often use those agencies ineveryday life. By positioning those agencies as the point of risk catching, educating andcollaborating with them, it is possible to catch the elderly person at risks more
effectively.
On those points above of practice for suicide prevention in community, the publichealthcare department have played important role in Japan. Though activity byprivate section such as NPO is of course very important and essential now in social
services for elderly people in community, there are also some difficulties in the case ofsuicide prevention. For example, it is activities in the depopulation area, approach tosensitivity of suicide issue, handing of personal information and so on. The publichealthcare departments have deep connection with medical agencies, they are familiar
with community, and they are enforceable as public section. So they are qualified forpractices for suicide prevention in community.
3) School: Suicide of School-age
Practice for suicide prevention in school is one of the centered issues in Broad
Outline. However, in term of suicide of children, especially early 10s and younger, it
actually have shown no significant change for past years. It is true that it had someincrease in 1998, but now, it has almost recovered to the level in before 1998. Rather,compared with level in the prewar period, it has decreased not a little.
Nevertheless, approach in school has been come on. The reason of it, one is perhaps
that school was selected as general life place before employment from the view point ofcovering whole population. And another is, it is thought, that suicide of elementary andjunior high student have been recognized as a social issues in past years because of its
big impact and cruel image, partly because in no small part of media impact.
In the field of school, there are those practices; conducting “the Class of Life”,
improvement of support system for early detection and action about health problem inboth of physical and mental, stuffing of school counselor or school social worker. Mostof those are not aiming at the suicide prevention directly, but at the prevention ofbullying or the approach to their family issues impacting children and their school life.
5. Future Issues
1) Suicide of 20s~30s
In a past few years, suicide of 20s~30s have been increasing. As noted before, it has
been shown the decrease about 2,000 in 50s group which have brought the big numberof suicide. Despite this, there have been no big changes in the total. It is because, of8

course, that there have been increase in other groups, and the group with most notable
increase is elderly as above, and 30s.
Characteristic of increase of 30s & 20s suicide is that it has tendency to increase also
in women compared with other groups, especially in 30s. On a issue related to increasein those two groups, it has been pointed out that young people who complain about
feeling of insufficiency of physical and mental in work place have increased in recent
years. Some of them are called “Shokuba - Utsu (it means “depression in work place”)”,
it also have been pointed out the tendency of depression which is felt mainly in work
place. This new type depression is said that it is different from traditional depression
and, naturally, needed different approach (Yoshino 2009).
And more, though the number of patient who visit psychiatrist because of depression
has increased in past years, it is reported that majority of them is 20s~30s, and more
women than men (MHLW 2009). From those situation, it is thought that 20s~30s
young people are pushed by stress from issues related work into situation with highsuicidal risk, and that it occurs increase of suicide in those ages.
In addition to those situation, the important problem of suicide in those ages is thatit have just started to be recognized, and so, that there have been made not so muchstudies still yet. It means that adequate practices also have not been carried out yet.
Also about the reason of increase of stress for those ages in work place, though there
have been some explanations, all of them are a matter for speculation, and there is no
revealed cause yet.
However, from the concerning about increasing situation of suicide and depression inrecently, and about stress in work place, it is sure that there is necessary of suicide
prevention focusing those ages. Thus, it is needed to promote studies related suicide ofthose ages, for example, actual condition survey at the start of it.
2) Suicide of University Student
Though I told that there have been slight increase in 20s suicide, awareness of theissue have been directed mainly to “young worker” at present. And on the other hand,
school is one of the three fields of suicide prevention, and but suicide of early 10s andyounger have made not big change.
However, about “suicide of students”, it has shown significant increase. And in fact,
major component of this increase is suicide of university students (Fig. 5). Junior highschool students also have shown increase, but university students are more greatly.
At the same time, it could be said that they are not likely to be caught by the safety
net of suicide prevention with such a perspective. It doesn’t mean that there are nopractices for suicide prevention in university, however, those are left to the each
university’s self-initiative, so conditions of practice is different between each
universities. And more, university and such high education institutions have
limitation in holding and controlling of the daily life of students compared with other9

level schools. Until now, practices for suicide
prevention in university are almost only
enlightenmentorcreation

of

a

kind

of

counseling counter, it shows difficulty ofoutreach approach from universities.
But then, it is clear that university student
suicides have been increasing, at the same time,
the reason of it has not been shown yet.
What is worse is that the category “university
student” is elusive group. They are minority inboth groups of 20s and students. The university
students are, in 20s group, absorbed by young
workers. And on another front, in the student
group, they are not likely to attract attention
compared with younger member, as we say

Fig. 5: The Number of Student’s Suicide“children”. As a result, studies about university

Source: “Jisatsu no Gaiyo Shiryo (Summary

student suicide have not been made enough. In
suicide of this category, same as 20s~30s suicide, the issue at present is assess what isreally happened.
3) The Earlier Catching and Potential of Social WorkAs has already been mentioned, the outreach is important in practice, what and how
we catch suicide risks have been concerned in the suicide preventions in Japan. And as
a next issue, we should now think about when.
There is the concept of “Early Intervention (EI)”. This is the concept that it tries to(or thinks it could) stop mental ill developing or becoming severe by providing
adequate care or treatment on the level of revealing any signs which suggest thatmental illness would develop in the later. Briefly speaking, it is intervention more
early stage of mental illness than previously. It could be, from the perspective ofprevention, the prevention on the level between first and secondary, or early secondary
prevention. It is early intervention just same in the categorization by Takahashi (2006).
Also in practice for suicide prevention, it would be needed to focus on practices for
those early detection and rapid prevention.
The importance of such approach on earlier level is pointed in Broad Outline in 2007
as “Development of human resource undertaking a role as “Gate Keeper” ”. In Broad
Outline, thought general practitioner is supposed as this resource because of earlyrecognition of depressions, and more, it is pointed out the importance of bringing such
recognition to public such as family or colleague who are closer to person at risks, in
Recommendation on Promotion of Comprehensive Suicide Prevention (Apr. 2007).
As real example, in Adachi Ward, Tokyo, they undertook the training for teller
10window officer to be gate-keeper. Or, LIFELINK (NPO) held the gate-keeper training
workshop for general public. In those training, they provide to participant theknowledge needed to notice the sign of suicide from persons’ attitude or atmosphereand to lead them to adequate specialized agency. Those approaches have been still only
in limited extent. So it is expected that those approaches developed widely and become
basic measure in suicide prevention in Japan. If it does, the gate-keeper who can noticethe sign of someone close to would increase, and it would be impossible to reduce therisk of suicide in earlier.
Meanwhile, the underlying reason of suicide is “life issues”. Even so the highest risk
factor linked with suicide is the depression, there could be “life issues” behind it. And,the primary and actual role of social work is support to those “life issues”. In thiscontext, general social work – not specialized social work activity for suicide prevention– could have a certain potential to contribute to suicide prevention.
In Japan, it is thought that general social workers are not much recognizing that
their own practice would link with suicide prevention (Hikitsuchi et al. 2010). But,social workers who are in direct contact with people’s “life issue” are one of thequalified persons for suicide prevention in early stage. It could be effective forcomprehensive suicide prevention that general social workers acquire the knowledge
for being gate-keeper or recognize that their own activities could promote suicide
prevention.
Thus, by increasing the number and type of people who plays a part of suicide
prevention as gate-keeper, as well as person close to him/her like family, colleague,social workers of general services and social service staffs, it could become to bepossible to prevent suicides in earlier stage.
Conclusion
The ideal practice of suicide prevention is, at least about social environment, making
the society without any social problems which drive people into the suicide andchanging the society for it. But it is actually impossible, and real practice for suicide
preventions are presupposed the existing of problems.
Suicides have been currently one of the social issues for many countries in the world.
In the midst of making many studies and surveys about suicide, it have been known
that suicide is not only personal problems or of responsibility, and that it is needed thecomprehensive approach in practices for suicide prevention by the whole national
agency. Meanwhile, practices for suicide prevention have been constructed of catching
the person at risks and of solution of their issues, and have been based on social
supports and medial procedures. And there have been not only various studies about
strategy for the escalation of situation or for the person who shows intention to commit
suicide, but also practices for those case. Therefore, after now, it is needed to enhance
the preventive practices in earlier stage on which people have not had consciousness of11

“Suicide” yet.
In addition, it is essential to recognize clearly the situation of suicide such as reasonsor characteristics and to take measures matching it. And, needless to say, because
suicides could be understood as issues much have been with social issues, the situation
have changed by times as well as culture, environment. So it is important to keep thecorrect recognition of situation in now, and keep to studies or surveys for it.
And more, suicide prevention will be required to carry out not only by utilizing
specialized persons or agencies but also by changing recognition of people. For it andpromoting field survey, it is required to make social environment in which whole
people can exchange opinions each other about this issue and make a move, instead oftaking it as taboo.
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