In May, the International Association for Suicide Prevention held its regional conference in Tokyo, and it was my first visit to the bustling capital of nearly 14 million people. Lonely Planet calls it a “cultural Galápagos where a unique civilization blossomed.” Imagine sacred Tibetan temples colliding with flashing neon of the Las Vegas strip, and Star Trek robotic technology swarming through the fused results. At times serene, then frenetic.
The contrasts are rich. One million people cross the street everyday at Shibuya Tokyo, but follow an orderly queue. The jam-packed, ultra-modern transit system is eerily quiet. There’s no loud talking or phone conversations. And individuals with a cold or the flu wear a cotton mask to prevent passing the sickness on to others.
I found the people warm and respectful. A little shy. Hard-working. More likely to be in a group.
And the suicide rate in Japan is one of the highest among high-income countries in the world, nearly three times higher than in the United Kingdom.
“The Rise and Fall of the Great Powers” predicted that Japan would become the next world superpower, succeeding America, but that didn’t happen. Instead, the late 1990s saw a serious banking crisis that led to decades of economic stagnation and downturn.
“In few other countries does joblessness trigger suicide so easily as in Japan,” says Yasuyuki Shimizu, “where being part of a corporate organization is seen as essential to one’s survival.” Shimizu runs Lifelink, a non-profit suicide prevention organization. The perception that one is contributing to the collective whole is important everywhere, but in the unique communal culture of Japan, layoffs and salary reductions in 1998 fueled a dramatic surge in suicide deaths among middle-aged men. Major financial institutions simply failed, including the bankruptcies of Yamaichi Securities Co., Hokkaido Takushoku Bank, and Sanyo Securities, and tens of thousands of jobs were lost in the aftermath. The steep 35% suicide increase in 1998 would be sustained for a decade.
One of the reasons I wanted to visit Tokyo was to learn more about the leadership in Japan in stepping up suicide prevention. The World Health Organization (WHO) reported that the still-high statistics in 2016 mask significant gains that have been achieved since 2006. Strong efforts to change have helped drive year-over-year declines in the death rates beginning in 2010 that have nearly brought the country back down to pre-1998 levels.
I first made acquaintance with Yasuyuki Shimizu at a prior international conference when he presented on Japan’s efforts, and he participated in the 2015 Zero Suicide in Healthcare summit in Atlanta. While in Tokyo, we visited the National Diet, which is Japan’s legislature, and Shimizu and I sat down with key leadership to discuss the successful progress of the program. Honorable Keizo Takemi-san was Vice Minister of Health, Labour and Welfare in 2006, and Honorable Mitsuyoshi Yanagisawa-san had been elected to the House of Councilors in 2004 and would later become Vice Minister of Economy, Trade and Industry in 2012.
According to the WHO, “In the late 1990s, suicide was a socially taboo topic in Japan, rarely discussed in the public sphere.” These leaders realized the scope of the challenge and worked together to enact the 2006 Basic Law on Suicide Countermeasures. Their goal was a society where no one is driven to suicide. The comprehensive strategy included a partnership with the national government and local public entities, as well as supports for those bereaved by suicide, and included intensive public awareness campaigns.
The expression “suicide prevention” was seen by many families who had been bereaved to suggest blame, and thus the terminology was changed to “suicide countermeasures.” There was also a strong focus on the non-medical, social determinants of health and their impact upon suicide deaths, as opposed to a preventive medicine approach.
Professor Yutaka Motohashi, the Director of the Japan Support Center for Suicide Countermeasures, led pilot studies in rural communities such as Akita Prefecture to measure the impact of the new approach, and there were strong reductions, especially among the older population. Within three to four years, reductions ranging from 23% to 47% were observed while the rates in comparable control areas remained relatively unchanged.
In March, Shimizu led a revision of the decade-old act, with a focus on shifting from national declaration to local action (which is also the theme for our upcoming 2017 Sydney Zero Suicide in Healthcare summit). “I believe this is a landmark amendment and huge step forward,” said Shimizu. Local governments will be responsible across the country for implementing concrete action plans. The new law will mandate funding for key projects in each municipality and include research analysis (see “Landmark new law”).
Breakthrough Technologies… For Good
There were so many amazing memories of my time in Tokyo. The blur of the enormous robot battles in a Shinjuku basement. Browsing through the center of the geek universe in Akihabara Electric Town. Whizzing along at 200 miles per hour on the Shinkansen bullet train. Japan is a temple of high tech.
So, I was naturally drawn to a very small presentation at the conference titled, “Joint Symposium with IT Companies,” which included professors from the University of Tokyo, two Japanese IT companies, and Mazda Motors.
When I was delivering mental health counseling services back in 1996, I gave the individual with depression a Montgomery–Åsberg rating scale to track our progress together, but it was dependent on the reliability of self-report. A decade later, researchers working for Dr. Madelyn Gould at Columbia University were listening in on crisis calls and making their own determinations about the level of distress and improvements from the time of the call to the conclusion, with a follow-up two weeks later.
Professor Tokuno Shinichi and his team at the University of Tokyo have developed software to evaluate distress by synthesizing in real-time 200 distinct variables in an emotional analysis of their voice. They are finding the early versions of the system are already nearly as reliable as a 30-item General Health Questionnaire and they believe they can eliminate the bias of self-reporting to identify individuals with depression.
These types of technologies are already being employed in other industries for “honesty maintenance” and to keep an eye on employees and screen out job applicants, but many of them are not real-time. In the recent movie “Ex Machina,” the main character Caleb comes to realize he should not answer any question from the beautiful Ava robot, as she can readily determine his truthfulness from a combination of biometric and voice analysis (Wall Street Journal, “App Tells You How You Feel”).
Professor Tokuno’s team has created an algorithm that generates feedback in real-time, and they are focused on how to use the technology to support better identification and treatment of mental health and suicide risk. I’ll be tracking this important work.