Lifetime prevalence of mental disorders and its relationship to suicidal ideation in a Japanese rural community with high suicide and alcohol consumption rates
Environ Health Prev Med
Lifetime prevalence of mental disorders and its relationship to suicidal ideation in a Japanese rural community with high suicide and alcohol consumption rates
Masatsugu Orui 0 1 2 3 4
Norito Kawakami 0 1 2 3 4
Noboru Iwata 0 1 2 3 4
Tadashi Takeshima 0 1 2 3 4
Akira Fukao 0 1 2 3 4
0 N. Kawakami Department of Mental Health, Tokyo University Graduate School of Medicine , Tokyo , Japan
1 M. Orui A. Fukao Department of Public Health, Graduate School of Medical Science, Yamagata University , Yamagata, Yamagata , Japan
2 M. Orui (&) Yamagata Prefectural Tsuruoka Hospital , 28 Sekishita, Takasaka, Tsuruoka, Yamagata 997-3690 , Japan
3 T. Takeshima National Institute of Mental Health, National Center of Neurology and Psychiatry , Tokyo , Japan
4 N. Iwata Department of Clinical Psychology, Hiroshima International University , Hiroshima , Japan
Objective The World Mental Health Survey Japan was conducted to address the current status of mental disorders in Japan. Among the various regions covered by the survey were Tendo City and Kaminoyama City in Yamagata Prefecture. The suicide and alcohol consumption rates in Yamagata are higher than the Japanese national average. Many studies have reported that major depressive disorder (MDD), alcohol use disorders (AUDs), and suicidal ideation are related to suicide risk. The prevalence of MDD, AUDs, and suicidal ideation, as well as the association between suicidal ideation and mental disorders must be investigated in order to implement mental health and suicide prevention measures in our community; however, only a few studies have addressed this issue. Methods The survey involved face-to-face interviews. The study population consisted of 1,684 adult residents, of
Mental disorders; Suicide; Alcohol; Lifetime prevalence; Describe epidemiology
which 770 (mean age 54.0 ± 17.4 years) who completed
the interview process. Mental disorders were assessed
using the World Mental Health version of the World
Health Organization Composite International Diagnostic
Results Among the study population, lifetime prevalence
of MDD was 4.4%, which was similar to values reported in
previous studies in Japan. Prevalence of AUDs, however,
was 10.2%, which was higher those reported previously.
We observed a significant association between suicidal
ideation and MDD [odds ratio (OR) 7.6], our results
showed precisely the opposite association between AUDs
and suicidal ideation (OR 0.5, not significant) compared to
Conclusions Although prevalences of MDD and suicidal
ideation were not high, this study revealed a high lifetime
prevalence of AUDs and a negative association between
suicidal ideation and AUDs.
The World Health Organization World Mental Health
Survey (WMH) was conducted in 28 countries with the aim
of addressing the current status of mental disorders and
mental health service use around the world. The Japanese
portion of this survey (WMHJ; World Mental Health
Japan) was conducted between 2004 and 2006 and
involved more than 4,000 residents in Okayama, Nagasaki,
Kagoshima, Tochigi, and Yamagata Prefectures and in
Yokohama City as a representative sample of the Japanese
population. In Yamagata Prefecture, this survey was
conducted specifically in Tendo City and Kaminoyama
City. Although the WMHJ has reported its findings on the
12-month and lifetime prevalence of mental disorders
], mental health service use , and the association
between suicidal ideation and mental disorders [
local prevalence rates in the surveyed regions have not
been reported to date.
The number of suicides in Japan increased dramatically
from 23,494 in 1997 to 31,755 in 1998 and has remained at
a high level since then, with a similar trend observed in
Yamagata Prefecture [
]. The suicide rate in Yamagata
(28.8 per 100,000 people) is higher than the national
average (24.0 per 100,000 people) . Suicide is a major
public health concern in Japan, especially in this
community. Moreover, alcohol consumption in Yamagata is
higher than the national average, with annual sales of
alcoholic beverages of 42.6 thousand yen per adult
compared to the national average of 36.1 thousand yen per
]. According to a national patient survey, the
proportion of those receiving medical treatment for
alcoholrelated disorders tended to be high in Yamagata [
studies have reported that suicide ideation and mental
disorders, particularly major depressive disorder (MDD)
and alcohol use disorders (AUDs), are associated with
suicide risk [
]. However, few data are available on
these parameters for Yamagata. In order to implement
effective mental health and suicide prevention measures,
more information is required on the prevalence of MDD
and AUDs. Accordingly, we analyzed the Yamagata survey
data from the WMHJ with the aim of assessing the
prevalence of suicide ideation and mental disorders, with a
specific focus on MDD and AUDs, and the association
between suicidal ideation and MDD or AUDs in this
Materials and methods
Survey population and participants
We chose two rural cities in Yamagata Prefecture for our
survey, Tendo (population in 2005: 63,864) and
Kaminoyama (population in 2005: 36,013) [
]. The proportion
of elderly residents aged C65 years was 21.6% in Tendo
and 28.6% in Kaminoyama. The average suicide rate of the
two cities between 2004 and 2008 was 27.8 per 100,000
]. The proportion of elderly residents and suicide
rates in these cities did not differ significantly from the
average of Yamagata Prefecture. We conducted the survey
in Tendo City from November 2004 to March 2005 and in
Kaminoyama City from October 2005 to February 2006. A
total of 1,684 randomly selected residents (807 in Tendo
and 877 in Kaminoyama) aged C20 years were surveyed.
For random sampling, a district was first randomly selected
from the electoral districts list. Subsequently, systematic
sampling from the selected electoral district (extraction
ratio 25%) was repeated until the number of subjects
reached the target number. As a result, we selected 26
electoral districts from the 53 districts in Tendo City and 23
from the 37 districts in Kaminoyama City. After selecting
subjects, community volunteers first contacted subjects in
their homes to explain the purpose of the survey and to
recruit them into the survey. Interviews were conducted
only after informed consent was obtained. This study was
approved by the Committee for Ethics at Yamagata
University Faculty of Medicine in September 2004.
Survey interviewers and instruments
The survey used the World Mental Health version of the
World Health Organization Composite International
Diagnostic Interview (WMH-CIDI), a fully structured
psychiatric diagnostic interview [
]. All 36 interviewers
were certified healthcare specialists, such as public health
nurses. Prior to the survey, interviewers received 5 days of
standardized, instrument-specific training from the official
trainer (NI) and assistants who were previously trained to
use the instrument. The training included didactic sessions
on general interview skills and reviews of the instrument
sections, mock interviews, and role-playing exercises.
Trained interviewers carried out structured face-to-face
interviews with those who agreed to participate in the
survey using the standardized instrument. The length of the
interview with each respondent was approximately 90 min.
The CIDI questionnaire is divided into two parts: Part I
assesses all mood and anxiety disorders, with the exception
of post-traumatic stress disorder (PTSD); Part II assesses
risk factors, correlates, and additional disorders, such as
PTSD and all substance use disorders. During Part I, a core
diagnostic assessment was administered to all respondents,
and their basic socio-demographic data were collected. Part
II was then administered to all Part I respondents who met
diagnostic criteria for a mental disorder and to a probability
subsample of other respondents (n = 344). Part II
respondents were weighted by the inverse of their
probability of selection to adjust for the differential sampling of
cases and non-cases. In addition, all samples were
weighted to adjust for differential probabilities of selection and
post-stratified to match population distributions on the
cross-classification for sex and age (for details, see [
Lifetime prevalence of WMH-CIDI/DSM disorders and suicidal ideation This study used the Japanese version of the computerassisted personal interview (CAPI) form of the WMH-CIDI,
a fully structured diagnostic interview that generates
diagnoses based on criteria of the Diagnostic and Statistical
Manual of Mental Disorders, 4th edition (DSM-IV). We
defined a mental disorder diagnosed by the WMH-CIDI
interview as a WMH-CIDI/DSM disorder. The lifetime
prevalence of WMH-CIDI/DSM disorders estimated in the
survey were (1) mood disorders, including MDD, minor
depressive disorder, bipolar I–II disorder, and dysthymia;
(2) anxiety disorders, including panic disorder, agoraphobia
without panic, social phobia, specific phobia, generalized
anxiety disorder, and PTSD; (3) substance use disorders,
including AUDs (alcohol abuse or dependence) and drug use
disorders (drug abuse or dependence). Lifetime prevalence
of WMH-CIDI/DSM disorders was determined based on
those who had met the diagnostic criteria for each mental
disorder by the time of the survey. Respondents who
experienced suicidal ideation were defined as those who had
‘‘seriously thought about committing suicide’’ by the time of
Association between suicidal ideation and WMH-CIDI/
We performed logistic regression analysis to assess the
association between suicidal ideation and WMH-CIDI/
DSM disorders by the time of the survey. In our survey, we
included cases where participants met the diagnostic
criteria by developing a mental disorder after experiencing
Simple cross-tabulation was used to calculate the lifetime
prevalence of WMH-CIDI/DSM disorders and suicidal
ideation by sex and age. Our logistic regression analysis
used suicidal ideation as the dependent variable and
WMHCIDI/DSM disorders, sex, and age as independent variables.
Statistical significance was evaluated using two-sided,
design-based tests with a 5% level of significance. All
statistical analyses were performed using SPSS ver. 15.0J
(Statistical Package for Social Science, Chicago, IL).
Characteristics of respondents
We confirmed the validity and representativeness of the
sample by using the chi-square test to compare differences
in gender and age distributions between the sample and
general populations in the two cities surveyed (data not
shown). Subjects who had died, moved, or had been
institutionalized were excluded. The interviews were
incomplete for 746 subjects who initially declined to
participate or requested to stop the interview before
completion, while 770 subjects completed the entire interview,
resulting in a response rate of 50.8% (Table 1). The mean
age of the respondents with complete interviews was
54.0 ± 17.4 (mean ± SD) years, and the proportion of
males was 47.5% (n = 366/770; Table 2).
Lifetime prevalence of WMH-CIDI/DSM disorders
and suicide ideation
The lifetime prevalence of mood disorders was 7.2%, of
which MDD accounted for 4.4%; the lifetime prevalence of
AUDs was 10.2%, but there were no drug use disorders.
There was a significantly higher lifetime prevalence of
MDD in females than in males (6.2 vs. 2.6%, p = 0.03),
while the lifetime prevalence of AUDs was significantly
higher in males than in females (15.4 vs. 4.9%, p = 0.01).
The lifetime prevalence of suicidal ideation was 8.1%.
Among all of the age groups evaluated, younger subjects
(age range 20–34 years) had a higher lifetime prevalence
of mood disorders and suicidal ideation, and middle-aged
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consumption and AUD prevalence in this community
(annual sales of alcoholic beverages: Gifu City, 32.0
thousand yen; national average, 36.1 thousand yen;
Spearman’s r = 0.50, not significant) [
Our findings on the association of suicidal ideation with
mood and anxiety disorders also agreed with the results of
previous studies conducted with similar methodology as
that of the WMH survey in Japan [
], China [
]. Although there was an association between
suicidal ideation and AUDs in the Sino-Japanese survey [
], and with high alcohol consumption in the Ukraine
survey , results to the contrary were obtained in our
study. We speculate that the reason for this lack of an
association between suicidal ideation and AUDs, which has
been described in these other studies [
4, 18, 19
], are the
strong social and community networks that support those
who experience AUDs, including family members,
community social workers, and alcohol support groups.
Although the frequency of aggressive behaviors related to
alcoholism might be the same in this area as in other areas,
people with AUDs in these communities suggest that they
do not experience suicidal ideation because of this
wellconstructed social network. As a result, even though the
prevalence of AUDs was high, the association between
suicidal ideation and AUDs was opposite to that of
It should be noted that the low response rate (50.8%)
may have skewed the findings of our study. In particular,
the prevalence of mental disorders may be underestimated,
since people who have experienced any mental disorder
may have been less willing to participate in the survey.
In addition, several important mental disorders, such as
schizophrenia and personality disorders, were not assessed
in the WMH surveys because the interview would have
been difficult due to the stigma associated with these
disorders. Previous validation studies have shown that
disorders such as psychotic disorders are overestimated
in lay-administered interviews such as the CIDI [
additional limitation is that the study was a descriptive
epidemiological study, and we were therefore unable to
clarify the causal relationship between mental disorders
and suicide ideation in community residents.
Despite its limitations, this study revealed a high
lifetime prevalence of AUDs and the opposite association
between suicidal ideation and AUDs compared with
previous studies. While the results of our study confirm an
association between suicidal ideation and MDD, some
suicide prevention programs and measures specifically
aimed at reducing depression have already been
implemented for community residents in Japan [
Therefore, our finding suggests that depression intervention can
be an effective approach for decreasing suicide in our
communities. Although there was no association between
suicidal ideation and AUDs, alcoholism treatment
measures would still be valuable intervention because of the
high prevalence of AUDs in Japanese communities.
This study provides basic data on the lifetime prevalence
of mental disorders and the association between suicidal
ideation and mental disorders, which will undoubtedly
contribute to increasing public awareness of the current
mental health situation.
Acknowledgments This survey was supported by Grants for
Research on Psychiatric and Neurological Diseases and Mental Health
(H13-SHOGAI-023, H14-TOKUBETSU-026, H16-KOKORO-013)
from the Japan Ministry of Health, Labour, and Welfare. The authors
would like to thank Hisateru Tachimori, PhD, and Yuko Miyake, PhD,
of the National Institute of Mental Health, Japan, and the other
members of the WMHJ. The survey was carried out in conjunction
with the World Health Organization World Mental Health Survey
Initiative. The authors would also like to thank the WMH staff for
assistance with instrumentation, fieldwork, and data analysis. These
activities were supported by the US National Institute of Mental
Health (R01MH070884), the John D. and Catherine T. MacArthur
Foundation, the Pfizer Foundation, the US Public Health Service
(R13-MH066849, R01-MH069864, and R01 DA016558), the Fogarty
International Center (FIRCA R01-TW006481), the Pan American
Health Organization, Eli Lilly and Company, Ortho-McNeil
Pharmaceutical Inc., GlaxoSmithKline, and Bristol-Myers Squibb.
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