The Social Burden of Depression in Japan

New York            César Chelala

Depression is widespread, largely undiagnosed, and rarely treated in Japan. Until the late 1990s, depression was largely ignored outside the psychiatric profession. Depression has been described as “kokoro no kaze” (a cold of the soul) and only recently it is being accepted in Japan as a medical condition that shouldn’t provoke shame in those suffering from it. In Japan, it is estimated that one in five people will experience some form of depression during their lifetime.

Depression is a state of low mood which can affect a person’s thoughts, behavior, feelings, and sense of well-being. Its symptoms include sadness, inactivity, difficulty in thinking and concentration, and altered appetite and sleep. Many depressed people have feelings of dejection and hopelessness that may drive them to suicide.

Depression can manifest at any age. It can begin during childhood or the teenage years. As happens also among adults, girls are more likely to experience depression than boys. Among women, one in seven experiences post-partum depression; about half of them start experiencing symptoms during pregnancy.

Clinical depression among the elderly is also common, affecting 6 million Americans ages 65 and older. Among the elderly, depression is frequently confused with the effects of other illnesses. Studies in nursing homes of elderly patients with physical illnesses show that depression substantially increases the risk of dying from those illnesses.

In most cases, depression can be treated. The U.S. FDA (Food and Drug Administration) recent approval of the drug esketamine will be a significant advance in the treatment of depression. Esketamine is particularly effective for those who have been resistant to conventional treatment, or who are at imminent risk of suicide.

Like ketamine, a related drug, esketamine, in addition to its anesthetic effects, is a rapid-acting antidepressant, whose medical use was started in 1997. On February 12, 2019, an independent panel of experts recommended that the Food and Drug Administration (FDA) approve the use of esketamine, as long as it is administered in a clinical setting to ensure patient safety. Esketamine may bring relief to millions of patients all over the world, particularly in Japan, where depression is widespread and largely neglected.

One of the reasons for this neglect is the feeling of shame associated with mental health issues. Many of those who suffer from depression prefer to think that there is something wrong with them, rather than that they suffer from a medical condition which can be treated. In most cases, people resort to a cultural impulse known as “gaman” or the will to endure.

Depression has been called a “democratic disease” because it affects people of all social and economic strata. According to the World Health Organization (WHO) estimates, more than 300 million people were affected by depression worldwide in 2015, equivalent to 4.4 percent of the world’s population. Nearly 50 percent of all people diagnosed with depression are also diagnosed with an anxiety disorder.

Depression is also a major contributor to suicide. According to WHO, almost 90 percent of people who attempt suicide suffer from depression. There are approximately 800,000 suicides globally every year. In Japan, although the total number of suicides has diminished in recent years, the high number of suicides among children and teenagers is a cause for concern.

Aside from the effects on health and on people’s well-being, depression exacts a heavy economic toll on individuals, families and on society as a whole. In Japan, the London School of Economics has estimated that the economic cost of depression is over $14 billion annually, compared to $210 billion in the U.S. That includes decreased productivity, medical expenses, and indirect medical costs. In Japan, some of those costs are more difficult to estimate because of the cultural issues surrounding depression and mental health in general.

It remains necessary to raise awareness of depression in the general population of Japan, through massive health communication campaigns, alerting on the seriousness of the untreated cases and about the possibility now of addressing the problem effectively. As depression is on the rise globally, the approval of a drug to treat cases resistant to treatment is a reason for hope.

César Chelala is an international public health consultant and winner of several journalism awards.