Knowledge and attitude towards suicide among medical students in Japan: Preliminary study
Chiaki Kawanishi, MD, PhD, Department of Psychiatry, Yokohama City University School of Medicine, 3-9 Fukuura Kanazawa-ku, Yokohama 236-0004, Japan. Email: email@example.com
Abstract Japan has one of the highest suicide rates in the world. Suicides numbered 32 863 in 1998 and have exceeded 30 000 in every subsequent year. Education of those involved in general and psychosocial patient care can contribute greatly to suicide prevention. The authors administered a brief knowledge and attitude assessment questionnaire concerning suicide to students in their first, third, and fifth years at a Japanese medical school. Participants numbered 160 (94 men with a mean age of 21.8 years, SD = 3.01, and 66 women with a mean age of 21.2 years, SD = 2.64); 59 first year, 52 third year, and 49 in their fifth year. The questionnaire consists of eight multiple-choice questions asking knowledge of suicide and one open-ended question asking attitude. In the knowledge part, only about half of the items were answered correctly (mean score was 4.21, SD = 1.28). A significant difference was observed in prevalence of attitudes as categorical variables between student years (P = 0.001). Sympathetic comments increased along with student years, while critical comments decreased. Given the frequent and interventional opportunities of primary-care medical contacts, poor understanding of suicide from the medical viewpoint was of concern. Moreover, judgmental attitudes were common, especially in earlier school years. Better informed, more understanding physicians and other health professionals could contribute greatly to prevention.
Japan has one of the highest suicide rates in the world. According to the National Police Agency, suicides numbered 32 863 in 1998 (rate, 26.0 per 100 000); suicides have exceeded 30 000 in every subsequent year. In 2003, suicides numbered 34 427, a record high that underscores the importance of this social problem.1
Medical personnel including general practitioners (GP), emergency department staff, and non-psychiatric nurses, are regarded as key interveners for preventing suicide, especially since the most frequent reason for suicide has been reported to be physical conditions or diseases.1 While over 90% of suicide victims have mental disorders such as depression,2–4 depressed patients tend to consult physicians other than psychiatrists. Those committing suicide were found to visit their GP frequently; up to 71% had seen their GP within 6 months,5 and up to 66% within 1 month, preceding suicide.6 Accurate knowledge about suicide and suicide prevention, therefore, is necessary for all medical staff.
A previous study has clearly shown that education of suicide prevention for GPs is important. In addition, the authors think it is also important to incorporate suicidology into medical education. It is questionable as to what extent medical students know about suicide in current medical education. In this study, the authors developed and administered a questionnaire regarding aspects of suicide in Japan for Japanese medical students who would be gatekeepers of suicide attempters in the future. The authors compared student knowledge between three years, concerns about suicide, and examined attitudes toward suicidal behavior. To date, medical students’ knowledge concerning suicide has not been studied in Japan.
SUBJECTS AND METHODS
Students in their first, third, and fifth years of medical school at Yokohama City University, Yokohama, Japan, participated in the study. Participants numbered 160 (94 men with a mean age of 21.8 [SD, 3.01] years, and 66 women with a mean age of 21.2 [SD, 2.64] years); 59 first year, 52 third year, and 49 in their fifth year. All participants had not had any lecture of suicidology before. The questionnaire was administered separately to the three class years in May 2004; it was handed out to all students attending the lecture, and returned anonymously from those who agreed to do the survey. The authors presented the special lecture concerning suicide to all participants after completion of the questionnaire.
The questionnaire was designed by the authors to assess knowledge concerning suicide in Japan (statistical data, risk factors, and suicide prevention measures). Eight multiple-choice questions and one open-ended question were used. The open-ended question concerned the student’s attitude toward suicidal behavior. The answers of the attitude part were classified by all authors’ consensus as sympathetic, critical, unconcerned, and no answer. Contents of the questionnaire are shown in Appendix I.
Statistical analysis was carried out using SPSS version 11 (SPSS Inc., Chicago, IL, USA). Mean score for multiple-choice questions were compared between groups by one-way anova and multiple comparisons (Tukey-Honesty Significant Difference). Prevalence of various attitude categories was compared using χ2 test.
This study was approved by the Ethics Committee of Yokohama City University School of Medicine.
Table 1 shows results for the multiple-choice questions. With 1 point for each correct reply among the eight questions (Q1 to Q8, perfect score = 8), the overall mean score was 4.21 (SD, 1.28). The highest scoring year was the fifth (4.61; SD, 1.51). There were no statistical differences in the mean score between first year and third year or fifth year students, while fifth year students got a significantly higher mean score than third year students (P < 0.01). Most students answered Q1 and Q6 correctly. For Q8, the fifth year students tended to give the right answer, but 20% failed to answer correctly. The fraction of students correctly answering Q2, Q3, and Q5 was highest in the fifth year, but was only 55.1% for Q2; more than half of the students answered incorrectly for the other questions. For Q5, 70.0% of all students answered that the most-affected age group for successful attempts was persons in their 40s or 50s. In fact, most victims are over 60, but only 21 students chose this answer. For Q7, 56.3% of students considered financial problems to be the most common reason for suicide, while only 13.1% of students cited health problems.
Table 1. Numbers of students who correctly answered
|Q1||57 (96.6%)||52 (100%)||48 (98.0%)||157 (98.1%)|
|Q2||24 (40.6%)||18 (34.6%)||27 (55.1%)|| 69 (43.1%)|
|Q3||26 (44.1%)||21 (40.4%)||23 (46.9%)|| 70 (43.8%)|
|Q4||27 (45.8%)||16 (30.8%)||18 (36.7%)|| 61 (38.1%)|
|Q5|| 6 (10.2%)|| 1 (1.9%)||14 (28.6%)|| 21 (13.1%)|
|Q6||52 (88.1%)||48 (92.3%)||44 (89.8%)||144 (90.0%)|
|Q7|| 4 (6.8%)|| 8 (15.3%)|| 9 (18.4%)|| 21 (13.1%)|
|Q8||49 (83.1%)||36 (69.2%)||43 (87.8%)||128 (80.0%)|
|Mean score (SD)|| 4.18 (0.94)|| 3.85 (1.29)|| 4.61 (1.51)|| 4.21 (1.28)|
Among risk factors for suicide, 68 students (42.5%) cited mental disorders, and 22.5% of students regarded separation, divorce, or widowhood as risk factors. Few students identified gender, age, personality, genetic factors, or history of past suicide attempts (Table 2) – all recognized as risk factors in many previous studies.7
Table 2. Risk factors of suicide given by medical students
|Age||2 (3.9%)||1 (1.9%)||9 (18.4%)|
|Gender||0 (0.0%)||1 (1.9%)||1 (2.0%)|
|Genetic factor||0 (0.0%)||0 (0.0%)||2 (4.1%)|
|Mental disorders||21 (35.6%)||19 (36.5%)||28 (57.1%)|
|Personality||2 (3.9%)||9 (17.3%)||3 (6.1%)|
|Divorce, widowhood||8 (13.6%)||12 (23.1%)||16 (32.7%)|
Table 3 shows the findings concerning medical student attitudes toward suicide and suicidal behavior. Students who showed sympathy toward suicide victims numbered less than 50%, while critical responses were notable in the first and third years. A significant difference was observed in prevalence of attitudes as categorical variables between student years (P = 0.001, d.f. = 6, two-tailed χ2 test). Concerning the mean score, there were no statistical differences between the categories of attitude.
Table 3. Attitude towards suicide and suicidal behavior
|Sympathetic||22 (37.2%)||20 (38.4%)||23 (46.9%)||4.12 (1.32)|
|Critical||28 (47.5%)||19 (36.5%)||5 (10.2%)||4.00 (1.20)|
|Unconcerned||6 (10.2%)||7 (13.5%)||9 (18.4%)||4.41 (1.33)|
|No answer||3 (5.1%)||6 (11.5%)||12 (24.5%)||4.76 (1.18)|
The authors investigated Japanese medical students’ knowledge concerning the current serious suicide problem. There are some studies which investigated medical students’ attitude towards suicide. Domino and Takahashi used the Suicide Opinion Questionnaire (SOQ) to investigate differences in attitudes toward suicide between Japanese and American students, showing that Japanese students had a more positive attitude towards the right to commit suicide than North American medical students.8 Etzersdorfer et al. compared medical students’ attitudes towards suicide in Madras with those in Vienna, finding that medical students in Madras were more rejective towards suicide than those in Vienna.9 Wallin reported final year students in medical school more often considered suicide to be an expression of psychiatric disease compared with first year students.10
In the present study, the authors investigated medical students’ knowledge in addition to their attitude towards suicide. The authors administered the questionnaire to three different year levels in order to compare the results according to length of medical education. The results showed that Japanese medical students had insufficient knowledge about frequency and characteristics of suicide in Japan. Students attained only half the maximum score in the multiple-choice questions. Fifth-year students obtained the highest scores; their mean score was significantly higher than that of third year students, but even their mean score was only 4.61. Although almost all students knew that suicide in Japan has been increasing during the last decade, they tended to underestimate the annual number of suicide victims. Many students considered that a financial problem was the most frequent reason for suicide, while the National Police Agency has reported the most frequent reason to be health problems. Additionally, the 40s and 50s was considered the most common age among suicide victims by more than half of the students, who seemed to regard reactive depression concerning economic problems as the major cause of suicide in Japan. It is true that suicide victims have been increasing especially among those aged in their 40s and 50s, however, in the 2003 report of the National Police Agency 33.5% of suicide victims were over 60 – a higher percentage than those in their 40s or 50s. The media may excessively emphasize the economically-related depression and suicide in middle age, at the cost of overlooking suicide in the elderly.
Almost all students knew that suicide is much more common in men than women and that mental disorders are related to suicide; yet they did not choose a list including gender and mental disorders as risk factors for suicide. Few students identified previous suicide attempts and family history as risk factors. Student perception of ‘risk factors’ may have been distorted by societal stress on economic stability and educational attainments, distracting them from confirmed risk factors in individuals.
In terms of suicide prevention, medical staff attitudes toward suicide victims and suicidal behavior also are important. In the present study, students who showed sympathy toward suicide victims represented less than 50%. Younger students tended to view suicide victims particularly critically, and many students stated that suicide victims and attempters create considerable effects on their families.
Concerning attitude toward suicide, fifth-year students tended to have more sympathetic attitudes such as ‘I feel sorry for them if they died because they thought it was the only way of the solution’ and the comments, ‘suicide is preventable’, was common in those who showed sympathetic attitude. This must be resulted by their longer medical education. However, in the present study, there was no significant difference in the mean score in the knowledge part between the groups. Their knowledge of suicide was not sufficient because of lack of education focusing on suicide prevention. First, it is important to know that suicide is a multifaceted problem; as a part, better understanding of suicide from the medical viewpoint is necessary for medical students who would be gatekeepers of suicide attempters. However, systematic educational programs for suicide prevention have not been implemented in Japanese medical schools, and the medical implications of suicide are not well recognized. For example, more than 90% of suicide victims have a mental disorder, particularly depression. Depressed patients are more likely to visit physicians rather than psychiatrists;11–13 a World Health Organization collaborative study noted that 21% of primary care patients had mental disorders but 70% of this subgroup did not consult a psychiatrist.14 A study performed in Gotland in Sweden suggested that education for GPs concerning prevention and treatment of depression could reduce suicide rates.15 Medical education concerning suicide is necessary for effective suicide prevention.
The authors do not know whether their findings are representative of Japanese medical students in general; nor do they know whether their data are specific to medical students. Additionally, usage of validated scales like SOQ is necessary to further investigate attitude toward suicide and compare differences among countries. The authors are now conducting the same survey among practicing physicians, nurses and social workers. An informed understanding of suicide is necessary for medical students and staff members who will be called upon to recognize and intervene in impending suicide.
This study was supported by a Grant-in-Aid for scientific research no. 16591152, from the Ministry of Health, Labour and Welfare of Japan, 2004–07.