Sociopsychological factors relating to suicide prevention in a Japanese rural community: Coping behaviors and attitudes toward depression and suicidal ideation

Authors


Shinji Sakamoto, PhD, Department of Psychology, College of Humanities and Sciences, Nihon University, 3–25–40 Sakurajyosui Setagaya-ku Tokyo, 156–8550, Japan. Email: JCB00146@nifty.com

Abstract

Abstract  In response to the rise in suicide in Japan since 1998, some suicide prevention measures in local communities have been put into action. However, in the previous suicide prevention measures, sociopsychological factors were not fully taken into consideration. In the present study, the authors surveyed sociopsychological factors relating to suicide and depression (i.e. people’s coping behavior and thoughts about depression and suicidal ideation, and their attitudes toward suicide and psychiatric treatment), and their differences in gender and generations. The present study was conducted in a rural area of Japan (Town A), where the suicide rate is much higher than the national average. The authors randomly selected 10% of the residents (i.e. 532 people) aged between 40 and 79 years on the basis of resident registration. Health promotion volunteers in Town A visited these 532 people individually, distributed questionnaires, and asked them to anonymously answer the questionnaire within 4 weeks. Data from 450 residents (193 men, 257 women) were analyzed in the present study. Although there were few gender differences, some significant differences were found between the younger (40–59 years) and older (60–79 years) residents. Generally, the younger were more pessimistic about their mental health than the elderly. It was also noteworthy that about 10% of the people thought that it was natural for them to have suicidal ideation, and about 18% reported that they had experienced suicidal ideation. Some suggestions were given to provide more effective suicide prevention measures.

INTRODUCTION

The aim of this study is to investigate sociopsychological factors relating to suicide and depression, and their differences in gedner and generations. The high prevalence of suicide is now a major social problem in Japan. The Community Safety Bureau of the Community Police Affairs Division in Japan1 reported that the annual number of suicides in Japan was 24 391 in 1997 (suicide rate, 19.3 per 100 000), then jumped to 32 863 in 1998 (suicide rate, 26.0). Since then, the annual number of suicides has been over 30 000 (suicide rate = 24.4–27.0). In response to the rise in suicide, some suicide prevention measures in local communities have been put into action.2,3 Most of the suicide prevention measures are attempting to reduce suicide among the elderly through secondary prevention of depression (i.e. early detection and treatment of depression).4 Moreover, since most of the people who committed suicide were suffering from depression,5–7 such suicide prevention strategies were deemed necessary, and have proven to be effective.

The authors believe that in order to further enrich the effectiveness of these suicide prevention measures, sociopsychological variables must also be considered.8,9 The authors assume that some sociopsychological factors are related to suicide prevention activities in communities, namely, how residents think about and cope with depression and suicidal ideation, and their attitudes toward suicide and psychiatric treatment. The authors shall explain how these factors relate to suicide and depression thereafter.

As for suicide and its major psychiatric cause (i.e. depression), previous studies have shown that people who often experience subthreshold depression are more likely to suffer from major depression,10,11 and people who experience suicidal ideation are more likely to commit suicide.12 The authors believe people who have experienced suicidal ideation (depression) repeatedly may think that suicidal ideation (depression) is natural for them. Therefore, it is thought that those who think of suicidal ideation (depression) as ‘natural for me’ may have a higher risk for committing suicide (suffering from major depression). In addition, those who think of suicidal ideation (depression) as ‘natural for me’ may not be able to cope with it appropriately. For example, a man who has some depressive symptoms may think his state as natural, and may not consult anyone, which may make his depression worse and lead to suicide. Therefore, in planning suicide prevention measures in local communities, it is necessary to know how residents think about their own suicidal ideation and depression. In the present study, the authors asked residents how they think about suicidal ideation or depression, whether they have experienced them, and how likely they will experience them in the future.

To know how residents cope with suicidal ideation and depression is also important for suicide prevention, because in Japan most of the suicide prevention measures in local communities are given through early detection and treatment of depression. Failure to seek care is troubling, given (i) the disorder’s attendant risk of suicide,5–7 and (ii) the present availability of efficacious treatments for many depressive conditions. Even if there may be substantial need for someone to seek help, seeking specialized care for depression is thought to be specifically difficult for people living in rural areas where mental health service is not readily available.13,14 In such an area, to know where people consult about depression or suicidal ideation may be important for effective early detection and treatment of depression. Therefore, we examined the coping behavior of the residents in the present study.

The attitudes toward psychiatric treatment and suicides should be considered. Even if people recognize depression, and think that they need to consult a psychiatrist, they are often reluctant to do so when they have negative attitudes (i.e. prejudice) toward psychiatric treatment. The negative attitudes also may interfere with psychiatric patients in continuing to receive psychiatric treatment. Therefore, in suicide prevention measures, it is necessary to examine to what degree residents have prejudice toward psychiatric treatment.

Next, let’s consider the attitudes toward suicide. There is a regional difference in the elderly suicide rate, with agricultural villages having a higher rate than urban areas. One of the reasons may be that in the area with a higher suicide rate, a rather receptive attitude toward suicide is shared.15 As suggested by the fact that suicide rates are high among countries where religious taboo on suicide is weak,16 receptive attitude toward suicide may facilitate suicide behavior. Therefore, the authors examine the attitude toward suicide in the present study.

In sum, the authors surveyed three sociopsychological factors relating to suicide and depression: how residents think about and cope with depression and suicidal ideation, and their attitudes toward suicide and psychiatric treatment. Additionally, their differences in gender and generations (i.e. younger = 40–59 years vs. older = 60–79 years) were examined.

METHOD

Survey area

For the present study, the authors received the cooperation from a community in a rural area with a relatively high suicide rate in Aomori Prefecture. The target for the present survey, Town A, is located in the north of Honshu (Japan’s main island). The main industry of the town is agriculture. Town A is depopulated, with aging areas, and has a population of approximately 10 000, of which 26% are aged 65 years or over, higher than the estimated national average in 2000 of 17.2%.

Participants and procedure

The authors randomly selected 10% of the residents (i.e. 532 people) aged between 40 and 79 on the basis of resident registration. Specifically, because Town A has 25 areas and the number of people suffering from depression and suicide may be different in each area, the numbers of participants selected were decided to be proportional to the areas’ population (i.e. stratified sampling method). Then, the authors selected 10% of the areas’ residents aged between 40 and 79 on the basis of resident registration by systematic random sampling method.

Health promotion volunteers in Town A visited these 532 people individually, distributed questionnaires, and asked them to anonymously answer the questionnaire within 4 weeks. As a result, the authors received responses from 500 people (199 men, 263 women, and 38 unknown; response rate = 94.0%), of which 50 people did not state their gender and age in the questionnaire. Therefore, in the present study, the authors excluded these data from the analyses, and reported results from the answers of the 450 residents.

The mean age of the men was 57.6 ± 11.0 years, and that of the women was 58.7 ± 11.2 years. A total of 278 (61.8%) had a job, 156 (34.7%) had no job, and the other 16 (3.6%) were unclear or gave no answer.

Ethical considerations

In administering the questionnaires, the authors asked the residents not to write their names (i.e. to answer anonymously). The residents were also asked to put the questionnaires into a sealed envelope when they handed them in. Therefore, the residents understood that their answers would not be identified. Moreover, according to the present study, the authors obtained permission from the mayor of Town A, and also received sufficient cooperation from public health nurses and health volunteers. Additionally, in order to alleviate the difficulties of answering the questionnaires, the authors gave them during the farmers’ off season.

Questionnaire

The authors investigated the following variables: sociodemographic variables (i.e. gender, age, job, and cohabitants), economic status, giving and receiving social support, reason for living, coping behavior and thoughts about depression and suicidal ideation, and the attitudes toward suicide and psychiatric treatment. In the present article, the authors reported their findings regarding the coping behavior and thoughts about depression and suicidal ideation, and the attitudes toward suicide and psychiatric treatment.

Thoughts about and coping behavior with depression and suicidal ideation

The authors presented two case vignettes describing depression and suicidal ideation to the participants in order to examine the coping behavior and thoughts about depression and suicidal ideation (shown in Appendix I). In order to examine thoughts about depression and suicidal ideation, the authors asked three questions: 1 (Naturalness), ‘Do you think such a state is natural for you?’; 2 (Experience), ‘Have you ever experienced such a state?’; and 3 (Possibility), ‘Do you think you will experience such a state in the future?’ The participants answered the first two questions dichotomously (i.e. ‘yes’ or ‘no’). Because it may be difficult to answer the last question dichotomously, participants answered it using a four-point scale (i.e. ‘1, certainly yes’; ‘2, probably yes’; ‘3, probably no’; and ‘4, absolutely no’). In the data analyses, the authors dichotomized these four alternatives in order to compare with the former two items (i.e. Naturalness and Experience) easily. Specifically, the authors combined the former two as ‘yes’, and the latter two as ‘no’. When the authors kept the data separate, they obtained similar results as shown in Table 2.

Table 2.  Thoughts about depression and suicidal ideation in the younger and older groups
 DepressionSuicidal ideation
YoungerOlderχ2YoungerOlderχ2
nYes%nYes%nYes%nYes%
  • Younger = 40–59 years, Older = 60–79 years.

  • As for the possibility, the participants answered using a four-point scale. However, in the data analyses, the authors dichotomized these four alternatives.

  • *

     P < 0.05,

  • ** 

    P < 0.01,

  • ***

     P < 0.001.

Do you think such a state is normal for you? (Naturalness)223 5122.91784726.4 2243013.417615 8.5 
Have you ever experienced such a state? (Experience)22410647.31745330.5***2225323.91742614.9*
Do you think you will experience such a state in the future? (Possibility)22315368.61819954.7**2208840.01815832.0 

Then, the authors examined the coping behaviors with depression and suicidal ideation. Participants were asked what they would do if they were in such circumstances as the case vignette. The authors presented eight choices (shown in Table 3) to the participants, and permitted them to select two or more responses.

Table 3.  Coping behavior with depression
 YoungerOlderEntire
(n = 450)
χ2
Men
(n = 106)
Women (n = 138)Total
(n = 244)
Men
(n = 87)
Women
(n = 119)
Total
(n = 206)
Freq%Freq%Freq%Freq%Freq%Freq%Freq%AgeGender
  • Younger = 40–59 years, Older = 60–79 years.

  • Freq, number of people who endorsed the item.

  • *

     P < 0.05,

  • *** 

    P < 0.001.

(1) Do not seek advice1514.2 96.5249.8 55.7 43.494.4337.3* 
(2) Seek advice from family and relatives7570.89871.017370.96675.98168.114771.432071.1  
(3) Seek advice from friends and acquaintances4542.57856.512350.41517.23025.24521.816837.3****
(4) Consult public health nurses 3 2.8128.7156.11011.51714.32713.1429.3* 
(5) Consult doctors (not psychiatrists)3028.33525.46526.63236.83428.66632.013129.1  
(6) consult psychiatrists1413.21712.33112.71112.61310.92411.75512.2  
(7) Seek advice from priests, monks etc. 0 0.0 32.231.2 44.6 10.852.481.8  
(8) Other 1 0.9 21.431.2 22.3 54.273.4102.2  

Attitudes toward suicide and psychiatric treatment

Although there are some questionnaires measuring attitudes toward suicide,17–19 and psychiatric treatment,20 they may be too long to be given in a general population. Therefore, the authos made up new questions used for the present study (see, Table 5). Specifically, the attitudes toward suicide and psychiatric treatment were measured by five and two items, respectively.

Table 5.  Attitude toward suicide and psychiatric treatment for the entire sample
 AgreeDisagreeMissingϕ coefficients
n%n%n%(2)(3)(4)(5)
Suicide
 (1) I think my life has no meaning if I cannot work any more.9721.627861.87516.7−0.030.24−0.080.24
 (2) I believe people should not commit suicide.33875.1449.86815.1 −0.220.14−0.15
 (3) Suicide may be forgiven if there are enough reasons.6614.731570.06915.3  −0.060.41
 (4) I cannot understand the feelings of people who try to commit suicide.19042.216536.79521.1   −0.14
 (5) I had better die than surviving and becoming burden of my family.9020.028864.07216.0   
Psychiatric treatment
 (1) I don’t want to consult a psychiatrist even if I’m recommended to do so.13028.924354.07717.1    
 (2) People need not conceal the fact that they consult a psychiatrist.27561.19020.08518.9    

Data analysis

Data analyses were carried out by using the Statistical Analysis System (SAS) software version 8.2 (SAS Institute Inc, Cary, NC, USA). Categorical variables were compared by means of the χ2-test statistics. Fisher’s exact test was used if the expected value in any cell of a two-by-two table was less than 5. For all statistical analyses differences were considered significant at P < 0.05.

RESULTS

Thoughts about depression and suicidal ideation

More than 20% (i.e. 21.8%) of the people thought the depressive state depicted in the vignette was ‘natural’, and 35.3% answered that they had experienced such a state (Table 1). It should be noted that more than half predicted that they would experience such a state sometime in the future. When it comes to suicidal ideation, 10.0% regarded having suicidal ideation as natural for them, 17.6% answered that they had experienced such a state, and 32.4% answered they would experience suicidal ideation in the future.

Table 1.  Thoughts about depression and suicidal ideation for the entire sample
 DepressionSuicidal ideation
YesNoMissingYesNoMissing
n%n%n%n%n%n%
  1. As for the possibility, the participants answered using a four-point scale. However, in the data analyses, the authors dichotomized these four alternatives.

Do you think such a state is normal for you? (Naturalness) 9821.830367.34910.94510.035578.95011.1
Have you ever experienced such a state? (Experience)15935.323953.15211.67917.631770.45412.0
Do you think you will experience such a state in the future? (Possibility)25256.015233.84610.214632.425556.74910.9

Next, the authors compared younger residents with older ones. Although ‘old age’ is usually defined as 65 years old or over, retirement age in business organizations in Town A is usually 60. Therefore, the authors divided residents into two groups at the age of 60. When they divided the participants into younger (40–59 years) and older (60–79 years) groups (Table 2), they found significant differences in the answers for experience and possibility in the depression case vignette. That is, comparing with the elderly, younger people were more likely to report past experiences of depression (χ2[1] = 11.60, P < 0.001), and an estimated higher future possibility for depression (χ2[1] = 8.24, P < 0.01). In the suicidal ideation case vignettes, the younger people were more likely to report past experiences of suicidal ideation than the elderly (χ2[1] = 4.87; P < 0.05). There was no significant gender difference in the thoughts about depression and suicidal ideation.

Coping behavior with depression and suicidal ideation

In the entire sample, 71.1% answered that they would seek advice from family and relatives (Table 3). People who selected non-professionals (i.e. ‘family, and relatives’ and/or ‘friends and acquaintances’) as advisors were 358 (79.6%). Although doctors (not psychiatrists) were somewhat selected as consultants, mental health professionals were less likely to be selected in general. That is, while 29.1% of participants chose doctors (not psychiatrists) as consultants, the proportion who chose psychiatrists and public health nurses was 12.2% and 9.3%, respectively. Only 1.8% people reported that they had sought advice from priests, monks, and so on, which may reflect the Japanese social background. Specifically, although Japan is often said to be a Buddhist country, Japanese people do not usually rely on Buddhism as a spiritual guide in their daily lives except in special cases (e.g. funerals).

Examining generation differences, the authors found that the younger people were more likely to seek advice from friends and acquaintances (χ2[1] = 38.96; P < 0.001), and were more likely not to seek advice from anyone (χ2[1] = 4.91; P < 0.05). Comparatively, the authors also found that older people were more likely to consult public health nurses (χ2[1] = 6.39; P < 0.05) than the younger people. People who selected at least one health professional (that is, a public health nurse, doctor, or a psychiatrist) as a consultant were 84 (34.0%) in younger residents, and 93 (44.5%) in their older counterparts, which reached a significance level (χ2[1] = 5.38; P < 0.05). There was only one gender difference in coping behavior with depression; women were more likely to seek advice from friends and acquaintances.

As to coping behavior with suicidal ideation (Table 4), the authors found that the younger people were more likely to seek advice from friends and acquaintances (χ2[1] = 25.35; P < 0.001), and were less likely to seek advice from anyone (χ2[1] = 11.65; P < 0.001). In contrast, the elderly people were more likely to seek advice from family and relatives (χ2[1] = 4.01, P < 0.05), and to consult public health nurses (χ2[1] = 11.02, P < 0.01). People who selected at least one health professional (that is, a public health nurse, doctor, or a psychiatrist) as a consultant were 68 (27.5%) in the younger residents, and 86 (42.6%) in their elderly counterparts, which reached a significance level (χ2[1] = 9.56; P < 0.01). There was only one gender difference in coping behavior with suicidal ideation; women were more likely to seek advice from friends and acquaintances.

Table 4.  Coping behavior with suicidal ideation
 YoungerOlderEntire
(n = 450)
χ2
Men
(n = 106)
Women (n = 138)Total
(n = 244)
Men
(n = 87)
Women
(n = 119)
Total
(n = 206)
Freq%Freq%Freq%Freq%Freq%Freq%Freq%AgeGender
  • Younger = 40–59 years, Older = 60–79 years.

  • Freq, number of people who endorsed the item.

  • *

     P < 0.05,

  • **

     P < 0.01,

  • ***

     P < 0.001.

(1) Do not seek advice2321.71813.04116.8 78.0 65.0136.35412.0*** 
(2) Seek advice from family and relatives6056.68662.314659.86372.47966.414268.928864.0  
(3) Seek advice from friends and acquaintances4037.76748.610743.91416.13025.24421.415133.6****
(4) Consult public health nurses 21.9 85.8104.1 910.31714.32612.6368.0** 
(5) Consult doctors (not psychiatrists)2725.52719.65422.12933.33226.96129.611525.6  
(6) Consult psychiatrists1211.31913.83112.7 910.31411.82311.25412.0  
(7) Seek advice from priests, monks etc. 00.0 42.941.6 44.6 00.041.981.8  
(8) Other 00.0 32.231.2 22.3 32.552.481.8  

Attitudes toward suicide and psychiatric treatment

Out of the five items measuring attitudes toward suicide, items 1, 3, and 5 measured positive attitudes; 21.6%, 14.7% and 20.0% of the people endorsed these items, respectively (Table 5). In contrast, items 2 and 4 measured negative attitudes toward suicide. About 10% (i.e. 9.8%) and 36.7% of the people disagreed with items 2 and 4, respectively. Additionally, the coefficients of association among positive attitude items (ϕ = 0.24–0.41; average ϕ = 0.30) were moderate and larger than the absolute values of ϕ coefficients between positive and negative attitude items (|ϕ| = 0.03–0.22; average |ϕ| = 0.11). By examining the generational differences (Table 6), the authors found that although younger people were more likely to agree with the idea that people should not commit suicide (item 2, χ2[1] = 7.75; P < 0.01), they were also more likely to sympathize with the feelings of people who committed suicide (item 4, χ2[1] = 13.46; P < 0.001). There was no significant gender difference in the attitudes toward suicidal ideation.

Table 6.  Attitude toward suicide and psychiatric treatment in the younger and older groups
 YoungerOlderχ2
MenWomenTotalMenWomenTotal
nFreq%nFreq%nFreq%nFreq%nFreq%nFreq%AgeGender
  • Younger = 40–59 years, Older = 60–79 years.

  • Freq, number of people who agreed the attitude item.

  • ** 

    P < 0.01,

  • *** 

    P < 0.001.

Suicide
(1) I think my life has no meaning if I
cannot work any more.
983535.7122 2923.8220 6429.1721723.6831619.31553321.3  
(2) I believe people should not commit suicide.988889.812411794.422220592.3746283.8867182.616013383.1** 
(3) Suicide may be forgiven if there are enough reasons.992424.2122 2016.4221 4419.9751317.385 910.6160 2213.8  
(4) I cannot understand the feelings of people who try to commit suicide.974950.5114 4741.2211 9645.5704868.6744662.2144 9465.3*** 
(5) I had better die than surviving and becoming burden of my family.992121.2121 3528.9220 5625.5741418.9842023.8158 3421.5  
Psychiatric treatment
(1) I don’t want to consult a psychiatrist ven if I’m recommended to do so.983131.6118 4739.8216 7836.1742533.8832732.5157 5233.1  
(2) People need not conceal the fact that they consult a psychiatrist.986667.3116 9279.321415873.8705781.4816074.115111777.5  

The authors measured attitudes toward psychiatric treatment by using the two items found in Table 5. About 60% (i.e. 61.1%) of the participants agreed with the idea that people do not have to conceal the fact that they consult a psychiatrist. However, 28.9% answered that they didn’t want to consult a psychiatrist even if they were recommended to do so. There was no significant generational as well as gedner difference in these two items. Moreover, there was almost no correlation between these two items (ϕ = −0.08).

DISCUSSION

The present study is a survey of a local town in Aomori Prefecture where the suicide rate is high, and about 10% of the residents (40–79 years) participated in the survey. The authors investigated sociopsychological factors relating to suicide and depression, which have not been thoroughly examined, and attempted to improve the effectiveness of the existing suicide prevention measures. Considering the high response rate (94.0%) and the lack of community surveys about sociopsychological studies regarding suicide and depression in Japan, the present study has theoretical as well as practical importance. Although there were few gender differences, some significant differences were found between the younger (40–59 years) and older (60–79 years) residents.

Thoughts about suicidal ideation

It is noteworthy that 10.0% of people thought it was natural for them to have suicidal ideation, and 17.6% reported that they had experienced suicidal ideation. Similar prevalences of suicidal ideation have been found in previous studies.21,22 For example, in Japan, Ono et al. found that 12% of the community residents aged 65 or over reported experiences of suicidal ideation.21 In Finland, Hintikka et al. reported that 14.7% of people (in the general population) had experienced suicidal ideation in the previous 12 months.22 Considering these previous studies, the result of 17.6% in the present study is not remarkable.

The estimation of naturalness is thought to be based on past experiences and the present state. Specifically, even if one has experienced suicidal ideation, he/she may not regard it as natural when his/her mental health is good. Therefore, the naturalness estimate may be lower than the reported past experiences. The present results were consistent with the above prediction, that is, the naturalness estimate (10.0%) was lower than the past experiences (17.6%).

People who regard suicidal ideation and/or depression as natural may not think it as a psychiatric problem, and, therefore, may not be able to cope with it appropriately. In other words, such people may have higher risks for suicide. The representative suicide prevention measures in Japan are to screen people who have high depressive symptoms, and follow and care for them individually. However, since such screening procedures are usually given only once or twice a year, their predictability of future depression and suicide may be limited. Although the naturalness estimate may change slightly, it may be more stable than depressive symptoms and suicidal ideation because it is thought to be based on past experiences as well as one’s present state. Therefore, it may be able to contribute to predict future depression and suicidal ideation.

High prevalence of future expectation for experiencing depression and suicidal ideation is also noteworthy. That is, 56.0% and 32.4% of the people answered that they would experience depression and suicidal ideation in the future, respectively. Since the authors don’t have ample research that is comparable with the present study, they are not yet able to accurately determine whether the high prevalence is limited to Town A, where suicide rate is higher than the average rate found in Japan. However, the future expectation estimate of suicidal ideation (i.e. 32.4%) is thought to be dangerously high. The expectation is especially high in younger people. Younger people may have more stressors, which may make them expect suicidal ideation and depression in the future.

Coping behavior with depression and suicidal ideation

Generally, the residents were less likely to seek help when they had suicidal ideation than when they experienced depression, although having suicidal ideation is more critical than experiencing depression. It may suggest the difficulty of crisis intervention and suicide prevention. However, 64.0% of the people answered that when they experienced suicidal ideation, they would seek advice from family and relatives, and 25.6% answered that they would consult a doctor. There are at least two points that are suggested from the results. The first point, according to the results, is that because a quarter of the people said that they would consult a doctor, the authors believe that by educating doctors (i.e. general practitioners) to be able to more appropriately and competently diagnose and treat depression will be effective for suicide prevention.23,24 The other point is educating residents about depressive symptoms and making them aware of these symptoms is also essential and effective.25 If community residents know that suicide is usually preceded by depression, and that most depression is able to be cured by appropriate medication and therapy, they will learn to consult with mental health professionals.

Attitudes toward suicide

In the present study, in order to assess the attitudes toward suicide, the authors originally developed five items (three items assessing positive and two items assessing negative attitudes toward suicide). As shown in Table 5, the coefficients of association among items assessing positive attitude were moderate, therefore, the internal consistency of these three items was ensured, although the coefficients of association among items assessing negative attitude was weak and the internal consistency of these two items was not verified. As other researchers have suggested,18 people may have ambivalent attitudes toward suicide. However, because the validity of negative attitude items was not verified in the present study, the relationship between positive and negative attitude toward suicide should be replicated in other studies.

Moreover, it is noteworthy that younger people have more receptive attitudes toward suicide than the elderly. There may be at least two reasons, that is, a developmental change and a cohort. In order to draw conclusion, the authors must wait for more future studies examining these points in Japan. However, considering the results that younger people not only had receptive attitudes toward suicide, but also had a higher estimate of experiencing depression, the risk of committing suicide may be higher in the younger residents than in the elderly.

Attitudes toward psychiatric treatment

Although 61.1% of the residents agreed with the item ‘people need not conceal the fact that they consult a psychiatrist’, there were 28.9% who agreed with the idea that they didn’t want to consult a psychiatrist even if they were recommended to do so. Considering that there was almost no correlation between these two, it could be said that even if people feel that one need not conceal the fact that one consults a psychiatrist, it does not necessarily lead to a help-seeking behavior of consulting psychiatrists. Prejudice and lack of understanding towards psychiatric illness and treatment are prevalent in Japan, which ultimately interferes with people seeking help from psychiatrists.26 Reducing prejudice and misunderstanding is necessary to strengthen the effectiveness of suicide prevention measures through early detection and intervention of depression.

Limitation

There are some limitations to the present study. First, although efforts were made to make the questionnaire understandable and easy to answer, some items could not be answered. For example, missing values were 12.0% to 14.0% in Table 4, and 17.4% to 23.6% in Table 5. From an opinion written in a questionnaire, the authors realized that it may be difficult for the respondents to answer dichotomously to the items measuring attitude toward suicide and psychiatric treatment, which the authors feel caused an increase in missing values in these items. Additionally, the authors cannot deny the possibility that those who have strong suicidal ideation are reluctant to answer the items measuring attitude toward suicide. Therefore, attention should be paid to reducing missing values in future research, and the results of the present study ought to be replicated in other areas. Second, the survey was conducted in a single agricultural area of Japan characterized by depopulation, aging and severe winters. Therefore, the results cannot be immediately generalized in Japan as a whole. Third, the present study is cross-sectional, therefore, the authors cannot refer to any causal relationships among the variables investigated in this study. Finally, because the present study used a case vignette method, it may not predict actual coping behavior.

ACKNOWLEDGMENTS

This project was supported in part by a Grant-in-Aid for Scientific Research from the Ministry of Health, Labor, and Welfare, Japan. The authors thank Yumiko Morio, Keio University, for her technical support.

Appendix

APPENDIX I

Case vignettes

Depression: If you felt sad and depressed, were unable to enjoy doing things that you normally enjoy doing, felt full of pain, and the routine of your life was disturbed, what would you do?

Suicidal ideation: If you thought about death and suicide and felt full of pain and were distressed, what would you do?

Ancillary