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Keywords:

  • debt;
  • middle age;
  • psychological autopsy;
  • suicide

Abstract

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

This study examined the psychosocial and psychiatric features of 16 Japanese suicide completers with unmanageable debt compared with 23 suicide completers without such debt at time of death, using a psychological autopsy method. The individuals with unmanageable debt were more likely to have been self-employed and to have experienced divorce. They were less likely to have engaged in help-seeking behavior, despite having mental health problems. Our findings suggest that providing comprehensive support and promoting help-seeking behavior may be important for suicide prevention in middle-aged men.

IN JAPAN, THE number of suicide completers has increased rapidly to over 30 000 in 1998. Since then, the number of suicides has continued to be high (suicide rate: 25.8 per 100 000 in 20091). In particular, suicides of middle-aged men, many of whom had unmanageable debt, have remarkably increased.2 Countermeasures to address financial problems may be essential for suicide prevention in middle-aged men. However, we question whether these measures alone can reduce suicide in this population, as previous studies have shown that an interaction of multiple factors, including psychiatric disorders, psychosocial isolation, and economic difficulties, may lead to suicidal behavior.3 We suspect that suicide in middle-aged individuals with financial problems might be caused not solely by economic difficulties; suicide risk may be aggravated by psychiatric or psychosocial problems.

The purpose of the present study was to examine psychosocial and psychiatric features of suicide completers with unmanageable debt compared to those without such debt, using a psychological autopsy method. This study also aimed to obtain useful findings relevant to suicide prevention in Japanese middle-aged men.

METHODS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Since December 2007, we have been conducting a Japan-wide study on suicide completers using a psychological autopsy method.4 We collected information on suicide completers who had died since January 2006 and whose bereaved consulted the prefectural Mental Health Welfare Centers (MHWC) that had consented to participate in our study. In cooperation with 54 prefectural MHWC, a semi-structured interview by a psychiatrist and other mental health professionals was conducted with the closest bereaved. The semi-structured interview was based on an assessment instrument developed by the Beijing Suicide Research and Prevention Center in China.5 The items included questions about family environment, history of suicide attempts, life history, socioeconomic and physical health status, and psychiatric diagnosis according to DSM-IV criteria6 at the time of death. This study was approved by the ethics committee of the National Institute of Mental Health, National Center of Neurology and Psychiatry.

As of December 2009, we had collected psychosocial and psychiatric information on 76 Japanese suicide cases. Of the 76 cases, 39 middle-aged men between 30 and 64 years of age (M = 44.9 ± 9.25) were selected as the subjects of this study. The subjects were divided into two groups according to those with unmanageable debt (the Debt group) or those without unmanageable debt (the No debt group) at the time of death, according to the bereaved. In this study, the term ‘unmanageable debt’ was defined as debt that is considered to be detrimental to a household budget by the closest bereaved, regardless of the amount. The following items were compared between these groups: demographic factors (age, employment, living situation, marital status), life history (family problems, job history, unmanageable debt), financial status (income, economic condition), sleep-related problems (sleep disturbance, regular ‘night cap’ drinking, regular use of sleep medication), physical illness, history of suicide attempt, disappearing episode including fugue, help-seeking behavior during the year prior to death (seeking help only from health professionals, which includes history of consultation or treatment from physicians, other medical professionals, or psychiatrists), and DSM-IV psychiatric diagnosis.

We compared the differences between the groups using Fisher's exact test for qualitative variables, and the Mann–Whitney U-test for the annual income, which is not normally a distributed variable. Statistical analyses were performed using spss Version 16.0 (spss, Chicago, IL, USA).

RESULTS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Table 1 shows the characteristics of the Debt and No debt groups. The former comprised 16 cases (41.0%), and the latter comprised 23 cases (59.0%). Although no significant differences were found in family environment and age between the groups, significant differences were found in employment and experience of divorce. The Debt group more frequently included self-employed or divorced individuals. This group was also more likely to have had financial problems, despite no significant differences in annual income between the two groups.

Table 1.  Sociodemographic, psychosocial, and psychiatric profiles of suicide completers with and without unmanageable debt
 Debt group (n = 16)No debt group (n = 23)P-value
  • **P < 0.01, *P < 0.05.

  • The value of the annual income of the family is a median value of each group.

Age group   
 30–39 years4 (25.0%)10 (43.5%)0.467
 40–49 years7 (43.8%)6 (26.1%)
 50–64 years5 (31.2%)7 (30.4%)
Employment   
 Self-employed7 (43.8%)1 (4.3%)0.007**
 Employee8 (50.0%)17 (73.9%)
 Unemployed1 (6.2%)5 (21.7%)
Living situation   
 Living alone2 (12.5%)1 (4.3%)0.557
Marital status   
 No spouse6 (37.5%)6 (26.1%)0.498
 Unmarried4 (25.0%)5 (21.7%)1.000
Family problems   
 Divorced5 (31.2%)0 (0.0%)0.008**
 Divorced during the year prior to death1 (6.2%)0 (0.0%)0.410
 Suicide of relative or friend10 (62.5%)18 (78.3%)0.307
Job history   
 Job change10 (62.5%)17 (73.9%)0.498
 Job change during the year prior to death2 (12.5%)3 (13.0%)1.000
 Administrative leave4 (25.0%)10 (43.5%)0.317
 Administrative leave during the year prior to death1 (6.2%)5 (21.7%)0.370
Financial status   
 Financial problems (economic poverty)11 (68.8%)5 (21.7%)0.007**
 Annual income of family¥6 120 000¥6 760 0000.987
Sleep-related problems   
 Sleep disturbance10 (62.5%)20 (87.0%)0.123
 Regular ‘night cap’ drinking5 (31.2%)2 (8.7%)0.127
 Regular use of sleep medication2 (12.5%)9 (39.1%)
 Regular ‘night cap’ drinking and use of sleep medication1 (6.2%)3 (13.0%)
Physical illness5 (31.2%)8 (36.4%)1.000
Behavior before suicide   
 History of suicide attempt5 (31.2%)3 (13.0%)0.235
 Disappearing episode including fugue8 (50.0%)5 (21.7%)0.090
 Help-seeking behavior during the year prior to death4 (25.0%)16 (69.6%)0.010*
Prevalence of psychiatric disorders speculated at the time of death16 (100.0%)20 (87.0%)0.255
DSM-IV psychiatric diagnosis   
 Alcohol abuse or dependence5 (31.2%)2 (8.7%)0.101
 Major depression6 (37.5%)15 (65.2%)0.112
 Dysthymic disorder0 (0.0%)4 (17.4%)0.130
 Bipolar II disorder1 (6.2%)1 (4.3%)1.000
 Obsessive–compulsive disorder0 (0.0%)1 (4.3%)1.000
 Generalized anxiety disorder3 (18.8%)1 (4.3%)0.286
 Panic disorder1 (6.2%)0 (0.0%)0.410
 Schizophrenia1 (6.2%)2 (8.7%)1.000
 Pathological gambling2 (12.5%)0 (0.0%)0.162
 Hypochondria1 (6.2%)0 (0.0%)0.410
 Personality disorder2 (12.5%)2 (8.7%)1.000
 Adjustment disorder4 (25.0%)0 (0.0%)0.022*
 Substance abuse or dependence0 (0.0%)1 (4.3%)1.000
 Mental retardation0 (0.0%)1 (4.3%)1.000

Prevalence of psychiatric diagnoses speculated at time of death were similar in the two groups, although the Debt group was conjectured to have had a higher rate of adjustment disorders. Help-seeking behavior was less frequent in the Debt group, despite the high prevalence of psychiatric disorders.

Twelve cases in the Debt group (75.0%) had unmanageable debt for over a year prior to death. Seven cases (43.8%) were multiply indebted individuals who borrowed from many lending companies. The following is a more detailed breakdown of debt (excluding four missing cases): one case (8.0%) under 300 000 yen, five cases (38.5%) 300 000–200 000 000 yen, five cases (38.5%) 200 000 000–600 000 000 yen, and one case (8.0%) over 600 000 000 yen. Debts resulted mainly from business funds (25.0%), money wasted on amusements (25.0%), financial difficulty in business (18.8%), gambling (12.5%), and shopping (12.5%).

DISCUSSION

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

To our knowledge, this is the first study to examine differences in psychosocial and psychiatric features between middle-aged suicide-completing men with and without unmanageable debt at time of death using a psychological autopsy method. Our study found no significant difference in annual income between the two groups. However, those with unmanageable debt were more likely to have had financial problems. This suggests stress related to debt repayment, not low income. Those with unmanageable debt resulting from financial difficulty in business more frequently included the self-employed. Such difficulties may lead to an adjustment disorder, which was more prevalent in this group.

More suicide completers with unmanageable debt had experienced divorce than those without debt. However, our study did not examine whether divorce was a cause or effect of unmanageable debt. It seems that suicide completers with unmanageable debt were more likely to have had difficulties not only in their jobs but also in their private lives. They may have lost relationships with significant others, resulting in psychosocial isolation before the time of death.

A most remarkable finding of the present study is that suicide completers with unmanageable debt engaged in considerably less help-seeking behavior than those without unmanageable debt. Namely, even though the financial and psychosocial burdens in their lives were supposed to cause mentally stressful conditions to such suicide completers, they had little contact with health professionals, including physicians and psychiatrists, during the year prior to death. This tendency is explained by the following two reasons: (i) the culturally prejudiced view regarding debt7,8 might prevent them from accessing health professionals; and (ii) demands for debt repayment might distract individuals' attention from their mental health condition. In fact, a previous study suggested the association between not utilizing psychiatric services and unmanageable debt,9 although additional researches are required to clarify the reason why subjects with unmanageable debt engage in less help-seeking behavior.

Three limitations of the present study should be noted. First, the sample size of this study is relatively small, and sample-representation is biased. Accordingly, generalization of the findings is limited. Second, recall and reporting bias cannot be excluded because information was collected retrospectively from the bereaved. Finally, this study lacks a comparison group. Therefore, risk factors for suicide in middle-aged men with unmanageable debt cannot be addressed.

Despite these limitations, this is the first study to clarify psychosocial and psychiatric features of suicide-completing men with unmanageable debt, using a psychological autopsy method. Our findings may be useful for suicide prevention in Japanese middle-aged men with economic difficulty, a population that has experienced a rapid increase in suicides since 1998. Comprehensive support, including both financial support and psychiatric treatment, and promotion of help-seeking behavior may be required for suicide prevention in middle-aged men.

REFERENCES

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES
  • 1
    Cabinet Office. White paper of suicide prevention in Japan. 2009.
  • 2
    Kondo N, Subramanian SV, Kawachi I, Takeda Y, Yamagata Z. Economic recession and health inequalities in Japan: Analysis with a national sample, 1986–2001. J. Epidemiol. Commun. H 2008; 62: 869875.
  • 3
    Meltzar H, Bebbington P, Brugha T, Jenkins R, McManus S, Dennis MS. Personal debt and suicidal ideation. Psychol. Med. 2010; 16: 18.
  • 4
    Katsumata Y, Matsumoto T, Takahashi Y et al. Psychological autopsy study in Japan, Suicide in Japan (symposium). The 2nd World Congress of Asian Psychiatry, Taipei, Nov 2009; 80.
  • 5
    Phillips MR, Yang G, Zhang Y, Wang L, Ji H, Zhou M. Risk factors for suicide in China: A national case-control psychological autopsy study. Lancet 2002; 360: 17281736.
  • 6
    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn. American Psychiatric Association, Washington DC, 1994.
  • 7
    Shimizu S, Kawano K, Ishihara T, Shimura Y, Takasaki F, Miyazaki T. The study for a method of clarifying suicide-related psycho-social factors: The community survey for suicide related problems. Annual report of the National Institute of Mental Health, NCNP, Japan. [Cited 26 August 2011.] Available from URL: http://ikiru.ncnp.go.jp/ikiru-hp/report/imada15/15-2-6.pdf.
  • 8
    Wong PWC, Chan WSC, Conwell Y, Conner K, Yip P. A psychological autopsy study of pathological gamblers who died by suicide. J. Affect. Disord. 2010; 120: 213216.
  • 9
    Law YW, Wong PWC, Yip P. Suicide with psychiatric diagnosis and without utilization of psychiatric service. BMC Public Health 2010; 10: 431.