Sociodemographic determinants of attitudinal barriers in the use of mental health services in Japan: Findings from the World Mental Health Japan Survey 2002–2006

Authors

  • Yoshifumi Kido RN, MS,

    Corresponding author
    1. Department of Psychiatric and Mental Health Nursing, St. Luke's College of Nursing, Tokyo, Japan
    • Department of Psychiatric Nursing, The University of Tokyo, Tokyo, Japan
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  • Norito Kawakami MD,

    1. Department of Mental Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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  • WHO World Mental Health Japan Survey Group


Correspondence: Yoshifumi Kido, RN, MS, Department of Psychiatric Nursing, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan. Email: yoshifumi-tky@umin.ac.jp

Abstract

Aim

Sociodemographic correlates of Japanese attitudinal barriers to mental health services might be different from previous studies in Western countries, reflecting a different culture. We investigated sociodemographic correlates of attitudinal barriers to mental health services in a community population in Japan, based on data collected in the World Mental Health Survey Japan surveys.

Methods

An interview survey was conducted of a random sample of residents living in 11 communities across Japan during 2002–2006. A total of 1359 participants were analyzed. The variables on attitudinal barriers to mental health services were measured by using the World Health Organization Composite International Diagnostic Interview 3.0. The association between these variables and sociodemographic variables were analyzed by using multiple logistic regressions.

Results

Being male was significantly associated with willingness to go for professional help and feeling comfortable to talk with a professional. Compared to the youngest group (20–34 years old), those aged from 35 to 49 years had a significantly lower prevalence of feeling embarrassed about friends knowing about their getting professional help, while the oldest group (aged over 65 years) had a significantly higher prevalence of being embarrassed. Being currently married was significantly associated with higher expectations about mental health services, but it was significantly and negatively associated with willingness to go for professional help.

Conclusion

These results suggest that demographic patterns of attitudinal barriers to mental health services in Japan are unique, compared with previous studies in Western countries. An anti-stigma campaign may need to consider such country-specific patterns in a particular country.

WHILE MENTAL HEALTH service utilization has been on the rise over the last decade, most people with mental disorders worldwide remain either untreated or poorly treated.[1, 2] Theoretical models of mental health help-seeking behavior suggest that several barriers affect individual progress through several stages prior to seeking mental health treatment.[3] These barriers have been broadly divided into system-level structural barriers (such as financial cost of services) and individual attitudinal barriers (such as fear of stigmatization, and thoughts that the problem would get better on its own).[4-6] Attitudinal barriers to mental health services use are more common than structural barriers, except for low-income respondents.[7] Attitudinal barriers consist of three components: ‘Psychological Openness’, which reflects openness to acknowledging psychological problems and the possibility of seeking professional help for the problems; ‘Help-seeking Propensity’, which reflects willingness and ability to seek help; and ‘Indifference to Stigma’, which reflects concern about how important people in one's life would react to help-seeking.[8]

Previous studies on attitudinal barriers to mental health services in Europe and North America broadly reported that women and older adults were more willing to seek help from professional services.[9-12] People with a higher social class, such as high educational attainment and high income, had lower attitudinal barriers to mental health services.[13] These patterns are generally consistent with sociodemographic patterns of stigma toward mental disorders.[13, 14] However, most studies on attitudinal barriers to mental health service were conducted in Western developed countries.

In Japan, the proportion of access to mental health services was lower among those who had mental disorders, almost half of other high-income countries.[15] Stigma toward mental disorders has been reported as higher in Japan than in Australia.[16] This is despite a recent anti-stigma campaign in Japan, which included changing the facility department name for the psychiatric outpatient clinic,[17] changing the diagnosis name for schizophrenia,[18-20] advertisements by pharmaceutical companies, education programs at schools and an anti-stigma campaign by the government. The sociodemographic correlates of attitudinal barriers to mental health services may be different from Western countries, reflecting a different history and culture. Japanese men may be more willing to seek professional help than women, as men have more opportunities to work in Japanese society than women. Older Japanese may feel more embarrassed about having friends know that they have sought professional help compared to other generations, as they are more prone to Japanese traditional culture and fears of losing ‘face’. In Japan, there are no studies on attitudinal barriers to mental health services and its sociodemographic correlates. If we are able to find some sociodemographic groups with high attitudinal barriers to mental health services, such information should be useful in interventions to improve access to mental health services in Japan.

In this study, we investigated sociodemographic correlates of the attitudinal barriers to mental health service in the community population of Japan, based on data collected in World Mental Health Survey Japan (WMH-J) surveys.[21]

Methods

Participants

The WMH-J was an epidemiological survey of Japanese-speaking household residents aged 20 and older. It was conducted in eleven communities across Japan in 2002–2006, including three urban cities and nine rural municipalities. These sites were selected on the basis of geographic variation, availability of site investigators, and cooperation of the local government. A random sample was selected from residents aged 20 years old or over in each survey site, based on a voter registration list or a resident registry. After a letter of invitation was sent, trained interviewers contacted the subjects and interviewed those who agreed to participate in the survey using the standardized instrument. The total response rate was 55.1%.

An internal sampling strategy was used in all surveys to reduce respondent burden by dividing the interview into two parts. Part I included a core diagnostic assessment of all respondents that took an average of about 1 h to administer. Part II included questions about risk factors, consequences and others, including questions of hesitation and expectation in the use of mental health service. Part II was administered to all Part I respondents with one or more lifetime disorders plus a probability subsample of approximately 25% of the remaining respondents. 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 this study, we analyzed 1343 participants with no missing values in the questions of hesitation and expectation in the use of mental health services.

The Ethics Committees of Okayama University, National Institute of Mental Health Japan, and Nagasaki University approved the recruitment, consent and, field procedures. Written informed consent was obtained from each respondent. More details of the study procedures are given in a separate article.[21]

Measures

The diagnostic interview included in the survey was the World Mental Health Survey Initiative Version of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI).[22, 23] The CIDI is a fully-structured interview designed to generate DSM-IV and ICD-10 diagnoses based on responses obtained in face-to-face interviews by trained lay interviewers. ‘Hesitations and Expectations’ about mental health service were measured in a section of Chronic Conditions (CC) in Part II.

‘Willingness to go for professional help’ was measured by a single-item question: ‘People differ a lot in their feelings about professional help for emotional problems. If you had a serious emotional problem, would you go for professional help?’ We grouped a four-point response into a dichotomous variable: not willing (‘would definitely not go’ and ‘would probably not go’) and willing (‘would definitely go’ and ‘would probably go’).

‘Feeling comfortable to talk with a professional’ was measured by another single-item question: ‘How comfortable would you feel talking about personal problems with a professional?’ We grouped a four-point response into a dichotomous variable: not comfortable (‘not at all comfortable’ and ‘not very comfortable’) and comfortable (‘very comfortable’ and ‘somewhat comfortable’).

‘Feeling embarrassed about friends knowing’ about getting professional help was measured by a single-item question: ‘How embarrassed would you be if your friends knew you were getting professional help for an emotional problem?’ We grouped a four-point response into a dichotomous variable of embarrassed (‘very embarrassed’ and ‘somewhat embarrassed’) and not embarrassed (‘not at all embarrassed’ and ‘not very embarrassed’).

‘Expectations from mental health services’ were assessed by a set of two questions. First, the percent of those helped by a professional was measured by a single-item question: ‘Of the people who see a professional for serious emotional problems, what percent do you think are helped?’ The response ranged from 0 to 100%. Second, the percent of those getting better without help was measured by a single-item question: ‘Of the people who get professional help, what percent do you think get better even without it?’ The response ranged from 0 to 100%. We subtracted the percent of those helped by a professional from the percent of those getting better without help, with the higher score being indicative of expectations from mental health services.

Sociodemographic variables were measured by sex, age, family income, marital status, education, and area. The variable of age was categorized into 20–34, 35–49, 50–64 and 65+ years following classifications in previous studies in the World Mental Health Surveys.[21, 24, 25] The variable of household income was categorized into JPY 0–1 800 000, 1 800 000–4 200 000, 4 200 000–7 100 000, and 7 100 000–15 730 000. Marital status was composed of ‘Currently married’, ‘Never married’, ‘Separated’, ‘Widowed’, and ‘Divorced’, and was given dichotomous variables (‘Married’ or not). The variable of education was categorized into 0–9, 10–12, 13–15, 16+ years, and unknown, and was composed of ‘Middle school or less,’ ‘High school,’ ‘Some college,’ ‘College or higher,’ and ‘Unknown.’ Area was given dichotomous variables (Rural or Urban), based on core city with a population of more than 300 000.

Data analysis

Proportions of ‘Willingness to go for professional help’, ‘Feeling comfortable to talk with a professional,’ and ‘Feeling embarrassed about friends knowing’ were compared with the groups classified on the basis of sex, age, family income, marital status, education, or urban/rural area (χ2-test). Multiple logistic regression was conducted to determine any unique associations between the demographic variables and the outcome variables. Average scores of ‘Expectations from mental health services’ were compared among the groups classified on the basis of the sociodemographic variables (multiple linear regression with dummy variables). Multiple linear regression was conducted to determine unique associations between the demographic variables and the outcome variables. In this study, all samples were weighted to adjust for differential probabilities of selection and post-stratified to match the population distributions on the cross-classification for sex and age.[26] All analyses were conducted with PROC SURVEYFREQ, SURVEYREG, and SURVEYLOGSITIC of sas 9.1.3 for Windows statistical package.

Results

Sample characteristics

Among 1359 respondents who completed the Part II interview, when unweighted, the number of female respondents was slightly greater than that of male respondents (Table 1). Twenty percent of the respondents were 65 years or older. Most (about 70%) respondents were married. One-fifth of the respondents completed middle school or less education; one-fifth completed university or higher education. Half of the respondents lived in urban areas. Weighting for differential probabilities of selection for Part II interview and biased distributions of sex and age due to non-responses did not greatly change the distribution. Of these demographic characteristics among the respondents, the male-to-female ratio was almost 1 and a greater proportion (about 25%) was 65 years or older among the weighted sample.

Table 1. Characteristics of survey participants in the World Health Organization World Mental Health Japan Survey 2002–2006 (n = 1359)
 Part II sample
Unweighted n (%)Weighted n (%)
  1. Weighted to adjust for differential probabilities of selection for Part II interview and biased distributions of sex and age due to non-responses.
Sex  
Male586 (43.6)681 (50.1)
Female757 (56.4)678 (49.9)
Age (years)  
20–34274 (20.4)270 (19.9)
35–49369 (27.5)371 (27.3)
50–64427 (31.8)367 (27.0)
65+273 (20.3)350 (25.8)
Household income  
Low335 (24.9)333 (24.5)
Low–average317 (23.6)320 (23.5)
Average–high290 (21.6)293 (21.5)
High350 (26.1)353 (25.9)
Unknown/refused to say51 (3.8)61 (4.5)
Marital status  
Currently married933 (69.5)931 (68.5)
Never married/ separated/ widowed/ divorced410 (30.5)428 (31.5)
Education  
Middle school or less276 (20.5)286 (21.0)
High school470 (35.0)432 (31.8)
Some college275 (20.5)291 (21.4)
College or higher252 (18.8)270 (19.9)
Unknown/ refused to say70 (5.2)80 (5.9)
Area  
Urban (Yokohama, Okayama, Nagasaki)647 (48.2)644 (47.4)
Rural (others)696 (51.8)715 (52.6)

Proportion of attitudinal barriers in the use of mental health services by sociodemographic group

The proportion of those who were willing to seek professional help and that expected results from mental health services was significantly higher among women than men (P < 0.001) (Table 2). Older people had a higher proportion of those who felt comfortable to talk with a professional (P = 0.039 for age group difference). Among participants aged 35–49, the highest proportion of those who felt embarrassed about friends knowing about their getting professional help was observed (P < 0.001 for age group difference). Older people had a higher proportion of those who expected results from mental health services (P < 0.001 for age group difference). Groups with higher family income had a higher proportion of those who felt embarrassed about friends knowing, while the group with lowest family income also had a higher proportion of those who felt embarrassed (P = 0.016). Groups with low–average family income had a higher proportion of those who expected results from mental health services (P < 0.001 for family income group difference). Participants currently married had a significantly higher proportion of those who were willing to go for professional help and felt comfortable talking with a professional (P = 0.017 and P = 0.003, respectively). They also had a higher proportion of those who expected results from mental health services (P < 0.001). Participants with a high-school or higher education had a higher proportion of those who felt embarrassed about friends knowing (P = 0.007) and had a lower proportion of those who expected results from mental health services (P < 0.001). Participants living in a rural area had a significantly higher proportion of those who expected results from mental health services compared with participants living in an urban area (P < 0.001).

Table 2. Proportion of attitudinal barriers in the use of mental health service by sociodemographic groups in the World Health Organization World Mental Health Japan Survey 2002–2006 (n = 1359)
 nWillingness to go for professional helpFeeling comfortable to talk with a professionalFeeling embarrassed about friends knowingExpectations from mental health service
n (%)Pn (%)Pn (%)PMean (SE)P
  1. *Significant at the 0.05 level, two-side test.
  2. Weighted N. All analyses were weighted to adjust for differential probabilities of selection for Part II interview and biased distributions of sex and age due to non-responses.
Sex         
Male681434 (63.7)<0.001*589 (86.5)0.091319 (46.8)0.12622.26 (1.3)<0.001*
Female678520 (76.7)614 (90.6)354 (52.2)24.88 (1.1)
Age (years)         
20–34350229 (65.4)0.176292 (83.4)0.039*171 (48.9)<0.001*19.68 (1.7)<0.001*
35–49367250 (68.1)326 (88.8)223 (60.8)23.13 (1.7)
50–64371273 (73.6)344 (92.7)179 (48.2)25.67 (1.6)
65+270201 (74.4)241 (89.3)101 (37.4)26.32 (1.8)
Household income
Low333233 (70.0)0.230282 (84.7)0.335164 (49.2)0.016*20.62 (1.6)<0.001*
Low–average320236 (73.8)286 (89.4)142 (44.4)26.04 (1.7)
Average–high293212 (72.3)262 (89.4)156 (49.1)24.79 (1.9)
High353240 (68.0)314 (89.0)195 (55.2)22.67 (1.7)
Unknown6133 (54.1)58 (95.1)17 (27.9)25.99 (4.5)
Marital status         
Currently married931679 (72.3)0.017*848 (91.1)0.003*476 (51.1)0.19725.37 (1.0)<0.001*
Never married/ separated/ widowed/ divorced428275 (64.3)355 (82.9)197 (46.0)19.64 (1.5)
Education         
Middle school or less286207 (72.4)0.631253 (88.5)0.510113 (39.5)0.007*28.02 (2.0)<0.001*
High school432297 (68.8)385 (89.1)227 (52.5)23.28 (1.4)
Some college291213 (73.2)259 (89.0)148 (50.9)23.44 (1.8)
College or higher270187 (69.3)230 (85.2)155 (57.4)18.00 (1.8)
Unknown8050 (62.5)76 (95.0)31 (38.8)28.46 (20.4)
Area         
Urban (Yokohama, Okayama, Nagasaki)644444 (68.9)0.427555 (86.2)0.054314 (48.8)0.64320.98 (1.2)<0.001*
Rural (others)715511 (71.5)648 (90.6)360 (50.3)25.89 (1.2)

Association between sociodemographic variables and attitudinal barriers in the use of mental health services

When all demographic variables (sex, age, family income, marital status, education, and area) were simultaneously entered into the multiple logistic or linear regression models (Table 3), being male was significantly associated with willingness to go for professional help and feeling comfortable to talk with a professional (P < 0.001 and P = 0.043, respectively). Compared to the youngest group (20–34 years old), those aged from 35 to 49 years had a significantly lower prevalence of feeling embarrassed about friends knowing about their getting professional help, while the oldest group (aged over 65 years) had a significantly lower prevalence (P = 0.02). Being currently married was significantly associated with higher expectation for mental health services (P = 0.044), but they were significantly and negatively associated with willingness to go for professional help (P = 0.019).

Table 3. Sociodemographic predictors of barriers to mental health service adjusted by sex, age, family income, marital status, education, and area in the World Health Organization World Mental Health Japan Survey 2002–2006 (n = 1359)
 Willingness to go for professional helpFeeling comfortable to talk with a professionalFeeling embarrassed about friends knowingExpectations from mental health service
OR (95%CI)POR (95%CI)POR (95%CI)Pβ (SE)P
  1. All analyses were weighted to adjust for differential probabilities of selection for Part II interview and biased distributions of sex and age due to non-responses.
  2. All OR and standardized regression coefficient were adjusted by sex, age, family income, marital status, education, and area.
  3. *Significant at the 0.05 level, two-sided test.
  4. CI, confidence interval; OR, odds ratio.
Sex        
Male1.93 (1.41–2.65)<0.0011.59 (1.02–2.48)0.0431.32 (0.99–1.76)0.059−2.54 (1.70)0.134
Female1.00 1.00 1.00 0.00 
 χ2 = 16.6, d.f. = 1, P < 0.001*χ2 = 4.11, d.f. = 1, P = 0.043*χ2 = 3.56, d.f. = 1, P = 0.059F = 2.24 ,d.f. = 1, P = 0.134
Age (years)        
20–341.00 1.00 1.00 0.00 
35–490.98 (0.61–1.57)0.9360.56 (0.25–1.27)0.4040.69 (0.45–1.05)0.0851.70 (2.47)0.493
50–640.72 (0.44–1.17)0.1790.47 (0.22–1.00)0.0501.06 (0.70–1.62)0.7732.71 (2.58)0.293
65+0.67 (0.38–1.17)0.1590.75 (0.38–1.48)0.1661.43 (0.86–2.37)0.1642.45 (2.82)0.385
 χ2 = 3.72, d.f. = 3, P = 0.293χ2 = 4.12, d.f. = 3, P = 0.249χ2 = 9.90, d.f. = 3, P = 0.020*F = 0.41, d.f. = 3, P = 0.747
Household income        
Low1.00 1.00 1.00 0.00 
Low–average0.82 (0.52–1.29)0.3870.69 (0.35–1.35)0.2791.16 (0.77–1.76)0.4725.18 (2.37)0.029
Average–high1.01 (0.61–1.67)0.9700.76 (0.40–1.51)0.4531.06 (0.69–1.64)0.7794.23 (2.68)0.115
High1.18 (0.72–1.94)0.5150.83 (0.40–1.72)0.6070.98 (0.63–1.53)0.9392.58 (2.57)0.314
Unknown3.07 (1.00–9.50)0.0510.67 (0.14–3.35)0.6304.46 (1.55–12.83)0.006−3.27 (7.31)0.655
 χ2 = 5.93, d.f. = 4, P = 0.204χ2 = 1.35, d.f. = 4, P = 0.852χ2 = 8.51, d.f. = 4, P = 0.075F = 1.52, d.f. = 4, P = 0.194
Marital status        
Currently married0.63 (0.42–0.93)0.0190.60 (0.35–1.03)0.0620.85 (0.60–1.21)0.3634.00 (1.99)0.044
Never married/ separated/ widowed/ divorced1.00 1.00 1.00 0.00 
 χ2 = 5.52, d.f. = 1, P = 0.019*χ2 = 3.49, d.f. = 1, P = 0.062χ2 = 0.83, d.f. = 1, P = 0.363F = 4.06, d.f. = 1, P = 0.044*
Education        
Middle school or less1.00 1.00 1.00 0.00 
High school0.99 (0.62–1.57)0.9530.78 (0.38–1.58)0.4880.76 (0.50–1.20)0.253−7.28 (3.29)0.027
Some college0.70 (0.39–1.24)0.2170.61 (0.25–1.46)0.2630.82 (0.49–1.36)0.441−2.95 (3.14)0.348
College or higher0.68 (0.38–1.24)0.2090.73 (0.29–1.85)0.5120.59 (0.35–1.00)0.049−7.28 (3.29)0.027
Unknown0.55 (0.20–1.49)0.2390.35 (0.08–1.47)0.1530.50 (0.21–1.19)0.1165.24 (6.73)0.436
 χ2 = 4.74, d.f. = 4, P = 0.315χ2 = 2.64, d.f. = 4, P = 0.620χ2 = 5.30, d.f. = 4, P = 0.258F = 1.96, d.f. = 4, P = 0.098
Area        
Urban (Yokohama, Okayama, Nagasaki)1.18 (0.85–1.65)0.3231.52 (0.92–2.50)0.1011.22 (0.90–1.64)0.201−3.39 (1.80)0.060
Rural (Others)1.00 1.00 1.00 0.00 
 χ2 = 0.98, d.f. = 1, P = 0.323χ2 = 2.69, d.f. = 1, P = 0.101χ2 = 1.64, d.f. = 1, P = 0.201F = 3.55, d.f. = 1, P = 0.060

Discussion

The present results showed that several sociodemographic factors, such as sex, age and marital status, were significantly associated with attitudinal barriers in the use of mental health services in the community population in Japan. Some of these patterns are not consistent with those in previous studies in Western countries.

The present study found that Japanese men were significantly more willing to go for professional help and felt comfortable talking with a professional. The finding is inconsistent with previous studies in Western countries where women were more willing to use mental health services.[9, 13, 14] Stigma is strongly associated with willingness to seek professional help.[14] Many studies in Western countries reported that men had higher stigma toward people with mental health problems.[10, 11, 27, 28] In Japan, however, there was no significant difference between men and women regarding stigma toward people with mental illness.[29, 30] This may be a reason for the discrepancy in the findings between Japan and other Western countries. Furthermore, in Japan, men have more opportunities to be actively involved in society, such as working full time and being in a better social position. In Japan, men may have more opportunities to learn about mental health services than women, who may have a less active position in society.

Those aged 65 years or older had a significantly higher prevalence of feeling embarrassed about friends knowing about their getting professional help. The youngest group (20–34 years old) also had a slightly higher prevalence compared to those aged 35–49 years old. Previous studies in Western countries reported that younger persons were more reluctant to visit mental health services and those older were more willing.[9-12] Younger persons may have higher attitudinal barriers to mental health services in both Japan and Western countries; however, there seems to be a large difference with the elderly. The elderly tend to hold more traditional Japanese cultural values, in which they may be more concerned about losing respect and status if others become aware of their mental health condition.

Those currently married were significantly less willing to go for professional help. On the other hand, they had significantly higher expectations for mental health services. In traditional Japanese society, those who are married would consider the possibility of stigma from their relatives in seeking mental health help, and hide and cope with their mental health problems within the family. On the other hand, married persons may obtain information and knowledge about mental health services from their spouse, and might expect more from mental health services. While a study showed that married people more frequently used mental health services in Japan,[21] interventions aimed at improving attitudes toward mental disorders of spouses may be effective in improving the use of mental health services in Japan.

Socioeconomic status, such as education and income, were not significantly associated with attitudinal barriers in the use of mental health services in this study. Compared with Western countries, these aspects might have only a small impact on the use of mental health services or stigma in Japan.

This study has several limitations. First, the questions used in this study to measure attitudinal barriers were not fully validated, although they have been used in all the World Mental Health Surveys. The definition of ‘people who had serious emotional problems’ in questions on attitudinal barriers used in this study was vague, and not conformable to psychiatric diagnoses. This might have caused a problem, leading to more null findings because people in Japan had low awareness and knowledge of mental illnesses, such as schizophrenia and depression.[31] Second, the sampling was done in several rural and urban areas, but was still only in one metropolitan area. The results may not reflect specific features of metropolitan areas. The relatively lower response rate may cause a selection bias. For instance, younger people were less likely to respond to the survey. If those who had a more positive attitude to mental health problems did not respond to the survey, this may result in an underestimation of attitudinal barriers in this group.

Conclusions

The study suggested that sociodemographic determinants of attitudinal barriers in the use of mental health services in Japan are inconsistent with those found in previous studies done in Western countries. Men tend to have a greater willingness to seek professional help and feel more comfortable talking with a professional than women. Compared to the youngest group, those aged from 35 to 49 years tended to not feel embarrassed about friends knowing about their getting professional help, while the oldest group (aged over 65 years) tended to feel embarrassed. Married people tended to have higher expectations for mental health services, but tended to have less willingness to go for professional help. An anti-stigma campaign might consider culturally specific patterns of attitudinal barriers to mental health services in each particular country.

Acknowledgments

The authors declare that they have no competing interests. WMH-J is supported by a Grant 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. We would like to thank WMHJ Survey Group members, Yutaka Ono, Yoshibumi Nakane, Yoshikazu Nakamura, Akira Fukao, Itsuko Horiguchi, Hisateru Tachimori, Noboru Iwata, Hidenori Uda, Hideyuki Nakane, Makoto Watanabe, Masatsugu Oorui, Kazushi Funayama, Yoichi Naganuma, Toshiaki A. Furukawa, Masayo Kobayashi, Tadayuki Ahiko, Yuko Yamamoto, Tadashi Takeshima, Takehiko Kikkawa, field coordinators, and interviewers of the WMH Japan 2002–2004 Survey. The WMH Japan 2002–2004 Survey was carried out in conjunction with the World Health Organization World Mental Health (WMH) Survey Initiative. We also 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. A complete list of WMH publications can be found at http://www.hcp.med.harvard.edu/wmhcidi/.

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