Japan’s medical system skewed toward men in treating depression


DEPRESSION IN JAPAN: Psychiatric Cures for a Society in Distress, by Junko Kitanaka. Princeton University Press, 2011, 264 pp., $29.95 (paperback)

Twenty-first century Japan is in the throes of a depression epidemic. Until the late 1990s, mental depression was not widely diagnosed or treated in Japan, but it has suddenly emerged from the closet of denial.

This is one of the quiet transformations in Japan, a society that was uncomfortable in dealing with mental illness until it began to do so. Junko Kitanaka has written the go-to book to understand how profound changes in norms and values have generated social legitimacy for depression.

This “discovery” of depression has coincided with a surge in suicides since 1998. The stunning finding is that psychiatrists in Japan interviewed by the author are ambivalent about medicalizing suicide and, according to her, many still cling to traditional views that romanticize and aestheticize suicide.

Drawing on extensive fieldwork, Kitanaka takes us behind the clinical curtain, helping us to understand the role and perceptions of psychiatrists in mobilizing the discourse of depression to respond to growing social distress. She shows that depression is not really new in Japan, but it has gained legitimacy and exposure as the language of suffering has evolved. Alas, the diffusion of depression diagnosis triggers collateral damage, leading to “aggressive pharmaceuticalization of everyday distress.”

Back in the day, men were supposed to suck it up and carry on, working and drinking their way through the blues. Japan’s stoic salarymen were portrayed as modern day samurai, willing to sacrifice everything for their company. Indeed, many have done so as the problem of karoshi (death from overwork) signifies. The story of a Dentsu employee’s suicide in 1991 reveals the nexus of changing legal and medical norms leading to legal recognition of “overwork suicide.”

In 2000, the Supreme Court ruled that excessive hours of overwork drove Ichiro Oshima to despair and suicide. Oshima, it turns out, was in his office twice the time of his normal working hours and faced stress generated by the inhumane work culture at Dentsu. Kitanaka writes, “Ichiro’s superior poured beer into his own shoe and forced Ichiro to drink out of it, hitting him when Ichiro refused to obey his orders.”

Since this landmark case, the medical community has played a significant role in changing perceptions about excessive work. By explaining how depression “tends to afflict those who work too hard,” psychiatrists have challenged prevailing values and opened up public space for depressed workers to retreat from unwelcome social engagements and obligations, and to protest workplace alienation. According to Kitanaka, this protest carries broader implications: “By linking depression to the ‘social ills’ brought on by neoliberalization — including the perils of privatization, the collapse of lifetime employment, and the crisis in national health care — people seem to be addressing their sense of alienation.”

Based on her hospital fieldwork, the author found that in diagnosing depression, “psychiatrists often deliberately stayed away from the realm of the psychological.” Furthermore, “even when patients dwell on the external pressures and psychological motives that drive them to attempt suicide, psychiatrists retain their focus strictly on the internal biological mechanisms.”

Kitanaka also asserts that, “It may not be an exaggeration to say that, until recently, most Japanese psychiatrists have taken a ‘hands-off’ approach to suicide.” However, the Basic Law on Suicide Countermeasures (2006) calls on psychiatrists to play a central role in suicide prevention. Based on extensive interviews with psychiatrists, she finds that most “seemed unenthusiastic about having to treat a much broader range of patients and becoming more responsible for the prevention of suicide.” She attributes this reluctance to the difficulties of the tasks involved, uncertainty about having “objective” knowledge about depression and suicide, and wariness about potential criticisms. But in her view this medicalization of suicide is happening and forcing a reconsideration of prevailing cultural interpretations among professionals and society in general.

Paradoxically, acceptance of male depression has been accompanied by a “curious void in the Japanese understanding of female suffering.” Kitanaka notes that, “Depression has long been represented in the West as a quintessential female malady,” but depressed women in Japan do not enjoy the same social legitimacy and sympathy as depressed men and often do not find treatment that suits their needs. Japan’s “burned out salaryman” syndrome trumps the archetypal “melancholic housewife.”

She observes, “While the men seemed to appreciate the psychiatrists’ benevolent paternalism … women repeatedly told stories where attempts by doctors to foster dependency appeared to reinforce their sense of powerlessness.” Doctors apparently don’t relate as well to women’s complaints and thus don’t empathize, creating mistrust with the patients.

The storyline of work-induced depression is more straightforward and one that doctors readily understand while the pain and mental distress of women tends to be multifaceted and thus goes unrecognized and undiagnosed, adding to their stress and sense of isolation.

This keenly observed and analytically powerful examination of depression in Japan provides insights on the convulsions of social change, and the consequences for identity and the meaning of life amid the tumult.

Jeff Kingston is the director of Asian Studies at Temple University, Japan campus