Long-taboo 'mood disorder' is now being seen as the common and crippling disease it is


‘Istarted to get to work late — sometimes at 11, then at 12 and then at 2; and then I had to quit my job.”

For a year and a half, Ryu Terayama (not his real name) has been suffering from clinical depression — although to meet this handsome, highly articulate and well-dressed individual, you would never imagine it.

Psychological depression — which Webster’s Dictionary defines as “an emotional condition, either neurotic or psychotic, characterized by feelings of hopelessness, inadequacy, etc.” — is a disease which the World Health Organization estimates afflicts some 121 million people worldwide. In Japan, the latest data from the Ministry of Health, Labor and Welfare put the number of sufferers at over 711,000 in 2002.

“I visited my father’s sick room the day before he died. Then I flew abroad on a business trip, and while I was flying he died,” says Ryu, 32, who was a successful automotive research and development engineer until a year ago.

“I heard about my father’s death from a colleague,” he continues, “but when I went back to Japan, the funeral was already over . . . so I couldn’t feel the reality of his death, and for about one month I couldn’t get up from my bed.”

But Ryu’s depression got worse. “I woke up hungry and ate, but after that I felt I lost the energy to move,” he recalls. “I wanted to lie down on the floor and until noon that was all I would do, though I had no clear awareness of what I was doing at all. Then I fed myself and then somehow . . . I would get up and watch TV or surf the Net — but those things do not have any meaning [when you are depressed].”

That routine, day after day and month after month, became what Ryu’s life was reduced to. That, and his weekly trips to a clinical psychologist for counseling and to a psychiatrist (who can prescribe medication). For the former high-flying engineer it was some plunge, as — despite a lack of formal education — his career before that had also seen him attend a pilot school in Los Angeles; conduct research into the latest automobile systems tests in South Korea and Japan; and also teach engineering in Bolivia on a Volunteer Overseas Program run by Nissan.

Utsubyo (literally, “mood disorder”), as depression is known in Japanese, is an increasingly well-recognized condition in Japan, with a recent NHK documentary putting the proportion of the population suffering from the disease as high as one in seven.

This alarming statistic and the apparent rapid rate of increase in sufferers nationwide has seen a great deal of attention focused on utsubyo by the media: Popular magazines such as Toyo Keizai and DaCapo were just two of many covering the subject in the last month.

“I treat about 1,000 patients a month,” says Isao Fukunushi, a seishinkai (psychiatrist) and director of the Antique Street Clinic in Tokyo’s upscale Aoyama district. “Clinical depression cases account for 50 percent of the practice.”

What is it that causes depresssion? As the textbooks say, a major depressive episode can be triggered by feelings of disappointment at home or at work, the death of a relative or friend, the recollection of traumatic childhood events such as abuse or neglect, stress or social isolation — which is common among the elderly.

As Sigmund Freud, the founder of the school of psychoanalysis, which pioneered the treatment of depressive symptoms in 19th-century Vienna, wrote in 1895, “Much will be gained if we succeed in transforming hysterical misery into common unhappiness. With a mental life restored to health, you will be better armed against unhappiness.”

In Ryu’s case, it was more than four of the above symptoms that caused his depression. As a child he was beaten by his father, and now says, “As long as I can remember my father beat my mother. I didn’t know why he beat her, because I was a child.” Now, through therapy, Ryu has been diagnosed as an “adult child” — someone who had to take on too much responsibility for his parents when he was young, and whose experience led him to reject formal schooling and, in his case, to take his exams from home. “I think I can relate to the hikikomori, the ‘hermit children’ who withdraw from society,” he says.

Through what he has learned from his treatment, Ryu now believes that it was those childhood feelings of social isolation — caused by having a major part of his life he felt he had to keep hidden — that first led to him suffering mild feelings of depression when he was laid off from a job running his own research team in 2000. Then, four years later, the death of his father brought on his clinical depression.

Yet, according to health experts, 60-80 percent of sufferers can be cured with primary care — through a mix of antidepressant medication and brief, structured psychotherapy. However, the chief barriers to effective care, according to the WHO, are a lack of trained providers and the social stigma associated with mental disorders.

In the last six years, much has been done to lift that contemporary stigma in Japan, not least by major pharmaceutical companies keen to carve out a stake in the Japanese antidepressant market. In 1999, for example, GlaxoSmithKline ran an advert that promoted antidepressants by talking about kokoro no kaze (literally, “a cold in the soul”), in the process educating the public that utsu wa byoki desu — “depression is an illness.”

But while that — and the fact that celebrities such as actress Nana Kinomi decided to talk about their own experiences of the disease on television — might have the clinics filling up with people seeking medication, the same cannot be said of “talk therapies,” which are often advised to go hand-in-hand with, or provide an alternative to, drugs.

“Doctors who share patients with kaunsera [qualified psycholgical counselors] observe that those who are going through counseling improve more quickly, and the doctors also feel more secure and more confident about the treatment they are giving,” says Kyoko Motojima, a rinsho shinrishi (clinical psychologist) at Kumagaya Shinkei Clinic in Saitama Prefecture.

But counseling is a time-consuming and therefore costly exercise. Yet, while there are very few rinsho shinrishi or kaunsera in Japan — just 11,533 to be precise — it remains a low-status job in the medical profession despite the six years of degree-level and other training it requires. It is also poorly paid, and a kaunsera working the public sector can be on as little as 10,000 yen per day, while one at a private clinic is unlikely to earn more than half a medical doctor’s salary.

“Within the medical profession these days, psychotherapy is generally regarded both as being not rewarding, and also as being rather airy-fairy theory,” says Yukio Saito, director of the nationwide helpline Inochi no Denwa. “A lot of people prefer to use the term ‘kokoro no kaze’ to describe depression, and they refuse to take the term ‘utsu byo’ seriously,” he says.

Ryu found a counselor shortly after he read a book on the subject, and has stayed with him for the five years since. Other sufferers, though, are not so lucky.

Thirty-one-year-old Kanako Nakamura (not her real name), who was formerly drumming up new finance and clients as an accountant for a major mergers and acquisitions firm, moved back to be with her family in Toyama Prefecture six months after becoming clinically depressed. However, she says that she decided to stop seeing the hospital psychiatrist there because “he clearly thought that I was deranged, and he talked to me as though I was a child.” She also cites the stigma associated with making regular visits to a hospital — especially for mental health treatment — in countryside communities.

Recently the government has started to intervene over the disease for the first time, setting aside a small amount — 300 million yen per year — for suicide prevention activities since 2001. “Ninety percent of those who commit suicide are considered to suffer from one kind of mental illness or other, and 70 percent [of suicides] are seen as attributable to depression,” says Ritsuko Yamaguchi, who is now head and founder of MDA (Mood Disorders Association of Japan), a support group for the clinically depressed and their care-givers. The suicide rate in Japan is still over 32,000 per year, about 88 people per day.

In 2001, the government asked the National Center of Neurology and Psychiatry Japan and the National Institute of Public Health to carry out suicide research, the first initiative of its kind. This resulted in an educational leaflet for doctors and some funding for helpline Inochi no Denwa and its 56 centers around the country — to the tune of 80 million yen per year. Since 2002 there have also been some incentives for corporations to hire sangyo kaunsera (workplace counselors.)

The funding for children’s depression is much higher. With the numbers of hikikomori and child truants going up, in 2004, Hayao Kawai [presently Minister of Culture and a clinical psychologist himself] backed a Ministry of Education law that now requires there to be a counselor — who is paid a decent wage — in every junior high school. Akio Ohshima, works in a counseling center attached to a seishingakuin (special education school) opened in Asakusabashi in Tokyo’s Taito Ward six years ago as a research school on hikikomori. Up to 400 kids attend the seishingakuin. “It is a place where kids who felt excluded, who did not go to school, can start to feel included, because it is an alternative kind of school,” he says.

“Some people think if a psychologist works with the kids there will be a miracle,” he says, “but the parents should give the kids much more attention . . . Society is not generous, it is kibishii [strict], and the family, which is a symbol for society, is closed.” He says “If kids become healthier they, can go back to school.”

Children can also be more proactive about finding a counselor as some counseling clinics are now running Web sites. Rika Masuda, a clinical psychologist working at the Komazawa University Care Center describes what the pressures on young people today are. “Communication,” she says. “They have a problem communicating with other people . . . this situation is not at all their fault, it is about adult’s relationships and how they communicate with their colleagues and their friends.”

Research initiatives

Indeed Hayao Kawai is so convinced that more public recognition of the role of the psychologist is needed that he is supporting a move for the new profession of iryo shinrishi [medical psychologist] to be introduced in hospitals — with the remit to work across all departments.

But all of these new research initiatives are of little help to the highest risk cohort for suicides — the over-60s group, constituting 11,529 of those who committed sucide in 2004, according to National Police Agency Statistics. They are also, perhaps, the group most unlikely to seek help. The older middle-aged group has been the most at risk since the 1950s, says William Wetherall, a U.S-trained independent Mental Health expert who has been working with Japan’s Institute of Mental Health since the 1970s. “While suicide risk is going down for the elderly,” he says, referring to the aging population, “. . . there is more need for geriatric preventative mental health.”

Does talk therapy work? Kanako Nakamura, who has survived two suicide attempts, is pretty sure it does. “If I were to go through the same experience again, then I would find people I could talk to, who can understand how you feel, who can share how you feel and do not live alone. Try to find a friend or those who can talk.”

As Italian Dr. David Gerbi, a Jungian psychoanalyst who runs group therapy workshops with the Tokyo-based organization Workshopland says, “Japanese people are attracted to the idea of instruction in how to move on in life. They need to become aware first, but then they are very quick in the process of healing.”

But for Japan’s older generation, who have paradoxically experienced the most rapid changes in society during Japan’s postwar period, that may be the hardest thing to do. For the nation’s many isolated and clinically depressed, the hope is that they will find someone to talk them out of it.