Suicides in Japan dropped for a decade. Then the pandemic hit.

Plagued by the notion that she may have transmitted COVID-19 to her child, a woman in her 30s took her own life last month.

Self-isolating with her daughter at her Tokyo home after both tested positive for the coronavirus, the woman was reportedly haunted by the possibility that she was the source of the infection. While both mother and child only exhibited mild symptoms, the woman apparently voiced concern to her husband about the chances of her daughter having spread the virus at her elementary school. He found his wife dead on the morning of Jan. 15.

“I’m so sorry to have caused trouble,” she left in a written note, according to reports.

The pandemic’s toll on mental health is unprecedented. Economic insecurity, social isolation and the lingering dread that those you love can suddenly fall victim to the pathogen have stirred a toxic mix of stress and anxiety impacting the well-being of billions across the globe.

In Japan, a nation that has long struggled with one of the highest suicide rates in the world, the emotional strain is manifesting itself in a disturbing trend. For the first time in a little over a decade, the number of those who took their own lives last year exceeded the previous year, reversing years of work to curb a stubbornly high number of self-inflicted deaths.

According to the health ministry’s preliminary data, 20,919 people died by suicide in 2020, up 3.7% from 2019, compared with 3,459 coronavirus-related deaths in the same period.

While men in Japan are typically more likely to die by suicide, last year saw the number of women killing themselves grow by 885 to 6,976, while suicides among men fell slightly. Meanwhile, figures for those in their 20s and those age 19 or younger grew by 17% and 14%, respectively, according to a tally by the Nikkei business daily, providing insight into which groups are the most vulnerable.

“Anxiety is rising amid the state of emergency, especially in the Tokyo metropolitan area as the reported number of infections grow,” says Katsuyoshi Shingyouchi, head of the counseling center for the nonprofit Tokyo Mental Health Square. The organization has been providing consultations via private messaging, phone interviews and face-to-face meetings.

On Tuesday, Prime Minister Yoshihide Suga extended the state of emergency covering Tokyo and other regions grappling with outbreaks until March 7. While the daily tallies of reported cases have decreased since the decree took effect last month, authorities have said they are still worryingly high.

Shingyouchi says around 70% to 80% of those who reach out to his group are women, many in their 20s, followed by those in their 30s and in their teens. Single mothers, those who lost their jobs to the pandemic and women suffering from domestic violence amid stay at home requests are among those who seek help.

“The pandemic is exacerbating the plight of many women,” he says, adding that “in terms of psychological impact, it’s as if we’re coping with a prolonged natural disaster with no end in sight.”

Japan’s suicide rate has consistently ranked at the top of the Group of Seven advanced economies for many years. The figure was 14.9 cases per 100,000 people in 2017, while it was 9.5 for Germany and 14.5 for the U.S., according to the OECD. Last year, it was 16.6 for Japan.

Historically, the high rates have been attributed to the nation’s intense work culture defined by exhaustingly long hours, as well as school and societal pressures and the stigma attached to openly discussing mental health issues. Suicide numbers peaked in 2003 at 34,427, then leveled off to around 33,000 through 2009 in the aftermath of the global financial crisis, when the country experienced its worst recession since World War II.

For the past decade, however, the numbers have been on a downward trend thanks to a coordinated campaign. Research into the medical and social causes of the phenomenon expanded while support measures were beefed up for survivors of attempted suicide. Meanwhile, more hotlines were set up and seminars were hosted for municipal leaders to deepen their understanding of the issue.

A fall in suicides during the first half of 2020 raised hopes that the pandemic’s strain on mental health may be limited. Japan, after all, has so far seen a relatively small coronavirus outbreak and avoided the harsh lockdown measures implemented in other nations with higher rates of COVID-19 infections and deaths. But figures soon began rising in July, not long after the nation’s first state of emergency was lifted in May.

“I believe the decrease in suicides last spring was due to people being overwhelmed by the first state of emergency,” says Masaki Nishida, a clinical psychiatrist and associate professor at Waseda University.

“But as the situation dragged on, the pent-up stress began surfacing,” he says. Financial problems, job insecurity, lack of in-person communication and strained relationships — a multitude of psychological factors started to pile on.

“All these things may have led to the growth in suicides from last autumn, especially among women. Many are employed part-time in the hospitality sector, which has been facing strong headwinds,” Nishida says.

Nomura Research Institute estimates that in December there were approximately 900,000 part-time female employees who were essentially unemployed, meaning their hours had been cut by over 50% or they were not receiving any leave allowances.

And even for those who kept their jobs, parenting tasks still often fall on mothers in Japan. With schools being kept open during the current state of emergency, anxiety over the well-being of children is taking a toll, placing extra burdens on mothers, Nishida says.

Koki Ozora, a 22-year-old student at Keio University, launched a free 24-hour mental health hotline last March, just as the reported number of coronavirus cases in the nation began seeing a noticeable uptick. Supported by donations and a global network of around 900 volunteers living in different time zones, his nonprofit called Anata no Ibasho (A Place for You) has done consultations with approximately 30,000 people to date via online messaging, he says, a significant portion of them being women.

“Besides the stress of child rearing and housework, I get the impression that victims of domestic violence and, more generally, women who don’t feel safe in their own homes, have grown since teleworking became commonplace and husbands have been stuck around the house,” he says. “Since last summer there has been a spike in the number of women contacting us about suicidal thoughts.”

A succession of celebrity suicides last year, including that of Yuko Takeuchi, a 40-year-old actress and mother of two, and the excessive media coverage of the deaths may have also been a contributing factor, Ozora says. Men, meanwhile, are far less likely to reach out until things are too late, he says, due to an ingrained cultural stigma against seeking psychological help.

And the pressure is mounting on children as well as the pandemic restricts school and social activities. College students despairing of online lectures and a lack of extracurricular activities have sought consultations. The trend was especially pronounced toward the end of the year, Ozora says, when students who would typically return home to spend time with their parents opted not to due to risks of transmitting the virus to their kin, enhancing a sense of isolation.

Ozora himself has considered ending his own life in the past.

“I come from a rather complicated family and there were phases where I went through depression and acute loneliness. If it weren’t for a high school teacher who reached out, I may not be here today,” he says. “And analyzing the consultations we have received over the past year, I sense that the root of the problem is isolation and loneliness, an issue that we’ve been asking the government to take up.”

Yasuyuki Shimizu, representative director of the Japan Suicide Countermeasures Promotion Center, says the nation’s response to the phenomenon is advanced compared to some other nations.

Shimizu was central in lobbying for a 2016 amendment to the suicide prevention law that obliges all municipalities to hammer out concrete action plans to address the issue. The revised law also defined the government’s responsibility to subsidize anti-suicide projects undertaken by municipalities based on those plans and to take steps to help universities nurture professionals versed in suicide prevention.

“What we’re seeing now is society’s most vulnerable — women, nonregular workers (those not on full-time, long-term contracts) and children — bearing the brunt of the pandemic’s wrath,” he says. “We’ve already seen some problems that need to be worked on, including the dangers of excessive reporting on celebrity suicides and the necessity of a stronger social safety net. Whether or not Japan’s suicide rate will continue to grow this year depends on whether we can resolve these issues.”

And for those who contract the virus, Shimizu says there’s no need to blame themselves for a situation that they do not have much control over.

Satsuki, a Tokyo office worker in her late 30s who did not want to use her real name due to privacy concerns, says she was tormented by the possibility of putting others in harm’s way when she tested positive for the coronavirus in December.

“I had a high fever, a splitting headache and a loss of smell and taste. I obsessively reached out to anyone I had come in contact with to check whether they showed any symptoms,” she says. Satsuki was hospitalized for a total of 11 days, during which she was also diagnosed with pneumonia. She has since been discharged and has gone back to work.

“I knew there was nothing I could do, but the sense of guilt that I may have given the illness to someone else never left my mind.”

If you or someone you know is in crisis and needs help, resources are available. In case of an emergency, please call 119 in Japan for immediate assistance. The TELL Lifeline is available for those who need free and anonymous counseling at 03-5774-0992. You can also visit telljp.com. For those in other countries, visit www.suicide.org/international-suicide-hotlines.html for a detailed list of resources and assistance.