2 conversations with experts

Japan enjoys an excellent reputation in the realm of physical health. It boasts a world-class health system, low rates of obesity, and the second highest longevity in the world. But it has much a poorer image when it comes to mental health—a stressed, overworked workforce, a high suicide rate, and a high stigma associated with mental disorders.

A stark reflection of this discrepancy is that Japan is ranked first for physical health but second lowest (37 out of 38) for mental well-being in a UNICEF survey of child well-being (Organisation for Economic Co-operation and Development (OECD)/European Union (EU) countries).¹

But what is the actual state of mental health in Japan, and how does it compare with Western countries? To discover more, I talked with two friends who have an intimate knowledge of the subject.

Dr. Roseline Yong is an assistant professor in mental health at Akita University. She specializes in researching the mental health of children and adolescents, with a special focus on people with hikikomori (a term used when people withdraw from society and spend almost their entire time in isolation at home). Her interest in these people goes beyond merely academic—in her spare time, she runs a ministry for hikikomori that includes a drop-in centre.²

Dr. Takashi Inoue, a board-certified child and adolescent psychiatrist from Japan, graduated from the University of Tokyo. After completing his psychiatric residency in Tokyo and a visiting fellowship in Vancouver, Canada, he now practices as a psychiatrist in Calgary, Canada. He personally feels a connection with people experiencing hikikomori, having gone through an extremely competitive educational system as a teenager and once needing to take some time off from medical school.

Comparing Japan and Canada

Takashi was quick to point out that despite Canada and Japan having very different cultures and health systems, there is a lot of overlap between common mental health challenges such as depression, anxiety, neurodiversity, and eating disorders and how they are treated. “Having worked in both countries, I’m astonished by how many things we share in common, regardless of our ethnicity or cultural background or social systems. In the end, we’re all humans,” he says.

However, one major difference between the two countries is substance abuse. Illicit drugs are much easier to access in Canada, and so many more people struggle with their abuse. Takashi says, “Illegal substances are strictly regulated in Japan, and so relatively few people struggle with them. However, there is a reported trend of misusing over-the-counter medicine as a means of coping with emotional distress.”

“In Canada, people suffering from substance-use disorder are usually viewed as individuals trying their best to escape emotional or physical pain. Support for them is based on the principles of harm reduction and decriminalization,” Takashi says. “In contrast, Japanese society has traditionally viewed such people as needing punishment rather than support, treatment, and, most importantly, connection. However, there is growing awareness of evidence-based approaches for supporting people with addictions.”

Another difference between the two countries is how young people respond to problems at school: Japanese students tend to isolate, whereas Canadians are more likely to spend time in social groups outside of school. “If young people in Canada struggle at school, they might hang out with their peers. And sometimes that can lead to homelessness,” Takashi says. “But in Japan, students with problems tend to quit going to school. And they don’t know where to go, so they might stay at home for an extended period.”

But in Japan, attitudes towards dropping out of school are changing. There is less stigma associated with it, and more alternatives to traditional schools are appearing.

Medicating prioritized over time

One point that Takashi and Roseline both raised was that psychiatrists in Japan tend to rely more heavily on medication for treating mental health conditions, which can lead to the problem of overprescription.

Roseline explains, “Many people don’t seek psychiatric treatment or discontinue it because they don’t think it will help them. A lot of the time, they are just given a prescription—it’s a very medication-dependent approach. Hikikomori people can be misdiagnosed as schizophrenic due to the two conditions having overlapping symptoms. Challenges such as inadequate resources in the mental healthcare system, limited communication regarding patients’ experiences, and a lack of awareness can obstruct accurate diagnoses. In Japan, however, obtaining a formal diagnosis is essential for accessing appropriate support and treatment options, which may include potential benefits from medications used for schizophrenia.”

Takashi views the shortage of trained therapists in Japan as another reason for a reliance on medication. “Both Canadian and Japanese guidelines recommend psychotherapy, such as cognitive behavioral therapy or interpersonal therapy, as first-line treatment for mild depression,” says Takashi. “However, due to limited access to these therapies by appropriately trained professionals in Japan, many psychiatrists there are forced to rely heavily on medication.”

Takashi emphasizes that medication can often be helpful in many cases. “Doctors ought to provide the best treatment options depending on availability and patient preferences, and it is a blessing for us to have effective medications that can save many patients,” says Takashi. “That said, I hope that access to psychotherapy in Japan will improve in the near future. This requires more trained therapists, better funding, and further improvements to the public healthcare system.”

A pressurized society

Roseline thinks that the mental health of the Japanese population suffers from the high pressure of society coupled with a reluctance to openly talk about personal problems. “I think a huge number of people are under a lot of stress,” she says. “But because they feel that it’s their own responsibility and don’t want to trouble others, they hide it and don’t talk about it.”

She sees the Japanese working environment as a major contributor to stress. “Big companies and organizations with entrenched hierarchies, such as hospitals, are very rigid,” she notes. “It’s not really about whether you perform well; you are evaluated by how well you follow your boss.”

She is especially critical of the transfer system within companies in which employees are periodically reassigned to different roles, usually without consultation or forewarning. “Every time when you are transferred, you have need to readjust, but that becomes harder with age,” she says. “I think everyone is very stressed, but there is no point in seeing a doctor because you probably just have to take a temporary break from work.”

On the positive side

But things aren’t all gloomy. A recurring theme throughout the discussion with Takashi was that Japan has made a lot of progress over the last couple of decades in terms of support for people with mental health issues. “I think there has been significant—even dramatic—improvement regarding mental health challenges in Japan,” Takashi says. “In particular, people seek help more easily compared to 10 or 20 years ago. There’s still a general hesitancy to meet psychiatrists or counselors because of the stigma, but I think it’s gradually improving.” But he also sees much room for further improvement. “I’m concerned that young people in Japan struggle with a lack of positive self-affirmation compared to those overseas. I see so much room for the quality of relationships within families or communities to be strengthened. I believe this will add protection against mental health challenges.”

Roseline also thinks things are changing for the better. “I feel that attitudes to mental health are improving in Japan,” she says. “In particular, the internet is making it easier for people to access the information and help that they need.”

And as Christians, we can also be encouraged that we have opportunities to make an impact on these issues. Both Takashi and Roseline see Christians as uniquely placed to be agents for promoting mental health in Japan. Since Christians are a tiny minority in Japan, Takashi thinks they should be able to identify well with other minorities such as those suffering from mental health problems. “I think lots of people are suffering in Japan,” he says. “Being a Christian in Japan gives us a greater capacity to be humble, to be compassionate, and to be open. I feel we are really called to support people with mental health issues.”

Roseline sees healthy community as the key for promoting mental health. “I think that community-based activities, such as church events . . . can provide a supportive environment for individuals struggling with mental health issues.”

As Christians living in Japan, there is much we can do to promote mental health: developing practices that promote our own mental health, growing in our own awareness of mental health, and fostering safe communities where anyone is welcome.

1. Anna Gromada, Gwyther Rees, & Yekaterina Chzhen, “Worlds of Influence: Understanding What Shapes Child Well-being in Rich Countries,” Innocenti Report Card 16, https://www.unicef.org/innocenti/reports/worlds-of-influence (May 2020).
2. Simon Pleasants, “Hikikomori ministry in Tohoku,” Japan Harvest (Summer 2016), 26–27.
Photos submitted by author