Psychiatry and Japan’s “National Disease”
An advertisement for an all purpose pill called Wakyōgan sold in premodern Japan (Wakyōgan Hikifuda, Courtesy of Nichibunken)
by Junko Kitanaka
In Japan, in the 1980s, the term “karôshi”, or “death from overwork”, was coined to describe cases where people have essentially worked themselves to death. In the late 1990s, when Japanese began to see suicide rates skyrocket, another term emerged in the media as a national concern. This was “karô jisatsu”, or “overwork suicide”, that refers to the suicide of people who are driven to take their own lives by excessive overwork. Concern with this problem became more pronounced since the Supreme Court ordered Dentsû, Inc., Japan’s biggest advertising agency, to pay to the family of a deceased employee Ichirô Ôshima the highest amount ever to be paid for a worker’s death in Japan. The Supreme Court determined that the cause of Ichirô’s suicide was clinical depression, and that his depression had been caused by chronic overwork, which was, according to the plaintiff, twice the amount of regular working hours for several months leading up to his death. After the precedent-setting verdict, a number of similar lawsuits followed, on the suicides of teachers, doctors, and employees of companies like Toyota, many of which brought victory (and economic compensation) to the families of the deceased workers. In the meantime, the national suicide rate continued to soar: more than 30,000 recorded victims annually for twelve consecutive years (the number is three to six times that of traffic accident deaths). Alarmed by the suicide rates and legal disputes, the government established in 1999 new guidelines for measuring psychological stress at work, and began to encourage overworked employees to seek out medical care. In 2006, the government further implemented the Basic Measures for Suicide Prevention Law, pledging to reduce suicide rates within a decade by twenty percent. It is only arguably now, after depression has emerged as a “national disease,” that psychiatric care is being offered to the Japanese as a cure for a society in distress.
The rise of psychiatric discourse about depression and suicide in Japan is intriguing for three reasons. First, despite the official institutionalization of psychiatry in the 1880s, psychiatry in Japan has, until recently, long been stigmatized as an apparatus of oppression, whose expansion into the realm of everyday distress was strongly resisted by lay people. Psychotherapy, introduced to Japan in 1912, was met with deep skepticism, and the fact that it only minimally took root in Japan was described by some social commentators as a sign of the good health of individuals and the Japanese social order.
Second, suicide in particular, has long been a site of conceptual struggle for psychiatrists, who have encountered resistance from lay Japanese holding on to the cultural notion of suicide as a morally positive act of self-determination, carried out at times as a protest against social injustice. The persistence of this cultural notion was demonstrated, for instance, in 1999 when literary giant Etô Jun killed himself after leaving a note: “I’ve decided to do away with what remains of me.” Admiration from fellow intellectuals flourished in the media, where they lauded his act as “embodying first-class aesthetics.” The voices of a few psychiatrists, who dared to suggest that his suicide might have been caused by depression, went largely ignored. Indeed, psychiatrists who have explicitly linked suicide with depression have at times been criticized for pathologizing free will and trivializing the existential and social meanings of suicide.
Finally, depression had been assumed by psychiatrists themselves to be “rare” among Japanese. Some prominent psychiatrists had even attributed this supposed rarity to a cultural difference whereby Japanese—unlike “Westerners,” who pathologize depression—maintain high tolerance for, and even find aesthetic dimensions of, depressive experiences. This assumption has been so firm that until recently psychiatrists advised drug company Eli Lilly & Co. against promoting and selling Prozac in Japan for the lack of a potential market. Thus, the fact that psychiatrists are now beginning to persuade the Japanese to regard their everyday distress in terms of depression, and even to think of suicide as a product of depression, signals a profound shift in thinking about mental distress, the nature of free will, and the extent to which society should take responsibility for individual suffering.
Drawing upon a decade-long anthropological fieldwork that spans the time before and after the onset of medicalization of depression in Japan, my book, Depression in Japan: Psychiatric Cures for a Society in Distress, investigates how this change has been made possible. One perspective on the rising concern over depression today maintains that it signals the beginning of a broad-scale medicalization, a process whereby the very act of living out everyday in Japan comes to be redefined as a pathology of individual biology or psychology. Some Japanese scholars have argued that psychiatrists, by medicating those in distress, serve to silence people’s dissent about the dominant social order, perceived as oppressive, and thus eradicate local cultural resources for reflecting on the nature of their suffering. Rather than continuing with this line of argument, the book instead highlights other more subtle aspects of the ongoing medicalization, and demonstrates that what has especially enabled psychiatrists to overcome the strong resistance to their professional services is their close engagement with (and in fact re-appropriation of) the cultural discourse about the social nature of depression and suicide.
In particular amongst the popular discourse on overwork suicide, psychiatrists have provided powerful descriptions of depressed and suicidal workers, explaining how, for instance, their self-sacrificing devotion to the company is no longer rewarded in the crumbling system of lifetime employment. By suggesting that the pathology lies not only in individual brains but also in the Japanese culture of work itself, psychiatrists have elevated workers’ depression and suicides to symbols of collective distress faced by many Japanese in times of economic uncertainty. Thus, they seem to be successfully altering the way the Japanese think about the borders of normalcy and abnormalcy, health and illness, and are shaping the cultural debates about how society should deal with individual subjects of social distress.
The book examines the psychiatric discourse on depression and suicide in Japan from different angles: historical, clinical and socio-legal. Historically, the concept of “depression” has gone through many shifts in Japan over centuries and demonstrates how it has come to be transformed from a “rarity” to a “national disease.” For instance, it became possible to question the long-held assumption among Japanese psychiatrists that a medical notion of depression did not exist as such in Japan prior to modernity by problematizing the biomedical notion of depression itself.
Psychiatrists and lawyers have used a distinctive, localized theory of melancholic premorbid personality—which is often assumed to be a scientific theory despite the fact that it is rarely heard outside Japan—in order to support claims for the social causes of depression. This indigenous psychiatric theory asserts that the depressed tend to be the ones who most clearly embody a “Japanese” work ethic, marked by hard work, thoroughness, excessive consideration for others, and a strong sense of responsibility. I was able to trace the conceptual origin of this peculiar theory to the early 20th century discourse about the alleged “epidemic” of neurasthenia. While such an epidemic was of a global concern from the late 19th century, it took a distinctive form in Japan as it helped familiarize Japanese with the Western concepts of nerves and the brain. As an early case of broad-scale medicalization, the discourse on neurasthenia had many parallels with the current depression discourse, most notably the public debates about its causality—i.e., whether neurasthenia was a result of overwork or of personal weakness. Japanese psychiatry has since relentlessly expanded the neurasthenia concept, only to later stigmatize those who had resorted to it and internalized this illness category—an ominous sign for what may be in store for the medicalization of depression today. There are historical links between neurasthenia and depression, and the depression concept has transformed through the introduction of the antidepressants in the 1950s, to the vehement antipsychiatry movement between the late 1960s and the 1980s, and to the 1990s when it was adopted by left wing lawyers, the government and pharmaceutical companies, in their respective campaigns to de-stigmatize and normalize depression.
Given that the aim of clinical practice is not to voice social critique but to provide a remedy for the disruptions in people’s lives, how do psychiatrists persuade patients about the nature of their “depression”? With this question in mind, the second part of my book shifts the attention from the broader historical contexts to what is happening in clinical settings today. The book examines how psychiatrists and patients actually deal with depression and suicide in daily clinical encounter, and starts out with the question of why it is that many Japanese psychiatrists—even those critical of biological reductionism—regard psychoanalytic psychotherapy to be “taboo for treating depression.” This seems puzzling, given that the increasing dominance of the biological treatment over psychotherapy has attracted heated criticism in the U.S., where some intellectuals argue that excessive use of antidepressants may impoverish people’s ability for critical self-reflection and impose blind conformity. Thus the fact that in Japan it is the psychological “cure” for depression—and not the biological fix—that seems to have created discomfort, even explicit interdiction, among psychiatrists, is an intriguing difference.
This pronounced lack of interest on the part of psychiatrists to determine individual agency in connection with depression is above all contested by patients over the question of suicide. Scenes from psychiatric case conferences show how psychiatrists try to persuade patients of the pathological nature of their suicidal intention, and how some patients explicitly resist such medicalization by evoking a cultural idiom: “suicide of resolve.” Analysis of the narratives of psychiatrists show the ways in which they try to deal with their own ambivalent attitudes towards pathologizing suicide by limiting their biomedical jurisdiction to treating what they regard as biological anomaly, while carefully avoiding the psychological realm. Through their repeated encounters with suicidal patients, psychiatrists learn to bracket out disturbing moral, existential and philosophical questions about where the border lies between pathological suicide and an intentional act. One ironic consequence of this medicalization may be that psychiatrists are reinforcing the dichotomy between normal and pathological, “pure” and “trivial” suicides, despite their clinical knowledge of the tenuousness of such distinctions and the ephemerality of human intentionality. The chapter thus asks if the medicalization of suicide in Japan is poised to supplant the cultural discourse on suicide that has elevated suicide to a moral act of self-determination, even if it is attempting to cultivate a new conceptual space for Japanese to talk about how to bring the suicidal back onto the side of life.
The final part of the book turns to the effects of medicalization beyond the walls of clinics and investigates how lay people and other professionals (including lawyers and public administrators) are drawing upon psychiatry as a framework for expressing—and interrogating—social ills. The peculiar gendering of depression in unique to Japan: although in the West, depression has long been represented as a quintessentially female malady (where women are said to be twice as likely as men to become depressed) in Japan, until recently, rates of male depression had been as high as—sometimes even higher than—those of women. Indeed, in sharp contrast to the prevailing image of the depressed person in the West as an isolated housewife, in Japan, depression’s victims have been overwhelmingly represented as the burnt out salaryman.
Examining individual understandings of depression in the context of an emergent collective movement, claims for the social origins of depression have gained force through a series of legal victories against overwork suicide. As lawyers have successfully incorporated psychiatric arguments to demonstrate that depressed workers are victims of the culture of workplaces, the government has introduced Stress Evaluation Tables to help determine if work stress is the primary cause for a worker’s mental illness and/or suicide. Psychiatrists are thus at the heart of important social changes, where they are urging Japanese to question the status quo, particularly in cases where model workers who have internalized a strong work ethic have been driven to suicide. What is also radical about these changes is the fact that the government has replaced the traditional psychiatric diagnostic system with the theory of a “stress-diathesis model,” with which mental illness is now explicitly conceptualized as a product of interactions between individual biology and society. This has opened up possibilities for almost all forms of psychopathology—not just depression but also schizophrenia—to be legally examined in terms of social causes and made it subject to worker’s compensation. As this has astonished even psychiatrists, there have been medical and legal debates about whose—and what kind of—stress should be recognized, how one can measure such stress objectively, and who should take responsibility for it.
In light of global political movements that are beginning to problematize the psychological burden of work through the discourse about depression, one can reconsider the local forces of medicalization. Is the fact that more and more Japanese people are claiming depression in order to demand public responsibility and economic compensation in itself suggestive of a new political environment under the influence of neoliberalism, whereby the Japanese are having to become more informed, responsible and autonomous workers? If so, then increasing calls for psychiatric care for the depressed should not be naively celebrated as an advancement in health care, but has to be carefully examined in light of the legal and social apparatuses that have legitimized, and indeed necessitated, the move to make the depressed into agents of their own management and into more “productive” citizens. Also questioning the allegedly sweeping effects of the ongoing medicalization, I ask in the end in what ways the Japanese articulation of social etiology of depression may be retained against the evidence of global and biological standardization.
About the Author:
Junko Kitanaka is a medical anthropologist and associate professor in the Department of Human Sciences, Keio University, Tokyo. For her McGill University doctoral dissertation on depression, she received the 2006 Margaret Lock Prize in Social Studies of Medicine, and the 2007 Dissertation Award from the American Anthropological Association’s Society for Medical Anthropology. This has now been published as a book titled Depression in Japan: Psychiatric Cures for a Society in Distress from Princeton University Press.