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Unformatted text preview: J Occup Health 2005; 47: 157–164 Journal of Occupational Health Karojisatsu in Japan: Characteristics of 22 Cases of Work-Related Suicide
Takashi AMAGASA1, 2, Takeo NAKAYAMA2 and Yoshitomo TAKAHASHI3
1 3 Mental Clinic Misato, 2Department of Health Informatics, Kyoto University School of Public Health and Department of Suicidology, Tokyo Institute of Psychiatry, Japan Abstract: Karojisatsu in Japan: Characteristics of 22 Cases of Work-Related Suicide: Takashi AMAGASA, et al. Mental Clinic Misato—With the rapidly increasing number of work-related suicides in Japan ( Karojisatsu , in Japanese), both applications for worker’s compensation insurance and civil suits are proliferating. The phenomenon of work-related suicide is examined along with the process and related factors. With informed consent from bereaved families, two certified psychiatrists independently reviewed and summarized 22 insurance and legal reports filed by psychiatrists on employee suicides that were related to heavy workloads. A clinical epidemiologist participated in discussions with psychiatrists to reach a consensus concerning the cause of the suicides. Only one case involved a female. Seventeen had experienced personnel changes, such as a promotion or transfer. Low social support was recognized in 18, high psychological demand in 18, low decision latitude in 17, and long working hours in 19 cases (more than 11 hours per day for 3 months or more, and without a day off in 9). The subjects had depressive episodes by the ICD-10 criteria and showed suicidal signs. Ten of them saw a general practitioner because of unspecified somatic complaints, but no effective measures were taken. None of them had a history of psychiatric consultation or had received mental health education dealing with job stress management. Although causality cannot be made from this case series report, we hypothesize that long working hours, heavy workloads, and low social support may cause depression, which can lead to suicide. Appropriate countermeasures are urgently needed and the present findings suggest some of them are possible. (J Occup Health 2005; 47: 157–164) Key words: Long working hours, Depression, Suicide
Received Sep 2, 2004; Accepted Jan 15, 2005 Correspondence to: T. Amagasa, Mental Clinic Misato, 1–5–6, Misato, City of Misato, Saitama 341-0024, Japan (e-mail: email@example.com) prevention, Psychological autopsy, Case series The number of suicide cases in Japan has increased since 1990 and accounts for more than 30,000 deaths annually from 1998 through 2003. This number is about 3.5 times that of people killed in traffic accidents in the same period. Particularly in 1998, the increased incidence of suicide among middle-aged individuals caused the average male life expectancy to drop to the lowest level since the Second World War. The raw suicide rate in 2002 was 25.2 per 100,000 (37.1 among males; 13.9, females) 1) . Applicants for workers’ accident compensation insurance, as well as civil suits, have proliferated since the 1990s. Beginning in the late 1990s, the courts began to hear more cases, and individuals began to win civil suits against their employers. The Japanese Ministry of Labor, Health and Welfare recently established some guidelines that are intended to prevent death and suicide due to overwork2, 3). Since Uehata reported on 17 cases of karoshi (death from overwork)4), several Japanese researchers5–8) have also reported that overwork can lead to death9). This is possible because of the unusually long working hours required of employees in Japan 10) . A moderate relationship has been established between overwork or job stress and cardiovascular disease5, 7). Currently, in addition to death from overwork, karojisatsu (workrelated suicide) is a spreading occupational threat11) and a social problem in Japan. Some reports deal with the impact of psychosocial factors on mental health problems12–14) and with mental problems associated with long working hours14–17). In addition, mental disorders have been cited as predictors of suicide 18). However, no report has dealt with the relationship between suicide and the psychosocial factors or long working hours at play in the workplace. Therefore, we studied 22 cases to examine the factors involved in overwork-related suicide so that we could develop a hypothetical model of the processes leading to 158 J Occup Health, Vol. 47, 2005 overwork-related suicides and propose appropriate countermeasures. Methods
Study Materials The Japanese Worker’s Compensation Department and civil court authorities require that members of bereaved families prove that labor conditions have a causal relationship with suicide. Therefore, affected families are seeking assistance from lawyers and psychiatrists. Psychiatrists generally write legal reports for civil trials and insurance reports for agencies dealing with workers’ compensation. In either case, the reports are based on the concept of “psychological autopsy” established by Shneidman19). A professional team, which might include a psychiatrist and a clinical psychologist, conducts a psychological autopsy immediately after a questionable death to determine the cause of death, i.e., how and why an individual died, by collecting and analyzing as much detailed information about the victim’s life as possible19). In the case of work-related suicide, the psychiatrist first reads all the materials submitted by the lawyer and the bereaved family, interviews the bereaved family for 2 to 3 hours on several occasions, and finally analyzes the collected data. As of December 2001, we had access to 24 reports of work-related suicide that had been written by colleagues; the reports were used as the basis for this study. Informed Consent After a lawyer or psychiatrist had explained the research, 22 of 24 bereaved families gave written consent for participation in the study. Of the two that did not give consent, one individual chose not to participate because she wanted to avoid potential trouble in the workplace. In the other case, no reply was received from mail sent to an attorney representing the bereaved family, whose attending psychiatrist had died. In total, 22 case reports were analyzed. Analytical Procedure Two certified psychiatrists (T.A. and Y.T.) independently analyzed the 22 reports, discussed the results, and reached a consensus in each case. A clinical epidemiologist (T.N.) then participated in further discussions with the psychiatrists to reach an objective consensus concerning the details of each case from the standpoint of a general physician and gave specific methodological advice about some of the limitations of this study and guidelines on possible future research. Identified Factors Many factors related to each individual’s death were identified: socio-demographic (sex, age, marital status, and death date) and socio-economic factors (job, position, and rank); individual and family history; and psychological issues (pre-morbid personality, preceding stress, life events, losses, social support in the workplace, and family relationships), working hours, and symptoms and signs of suicide (prior suicide attempts, changes in habits, physical and psychiatric symptoms, suicidal signs, and accident proneness). Furthermore, the way in which the individuals coped with their various problems, families, and co-workers was analyzed. A history of psychiatric consultation and other types of consultations was compiled. Work safety, health education, and psychiatric diagnoses at the time of death according to definitions from the ICD-1020), method of suicide, and suicide notes were examined, as were employee records involving accidents and lawsuits as of April 2002. The definitions from the ICD-10 were used because the new guideline adopted in 1999 to certify mental disorders as work-related accidents2) p rincipally uses the ICD-10 criteria for psychiatric diagnosis. Statistical Analysis Basic descriptive statistics, such as mean, median and range were used. Results
Socio-demographic Factors (shown in Table 1) Of the 22 cases, only one involved a woman. The youngest victim was a 24-yr-old man, and the oldest was 54. Six were in their 20s, 6 in their 30s, 8 in their 40s, and 2 in their 50s; the median age was 35. The years of the suicides ranged from 1983 to 2000; the median was 1996. Sixteen (72.7%) were married. Six (27.3%) men were single but had a fiancée or girlfriend. Seventeen (77.3%) were private sector workers; 5 (22.7%) were civil servants; and 3 (13.6%) were teachers. Twenty-one (95.5%), all except case 4, were middle-ranking managers. Individual and Family History None of the subjects had been diagnosed with mental health problems before suffering from depression leading to suicide. They did not have individual or family histories involving suicide or attempts. None had been diagnosed with a personality disorder. Occupational Stress Each subject experienced two types of occupational stress, one from the worksite and the other from the job itself. Examples of environmental stress included job transfers, changes in personnel, lack of social support in the workplace, poor human relationships, and psychological harassment. Examples of stress from the job included long working hours and heavy workloads. A subject was identified as experiencing low levels of social support, high levels of psychological demand, and low levels of decision latitude when two psychiatrists Table 1. Outlines of the cases in order of age at the time of death
Position and Rank Personality Worksite stress Personnel change personnel reorganization, promotion transfer + + + transfer + + + transfer, promotion transfer transfer, downsizing transfer, promotion promotion promotion promotion, downsizing personnel reorganization promotion promotion promotion + promotion no deviation meticulous immodithymia business bachelor, promotion restructurig, personnel reorganization + + + + + (continued on next page) + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Case Sex* Age Death No. year Person in charge bright, sense of responsibility sincere, mild temper immodithymia bright, sportsman hard worker, considerate to others neurotic but no deviation no deviation immodithymia no deviation cyclothymia immodithymia Chief teacher Chief programmer Official in charge Chief Business manager Chief teacher Section member Personnel chief Group leader Chief Branch manager substitute no deviation Chief immodithymia serious, meticulous no deviation immodithymia immodithymia immodithymia no deviation Teacher Chief Chief Person in charge Chief Marital status† Workplace LSS‡ HPD§ LC|| + + + + + + + + + 1 M 24 1995 S Food company 2 M 26 1998 S High school 3 M 26 1997 S Program development company 4 M 28 1997 S Municipal office 5 M 28 1997 S Manufacturing company 6 M 29 2000 S Underwear company 7 M 30 1983 M Elementary school 8 M 30 1997 S Manufacturing company 9 M 31 1998 M Manufacturing company 10 M 31 1985 M Manufacturing company 11 M 35 1988 M Automobile company Takashi AMAGASA, et al.: Characteristics of 22 Cases of Work-Related Suicid 12 M 35 1998 M Water service construction store 13 M 41 1991 M Manufacturing company 14 W 41 1996 M Elementary school 15 M 41 1999 M Restaurant 16 M 42 1995 M Municipal office 17 M 46 1996 M Research & development company 18 M 46 1993 M Shipbuilding company 19 Chief of the shop Manager Site foreman M 46 1996 M Household/ electric appliance company Section chief 20 M 49 1996 M Store 21 M 53 1998 M Manufacturing company 22 M 54 1997 M General construction company 159 160 (continued) Table 1. Outlines of the cases in order of age at the time of death Case Sex* Age No. Increased Physical Accident alcohol symptom proneness consumption Prior Medical suicide consultation attempts Presumed diagnosis Suicide means Suicide notes Authorization/ lawsuit situation – + Depressive episode Hanging – – – + + + + – Hanging Hanging Jumping Hanging Jumping Hanging Depressive episode Depressive episode + + + – + – – + + + – Depressive episode Depressive episode Depressive episode Depressive episode Depressive episode Depressive episode Jumping Jumping Hanging Drowning Inhalation Jumping Inhalation Hanging + – – – – + + + – + + – – – Hanging Hanging Hanging Hanging Hanging Hanging Hanging Depressive episode Depressive episode Depressive episode Depressive episode Depressive episode Depressive episode Depressive episode Depressive episode Depressive episode Depressive episode Depressive episode Depressive episode Depressive episode – – + – – – – – – – – + – + + – – – Authorized/ won /Under dispute – + – – – traffic accident – wrist–cutting – – – – – – – – – – – – – – – – – – – – – – – – – – – injury – – – + + + + + – + + + + + + + + + + + + + + – + – – – – – – – – + – – + – – – – + + Job stress LWH (EWH)¶ Duration 1 M 24 + 2 M 26 3 M 26 +, 322(162)h/month 3 month Authorized/ reconciled Not authorized /Reconciled Not applied /Won first instance /Under dispute Under examination /Won /Under dispute Authorized/under dispute Authorized/won / Under dispute Authorized Not authorized /Under dispute Authorized/under dispute /Won Authorized/ under dispute /Under dispute Under examination 4 M 28 + 5 M 28 +, without a holiday 6 M 29 + 7 M 30 +, midnight going home 8 M 30 +, until midnight 9 M 31 +, 375(215)h/month at least 25 d 10 M 31 +, 378(218)h/month more than 11 months 11 M 35 +, until 11:00pm 12 M 35 +, 287(127)h/month 7.7 months 13 M 41 +, 368(208)h/month 5 months 14 W 41 + 15 M 41 +, 13(5)h/d 4 months 16 M 42 +, without a holiday 17 M 46 +, 15.5(7.5)h/d at least 1.5 months 18 M 46 +, 300(140)h/month 6 months 19 M 46 20 M 49 +, 11(3)h/d at least 40 d 21 M 53 22 M 54 +, until midnight *In the Sex column, M denotes men, and W denotes women. †In the Marital status column, S denotes single, and M denotes married. ‡LSS denotes low levels of social support. §HPD denotes high levels J Occup Health, Vol. 47, 2005 of psychological demand. || LC denotes low levels of control. ¶LWH denotes long working hours, and EWH denotes excessive working hours. Takashi AMAGASA, et al.: Characteristics of 22 Cases of Work-Related Suicid 161 (T.A. and Y.T.) reached a consensus that, before the manifestation of any mental disorder, the individual would have answered ‘agree or strongly agree’ to the following propositions: he did not have enough instrumental and emotional support; his relationship with his supervisor and co-workers were bad, his position required him to work very fast or hard; he was asked to do too much work, he was not free to decide what he was going to do in his work; and he was not free to decide the amount of work he would do. As a result, low levels of social support at work were identified in 18 cases (81.8%); high levels of psychological demand in 18 (81.8%); and low levels of decision latitude in 17 (77.3%) (Table 1). Long working hours were noted in the psychiatrists’ reports in 19 cases (86.4%) but not in 3 (Table 1). A close examination of nine cases of suicide (Case Nos. 3, 9, 10, 12, 13, 15, 17, 18, and 20) (40.9%) showed that the individuals had been working between 10 and 16 h per day, i.e., an excess of 2 to 8 h per day; the median was an excess of 5 h per day. These individuals had worked extremely long hours for at least 25 d and, in some cases, up to 11 months before manifestation of a mental disorder. Not one individual who had committed suicide had received mental health education dealing with occupational stress management during a promotion or personnel change. Time Course, Symptoms, and Suicidal Signs The suicides in this study occurred within 5 to 18 months after eventful episodes such as a promotion, transfer, or personnel reorganization; the median time was 11 months. The interval between the manifestation of a mental disorder and suicide ranged from 2 weeks to 8 months; the median was 2 months. The symptoms observed by family members, friends, and colleagues of the individuals who committed suicide included sleep disturbance, such as insomnia and difficulty getting up in 15 of the cases (68.2%) and autonomic symptoms, such as headache, stiffness in the shoulders, susceptibility to colds, mild fever, lumbar pain, diarrhea, and constipation, in 18 (81.8%). Other indications of suicidal feelings were the manifestation of an intention to retire or hope for a change in the workplace, which occurred in 8 cases (36.4%), excessive absences in 5 (22.7%), increased consumption of alcohol and tobacco in 6 (27.3%), reduction of interest in sexual intercourse in 4 (18.2%), amnesia or very unusual mistakes in 2 (9.1%), accident proneness in 2 (9.1%), and prior suicide attempts in 3 (13.6%). These same symptoms appeared within 2 to 3 months after personnel changes and got progressively worse until the suicide. Access to Medical Service Ten individuals (45.5%) who committed suicide had seen a physician because of unspecified somatic complaints, such as chest pain, stomach ache, or mild fever; however, none of them had complained of depressive feelings. None had a history of psychiatric consultation or psychiatric hospitalization. The Japanese general physicians might have been reluctant to diagnose reactive depression or might have not been provided with sufficient information about it. One individual (4.5%) claimed that he was exhausted during a medical checkup, but the company physician thought that he was suffering temporarily from mental stress and did not follow up. Diagnosis Each victim was presumed to have suffered from depression at the time of death (Table 1). Reports of problems with mental health were assumed to be reactions to a combination of worksite and job stress. Suicide Notes and Methods of Suicide Eleven of the victims (50%) wrote suicide notes (Table 1). All of the documents had a tone of self-reproach for their poor performance at work rather than blame for others. Work seemed to be so central to these people’s self-esteem that inability to cope with work demands was perceived as a very salient problem. Thirteen of the victims (59.1%) hung themselves, 5 (22.7%) jumped from high places, 3 (13.6%) inhaled lethal substances, and one (4.5%) drowned himself (Table 1). Employee Compensation Insurance and Lawsuits The records for employee compensation insurance and lawsuits were examined to determine whether or not mental health problems and suicides had been certified as work-related and whether or not bereaved families had won civil lawsuits (Table 1). Two cases (9%) were undecided four years after (April 2002) applying for employee compensation insurance, and nine (40.9%) had not been determined within the same period. Discussion and Conclusions
This is the first case study of suicides related to overwork in Japan that includes analyses and psychological autopsies. Figure 1 depicts a hypothetical time sequence of work-related suicides 21) . The individuals who committed suicide worked long hours and experienced heavy workloads. Eleven individuals (50%) had experienced a significant life event before experiencing any mental health problems, and the other 11 (50%) had experienced the same kinds of significant life events before committing suicide. Poor physical health manifested itself in a lack of desire to talk and eat and various behavioral changes. Individuals might have indicated that they were tired or exhausted or that they wanted to retire. Many symptoms occurred before mental health problems were diagnosed or apparent and 162 J Occup Health, Vol. 47, 2005 Fig. 1. An Examination of Suicide from Overwork. This was reconstructed from the details of the findings in the time sequence in which they occurred. 2W denotes 2 weeks; 2M denotes 2 months; 2W-2M-8M before denotes an interval ranging from 2 weeks to 8 months; the median is 2 months before suicide. 10–13–16 h/d without a holiday denotes the average working time per day ranging from 10 to 16 h; the total working hours in a month were divided by 30 d; the median is 13 h per day before manifestation of a mental disorder. continued until the individual committed suicide. Overwork might not have been a direct cause of suicide; however, mental health problems, especially depression, may have contributed to the factors that led up to suicide. For comparison, the table in the Appendix shows the prevalence of stress and symptoms in Japanese workers10, 22, 23). When the families first became aware of the symptoms, they tried to relieve the individual of any burdens over which they had control. However, they might have stopped trying when they saw that they were unable to have an effect. Members of management in the workplace tried to encourage the individuals who were suffering. Some supervisors gave workers new tasks because they determined that the workers were easily bored with their regular tasks. It is unlikely that suicide can be prevented without appropriate action from employers and the immediate family. In the cases studied, the individuals continued to work until they, unfortunately, committed suicide. Generally, suicidal individuals have many risk factors, some of which include suicide attempts, mood disorders, personality disorders, lack of social support systems, age disadvantages, male gender, and being single. Others include various types of loss, unemployment, physical or sexual abuse in childhood, accident proneness, family history of suicide, and exposure to other cases of suicide or tragic accidental deaths24, 25). However, in the cases studied, the individuals were only exposed to a few of these risk factors. The overwhelming majority were men, although the rate for general suicide is only 2.6 times higher among men than women (the aggregate worldwide ratio is 3.5; the workplace ratio is 7)1, 26, 27). The workrelated suicide ratio is similar to that for death from overwork, which is 196 males to 7 females28). This may be because males work longer than females in Japan or because, when a male commits suicide, the family is more threatened economically. Almost all individuals in this study worked long hours, experienced pressing psychological demands, and received little social support at work. Ultimately, they began to experience depression and committed suicide. The relative risk of depression before committing suicide has been estimated to be about 20 times that of the general population, according to the Harris report18). Furthermore, some research deals with psychosocial factors or perceived job stress by workers and depressive symptoms or depression12, 13). Niedhammer reported in a cohort study that high levels of psychological demands, low levels of decision latitude, and low levels of social support at work were significant predictors of subsequent symptoms of depression in men and women. The odds ratio (OR) for men was 1.77, 1.38, and 1.58 for the three factors, respectively12). Mausner-Dorsch reported that high job strain composed of high psychological demands and low decision latitude significantly increased the OR (major depressive episode, 7.16; depressive syndrome, 4.06)13). On the other hand, there is much less information about the effects of long working hours on mental health, and the results of some research are controversial. Shields’ main result of a 2-year follow-up study was that only women who worked long hours had an increased OR (2.2) of subsequently experiencing depression17). However, Tyssen reported that, among medical interns, the number of working hours was not linked to mental health problems28). Although long working hours are generally defined as those from 41 to 50 h or more per week, further studies should be conducted to determine the effects of much longer working hours on mental health. We emphasize here that the Japanese worker might be influenced to commit suicide under certain circumstances related to work. More than half of the workers in Japan work in excess of 42 h a week10). After the collapse of the Japanese economy in the early 1990s, restructuring and downsizing of companies has placed workers under enormous pressures29). Japanese workers work very hard, even when suffering from poor physical or mental health due to overwork, and many workers will say, “If I fail now, I will burden my co-workers. Therefore, I cannot avoid work.” Several cases can be made to explain why typical Japanese workers work so hard and do not retire earlier than they do. Confucianism continues to have a profound influence on the Japanese culture and worldview. The Takashi AMAGASA, et al.: Characteristics of 22 Cases of Work-Related Suicid 163 basic unit of society in the Japanese mind lies in a concept that literally means “house” (ie in Japanese). However, the word implies other groups, such as families, companies, schools, and religious sects that bind people together. The Japanese education system has strengthened this concept of togetherness. The Japanese are educated to cooperate and conform with the group. Therefore, Japanese workers behave as their co-workers do and do not assert themselves too much in order to work harmoniously. Moreover, the Japanese business management system appears to contribute significantly to work-related suicides6). Three principles have served as the foundation of the Japanese system of work. They are lifetime employment, a pay scale based on seniority, and loyalty to the employer. As a result, employees do not usually change companies. Japanese general physicians seem to be more reluctant to diagnose depression26, 30) and less able to manage people suffering from depression and contemplating suicide. This might be because, in Japan, both medical students and general physicians have been trained insufficiently about psychiatry and because Japanese male workers tend to show physical symptoms rather than depressive feelings due to unfavorable attitudes toward depression31). In their efforts to improve working conditions, the bereaved families of suicide victims and their attorneys have lobbied the Ministry of Labor, Health and Welfare to develop guidelines to ameliorate the kinds of conditions that lead to work-related suicide2, 3). As a result of their efforts, new standards were adopted in 1999 to certify mental disorders as work-related accidents2). Guidelines for the promotion of mental health in the workplace were established in 2000, and a description of appropriate working hours was written and distributed to employers in 2001. Furthermore, the instructions contained specific guidelines for recording working hours, which are to be monitored by employers, and an admonition that excessive hours are in violation of the laws governing labor standards. In addition, comprehensive measures were developed to prevent harm from overwork in 20023). Such measures encourage employers to seek advice from their company physician with regard to employees who work more than 45 h per month in excess of the acceptable working load. They also encourage employees who have worked more than 100 h in excess of the acceptable working load or more than 80 h on average in excess of the acceptable working load in the last 2 to 6 months to meet with their company physician because such long working hours may increase health risks. A final report from the Special Committee on Prevention of Suicide was released in 20023). However, these reforms have not been implemented by many employers. There are some limitations with the present study. First, the nature of a case series report that has no comparison cannot determine the causality and we stress that conducting appropriate case-control studies or cohort studies is difficult on this topic. Second, the reports from the bereaved families may be somewhat biased. However, all of the reports were based upon psychological autopsies and information from employers, which had been used to obtain employee compensation or file a lawsuit, and it must be emphasized that the present study could not have been possible if these reports had not been utilized. The identification and description of real cases may contribute to make well-timed countermeasures. Appropriate countermeasures are critical at present in Japan, and some of them should be implemented immediately with reference to the cases presented here. The present findings might be helpful to workers in other countries who are subjected to poor working conditions, as are the Japanese. References
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