Asian Journal of Psychiatry 47 (2020) 101831

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Asian Journal of Psychiatry

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Japanese young adults’ attitudes toward suicide and its influencing factors T
a, b a a a
Hisashi Otsuka *, Sachiko Anamizu , Shoko Fujiwara , Risa Ito , Mariko Enomoto ,
Mayumi Furukawaa, Akira Takanoa
a
The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8654, Japan
b
International University of Health and Welfare, Japan

A R T I C LE I N FO A B S T R A C T

Keywords: This study investigated young Japanese adults’ attitudes toward suicide and factors affecting them. Results
Suicide revealed that 28.78% of respondents had serious suicidal ideation history; 18.53% knew suicidal others; and
Attitude 15.29% took suicide-prevention training. A t-test showed that respondents’ “Right to suicide” and “Common
Ideation occurrence” scores were higher with suicidal ideation history, but “Unjustified behavior” was lower than in those
ATTS
without history. Results indicated that certain young adults were unsupportive by being permissive of suicide
Young adults
Japan
due to their suicidal ideation or becoming bystanders due to inexperience. For young Japanese adults, enhancing
preventive education to alter permissive/bystander attitudes is crucial.

1. Introduction 2. Methods

In Japan, younger generation suicides are a serious problem. Among
the seven major industrialized nations, only in Japan, suicide is young
people’s leading cause of death, with a mortality rate higher than in the
other six countries (MHLW, 2018). Recent research shows that over
20% of Japanese university students feel ongoing suicidal ideation
(Otsuka and Anamizu, 2019).
Unfortunately, many young people experiencing suicidal crises do
not ask for expert help (Uchida, 2010; Kisch et al., 2005) but rather seek
help from friends for both non-suicidal and suicidal problems (Dean
et al., 2001). Therefore, non-professional peers around people con-
sidering suicide should perceive these crises and provide appropriate
help.
However, helping behavior seems influenced by caregivers’ atti-
tudes toward suicide (Bagley and Ramsay, 1989). Particularly, per-
missive attitudes can lead to unsupportive behavior (Kodaka et al.,
2013b). Studies have reported various factors influencing young peo-
ple’s attitudes toward suicide. College students with history of suicidal
crises saw suicide as rational and appropriate (Lester et al., 1991), fe-
males and nonreligious adolescents held more accepting attitudes (Stein
et al., 1992), and male students agreed that suicidal behavior lacks real
intent (McAuliffe et al., 2003).
This study examines the attitude Japanese young adults currently
hold toward suicide.
2.1. Participants and procedures
We conducted quantitative national research, using a web research
company (Cross Marketing, Tokyo, Japan), with 556 Japanese young
adults (274 males, 278 females, 4 other genders; mean age ± SD:
24.98 ± 3.16years; range: 18–29 years). We requested unbiased sam-
pling by residential area and employment status roughly proportionate
to Japanese government statistics (MIAC, 2018). We included two other
measures on suicide. To secure responses’ reliability, we excluded re-
spondents who answered all items with the same numerical value and
made errors in the dummy items, “Please answer 1 here.”
According to the web survey system, questionnaires were dis-
tributed to 27,259 people, and because more than 500 valid responses
to preset collection targets were reached in 3 days, collection was au-
tomatically terminated. There were 823 total responses, of which 267
were invalid (valid responses/total responses = 67.56%).
From January to February 2019, online respondents completed
questionnaires anonymously after providing written informed consent.
Regarding mental upset caused by participation, we also provided in-
formation on public/private organizations’ consultation desks.
Participants received small loyalty-program rewards from the research
company. The University of Tokyo ethics committee approved this
study.

⁎
Corresponding author.
E-mail address: otsuka.hisashi@mail.u-tokyo.ac.jp (H. Otsuka).

https://doi.org/10.1016/j.ajp.2019.10.011
Received 10 August 2019; Received in revised form 8 October 2019; Accepted 8 October 2019
1876-2018/ © 2019 Elsevier B.V. All rights reserved.
H. Otsuka, et al. Asian Journal of Psychiatry 47 (2020) 101831

2.2. Measures Table 2

Sex-based Differences.
We employed a six-factor Japanese version of the Attitudes Toward Male Female
Suicide questionnaire (ATTS-J; Kodaka et al., 2013a). We reversed the
Likert scale to unify survey responses on a 5-point scale from 1. Strongly M SD M SD ｔ
disagree to 5. Strongly agree. We collected information on gender, age,
Right to suicide 3.13 0.73 3.05 0.91 1.23
lifetime history of serious suicidal ideation, experience with another Common occurrence 3.11 0.69 3.13 0.82 −0.29
with suicidal ideation, and history of participation in suicide prevention Suicidal expression as mere threat 3.05 0.74 3.05 0.87 −0.10
education. Unjustified behavior 3.09 1.06 3.21 1.01 −1.39
Preventability/ Readiness to help 2.88 0.73 2.84 0.72 0.62
Impulsiveness 2.98 0.64 3.03 0.70 −0.90
2.3. Data analysis
Right to suicide, Common occurrence, Suicidal expression as mere threat:
A t-test was performed to examine differences in ATTS-J subscale Welch's t.
scores between gender and personal experiences. Because only four
respondents reported gender as other, we analyzed differences between Table 3
males and females. IBM SPSS Statistics version 25 (IBM, Armonk, NY, Differences in history of suicide ideation.
USA) was used to perform all analyses.
Yes No

3. Results M SD M SD ｔ

Of respondents, 160 (28.78%) had experienced serious suicidal Right to suicide 3.50 0.81 2.93 0.77 7.79 ***
Common occurrence 3.70 0.60 2.88 0.68 13.32 ***
ideation, 103 (18.53%) had experience with suicidal individuals, and Suicidal expression as mere threat 3.04 0.93 3.06 0.75 −0.25
85 (15.29%) had participated in suicide prevention education (Table 1). Unjustified behavior 2.82 1.08 3.29 0.99 −4.94 ***
The t-test results showed no significant difference between genders Preventability/ Readiness to help 2.87 0.76 2.86 0.71 0.12
(Table 2). The “Right to suicide” (t(554) = 7.79, p < 0.001, Cohen’s d Impulsiveness 2.97 0.65 3.03 0.68 −0.94
= 0.72) and “Common occurrence” (t(554) = 13.32, p < 0.001, Co-
Suicidal expression as mere threat: Welch's t *** p < .001.
hen’s d = 1.28) scores of those with history of suicidal ideation were
higher. “Unjustified behavior” (t(554) = −4.94, p < 0.001, Cohen’s d
Table 4
= 0.45) was lower than in those with no history (Table 3). The means
Experiences with suicidal individuals.
of “Right to suicide” (t(554) = 2.06, p < 0.05, Cohen’s d = 0.22) and
“Common occurrence” (t(554) = 3.19, p < 0.01, Cohen’s d = 0.35) Yes No
scores of respondents with experience with suicidal others were also
M SD M SD ｔ
higher; “Unjustified behavior” (t(554) = −2.42, p < .0.05, Cohen’s d
= 0.26) was lower than in those with no experience (Table 4). The Right to suicide 3.24 0.91 3.06 0.80 2.06 *
mean score of “Preventability/Readiness to help” (Welch’s t Common occurrence 3.33 0.78 3.07 0.74 3.19 **
(106.16) = 3.84, p < 0.001, Cohen’s d = 0.51) for respondents who Suicidal expression as mere threat 3.14 0.95 3.03 0.77 1.03
Unjustified behavior 2.93 1.11 3.20 1.01 −2.42 *
had participated in suicide prevention education was higher, but “Un- Preventability/ Readiness to help 2.94 0.78 2.85 0.71 1.12
justified behavior” (t(554) = 2.56, p < 0.05, Cohen’s d = 0.30) was Impulsiveness 3.00 0.67 3.01 0.67 −0.20
lower than in those who had not (Table 5).
Suicidal expression as mere threat: Welch's t * p < .05, ** p < .01.
4. Discussion
Table 5
In North America, a lifetime history of serious suicidal thought was Participation in suicide prevention education or training.
reported at 18.2% in early adulthood (Brezo et al., 2007). Among col- Yes No
lege students in member countries of the Association of Southeast Asian
Nations, 11.7% had such a history (Peltzer et al., 2017). Of Chinese M SD M SD ｔ
university students, 20.4% had a lifetime history of suicidal thoughts
Right to suicide 3.04 0.91 3.10 0.81 −0.68
(not including “seriously”) (Zhang et al., 2012). This study suggested Common occurrence 3.12 0.74 3.11 0.76 0.01
nearly 30% Japanese young adults had a history of “serious” suicidal Suicidal expression as mere threat 3.16 0.89 3.03 0.79 1.28
ideation. The World Mental Health Japan Second Survey, a large-scale Unjustified behavior 3.42 1.05 3.11 1.03 2.56 *
Preventability/ Readiness to help 3.17 0.83 2.81 0.69 3.84 ***
epidemiological survey, reported that 8.6% young adults have such a
Impulsiveness 2.96 0.73 3.02 0.66 −0.72
history (Yamauchi et al., 2016). This ratio was obtained through face-
to-face household interviews; our study has shown a higher value be- Suicidal expression as mere threat, Preventability/ Readiness to help: Welch's t
cause respondents answered anonymous questionnaires without any * p < .05, *** p < .001.
preoccupation about the investigator.
Conversely, only 18% had experience with suicidal others,

Table 1
Participants’ personal experience.
Yes No

n % (95% CI) n % (95% CI)

History of serious suicidal ideation 160 28.78 (25.05–32.74) 396 71.22 (67.26–74.96)
Experience with someone who has had suicidal ideation 103 18.53 (15.38–22.01) 453 81.47 (77.99–84.62)
History of participation in suicide prevention education or training 85 15.29 (12.40–18.55) 471 84.71 (81.45–87.60)

2
H. Otsuka, et al.
considerably lower than previous studies showing 47% of Japanese
pharmacists and 60% of social workers “personally” (meaning not
“occupationally”) had experience with others (Kodaka et al., 2013a,
2013b). Although many young adults experience suicidal ideation,
young people around them might not detect it. Since only 15% of re-
spondents had participated in suicide prevention education, we should
provide preventive education to involve them properly in a crisis.
Regarding ATTS-J, Otsuka et al. (2018) showed that Japanese stu-
dents with history of suicidal ideation had higher agreement with
“Right to suicide” and higher “Common occurrence,” indicating
stronger views of suicide as common and normal, and lower “Un-
justified behavior,” revealing weaker belief that suicide is an unjustified
action. Our results followed theirs. Targeting professionals, Kodaka
et al. (2013a; 2013b) also showed that “Right to suicide” and “Common
occurrence” were higher among those with a history of suicidal idea-
tion.
In regards to differences in experiences with suicidal others, Kodaka
et al. (2013a) showed that those experienced with suicidal individuals
have higher “Common occurrence” but lower “Suicidal expression as
mere threat” and “Unjustified behavior” than those without such ex-
perience. In this research, besides one’s own suicidal ideation, those
who had experience with suicidal others had higher “Right to suicide”
and “Common occurrence” but lower “Unjustified behavior.” Cohen’s d
values indicated that one’s own experience had stronger effect size.
Significantly, people who have not experienced suicidal ideation in
themselves or others might see suicide as less common, thus believing
that suicide is never justified. With nearly 30% of young adults having
experienced it, the problem is evidently common. Another study re-
vealed that persons with suicidal ideation experience also had more
experience with suicidal individuals (Otsuka et al., 2018). Therefore,
some see suicide as familiar and others as remote; between them exists
a wide attitudinal gap.
Possibly, some who experienced suicidal ideation might become
accustomed to or neglect another’s suicide crisis. They might have a
permissive attitude. Among people who had not experienced suicidal
ideation, suicide might be “a matter for others”; they might be less
likely to notice an imminent crisis or be bystanders, leading to un-
supportive behavior.
The result that people who had attended preventive programs had
higher “Preventability/ Readiness to help” means that enhancing pre-
ventive programs to alter permissive or bystander attitudes is crucial.
Providing a place for people who have accepted suicide based on their
experiences is vital for preventing their drag on positive support and
arousing empathy. We must convince people unfamiliar with suicidal
crises to be more sensitive to the issue.
In addition, Snowdon (2018) has reported that sociocultural factors
have a significant impact on suicide in East Asia while mental disorders
are a common cause in the West; further, drug abuse affects the young
generation. Drug overdose among young people is a critical issue in
Japanese emergency medicine (Yasuda and Kobayashi, 2019). If young
adults with suicidal ideation and permissive attitudes toward suicide
have access to drugs, their risk of suicide increases. Therefore, pre-
vention of drug abuse is essential.
As for limitations, we conducted a subjective questionnaire that
might be susceptible to biases including desirability bias. As a metho-
dological problem in web surveys, the tendencies of sincere respondents
who make valid responses in a short collection period might be easily
reflected. This study also had no confirmation of respondents’ mental
conditions, so further investigation using scales to exclude psychiatric
problems is necessary.
5. Conclusions
We administered questionnaires involving ATTS-J to 556 Japanese
young adults, finding a high rate of serious suicidal ideation (28.78%),
and low rates of history with suicidal individuals (18.53%) and of
3
Asian Journal of Psychiatry 47 (2020) 101831
participation in prevention education (15.29%). This study indicated
the possibility that certain young adults had behaved in unsupportive
ways, i.e., being permissive about suicide owing to their suicidal
ideation experiences or becoming bystanders because of inexperience.
For Japanese young adults, enhancing preventive education to alter
permissive or bystander attitudes is crucial.
Contributors
Hisashi Otsuka developed the study’s original idea, performed sta-
tistical analysis, and drafted the manuscript. All authors participated in
design and coordination, supervised data collection and analysis, and
read and approved the final manuscript.
Funding
This study was supported by JSPS KAKENHI [grant number
JP17K13946].
Declaration of Competing Interest
None.
Acknowledgments
We thank Dr. Manami Kodaka (Musashino University) for advice on
analysis and giving permission to use the scale. We also thank Dr.
Yotaro Katsumata (University of Niigata Prefecture) and Dr. Masanori
Sugioka (Nagoya University) for advice on study protocol, and Enago
(www.enago.jp) for the English language review.
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