Psychiatry and
PCN
Clinical Neurosciences
Prevalence of mental disorders and mental health service use
in Japan
Daisuke Nishi, MD, PhD,1,2* Hanako Ishikawa, MD, PhD1 and Norito Kawakami, MD, PhD1
A high disease burden of mental disorders has been noted
worldwide, including Japan. It is important to monitor mental
disorder prevalence trends and the use of mental health ser-
vices over time using epidemiological data and to plan
appropriate policies and measures that consider mental
health in each country. This review outlines the prevalence
trends of common mental disorders (CMD) and the use of
mental health services in Japan from the 2000s to the 2010s
and compares them with those in other countries. This
review clarifies that the prevalence of CMD in Japan has
been relatively stable in the past decade. The 12-month
prevalence of mental health service use has increased about
1.2 times to 1.6 times in the past 10–15 years. Thus, it is
very likely that the rise in mental health service use contrib-
utes to increased patient numbers. Regarding cross-national
The disease burden of mental disorders has been shown to be very
large worldwide, including Japan.1 As of 2016, depressive disorders
ranked 12th and self-injury ranked 8th in terms of disability-adjusted
life years in Japan.2 In addition, some previous studies have
suggested that the economic loss due to depression ranges from 1290
billion to 3 trillion yen annually in Japan.3–5 Common mental disor-
ders (CMD), such as mood, anxiety, and substance-related disorders,
are prevalent, and the need for treatment is still unmet, both in Japan
and worldwide.6,7
It is important to monitor the trend of the prevalence of mental
disorders and the use of mental health services over time to plan
appropriate policies and measures that consider mental health in each
country.8 Community-based mental health epidemiology plays an
essential role in estimating the prevalence of and service use for men-
tal disorders because most people do not seek treatment even if they
experience psychological distress equivalent to diagnosable mental
disorders. On the other hand, community-based mental health surveys
may have some limitations, such as low response rate, which can bias
the results; thus, it is necessary to utilize the results of surveys
targeting patients who visit medical institutions.
Many mental health epidemiological studies have been con-
ducted in Japan for which the data are available. However, only a few
population-based surveys exist. For instance, the World Mental
Health Survey Japan (WMHJ) was a representative community-based
mental health epidemiological study.6,9 The Comprehensive Survey of
Living Conditions (CSLC) is a large nationwide community-based
survey measuring a broad range of health-related topics conducted
every 3 years that also assesses psychological distress and the use of
mental health services using self-report questionnaires.10 The Patient
1
Department of Mental Health, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
2
Department of Mental Health Policy, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
* Correspondence: Email: d-nishi@m.u-tokyo.ac.jp
458 © 2019 The Authors
Psychiatry and Clinical Neurosciences © 2019 Japanese Society of Psychiatry and Neurology
PCN
PCN FRONTIER REVIEW
comparison, the prevalence rate of CMD in Japan is much
lower compared to rates in the USA and Europe. The
12-month prevalence of mental health service use was also
lower in Japan compared to prevalence rates in other high-
income countries. Mental health epidemiology has clarified
that the prevalence of CMD worldwide has remained
unchanged, even though mental health service use has
increased in high-income countries. Thus, the gap in treat-
ment quality and prevention should be addressed in the
future.
Keywords: common mental disorders, epidemiology, Japan, mental
health service use, prevalence.
http://onlinelibrary.wiley.com/doi/10.1111/pcn.12894/full
Survey examines the actual condition of both inpatient and outpatient
mental health patients every year.11 In addition, health-insurance-
claims information for all insurance-based treatments is also available
to grasp the actual number of patients and the contents of treatment.
In this review, we aimed to examine the trend of the prevalence of
mental disorders and mental health service use in Japan, and to com-
pare them with those in other countries by reviewing these mental
health epidemiological data. Furthermore, we emphasize the impor-
tant roles of mental health epidemiology as well as its challenges and
future prospects.
Trends of the Prevalence of Mental Disorder
World Mental Health Survey Japan
Participants and measurement
The World Mental Health Survey is a collaborative study conducted
by the World Health Organization (WHO) and the Harvard Medical
School that includes 28 countries around the world.12 In Japan, the
World Mental Health Japan Survey First (WMHJ1) was conducted
from 2002 to 2006, followed by the World Mental Health Japan Sur-
vey Second (WMHJ2) conducted from 2013 to 2015. A total of 4134
randomly selected residents aged 20 years or over (participation rate
55.1%) participated in the WMHJ1 from 11 areas from Yamagata
prefecture to Kagoshima prefecture. The participants were recruited
using the electoral register or resident registry from each area. A total
of 2450 people (participation rate 43.4%) participated in the WMHJ2
out of a nationally representative sample of 5000 residents between
20 and 75 years old from about 150 municipalities in Japan recruited
using a two-stage random selection. The age distribution of each sur-
vey was considered comparable.
Psychiatry and Clinical Neurosciences 73: 458–465, 2019
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Psychiatry and
PCN Clinical Neurosciences Prevalence of mental disorders in Japan

As an assessment instrument, the Japanese version of a
computer-assisted personal interview of the WHO Composite Interna-
tional Diagnostic Interview (CIDI) version 3.013 was used to diagnose
CMD. Specifically, specially designed computer software was used to
display CIDI questions on the screen of the computer brought by an
interviewer. In accordance with a determined procedure, the inter-
viewer read the questions and input the answer from the study partici-
pant to the computer.
CMD prevalence trends
Lifetime prevalence and 12-month prevalence of any mental disorder
were 17.9% (SE 1.1) and 5.6% (SE 0.6) in the WMHJ1, and 22.0%
(SE 0.8) and 5.2% (SE 0.5) in the WMHJ2, respectively.9 The life-
time and 12-month prevalence of CMD in the WMHJ1 and WMHJ2
by sex are shown in Tables 1 and 2, respectively. The lifetime and
12-month prevalence of anxiety and mood disorders are higher in
women compared to men while the lifetime prevalence of substance-
related disorders is higher in men than in women.
Lifetime and 12-month prevalence of any anxiety disorders were
lower in the WMHJ2 compared to the WMHJ1 while lifetime and
12-month prevalence of mood disorders in men were higher in the
WMHJ2 compared to the WMHJ1. Lifetime prevalence of substance-
related disorders clearly increased both in men and women from the
WMHJ1 to the WMHJ2, which seemed to explain the increase of life-
time prevalence of any mental disorders in men in the WMHJ2.
Twelve-month prevalence of any mental disorder in women was
mostly unchanged, although it decreased in men. The lifetime and
12-month prevalence of comorbidity were mostly unchanged from the
WMHJ1 to the WMHJ2, although in women, it was consistently
higher compared to that in men.
It is not clear why the lifetime prevalence of alcohol use disorder
increased in the WMHJ2 compared to the WMHJ1. A previous study
in the USA reported an increased prevalence of alcohol use in the
2010s.14 Due to the increased awareness of alcohol problems in the
past decade in Japan, participants might have been more likely to
report relatively mild drinking problems even though the lifetime
prevalence of alcohol abuse might have not actually increased. The
reasons why anxiety disorders decreased and mood disorders in men
increased are also unclear. It is necessary to monitor this trend
long term.
Lifetime and 12-month prevalence rates of bipolar disorders
were very low in both men and women in both the WMHJ1 and
WMHJ2.15 However, previous studies have suggested that bipolar dis-
order is often underdiagnosed.16–19 The diagnosis of bipolar disorder
is not necessarily easy, and it might require information from other
informants (family members or coworkers) as well as careful and
repeated interviewing.20 These difficulties could be a challenge in
case lay interviewers collect data from one source in one session and
have to comply with the wording of the questions to ensure unifor-
mity and reliability.19 As a result, bipolar disorders might be
underreported.19
Other mental health problems assessed in the WMHJ
Suicide-related behaviors
The WHO estimates that approximately 800 000 people worldwide
and more than 20 000 people in Japan die due to suicide every
year.21,22 Many more attempt suicide, which is known as the most
potent predictor of suicide.23–25
Suicide ideation, suicide plan, and suicide attempt are assessed
in the WMHJ using the questions, “Have you ever thought seriously

Table 1. Lifetime and 12-month prevalence rates of common mental disorders in the WMHJ1 (n = 3868) by sex

Prevalence in WMHJ1

Lifetime Twelve-month prevalence

Male Female Male Female

Disorder classes/individual disorders % SE % SE % SE % SE

Anxiety disorders
Panic disorder 0.67 0.20 0.88 0.21 0.11 0.08 0.50 0.17
Agoraphobia without panic disorder 0.09 0.07 0.34 0.10 0.05 0.05 0.23 0.07
GAD 1.36 0.26 2.65 0.31 0.62 0.18 1.26 0.25
Social phobia 1.77 0.31 1.21 0.26 0.94 0.29 0.63 0.19
PTSD 0.52 0.28 2.07 0.42 0.08 0.08 1.29 0.31
Any anxiety disorders 4.63 0.74 6.15 0.75 2.36 0.67 3.23 0.46
Mood disorders
Major depressive disorder 3.85 0.52 9.28 0.66 1.22 0.28 3.44 0.51
Bipolar I and II disorders 0.27 0.18 0.19 0.10 0.07 0.07 0.16 0.09
Dysthymia 0.35 0.12 1.10 0.27 0.24 0.09 0.47 0.18
Any mood disorders 4.12 0.54 9.80 0.71 1.29 0.29 3.70 0.54
Substance use disorders
Alcohol abuse or dependence 13.63 1.40 2.75 0.81 1.40 0.45 0.28 0.15
Drug abuse or dependence 0.28 0.18 0.30 0.16 0.08 0.06
Any substance use disorders 13.63 1.40 2.87 0.82 1.40 0.45 0.32 0.16
Any mental disorder
One or more disorders 20.82 1.64 15.24 1.55 5.02 0.91 6.15 0.74
One disorder 17.30 1.66 11.04 1.33 4.50 0.91 4.35 0.66
Two disorders 2.77 0.71 2.93 0.44 0.21 0.12 1.32 0.32
Three or more disorders 0.75 0.22 1.26 0.30 0.32 0.12 0.49 0.21

GAD, generalized anxiety disorder; PTSD, post-traumatic stress disorder; WMHJ1, World Mental Health Japan Survey First.

Psychiatry and Clinical Neurosciences 73: 458–465, 2019 459

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Psychiatry and
Prevalence of mental disorders in Japan PCN Clinical Neurosciences

Table 2. Lifetime and 12-month prevalence rates of common mental disorders in the WMHJ2 (n = 2450) by sex

Prevalence in WMHJ2

Lifetime Twelve-month prevalence

Male Female Male Female

Disorder classes/individual disorders % SE % SE % SE % SE

Anxiety disorders
Panic disorder 0.43 0.19 0.70 0.23 0.26 0.15 0.47 0.19
Agoraphobia without panic disorder 0.34 0.17 0.47 0.19 0.09 0.09 0.39 0.17
GAD 0.86 0.27 2.25 0.41 0.34 0.17 0.78 0.24
Social phobia 1.47 0.35 2.09 0.40 0.69 0.24 1.32 0.32
PTSD 0.17 0.12 0.85 0.26 0.09 0.09 0.31 0.15
Any anxiety disorders 2.93 0.50 5.27 0.62 1.21 0.32 2.64 0.45
Mood disorders
Major depressive disorder 4.31 0.60 6.90 0.71 2.16 0.43 3.18 0.49
Bipolar I and II disorders 0.09 0.09 0.23 0.13 0.08 0.08
Dysthymia 0.95 0.28 0.78 0.24 0.34 0.17 0.23 0.13
Any mood disorders 4.57 0.61 7.21 0.72 2.24 0.43 3.26 0.49
Substance use disorders
Alcohol abuse or dependence 22.76 1.23 8.14 0.76 1.03 0.30 1.16 0.30
Drug abuse or dependence 0.34 0.17 0.39 0.17
Any substance use disorders 22.84 1.23 8.29 0.77 1.03 0.30 1.16 0.30
Any mental disorder
One or more disorders 27.93 1.32 16.74 1.04 4.14 0.58 6.20 0.67
One disorder 24.91 1.27 12.48 0.92 3.62 0.55 4.88 0.60
Two disorders 2.33 0.44 3.02 0.48 0.17 0.12 0.93 0.27
Three or more disorders 0.69 0.24 1.24 0.31 0.34 0.17 0.39 0.17

GAD, generalized anxiety disorder; PTSD, post-traumatic stress disorder; WMHJ2, World Mental Health Japan Survey Second.

about suicide?,” “Have you planned suicide so far?,” and “Have you
tried to commit suicide so far?” The study participants responded to
each question about the existence of this experience. In the WMHJ1,
suicide-related behaviors were published using only 2002 to 2003
data.26
The proportions of those who had experienced suicide ideation,
suicide plan, and suicide attempt and the risk of suicidal outcomes by
mental disorders are shown in Table 3.26,27 The proportions of those
who had experienced suicide ideation, suicide plan, and suicide
attempt seemed to decrease in the past 10 years. This finding was
consistent with a decline in suicide rates in Japan. In addition, the
association between suicide-related outcomes and substance use dis-
order in the WMHJ2 was non-significant. This might be explained by
the possibility that many mild cases of alcohol abuse were included
in the WMHJ2.
Hikikomori
Hikikomori, or social withdrawal, is a public mental health concern
that has been viewed not only as a Japanese culture-bound syndrome,
but also as an internationally increasing condition.28,29 Hikikomori
was defined in the WMHJ as: “Staying in the house continuously for
more than 6 months, not going to work or school and having little
communication with people other than your family.”30 The analyses
on hikikomori were conducted with 1660 participants aged
20–49 years in the WMHJ1 and 1776 participants aged 20–64 years
in the WMHJ2.
The proportions of those who had experienced hikikomori in
their lifetime were 1.2% (95% confidence interval [CI], 0.6–1.7) in
the WMHJ1 and 2.2% (95%CI, 1.6–3.0) in the WMHJ2. In addition,
460
2.9% (95%CI, 2.0–4.1) of 20–49-year-olds were defined as
hikikomori in the WMHJ2.30,31
The average age at start of hikikomori was 23.6 (SD = 10.4)
years in the WMHJ1 and 27.1 (SD = 9.9) years in the WMHJ2. Four-
teen men (2.0%) and five women (0.5%) had experienced hikikomori
in the WMHJ1, and 23 men (2.8%) and 16 women (1.7%) in the
WMHJ2. The average “withdrawal” period was 11.8 (SD = 9.3)
months in the WMHJ1 and 2.4 (SD = 4.0) years in the WMHJ2. Fif-
teen participants with hikikomori experience (78.9%) in the WMHJ1
and 19 (48.7%) in the WMHJ2 had suffered from irritation, embar-
rassment, or distress in relation to their hikikomori experience.
Among those who had experienced hikikomori, 12 (63.2%) in the
WMHJ1 and 25 (64.1%) in the WMHJ2 had met the psychiatric diag-
nostic criteria at least once in their lifetime. Prevalent comorbid disor-
ders were major depressive disorder and social phobia.
The prevalence of hikikomori has increased in the past 10 years.
Those who experience hikikomori tend to feel less distress, which
might prolong the duration of hikikomori.
Limitations
Although standardized interviews, such as the CIDI, improve the
quality of mental health epidemiological studies, accurate measure-
ment remains an issue. In addition to applying global standard diag-
nostic criteria to Asian countries, as mentioned above, many factors,
such as the response rate, the quality of interviewing, and partici-
pants’ perceptions of the interviewer, could affect the results.32 Fur-
thermore, a previous study showed that lifetime prevalence
approximately doubles when it is assessed prospectively, though it is
usually assessed retrospectively.33
Psychiatry and Clinical Neurosciences 73: 458–465, 2019
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Psychiatry and
PCN Clinical Neurosciences Prevalence of mental disorders in Japan

Table 3. Lifetime prevalence of suicide-related outcomes and mental disorders as risk factors for suicide-related outcomes

Ideation Plan Attempt

% SE % SE % SE
WMHJ1 10.9 0.5 2.1 0.3 1.9 0.3
WMHJ2 7.5 0.5 1.3 0.2 1.2 0.2
OR 95%CI OR 95%CI OR 95%CI
WMHJ1
Any mood disorders 5.5 2.9–10.6 6.9 2.1–22.3 19.4 7.6–49.0
Any anxiety disorders 3.3 1.8–5.9 5.9 2.6–13.2 5.1 2.6–10.1
Any substance use disorders 3.9 1.8–8.2 5.2 1.7–16.1 7.7 2.5–23.7
WMHJ2
Any mood disorders 3.0 1.9–4.8 6.7 2.9–15.3 4.3 1.7–10.7
Any anxiety disorders 3.8 2.2–6.2 1.3 0.4–4.3 4.6 1.7–12.0
Any substance use disorders 1.0 0.6–1.6 1.4 0.5–3.6 1.6 0.5–4.1

CI, confidence interval; OR, odds ratio; WMHJ1, World Mental Health Japan Survey First; WMHJ2, World Mental Health Japan Survey Second.

Trends of Mental Health Service Use
World Mental Health Survey
Twelve-month treatment was evaluated by asking the study partici-
pants whether they ever saw, either as outpatients or inpatients, any
professional or professionals on the list that they were provided for
problems with mental health, emotions, nerves, or alcohol or drug
use. Professionals were classified into the following three sectors
according to the services provided: mental health specialty (psychia-
trists, psychologists, other mental health professionals in any setting),
general medical care (other general medical doctor or nurse), and
non-health care (human services, such as religious provider; social
worker or counselor in a non-mental health setting; and complemen-
tary alternatives, such as Internet group, self-help group, or alternative
provider). The participants who had used any of these services within
12 months were placed in a category labeled ‘Any treatment’ while
those who did not seek treatment were categorized as ‘No treatment.’9
The percentage of those who had received any treatment within
12 months before the interview was 5.3% (SE was not reported)6 in
the WMHJ1 and 4.7% (SE 0.4)9 in the WMHJ2. The percentage of
those with any 12-month mental disorder who had received any treat-
ment within 12 months before the interview was greater in the
WMHJ2, specifically, 27.8% (SE 4.7) in the WMHJ1 and 33.6%
(SE 4.2) in the WMHJ2. The treatment rates at any health-care setting
for cases with serious and moderate CMD were greater in the
WMHJ2 (45.2% and 31.7%, respectively) compared to the MWHJ1
(37.0% and 17.5%, respectively), while this pattern was not clear for
mild cases (15.9% and 17.9% in the WMHJ1 and WMHJ2, respec-
tively).9 Treatment of 12-month mental disorders according to the
severity and sector of mental health services by sex is shown in
Table 4. The proportion of men with 12-month disorders receiving
any treatment, any health care, and any mental health care was much
higher in the WMHJ2 compared to the WMHJ1, while the proportion
among women did not increase. This trend was noted particularly in
men with disorders of moderate severity.
The development and implementation of relevant policies and
programs in Japan, such as community-based campaigns to alleviate

Table 4. Treatment of 12-month mental disorders according to severity and sector of mental health services in the WMHJ1 (n = 3868) and
WMHJ2 (n = 2450) by sex

Any treatment Any health care Mental health specialty General medical

Male Female Male Female Male Female Male Female

% SE % SE % SE % SE % SE % SE % SE % SE
WMHJ1
Any mental disorder 17.4 5.4 35.7 5.6 14.9 5.4 33.2 5.7 10.9 3.9 25.2 5.3 4.0 2.5 18.7 5.2
Severity
Severe 27.1 13.0 67.0 12.2 22.9 12.3 55.9 13.8 13.8 9.8 43.0 13.8 9.0 6.9 15.3 10.6
Moderate 14.7 6.1 23.4 5.4 12.7 5.8 20.4 5.0 9.2 4.7 19.9 5.0 5.7 4.2 12.9 4.5
Mild 9.3 4.6 21.0 7.3 9.3 4.6 20.5 7.3 8.3 4.6 10.4 4.8 3.4 2.7 16.8 7.0
WMHJ2
Any mental disorder 31.3 6.7 35.0 5.3 29.2 6.6 28.8 5.1 27.1 6.4 15.0 4.0 6.3 3.5 15.0 4.0
Severity
Severe 36.4 14.5 55.0 11.1 36.4 14.5 50.0 11.2 36.4 14.5 30.0 10.2 9.1 8.7 20.0 8.9
Moderate 50.0 12.5 28.0 9.0 43.8 12.4 24.0 8.5 43.8 12.4 12.0 6.5 6.3 6.1 16.0 7.3
Mild 14.3 7.6 28.6 7.6 14.3 7.6 20.0 6.8 9.5 6.4 8.6 4.7 4.8 4.6 11.4 5.4

WMHJ1, World Mental Health Japan Survey First; WMHJ2, World Mental Health Japan Survey Second.

Psychiatry and Clinical Neurosciences 73: 458–465, 2019 461

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Psychiatry and
Prevalence of mental disorders in Japan PCN Clinical Neurosciences

the stigma and to encourage people with mental disorders to use men-
tal health services through gatekeepers, might be effective mainly for
men. However, despite the increase in the rate of receiving treatment,
more than 65% of those who met the diagnostic criteria of CMD did
not use mental health services in Japan.
Comprehensive Survey of Living Conditions
The CSLC is a survey conducted by the Japanese government every
3 years. In this large-scale survey, all households (about 290 000
households within the 5410 National Census districts) and their
household members (about 710 000 people) randomly extracted from
the nationwide census are examined, and the response rate is typically
as high as 70% level.
The lack of structural interviews makes it impossible to examine
the prevalence of mental disorders in the CSLC. Instead of structural
interviews, psychological distress is measured by the Japanese version
of the Kessler Psychological Distress Scale (K6).34 Based on previous
studies, a score of ≥13 and a score between 5 and 12 on the K6 indi-
cates severe psychological distress and moderate psychological dis-
tress, respectively.35,36 The current use of mental health services was
assessed by asking whether the participants were seeing mental health
providers (medical doctors in any hospital or clinic) for their depres-
sion or other psychological problems at the time of the CSLC survey.
The proportion of those who had severe and moderate distress
was mostly unchanged, specifically, 4.0%–4.2% and 24.2%–24.9% in
Japan between 2007 and 2016, respectively.37 Compared to 2007,
mental health service use among those with moderate psychological
distress and severe psychological distress significantly increased in
2016 (2.6%–3.6% for those with moderate distress, P < 0.01; and
12.0%–15.8% for those with severe distress, P < 0.01). The propor-
tion of those with severe distress seeking treatment was highest
among 40–44-year-old women (24.6%), followed by 35–39-year-old
women (22.4%) as of 2016.38
Patient Survey
The Ministry of Health, Labour and Welfare conducted the Patient
Survey to clarify the actual condition of patients in medical institu-
tions and to obtain basic data for medical administration. Hospitals
were randomly selected by secondary medical care areas for inpatient
treatment and hospitals and clinics were randomly selected by prefec-
tures for outpatient treatment. The patients using the extracted medi-
cal institution were examined on a specified day in mid-October. The
total number of patients with a certain disease was calculated as ‘the
number of hospitalized patients + the number of outpatients at first
visit + the number of outpatients visiting again × average interval
(days) × adjustment factor (6/7).’11
The number of patients with depression increased by about 1.64
times, from 444 000 in 2003 to 729 000 in 2014.11 It should be noted
that the Patient Survey represents the number of patients at a specific
point in time, rather than the number of patients per year; hence their
prevalence rates could not be compared to 12-month prevalence rates
reported in regional epidemiological studies. Furthermore, diagnosis in
the Patient Survey corresponds to diagnostic practice, such as examina-
tion and medication in the health-insurance-claim information.
National Database of Health-Insurance-Claim
Information and Specified Medical Checkups
The data on all insurance treatments in Japan are accumulated in the
database of the Ministry of Health, Labour and Welfare as the
National Database of Health-Insurance-Claim Information and Speci-
fied Medical Checkups (NDB). It can be used to improve the quality
of medical services39 and the data on mental disorders have been
made available from the website of the Department of Mental Health
Policy, National Institute of Mental Health, National Center of Neu-
rology and Psychiatry, Japan.40
Only FY2015 and FY2016 data are currently available.
According to the NDB, the numbers of outpatients with
depression/manic depressive disorder were 3 098 966 in FY2015 and
3 173 355 in FY2016 (the number of those who received treatment
twice or more was 2 813 680 in FY2015 and 2 886 544 in FY2016).
Because the Patient Survey includes patients as of the survey date,
the number of patients that the NDB indicates is considerably larger.
It is worth noting that the NDB does not include patients who
receive treatment or examination without insurance, those who live
with livelihood protection, and those treated under the Medical
Treatment and Supervision Act. As with the Patient Survey, health-
insurance-claim information reports a diagnosis that corresponds to
the diagnostic practice. It is also necessary to consider the fact that a
disease name can remain on health-insurance-claim information even
after remission, and it can be listed even if it is not the main disease.
Cross-National Comparison of CMD Prevalence
The prevalence of CMD in Japan is not so different from that in
China, but it is much lower compared to that in the USA and Europe
(varying from 4.3% in Shanghai to 26.4% in the USA, with an inter-
quartile range of 9.1%–16.9%; Fig. 1).41 In particular, the prevalence

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462 Psychiatry and Clinical Neurosciences 73: 458–465, 2019

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Psychiatry and
PCN Clinical Neurosciences Prevalence of mental disorders in Japan

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ga

nz
ex
om

In

U
Br

Ja

ba

al

om

e
l

M
Bu

Ze
ol

Sh
Le

R
C

ew
Fig.2 Lifetime prevalence of bipolar disorders in 11 countries.

N
of CMD in the USA is approximately three times that of Japan.41 with increased stress sensitivity.44,45 Interestingly, however, people in
Regarding bipolar disorders, the results in Japan are nearly consistent collectivistic cultures, such as Japan, are more likely to carry the S
with the worldwide findings of a previous study showing that the life- allele.46 In other words, a greater population frequency of S allele car-
time prevalence of bipolar I disorder ranged from 0.0% to 1.0% riers might be associated with a decreased prevalence of CMD due to
(Fig. 2).15 increased cultural collectivism.46 Chiao and Blizinsky hypothesized
There could be several potential explanations. First, the partici- that greater vigilance to negative information in collectivistic cultures
pants in Asia might underreport psychiatric symptoms due to their might be useful for early detection of another person’s anger or fear
stigma against mental illness. The results of the CSLC may provide and advantageous to achieving collectivistic cultural norms, which
clues about this issue. As mentioned above, the ranges of severe and might prevent the onset of CMD.46
moderate distress were 4.0%–4.2% and 24.2%–24.9%, respectively, Third, current diagnostic tools, such as the ICD and the DSM,
in Japan between 2007 and 2016.37 These ratios seem to be slightly may not accurately evaluate psychiatric disorders in Asian countries.
higher compared to those for severe and moderate distress in the Although the Japanese version of the CIDI was appropriately vali-
USA, which were 2.9%–3.3% and 14.6%–16.5% between 2001 and dated, Kessler noted that ‘there is no guarantee that the same good
2012, respectively.42 The fact that face-to-face interviews conducted validity of the CIDI will be found in other parts of the world.’47
in the WMHJ yielded a relatively low prevalence of CMD while self-
report questionnaires conducted in the CSLC yielded relatively high
proportions of distress might suggest the possibility of Cross-National Comparison of Mental Health
underreporting. However, it is also known that the prevalence of diag- Service Use
nosable mental disorders is not always consistent with the prevalence The proportion of mental health service use by all persons and those
of subthreshold mental disorders.43 It is possible that countries with a with CMD was lower in Japan compared to most high-income coun-
lower prevalence of diagnosable mental disorders, like Japan, may tries from the 2000s to the 2010s. Specifically, the percentage of those
have a higher prevalence of subthreshold mental disorders. who received any mental health treatment in 10 high-income coun-
Second, culture–gene coevolution might explain the lower preva- tries was shown to range from 4.4% to 17.9% from 2001 to 2005,
lence of CMD in Japan. It is known that a serotonin transporter pro- and the proportion in Japan was the second lowest after Italy
moter polymorphism (5-HTTLPR) moderates the relationship (Fig. 3).48 Additionally, the 12-month treatment rate for CMD in
between stress and depression, and the short (S) allele is associated Japan (27.8% in the WMHJ1 and 33.6% in the WMHJ2; no

20
18
Mental health service use (%)

16
14
12
10
8
6
4
2
0
m

el

ly

SA
an

nd
c

pa

an

ai
Ita
ra
iu

an

Sp

U
lg

rla
Is

Ja

al
Fr
Be

er

Ze
he
G

Fig.3 Twelve-month mental health service use in 10 developed

et

ew
N

countries according to the World Mental Health Survey.

N

Psychiatry and Clinical Neurosciences 73: 458–465, 2019 463


Prevalence of mental disorders in Japan
statistically significant difference) was also lower than that in the
USA and Australia, which were reported to be: 41.1% from 2001 to
2003 in the USA49; and 37% in 2006–2007 and 46% in 2009–2010
in Australia.50
However, the proportion of mental health service use by those
with serious and moderate CMD in Japan seemed to increase in the
past 10 years. The treatment rates at any health care setting for seri-
ous and moderate CMD cases in the WMHJ2 (45.2% and 31.7%,
respectively) improved from the rates reported in the WMHJ1,9 and
the rates in the WMHJ2 were even close to the rates in the USA
(52.3% and 34.1%, respectively).41 More interestingly, our sex-
specific analysis of the treatment rates indicated a clear pattern for
men but not for women. This may be due to the nationwide awareness
and campaign aimed at the treatment for depression in Japan in the
past 10 years with an emphasis on the prevention of suicide among
men.51 Further effort should be made to improve the awareness and
treatment of CMD among both men and women in Japan.
Summary and Future Perspectives
This review has clarified that the prevalence of CMD in Japan has
been relatively stable in the past decade. The 12-month prevalence of
mental health service use has increased about 1.2 times to 1.6 times
in the past 10–15 years according to the results of the WMHJ1,
WMHJ2, CSLC, and the Patient Survey. Thus, it is very likely that
the rise in mental health service use contributes to the increase in the
number of patients. Whether the prevalence of depression has really
increased needs further research. Regarding cross-national compari-
son, the prevalence rate of CMD in Japan is not so different from that
in China, but it is much lower compared to rates in the USA and
Europe. The 12-month prevalence of mental health service use was
still lower in Japan compared to prevalence rates in other high-income
countries.
Epidemiological research has helped clarify that the prevalence
of CMD is unchanged, though mental health service use has
increased in high-income countries. In particular, previous studies did
not show clear changes in the prevalence of CMD in the USA, UK,
Australia, Canada, and Korea,52–56 while one study in the USA found
a more than twofold increase in the prevalence of major depressive
episodes between 1991 and 2002.57 Conventionally, the focus has
been on reducing treatment gaps to decrease the prevalence of mental
disorders. Meeting unmet needs is still a major issue, especially for
those who have severe mental disorders. However, previous studies
have shown that merely increasing the use of mental health service
and the use of antidepressant drugs does not lead to a decrease in the
prevalence of CMD.58 The importance of filling the gap in the quality
of treatment as well as the treatment gap in general should be empha-
sized. It is also critically important to provide evidence for the pre-
vention of CMD and disseminate it to fill the prevention gap.58
In addition, clarification of secular changes in prevalence is one
of the important roles of epidemiological research, because economic
situations, cultural changes, large-scale disasters, and other factors
could affect CMD prevalence and mental health service use. In rela-
tion to this, the results of the CSLC suggested that psychological dis-
tress in Fukushima prefecture significantly increased from 2010 to
2013 and was sustained through 2016,37 presumably caused by the
nuclear power plant accident following the Great East Japan Earth-
quake and tsunami in 2011. Long-term epidemiological monitoring is
necessary to understand the effect of specific events, such as large-
scale disasters, on mental health and to take measures for mental
health promotion.
Disclosure statement
Dr Nishi reports personal fees from VOYAGE GROUP, Inc., Startia,
Inc., en-power, Inc., Seiko Instruments Inc., and MD.net outside the
submitted work. Dr Ishikawa has nothing to disclose. Dr Kawakami
reports grants from Inforcom Corp, Fujistu Ltd., Fujitsu Software
Technologies Ltd., and SE@WORK; and personal fees from
464
14401819, 2019, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pcn.12894 by Cochrane Mexico, Wiley Online Library on [11/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Psychiatry and
PCN Clinical Neurosciences
Occupational Health Foundation, Japan Dental Association, Sekisui
Chemicals, Junpukai Health Care Center, SB@WORK, and Osaka
Chamber of Commerce and Industry outside the submitted work.
Author contributions
D.N. conceptualized this review. H.I. reanalyzed the data for Tables 1–
2, and 4. N.K. advised the data interpretation. D.N. drafted the first
manuscript. H.I. and N.K. revised the manuscript.
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