Gendered Vulnerability: LGBTQ+ & Psychological Impact

S H O R T C O M M U N I C A T I O N

Changes in suicide rates in disaster-stricken areas following the Great East Japan Earthquake and their effect on economic factors: an ecological study

Masatsugu Orui • Shuichiro Harada •

Mizuho Hayashi

Received: 12 May 2014 / Accepted: 1 September 2014 / Published online: 22 October 2014

� The Japanese Society for Hygiene 2014

Abstract

Objective Devastating disasters may increase suicide

rates due to mental distress. Previous domestic studies have

reported decreased suicide rates among men following

disasters. Few reports are available regarding factors

associated with disasters, making it difficult to discuss how

these events affect suicide rates. This study aimed to

observe changes in suicide rates in disaster-stricken and

neighboring areas following the Great East Japan Earth-

quake, and examine associations between suicide rates and

economic factors.

Methods Monthly suicide rates were observed from

March 2009 to February 2013, during which time the

earthquake occurred on March, 2011. Data were included

from disaster-stricken (Iwate, Miyagi, and Fukushima

Prefectures) and neighboring (control: Aomori, Akita, and

Yamagata Prefectures) areas. The association between

changes in suicide rates and economic variables was

evaluated based on the number of bankruptcy cases and

ratio of effective job offers.

Results In disaster-stricken areas, post-disaster male sui-

cide rates decreased during the 24 months following the

earthquake. This trend differed relative to control areas.

Female suicide rates increased during the first seven

months. Multiple regression analysis showed that bank-

ruptcy cases (b = 0.386, p = 0.038) and ratio of effective job offers (b = -0.445, p = 0.018) were only significantly associated with male post-disaster suicide rates in control

areas.

Conclusion Post-disaster suicide rates differed by gender

following the earthquake. Our findings suggest that con-

sidering gender differences might be important for devel-

oping future post-disaster suicide prevention measures.

This ecological study revealed that increasing effective job

offers and decreasing bankruptcy cases can affect protec-

tively male suicide rates in control areas.

Keywords Disaster � Earthquake � Suicide � Socioeconomic � Epidemiology

Introduction

The Great East Japan Earthquake occurred on March 11,

2011, with a magnitude of 9.0 and an epicenter approxi-

mately 130 km off the shore of Sanriku and east–southeast

of the Ojika Peninsula. This earthquake was the largest

ever recorded in Japan’s history. The earthquake generated

a massive tsunami, which reached a maximum height of

9.3 m. This disaster led to 15,859 deaths and 3,021 missing

people, with more than 90 % of deaths caused by drowning

and 65 % of deceased individuals being over the age of 60.

Approximately, 100,000 structures were demolished and

6,000 were partially destroyed [1].

The devastating nature of disasters and their aftermath are

known to cause psychological distress in affected individuals

[2, 3]. There have been growing numbers of studies con-

cerning post-disaster mental distress, including posttrau-

matic stress disorder (PTSD), depression, and suicidality [4,

5]. These studies suggest that mental health care is required

at an early stage following a disaster. In regards to the Great

East Japan Earthquake, many activities attributed to mental

health care teams have been reported, with a total of 3,498

mental health professionals having provided care within

M. Orui (&) � S. Harada � M. Hayashi Sendai City Mental Health and Welfare Center, 1-6

Sankyozawa, Aramaaki, Aoba-ku, Sendai 980-0845, Japan

e-mail: [email protected]

123

Environ Health Prev Med (2014) 19:459–466

DOI 10.1007/s12199-014-0418-2

disaster-stricken areas [6–10]. It is thought that suicide rates

in disaster-stricken areas may increase due to disaster-related

mental distress, which is significantly associated with mental

health problems and suicidal ideation among the general

population [11–14]. However, previous studies in Japan

relating to the Hanshin-Awaji and Niigata-Chuetsu earth-

quakes reported decreased male suicide rates for two to three

years following these disasters, while female suicide rates

increased or did not change significantly [15, 16]. Based on

this, it was assumed that changing suicide rates in disaster-

stricken areas of the Great East Japan Earthquake would

exhibit a similar trend to those reported in previous domestic

studies. However, few reports are available that detail factors

associated with such disasters, making it difficult to deter-

mine how these events affect suicide rates.

To implement effective suicide prevention measures

after disasters, this study aimed to (1) observe changes in

suicide rates in disaster-stricken and neighboring areas

following the Great East Japan Earthquake and (2) examine

associations between suicide rates and related factors.

Materials and methods

The Great East Japan Earthquake occurred at 14:46 Japan

Standard Time (JST) on March 11, 2011. The maximum

seismic intensity level reached 7 near the epicenter

(Fig. 1). In addition, the ensuing tsunami caused enormous

damage to the Pacific coast, specifically in Iwate, Miyagi,

and Fukushima Prefectures in the Tohoku region. In

addition to these areas, Hokkaido and other prefectures of

the Tohoku and Kanto region, including Tokyo, were

damaged by the earthquake, with several casualties.

However, the death toll and number of missing individuals

P ref. P opulat ion (million)

Age >65 (%) P ref.

P opulat ion (million)

Age >65 (%)

Iwat e 1.30 27.9 Aomori 1.35 27.0

Miyagi 2.32 22.9 Akit a 1.06 30.7

Fukushima 1.96 26.1 Yamagat a 1.15 28.3

Annual est imat ed populat ion dat a (Oct . 1, 2012)

Disast er-st ricken Neighboring (cont rol)

Fig. 1 Earthquake epicenter and disaster-stricken and neighboring (control) areas. The Great East Japan Earthquake occurred on March

11, 2011, with a magnitude of 9.0 and an epicenter approximately

130 km off the shore of Sanriku and east-southeast of the Ojika

Peninsula. The disaster-stricken area was defined as the region

comprising Iwate, Miyagi, and Fukushima Prefectures. The control

area was defined as the region comprising Aomori, Akita, and

Yamagata Prefectures

460 Environ Health Prev Med (2014) 19:459–466

123

within Iwate, Miyagi, and Fukushima Prefectures accoun-

ted for more than 99 % of the total casualties (white paper

on disaster management) (Table 1) [1]. Therefore, for this

study, the disaster-stricken area was defined as the region

comprising Iwate, Miyagi, and Fukushima Prefectures, and

the neighboring (control) area was defined as the region

comprising Aomori, Akita, and Yamagata Prefectures,

based on the inclusion of these prefectures in the Tohoku

region, which also includes the disaster-stricken areas.

Notably, the populations and proportions of elderly resi-

dents in neighboring (control) areas did not differ greatly

from those in disaster-stricken areas (Fig. 1). Changes in

suicide rates were observed during each of the 48 months

from March 2009 to February 2013.

To evaluate associations between suicide rates and related

factors, the following economic variables were used:

monthly number of bankruptcy cases per 100,000 people and

monthly ratio of effective job offers. After the 2008 global

economic crisis, male suicide rates increased in 2009 in

European and American countries [17]. Since economic

trends are thought to be intimately and immediately related

to suicide rates, we chose these variables as economic factors

potentially related to changing suicide rates.

Data sets

Monthly suicide data (ICD-10 codes X60–X84) were col-

lected both nationally and across six prefectures in the

disaster-stricken and control areas. Data were provided by

the Ministry of Health, Labor, and Welfare [18]. Annual

estimated population data were also collected annually on

October 1st for each prefecture by the Ministry of Internal

Affairs and Communications Statistics Bureau [19]. To

more accurately observe changes in suicide rates, this study

used a 12-month centralized moving average of suicide

rates, to remove seasonal differences.

These economic variables were chosen based on their

use by local governments as main indicators of economic

status, as well as the ability to obtain these data every

month. Moreover, previous domestic studies reported

associations between suicide rates and the number of job

applicants and bankruptcy rates [20, 21]. The numbers of

bankruptcy cases were obtained from Tokyo Shoko

Research, Ltd., and the ratios of effective job offers were

reported by local employment security offices. Employ-

ment security offices included public facilities in which job

introductions and job application registrations are con-

ducted. Numbers of bankruptcy cases were adjusted for

seasonal variation using a 12-month centralized moving

average. The ratios of effective job offers were already

adjusted for seasonal variation.

Monthly suicide data and economic data (Table 2) were

obtained from open-access websites as unlinkable, anony-

mous data. According to epidemiological research guide-

lines set forth by the Ministry of Education, Culture,

Sports, Science and Technology and the Ministry of

Health, Labor and Welfare, ecological studies are exempt

from ethical review. Accordingly, review by an ethics

committee was not necessary.

Data analysis

Forty-eight months of suicide rate data were divided into

pre-disaster (March 2009 to February 2011) and post-

disaster (March 2011 to February 2013) periods. Changes

in suicide rates from the previous month were compared

using a Poisson distribution test. Univariate and multiple

regression analyses were performed using monthly pre- and

post-disaster suicide rates as dependent variables, and

economic factors as independent variables. Before uni-

variate regression analysis was performed, monthly suicide

rates and economic variables were converted by logarith-

mic transformation. Subsequently, differences from the

previous month [difference = log(Xt)-log(Xt-1)] were cal-

culated. Because economic data often follow a random

walk and show non-stationarity, these data have undesir-

able properties for regression analysis. Statistical signifi-

cance was evaluated using two-sided, design-based tests

with a 5 % level of significance. Statistical analyses were

performed using Ekuseru-Toukei 2012 (Social Survey

Research Information Co., Ltd. Tokyo, Japan).

Table 1 The death toll and number of missing individuals in the Great East Japan Earthquake

Regions Prefectures Death tolls Missing

individuals

Hokkaido Hokkaido 1 0

Tohoku Region Iwate 4,671 1,222

Miyagi 9,517 1,581

Fukushima 1,605 214

Aomori 3 1

Akita 0 0

Yamagata 2 0

Kanto Ibaraki 24 1

Tochigi 4 0

Gunma 1 0

Saitama 0 0

Chiba 20 2

Tokyo 7 0

Kanagawa 4 0

As of 30 May 2012

Cabinet Office, Government of Japan. White paper on Disaster

Management

Environ Health Prev Med (2014) 19:459–466 461

123

Results

Changes in suicide rates in disaster-stricken and control

areas

Changes in suicide rates in disaster-stricken and control areas

are shown in Fig. 2. Pre-disaster male suicide rates in both

areas were higher than the national average. Female suicide

rates in disaster-stricken areas varied similarly, as compared

to the national average. Post-disaster male suicide rates in

disaster-stricken areas decreased during the 24 months fol-

lowing the earthquake, despite a slight increase in suicide rates

during the fifth through seventh months after the earthquake.

In contrast, post-disaster female suicide rates increased fol-

lowing the earthquake with no significant change (suicide

rates per 100,000 of 14.3 in Feb 2011 vs. 14.9 in Mar 2011,

Poison distribution test, p = 0.482) and remained high for

7 months, while suicide rates in control areas decreased. Post-

disaster male suicide rates decreased during the first

12 months following the earthquake not only in disaster-

stricken areas, but also in control areas. However, this rate

increased during post-disaster months 13–20 in control areas.

Associations between pre- and post-disaster suicide

rates and economic variables

Changes in economic variables in both disaster-stricken and

control areas are shown in Fig. 3. Associations between pre-

and post-disaster suicide rates and economic variables are

shown in Tables 3 and 4. Correlations between monthly

suicide rates and economic variables were examined based on

each variable to confirm multicollinearity. As a result, all

correlation coefficients between the variables were below 0.50

(data not shown). In these univariate and multiple regression

models, if the regression coefficient is positive, suicide rates

would increase under situations increasing values of eco-

nomic factors. And if the coefficient is negative, the rates

would decrease under situations increasing the values. Uni-

variate regression analysis showed that the number of bank-

ruptcy cases per 100,000 people (b = 0.411, p = 0.046), and the ratio of effective job offers (Regression coefficient

b = -0.467, p = 0.022), were only significantly associated with male suicide rates in post-disaster control areas. No

significant associations were found between economic vari-

ables and monthly suicide rates for males in disaster-stricken

areas, or females in both areas. Multiple regression analysis

showed that the number of bankruptcy cases per 100,000

people (b = 0.386, p = 0.038) and ratio of effective job offers (b = -0.445, p = 0.018) were significantly associated with male suicide rates in control areas (coefficient of deter-

mination, R 2

= 0.366). However, for males in disaster-

stricken areas and females in both areas, multiple regression

analysis revealed no significant associations between eco-

nomic variables and monthly suicide rates.

Discussion

In this study, we found that male suicide rates in disaster-

stricken areas decreased more than those in control areas

Table 2 Characteristic of monthly suicide rates and

economic variables

SD standard deviation, Disaster-

stricken areas Iwate, Miyagi,

and Fukushima, Neighboring

(control) areas Aomori, Akita,

and Yamagata

Suicide rates per 100,000

populations (male)

Suicide rates per 100,000

populations (female)

Mean (SD) Mean (SD)

Pre-disaster

(2009.3–2011.2)

Post-disaster

(2011.3–2013.2)

Pre-disaster

(2009.3–2011.2)

Post-disaster

(2011.3–2013.2)

Disaster-stricken

areas

33.2 (2.4) 27.5 (1.6) 11.5 (0.4) 11.3 (0.9)

Neighboring

(control) areas

38.4 (2.5) 32.1 (1.6) 14.0 (0.5) 12.5 (0.4)

National 28.9 (1.0) 26.0 (1.0) 11.0 (0.3) 10.8 (0.6)

Number of bankruptcy case

per 100,000 populations

Ratio of effective job offers

Mean (SD) Mean (SD)

Pre-disaster

(2009.3–2011.2)

Post-disaster

(2011.3–2013.2)

Pre-disaster

(2009.3–2011.2)

Post-disaster

(2011.3–2013.2)

Disaster-stricken

areas

0.55 (0.06) 0.30 (0.07) 0.41 (0.07) 0.84 (0.23)

Neighboring

(control) areas

0.62 (0.08) 0.45 (0.03) 0.38 (0.07) 0.63 (0.10)

National 0.93 (0.07) 0.81 (0.33) 0.50 (0.06) 0.74 (0.08)

462 Environ Health Prev Med (2014) 19:459–466

123

during the 24 months following the Great East Japan

Earthquake, reaching the same level as the national aver-

age. In contrast, female suicide rates in disaster-stricken

areas increased with no significant changes following the

earthquake, while suicide rates in control areas decreased.

Gender-dependent changes in suicide rates in disaster-

stricken areas as observed in the present study were also

consistent with those from previous studies in Kobe City

and Niigata-Chuetsu [15, 16]. A previous study, conducted

in Kobe City, Japan (the disaster-stricken area of the 1995

Hanshin-Awaji Earthquake), reported that male suicide

rates decreased significantly two years post-disaster,

whereas female suicide rates did not significantly change

[15]. Likewise, male suicide rates in the Chuetsu region of

Niigata decreased, while female suicide rates increased,

during the 3-year period following the 2004 Niigata-

Chuetsu Earthquake [16]. Moreover, studies in Taiwan

revealed that suicide rates increased significantly following

a major earthquake, with female suicide rates increasing

immediately, and male suicide rates showing a delayed

increase [22]. Gender differences observed in post-disaster

suicide rates have important implications. Notably, female

suicide rates increased in disaster-stricken areas during the

first 7 months following the Great East Japan Earthquake.

In general, women have a lower risk of committing suicide

than men, but could potentially become a high-risk group

after earthquakes. The findings of this study suggest the

importance of considering gender differences in suicide

rates when implementing suicide prevention measures after

disasters.

36.6

33.4 30.2

44.5

36.5 35.4

30.5 31.8

49.8

42.4

35.8 39.4 38.3

0.0

10.0

20.0

30.0

40.0

50.0

60.0 Suicide rates (men)

Neighboring (control) area

Disaster-stricken area

earthquake

National

Suicide rates (the annualized rate)

13.4 12.4

14.6 14.3

14.9 14.9

12.2 12.8

17.4

15.4 14.2

0.0

4.0

8.0

12.0

16.0

20.0

2009.3 2010.3 2011.3 2012.3 2013.2

Suicide rates (Women)

National Disaster-stricken Neighboring (control)

Neighboring (control) area

Disaster-stricken area

earthquake

Suicide rates (the annualized

National

Suicide rates (annualized rate): monthly suicide number/population* 100,000* 12

2009.3 2010.3 2011.3 2012.3 2013.2

Disaster-stricken areas: Iwate, Miyagi, and Fukushima Neighboring (control) areas: Aomori, Akita, and Yamagata

Fig. 2 Changes in suicide rate trends in disaster-stricken and

neighboring (control) areas.

Suicide rate trends in disaster-

stricken and control areas are

shown. Suicide rates are

depicted per 100,000 people.

The down arrow corresponds to

the occurrence of the Great East

Japan Earthquake

Environ Health Prev Med (2014) 19:459–466 463

123

Disaster-stricken areas: Iwate, Miyagi, and Fukushima Neighboring (control) areas: Aomori, Akita, and Yamagata

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

2009.3 2010.3 2011.3 2012.3 2013.2

Number of bankruptcy cases

Neighboring areas

Disaster-stricken areas

earthquakeNational

/ 100,000 populations

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

2009.3 2010.3 2011.3 2012.3 2013.2

Ratio of effective job offers

National Disaster-stricken Neighboring (control)

Neighboring

Disaster-stricken areas

earthquake

total number of job offers / applicants

National

Fig. 3 Changes in economic variables in disaster-stricken

and neighboring (control) areas.

The number of bankruptcy cases

per 100,000 people and ratio of

effective job offers in disaster-

stricken and control areas are

shown. The down arrow

corresponds to the occurrence of

the Great East Japan Earthquake

Table 3 Univariate regression analysis between suicide rates and economic variables

Number of bankruptcy case per 100,000 populations Ratio of effective job offers

Pre-disaster

(2009.3–2011.2)

Post-disaster

(2011.3–2013.2)

Pre-disaster

(2009.3–2011.2)

Post-disaster

(2011.3–2013.2)

b p-value b p-value b p-value b p-value

Men

Disaster-stricken areas 0.037 0.862 0.325 0.121 -0.234 0.272 -0.200 0.348

Neighboring (control) areas 0.046 0.832 0.411 0.046 -0.032 0.882 20.467 0.022

Women

Disaster-stricken areas 0.206 0.333 0.358 0.086 0.175 0.413 -0.271 0.201

Neighboring (control) areas -0.180 0.399 0.327 0.119 -0.137 0.522 -0.043 0.841

b Standardized partial regression coefficient, Disaster-stricken areas Iwate, Miyagi, and Fukushima, Neighboring (control) areas Aomori, Akita, and Yamagata

Italic: p \ 0.05

464 Environ Health Prev Med (2014) 19:459–466

123

To investigate factors related to suicide rates, the asso-

ciation between monthly suicide rates and economic vari-

ables was examined. This analysis revealed that the number

of bankruptcy cases per 100,000 people and ratio of

effective job offers were only significantly associated with

male suicide rates in post-disaster control areas. Aihara

et al. reported that the number of job applicants, bank-

ruptcy rate, and amount of savings per household were

significantly associated with male suicide rates [18]. Fur-

thermore, Yamasaki et al. reported that socioeconomic

variables, such as low income or unemployment, were

important determinants of suicide rates among Japanese

men [19]. A previous study on the Niigata-Chuetsu

Earthquake reported that economic conditions in the

disaster area improved due to temporary government

financial aid [16]. Economic conditions following the Great

East Japan Earthquake, including higher ratios of effective

job offers and lower numbers of bankruptcy cases,

improved in both disaster-stricken and control areas due to

the emerging demand for disaster-recovery services (i.e.,

construction and waste disposal) [23]. Given that a stable

economic status is a protective factor against suicide,

increasing effective job offers and decreasing bankruptcy

cases were assumed to have affected the suicide rates.

However, the goodness of fit in this regression model was

low (male, R 2

= 0.112; female R 2

= 0.148) in the disaster-

stricken area. Thus, post-disaster suicide rates in disaster-

stricken areas may be associated with other factors, such as

mental health care activity, which may have a greater

impact on changes in suicide rates.

The present study has several limitations worth noting.

First, the disaster-stricken and control areas had the highest

suicide rates in Japan. In this context, suicide rates in Japan

increased sharply in 1988 and have remained relatively

high ever since. Given this trend, many continuous suicide

prevention measures had already been implemented for a

decade before the earthquake occurred. These efforts may

have influenced the observed changes in suicide rates.

Despite the devastating disaster, an important point is that

male suicide rates in the disaster-stricken area decreased

continuously after the earthquake occurred with rates

eventually reaching the national average. Secondly, some

earthquake victims were evacuated from the disaster-

stricken areas due to the earthquake. This relocation may

have affected the findings by changing post-disaster suicide

rates in each prefecture. However, the Reconstruction

Agency reported that 75 % of earthquake victims had been

evacuated within Iwate, Miyagi and Fukushima Prefec-

tures, as of February 2013 [24]. Therefore, the findings of

this study can only be considered reliable to a certain

extent. Thirdly, additional variables may be associated with

changes in suicide rates. It can thus be assumed that social

factors such as voluntary community networks, relation-

ships based on trust [25, 26], mental health care services

provided to the disaster-stricken population by mental

health specialists, and other public health services, are

protective factors against suicide. Unfortunately, no quan-

titative monthly data on these variables were available at

the prefectural level. Fourthly, the economic variables

selected in this study may not be adequate; however, we

chose these variables because they could be obtained on a

monthly basis at the prefectural level. Lastly, the ecological

study design did not allow the determination of the cause of

changes in suicide rates. Certainly, mental and physical

health condition, past history of suicide attempts, lifestyle,

economic status, and others are important risk factors for

suicide [27]; unfortunately, these data for individuals were

not readily available. Further studies, which take into

consideration such data, will be needed to examine the

cause of changing suicide rates.

Table 4 Multiple regression analysis between suicide rates and economic variables

Pre-disaster (2009.3–2011.2) Post-disaster (2011.3–2013.2)

Number of bankruptcy

case per 100,000

populations

Ratio of effective

job offers

R 2

Number of bankruptcy

case per 100,000

populations

Ratio of effective

job offers

R 2

b p-value b p-value b p-value b p-value

Men

Disaster-stricken areas 0.181 0.450 -0.316 0.193 0.080 0.291 0.207 -0.086 0.705 0.112

Neighboring (control) areas 0.062 0.790 -0.051 0.825 0.004 0.386 0.038 20.445 0.018 0.366

Women

Disaster-stricken areas 0.160 0.510 0.103 0.671 0.051 0.297 0.189 -0.154 0.490 0.148

Neighboring (control) areas -0.152 0.506 -0.090 0.693 0.040 0.325 0.130 -0.024 0.907 0.107

b Standardised partial regression coefficient, R2 coefficient of determination, Disaster-stricken areas Iwate, Miyagi, and Fukushima, Neigh- boring (control) areas Aomori, Akita, and Yamagata

Italic: p \ 0.05

Environ Health Prev Med (2014) 19:459–466 465

123

In conclusion, post-disaster suicide rates in disaster-

stricken areas decreased among men during the 24 months

following the earthquake, and increased for females during

the first seven post-disaster months. Economic variables

(number of bankruptcy cases and ratio of effective job

offers) were not significantly associated with suicide rates

in disaster-stricken areas. Despite the limitations of the

present study, the findings regarding gender differences in

post-disaster suicide rates will contribute to public health

efforts aimed at post-disaster suicide prevention. Given that

this study did not find an association between changing

suicide rates and the selected economic variables, further

studies will be needed to clarify the reasons underlying

changing suicide rates. Previous domestic studies, which

showed decreased male suicide rates following devastating

earthquakes, are limited to a period of two to three years

after a disaster [15, 16], and have reported that suicide rates

increase after 3 years in both genders [15]. Long-term

suicide rate trends must be tracked carefully to implement

adequate suicide prevention measures.

Acknowledgments This study was supported by a Grant from the Sendai City Public Health Research Project.

Conflict of interest The authors have no conflicts of interest to declare.

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