Risk factors for psychological distress in the general population of Japan: A nationally representative survey

doi:10.21203/rs.3.rs-2714829/v1

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Risk factors for psychological distress in the general population of Japan: A nationally representative survey

https://doi.org/10.21203/rs.3.rs-2714829/v1

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Background

Psychological distress in the general population in Japan has not been analyzed. This study is the first to examine risk factors for psychological distress in the general population using official statistics available to researchers.

Methods

The anonymous data of the 2013 National Survey of Living Conditions were used. Binomial logistic analysis was conducted incorporating age, marital status, living arrangements, education, household income, working status, smoking, and drinking as independent variables and the low and high-risk groups for psychological distress (K6 scale) as dependent variables, differentiating by gender.

Results

The odds ratios (OR)were lower for both genders aged 60 years and older (men, 0.21–0.23; women, 0.28–0.40), while they were higher for respondents of both genders who were unemployed (men, 3.16; women, 3.42). In addition, never-married (1.65), being in the third-highest household income quantile (1.71), doing mainly housework (2.66) and abstainers from alcohol (1.70) among men and having a middle level of education (1.58), receiving the lowest quantile of household income (1.54), and smoking (1.91) among women were risk factors that increased the odds ratios. By contrast, moderate drinker (0.51) and abstainer (0.64) were risk factors that decreased the odds ratio for women.

Conclusions

For the first time, the risk factors for psychological distress in a general population were identified using nationally representative survey data. Further studies are needed to analyze the above high-risk groups to identify reasonable measures for mental health promotion. We hope this current study will lead to further study in Japan.

Psychological Distress

Japan

general population

To the best of our knowledge, psychological distress in the general population in Japan has not been analyzed, and this study is the first of its kind. This study investigated the risk factors for psychological distress in the general population of Japan. For this purpose, we analyzed Japanese official statistics that are available to researchers, including variables for psychological distress.

Adverse socioeconomic circumstances can seriously affect health and wellbeing, and health inequality therefore is a major public health concern around the world.[1] [2] Mental health is influenced by a combination of genetic, developmental, environmental, and socioeconomic factors, such as age, gender, education, income, stigma, and ethnicity.[3] [4] In Japan, however, few surveys have been performed in the general population, with the exception of two (The World Mental Health Surveys 1 and 2[5]) and two sets of official governmental statistics (Patient Survey[6] and Comprehensive Survey of Living Conditions, CSLC[7]). This has been attributed in part to Japan’s status as among the healthiest and most egalitarian nations in the world, with social inequalities not strongly expressed within the population.[8, 9] Moreover, the use of these data for research purposes has been very limited. However, the situation has been gradually changing since 2011, when the Ministry of Health, Labor, and Welfare (MHLW) began providing anonymized data of the CSLC,[10] including data on psychological distress in the general population. The purpose of the CSLC is to obtain the basic data necessary for the MHLW’s planning and administration by examining basic features of people’s lives, including their health, medical care, welfare, pensions, and income. These anonymous data are then provided to researchers in accordance with the Statistics Law in Japan. That is, data are only provided if the study is recognized as contributing to the development of academic research and education. So far, few studies have been conducted on psychological distress using nationally representative data in Japan. This study was conducted to identify groups that are at high-risk for psychological distress in the general population in Japan, using the 2013 CSLC anonymous data.

In this study, we compared risk factors between low- and high-risk groups for psychological distress using anonymous data from the anonymous data of the 2013 CSLC.[7] [10] This survey collects household and income status annually and household, health, and savings every 3 years. More than 5000 districts were chosen for surveying through stratified random sampling. All households in the districts were subjected to the survey. In 2013, the response rate was 74.4%. Overall, the data of 16,262 individuals were obtained.

Psychological Distress Evaluation

The Japanese version of the K6[11] was used for the psychological distress evaluation (independent variable) included in the 2013 CSLC anonymous data; the K6 questionnaire is used to identify possible mental disorders, such as depression and anxiety disorders. Respondents are asked the following six questions with reference to the previous 30 days: (1) "During the past 30 days, how often did you feel nervous?” (2) “hopeless?” (3) “restless or fidgety?” (4) “so depressed that nothing could cheer you up?” (5) “that everything was an effort?” and (6) “worthless?” The respondents were asked to respond to the six questions on a 5-point scale, as follows “None of the time” (0 point), “A little of the time,” (1 point), “Some of the time” (2 points), “Most of the time” (3 points), and “All of the time” (4 points). Following a previous study,[11] we defined the high-risk group as having a K6 score of 13 or higher and the low-risk group as having a K6 score of 4 or lower.

Possible Risk Factors

For possible risk factors (independent variables) for psychological distress, we selected Age, Marital status, Living arrangements, Education level, Household income quartile, Working status, Smoking status, and Drinking status, following using previous studies.[8] [9] [12]^–[13]

The subjects were classified into 8 age groups (20–29, 30–39, 40–49, 50–59, 60–69, 70–79, 80–89, and 90+) in 10-year age increments. Marital status was classified into four categories: married, never-married, divorced, and widowed. Divorced and widowed statuses were combined into one because the number of widows was small. Living arrangements were classified into two categories based on the number of household members: living alone and living with others. The six education levels were further grouped into three categories: low level of education (elementary school, middle school, and below), middle level of education (high school, vocational school, two-year college, and technical college), and high level of education (four-year university, graduate school, and above). Those whose level of education was not known were classified as Unknown. Household income was classified into four quartiles, Q1 (top 25% of income), Q2, Q3, and Q4 (bottom 25% of income). Working status was classified into four categories: mainly working, mainly housework, mainly in school, and unemployed. Smoking status was categorized as smoker (daily or occasional smoker), nonsmoker (former smoker or never smoked), or Unknown. Drinking status was classified following previous studies[12] as heavy drinker (more than about 44 g alcohol per day), moderate drinker (less than about 44 g alcohol per day), and abstainer (never drinker or currently non-drinker).

Statistical Analysis

Subjects for whom data on some independent and dependent variables were not available were excluded from the analysis. In addition, subjects with a K6 score of 5 to 12 (moderate-risk group), and subjects under the age of 20, who were not of legal drinking or smoking age at the time of the survey, were excluded from the analysis.

First, descriptive statistics were established for the above independent variables by gender. Then, a binomial logistic regression model (forced entry method) was used to analyze the high- and low-risk groups by gender, and adjusted odds ratios were calculated for each independent variable. All statistical analyses were performed using SPSS ver. 29.0 with a significance level of p < 0.05.

Ethics

The 2013 CSLC anonymous data included no identifying information for any individual. For research purposes, MHLW provides anonymous data upon application and approval via website (https://www.mhlw.go.jp/toukei/itaku/tokumei.html). And the MHLW does not require any approval of the ethics committee on the publication of the results.

Figure 1 shows a flowchart of subject sampling. In all, data from 7,538 subjects were used in the analysis.

Figure 1　Flowchart of the study subjects.

Table 1 presents the basic characteristics of the subjects by gender for the high- and low-risk groups.

Table 1 Basic characteristics of the participants for each drinking status and sex.

Figure 2 Results of multinominal logistic regression for men and women.

Table 2 and Figure 2 present the results of the binomial logistic regression analysis for psychological distress and the risk factors in men and women. For men, 3,620 participants in the low-risk group and 172 participants in the high-risk group were entered into the final analysis. The factors with the highest odds ratios were: never-married (OR=1.65), third quantile of household income (OR=1.71), mainly housework (OR=2.66), unemployed (OR=3.16). and abstainer (OR=1.70). The lowest odds ratios were for 60–69 years old (OR=0.23), 70–79 years old (OR=0.27), and 80–89 years old (OR=0.21).

Data from 3,498 women in the low-risk group and 248 in the high-risk group were entered into the analysis. The factors with the highest odds ratios were education level (middle) (OR = 1.58), unemployed (OR = 3.41), and smoker (OR = 1.92). The lowest odds ratios were for 60–69 years old (OR = 0.28), 70–79 years old (OR = 0.40), moderate drinker (OR = 0.51), and abstainer (OR = 0.64).

Table 2 Results of multinominal logistic regression analysis for men　and women.

The risk factors for psychological distress in the general Japanese population were analyzed using nationally representative survey data. Each risk factor is discussed in the following.

<Age>

For both men and women, the odds ratios were lower for those aged 60 and older. Most mental disorders begin in childhood or adolescence.[14] While the risk for dementia and other mental disorders increases with age, the relative reduction in psychological distress may be due to the relative freedom experienced after work and childbearing are complete. However, psychological distress increases for the elderly due to the greater likelihood of adverse life events, such as bereavement and illness or care for a family member. In fact, in almost all regions of the world, mortality rates by suicide are the highest for those over the age of 70, both men and women.[15] [16] In Japan in particular, this result may be because Japan has a long life expectancy and a public healthcare system that is less burdensome for the elderly. It is necessary to explore the reasons why psychological distress seems to be lower among the Japanese elderly in a future study.

<Marital status>

Among men, the odds ratio was higher in the never-married group, but among women, there was no change by marital status. This result is consistent with the findings of several previous studies. Using national statistical data from 1998, Inaba examined the association between sociodemographic characteristics and distress and between marital status and distress. The relation between marital status and distress by gender showed that unmarried men's distress was significantly higher than married men's, but such was not the case with women. Thus, Inaba found that marriage provided greater psychological benefits to men in general.[17] In addition, Suemori found that marital status and family relationship status were associated with psychological distress for men, but no such associations were found for women.[18] According to the National Institute of Population and Social Security Research, the lifetime never-married rate for men has increased 6.5-fold from 3.9% in 1985 to 25.7% in 2020, and for women, it has increased 3.5-fold from 4.3% to 14.9%; that report predicts that by 2040, 30% of men and 20% of women will live their entire lives unmarried.[19] If the number of never-married men continues to increase, it might be necessary to follow up on them as an emerging high-risk group.

＜Living Arrangements＞

Living arrangements (living alone or living with others) were not related to psychological distress for either men or women. The Japanese Census reported that the number of persons per household decreased from 4.14 in 1960 to 2.33 in 2015. The percentage of single-person households increased from 16.5% in 1960 to 34.5% in 2015.[20] On the other hand, earlier U.S. studies have shown that social isolation and loneliness increase the risk of mental disorders.[21, 22] [23] Therefore, although this present study did not identify an association, the link between declining household size and psychological distress in Japan should be examined with due care. In addition, it is important to consider not only the binary analysis of single and cohabiting households but also to decompose households into single-person households of the elderly, of students, of workers posted to work alone, and so on. Additional analysis is needed to determine if this trend is limited to Japan or if a detailed analysis would reveal a similar trend elsewhere.

<Education level>

The odds ratio did not change for men at all across education levels, but it was higher for women with a middle level of education. In general, the higher the level of education, the better the mental health status. For example, Lorant et al. conducted a meta-analysis from 56 epidemiological studies and found that socioeconomically disadvantaged individuals have an 80 percent greater risk of having depression. They reported that a dose-response relation was observed for education and income.[24] Niemyer et al. also found that lower education was associated with a lack of psychosocial resources, which, along with daily hassles, was a pathway between education and depressive symptoms and positive mental health.[25] Okui observed a clear gradient by educational level across almost all age groups for the prevalence of psychological distress in Japan, using his analytical model with the 2019 CSLC.[26] In this study, the association between educational level and psychological distress was not very clear except among women with a middle level of education. Women with a high level of education may not have shown a statistically significant difference due to the low numbers of this population. Yamada[27] noted that Japanese women at the middle level of education tend to be non-married because of their high expectations of their desired husband's income and educational　background. This may have influenced the increase in the odds ratio of women in middle level education.

<Household income quantile>

Using Q4 (top 25% of income quantile) as a reference, the odds ratios of 　Q3 for men and Q1 for women was found to be statistically significant. As noted, socioeconomic status, including income, is generally associated with psychological distress.[24] Tsutsumi et al. reported that the risk of mental health problems (odds ratio adjusted for attributes and employment status) for male low-income workers in Japan was 1.26, and it was 1.62 for women.[28] Furthermore, in a prospective cohort study using the Belgian Household Panel Survey (1992–1999), Lorant et al. found that a lower material standard of living was associated with an increased incidence of depressive symptoms and major depression.[29] Using the 2013 CSLC, Nishikitani showed that improving low incomes for nonregular employees could improve health challenges, but income alone would not result in the same health status for regular and nonregular employees.[30] The results of that study, while they were not all statistically significant, showed a similar trend for women but not for men. Whether the present results mark a temporary phenomenon needs to be clarified in future studies.

<Working status>

The odds ratio for unemployed was high for both men and women. The odds ratio for mainly housework was high for men. The former result is in line with previous studies: Paul et al. used meta-analytic methods to examine the effects of unemployment on mental health in 237 cross-sectional and 87 longitudinal studies, finding that unemployed persons exhibit more distress than employed persons do.[31] In a public opinion survey conducted by the Cabinet Office in Japan, 51.6% of respondents in 2012 and 44.6% in 2014 agreed with the notion that “husbands should work outside the home and wives should take care of the home.”[32] The high odds ratio for mainly housework may be due to this normative attitude regarding the gender role division of labor that is prevalent in Japan. To improve gender equality, the Japanese government is continuing its policy of encouraging men to participate in housework and childrearing. According to the same survey, husbands with children under the age of six have increased the time they spent on housework and childcare from 38 minutes per day in 1996 to 60 minutes in 2006, 67 minutes in 2011, and 83 minutes in 2016.[19] It will be interesting to see whether psychological distress improves with future shifts in the division of gender roles in work attitudes.

<Smoking status>

The odds ratio for smoking status was only high among female smokers. According to the National Nutrition and Health Survey, the smoking rate in Japan in 2013 was 32.1% for men and 8.2% for women. Among men, smoking has seen a decreasing trend since 1995 among those in their 20s to 60s, while a gradual downward trend has been seen among women since 2004, with an increasing trend among those in their 50s.[33] Although many studies have shown the negative health effects of smoking,[34] meta-analyses show that smoking cessation is associated with reduced depression, anxiety, stress, and improved positive mood and quality of life compared to continuing smoking.[35] Tomioka found nearly the same result using the 2013 CSLC.[36] Further policy interventions should be considered for female smokers.

<Drinking status>

This study suggests a trend toward higher odds ratios for male abstainers with lower odds ratios for female abstainers and moderate drinkers. Using the 2013 CSLC, Midorikawa reported that being in the high-risk drinking group was significantly associated with having worse mental health among people aged 65 over.[37] Akechi reported that in a prospective cohort study in Japan, the multivariate relative risk with 95% CI of suicide was 2.3 (1.2–4.6) and 2.3 (1.2–4.7) for abstainers and regular heavy drinkers, respectively, compared with occasional drinkers. Akechi noted a U-shaped association between alcohol consumption and subsequent suicide.[13] By contrast, this study suggested a similar trend toward decreased psychological stress for female abstainers and moderate drinkers, while the opposite trend was found for men. In short, contradictory correlations were found between drinking and psychological distress across genders. Further study is needed to investigate this difference.

According to a study by Nishi, the prevalence of psychological distress (K6) in Japan remained unchanged from 2007 to 2016 or even slightly increased in that period using the CSLC, despite an observed increase in the use of mental health services.[38] As Nishi noted, further studies are needed to identify the socioeconomic factors that support the use of vulnerable demographic groups to take reasonable measures for mental health promotion. We hope that this study will lead in this direction in Japan.

Limitations

This study had the following limitations. Only correlations between independent and dependent variables were analyzed, and causality was not investigated. Second, as the data were drawn from a self-administered questionnaire, responses may be imprecise. Third, cases with missing variables were excluded from the analysis, which may have affected the results of the study. Fourth, because drinking and smoking status were selected as independent variables, the analysis excluded subjects under 20 years of age from the general population, as they were not of legal age. Fifth, CSLC does not include questions about ethnicity, so it was not selected as the independent variable, while non-Japanese aliens were only 1.8% of the total population of Japan in 2013.[39] Finally, the delay in releasing anonymous data by the MHLW makes it difficult to use the most recent data for health policymaking; therefore, it would not be reasonable to use the results of the analysis in this study as the only basis for new policymaking in 2023. The 2016 CSLC anonymous data newly published in 2021 were analyzed by our research group. Despite these limitations, this study first used nationally representative survey data in Japan provided by the MHLW in a form that allowed for secondary analysis, and the results of this study can be generalized to all of Japan to some extent.

In addition to our analysis of the 2016 CSLC anonymous data, we applied for the use of not-anonymized 2019 CSLC data in accordance with Article 33 of the Statistics Law and have obtained them. It is expected that a significant increase in the number of subjects to be analyzed will enable identification of more detailed risk factors for psychological distress in the population. We will continue to identify high-risk groups, clarify the mechanisms that increase risk, and consider policy interventions to make more effective use of limited health and welfare resources.

Using the 2013 CSLC anonymous data, a nationally representative survey dataset, we analyzed risk factors for psychological distress in the general population of Japan by gender. In both genders, being younger than 60 years old and being unemployed seemed to be major risk factors for psychological distress. In addition, the risk factors of drinking status and marital status among Japanese were different relative to previous studies in other countries. Further longitudinal studies with larger cohorts are needed.

CSLS Comprehensive Survey of Living Conditions

MHLW Ministry of Health, Labor, and Welfare

Acknowledgments

None.

Author’s contributions

S.H. conceived and designed the study. S.H. wrote the first draft of the manuscript, and all other authors revised the manuscript critically. All authors approved the final version of the manuscript.

Funding

This study was funded by Grant-in-Aid for Scientific Research of the Ministry of Education, Culture, Sport, Science, and Technology (KAKENHI Grant Number: 21K17259.)

Availability of data and materials

The anonymous data used in this study can be obtained from the MHLW. The statistical results obtained in this study were made and analyzed independently by the author using the anonymous data, and they are different from the statistics that the MHLW made and published. Please contact the MHLW (https://www.mhlw.go.jp/toukei/itaku/tokumei.html) to request the anonymous data of CSLS.

Ethics approval and consent to participate

For research purposes, MHLW provides anonymous data upon application and approval via website (https://www.mhlw.go.jp/toukei/itaku/tokumei.html). And the MHLW does not require any approval of the ethics committee on the publication of the results

Consent for publication

Not applicable.

Competing interests

There are no potential competing interests to declare.

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Tables 1and 2 are available in the Supplementary Files section.

No competing interests reported.

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Risk factors for psychological distress in the general population of Japan: A nationally representative survey

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Background

Methods

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Discussion

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