Journal of J Occup Health 2005; 47: 157Ð164 Occupational Health

Karojisatsu in : Characteristics of 22 Cases of Work-Related

Takashi AMAGASA1, 2, Takeo NAKAYAMA2 and Yoshitomo TAKAHASHI3

1Mental Clinic Misato, 2Department of Health Informatics, Kyoto University School of Public Health and 3Department of , Tokyo Institute of Psychiatry, Japan

Abstract: Karojisatsu in Japan: Characteristics of prevention, Psychological autopsy, Case series 22 Cases of Work-Related Suicide: Takashi AMAGASA, et al. Mental Clinic Misato—With the rapidly The number of suicide cases in Japan has increased increasing number of work-related in Japan since 1990 and accounts for more than 30,000 deaths (Karojisatsu, in Japanese), both applications for annually from 1998 through 2003. This number is about worker’s compensation insurance and civil suits are 3.5 times that of people killed in traffic accidents in the proliferating. The phenomenon of work-related suicide same period. Particularly in 1998, the increased incidence is examined along with the process and related factors. With informed consent from bereaved families, two of suicide among middle-aged individuals caused the certified psychiatrists independently reviewed and average male life expectancy to drop to the lowest level summarized 22 insurance and legal reports filed by since the Second World War. The raw suicide rate in psychiatrists on employee suicides that were related 2002 was 25.2 per 100,000 (37.1 among males; 13.9, to heavy workloads. A clinical epidemiologist females)1). Applicants for workers’ accident participated in discussions with psychiatrists to reach compensation insurance, as well as civil suits, have a consensus concerning the cause of the suicides. proliferated since the 1990s. Beginning in the late 1990s, Only one case involved a female. Seventeen had the courts began to hear more cases, and individuals began experienced personnel changes, such as a promotion to win civil suits against their employers. The Japanese or transfer. Low social support was recognized in 18, Ministry of Labor, Health and Welfare recently high psychological demand in 18, low decision latitude established some guidelines that are intended to prevent in 17, and long working hours in 19 cases (more than 2, 3) 11 hours per day for 3 months or more, and without a death and suicide due to overwork . day off in 9). The subjects had depressive episodes Since Uehata reported on 17 cases of (death by the ICD-10 criteria and showed suicidal signs. Ten from overwork)4), several Japanese researchers5Ð8) have of them saw a general practitioner because of also reported that overwork can lead to death9). This is unspecified somatic complaints, but no effective possible because of the unusually long working hours measures were taken. None of them had a history of required of employees in Japan10). A moderate psychiatric consultation or had received mental health relationship has been established between overwork or education dealing with job stress management. job stress and cardiovascular disease5, 7). Currently, in Although causality cannot be made from this case addition to death from overwork, karojisatsu (work- series report, we hypothesize that long working hours, related suicide) is a spreading occupational threat11) and heavy workloads, and low social support may cause a social problem in Japan. depression, which can lead to suicide. Appropriate countermeasures are urgently needed and the present Some reports deal with the impact of psychosocial 12Ð14) findings suggest some of them are possible. factors on mental health problems and with mental (J Occup Health 2005; 47: 157–164) problems associated with long working hours14Ð17). In addition, mental disorders have been cited as predictors Key words: Long working hours, Depression, Suicide of suicide18). However, no report has dealt with the relationship between suicide and the psychosocial factors Received Sep 2, 2004; Accepted Jan 15, 2005 or long working hours at play in the workplace. Correspondence to: T. Amagasa, Mental Clinic Misato, 1Ð5Ð6, Therefore, we studied 22 cases to examine the factors Misato, City of Misato, Saitama 341-0024, Japan involved in overwork-related suicide so that we could (e-mail: [email protected]) develop a hypothetical model of the processes leading to 158 J Occup Health, Vol. 47, 2005 overwork-related suicides and propose appropriate psychological issues (pre-morbid personality, preceding countermeasures. stress, life events, losses, social support in the workplace, and family relationships), working hours, and symptoms Methods and signs of suicide (prior suicide attempts, changes in Study Materials habits, physical and psychiatric symptoms, suicidal signs, The Japanese Worker’s Compensation Department and and accident proneness). Furthermore, the way in which civil court authorities require that members of bereaved the individuals coped with their various problems, families prove that labor conditions have a causal families, and co-workers was analyzed. A history of relationship with suicide. Therefore, affected families are psychiatric consultation and other types of consultations seeking assistance from lawyers and psychiatrists. was compiled. Work safety, health education, and Psychiatrists generally write legal reports for civil trials psychiatric diagnoses at the time of death according to and insurance reports for agencies dealing with workers’ definitions from the ICD-1020), method of suicide, and compensation. In either case, the reports are based on the suicide notes were examined, as were employee records concept of “psychological autopsy” established by involving accidents and lawsuits as of April 2002. The Shneidman19). A professional team, which might include definitions from the ICD-10 were used because the new a psychiatrist and a clinical psychologist, conducts a guideline adopted in 1999 to certify mental disorders as psychological autopsy immediately after a questionable work-related accidents2) principally uses the ICD-10 death to determine the cause of death, i.e., how and why criteria for psychiatric diagnosis. an individual died, by collecting and analyzing as much detailed information about the victim’s life as possible19). Statistical Analysis In the case of work-related suicide, the psychiatrist first Basic descriptive statistics, such as mean, median and reads all the materials submitted by the lawyer and the range were used. bereaved family, interviews the bereaved family for 2 to 3 hours on several occasions, and finally analyzes the Results collected data. As of December 2001, we had access to 24 Socio-demographic Factors (shown in Table 1) reports of work-related suicide that had been written by Of the 22 cases, only one involved a woman. The colleagues; the reports were used as the basis for this study. youngest victim was a 24-yr-old man, and the oldest was 54. Six were in their 20s, 6 in their 30s, 8 in their 40s, Informed Consent and 2 in their 50s; the median age was 35. The years of After a lawyer or psychiatrist had explained the the suicides ranged from 1983 to 2000; the median was research, 22 of 24 bereaved families gave written consent 1996. Sixteen (72.7%) were married. Six (27.3%) men for participation in the study. Of the two that did not were single but had a fiancée or girlfriend. Seventeen give consent, one individual chose not to participate (77.3%) were private sector workers; 5 (22.7%) were civil because she wanted to avoid potential trouble in the servants; and 3 (13.6%) were teachers. Twenty-one workplace. In the other case, no reply was received from (95.5%), all except case 4, were middle-ranking mail sent to an attorney representing the bereaved family, managers. whose attending psychiatrist had died. In total, 22 case reports were analyzed. Individual and Family History None of the subjects had been diagnosed with mental Analytical Procedure health problems before suffering from depression leading Two certified psychiatrists (T.A. and Y.T.) to suicide. They did not have individual or family independently analyzed the 22 reports, discussed the histories involving suicide or attempts. None had been results, and reached a consensus in each case. A clinical diagnosed with a personality disorder. epidemiologist (T.N.) then participated in further discussions with the psychiatrists to reach an objective Occupational Stress consensus concerning the details of each case from the Each subject experienced two types of occupational standpoint of a general physician and gave specific stress, one from the worksite and the other from the job methodological advice about some of the limitations of itself. Examples of environmental stress included job this study and guidelines on possible future research. transfers, changes in personnel, lack of social support in the workplace, poor human relationships, and Identified Factors psychological . Examples of stress from the Many factors related to each individual’s death were job included long working hours and heavy workloads. identified: socio-demographic (sex, age, marital status, A subject was identified as experiencing low levels of and death date) and socio-economic factors (job, position, social support, high levels of psychological demand, and and rank); individual and family history; and low levels of decision latitude when two psychiatrists Takashi AMAGASA, et al.: Characteristics of 22 Cases of Work-Related Suicid 159

++

++

++ +

++ + + +

++ + ++ +

++ +

+

LSS‡ HPD¤ LC||

(continued on next page)

Personnel change

personnel reorganization, promotion transfer + +

personnel reorganization

immodithymia + + +

neurotic but no deviation

no deviation promotion + + +

Chief programmer

Chief hard worker, considerate to others Business manager Chief teacher no deviation transfer, promotion Section member immodithymia transfer + + + Personnel chief no deviation transfer, downsizing Group leader cyclothymia transfer, promotion Chief immodithymia promotion + + + Branch manager substitute Chief immodithymia promotion, downsizing Teacher serious, meticulous

Person in charge immodithymia promotion + + Chief immodithymia + + + Section chief no deviation promotion +

Manager meticulous business bachelor, promotion

Site foreman immodithymia restructurig, personnel reorganization

24 1995 S Food company Person in charge bright, sense of responsibility 26 1998 S High school Chief teacher sincere, mild temper 26 1997 S Program development company 28 1997 S Municipal office Official in charge bright, sportsman transfer + + + 28 1997 S company Manufacturing 29 2000 S Underwear company 30 1983 M Elementary school 30 1997 S Manufacturing company 31 1998 M Manufacturing company

Outlines of the cases in order of age at the time of death

Table 1.

Case Sex* Age Death Marital Workplace Position and Rank Personality Worksite stress No. year status†

1M 2M 3M 4M 5M 6M 7M 8M 9M 10 M 31 1985 M company Manufacturing 11 M 35 1988 M Automobile company 12 M 35 1998 M service construction store Water 13 M 41 1991 M Manufacturing company 14 W 41 1996 M Elementary school 15 M 41 1999 M Restaurant Chief no deviation promotion + + + 16 M 42 1995 M Municipal office Chief immodithymia promotion + + 17 M 46 1996 M Research & development company 18 M 46 1993 M Shipbuilding company 19 M 46 1996 M Household/ electric appliance company 20 M 49 1996 M Store Chief of the shop no deviation + + + 21 M 53 1998 M Manufacturing company

22 M 54 1997 M General construction company 160 J Occup Health, Vol. 47, 2005

Hanging Ð Authorized/ won Hanging Ð /Under dispute Hanging Ð Authorized/ reconciled Hanging + Not authorized Hanging + /Reconciled Hanging + Not applied Hanging + first instance /Won Hanging Ð /Under dispute Hanging + Under examination Hanging Ð /Won Jumping Ð /Under dispute Hanging Ð Authorized/under dispute Jumping Ð Authorized/won Hanging + Under dispute / Jumping + Authorized Jumping + Not authorized Hanging Ð /Under dispute Drowning + Authorized/under dispute Inhalation + /Won Jumping Ð Authorized/ under dispute Inhalation Ð /Under dispute

Hanging Ð Under examination

ing hours.

. ‡LSS denotes low levels of social support. §HPD denotes high levels

diagnosis means notes lawsuit situation

Depressive episode

Depressive episode

Depressive episode Depressive episode

Ð

Ð

+ +

consultation

ttempts

wristÐcutting Ð Depressive episode

Ð

ÐÐ

ÐÐ

ÐÐ ÐÐ

Ð+

Ð+

Ð+

Ð+

++

consumption a

3 month Ð Ð Ð Ð Ð Depressive episode

at least 25 d Ð Ð Ð Ð Ð Depressive episode more than 11 months

7.7 months Ð + Ð Ð Ð Depressive episode 5 months + + Ð Ð + Depressive episode

6 months Ð + Ð Ð + Depressive episode

24 + Ð + Ð Ð + Depressive episode 26 + Ð Ð Ð Ð Depressive episode 26 +, 322(162)h/month 28 + + + traffic accident Ð + Depressive episode 28 +, without a holiday 29 + Ð + Ð Ð Ð Depressive episode 30 +, midnight going home 30 +, until midnight Ð + Ð Ð Ð Depressive episode 31 +, 375(215)h/month

Outlines of the cases in order of age at the time of death

(continued) Table 1.

Case Sex* Age Job stress Increased Physical Accident Prior Medical Presumed Suicide Suicide Authorization/ No. LWH (EWH)¦ Duration alcohol symptom proneness suicide

1M 2M 3M 4M 5M 6M 7M 8M 9M 10 M 31 +, 378(218)h/month 11 M 35 +, until 11:00pm Ð + Ð Ð Ð Depressive episode 12 M 35 +, 287(127)h/month 13 M 41 +, 368(208)h/month 14 W 41 + Ð + Ð Ð Ð Depressive episode 15 M 41 +, 13(5)h/d 4 months Ð + Ð Ð + Depressive episode 16 M 42 +, without a holiday 17 M 46 +, 15.5(7.5)h/d at least 1.5 months 18 M 46 +, 300(140)h/month 19 M 46 Ð + Ð + + Depressive episode 20 M 49 +, 11(3)h/d at least 40 d Ð + injury Ð + Depressive episode 21 M 53 + + Ð + + Depressive episode

22 M 54 +, until midnight + + Ð Ð Ð Depressive episode

*In the Sex column, M denotes men, and W denotes women. †In the Marital status column, S denotes single, and M denotes married of psychological demand. || LC denotes low levels of control. ¦LWH denotes long working hours, and EWH denotes excessive work Takashi AMAGASA, et al.: Characteristics of 22 Cases of Work-Related Suicid 161

(T.A. and Y.T.) reached a consensus that, before the complaints, such as chest pain, stomach ache, or mild manifestation of any mental disorder, the individual would fever; however, none of them had complained of have answered ‘agree or strongly agree’ to the following depressive feelings. None had a history of psychiatric propositions: he did not have enough instrumental and consultation or psychiatric hospitalization. The Japanese emotional support; his relationship with his supervisor general physicians might have been reluctant to diagnose and co-workers were bad, his position required him to reactive depression or might have not been provided with work very fast or hard; he was asked to do too much sufficient information about it. One individual (4.5%) work, he was not free to decide what he was going to do claimed that he was exhausted during a medical checkup, in his work; and he was not free to decide the amount of but the company physician thought that he was suffering work he would do. As a result, low levels of social support temporarily from mental stress and did not follow up. at work were identified in 18 cases (81.8%); high levels of psychological demand in 18 (81.8%); and low levels Diagnosis of decision latitude in 17 (77.3%) (Table 1). Long Each victim was presumed to have suffered from working hours were noted in the psychiatrists’ reports in depression at the time of death (Table 1). Reports of 19 cases (86.4%) but not in 3 (Table 1). A close problems with mental health were assumed to be reactions examination of nine cases of suicide (Case Nos. 3, 9, 10, to a combination of worksite and job stress. 12, 13, 15, 17, 18, and 20) (40.9%) showed that the individuals had been working between 10 and 16 h per Suicide Notes and Methods of Suicide day, i.e., an excess of 2 to 8 h per day; the median was an Eleven of the victims (50%) wrote suicide notes (Table excess of 5 h per day. These individuals had worked 1). All of the documents had a tone of self-reproach for extremely long hours for at least 25 d and, in some cases, their poor performance at work rather than blame for up to 11 months before manifestation of a mental disorder. others. Work seemed to be so central to these people’s Not one individual who had committed suicide had self-esteem that inability to cope with work demands was received mental health education dealing with perceived as a very salient problem. Thirteen of the occupational stress management during a promotion or victims (59.1%) hung themselves, 5 (22.7%) jumped from personnel change. high places, 3 (13.6%) inhaled lethal substances, and one (4.5%) drowned himself (Table 1). Time Course, Symptoms, and Suicidal Signs The suicides in this study occurred within 5 to 18 Employee Compensation Insurance and Lawsuits months after eventful episodes such as a promotion, The records for employee compensation insurance and transfer, or personnel reorganization; the median time was lawsuits were examined to determine whether or not 11 months. The interval between the manifestation of a mental health problems and suicides had been certified mental disorder and suicide ranged from 2 weeks to 8 as work-related and whether or not bereaved families had months; the median was 2 months. The symptoms won civil lawsuits (Table 1). observed by family members, friends, and colleagues of Two cases (9%) were undecided four years after (April the individuals who committed suicide included sleep 2002) applying for employee compensation insurance, disturbance, such as insomnia and difficulty getting up and nine (40.9%) had not been determined within the in 15 of the cases (68.2%) and autonomic symptoms, such same period. as headache, stiffness in the shoulders, susceptibility to colds, mild fever, lumbar pain, diarrhea, and constipation, Discussion and Conclusions in 18 (81.8%). Other indications of suicidal feelings were This is the first case study of suicides related to the manifestation of an intention to retire or hope for a overwork in Japan that includes analyses and change in the workplace, which occurred in 8 cases psychological autopsies. Figure 1 depicts a hypothetical (36.4%), excessive absences in 5 (22.7%), increased time sequence of work-related suicides21). The consumption of alcohol and tobacco in 6 (27.3%), individuals who committed suicide worked long hours reduction of interest in sexual intercourse in 4 (18.2%), and experienced heavy workloads. Eleven individuals amnesia or very unusual mistakes in 2 (9.1%), accident (50%) had experienced a significant life event before proneness in 2 (9.1%), and prior suicide attempts in 3 experiencing any mental health problems, and the other (13.6%). These same symptoms appeared within 2 to 3 11 (50%) had experienced the same kinds of significant months after personnel changes and got progressively life events before committing suicide. Poor physical worse until the suicide. health manifested itself in a lack of desire to talk and eat and various behavioral changes. Individuals might Access to Medical Service have indicated that they were tired or exhausted or that Ten individuals (45.5%) who committed suicide had they wanted to retire. Many symptoms occurred before seen a physician because of unspecified somatic mental health problems were diagnosed or apparent and 162 J Occup Health, Vol. 47, 2005

these risk factors. The overwhelming majority were men, although the rate for general suicide is only 2.6 times higher among men than women (the aggregate worldwide ratio is 3.5; the workplace ratio is 7)1, 26, 27). The work- related suicide ratio is similar to that for death from overwork, which is 196 males to 7 females28). This may be because males work longer than females in Japan or because, when a male commits suicide, the family is more threatened economically. Almost all individuals in this study worked long hours, experienced pressing psychological demands, and received little social support at work. Ultimately, they began to experience depression and committed suicide. The relative risk of depression before committing suicide Fig. 1. An Examination of Suicide from Overwork. This was has been estimated to be about 20 times that of the general 18) reconstructed from the details of the findings in the population, according to the Harris report . time sequence in which they occurred. 2W denotes 2 Furthermore, some research deals with psychosocial weeks; 2M denotes 2 months; 2W-2M-8M before factors or perceived job stress by workers and depressive denotes an interval ranging from 2 weeks to 8 months; symptoms or depression12, 13). Niedhammer reported in a the median is 2 months before suicide. 10Ð13Ð16 h/d cohort study that high levels of psychological demands, without a holiday denotes the average working time low levels of decision latitude, and low levels of social per day ranging from 10 to 16 h; the total working hours in a month were divided by 30 d; the median is support at work were significant predictors of subsequent 13 h per day before manifestation of a mental disorder. symptoms of depression in men and women. The odds ratio (OR) for men was 1.77, 1.38, and 1.58 for the three factors, respectively12). Mausner-Dorsch reported that high job strain composed of high psychological demands and continued until the individual committed suicide. low decision latitude significantly increased the OR (major Overwork might not have been a direct cause of suicide; depressive episode, 7.16; depressive syndrome, 4.06)13). however, mental health problems, especially depression, On the other hand, there is much less information about may have contributed to the factors that led up to suicide. the effects of long working hours on mental health, and For comparison, the table in the Appendix shows the the results of some research are controversial. Shields’ prevalence of stress and symptoms in Japanese main result of a 2-year follow-up study was that only workers10, 22, 23). women who worked long hours had an increased OR (2.2) When the families first became aware of the of subsequently experiencing depression17). However, symptoms, they tried to relieve the individual of any Tyssen reported that, among medical interns, the number burdens over which they had control. However, they of working hours was not linked to mental health might have stopped trying when they saw that they were problems28). Although long working hours are generally unable to have an effect. Members of management in defined as those from 41 to 50 h or more per week, further the workplace tried to encourage the individuals who were studies should be conducted to determine the effects of suffering. Some supervisors gave workers new tasks much longer working hours on mental health. because they determined that the workers were easily We emphasize here that the Japanese worker might be bored with their regular tasks. It is unlikely that suicide influenced to commit suicide under certain circumstances can be prevented without appropriate action from related to work. More than half of the workers in Japan employers and the immediate family. In the cases studied, work in excess of 42 h a week10). After the collapse of the individuals continued to work until they, the Japanese economy in the early 1990s, restructuring unfortunately, committed suicide. and downsizing of companies has placed workers under Generally, suicidal individuals have many risk factors, enormous pressures29). Japanese workers work very hard, some of which include suicide attempts, mood disorders, even when suffering from poor physical or mental health personality disorders, lack of social support systems, age due to overwork, and many workers will say, “If I fail disadvantages, male gender, and being single. Others now, I will burden my co-workers. Therefore, I cannot include various types of loss, unemployment, physical avoid work.” or sexual abuse in childhood, accident proneness, family Several cases can be made to explain why typical , and exposure to other cases of suicide Japanese workers work so hard and do not retire earlier or tragic accidental deaths24, 25). However, in the cases than they do. Confucianism continues to have a profound studied, the individuals were only exposed to a few of influence on the Japanese culture and worldview. The Takashi AMAGASA, et al.: Characteristics of 22 Cases of Work-Related Suicid 163 basic unit of society in the Japanese mind lies in a concept cannot determine the causality and we stress that that literally means “house” (ie in Japanese). However, conducting appropriate case-control studies or cohort the word implies other groups, such as families, studies is difficult on this topic. Second, the reports from companies, schools, and religious sects that bind people the bereaved families may be somewhat biased. However, together. The Japanese education system has strengthened all of the reports were based upon psychological autopsies this concept of togetherness. The Japanese are educated and information from employers, which had been used to cooperate and conform with the group. Therefore, to obtain employee compensation or file a lawsuit, and it Japanese workers behave as their co-workers do and do must be emphasized that the present study could not have not assert themselves too much in order to work been possible if these reports had not been utilized. harmoniously. The identification and description of real cases may Moreover, the Japanese business management system contribute to make well-timed countermeasures. appears to contribute significantly to work-related Appropriate countermeasures are critical at present in suicides6). Three principles have served as the foundation Japan, and some of them should be implemented of the Japanese system of work. They are lifetime immediately with reference to the cases presented here. employment, a pay scale based on seniority, and loyalty The present findings might be helpful to workers in other to the employer. As a result, employees do not usually countries who are subjected to poor working conditions, change companies. as are the Japanese. Japanese general physicians seem to be more reluctant References to diagnose depression26, 30) and less able to manage people suffering from depression and contemplating suicide. 1) Japanese Police Agency. Outline of Suicide in Heisei This might be because, in Japan, both medical students 14 (2002). Tokyo: Japanese Police Agency, 2002. (in and general physicians have been trained insufficiently Japanese) 2) J Watts: Japanese government offers guidelines for about psychiatry and because Japanese male workers tend stressed workers [correspondence]. Lancet 354, 1273 to show physical symptoms rather than depressive (1999) 31) feelings due to unfavorable attitudes toward depression . 3) K Ueda and Y Matsumoto: National strategy for suicide In their efforts to improve working conditions, the prevention in Japan [correspondence]. Lancet 361, 882 bereaved families of suicide victims and their attorneys (2003) have lobbied the Ministry of Labor, Health and Welfare 4) T Uehata: A study on death from overwork. (I) to develop guidelines to ameliorate the kinds of conditions Consideration of 17 cases [abstract]. Jpn J Ind Health that lead to work-related suicide2, 3). As a result of their 20, 479 (1978) (in Japanese) efforts, new standards were adopted in 1999 to certify 5) T Uehata: Long working hours and occupational stress- mental disorders as work-related accidents2). Guidelines related cardiovascular attacks among middle-aged for the promotion of mental health in the workplace were workers in Japan. J Hum Ergol 20, 147Ð153 (1991) 6) K Nishiyama and JV Johnson: Karoshi: Death from established in 2000, and a description of appropriate overwork. Occupational health consequences of working hours was written and distributed to employers Japanese production management. Int J Health Serv in 2001. Furthermore, the instructions contained specific 27, 625Ð641 (1997) guidelines for recording working hours, which are to be 7) S Sokejima and S Kagamimori: Working hours as a monitored by employers, and an admonition that risk factor for acute myocardial infarction in Japan: A excessive hours are in violation of the laws governing case-control study. BMJ 317, 775Ð780 (1998) labor standards. In addition, comprehensive measures 8) N Kawakami and T Haratani: Epidemiology of job were developed to prevent harm from overwork in 20023). stress and health in Japan: Review of current evidence Such measures encourage employers to seek advice from and future direction. Ind Health 37, 174Ð186 (1999) their company physician with regard to employees who 9) S Michie and A Cockcroft: Overwork can kill. BMJ work more than 45 h per month in excess of the acceptable 312, 921Ð922 (1996) 10) Japanese Ministry of Labor, Health and Welfare. working load. They also encourage employees who have Yearbook of Labor Statistics 1999. Tokyo: Institute of worked more than 100 h in excess of the acceptable Labor, Health, and Welfare Administration, 2001. (in working load or more than 80 h on average in excess of Japanese) the acceptable working load in the last 2 to 6 months to 11)K Inoue and M Matsumoto: Karojisatsu (suicide from meet with their company physician because such long overwork): A spreading occupational threat working hours may increase health risks. A final report [correspondence]. Occup Environ Med 57, 284aÐ285a from the Special Committee on Prevention of Suicide (2000) was released in 20023). However, these reforms have not 12) I Niedhammer, M Goldberg, A Leclerc, I Bugel and S been implemented by many employers. David: Psychosocial factors at work and subsequent There are some limitations with the present study. First, depressive symptoms in the Gazel cohort. Scand J Work the nature of a case series report that has no comparison Environ Health 24, 197Ð205 (1998) 164 J Occup Health, Vol. 47, 2005

Appendix. Reference data for Japanese workers (ref. 10, 21, 22)

item rate (%)

job transfer during the last 6 months 6.4 promotion during the last 6 months 1.9 personnel reorganization during the last 6 months 8.2 heavy workload 32 low social support at work 35 high psychological demand 34 long working hours (more than 60 h/wk) in male workers during the last week 23.4 long working hours (more than 11 h/d) during the last week 3.1 sleep disturbance 6.4 physical symptoms 84 suicidal feelings 4.5 intention to retire or hope for a change in the workplace 15 increased consumption of alcohol and tobacco 23 mistakes 12

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