JAPAN: Saving Face, Losing Money?


It’s a saying [the Japanese] have, that a man has a false heart in his mouth for the world to see, another in his breast to show to his special friends and his family, and the real one, the true one, the secret one, which is never known to anyone except to himself alone, hidden only God knows where

James Clavell, Shōgun

As observed by Clavell, there exists a historical and cultural ideology in Japan that exerts: one should always keep their true inner image, feelings and emotions internalised for only the individual to know about. This suppression of emotion deteriorates the human psyche and so is a contributing factor to Japan owning the most mental health beds in mental health facilities in the entire world. As classical economic theory suggests, this significant level of supply must have been developed due to increasing demand; the drive for this demand logically being that a large portion of the Japanese population will likely suffer from a damaging mental health issue at some stage.

Beds in general hospitals for mental health per 100,000 people

Mental health disorders are often culturally stigmatised around the world and Japan is no exception, resulting in 80% of Japanese patients who are diagnosed with depression not actually seeking professional help – and that is only accounting for those who are formally diagnosed. This is likely because of a shaming culture in the Asian subcontinent. A 2018 study revealed that it is widely believed in Japan that mental health issues have a higher chance of occurring as a result of weakness of character rather than due to biological factors. Therefore, many people do not allow themselves to receive the help that they need for fear of loosing face amongst their peers.

The Japanese concept of ‘face’ – mentsu – has been deeply ingrained in Japanese society for centuries, having stemmed from the desire to bring honour to one’s clan. Therefore, it is easy for someone to feel like they would bring shame upon their family, thus losing them face – mentsu wo ushinau – for having a ‘weakness of character’ because they suffer from a mental illness. This is a genuine concern for Japanese people with poor mental health, as numerous studies have highlighted that the majority of the general public do indeed keep a greater social distance from individuals with mental illness, especially in close personal relationships.

Moreover, if the individual suffers from schizophrenia then this only exasperates the judgement they will face from others. The stigma behind schizophrenia in Japan was so great that 93% of Japanese doctors neglected to inform their patients if they were diagnosed with it. This is because of the immense difficulty involved in telling a patient that they suffer from something that the patient and their family likely do not fully understand themselves and potentially harbour the common cultural stigma against. Whilst this has improved since this disease was renamed from the translation of ‘mind-split disease’ to ‘integration disease,’ there is still less understanding for it compared to depression.

Evidently, mental health is a real challenge that Japan faces, further demonstrated by 0.5% of Japan’s GDP being spent on mental health care. Not only is this clearly a large proportion, three quarters of this expenditure is funnelled into the institutionalisation of the people with a mental illness –removing them from society. Instead this money may be better spent in educational programs and community caring projects to make further progress to normalise mental illnesses and keep people who need help close to their support systems – their friends and family. This is exemplified by Japan accounting for a whopping 20% of all the world’s beds reserved for institutionalised mental patients.

A study conducted by the London School of Economics suggests that this could be due to Japanese workers fearing that they could lose their job if their depression is revealed at work: when feeling unwell, workers are more likely to stay at home where their illness cannot be identified rather than to run the risk of it being spotted in the workplace. This has resulted in Japan having the highest costs per person associated with employees taking time off for depression, with 22% of the workforce taking 21 or more days away from work. This has cost the economy an unprecedented $14 billion in forgone output.

But it is not all doom and gloom! It is clear that the Japanese health care system takes mental health very seriously as they are more than willing to direct funds towards providing facilities for those who are suffering. Additionally, one could argue that such a large proportion of Japanese people being willing to take an extended leave from work when they have a depressive period, shows that they prioritise their mental health comparative to other countries. This suggests that they are better at recognising and accepting when they are struggling and having the courage to take a step back from work and focus on their wellbeing.

% of respondents with life prevalence of depression

This conscientiousness pertaining to one’s mental state and taking effective action could help to prevent long lasting issues. Evidence of this is shown in a study conducted by the World Mental Health Survey Initiative that uncovered only 6.6% of Japan’s population will experience a recurrence of depression across their lifetime compared to 17.9% of the Netherlands and 21% of France! Therefore, whilst the economy might see losses in productive capacity in the short run as workers take extended periods of leave to tend to their own wellbeing, the potential benefit of them doing so is that it reduces the likelihood of it becoming a deteriorating issue down the line that would result in an even greater loss of productivity.

Whether the overall mental health of the Japanese population is better or worse compared to other countries is ultimately a subjective matter. The economic impact, however, of mental health and existing stigmas is all too apparent. A worker becoming unemployed due to hospitalisation or becoming less productive, stemming from low attendance at work and general poor mental health, merely seems like a small loss of efficiency on an individual scale. The reality is the opposite. The accumulation of mentally ill workers quickly translates to a country having a stunted productive capacity, causing unexpectedly large knock-on costs on the country’s potential for growth in the future. The quality of life of a population and a thriving economy go hand in hand, so investment in nurturing the souls of the people is money well spent. Indeed, if the eyes really are the windows to the soul, it might not be a bad idea to have dollar signs in them too.


  1. Psychiatr, AJP.2018 ‘Public Perceptions toward Mental Illness in Japan’
  2. Okumura Yo and Higuchi 2011, ‘Cost of Depression Among Adults in Japan’
  3. Hamid et al, 2008, ‘Evaluating the WHO Assessment Instrument for Mental Health Systems by comparing mental health policies in four countries
  4. Kessler KCR and Bromet EJB, 2014, ‘The epidemiology of depression across cultures’
  5. 2016, WHO, Beds in general hospitals for mental health and beds in mental hospitals (per 100 000 population)


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