Modern-Type Depression as an “Adjustment” Disorder in Japan: The Intersection of Collectivistic Society Encountering an Individualistic Performance-Based System

Japan has recently seen an increase in cases similar to that of Mr. A, especially among young adults, a syndrome referred to as “modern-type depression” (MTD) (1). Characteristics of MTD include situation-dependent depressive state, blaming others, and strong avoidant tendencies (2, 3). Individuals with MTD display absenteeism from work or school, complaining of mental health problems, but because they can function relatively well at other times, dealing with MTD poses a new challenge, especially in occupational health. Notably, these characteristics are the complete opposite of those of individuals with Japan’s traditional depression prototype, who would respect the virtues of Japan’s collectivistic society, maintaining harmony and adjusting themselves to the traditional hierarchical social order, and usually concealing their depressive state (4, 5).

Currently, there are no adequate diagnostic criteria or evidence-based treatment guidelines for MTD (2). According to DSM and ICD, some cases fall under atypical depression, dysthymia, or personality disorder (narcissistic, avoidant, etc.), but many do not reach any of the diagnostic thresholds and tend to be diagnosed as “adjustment disorder.” Patients are sometimes misdiagnosed as having major depression because they overstate their depressive symptoms, and so they are treated with antidepressants, often with poor response. Third-party information is often useful in the assessment of such cases because family members and coworkers often suspect that the patient is “slacking off” (6). Even psychiatrists tend to regard MTD as a non-disorder needing no treatment (7). However, with increasing numbers of MTD cases exhibiting social maladjustment in Japan, this phenomenon cannot be ignored. A recent Australian longitudinal study proposed that adjustment disorder is a “gateway disorder” that can lead to more serious psychiatric conditions down the road (8). While empirical data are sparse at the moment, we propose that MTD is a similar gateway condition and that prolonged MTD may lead to a more severe form of social maladjustment called hikikomori (9).

We have seen some success with a rehabilitation program called “Re-Work” that provides group adaptive training to individuals on sick leave—especially due to depression, including MTD—who have difficulty adapting to their workplace (10). Participants learn adaptive skills tailored to Japanese workplace culture through counseling, group activities, and group-based cognitive-behavioral therapy, enabling them to return to work within several months. The popularity of this program is rising, and there are currently over 200 participating facilities nationwide.

In addition, we suggest that individual and group-based psychodynamic interventions are needed in order to overcome the avoidant tendency originating in the developmental period that lies at the root of MTD. The rise in MTD cases in the early 2000s was partly due to amae (accepting dependent behaviors) culture, kahogo (overprotectiveness), and yutori (relaxed) education, which deemphasized competition and allowed students more freedom (2). This paralleled the corporate cultural shift toward a more Westernized individualistic and performance-based practice and culture, which occurred as a result of an economic downturn and increased global competition, while preserving the emphasis on collectivism, creating a challenging situation for the workers who were now pressed to adjust and function within these two conflicting value systems. We suspect that this situation contributed to the rise in suicide during this time among middle-senior workers with Japan’s traditional mindset. On the other hand, youths with MTD who grew up during this educational reform period have not adequately formed the resilience to bear the conflicting pressures both to “adjust” into Japan’s traditional vertical hierarchy and to compete with others. They are more likely to experience stress as trauma, are more self-aware of depressive mood, and avoid difficult social situations, and thus they are also ill equipped to adapt to the demands and requirements of recent Japanese society.

The needs and levels of adjustment expected in society vary by sociocultural environment and era. Why do Japanese psychiatrists tend to diagnose MTD as adjustment disorder? The name “adjustment” disorder itself intrinsically implies a failure on the part of the individual to adjust, even when adjusting means bearing the impact of overwhelming and stressful situations. In Western countries where individualism with self-responsibility and freedom of choice are encouraged, would individuals with MTD also be considered “maladjusted” to society (i.e., labeled with “adjustment” disorder), or simply as having their own personality (sometimes extended to “personality” disorder)? Following DSM-5’s cultural concepts of distress, adjustment disorder, including MTD, should be reformed based on nosological, cross-cultural comparative and epidemiological studies to develop appropriate culture-oriented therapeutic approaches.