Mental Kiyoka
Paul
Health
Koizumi,
Harris,
Ph.D.
M.D.
Long-term institutionalization has been theprimary treatment for mentally ill patients in Japan since the early 1920s. The average length ofstay in ajapanese mental hospital in 1989 was 496 days, 41 times the average stay of patients in the United States. Although the government has encouraged and supported the integration of mentally ill people in the community and the development of rehabiitation programs since enactment of the Mental Health Law of 1988, implementation of such programs has been slow. The authors summarize the history ofmentai health care in Japan, discuss the current availability of mental health care facilities and personnel, and recommend changes needed to improve care.
Although Japan is among the most technologically advanced countries in the world and has the lowest infant mortality rate and highest life expectancy, the level of public understanding ofmental illness and the quality ofpsychiatric care lag fan behind those in other industrialized countries. Mental illness and other disabilities such as blindness and deafness still carry a major stigma.
Dr. Koizumi
is assistant
professor
in the department of health and nutritional sciences, Brooklyn College,
City
University
of
New
York, Bedford Avenue and Ayenue H, Brooklyn, New York 11210. Dr. Harris is associate professor of clinical pediatrics at the State University of New York Health
Sciences
lyn College
1100
Center
of Medicine.
at Brook-
Care in Japan J apanese parents thoroughly investigate the mental health histories of the families ofpotential sons- and daughters-in-law, not only of members of the immediate family but of distant relatives as well, alive or dead. People who are mentally ill themselves or have a family member who is mentally ill make extreme efforts to hide the fact from others. For example, people will often pay for their own care rather than make an insurance claim. This paper summarizes the histonical background of mental health care in Japan and discusses its current status, including the mental problems that are most prevalent, current availability of mental health facilities, and the kind of care patients receive. The data cited were collected by the senior author duning interviews with personnel at Japanese mental health facilities and government offices in July 1991.
deserves ennizing
credit mental
as a pioneer health care
in modin Japan
(1,2).
Historical background Until the early 20th century, the pnimary treatments for mental illness in J apan were folk medicine and “impnisonment” at home. Mentally ill people were regarded as burdens to society and were kept out of sight. Although a few mental hospitals cxisted in Tokyo, Kyoto, and Osaka, most were private facilities cxclusively for the wealthy (1). In 1900 the government enacted the Law ofEnclosure ofthe Mentally Disturbed, which required families to keep mentally ill family members locked in a special room at home. In 1901, however, Dr. Shuzo Kure, head ofthe Tokyo University Mental Hospital, a public facility, initiated the first major changes in the care of hospitalized patients. He prohibited the use ofrestraints on patients at his hospital and introduced exercise programs and occupational therapy such as gardening and sewing. Dr. Kure
In 1919 the government enacted the Mental Health Hospital Law, which required each prefecture (distnict) to build a mental health hospital. This law signified the beginning of systematic care and treatment of mentally ill patients by the public sector. As a result, society’s attitude toward the mentally ill gradually began to shift from one of confinement and physical restraint to one of protection and treatment (1). In 1940, however, the Eugenic Protection Law was enacted (3). The purpose of this law, which was similan to one enacted in Nazi Germany, was to make the nation healthy and strong by eliminating “bad genes.” Although the Japanese law permitted the liberal use ofabortion and sterilization, there is no record that genocide was practiced in Japan, as was the case in Nazi Germany (1,4). The Eugenic Protection Law remains in effect; its major current significance is to guarantee Japanese women access to abortion. In 1949 the Mental Health Hospital Association was established; its mission was to promote public mental health care. This association served as a catalyst for passage of the Mental Hygiene Law of 1950-a milestone in the history of mental health care in Japan. This law not only made the practice of confining mentally ill patients at home illegal but also strengthened the earlier requirement that each prefecture build a mental hospital. It also introduced the concept ofpublic counseling centens for psychiatric patients and a home-visit treatment program, new concepts for mental health care in Japan (1). (The programs mandated by law were not fully implemented, however, until 1 5 years later.) The Medical Care Financing Act
November
Hospital
1992
Vol. 43
No.
11
and
Community
Psychiatry
Table 1 Prevalence of mental disorders per 100,000 population in Japan in 1987, by age group1 Age group Under 15to19
(years)
Prevalence
15
20 58
20to24 25to34 35to44 45to54
139 295 462 587
55to64 65to69
571 508 549
70to74 75to79
594
80to84
714
Over84
981
I Source:
Ministry
ofHealth
and
WeIflire
(5).
Mental
disorders include schizophrenia, major depressive disorder, neuroses (neurotic conditions such as phobias and compulsions), organic mental disorder, mental retardation, epilepsy, and senile dementia.
of 1 960 provided public financial assistance to private institutions for the development of new psychiatric hospitals and the expansion of existing facilities. The result was a sharp increase in the number of psychiatric hospitals during the 1960s and 1970s. The act also provided government funds to coven half the cost of outpatient treatment (5). In 1965 the Mental Hygiene Law of 1950 was amended when a mentally disturbed 19-year-old assaulted the American ambassador to Japan with a knife and disabled him for life. This amendment led to several improvements in mental health care (1,6,7). For example, each prefecture was required to establish a counseling center. Partial coverage of the costs of psychiatric care was guaranteed by the government. The homevisit treatment program authorized by the Mental Hygiene Law of 1950 was implemented. Hospital admission procedures were improved. In addition, the police were given broad responsibility for registering the names ofmentally disturbed citizens with city and prefectural governments and, in severe cases, arresting and hospitalizing them. In 1 984 another scandal involving mentally illpatients occurred. At Utsunomiya Hospital in Utsun-
Hospital
and
Community
Psychiatry
omiya City, a few hundred miles north ofTokyo, two mental patients were beaten to death by hospital attendants (1,8-10). A police investigation revealed a series of criminal acts: the hospital had admitted more patients than it had beds, patients were forced to perform factory work, their money was spent without permission, and treatment was provided by unlicensed personnel. Complaints by mental health professionals and the public about these and other human rights abuses subsequently to an investigation by a team dispatched by the United Nations Human Rights Committee. Embarrassed by the team’s findings
and
strong
recommendations,
Prevalence of mental illness The overall prevalence ofmcntal disorders per 100,000 population increased from 67 in 1955 to 207 in 1965 and from 269 in 1975 to 339 in 1987. Whether the sharp increase represents an increase in the actual prevalence or an increase in the numben of cases reported is unclear. In the
prevalence
rate
represented
nearly 414,000 patients, and, according to a survey by the Ministry ofHealth and Welfare, 79 percent of those patients were hospitalized (5). Table 1 shows the prevalence of mental disorders in various age groups in 1987. Because ofthc increased longevity of the population, the high prevalence ofmental illness, including senile dementia, among the elderly is not surprising. The dis-
November
1992
Vol. 43
Diagnoses (N=
No.
11
Ion
339,749’)
inpatient and
(N=9.63 million1) percentages2
admissions
outpatient
injapan
visits
in 1987,
in
Inpa-
Outpa-
Diagnosis
tient
tient
Schizophrenia Senile dementia
61.1 9.3 6.2
18.2 3.4 33.1
Neuroses
Alcohol-related problems Manic-depressive disorder Mental retardation
4.6 4.4
12.7 1.8
Epilepsy
3.5
17.0
Other
5.0
12.0
1
the government enacted the Mental Health Law of 1988, which replaced the old Mental Hygiene Law of 1950. The new law called for increased protection ofpatients’ human rights, improved rehabilitation programs, and more effective programs for integrating mentally ill people into the community. So far, however, this law has had little apparent effect (7,11-13). The following sections outline the prevalence ofmental illness inJapan, the average length of hospitalization, the current status of mental health facilities, and the personnel responsible for care. The paper closes with an assessment of the changes necessary to achieve more humane care of mentally disturbed patients.
1987
Table 2
Based
6.0
on extrapolations
1989 data reported Health and Welfare
2
Source:
Shinfuku
(14)
from by the
1.8
1 988
Ministry
and
of
(21)
tnibution of mental disorders among hospitalized patients and outpatients is shown in Table 2. As in other Asian countries, schizophrenia is the major psychiatric illness among psychotic inpatients (14). (Note that the generic term neurosis is used in government documents and that mental retardation and epilepsy are included in the list of mental illnesses.) Length of hospitalization The average length of hospitalization fonJapanese mental patients was 496 days in 1989 (5), about seven times longer than in Sweden (72 days) and 41 times longer than in the United States (12 days) ( 1 5). Among schizophncnic patients, the average hospital stay was 632 days (5); for schizophnenic patients aged 65 and older, the average length of hospitalization was 2,758 days, on about seven and a half years. Extended lengths of stay were the result ofthe strong focus on inpatient treatment for all mentally ill patients until recent years (5). Long hospitalizations are also typical for medically ill patients in Japan; in 1989 the average length of stay in a hospital was 51.4 days (5,16). A lack of nursing homes may be a major contributor to the phenomenon of extended stays in general hospitals as well as in psychiatric hospitals. Since enactment of the Mental
1101
Health Law of 1988, the Ministry of Health and Welfare has encouraged the use of outpatient facilities for treatment. The number of clinics, day care centers, social rehabilitation facilities,
and
sheltered
workshops
is
increasing, often with the help of government subsidies. As a result, the number of inpatients, excluding those with senile dementia, is gradually declining. In July 1991 a total of 252 persons per 100,000 of the population were inpatients (17; Ogata T, personal communication, July 8, 1991). The decline has been slow, however, because many fami,
lies
do
family
because
not
want
their
mentally
member
to return
there
are few halfway
ill
home
and
houses.
Mental health facilities Hospitals. After years of significant increases in the number of psychiatnc hospitals, apparently as a result of the Medical Cane Financing Act of 1960 (8), the number has stabilized (18). As of 1988, Japan had 1,048 mental hospitals, 90 percent of which were private (5). The occupancy rate has been close to 100 percent for the last few decades (8). The total number of psychiatric beds was 439,963 in 1990 (14); those beds accounted for about 20 percent of all hospital beds (8). According to data collected by the Ministry of Health and Welfare (5, Ogata T, personal communication, July 8, 1991), 20 ofJapan’s 47 prefectures have a shortage of psychiatnc beds, whereas the remaining 27 prefectures have an excess number of beds. The hospitals with empty beds tend to be public hospitals that care for seriously ill patients who require hospitalization for long periods. Nevertheless, the ministry apparently believes that the overall number of psychiatric beds is adequate, except for patients with senile dementia (5, 18). In 1991 some of the smaller private hospitals were extremely crowded, and patients with different types and degrees of mental illness sometimes shared the same room. Public hospitals change patients 7,000 to 12,000 yen ($56 to $96) per day for inpatient care. For example, one large public hospital in Tokyo charged 10,685 yen ($85) in May 1991. Both public and private hospi-
1102
tals change more for private rooms. At one private hospital in Tokyo, the rate was 36,000 yen ($250) for a pnivate room, compared with 1 5 ,000 to 25,000 yen ($120 to $200) for nonprivate rooms. Although most public psychiatric deficit,
ment pitals,
they
hospitals are
assisted
subsidies, whereas which represent
all psychiatric
hospitals,
operate
at a
by govenn
private hos90 percent of must
cover
their deficits by other means, such as dispensing drugs and administering medical tests (1 9,20). The fact that the government subsidizes only public hospitals is a sore point for private hospitals. Outpatient clinics. The number of psychiatric outpatient facilities has increased dramatically since enactment of the Mental Hygiene Law of 1965, which guaranteed pubtic financial assistance for outpatient services. As of 1989,Japan had 520 psychiatric clinics, and the number is increasing (17,20). Patient visits to these facilities more than tripled between 1965 and 1988-from 2.76 million to 9.96 million (21). Otberfacilities and programs. Establishment of rehabilitation programs and community-based treatment represents the major thrust of future efforts to provide psychiatric cane. In 1991 the Ministry of Health and Welfare announced that the foltowing facilities would be completed within the next few years: 186 day or night care centers that provide multidisciplinary treatment, 1 ,438 rehabilitation centers for ambulatory patients, 57 dormitories and welfare homes (halfway houses), 41 training centers for pregnant mentally ill women, and 209 occupational training facilities (5). Care providers The personnel who work with psychiatnic patients include 8,700 psychiatnists, 53,000 nurses, 14,000#{149} nurses’ aides, 2,000 clinical psychologists, 469 occupational therapists, and
several
thousand
psychiatric
so-
Health and Welfare to introduce a system of licensing and registration for clinical psychologists and psychiatnic social workers have been unsuccessful (22; Shinfuku N, personal communication, April 28, 1992). During her visit, the senior author met only seven clinical psychologists working in mental health facilities at three different institutions. Six were supervised directly by psychiatrists; the seventh headed one of the fewer than ten psychiatric counseling centens in Japan operated by clinical psychologists. The 469 occupational therapists who work with psychiatric patients represent only 1 1 percent of the 4,018 registered occupational therapists in Japan. Occupational therapy is a relatively
(8).
Other
cat
Hospital
11
industrialized
services,
November
No.
in Japan;
the
countries
including
feeding
the
patient, cleaning the patient’s room, and doing the patient’s laundry. Another reason is the Medical Care Act of 1948, which allows the ratio of providers to patients to be much lower in psychiatric hospitals than in general hospitals (8). J apanese psychiatrists often complain
VoL 43
field
have a much higher number of professionat caregivers. For example, the rate pen 1 00 beds is 267 in the United States, 1 74 in Sweden, 1 37 in France, and 1 1 3 in Germany. One reason for the lower ratio of professionals to patients in Japanese psychiatric hospitals is that to reduce costs, family members arc often recruited as unpaid auxiliary caregivers. They provide many nonmedi-
cial workers (18). The number of psychiatrists per 100,000 population in Japan as of 1991 was 7.08, which is one of the highest among the countries in the Asian and Western Pacific region (14). Attempts by the Ministry of
1992
new
first professional training program for occupational therapists was established in 1975 (23). The shortage of professional personnet is greaten in mental health cane facilities than in other health cane settings. An average ofonly 22 professional personnel are available for each 100 psychiatric beds, whereas the average is 77 professionals for every 100 beds in general hospitals
that
their
salaries
are
much
lower than the salaries of other specialists. Insurance programs do not recognize counseling and psychotherapy as methods of medical treatment that deserve to be reimbursed. Many of the psychiatrists inter-
and
Community
Psychiatry
viewed complained that insurance reimbursements amount to only 2,500 yen ($20) for one counseling or psychotherapy session, no matter whether the session lasts 20 minutes or two hours. As a result, psychiatnists are forced to see as many patients as possible per day. One psychiatnist in the outpatient department of a large public psychiatric hospital scheduled more than 60 patients during a nine-to-ten-hour day. He said the average session lasted only ten minutes unless the patient had a special need. The same situation was reported by personnel in the psychiatric outpatient department of a lange private hospital in Tokyo. In general, primary care physicians provide little care for mentally ill patients.
Psychiatrists
often
plained about other physicians’ of interest in and discrimination against mentally ill patients.
com-
tack
Conclusions Japan’s Mental Health Law of 1988 set two major goals: enhanced protection of the human rights of mentally ill patients and an increased number of rehabilitation programs to enable patients to be integrated into their communities (24). The slow progress toward achieving these goals is partly the result of public apathy and the slow-moving efforts typical ofgovernments (7,1 1-13). As the Japanese public becomes better educated about mental illness and the importance of prevention and early treatment and as nonpsychiatric health care professionals increase their understanding of mental illness, the stigma associated with mental disorders is likely to decline. Education ofthe public and health cane professionals is not yet well developed but could include discussion of the problem of stigma in medical schools and local school systems and dissemination of information to the public by local health departments. With reduced stigma and greater community acceptance of mentally ill patients, the government ofJapan and health cane professionals wilt need to focus on the following goals: #{149}The number of day care programs and halfway houses must be increased to reduce unnecessary hospitalizations.
Hospital
and
Community
Psychiatry
#{149}The Medical Cane Act of 1948 must be amended to eliminate the inequities in staffing between psychiatnic and general hospitals. #{149}Insurance payments for psychiatric counseling, therapy, and hospitalization must be reevaluated so that reimbursement for psychiatric care approaches that for nonpsychiatnic illnesses. #{149}Outpatient care and rehabititation programs must be improved to reduce the length ofhospital stays. #{149}Strategies must be developed to meet the needs of the rapidly increasing populations ofpatients with senile dementia. #{149}The physical environment of old, often overcrowded mental health facilities must be improved. Mental health care in Japan has much room for improvement. However, data from the literature review reported in this paper and from interviews with conscientious, devoted mental
health
professionals
that care of mentally slowly but surely humane direction.
seishin byoin [Evolving
10.
megutte [Amendment Hygiene Law]. Kokoro and Society] 46:15-20, 11.
12.
13.
14.
politan
3.
the
5.
(eds):
No
Seijin
Ternon Alienes. Kokumin
Tokyo,
[Human
Report]. Welfire,
Tokyo, Statistics
rights,
iryo
[Mental
problems
Health
care
Innovative Care].
1992
1991 file: overview and Care Financing
des
21.
Regional Office, Feb 1987 Ogata T: Review of progress on mental health legislation in Japan. Presented at the World Health Organization regional coordinating group meeting on the men1991 Takeda
programme, S: Iryo-hi
Manila,
kaitei
in medical law],
Feb-Mar
to iryo-ho kaisei care cost and mcd-
in Proceedings
ofthe
See-
on Psychiatric H. Tokyo, Japan
Care. Psy-
chiatric Association, 1990 Asai K: Iryo keizai to iryoho kaisei [Mcdical economics and the new medical law],
22.
23.
giene law]. Kokoro Society] 46:39-43, Ministry ofHealth
and
24.
1991 Kubota
shisetsu
[Mind shiko-go
no
[On the amendment
mondaiten
after
the
of Mental
Metropolitan
Vol. 43
World Pacific
ibid
hoken-ho
sum
Manila, Western
Ministry of Health and Welfare: Kosei Hakusho [White Paper on Health and Welfare]. Tokyo, Kosei Tokel Kyokai [Health and Statistics Association], 1990 KanekoS:Seishineisei-hokaisei ni tsuite
1986
Health
Programme. Organization,
ond Symposium Edited by Inoue
to ho kaisei and the
Revolution Tokyo,
Community Mental Group, 1990 9. Akimoto H: Henbo
November
Sept data
[Health care in Japan]. Tokyo, 1990 Report oftheThird Regional Coordinating Group Meeting on the Mental
ical care
implementation of the Mental Health Law], in Proceedings of the Second Symposium on Psychiatric Care. Edited by Inoue H. Tokyo, Japan Psychiatric Association, 1990 Fujisawa T (ed): Seishin Iryo no Bappon Teki Kaikaku wo Mezashite [Aiming at
the
Public
Iryo
[Changes
20.
KokorotoShakai
and Society] 46:27-31, Takemura K: Seishin ni okeru seishin-ka
19.
of the Ministry of
rehabilitation,
health
Office, Health
tal health
Ministry Bureau,
Y, Helman 5: Le Massacre Paris, Casterman, 1971 Eisei No Doukou [Status
lawamendmentl.
8.
Metro-
Hospital, Oct 1989 Hokoku [Eugenic Pro-
Nation’s Health]. Tokyo, Health and Welfare, 1991 6. Kato M: Jinken, shakai fukki
7.
Kan-
1989
Hospital.
Statistics of Health and 1990 4.
M
Matsuzawa Hogo Tokei
Yusei tection
health
16.
17.
Kanahara,
of
shikou
of one-
Gyosei,
Maeda
Tokyo,
ingj.
mental
methodology. Health Review ll(annual suppl):lll-l94, 1989 Ministry ofHealth and Welfare: Nippon
Kakuron[TheoniesofAdultNurs-
Outline
the
Regional PoullierJ:
Health Health
T,
of
1 5.
18.
2
implementation
health law], ibid Ogino T: Seishin hoken ho ichinen no keiken [Experience year implementation of mental law], ibid Shinfttku N: A Study of the
Health Approach to Mental Health in the Western Pacific Region: Theory and Practice From an International Public Health Perspective. Manila, World Health Organization, Western Pacific
References 1. Yoshida gogaku
of the Mental to Shakai [Mind 1986
ShikibaS: Seishinhoken-honokongono kadai [Future project under the new mental health lawj, in Proceedings of the Second Symposium on Psychiatric Cane. Edited by lnoue H. Tokyo, Japan Psychiatric Association, 1990 Furuya I: Seishin hoken ho shikou ichinen no keiken [Experience of one-
year
suggest
ill patients will move in a more
mental hospitals United States]. Kokoro to Shakai [Mind and Societyl 46:85-98, 1986 Doge C: Seishin kaisci ho no kaisei wo in the
Tokyo
Research America
No.
no
11
of the mental to Shakai
[Mind
hyand
1986 Welfare: Niju-lsseiki Wo Ninau Hitobito [Manpower of the 21st Century]. Tokyo, Chuo Hoki,
(seishin [Practice hospital, Seishin
A:
Iryo
deno
jissen
byoin, sogo byoin, shinryo-jo) in medical facilities (mental general hospital, clinics)], in Hoken Jissen Koza [Lecture on
the Practice
of Mental
Chuo Hoki,
1990
Health].
Tokyo,
1103
Paul
Health
Koizumi,
Harris,
Ph.D.
M.D.
Long-term institutionalization has been theprimary treatment for mentally ill patients in Japan since the early 1920s. The average length ofstay in ajapanese mental hospital in 1989 was 496 days, 41 times the average stay of patients in the United States. Although the government has encouraged and supported the integration of mentally ill people in the community and the development of rehabiitation programs since enactment of the Mental Health Law of 1988, implementation of such programs has been slow. The authors summarize the history ofmentai health care in Japan, discuss the current availability of mental health care facilities and personnel, and recommend changes needed to improve care.
Although Japan is among the most technologically advanced countries in the world and has the lowest infant mortality rate and highest life expectancy, the level of public understanding ofmental illness and the quality ofpsychiatric care lag fan behind those in other industrialized countries. Mental illness and other disabilities such as blindness and deafness still carry a major stigma.
Dr. Koizumi
is assistant
professor
in the department of health and nutritional sciences, Brooklyn College,
City
University
of
New
York, Bedford Avenue and Ayenue H, Brooklyn, New York 11210. Dr. Harris is associate professor of clinical pediatrics at the State University of New York Health
Sciences
lyn College
1100
Center
of Medicine.
at Brook-
Care in Japan J apanese parents thoroughly investigate the mental health histories of the families ofpotential sons- and daughters-in-law, not only of members of the immediate family but of distant relatives as well, alive or dead. People who are mentally ill themselves or have a family member who is mentally ill make extreme efforts to hide the fact from others. For example, people will often pay for their own care rather than make an insurance claim. This paper summarizes the histonical background of mental health care in Japan and discusses its current status, including the mental problems that are most prevalent, current availability of mental health facilities, and the kind of care patients receive. The data cited were collected by the senior author duning interviews with personnel at Japanese mental health facilities and government offices in July 1991.
deserves ennizing
credit mental
as a pioneer health care
in modin Japan
(1,2).
Historical background Until the early 20th century, the pnimary treatments for mental illness in J apan were folk medicine and “impnisonment” at home. Mentally ill people were regarded as burdens to society and were kept out of sight. Although a few mental hospitals cxisted in Tokyo, Kyoto, and Osaka, most were private facilities cxclusively for the wealthy (1). In 1900 the government enacted the Law ofEnclosure ofthe Mentally Disturbed, which required families to keep mentally ill family members locked in a special room at home. In 1901, however, Dr. Shuzo Kure, head ofthe Tokyo University Mental Hospital, a public facility, initiated the first major changes in the care of hospitalized patients. He prohibited the use ofrestraints on patients at his hospital and introduced exercise programs and occupational therapy such as gardening and sewing. Dr. Kure
In 1919 the government enacted the Mental Health Hospital Law, which required each prefecture (distnict) to build a mental health hospital. This law signified the beginning of systematic care and treatment of mentally ill patients by the public sector. As a result, society’s attitude toward the mentally ill gradually began to shift from one of confinement and physical restraint to one of protection and treatment (1). In 1940, however, the Eugenic Protection Law was enacted (3). The purpose of this law, which was similan to one enacted in Nazi Germany, was to make the nation healthy and strong by eliminating “bad genes.” Although the Japanese law permitted the liberal use ofabortion and sterilization, there is no record that genocide was practiced in Japan, as was the case in Nazi Germany (1,4). The Eugenic Protection Law remains in effect; its major current significance is to guarantee Japanese women access to abortion. In 1949 the Mental Health Hospital Association was established; its mission was to promote public mental health care. This association served as a catalyst for passage of the Mental Hygiene Law of 1950-a milestone in the history of mental health care in Japan. This law not only made the practice of confining mentally ill patients at home illegal but also strengthened the earlier requirement that each prefecture build a mental hospital. It also introduced the concept ofpublic counseling centens for psychiatric patients and a home-visit treatment program, new concepts for mental health care in Japan (1). (The programs mandated by law were not fully implemented, however, until 1 5 years later.) The Medical Care Financing Act
November
Hospital
1992
Vol. 43
No.
11
and
Community
Psychiatry
Table 1 Prevalence of mental disorders per 100,000 population in Japan in 1987, by age group1 Age group Under 15to19
(years)
Prevalence
15
20 58
20to24 25to34 35to44 45to54
139 295 462 587
55to64 65to69
571 508 549
70to74 75to79
594
80to84
714
Over84
981
I Source:
Ministry
ofHealth
and
WeIflire
(5).
Mental
disorders include schizophrenia, major depressive disorder, neuroses (neurotic conditions such as phobias and compulsions), organic mental disorder, mental retardation, epilepsy, and senile dementia.
of 1 960 provided public financial assistance to private institutions for the development of new psychiatric hospitals and the expansion of existing facilities. The result was a sharp increase in the number of psychiatric hospitals during the 1960s and 1970s. The act also provided government funds to coven half the cost of outpatient treatment (5). In 1965 the Mental Hygiene Law of 1950 was amended when a mentally disturbed 19-year-old assaulted the American ambassador to Japan with a knife and disabled him for life. This amendment led to several improvements in mental health care (1,6,7). For example, each prefecture was required to establish a counseling center. Partial coverage of the costs of psychiatric care was guaranteed by the government. The homevisit treatment program authorized by the Mental Hygiene Law of 1950 was implemented. Hospital admission procedures were improved. In addition, the police were given broad responsibility for registering the names ofmentally disturbed citizens with city and prefectural governments and, in severe cases, arresting and hospitalizing them. In 1 984 another scandal involving mentally illpatients occurred. At Utsunomiya Hospital in Utsun-
Hospital
and
Community
Psychiatry
omiya City, a few hundred miles north ofTokyo, two mental patients were beaten to death by hospital attendants (1,8-10). A police investigation revealed a series of criminal acts: the hospital had admitted more patients than it had beds, patients were forced to perform factory work, their money was spent without permission, and treatment was provided by unlicensed personnel. Complaints by mental health professionals and the public about these and other human rights abuses subsequently to an investigation by a team dispatched by the United Nations Human Rights Committee. Embarrassed by the team’s findings
and
strong
recommendations,
Prevalence of mental illness The overall prevalence ofmcntal disorders per 100,000 population increased from 67 in 1955 to 207 in 1965 and from 269 in 1975 to 339 in 1987. Whether the sharp increase represents an increase in the actual prevalence or an increase in the numben of cases reported is unclear. In the
prevalence
rate
represented
nearly 414,000 patients, and, according to a survey by the Ministry ofHealth and Welfare, 79 percent of those patients were hospitalized (5). Table 1 shows the prevalence of mental disorders in various age groups in 1987. Because ofthc increased longevity of the population, the high prevalence ofmental illness, including senile dementia, among the elderly is not surprising. The dis-
November
1992
Vol. 43
Diagnoses (N=
No.
11
Ion
339,749’)
inpatient and
(N=9.63 million1) percentages2
admissions
outpatient
injapan
visits
in 1987,
in
Inpa-
Outpa-
Diagnosis
tient
tient
Schizophrenia Senile dementia
61.1 9.3 6.2
18.2 3.4 33.1
Neuroses
Alcohol-related problems Manic-depressive disorder Mental retardation
4.6 4.4
12.7 1.8
Epilepsy
3.5
17.0
Other
5.0
12.0
1
the government enacted the Mental Health Law of 1988, which replaced the old Mental Hygiene Law of 1950. The new law called for increased protection ofpatients’ human rights, improved rehabilitation programs, and more effective programs for integrating mentally ill people into the community. So far, however, this law has had little apparent effect (7,11-13). The following sections outline the prevalence ofmental illness inJapan, the average length of hospitalization, the current status of mental health facilities, and the personnel responsible for care. The paper closes with an assessment of the changes necessary to achieve more humane care of mentally disturbed patients.
1987
Table 2
Based
6.0
on extrapolations
1989 data reported Health and Welfare
2
Source:
Shinfuku
(14)
from by the
1.8
1 988
Ministry
and
of
(21)
tnibution of mental disorders among hospitalized patients and outpatients is shown in Table 2. As in other Asian countries, schizophrenia is the major psychiatric illness among psychotic inpatients (14). (Note that the generic term neurosis is used in government documents and that mental retardation and epilepsy are included in the list of mental illnesses.) Length of hospitalization The average length of hospitalization fonJapanese mental patients was 496 days in 1989 (5), about seven times longer than in Sweden (72 days) and 41 times longer than in the United States (12 days) ( 1 5). Among schizophncnic patients, the average hospital stay was 632 days (5); for schizophnenic patients aged 65 and older, the average length of hospitalization was 2,758 days, on about seven and a half years. Extended lengths of stay were the result ofthe strong focus on inpatient treatment for all mentally ill patients until recent years (5). Long hospitalizations are also typical for medically ill patients in Japan; in 1989 the average length of stay in a hospital was 51.4 days (5,16). A lack of nursing homes may be a major contributor to the phenomenon of extended stays in general hospitals as well as in psychiatric hospitals. Since enactment of the Mental
1101
Health Law of 1988, the Ministry of Health and Welfare has encouraged the use of outpatient facilities for treatment. The number of clinics, day care centers, social rehabilitation facilities,
and
sheltered
workshops
is
increasing, often with the help of government subsidies. As a result, the number of inpatients, excluding those with senile dementia, is gradually declining. In July 1991 a total of 252 persons per 100,000 of the population were inpatients (17; Ogata T, personal communication, July 8, 1991). The decline has been slow, however, because many fami,
lies
do
family
because
not
want
their
mentally
member
to return
there
are few halfway
ill
home
and
houses.
Mental health facilities Hospitals. After years of significant increases in the number of psychiatnc hospitals, apparently as a result of the Medical Cane Financing Act of 1960 (8), the number has stabilized (18). As of 1988, Japan had 1,048 mental hospitals, 90 percent of which were private (5). The occupancy rate has been close to 100 percent for the last few decades (8). The total number of psychiatric beds was 439,963 in 1990 (14); those beds accounted for about 20 percent of all hospital beds (8). According to data collected by the Ministry of Health and Welfare (5, Ogata T, personal communication, July 8, 1991), 20 ofJapan’s 47 prefectures have a shortage of psychiatnc beds, whereas the remaining 27 prefectures have an excess number of beds. The hospitals with empty beds tend to be public hospitals that care for seriously ill patients who require hospitalization for long periods. Nevertheless, the ministry apparently believes that the overall number of psychiatric beds is adequate, except for patients with senile dementia (5, 18). In 1991 some of the smaller private hospitals were extremely crowded, and patients with different types and degrees of mental illness sometimes shared the same room. Public hospitals change patients 7,000 to 12,000 yen ($56 to $96) per day for inpatient care. For example, one large public hospital in Tokyo charged 10,685 yen ($85) in May 1991. Both public and private hospi-
1102
tals change more for private rooms. At one private hospital in Tokyo, the rate was 36,000 yen ($250) for a pnivate room, compared with 1 5 ,000 to 25,000 yen ($120 to $200) for nonprivate rooms. Although most public psychiatric deficit,
ment pitals,
they
hospitals are
assisted
subsidies, whereas which represent
all psychiatric
hospitals,
operate
at a
by govenn
private hos90 percent of must
cover
their deficits by other means, such as dispensing drugs and administering medical tests (1 9,20). The fact that the government subsidizes only public hospitals is a sore point for private hospitals. Outpatient clinics. The number of psychiatric outpatient facilities has increased dramatically since enactment of the Mental Hygiene Law of 1965, which guaranteed pubtic financial assistance for outpatient services. As of 1989,Japan had 520 psychiatric clinics, and the number is increasing (17,20). Patient visits to these facilities more than tripled between 1965 and 1988-from 2.76 million to 9.96 million (21). Otberfacilities and programs. Establishment of rehabilitation programs and community-based treatment represents the major thrust of future efforts to provide psychiatric cane. In 1991 the Ministry of Health and Welfare announced that the foltowing facilities would be completed within the next few years: 186 day or night care centers that provide multidisciplinary treatment, 1 ,438 rehabilitation centers for ambulatory patients, 57 dormitories and welfare homes (halfway houses), 41 training centers for pregnant mentally ill women, and 209 occupational training facilities (5). Care providers The personnel who work with psychiatnic patients include 8,700 psychiatnists, 53,000 nurses, 14,000#{149} nurses’ aides, 2,000 clinical psychologists, 469 occupational therapists, and
several
thousand
psychiatric
so-
Health and Welfare to introduce a system of licensing and registration for clinical psychologists and psychiatnic social workers have been unsuccessful (22; Shinfuku N, personal communication, April 28, 1992). During her visit, the senior author met only seven clinical psychologists working in mental health facilities at three different institutions. Six were supervised directly by psychiatrists; the seventh headed one of the fewer than ten psychiatric counseling centens in Japan operated by clinical psychologists. The 469 occupational therapists who work with psychiatric patients represent only 1 1 percent of the 4,018 registered occupational therapists in Japan. Occupational therapy is a relatively
(8).
Other
cat
Hospital
11
industrialized
services,
November
No.
in Japan;
the
countries
including
feeding
the
patient, cleaning the patient’s room, and doing the patient’s laundry. Another reason is the Medical Care Act of 1948, which allows the ratio of providers to patients to be much lower in psychiatric hospitals than in general hospitals (8). J apanese psychiatrists often complain
VoL 43
field
have a much higher number of professionat caregivers. For example, the rate pen 1 00 beds is 267 in the United States, 1 74 in Sweden, 1 37 in France, and 1 1 3 in Germany. One reason for the lower ratio of professionals to patients in Japanese psychiatric hospitals is that to reduce costs, family members arc often recruited as unpaid auxiliary caregivers. They provide many nonmedi-
cial workers (18). The number of psychiatrists per 100,000 population in Japan as of 1991 was 7.08, which is one of the highest among the countries in the Asian and Western Pacific region (14). Attempts by the Ministry of
1992
new
first professional training program for occupational therapists was established in 1975 (23). The shortage of professional personnet is greaten in mental health cane facilities than in other health cane settings. An average ofonly 22 professional personnel are available for each 100 psychiatric beds, whereas the average is 77 professionals for every 100 beds in general hospitals
that
their
salaries
are
much
lower than the salaries of other specialists. Insurance programs do not recognize counseling and psychotherapy as methods of medical treatment that deserve to be reimbursed. Many of the psychiatrists inter-
and
Community
Psychiatry
viewed complained that insurance reimbursements amount to only 2,500 yen ($20) for one counseling or psychotherapy session, no matter whether the session lasts 20 minutes or two hours. As a result, psychiatnists are forced to see as many patients as possible per day. One psychiatnist in the outpatient department of a large public psychiatric hospital scheduled more than 60 patients during a nine-to-ten-hour day. He said the average session lasted only ten minutes unless the patient had a special need. The same situation was reported by personnel in the psychiatric outpatient department of a lange private hospital in Tokyo. In general, primary care physicians provide little care for mentally ill patients.
Psychiatrists
often
plained about other physicians’ of interest in and discrimination against mentally ill patients.
com-
tack
Conclusions Japan’s Mental Health Law of 1988 set two major goals: enhanced protection of the human rights of mentally ill patients and an increased number of rehabilitation programs to enable patients to be integrated into their communities (24). The slow progress toward achieving these goals is partly the result of public apathy and the slow-moving efforts typical ofgovernments (7,1 1-13). As the Japanese public becomes better educated about mental illness and the importance of prevention and early treatment and as nonpsychiatric health care professionals increase their understanding of mental illness, the stigma associated with mental disorders is likely to decline. Education ofthe public and health cane professionals is not yet well developed but could include discussion of the problem of stigma in medical schools and local school systems and dissemination of information to the public by local health departments. With reduced stigma and greater community acceptance of mentally ill patients, the government ofJapan and health cane professionals wilt need to focus on the following goals: #{149}The number of day care programs and halfway houses must be increased to reduce unnecessary hospitalizations.
Hospital
and
Community
Psychiatry
#{149}The Medical Cane Act of 1948 must be amended to eliminate the inequities in staffing between psychiatnic and general hospitals. #{149}Insurance payments for psychiatric counseling, therapy, and hospitalization must be reevaluated so that reimbursement for psychiatric care approaches that for nonpsychiatnic illnesses. #{149}Outpatient care and rehabititation programs must be improved to reduce the length ofhospital stays. #{149}Strategies must be developed to meet the needs of the rapidly increasing populations ofpatients with senile dementia. #{149}The physical environment of old, often overcrowded mental health facilities must be improved. Mental health care in Japan has much room for improvement. However, data from the literature review reported in this paper and from interviews with conscientious, devoted mental
health
professionals
that care of mentally slowly but surely humane direction.
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