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Japan’s mental health policy: Disaster or reform?

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Recently, the Japanese government’s plan to release 70,000 mentally ill Japanese hit the headlines.

When I saw it, I did not have a very good feeling inside.

As a psych major, I studied about the disastrous legacy of deinstitutionalization in school. I grew up in Philadelphia and saw what happened in the 1980s – mentally ill homeless people, clearly off their meds, wandering the streets panhandling, talking to themselves, relieving themselves in the gutters, dying whenever there was extreme whether, and occasionally getting beaten to death by delinquent youths, themselves in dire need of help.

Despite this, the idea of deinstitutionalization in itself was a good idea. It was considered humane, as many public institutions even at that time, were little more than warehouses of horror rife with violence and neglect.

The idea was to use newly developed medications to stabilize mentally ill people, get them into community care and offer treatment, support and social rehabilitation as necessary. But by the 1980s, the safety nets were gone and many, institutionalized for years without friends or family, wound up in the streets.

Japanese deinstitutionaliztion: Is it the same?

Needless to say, the question arises: Are we looking at the same situation in Japan?

The answer is yes and no.

First, a few psychiatric definitions are needed.

Schizophrenia is an incurable often-debilitating brain disorder with a lifetime prevalence of about 1% in most parts of the world. According to the WHO, it affects 24 million people worldwide. In Japan, a 2002 study reported that over 200,000 people a day were being treated for the disorder. Schizophrenia’s prevalence makes it many times more common than HIV, Insulin Dependent Diabetes or even Alzheimer’s.

There are different types of schizophrenia. Some involve hearing voices and having delusional thoughts. Other sufferers may speak in a type of gibberish. Their speech, thought and behavior often make little sense, and they’re unable to take care of themselves. In contrast, catatonics exhibit strange but voluntary movements, sometimes repetitive – they may also repeat what people say or imitate the movements of others. They can go into stupors that can last for months in which they contort their body into bizarre postures and resist any effort to change the position.

Although the condition is not fully understood, it is currently believed to result from a mix of biological and genetic vulnerability as well as stress from life experience.

Up until the mid-1950s, schizophrenia was untreatable, and patients had to be “warehoused” in asylums. In Japan, some were kept restrained by families in small rooms or huts. Early drugs offered some hope; however, first generation anti-psychotics tended to have severe effects, including heavy sedation and permanent motor damage. Today, with the availability of many newer, more tolerable and more effective anti-psychotic medications, the prognosis is good for about 75% of patients suffering from the condition.

The stigma of mental illness

Up until the 1990s in Japan, schizophrenia was referred to as “seishin bunretsu byo” (split personality disorder) and was viewed as a type of untreatable degenerative insanity. Because of this, out of consideration for the patient and family, many doctors were reluctant to use the diagnosis. Furthermore, according to a survey in 1996, 77.3% of Japanese Society of Psychiatry and Neurology members still viewed the disease as untreatable.

To solve the problem, the condition was renamed “togo shitcho sho” (integration disorder). The new clinical definition indicated recovery was possible if a combination of advanced pharmacotherapy and appropriate psychosocial intervention was used. The result of the renaming was that up to almost 90% of doctors reported that they found it easier to inform patients of the diagnosis and concept of the disorder – improving the likelihood for treatment consent and compliance. But acceptance of the term also resulted in a surge of diagnoses, meaning, more hospitalizations just at a time most hospitals in the West were emptying out.

Today, the average hospital stay in America is just a few days, but in Japan, it is a little over a year. One theory is that 80% of hospitals in Japan are privately owned and that as a type of “corruption,” hospitals keep patients hospitalized longer than they have to.

Dr Isao Shibata, an English-speaking psychiatrist at Kawaguchi Hospital in Saitama, who specializes in the treatment of schizophrenia, disagrees.

He explains, “In Japanese psychiatric hospitals, there are many in-patients who don’t seem to need admission, but the hospital has a role as an accommodation facility for stable patients whose family reject them.” He also points to a lack of community care options. “In Japan, there are few social resources available as accommodation for psychiatric patients.”

Dr Shibata says more accommodation needs to be built, but community opposition is a problem. “If there were more life-training facilities and more group homes, more patients could be discharged,” he explains. “In my hospital, there are many stable in-patients, so sometimes I can’t admit acute patients who really need admission.”

Dr Shibata estimates that if more outpatient facilities were available, about one third of his patients could be immediately released.

I asked Dr Shibata about the government’s order to release 70,000 mental patients. “The Ministry of Health, Labor and Welfare had decided that 70,000 psychiatric patients were to be discharged over the next 10 years, but without force," he explained. "In order to encourage it, the ministry decided that if the hospitals discharged 5% of long-stay patients every year, they could receive a special allowance from April 2008.”

The idea is for the special allowance to help hospitals “downsize” by transitioning to outpatient and residential care facilities. This will also keep them from going bankrupt in the process, especially as their services will still be needed to treat acute patients.

And so the question arises, with overwhelming evidence that long-term hospitalizations are unnecessary and community care is the way to go, is cash-strapped Japan prepared to make the transition?

© Japan Today

©2022 GPlusMedia Inc.

11 Comments
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Japan doesn't look at their mentally ill well at all. "Releasing" people isn't the solution for them - it is a cost cutting measure for the government. I think the public will be the one to pay the price for it. Japan needs to get its head out of the sand and start addressing issues like depression, postpartum and various other illness that run rampant here.

0 ( +2 / -2 )

With all due respect to Mr. Landsberg, being a "psych major" does not qualify one to write an article on Japan's mental health policy. My criticisms of this article (as a qualified, registered and experience psychologist) are numerous, such as:

The article deals almost exclusively with schizophrenia, however no data is provided on what percentage of the patients currently institutionalised have been diagnosed with this condition, Some conditions are respond very well to outpatient and self-medication, while schizophrenia is notorious for not being one of these.

The author makes a spurious comparison between treatment in the U.S. where treatment is just a few days, and compares is to the average of a year in Japan, and then alleges corruption, but clearly has no understanding that if anything the Japanese approach is more correct, since while the onset time of antipsychotic medications is very rapid (within a day or so in most cases) the critical problem is that patients feel better and stop taking the medication. A few months, at minimum, of institutionalisation or supervised medication, are required to establish a "habit" of taking medication, or else the risk of relapse is extremely high. Studies have shown that as schizophrenia is a life-long condition it is cheaper in the long-run to institutionalise initially for a longer period and lower the possibility of relapse, rather than having the patient come in repeatedly for short-term visits of a few days on a virtually monthly basis when they almost inevitably relapse from not taking their medication. In this light the author's contention that the longer institutionalisation period in Japan is linked to corruption is incorrect, and rather the U.S. policy of short institutionalisations borders, in my opinion, on administratively convenient malpractice.

The author's comparison between the situation in the 1980's and the current situation nearly 3 decades later completely ignores incredible advances in the medications available to patients and the less severe side-effects and more efficient action of these medications. In short, the comparison is spurious. While the issue of homelessness and a lack of social support is relevant the assumption that released patients will not pass the functionality test (i.e. that they will be unable to find employment and housing, and live relatively normal lives) is a huge leap in logic, and essentially starts from the assumption that Japanese mental health care professionals will not consider this in their decision to discharge patients.

In short this article is precisely what one would expect from someone with an undergraduate degree in psychology, not addressing the major issues, leaping to unfounded conclusions and filled with unsupported criticisms. I would agree that the state of mental health care in Japan is generally deplorable, however, on the basis of the evidence presented in this article, this policy is not in and of itself a retrograde step, and could be carried out successfully and to the benefit of patients.

-1 ( +5 / -6 )

Mental health is a serious issue. I worked as a volunteer with mental health patients(in the community) in the UK for 12 years and have assisted 2 Japanese since being in Japan.Hands on is the only way to know about this subject properly, nota UNI course and 1 interview with a shrink.

Most people with mental health issues can live good lives and work. In Japan though they are encouraged to be on welfare for life, without therapy or help with finding woirk. That is the real scandal, not the news about releasing 70'000 people.

0 ( +3 / -3 )

My wife works at a mental clinic as a dietician/ advisor/ mentor and she seems to support this move.Many of the people at her clinic are Schizophrenics or have dissociative personality disorder..of course quite a lot are manic depressives too. They come to her clinic and she teaches them how to cook nutritious meals as many folk with mental illness lock themselves in their houses and eat pure junk, which then makes them fat and gives them bad skin etc and this further makes them reluctant to leave their houses. The important thing is follow-up, I guess. In many cases the patients with severe conditions will stop taking their medication and not attend the clinics.This can lead to dangerous situations for both the patient and others. My own experiences with mental health practitioners here have been very unsatisfactory..very little time to talk and try to get to the root of the problem and palming off handfuls of drugs.

0 ( +2 / -2 )

Mr Brannan; Sounds like great work your wife does working with people who can be difficult at times and make the job hard at times.

You are right about the lack of helping the people back into society re looking after tehmselves. A big problme i have found is money management. Some get welfare while inside and teh hospital holds some of the money. Many are released and tnd blow the lot in days with any monitoring. Usually they are back at the institution within months.

0 ( +3 / -3 )

Also, I think people who don't live in Japan also aren't qualified to comment on its issues.

-1 ( +0 / -1 )

Well - it rather looks as though the writer of the article does live in Japan.

He knows some Japanese and has Japanese contacts.

But I wonder who would be qualified to comment on mental health issues?

If it were a problem about music, you would expect comments from a person who could actually play an instrument.

But since no one actually gets cured in a psychiatric hospital, I don't suppose anyone could be found who is qualified to comment on the issue.

So, Mr Landsberg's comments are probably as good as anyone else's.

0 ( +0 / -0 )

@johninnaha The author doesn't seem to be expressing his own opinion. He's citing facts then interviews an expert. The first part of the story is him wondering about the issue and stating facts about the American side -- then he provides statistics then he interviews the doctor then asks the reader to decide. I don't see what's so controversial about that.

0 ( +0 / -0 )

I lived in San Francisco when Pres. Reagan signed the bill that released all the mental cases into the general population. From that time on, I witnessed plenty of "integration into the mainstream"...such as the local parking lot, the street corners, and under the main stream bridges. Not a good idea to release nutters without a system to support them.

0 ( +0 / -0 )

When I was a kid in England, only the really dangerous cases were in psychiatric hospitals. One of the harmless ones worked in the local bacon factory, preparing the intestines for sausage skins. I wouldn't do that job at ten times his salary, but he was very happy. Another worked on the dust cart and was one day told to sweep a certain street. When he hadn't returned, they went out to look for him and he was halfway to the next town, still sweeping.

These guys and several others were quite harmless and they performed a useful function in society. Perhaps if Japanese people didn't have a stigma against more or less any kind of handicap these people could perform a useful function in Japan too.

0 ( +0 / -0 )

Those mentally illness need to have their own freedom for the human rights.

Mental Illness has the world of themselves, reasoning of their own action and thoughts. So with the those who do not have the mental illness. This is the fight between those in Mental healthy versus Mental illness.

However, the writer has expressed his mental is in such a great condition by talking bad about Mental Illness people.

Gosh, how do we define the "twisted" mind that would describe mental is healthy.

0 ( +0 / -0 )

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