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