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Shedding light on problems with Japan’s psychiatric care

by Jeff Kingston

MENTAL HEALTH CARE IN JAPAN, edited by Ruth Taplin and Sandra J. Lawman. Routledge, 2012, 148 pp., $155 (hardcover)

This collection of seven chapters makes for grim reading because it details the miserable state of mental health care in Japan.

One key problem is the, “megadose culture in psychiatric care.” Patients are kept sedated with massive doses of psychiatric drugs to pacify them, a situation partially due to chronic understaffing. According to these experts, this antediluvian approach fails to help these “quiet patients” and is symptomatic of wider problems.

There is a strong stigma attached to mental illness in Japan that discourages many people from seeking the help they need. But even if they do, the health care system does not cater to their needs and is skewed toward a high dosage, poly-pharmacy therapy that generates profits for the prescribing doctors.

Yayoi Imamura suggests that this problem stems from inadequate psychiatric medical education and the reimbursement system of national health insurance. These shortcomings contribute to relatively poor care (and outcomes) for patients.

Renaming the disease was undertaken to reduce the social stigma. According to Hiroto Ito, the 2002 shift in the term for schizophrenia from seishin bunretsu byo (disease of a split and disorganized mind) to togo shicchou sho (dysfunction of integration) “has been well accepted.”

Perhaps, but as he and other authors acknowledge, awareness of mental illness in Japan remains low and overall public perceptions of mental disorders tend to be negative.

U.S. Ambassador Edwin Reischauer played an inadvertent role in the evolution of mental health care in Japan and a spike in social stigma. In 1964, a knife-wielding schizophrenic seriously injured Reischauer, prompting a mass media campaign highlighting the dangers poised by the mentally ill. As a result of this orchestrated public hysteria, the government introduced compulsory institutionalization. In addition, doctors were required to notify local police in cases where the patient might cause harm. In 1970, over 75,000 patients, mostly from lower income groups, were forcibly institutionalized, a figure that has dropped to 1,800 owing to concerns about patient’s human rights and greater emphasis on outpatient care.

The media later became a force for reform as one Asahi reporter actually had himself committed and then reported about the mistreatment of patients.

More spectacularly, in a case that drew global attention, the media exposed gross violations and physical abuse at a mental hospital in Utsunomiya, Tochigi Prefecture, causing injuries that led to death.

Subsequently, reforms have shifted care from hospitals to rehabilitation centers and more recently to communities, with greater emphasis on outpatient care and social integration. Despite some success with anti-stigma campaigns, however, a sensationalist media is ever eager to highlight violent crimes and speculate irresponsibly about the mental health of suspects, fanning prejudice and anxieties.

According to Hajime Oketani and Hiromi Akiyama, “no major step toward fundamental and radical changes has been taken for the past 50 years.”

They argue that further reform is blocked by the Japanese Association of Psychiatric Hospitals, a private industry lobby group that zealously guards its beds and profits. As a result, dysfunctional practices in Japan’s mental health care system persist.

Given the high number of suicides in Japan, annually over 30,000 since 1998, there is an urgent need to improve diagnosis and treatment of mental illness, but the authors find few promising signs that the government is effectively addressing this crisis. It is encouraging, nonetheless, that a user-centered movement on mental care services is emerging, providing mutual support, mobilizing pressure against discrimination and raising awareness about problematic practices. Yet there is a long way to go.

Although this book could benefit from better editing and translation, and in some places reads like a tedious official report, it contributes to our understanding of what is wrong and what needs to be done. But at this steep price, it is one for the libraries.

Jeff Kingston is the director of Asian Studies at Temple University, Japan campus.