Staff writer Unlike the common image of mental institutions with tight security and barred windows, the Yowa Hospital in Nerima Ward, Tokyo, looks no different than a general hospital.

Together with its renovated entrance, cafeteria and green courtyard, the hospital’s interior showcases efforts made to improve the environment for patients. Still, the hospital admits there is much room for improvement.

“More than anything, I want to give patients more bed space and amenities,” said Kimio Moriyama, president of the privately run hospital that currently accommodates around 400 patients.

“But government funding for treatment of mental patients is too low to bring all the necessary improvements to our hospital.”

The killing of eight children at an Osaka elementary school by a knife-wielding man with a history of mental illness put the spotlight on psychiatric services, which are often criticized as ineffective or inhumane.

Despite efforts to create more space, most of the bedrooms, dining and amenity spaces inside Yowa Hospital are congested with patients, 30 percent of whom have stayed at the hospital for more than four years.

Nonetheless, a 48-year old patient treated for depression who left the hospital in February after spending three years there said it was the best of the four mental institutions he had spent time in. “At least Yowa was trying to help its patients back into society,” he said.

Highest rates in the world

Statistics paint a dreary picture of the state of Japan’s mental health. Japan has the highest number of hospital patients with mental illness in the world. The average stay at mental institutions is also the longest in the world.

As of the end of June 1999, there were 332,930 patients with psychiatric illnesses living in 1,663 mental hospitals throughout the country, which had a total bed capacity of 348,810.

The average stay at such hospitals was a lengthy 406 days.

Since the early 1960s, many industrialized countries have promoted the “deinstitutionalization” of mental patients, following the development of effective medicines for schizophrenia and depression that enable patients to live in society.

In the United States, for example, the number of beds at mental institutions was reduced from 600,000 in the mid-1960s to the current 90,000. European countries followed a similar path, while providing welfare facilities such as workshops and group homes to help mental patients live outside hospitals.

In Japan, however, exactly the opposite has happened. Total bed capacity jumped from 85,000 in 1960 to 340,000 by the early 1980s — and has remained steady ever since. In 1999, Japan had 28 beds for psychiatric patients per 10,000 people.

The U.S. had 4 beds per 10,000 people and Britain 10 per 10,000, in 1998.

It is only in recent years that the Japanese government has started to place emphasis on the treatment of mental patients.

Under the Law for the Custody of Insane Persons, which was in effect between 1900 and 1950, parents were obliged to confine their mentally ill children at home.

Since the 1960s, the government’s basic policy has been one of building institutions, increasing the number of mental facilities around the country.

While the government finally shifted to a policy of community-based care and deinstitutionalization in 1987, there are few signs that anything has changed.

Mental illness ‘incurable’

Experts say health authorities’ traditional neglect of psychiatry is still reflected in the gap in standard medical fees set by the government for mental patients and patients at general hospitals.

Medical compensation paid by public health insurance programs to general hospitals currently averages around 34,000 yen per patient per day; the figure at mental institutions stands at only 13,000 yen.

Although mental patients accounted for 24 percent of all hospital patients in 1999, only 5.3 percent of public medical funding was spent on such patients.

Health, Labor and Welfare Ministry officials said the situation reflects the traditional belief that mental diseases are incurable.

“Psychiatry used to be regarded as a peripheral field in medical circles,” said one official.

Such beliefs also lie behind the gap between the legally required ratio of patients to doctors at psychiatric institutions, and the ratio at hospitals treating patients with physical diseases.

The Medical Service Law stipulates that there be at least one doctor per 16 patients and at least one nurse per three patients at hospitals for physical diseases.

Psychiatric institutions, however, are allowed to have 48 patients per doctor and six patients per nurse by a special provision made by the health ministry in 1958.

“Psychiatric service usually requires more staff, as it relies on mutual trust between doctors and patients,” said Toshio Fujisawa, a psychiatrist at a Nishinoki Clinic in Tachikawa in western Tokyo.

“Lack of sufficient funding and staff also diminishes patients’ chances of returning to society, as it forces treatment based on medication rather than on counseling.”

Pitfalls of privatization

One major reason behind the slow progress in the government’s deinstitutionalization policy can be traced back to the history of Japan’s psychiatric institutions.

Between the 1950s and the 1980s, the government pursued a policy of granting low-interest loans or subsidies to private hospitals to expand their mental wards.

Currently, 82 percent of the country’s 1,670 mental institutions are privately run. The structure is the opposite in many other industrialized countries.

“Private hospitals often sacrifice patients’ rights for the sake of their operations,” said psychiatrist Fujisawa of the Nishinoki Clinic.

“Many hospitals keep patients only to fill up their beds.”

One of the worst examples came to light in December, when Asakura Hospital in Showa, Saitama Prefecture, was found to have unnecessarily used a risky and expensive feeding method on its patients only to pad bills.

Several patients died as a result.

The private hospital, which was shut down in July, also reportedly tied and locked up inpatients.

The reason? There weren’t enough staff to look after the patients.

Fujisawa said he believes there is at least one hospital in every prefecture that similarly ignores patients’ rights.

The Japanese Association of Psychiatric Hospitals, which represents 90 percent of private mental hospitals, has reportedly opposed every move by the government to reduce bed capacity.

It has also opposed government efforts to increase the number of doctors and nurses per patient.

It’s hardly surprising that the association is said to have strong lobbying power over the health ministry’s decision making.

Tsuneo Senba, chairman of the association, said the government must increase medical fees for psychiatric patients so that private hospitals can survive with fewer beds.

“The current situation is that the ministry is asking us for better service while ignoring its duty to spend more money on psychiatry.”