Her schizophrenia repeatedly sent her over the edge.
In the past decade, the parents of the Yokohama woman, now in her 40s, were forced to have her hospitalized more than 10 times.
When she lost control and turned violent late one night 10 years ago, her parents made the painful decision to call the police, because the local daytime mental health services were unavailable.
Confined for several hours in a police station, in unfamiliar surroundings, her condition worsened and she had to be committed to a mental hospital.
“That night instilled in my daughter a great mistrust in us and in the medical community,” recalled the woman’s father, a retiree in his 80s.
“Neither parents nor police have even a remote chance of calming down an acute psychiatric case,” he said. “For such patients to live outside hospitals, 24-hour emergency medical care is indispensable.”
Japan has long drawn criticism because among developed nations it has the most mental patients in institutions and their stays in those facilities are the longest. The current tally is 330,000 and the average hospital stay is 330 days.
The numbers don’t get any better in part because of a lack of sufficient care facilities, including special workshops and group homes, that could enable psychiatric patients to live outside institutions.
Medical experts believe Japan is in urgent need of an emergency psychiatric care system available round the clock that would serve as a safety net for people with severe problems living alone or with their families.
The Health, Labor and Welfare Ministry estimates that about 72,000 people with psychiatric conditions remain institutionalized not for medical reasons but because of personal or social problems, including lack of family or welfare support to enable them to live in society.
“Emergencies do not always hit during normal hospital hours,” said Kazuko Hirota, a schizophrenic and member of a special committee appointed by the health ministry to discuss psychiatric issues.
“The government should focus on developing 24-hour emergency care for mentally ill people in its current effort to help such patients live in society,” she said.
The ministry has divided the country into 160 medical districts and has recommended that the local governments in these zones make at least one hospital bed available for mental patients during nights and weekends, an option that can be costly. The measure, however, is not mandatory and many areas do not comply, ministry officials said.
Critics say the problem is compounded by the minuscule national health insurance payment — 16,000 yen per patient a day — for emergency psychiatric services. The payment, set by the government, for other types of medical emergencies is around 100,000 yen a day.
“The current medical payment is hardly enough for hospitals to provide proper treatment for acute mental patients, who require intensive treatment and manpower,” said psychiatrist Kazuo Kemmi, president of the Chiba Psychiatric Medical Center and one of the country’s leading experts on emergency psychiatric services.
“Hospitals cannot afford to make beds available for emergency mental patients at night unless substantial subsidies are granted,” he said.
The ministry provides hospitals with a daily 5,000 yen subsidy per bed for nighttime emergency psychiatric care, but health ministry officials admit that amount is no inducement.
Another problem is the lack of a 24-hour information service that could promptly connect patients to mental facilities with available beds.
Starting this year, the health ministry began granting about 20 million yen in subsidies to prefectural governments and major municipal governments to operate such services.
At least 12 prefectures and cities have set up centers, and 10 more are preparing to do so, the officials said.
The shortage of nighttime beds and information about those that exist has forced people with psychiatric emergencies to often suffer through their conditions at home or at police stations.
The Kanagawa Prefectural Police said some of its stations receive more than 10 calls a night from patients, families and neighbors alerting them to problems.
Last year, the force took care of patients 2,110 times and reported 555 of the cases to public health centers so that medical authorities could take over. The Mental Health and Welfare Law requires police to report cases involving people who pose physical danger to themselves or others.
Kanagawa Prefecture started up a 24-hour information center in April to help police and rescue workers find available night and weekend hospital beds.
The prefecture has also made 19 beds at five hospitals available for psychiatric emergencies, but it still takes more than four hours on average for people in police protective care to find hospitals.
“It usually takes several hours, often until morning, before a patient finds an empty bed,” a senior Kanagawa police officer said. “It causes great stress both for the patients and our officers, as we have no medical knowledge.”
There are around three occasions a year in the prefecture when emergency cases must wait for more than 40 hours at police stations.
Tokyo, which has the largest mental outpatient population at some 130,000, had 16 emergency beds available at four public hospitals during the night and weekends until the beginning of September.
Last year, patients either visited the hospitals on their own, via police or were brought in by rescue workers in 2,149 cases. In 1,816 cases, patients were immediately hospitalized.
Because there weren’t enough beds, people suffering minor psychiatric emergencies could not be treated, metropolitan officials said, noting help was only provided in serious cases involving police.
The metropolitan government added five more nighttime emergency beds in September and ordered three hospitals to provide nighttime outpatient service. It has also opened a 24-hour information center.
For many years, only Chiba Prefecture offered an institutionalized 24-hour medical information center and a system to immediately connect all people in need of immediate treatment with care services.
Chiba out in front
The Chiba Psychiatric Medical Center opened in 1985 in the city of Chiba, and it is still the only mental hospital in the country specializing in 24-hour emergency service. It also serves as an information hub for all patients in the prefecture.
The 50-bed institution accepts some 450 emergency mental patients annually. Staffed with psychiatric social workers, its “Intake Room” information center each year receives some 20,000 emergency calls and inquiries from patients, their families, police, rescue workers and other hospitals.
The main job of the information center is to judge whether it is necessary for people who contact it to be hospitalized immediately and to arrange beds for them at the institution or other hospitals that are open at night.
Many people call merely to complain about minor problems, such as insomnia, or to report that they did not take their medication properly.
“By just talking with us, many of them feel better or become able to wait until their clinics open the next day,” said Ikuo Watanabe, one of the psychiatric social workers.
“What is important is to provide patients with the security of knowing they always have access to medical services when necessary,” he said.
One surprising achievement the hospital can boast is the much shorter stay by patients — 40 days — compared with the 330-day national average, even though most of its patients are admitted with acute conditions.
Kemmi, the center’s founding president, said emergency psychiatry is the key.
“Treatment during the acute stage affects the entire treatment course,” the veteran psychiatrist said. “Thus giving maximum treatment at that phase is necessary to avoid an unnecessarily long hospital stay.”
The institution has been successful because of its high doctor-patient ratio: It provides intensive care to its 50 inpatients through 12 doctors and 40 nurses.
The health ministry allows mental hospitals to have 48 inpatients per doctor and six per nurse.
Until last year, the Chiba center was partly sustained by some 520 million yen in annual subsidies by the prefectural government until last year. This year, the ministry increased the daily inpatient insurance outlay to 30,000 yen thanks to its highly effective treatment.
“The costs are not high compared with the social cost of long-term hospitalization,” Kemmi said. “Besides, our system better helps patients live normal lives in society.”
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