[Event Report] The 76th Breakfast Meeting—”Reflections from Abroad on Issues Facing Japan—Mental Health” (March 3, 2019)
HGPI was quick to recognize the importance of finding NCD countermeasures and has cooperated with the NCD Alliance since 2011. HGPI became a full member of the NCD Alliance this year, in 2019. We will work to provide a platform where multi-stakeholders can discuss improvements in policy countermeasures for all NCDs and we will continue to promote the importance of civil society’s role in fighting NCDs both domestically and abroad.
76th Breakfast Meeting focused on mental health, a particularly important topic among NCDs. It featured a presentation from Dr. Kanna Sugiura, a psychiatrist with clinical experience treating people with mental illnesses and a background in international organizations and the Ministry of Foreign Affairs (MOFA).
■ The sense of discomfort during her time as a clinician
During her time as a clinician in the psychiatric ward, Dr. Sugiura witnessed long-term hospitalizations and physical restraint, as well as a difference in the care environment between the psychiatric ward and the general ward. For example, there are significant differences between them in the number of healthcare providers per patient and the usage of private rooms. This made her question the so-called “best practices” employed in mental healthcare. After looking into the state of mental healthcare in other countries, Dr. Sugiura found some countries offered full, well-developed services while other countries had no psychiatrists whatsoever. She became interested in two topics: how to improve existing services, and how to introduce services where there are none. In pursuit of these questions, Dr. Sugiura travelled to England to enroll at London University to reinforce her clinical experience with knowledge of public health and public health systems.
■Is mental health a low-priority field?
In discussions on issues facing global healthcare, Dr. Sugiura has heard people question the necessity of discussing mental health or the opinion that it is a low-priority issue compared to providing perinatal care for mothers and children or controlling infectious diseases. However, there are approximately 800,000 suicide victims each year worldwide. While the number of annual suicide victims in Japan has been trending downwards to under 30,000 from 2012, over 20,000 people in Japan take their own lives every year. The effect of suicide on society is enormous. Suicide is the leading cause of death for Japanese people between ages 15 and 39 *1, and this trend can be observed around the world. Additionally, in Japan, deaths that cannot be clearly be determined to be suicide are not included in the statistics on suicide victims. It is reasonable to assume the actual number of suicide victims is greater than reported. Even for other causes of death, people with mental illnesses have average life spans 20 years shorter *2 than people with none.
Disability-Adjusted Life Years (DALYs) are used to quantify the burden of a disease and express years lost to morbidity, disability, and early death. When examining mental illness, DALYs show that the heaviest burden is placed on people between ages 10 and 20. This age range covers a critical period in life, when people are educated and make decisions concerning their future employment. To shoulder a mental illness during this period places a long-lasting burden on the person effected. We need measures that target this issue at its core.
*1 According to Ministry of Health, Labour and Welfare (MHLW) estimates published in the Outline of Health, Labour and Welfare Statistics for 2017.
*2 Kondo, Shinsuke et al. Premature deaths among individuals with severe mental illness after discharge from long-term hospitalization in Japan: a naturalistic observation during a 24-year period. British Journal of Psychiatry Open, 3(4),193-195, 2017
■The position of mental health within global health topics
A special report published in 2007 called Global Mental Health: The Lancet brought worldwide attention to mental health. This led the way for many other 2007 publications from around the world that placed mental health at the forefront. For example, the World Health Organization published the WHO Mental Health Gap Action Programme (mhGAP) to provide guidelines for psychiatric evaluation and care processes and created the WHO Quality Rights to outline methods for evaluating institutions providing psychiatric care services and specific methods for handling issues raised by evaluations. In addition, NCDs were identified as a Sustainable Development Goal (SGD) in Goal 3.4. The global response to mental health is still developing based on the publications from 2007.
■The situation concerning mental illness in Japan
The Medical Care Act of 1958 included a psychiatry exception that set higher ratios of healthcare providers to patients in psychiatric hospitals than in general hospitals. The doctor-to-patient ratio for psychiatric hospitals was set to one-third of that of general hospitals while the ratio of nurses and assistant nurses to patients was set at two-thirds of that of general hospitals. This decision could be considered discriminatory towards people with mental illnesses. Since then, the quality of psychiatric care has declined due to a lack of human resources, and mental healthcare providers are criticized for their overuse of seclusion and restraint in the name of efficiently ensuring safety. In 2007, the Organisation for Economic Co-operation and Development (OECD) determined that approximately 20% of the world’s psychiatric hospital beds were located in Japan. The number of psychiatric beds available in Japan is increasing while it is trending downwards in other countries. Additionally, in Japan, over 90% of psychiatric hospital beds are located in private hospitals, where decisions are made to maximize profitability. These hospitals tend to favor long-term hospitalization and are actively hospitalizing people with dementia to prevent beds from going empty. With trends like these, patient-centered mental healthcare is still far out of reach.
The General Assembly of the United Nations adopted the Convention on the Rights of Persons with Disabilities (CRPD) in 2006, to which Japan became a signatory in 2007. The CRPD bans involuntary hospitalization, declaring it a violation of human rights, and recommends voluntary hospitalization instead. However, over half of the people currently hospitalized for mental illness in Japan were hospitalized involuntarily. This includes involuntary admission and hospitalization for medical care and protection. With hospitalizations for medical care and protection, hospitals obtain custody of someone just by getting their legal guardian’s permission. The situation surround this system is especially unclear.
According to the Hospital Report published in 2016 by the Ministry of Health, Labour and Welfare (MHLW), the average hospital stay for psychiatric beds was 269.9 days. This is overwhelmingly longer than the average stay for general beds, 16.2 days. Also, according to a report published August 21, 2018 by the Mainichi, there are more than 1,773 people who have been kept in psychiatric care wards for over fifty years. According to the National Center of Neurology and Psychiatry’s (NCNP) 2017 “630 Survey *3,” approximately 12,000 people were restrained, 64% of them elderly. From that same report, approximately 13,000 people were secluded, and among them, 51% of them had been hospitalized for 1 year or longer. These rates are increasing. The 603 Survey also showed that the Japanese Association of Psychiatric Hospitals (JAPH) is unwilling to carrying out investigations and publish findings. We may never learn the truth of the situation. One might say mental healthcare in Japan is in a critical state.
At the same time, we have not been able to construct an environment in which effective in-home care for people with medical illnesses can be provided. There is an old Japanese term called Zashikiro which refers to in-home prison cells used for confining criminals and the criminally insane. In 1900, it became legal to use these rooms for people with mental illnesses under the Custody of Mentally Ill Persons Law. This allowed family members to take custody of relatives with mental illnesses and confine them in the home. This law was abolished in 1950 after the enactment of the Mental Health Law, making it illegal for people to confine relatives with mental illnesses in the home. This led to a decrease in the physical restraint and confinement of people with mental illnesses in private homes, but even now, we hear reports of people passing away after being confined in Zashikiro . Of particular note is the tragic case of Ms. Airi Kakimoto, who was found dead at the age of 33 after her parents confined her for over 15 years.
*3 The 630 Survey in an annual survey of certain regions and cities published on June 30 and is conducted by the Mental and Disability Health Division of the Department of Health and Welfare for Persons with Disabilities at the MHLW’s Social Welfare and War Victims’ Relief Bureau. Its formal title is “Data on social security/welfare for mental health.”
■Changes in Japanese society concerning mental health
In 2002, the Japanese Society of Psychiatry and Neurology (JSPN) changed the name of schizophrenia in Japan after a request from the National Federation of Associations of Families with The Mental Illness in Japan (Or “Minna-net”). This is an uncommon occurrence worldwide. Before the change, it was written with characters that indicated it was a “split mind disease.” Afterwards, it became “integration disorder.” Two of the stated reasons for the change were to alter the concept of the disease and to transition from a healthcare model to a social model to help people with schizophrenia. Two years after the name change, the percentage of cases in which patients were informed of their diagnosis jumped from 20% to 69.7%. Additionally, there have been efforts to promote understanding of the disease outside of the medical field, such as in schools. Society once thought of it as a mysterious, incurable disease that appears out of nowhere, but now recognizes that it is a disease that can be treated by both medication and psychotherapy that is caused by a disorder in brain nerve transmission ability or genetics.
The General Principles for Suicide Prevention Policy (GPSP) were established after the Basic Law on Suicide Countermeasures took effect in 2007. They were revised twice, once in 2012 and again in 2017. Currently, practical measures for preventing suicides are being promoted and strategic policies for topics like preventing suicides among young people are being incorporated in each region. There are few countries engaged in cross-disciplinary suicide prevention measures that reach beyond the field of public health, so one might say Japan has been more progressive on this front than other countries. Also, by continuing these efforts going forward, suicide prevention has become more widely-recognized, and the number of people who commit suicide is trending downwards.
When the 6th revision of the Medical Care Plan System came into effect in 2013, the diseases and services targeted by the plan were expanded to include mental health, making five diseases to target and five services to provide *4. This was progress in the effort to create an environment in which people with mental illnesses can receive in-home care whenever possible so that they may continue to live where they want to live.
*4 The five diseases are cancer, cerebral apoplexy, acute myocardial infarction, diabetes, and mental illness (including schizophrenia, depression and bipolar disorder, dementia, mental illnesses in juveniles and adolescents, and addiction). The five services are emergency medical care, medical care in disasters, medical care in remote areas, maternal and perinatal service, and medical care for children including emergency child medical services.
■ Encouraging self-determination and self-expression for people with mental illnesses
Dr. Sugiura is currently co-producing research with people who have experienced involuntary hospitalization and, together, they are creating research designs, conducting research, and interpreting research results so that they can be utilized. They are conducting interviews with people currently being hospitalized involuntarily as well as the families and doctors of those hospitalized. Through these efforts, Dr. Sugiura and her co-producers have identified the elements needed to propose a method for grasping the decision-making process for and thoughts concerning hospitalizations, as well as necessary elements for people with mental illnesses to decide on their own whether or not they want to be hospitalized.
People with mental illnesses are facing risks like long-term hospitalization, physical restraint, and confinement that are unthinkable to other people living in modern Japan. As written in the Plan for Welfare of Persons with Disabilities, the 7th revision of the Medical Care Plan System, or the CRPD, in the future, the opinions of people with mental illnesses must be taken into account from the outset when creating policies or deciding which policies to promote. Doctors should make it a goal to work together when conducting research in this field.
Photographed by：Kiyoshi Takahashi
Ms. Kanna Sugiura (Psychiatrist)
After graduating from Tokyo Women’s Medical University, Kanna Sugiura completed her general residency at Tokyo Women’s Medical University Hospital and her psychiatric residency at Yokohama City University Hospital. Interested in health systems due to issues such as long-term psychiatric hospitalization as well as the use of seclusion and restraint, she then received a Master of Science in Public Health degree (MScPH) from London University. She has worked in global mental health as a visiting lecturer for the University of Fiji, School of Medicine, as a WHO Intern/Junior Professional Officer (JPO)/consultant, and as a consultant at the Equatorial Guinea National Hospital. After returning to Japan, she became involved in projects such as the implementation of the “Basic Design for Peace and Health initiative,” while working as an administrative official in the Global Health Policy Division of the Ministry of Foreign Affairs. Kanna Sugiura is currently researching compulsory psychiatric admission and decision-making support (India/Japan) in a doctoral program at the University of Tokyo, while also providing outpatient psychiatric services.