[Event Report] The 104th HGPI Seminar – “Prospects for Building an Integrated Community Care System That Can Respond to Mental Disorders and for Outreach Support” (March 4, 2022)
At the 104th HGPI Seminar, we hosted Dr. Chiyo Fujii, Director of the Department of Community Mental Health & Law at the National Institute of Mental Health of the National Center of Neurology and Psychiatry. While explaining how to create an integrated community care system that can respond to and include mental disorders, Dr. Fujii discussed trends in related policies, shared issues facing those on the frontlines of outreach support and related fields, and examined prospects for the future.
<Key points of the lecture>
- Although cooperation with mental health and medical welfare services is essential for supporting the diverse needs of community members, there are many cases in which it is difficult to respond to those needs with mental health and medical welfare services alone. Regional networks that incorporate multiple institutions and include mental health and medical welfare services are needed.
- Building an integrated support system that extends support even to the people who have fallen into the gaps among systems will require perspectives on mental health and appropriate intervention from mental health care.
- An integrated community care system that can respond to and include mental disorders will contribute to achieving a society of communal coexistence in which everyone can live with peace of mind regardless of whether they have a mental disorder or not, or its severity.
- The people we refer to when we say “include mental disorders” are not only people with moderate to severe mental disorders. Its field of view also includes responding to mental health issues faced by a broad variety of community members. This means it will be important to provide appropriate early interventions to prevent those issues or diseases from growing more complicated or severe, to consider how to build partnerships, and to address community issues through attentive individual support.
- A system that enables comprehensive care and outreach support centered on individuals will be necessary to support recovery.
- Attentive individual support can be used to share community issues and be linked to community-wide collaboration and community development.
■ The various issues related to mental health and medical welfare
There are various issues surrounding mental health and medical welfare. These are wide-ranging and include misconceptions and prejudices (stigma) toward mental health (including mental disorders and disabilities); the protection of human rights; insufficient initial support for mental disorders; cooperation among healthcare, welfare, long-term care, and other fields; the quality of mental health and medical welfare services; social connections and participation; long-term hospitalizations; responding to physical complications; and insufficient financial and human resources. It is difficult to respond to problems like these with measures in mental health and medical welfare alone, so measures must be taken from a broader perspective.
■ There are various unmet needs in communities
There are people in communities facing a wide variety of troubles. Unmet needs in communities include economic hardship; all varieties of dependencies; abuse; school absenteeism; social withdrawal; the “8050” problem (the cohabitation of elderly parents and their unemployed, unmarried children in their 50s); elderly people acting as caregivers to other elderly people; young caregivers; undiagnosed people; and people with interrupted treatment. These unmet needs fall through the gaps between existing services, so mental health issues cannot be thought of as separate.
■ The negative cycle of challenges in everyday life and mental health issues
In communities, there are close relationships among lifestyle challenges and mental health problems or behavioral disturbances which can easily result in negative cycles. Adding the economic impact of job losses caused by the COVID-19 pandemic makes it even easier for people to begin to experience anxiety, depression, or other disorders. In communities, this vicious cycle can even start from insignificant occurrences.
To respond to community members’ various support needs, collaboration with mental health and medical welfare services is often necessary and it is difficult to respond to these needs with mental health and medical welfare services alone. Therefore, regional networks that incorporate multiple institutions and include mental health and medical welfare services are needed.
■ Changes in Japan’s social structure
In Japan, population decline due to population aging and a falling birthrate is continuing to accelerate as the country enters what is called the era of the 100-year lifespan. The number of single-person households is increasing. The ability of communities and households to function as a form of mutual support is declining, and concepts like community, family, and company connections are becoming obsolete. With a growing number of workers from overseas and an expansion of gender identities, diversity among members of society and their values is on the rise.
Amidst this transformation of the social structure, individuals and households are beginning to face more complex, varied forms of difficulties or problems in everyday life. This makes the maintenance of the social security system even more important. However, since it is difficult to meet these needs with public support alone, it is necessary for entire communities including healthcare, welfare, education, industry, and citizens to come together and cooperate across fields to sustain their local communities.
■ Mental health care is essential for providing the comprehensive support needed to achieve a society of communal coexistence
With this backdrop, the “society of communal coexistence” the Government aims to create will have participation from diverse groups like community members and communities and, by connecting people with other people or with resources in a manner that surpasses generations and fields, become a place where all citizens shape their own lives and define their own purposes together with their communities. It will transition away from the conventional methods of solving issues, which was siloed by field, under the concept of providing comprehensive support for personal and overarching issues faced by individuals and households.
Until now, expansions to public compensation from Japan’s social security system were made in anticipation of common risks and life events like illness, disability, long-term care, childbirth, and child rearing. The ability of the social security system to function as a form of livelihood support or as a safety net has been reinforced according to the needs of each target group and their attributes, leading to the provision of specialized support for people in harsh economic conditions, long-term care for elderly people, disability welfare, and child welfare. Because of this, cases that were not common sometimes fell into the gaps of the system.
The Ministry of Health, Labour and Welfare (MHLW) has proposed existing forms of support for elderly people (such as the integrated community care system), disabled people, people facing economic hardships, and children and child-rearing families can be operated in a comprehensive manner to create a comprehensive support system and achieve a society of communal coexistence. In the backdrop of that are compounding issues like the “8050 problem” and double care (in which people provide long-term care while rearing children), as well as problems that fall into the gaps among systems, such as hoarder houses.
We should note that each of these problems involves mental health care. Issues related to mental health can frequently be found in the background of various unmet needs and problems in communities. As such, mental health care is an essential element of comprehensive support for achieving a society of communal coexistence. Including perspectives from mental health care in various systems will be important for supporting people with complex issues.
The scope of mental health is broad and includes a wide range of people, including people who do not currently require treatment or support in their everyday lives, and anyone can be affected by a mental disorder even due to something trivial. A system is needed that enables people to consult with each other in times of mental distress that provides suitable and coordinated healthcare, welfare, and long-term care services as necessary so every citizen can receive mental health care.
■ The need for multi-disciplinary cooperation
Such a system would involve various institutions outside of the field of mental health including departments for physical health, health centers, community medical centers, integrated community support centers, home nursing stations, and companies providing community assistance, so it will be necessary to build partnerships that support households. In an imaginary case presented during the lecture, the person affected by a mental health disorder was not linked to contracted services at all when they began receiving support. In response, the public departments at the city involved in the case cooperated and one municipal officer, a mental health social worker, provided overall management for the case, building a system for collaboration. As this example demonstrates, it is important to arrange circumstances so networks spanning various fields can be built in communities.
■ What does it mean to “include mental disorders”?
The “integrated community care system that can respond to and include mental disorders” is a system for ensuring comprehensive medical care, disability welfare and long-term care, housing, social participation (employment, etc.), mutual support in communities, and dissemination and awareness-building (education, etc.) so everyone, regardless of the presence of a mental disorder or its severity, can live true to themselves and with peace of mind.
According to an MHLW Inclusivity Study Group Report, the integrated community care system that can respond to mental disorders is a system for supporting life in communities for people with mental disabilities, people with problems related to mental health, and community members; and that this system must be fostered with perspectives on community members’ daily lives and community development and that it will be essential for moving toward a society of communal coexistence.
The intent behind the words to “include mental disorders” is to say that mental disorders cannot be provided with their own system and excluded from all other forms of support (including medical support) or policy. The goal is to deepen understanding toward mental illness and disorders while emphasizing the importance of perspectives from mental health with the objective of establishing a system that can provide specialized medical care and support when needed.
As for the regions and areas it is directed toward, the report clearly states that the integrated community care system that can respond to mental disorders is to be promoted based on the area of daily living for people with mental disorders or other parties with basic municipalities like cities, towns, and villages serving as its foundation. This is so municipal governments that are nearer to people can successfully provide support (with emphasis on responding before conditions grow severe or complex) in a form that emphasizes lifestyle support and is closer at hand.
■ Duties performed by municipal governments and mental health
A survey on mental health welfare services in municipalities (conducted with the FY2020 Health, Labour and Welfare Administration Promotion Research Subsidy, titled “Policy Research to Promote the Strengthening of the Community Mental Health and Welfare System,” lead researcher: Chiyo Fujii) asked to what extent issues related to mental health are factors in initiatives for each of the following topics: suicide prevention, abuse (of children, elderly people, and disabled people), support for people facing economic hardships and livelihood support, maternal and child health, child-rearing support, aging and long-term care, dementia response, spousal violence (domestic violence), and adult health. Most municipalities answered “a great amount” or “somewhat” for all initiatives (N=1267). This demonstrates the importance of mental health perspectives in duties performed by municipal governments.
■ Who is included when we say the system “includes mental disorders”?
When we say the system “includes mental disorders,” we are speaking of the inclusion of all citizens, starting with people experiencing problems related to mental health, people with mental disabilities, and people with mental disabilities who require comprehensive support from welfare, long-term care, and other services (including people who have been hospitalized for long periods).
While medical interventions will be considered as necessary, the objective is not to link people to medical services. Assessments that utilize skills from mental health care will be performed to determine the need for medical care and urgency. Furthermore, when introducing services, the use of medical services may also be considered.
■ The importance of outreach support
It is difficult to require a household that is facing problems due to mental health-related issues to go visit a support institution. It is important to visit them to build familiarity, see their actual living conditions, and confirm the situation. These visits might be made by commissioned psychiatrists or staff who handle public assistance at integrated community support centers or municipal welfare departments. There are many cases in which the more a person is in need of assistance, the more difficult it is for them to visit the support office on their own. Therefore, to realize the philosophy of “a society of communal coexistence,” which is to provide comprehensive, total support for issues faced by individuals and households, outreach support provided at suitable stages will be essential.
The Outreach Promotion Project for Regional Coordination Projects led to the creation of systems that provide services meeting Assertive Community Treatment (ACT) program standards in each prefecture, but these were only implemented in a few locations on a temporary basis and have now fallen almost entirely out of use.
■ Person-centered comprehensive care
The goal of ACT is to support recovery. Recovery refers to methods that enable people to live life to the fullest with satisfaction and hope even if they have to live with limitations because of a disease. Furthermore, in the context of the severe effects of mental disorders, it can refer to finding new meaning and purpose in life. Recovery from a mental illness means more than just recovering from the disease itself (Anthony, 1993). In ACT, it is important to provide continuous support to enable the individual to lead a life that is faithful to their own values and that is true to them.
Recovery is not only limited to “clinical recovery” (the improvement of symptoms or the recovery of functions), where the aim is to improve the disease itself; it also includes “social recovery,” which aims to expand opportunities for housing, employment, education, and the creation of social networks. In the future, “personal recovery,” which are processes by which people aim to achieve the lives they choose, will grow more important.
There is global consensus that the desired goal of support provided by mental health and medical welfare services is this approach to personal recovery, and there is shared understanding toward the importance of policies that can provide support that emphasize the values of the people receiving support. Efforts to “include mental disorders” in this form of support in Japan are based on this concept and overlap with the approach behind a society of communal coexistence.
To assist in personal recovery, after the person receiving support sets personal goals and their preferences, values, and strengths have been assessed, it is important to provide support that aims to help them achieve the things they wish to achieve in everyday life and to provide ample individual support that respects the personal goals they have set. To do so, comprehensive support must be given through community cooperation, with outreach support provided as necessary. When thinking about how to also “include mental disorders,” this concept of person-centered comprehensive care must be shared among all supporters.
■ Standards in outreach support must be improved first
There are several case management models that are important in individual support. These include brokering, the English model of case management, the strength model, and ACT. While ACT is certainly effective when providing intensive services to ten or fewer people, whether or not current circumstances in Japan are favorable for disseminating ACT remains a question.
According to The Mental Health Matrix: A Manual to Improve Services, specialized community mental health teams as seen in ACT can fully utilize their abilities in communities with abundant local service resources. On the other hand, using ACT by itself in regions with insufficient resources will result in total reliance on ACT. This will exhaust teams and hinder sustainability of the system. This is exactly what is happening in Japan.
In communities with few resources, it will be necessary to raise standards for outreach support first. It must be kept in mind that intensive care can be maintained only after a foundation has been formed in the community. In recent years, both the number of consultations related to mental health and the number of support visits made have been increasing in cities, towns, and villages. At the same time, looking at the number of staff specializing in mental health, full-time staff have decreased while part-time staff have increased. Providing case management and promoting cooperation in communities is stretching manpower thin, making it difficult for the advantages of ACT to be fully utilized.
To respond to this, some communities are utilizing various methods of expanding outreach such as adopting the individual team formation model or the network model. To raise the standards for outreach support, local governments must first expand home support visits. This will require various measures. Public health nurses with perspectives and skills on mental health must be trained, coordination with other support programs (such as the system for acute social withdrawal or the Initial-phase Intensive Support Team System for Dementia) must be planned, training programs for mental health social workers must be reviewed, and municipal offices, health centers, and mental health and welfare centers must be appropriately staffed.
It will also be important to enhance outreach from medical institutions. This is likely to require: implementing case management by visiting nurses, providing house calls from psychiatric institutions, promoting in-home treatment (by reviewing reimbursements and isolating or integrating the in-home psychiatric patient support management premium and the comprehensive in-home medical management premium), cooperation from local governments for home visit support, and a review of medical education.
The goals of building a system that also “includes mental disorders” are to realize a society of communal coexistence by improving mental health literacy among all citizens and to decrease crisis interventions and other interventions by building inclusive communities, supporting lifestyles, and utilizing preventive healthcare. To promote early responses, it is clear that outreach will be important.
■ Expanding the scope of inclusion from small to large
Community networks that support individuals or households can also be called a small-scale form of this inclusion. The basic concept behind “including mental disorders” is to lay a strong foundation of small-scale inclusion to serve as the basis for large-scale inclusion. Repeatedly providing attentive individual support centered on people with various support needs who require comprehensive support and continuously establishing in-person forms of cooperation at disability welfare services, administrative agencies, and healthcare services will not only support certain people or households, they will also support future users. In that context, sharing community issues will lead to greater inclusion. The goal is to make society a place where it is considered a given that people with mental health issues or mental disorders can receive the support they need without having to point out when care systems “can also respond to mental disorders.”
To move forward on establishing an integrated community care system that can respond to mental disorders, it will be important to repeat a cycle that builds up a framework to enable sufficient outreach support. That cycle will include: sharing issues in communities (analyzing current circumstances and sharing community issues during opportunities for discussion with municipal governments, healthcare institutions, welfare offices, and other related parties), setting goals (each fiscal year at aforementioned meetings and discussing plans for achieving them), building a support system through individualized support (by establishing face-to-face relationships among related parties through case support and making effective use of existing resources and mechanisms through collaboration), and assessing results (by periodically reviewing progress on goals and achievements and revising plans).
- Speaker: Dr. Chiyo Fujii (Director, Department of Community Mental Health & Law, National Institute of Mental Health, National Center of Neurology and Psychiatry)
- Date and time: Friday, March 4, 2022; 18:30-19:45 JST
- Venue: Zoom webinar
- Participation fee: Free
- Languages: Japanese only
Dr. Chiyo Fujii (Director, Department of Community Mental Health & Law, National Institute of Mental Health, National Center of Neurology and Psychiatry)
After graduating from National Defense Medical College in 1993, Professor Chiyo Fujii served in the Department of Psychiatry at the National Defense Medical College Hospital. In 2001, she earned her Ph.D from Keio University Graduate School of Medicine and began working at the Self-Defense Forces Central Hospital Department of Psychiatry. In 2008, she became Associate Professor at the Saitama Prefectural University Faculty of Health and Medical Welfare. She later joined the National Institute of Mental Health, National Center of Neurology and Psychiatry where she was appointed Section Chief of the Department Forensic Psychiatry in 2014 and Director of the Forensic Psychiatry Social Rehabilitation Research Department in 2015. She assumed her current position in 2018. Her specialties include community mental health, early intervention, and mental health policy. Professor Fujii’s positions in academic societies include Delegate, Japanese Society of Psychiatry and Neurology; Chairperson, Medical Ethics Committee; Chairperson, Investigative Committee on Defining Independence Support in Community Care; Vice President and Editorial Board Chair, Japanese Society for Social Psychiatry; Director, Japanese Society for Mental Health and Welfare Policy; Councilor, Japanese Society for Prevention and Early Intervention in Psychiatry; and Councilor, Japanese Society of Forensic Mental Health. Her other positions include Member, Subcommittee for People with Disabilities, Medical Social Security Council; Member, Study Group for Achieving a Mental Health and Medical Welfare System for Secure Community Living; and Regional Advisor, Project for Supporting the Construction of an Integrated Community Care System for Mental Disorders.