<Key Points>

・As the Coronavirus Disease 2019 (COVID-19) pandemic continues to grow, preventing infections within mental health facilities has become an urgent issue. The unique characteristics of mental health care make it particularly difficult to maintain normal standards of care while implementing measures against COVID-19 within care facilities.

・Local and prefectural governments must independently formulate guidelines and build cooperative frameworks for local healthcare facilities, public health centers, municipal governments, and other such organizations so that effective treatment can be provided to people hospitalized in mental health facilities who have been affected by COVID-19.

・The spread of COVID-19 infections has highlighted the need for discussions on infection prevention measures within Regional Medical Care Visions, which local and prefectural governments are required to formulate. From the perspective of stopping the spread of infectious diseases, Regional Medical Care Visions should include psychiatric care beds in the future.

 

Coronavirus Disease 2019 (COVID-19) is currently spreading worldwide. As of July 28, 2020, the time of writing, COVID-19 has infected over 16 million people and has killed over 650,000 people worldwide *1. In Japan, over 31,000 people have tested positive for COVID-19 *2.
In addition to its effects on physical health, society, and the economy, the spread of COVID-19 has had significant effects on mental health. According to COVID-19 and the Need for Action on Mental Health, a policy proposal presented by the United Nations (UN) on May 13, 2020 *3, an increasing number of people are suffering from anxiety towards infection, isolation from their families, disruptions in their daily living environments due to shelter-in-place orders and other restrictions, loss of employment and other employment-related problems caused by worsening economic circumstances, and domestic violence. For example, a large-scale study conducted in Ethiopia showed an almost threefold increase in the prevalence of symptoms consistent with depressive disorder compared with estimates from before the COVID-19 pandemic. In Japan, COVID-19 has become a particularly serious issue for both the people affected by the virus and for healthcare professionals treating infectious diseases.
In this column, we will consider the effects of COVID-19 on the field of mental health with a particular focus on its effects on mental health facilities with psychiatric care beds.

*1: Presented by Johns Hopkins University at https://coronavirus.jhu.edu/ Last retrieved August 4, 2020
*2: NHK. Coronavirus Infections in Japan (Summary). https://www3.nhk.or.jp/news/special/coronavirus/data-all/ Last retrieved August 4, 2020.
*3: United Nations. Policy Brief: COVID-19 and the Need for Action on Mental Health. https://unsdg.un.org/sites/default/files/2020-05/UN-Policy-Brief-COVID-19-and-mental-health.pdf  Last retrieved August 4, 2020.

 

■Overview of Mental Disorders and Mental Health Facilities in Japan

We will begin with a general overview of mental health facilities and mental disorders in Japan. According to Mental Health and Welfare Data from FY2019, 1,577 healthcare facilities in Japan have psychiatric care beds and approximately 90% of those facilities are owned by the private sector. There are approximately 310,000 psychiatric care beds in Japan and their number has trended downward over the past decade. However, according to a 2016 report compiled by the Organization for Economic Co-operation and Development (OECD), Japan possessed 2.63 psychiatric care beds per 1,000 people. This rate was significantly higher than in Belgium, the country in second place, which had 1.38 psychiatric care beds per 1,000 people. From an international point of view, it is safe to say Japan has many psychiatric care beds. It was estimated that 4.193 million people had mental disorders in 2017 and their numbers have followed an upwards trend. However, the number of people hospitalized decreased from approximately 329,000 in 2002 to about 302,000 in 2017 and is gradually decreasing. Also, according to hospital surveys, the average length of stay in psychiatric care beds has shortened by a significant amount over the past 30 years, from 496 days in 1989 to 265.8 days in 2018. However, it is still much longer than the average length of stay for general care beds, which is 16.1 days.
For more details on the structure of the mental health care provision system in Japan, please refer to Mental Health 2020 – Proposal for Tomorrow: Five Perspectives on Mental Health Policy, presented by Health and Global Policy Institute (HGPI) on July 21, 2020.

Mental Health 2020 – Proposal for Tomorrow: Five Perspectives on Mental Health Policy can be viewed in Japanese here. An English version is coming soon.

 

■Difficulties Faced When Implementing Infectious Disease Countermeasures in Mental Health Facilities

Preventing the spread of COVID-19 has caused significant difficulties for many healthcare facilities. As described above, there are approximately 300,000 people hospitalized in mental health facilities in Japan. It has been reported that some of them have been infected with COVID-19 and that clusters have appeared in some of those facilities.
The unique characteristics of mental health care make it extremely difficult to provide the normal standards of care while infectious disease countermeasures are in place within facilities. When writing this column, we conducted hearings to gather information on the differences in the difficulties faced when implementing such countermeasures within mental health care compared to other fields of medicine and have categorized those difficulties as follows.

– Differences in the Physical Structures of Facilities
Mental health facilities have closed wards that general care facilities do not. As a general rule, the entrances and exits to these wards are locked at all times. According to the Mental Health and Welfare Data from FY2019, among the reported 308,000 beds, 219,000 of them were in closed wards, meaning that they account for approximately 71% of the total number of psychiatric care beds. By their nature, closed wards require many doors in their construction, so from the perspective of infectious disease control, patients or staff touching those doors is a factor in spreading infections. Also, some portions have no windows and some rooms have windows that are difficult to open, so closed wards can be more difficult to ventilate than general wards. Another source of difficulty facing efforts to prevent the spread of infections within mental health facilities is that it can be difficult to implement standard infectious disease countermeasures used at general care facilities. For example, certain facilities cannot place disinfectant hand spray, paper towels, and other such tools for preventing infection near the ward entrances out of concern for patient safety. Furthermore, when mental care facilities have outdoor smoking areas on the premises, contact between people there can be another factor for the spread of infections.

– Differences in Patient Characteristics
During our hearings, it was pointed out that, depending on their condition, it can often be difficult to get people to cooperate with infection prevention measures, such as mask-wearing or handwashing. Furthermore, some people require special measures, like those who are unable to stay in bed and walk around while vomiting, or those who self-injure.
There are also times when someone’s symptoms make it difficult to test them for infection or to provide them with proper medical examinations. This makes it harder to detect infections in a timely manner and increases the risk that infections spread.

– Differences in Staff Size
It was also pointed out that mental health facilities are staffed by fewer healthcare professionals compared to general care facilities, which makes implementing infectious disease countermeasures more difficult. According to the 2017 Survey of Medical Institutions and Hospital Report, general care facilities had 148.4 full-time employees per 100 beds while mental health facilities had less than half with 68.2 full-time employees per 100 beds. The gap was especially prominent for doctors; general care facilities had 16.1 doctors on staff per 100 beds while mental health facilities only had 3.7. According to our hearings with experts, another factor that makes it more difficult to implement infectious disease countermeasures in mental health facilities compared to general care facilities is that mental health facilities have fewer staff members specializing in infection control.
These three differences must be kept in mind when implementing infectious disease countermeasures within mental health facilities. Also, psychiatric symptoms can worsen due to anxiety towards the spread of infection as well as activity restrictions and other such infection countermeasures, so patients require more care and attention when infectious disease control measures are in place.
The medical service fee schedule provides one infection prevention allowance per hospitalization for covering infection countermeasures. However, as discussed above, the average length of stay for psychiatric care beds is considerably longer than that of general care beds – 265.8 days compared to 16.1 days – so incentives for implementing infectious disease control measures in mental health facilities have been criticized as insufficient.
COVID-19 has also affected rights advocacy activities for hospitalized people conducted as part of post-discharge support or through face-to-face meetings. While implementing measures against COVID-19 infection, efforts that enable the people involved in those activities to share information or to hold meetings with hospitalized people online are needed so they can continue their activities in a smooth manner.

 

■The Need for Systems for Cooperation Between All Healthcare Facilities, Public Health Centers, Local Governments, and Related Parties

On their own, it is difficult for mental health facilities to handle clusters or the treatment of patients with severe psychiatric symptoms and severe physical symptoms due to infectious disease. Systems that will allow them to cooperate with other healthcare facilities, public health centers, local governments, and other organizations to respond to those situations are necessary. Because it can be difficult to treat people with severe psychiatric symptoms at general care hospitals, there have been cases in which mental health facilities were unable to transfer patients affected by COVID-19 to general care hospitals. Some of these cases resulted in clusters at mental health facilities. In response, the Ministry of Health, Labour and Welfare (MHLW) published an administrative circular on June 2, 2020 entitled “Measures for Novel Coronavirus Infection, etc. in Mental Health Facilities,” *4 which requires mental health facilities to network with other healthcare facilities in advance so that their patients can receive treatment in the event they become infected.
In Miyagi Prefecture, representatives from various organizations (namely, the prefectural mental health department, the mental health department of Sendai City, general hospitals with psychiatric care beds located within Miyagi Prefecture, Miyagi Psychiatric Center, the Miyagi branch of the Japan Psychiatric Hospitals Association, the Miyagi Psychiatric Clinic Association, and the Miyagi branch of the Japanese Association of Neuro-Psychiatric Clinics) established the Miyagi Prefecture Association for Novel Coronavirus Countermeasures in Mental Health Facilities. Together, they formulated the “Guidelines for Novel Coronavirus Infection Prevention within Mental Health Facilities in Miyagi Prefecture.” Similarly, in response to the appearance of clusters at mental health facilities within Kanagawa Prefecture, facilities called “Intensive Care Facilities for COVID-19 and Psychiatric Care” were established to ensure that both care for mental disorders and appropriate COVID-19 treatment can be provided. As these examples demonstrate, it is necessary for prefectural and local governments (which shoulder most of the responsibility for creating systems for providing healthcare in each region) to independently formulate response guidelines to use in the event a person with a mental disorder is affected by COVID-19. They must also create systems that allow for information exchange between all related institutions. Furthermore, as described above, the spread of COVID-19 has affected post-discharge support for hospitalized patients as well as rights advocacy activities. In addition to measures for preventing the spread of COVID-19, we hope that post-discharge support for hospitalized people and rights advocacy activities are also given sufficient consideration when guidelines are being created.

*4: Ministry of Health, Labour and Welfare. “Measures for Novel Coronavirus Infection, etc. in Mental Health Facilities.” https://www.mhlw.go.jp/content/000636429.pdf  Last retrieved August 4, 2020.

 

■In Conclusion
In this column, we considered the effects of COVID-19 on mental health facilities. Due to the unique characteristics of psychiatric care, it is extremely difficult to maintain the normal standards of care while implementing measures against infectious disease. This means it is growing more urgent for prefectural and local governments to unite with local healthcare facilities to independently formulate response guidelines for when people with mental disorders are affected by COVID-19. Also, the spread of COVID-19 has increased awareness towards the need for perspectives on infectious disease control to be included in Regional Medical Care Visions, which the Government and each regional government are obligated to formulate *5. Systems must be created that enable cooperation between various local healthcare institutions including mental health facilities during both ordinary times and during emergencies. However, psychiatric care beds are currently considered outside the scope of Regional Medical Care Visions *6, so in the future, we believe it is necessary for Regional Medical Care Visions to include psychiatric care beds and for communities to take the creation of Regional Medical Care Visions as opportunities to come together to think about healthcare provision systems.

*5: From the summary of the June 5, 2020 press conference held by Minister of Health, Labour and Welfare Katsunobu Kato. https://www.mhlw.go.jp/stf/kaiken/daijin/0000194708_00250.html  Last retrieved August 4, 2020.
*6: The Act on Promotion of Comprehensive Assurance of Medical Care and Long-Term Care requires each prefecture to formulate a Regional Medical Care Vision as part of its medical care plan. Regional Medical Care Visions aim to help create the best possible medical care provision systems according to the needs of each region by 2025, when the baby boomer generation will reach 75 years of age or older. To do so, Regional Medical Care Visions promote the separation of hospitals by function, encourage cooperation between hospitals, estimate the demand for medical care and hospital bed requirements in each region, and foster measures for improving home medical care, securing medical professionals, and writing legislation.

 

About the author
Go Aso (HGPI Associate)

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