Recent topics in psychiatry and mental health in Japan

We intend to discuss recent developments in Japanese psychiatry and matters of major concern, i.e., psychiatric services following the amendment of Japan's Mental Health Law, schizophrenia, dementia and culture-specific problems to Japan.

Japan's Mental Health Law was amended in 1987 (enacted in 1988) and the main points of the amend ment were: introduction of voluntary admission and its recommendation; establishment of the Local Psychiatric Review Board to supervise involuntary admission and to protect rights of mentally ill patients; and recommendation of establishment of psychiatric facilities to support patients living in the community (Mino Ã©tal, 1990;Koseisho Hoken-Iryo-Kyoku Seishin-Hoken-Ka, 1989). In general, most professionals in the field of psychiatry and mental health believe the new law to be better than the former one and the amendment as a reflection of the beginning of community care. In 1992, it is to be re-amended, after discussion of the practices of the past five years.
There has therefore been vigorous discussion on the evaluation of the reformed law, and during the 85th and 86th Conferences of the Japanese Society of Psychiatry and Neurology symposiums on the Mental Health Law were held.
At the conferences, firstly, there was criticism that many patients with voluntary admission were treated in closed wards. In fact, 50.8% of voluntarily admit ted patients were treated in closed wards, according to the study by Seishin-byoin Kyokai. Some speakers insisted that the government and the Local Psychi atric Review Board should more rigorously play a leading role to protect the human rights of the mentally ill and to improve psychiatric services (Koike, 1989).
Secondly, in the law, there is an article on 'persons responsible for custody', who are usually relatives. It states that "a person responsible for custody shall ensure that the mentally disordered person receives medical care, shall supervise him so as not to injure himself and others, and shall protect his interests of a proprietary nature". However, it has become more prevalent to consider that this article is out of date and should be abolished (Yamashita, 1990). Although the article was based on strong familial bonds which have been one of the characteristics of the Japanese family, traditional family systems have been deteriorating since World War II, one result of economic development. As an alternative, the community should take responsibility for caring for the mentally ill.
Thirdly, the article on psychiatric facilities says that the national, prefectural and local governments shall expand and improve the facilities needed for social rehabilitation and welfare. Although this is very important, and most mental health workers have received it favourably, practical policy and economic support remain vague.
In spite of these criticisms, psychiatric services in Japan have improved after the amendment. For example, the proportion of voluntarily admitted patients had increased to 44% of all in-patients by June 1989 (Kosei Tokei Kyokai, 1990), and the number of day care and other rehabilitation facilities has been increasing (Koseisho Hoken-Iryo-Kyoku Seishin-Hoken-Ka, 1989). Integrated community mental health care would be better developed with the cooperation of health centres, mental health centres, mental hospitals, local authorities and the government. We think that international support and discussion are essential for this.

Schizophrenia
In 1990, two follow-up studies were published. Sakamoto (1990) conducted a retrospective follow-up study of 96 schizophrenics who had psychosurgery during [1949][1950][1951][1952][1953][1954][1955][1956][1957][1958][1959][1960][1961]. He showed that psychosurgery had no favourable effects on the long-term course and also observed that the chances of relapses and convulsive seizures in the patients were greater than previously reported (Freeman & Watts, 1947). Kalo and his colleagues (1990) studied 129 chronic schizophrenic patients retrospectively and showed six patterns of the course, suggesting that the out come of the disease can be predicted around 15years from onset. In Japan, prospective studies are needed to identify risk factors for relapse and social dys function of schizophrenic patients living in a com munity. These kinds of efforts would result in better community care for schizophrenic patients.
Apart from epidemiolÃ³gica!studies, studies using computerised tomography (CT) are also promising, and Kaiya and his colleagues (1989) found that each of three subgroups classified by hereditary form had a specific combination of CT findings and clinical features. Japanese psychiatry has been putting more emphasis on biological research than clinical prac tices or other specialities. One of the results of this imbalance was said to produce plenty of long-term patients in mental hospitals (Lin, 1985).

Dementia
Recently, studies of dementia have become more important and a wide range of researches have been conducted actively, because the number of elderly persons with dementia in Japan is estimated to increase in future, with an increasing proportion of the elderly among the general population.
Fukunishi and his colleagues (1989) conducted an epidemiological survey and reported that the prevalence rate of dementia was 4.1 % and the inci dence rate per year was 1.0% among the elderly (65 years old or more) at home. Considering some 20 epidemiological studies on dementia, the prevalence rate would be 4.0 to 5.0% among the elderly in Japan. The incidence rate would be around 1.0%, according to the two reported surveys.
Unfortunately, the social support system for demented elderly patients has not been well devel oped and Japan's governmental policy is mainly focused on caring for them at home (Koseisho Hoken-Iryo-Kyoku Seishin-Hoken-Ka, 1989). It may, indeed, be very important to support them so they may live there. However, it would be dangerous to emphasise this policy strongly, because at present most demented elderly patients are cared for at home and often burdens of care are too heavy for family members. Therefore a community-care system which supports patients and their families should be devel oped and more nursing homes in which appropriate care could be supplied should be established. We emphasise that the new policy must face this problem 501 MÃ©zame kyo-do Sagyo-sho (a sheltered workshop).
as soon as possible because of the poor quality of life of the patients living at home.

Cultural psychiatry and related matters
Recently an increasing number of foreigners have come to Japan for study and work, some of them refugees or immigrants, and increasing efforts have been made for their mental health care. Ebata (1989) reported 24 foreign-born cases who were admitted to the emergency unit. Interestingly, the clinical symp toms and course of two of the patients were unique, being brought about only by a rapid time difference. He therefore named them as suffering from 'jet-lag psychosis'.
Another important issue is related to the work situation, the Japanese being famous for their hard work and long hours. "Karo-shi (Death from Over work)" is one of the hottest issues. Occupational stress is another important issue, and Kawakami and his colleagues (1990) reported that occupational stress due to unsuitable employment was associated with the onset of major depression.
We have described recent topics in psychiatry and mental health services and hope that this paper will encourage an international exchange of information which could be beneficial not only for Japan but also for psychiatry in general.