Shinshu Med J, 72⑵：95～105, 2024

Comparative Empirical Analysis of Challenging Inpatients
under the Medical Treatment and Supervision Act andthe Mental Health and Welfare Act
Katsuhito Saitoh1）, Daimei Sasayama2）＊, Tomonari Yoshizawa3）
Mio Suzuki1）, Kenji Murasugi1） and Shinsuke Washizuka2）
1） Department of Psychiatry, National Hospital Organization, Komoro Kogen Hospital2） Department of Psychiatry, Shinshu University School of Medicine
3） Department of Psychiatry, Suwa Red Cross Hospital

Background : Psychotic symptoms leading to self-harm and harm to others are a critical concern in treatment.
This study aimed to investigate the characteristics and treatment methods of difficult-to-treat patients under
the Medical Treatment and Supervision Act (MTSA) and long-term involuntary inpatients under the Mental
Health and Welfare Act and assess the impact of the MTSA on psychiatric treatment.
Methods : Data were collected from 233 inpatients (179 men and 44 women) under the MTSA and 65 inpatients(58 men and 7 women) who were involuntarily hospitalized for ＞18 months due to the risk of self-harm or harm
to others under the Mental Health and Welfare Act. We compared basic demographics and pharmacotherapy
between the 102 inpatients under the MTSA and 53 inpatients under the Mental Health and Welfare Acts withpsychotic disorders.
Results : Difficult-to-treat cases under the MTSA included 82 grievous bodily harm cases (35 ％), 80 murder cases(34 ％), 48 arson cases (21 ％), and cases of other offenses. Psychotic disorders were the most frequent primary
diagnosis (85 ％), and comorbid psychiatric disorders were present in 68 cases (25.8 ％). In contrast, long-term
hospitalizations under the Mental Health and Welfare Act were predominantly due to schizophrenia (80 ％).
Comparative analysis of pharmacotherapy revealed higher usage of clozapine in the MTSA group and antipsy­
chotic and anti-parkinsonian medications in the Mental Health and Welfare Act group.
Conclusion : These findings suggest that the MTSA encourages a reduction in the use of multiple antipsychotics
and the adoption of clozapine in treatment regimens. Shinshu Med J 72 : 95―105, 2024
(Received for publication December 14, 2023 ; accepted in revised form January 10, 2024)
Key words : psychotic symptoms, Medical Treatment and Supervision Act, Mental Health and Welfare Act,difficult-to-treat patientsＩ Introduction

the Mental Health and Welfare Act, govern the hos­pitalization of such patients. The MTSA emphasizes

Managing patients with severe psychotic symptoms

social rehabilitation through a therapeutic alliance be­

who are at risk of self-harm or harming others is no­

tween patients and medical personnel, targeting indi­tably challenging. In Japan, two legislative acts, theviduals involved in specific crimes, such as murder

Medical Treatment and Supervision Act (MTSA) andand arson1）. The aim is to reintegrate them into soci­＊Corresponding author : Daimei Sasayama
Department of Psychiatry, Shinshu University School of
Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
E-mail : sasayama@shinshu-u.ac.jp

No. 2, 2024

ety within the recommended hospitalization period of
approximately 1.5 years (Fig. 1). However, some pa­
tients have been hospitalized for extended periods2）.
Such prolonged hospitalization can be attributed to a95

Saitoh・Sasayama・Yoshizawa et al.

Fig. 1 Structure of the Medical Treatment and Supervision Act
This diagram (translated from the Japanese version available online1）) illustrates the structure of theMedical Treatment and Supervision Act.

variety of complex factors beyond inherent psychotic

In an effort to understand challenging cases in psy­

symptoms, such as coexisting disorders and social

chiatry, this study aimed to examine difficult-to-treat

challenges3）. Understanding these cases could signifi­

cases under the MTSA (hereinafter referred to as

cantly enhance the psychiatric treatment under the“difficult-to-treat cases”) and those with prolonged

MTSA. In contrast, the Mental Health and Welfare

hospitalization under the Mental Health and Welfare

Act allows involuntary hospitalization of individuals

Act due to risks of self-harm and harm to others.

with mental disorders who pose a risk of self-injury

Additionally, we assessed the impact of the MTSA

or harm to others. Once their condition improves,on psychiatric treatment based on patient character­these patients are typically discharged, facilitating

istics and treatment methods.

their reintegration into society. Retrospective cohort

Ⅱstudies4） showed that 97 ％ of the patients hospital­
ized due to risks of self-harm or harm to others wereＡ

Methods

Difficult-to-treat cases under the MTSA

discharged within 180 days, while approximately

We defined a case as a difficult-to-treat case if at

3 ％ remained hospitalized for an extended duration.

least one of the following criteria was applicable, as

Such extended hospital stays are a notable concern

described by Hirabayashi3）: (1) hospitalized for ＞6

in psychiatric treatment.

years, (2) requiring frequent isolation ( ≥ 5 times sinceCompared to general psychiatric treatment, MTSA

admission), (3) requiring long-term isolation ( ≥ 28

psychiatric treatment involves a multidisciplinary teamdays since admission), (4) requiring physical restraints

and employs specialized therapies, such as clozapine(at least once since admission), (5) re-hospitalized,

and electroconvulsive therapy (ECT), for treatment-and (6) re-treated under the MTSA. Rehospitalization

resistant schizophrenia. The active promotion of thesewas defined as readmission due to a deterioration intherapies aims to enhance treatment responsiveness5）.

the patient’s condition or problematic behavior during

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Comparative analysis of challenging inpatients under different acts

outpatient treatment, while retreatment referred to

der the public medical insurance system (n＝11). As

hospitalization due to the occurrence of a new target

noted by Seto et al.4）, as of June 30, 2017, 65 patientsact.

had been hospitalized for more than 18 months under

We conducted a detailed survey of hospitalized

the Mental Health and Welfare Act because of risks ofpatients who met the criteria for being difficult to treat.

self-harm and harm to others. Permission to use these

Questionnaires were distributed to designated inpatient

data for this study was obtained from Seto et al. .

institutions across Japan under the MTSA. The fol­In this study, questionnaires were distributed tolowing information was collected : age, sex, diagnosis,

those hospitals that expressed willingness to partici­

nature of the target act, admission date, the status ofpate. Additionally, notices were placed in the wards

post-discharge medical care arrangements, economic

to inform patients that they had the option to decline

status, challenges in treatment and discharge, ratio­

participation in the study. Of the 1,386 hospitals, 686

nale and objectives for the latest petition for contin­(49.5 ％ ) responded to the preliminary survey. Of

ued hospitalization, a summary of medical treatment

these, 62 institutions reported a total of 122 cases ofand illness progression in the past six months, andlong-term hospitalization. Subsequently, question­

the use of clozapine or ECT. Participants were re­naires were mailed to 87 patients from 38 participat­

quested to input these data into the survey. The col­ing medical institutions, and responses were received

lected questionnaires were analyzed quantitatively

from 75 patients (58 men and 17 women) across 34

and qualitatively using the textual data from hospi­

institutions. We collected data on age, sex, diagnosis,

talization continuation sheets. A report, submitted totreatment history, instances of serious harm, current

the court every six months by designated inpatient

problematic behavior, current symptoms and condi­

facilities, serves as the basis for judicial decisions re­tions, current activity restrictions, treatment status

garding treatment. Between 2016 and 2017, data wereand plans, instances of temporary hospital discharge,collected from 26 out of the 33 designated inpatientand medication usage.

institutions that existed in Japan at the time, and aＣ Comparative analysis of pharmacotherapy intotal of 233 patients (179 men and 44 women) wereschizophrenia between difficult-to-treat patients

included in the analysis. The collected data included

under the MTSA and long-term hospitalized in-various parameters : sex, age at admission, age at thepatients at risk of self-harm or harming others

time of the survey, Intelligence Quotient (IQ) scoreunder the Mental Health and Welfare Act(assessed using the Wechsler Adult Intelligence Scale

Of the 233 difficult-to-treat cases, 119 had hospital

3rd edition), use of clozapine, history of ECT treat­stays exceeding 18 months. Among the 119 difficult-ment, instances of physical restraints and isolation,

to-treat cases under the MTSA and 65 cases in the

diagnosis, and details about the victimization of thelong-term hospitalization group under the Mental

target act. Multiple diagnoses were allowed for co­

Health and Welfare Act, 102 and 53 were primarily

morbid disorders.

diagnosed with psychotic disorders, respectively. The

Ｂ Long-term hospitalized inpatients at risk offollowing data were collected for both groups : sex,

self-harm or harming others under the Mental

age at the time of the survey, percentage of clozapine

Health and Welfare Act

use, percentage of ECT use, the number of oral and4）

Seto et al. conducted a preliminary survey of 1,386

antipsychotic medications, chlorpromazine equivalent

hospitals, including national hospitals with psychiatricdose, the number of benzodiazepine medications andwards (n＝28), public hospitals with psychiatric wards

their diazepam equivalent dose, the number of anti­(n＝139), hospitals affiliated with the Japan Psychiatricdepressant medications and their imipramine equiva­

Hospital Association (n＝1,208), and other hospitals

lent dose, and the number of anti-parkinsonian drugs

with high-standard specialized psychiatric wards thatand their biperiden equivalent dose.

play a central role in psychiatric emergency care un­
No. 2, 2024

Comparisons between the two groups were per­97

Saitoh・Sasayama・Yoshizawa et al.
Table 1

Sex
Male
FemaleAge at admission
Age at time of survey
Full scale IQ
CLZ usage rate
ECT usage rate
Seclusion
Medical restraint

Demographic and clinical characteristics of difficult-to-treat cases

bodily harm

n＝11

Aggravatedindecent
assault
n＝12

n＝82

n＝233

9 (82 ％)
2 (18 ％)
37.9 (11.7)
40.6 (10.9)
64.2 (12.1)
2 (18 ％)
0 (0 ％)
5 (46 ％)
8 (73 ％)

12 (100 ％)0 (0 ％)
44.2 (12.1)
47.1 (12.0)
64.4 (17.6)
4 (33 ％)
0 (0 ％)
1 (8 ％)
2 (17 ％)

70 (85 ％)
12 (15 ％)41.6 (11.6)
44.1 (11.4)
82.2 (15.9)
36 (44 ％)
8 (10 ％)
35 (43 ％)
10 (12 ％)

179 (80 ％)44 (20 ％)42.1 (11.5)
44.6 (11.4)
77.0 (19.9)
93 (40 ％)21 (9 ％)
95 (41 ％)
40 (17 ％)MurderArson

Burglary

n＝80

n＝48

65 (81 ％)
15 (19 ％)42.5 (12.3)
45.1 (11.9)
82.5 (17.2)
31 (39 ％)
8 (10 ％)
31 (39 ％)
13 (16 ％)

30 (63 ％)
18 (38 ％)43.0 (10.4)
45.1 (10.5)
72.8 (16.8)
20 (42 ％)
5 (10 ％)
23 (48 ％)
7 (15 ％)

Grievous

Total

Data are shown as mean (standard deviation) or the number of patients (frequency).
CLZ : clozapine ; ECT : electroconvulsive therapy

formed using the t-test for continuous variables and

The mean IQ score (S.D.) was highest for murder

Fisher’s exact test for categorical data. Statistical sig­

cases at 82.5 (17.2) and lowest for burglary cases atnificance was defined as a two-tailed P＜0.05. Statis­64.2 (12.1). A histogram illustrating the distribution oftical analyses were performed using the R software

IQ scores across all cases is shown in Fig. 2. Regard­(version 4.2.1).

ing treatment, clozapine was administered to 40.0 ％Ｄof cases, whereas ECT was employed in 9.0 ％ of

Ethical considerations
Data were collected from relevant medical institu­

cases. Isolation was implemented in 41.0 ％ of cases,

tions, and no personal identification was collected.

and physical restraint was used in 17.2 ％ of cases.

Informed consent was not required given the deiden­

Notably, physical restraints were most frequently

tified nature of the data. This study was reviewed

employed in burglary cases.

and approved by the Research Ethics Committee of２

the Komoro Kogen Hospital on August 23, 2021 (Eth­ics Committee Approval No. 3-3).
Ⅲ

Results

Primary diagnosis and comorbid disorders
The primary diagnoses were frontotemporal lobe

dementia (ICD-10 Code : F02) in one case, organic delu­
sional disorder (F06) in two cases, substance use disor­der (F1X) in seven cases, schizophrenia (F20) in 184

Difficult-to-treat cases under the MTSA

cases, delusional disorder (F22) in four cases, acute１ Clinical and demographic characteristics of diffi­

polymorphic psychotic disorder with schizophrenicＡ

cult-to-treat cases

symptoms (F23) in one case, schizoaffective disorder

Clinical and demographic characteristics of the pa­(F25) in ten cases, bipolar affective disorder (F31) intients are shown in Table 1. The sex ratio was 4.1 : 1,seven cases, depression (F32) in three cases, moderate

which is higher than the 3.3 : 1 ratio reported in therecurrent depressive disorder (F33) in one case, mixed

4）2020 MTSA Statistics for all MTSA hospitalization

anxiety and depression disorder (F41) in one case,

cases in Japan. Specifically, for cases of sexual as­

personality disorder (F60) in two cases, mild intellec­

sault, the proportion of male patients was 100 ％ ,tual disability (F70) in one case, moderate intellectual

while for arson, a higher proportion of female pa­

disability (F71) in two cases, and pervasive develop­

tients was noted in the MTSA than in other types ofmental disorder (F84) in seven cases (Table 2).

target acts. The mean age at admission (standard
deviation [S.D.]) was 42.1 (11.5) years.
98

Comorbid disorders were diagnosed in 68 cases(28.5 ％). Specifically, the comorbid conditions included
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Comparative analysis of challenging inpatients under different acts

Fig. 2 Histogram of total test IQ
A histogram of total test IQ in difficult-to-treat cases is shown.

Table 2Main diagnosis and supplementary diagnosis in ICD-10 codes of difficult-to-treat cases

Main diagnosis
F00-09F10-19F20-29F30-39F40-49F70-79F80-89Supplementary diagnosis
F00-09F10-19F20-29F40-49
F60-69F70-79F80-89F90-99OthersMurderArson

Burglary

n＝80

n＝48

n＝11

3 (4 ％)
70 (88 ％)
4 (5 ％)
1 (1 ％)
1 (1 ％)
1 (1 ％)

40 (83 ％)
4 (8 ％)

1 (9 ％)
3 (27 ％)
7 (64 ％)

1 (2 ％)
3 (6 ％)

Aggravatedindecent
assaultn＝12

11 (92 ％)

1 (8 ％)

Grievous
bodily harm

Total

n＝82

n＝233

2 (2 ％)
1 (1 ％)
71 (87 ％)
3 (4 ％)
1 (1 ％)
1 (1 ％)
3 (4 ％)

3 (1 ％)
7 (3 ％)
199 (85 ％)
11 (5 ％)
2 (1 ％)
4 (2 ％)
7 (3 ％)

1 (2 ％)
4 (5 ％)
2 (3 ％)

4 (5 ％)
5 (6 ％)
2 (3 ％)

2 (18 ％)

1 (2 ％)
9 (19 ％)
4 (8 ％)
1 (2 ％)

2 (18 ％)
1 (9 ％)

3 (4 ％)
1 (1 ％)
2 (2 ％)
1 (8 ％)
1 (8 ％)
3 (25 ％)
1 (8 ％)

9 (11 ％)
5 (6 ％)
2 (2 ％)
2 (2 ％)

1 (2 ％)
9 (13 ％)
3 (4 ％)
2 (3 ％)
2 (3 ％)
25 (37 ％)
17 (25 ％)
7 (10 ％)
2 (3 ％)

Numbers indicate the number of pateints (frequency).

organic mental disorder (F09) in one case, substancedisability in 18 cases, moderate intellectual disability

use disorder in nine cases, schizophrenia (F20) inin five cases, unspecified intellectual disabilities (F79)three cases, obsessive-compulsive disorder (F42) inin two cases, pervasive developmental disorder in

two cases, personality disorder in one case, sexual

seventeen cases, attention deficit hyperactivity disor­

preference disorder (F65) in one case, mild intellectual

der (F90) in 6 cases, Gilles de la Tourette syndrome

No. 2, 2024

99

Saitoh・Sasayama・Yoshizawa et al.

Fig. 3 Criminal types and victims(Ａ) Victim categories of murder, burglary, sexual assault, and grievous bodily harm are presented.
(Ｂ) The target category of the arson is shown.
The numbers shown in the pie charts indicate the count and percentage of patients.

(F95) in one case, hyponatremia (E87) in one case, andtargeted family member was the mother, with 15

22q11.2 deletion syndrome in one case. Notably, cases

cases, followed by the father in 11 cases. Additionally,of burglary showed a notably high proportion of both

siblings were the victims in three cases, children in

primary and comorbid diagnoses with the ICD-code

three cases, and a spouse in one case.

F10-19 (Table 2).

Among the 82 cases of grievous bodily harm, theTarget act, victim type, and victim classification

identity of the victims was unknown in 23 instances.

In the 233 difficult-to-treat cases, the breakdown ofFathers were the victims in 10 cases, while mothers

target acts was as follows : 80 cases of murder (com­were targeted in seven cases. Spouses were the vic­

prising 43 murder attempts) (34 ％, 95 ％ CI : 28-40 ％),tims in four cases, and children were involved in one

48 cases of arson (including 7 attempts) (21 ％, 95 ％

case.

３

CI : 15-25 ％ ), 11 cases of burglary (including 5 at­

Arson was most commonly committed in a home

tempts) (5 ％, 95 ％ CI : 2-7 ％), no instances of rape,

setting.

12 cases of aggravated indecent assault (including 1

Ｂ Long-term hospitalized inpatients at risk of self-

attempt) (5 ％, 95 ％ CI : 2-8 ％), and 82 cases of griev­

harm or harming others under the Mental Healthous bodily harm (35 ％, 95 ％ CI : 29-41 ％).

and Welfare Act

Fig. 3 shows the victim categories for murder,

Clinical and demographic characteristics of theseburglary, sexual assault, and grievous bodily harm,

patients are shown in Table 3. The proportion of males

as well as the target categories for arson. Among thewas higher than that of females. More than 80 ％ of

80 murder cases, two incidents involved the killing of

the primary diagnoses were schizophrenia. The usage

multiple family members : one case was the murderof clozapine among patients was 7 ％ , while 13 ％of a mother and another relative, while the other casereceived ECT.

involved a father and his siblings. The most frequently
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Comparative analysis of challenging inpatients under different acts
Table 3 Demographic and clinical characteristics, main diagnosis, and supplementary diagnosis of long-term inpatientsat risk of self-harm or harming others under the Mental Health and Welfare Act

VariableSex
Male
FemaleAge at admission
Age at time of survey
CLZ usage rate
ECT usage rateLong-term inpatients at riskof self-harm or harming othersn＝65
58 (89 ％)
7 (11 ％)
42.1 (12.9)
52.0 (13.6)
5 (7 ％)
10 (13 ％)ICD-10Main diagnosis
n＝65

Supplementary
diagnosis
n＝20

F00-09F10-19F20-29F30-39
F60-69F70-79F80-893 (5 ％)
4 (6 ％)
53 (82 ％)
1 (2 ％)
1 (2 ％)
1 (2 ％)
2 (3 ％)

1 (5 ％)
1 (5 ％)
1 (5 ％)
1 (5 ％)
5 (25 ％)
9 (45 ％)
2 (10 ％)

Data are shown as mean (standard deviation) or the number of patients (frequency).
CLZ : clozapine ; ECT : electroconvulsive therapy

Table 4 Comparison of pharmacotherapy for patients with schizophrenia : difficult-to-treat patients under the MTSA
vs. long-term inpatients at risk of self-harm or harming others under the Mental Health and Welfare Act

VariableSex
Male
FemaleAge at time of survey
CLZ usage rate
ECT usage rate
Number of oral medications
Number of antipsychotics
Chlorpromazine equivalent
Number of benzodiazepines
Diazepam equivalent
Number of antidepressantsImipramine equivalent
Number of antiparkinsonian drugs
Biperiden equivalent

Difficult-totreat cases
n＝102Long-term inpatients at risk of
self-harm or harming othersn＝53

81 (79 ％)
21 (21 ％)44.1 (10.5)
48 (47 ％)
12 (12 ％)5.4 (3.2)
1.6 (0.9)
917.1 (588.3)
0.9 (0.9)
10.2 (14.5)
0.1 (0.3)
11.2 (36.2)
0.3 (0.6)
0.8 (1.9)

46 (87 ％)
7 (13 ％)
52.7 (13.9)
2 (3.8 ％)
10 (19 ％)
6.4 (2.9)
2.2 (1.1)
1019.2 (678.2)
1.2 (1.1)
11.4 (12.6)
00.5 (0.5)
1.6 (2.0)

Statistics

p＝0.282†
t＝-4.30, df＝153, p＜0.05
p＜0.05†p＝0.236†t＝-1.86, df＝153, p＝0.065
t＝-3.25, df＝153, p＜0.05
t＝-0.97, df＝153, p＝0.332
t＝-1.28, df＝153, p＝0.201
t＝-0.5, df＝153, p＝0.618

t＝-2.01, df＝153, p＜0.05
t＝-2.33, df＝153, p＜0.05

Data are shown as mean (standard deviation) or the number of patients (frequency).
CLZ : clozapine ; ECT : electroconvulsive therapy†Fisher’s exact testＣ Comparison of pharmacotherapy in schizophre-cant difference was observed in the chlorpromazine

nia between difficult-to-treat patients under theequivalent doses of antipsychotics between the two

MTSA and long-term inpatients at risk of self-groups.

harm or harming others under the Mental Healthand Welfare Act

Ⅳ Discussion

The number of antipsychotic medications and anti-

The treatment of patients with psychotic symptoms,

Parkinsonian medications, as well as the diazepam

which can lead to self-harm and harm to others, is aequivalent doses of benzodiazepines, was higher incritical challenge in psychiatric care. This study fo­

the long-term inpatient group (Table 4). No signifi­

cused on difficult-to-treat inpatients under the MTSA

No. 2, 2024

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Saitoh・Sasayama・Yoshizawa et al.

and long-term inpatients under the Mental Healthfrom nervousness, anguish, anxiety, and hopelessness

and Welfare Act who were at risk of self-harm or

are suggested to be associated with relatively higher

harm to others. These groups represent the mostintelligence. Further studies with an increased sam­severe cases in the field of psychiatry. The majority

ple size are necessary to confirm the trends in IQ

of difficult-to-treat inpatients under the MTSA andscores among various patient categories.

long-term hospitalization cases under the Mental

The most common diagnosis in difficult-to-treat

Health and Welfare Act were male patients with schizo­cases was schizophrenia, and many patients had co­phrenia. Murder and grievous bodily harm were themorbid disorders. Intellectual disability was the most

most common target acts for patients under the MTSA.

prevalent comorbidity, followed by pervasive develop­

Clozapine was used in a higher proportion of patientsmental disorders. Patients with comorbid schizophrenia

treated under the MTSA.

and intellectual disability encounter significant obsta­

Collecting and analyzing data on cases under thecles in their treatment8）. While it is possible to manage

MTSA and involuntarily admitted inpatient cases

psychotic symptoms such as hallucinations and delu­

under the Mental Health and Welfare Act due to thesions to some extent through treatment, the presencerisk of self-harm or harm to others is challenging dueof intellectual disabilities, autistic traits, and problem­

to stringent information management protocols. To

atic behaviors, such as difficulties with impulse con­the best of our knowledge, no similar studies havetrol, presents significant challenges in the overallbeen published to date.

treatment process.

No significant differences were found in patient de­In murder cases, victims tended to have a closemographics between the difficult-to-treat cases in therelationship with the perpetrator, whereas in cases ofpresent study and those reported in the 2020 MTSA

burglary, sexual assault, and grievous bodily harm,

6）statistical data , which encompassed 3,761 patientsthe majority of victims were usually unknown or

hospitalized from the enactment of the MTSA until

strangers to the perpetrator. The targets of arson

December 31, 2020. The proportions of the target acts

were predominantly the patient’s own residences, in­in the difficult-to-treat cases in the present study

dicating a potential association with attempted sui­were similar to those in previous data.

cide. Higher suicidality has been reported in individ­

In difficult-to-treat cases, the patients were pre­uals with mental disorders who commit arson9）.

dominantly male, and their average age at admission

Associations between psychiatric symptoms and thewas in the early 40s, similar to the demographics re­targets of the crime should be explored in future

ported in the 2020 MTSA statistical data. The length

studies.

of hospital stay often exceeded the MTSA’s goal (1.5

In the long-term hospitalization group, many pa­

years). The mean IQ score was 77.0, indicating thattients were primarily diagnosed with schizophrenia

many patients were in the borderline intelligence

under the Mental Health and Welfare Act. Among

range. Some patient groups showed higher rates ofthese long-term hospitalized individuals, 31 ％ had

intellectual disability, whereas others exhibited intel­

comorbid diagnoses. Seto et al.4） showed that “diffi­

ligence within the typical range (Fig. 2).

culty in symptom improvement” and “inadequate

Research on the relationship between IQ and crimi­

impulse control” were the most common reasons fornal behavior is limited. Some reports propose thatthe challenges in discharging patients who were in­individuals with schizophrenia and below borderline

voluntarily hospitalized due to risks of self-harm andintellectual functioning may experience more severe

harming others and that many of these patients had

7）

psychotic symptoms . The behaviors of those withhallucinations, delusions, and impulse control prob­

intellectual disabilities might be more susceptible tolems. In managing these conditions, patients oftendelusions, potentially leading to impulsive criminal

receive high doses of antipsychotic drugs and are

activities. Conversely, instances where actions stem

commonly prescribed two or more medications de­102

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Comparative analysis of challenging inpatients under different acts

spite experiencing no significant improvement instringent regulations regarding the safe prescription

symptoms, highlighting the complexities and chal­of clozapine compared to other countries. However,lenges in treating these cases.

in 2021, there was a revision in the package insert toIn a survey of 10,106 inpatients with schizophrenia

relax these regulations. The Ministry of Health, Labor

conducted by the Japanese Psychiatric Clinical Phar­and Welfare has set a goal to expand the use of clozap­

10）

macy Research Group , it was found that the averageine to reach 25 ％ of patients with treatment-resistantnumber of antipsychotic drugs was 1.7, with a meanschizophrenia. Despite these efforts, the factors con­chlorpromazine-equivalent dose of 722 mg/day. In

tributing to the low prescription rate of clozapine incontrast, the chlorpromazine-equivalent dose wasJapan remain unclear and warrant further investiga­

higher in difficult-to-treat schizophrenia patients intion.

the present study.

Based on our findings, clozapine is used more fre­

The prevalent use of multiple antipsychotic medi­

quently under the MTSA than in other countries or

cations and anti-parkinsonian drugs in long-term

the broader Japanese medical systems. One reason

hospitalized inpatients under the Mental Health andmay be that the guidelines for inpatient treatment

Welfare Act suggests that each antipsychotic wasunder the MTSA recommend the use of clozapine,

typically prescribed at a relatively low dose. In con­which has been proven to be effective in severe chronic

trast, the proportion of clozapine prescriptions amongschizophrenia22）, for patients with treatment-resistantpatients under the MTSA was 47 ％ , significantly

schizophrenia. Additionally, the prevalence of partic­

higher than the proportion (3.8 ％) in patients underularly difficult-to-treat cases under the MTSA might

the Mental Health and Welfare Act. The higher ratenecessitate the use of clozapine. However, the chlor­of clozapine use might have facilitated more effective

promazine-equivalent dose of antipsychotics was not

monotherapy with antipsychotic medications, thereby

significantly higher in patients under the MTSA than

reducing the need for additional anti-Parkinsonianin those under the Mental Health and Welfare Act inmedications in inpatients under the MTSA. Compar­

the present study. Notably, the number of prescribedatively, a survey of schizophrenia patients conducted

antipsychotics was minimal in inpatients under theby the Japanese Psychiatric Clinical Pharmacy Re­

MTSA, implying that adherence to treatment guide­

search Group10）

found that the percentage of clozap­

ine prescriptions among psychiatric inpatients inJapan was 4.8 ％, a figure much lower than the 47 ％for inpatients under MTSA.

lines led to monotherapy with antipsychotics, partic­
ularly clozapine.
The utilization of ECT was notably higher among
participants in the current study compared to patients

11）

According to Gaebel et al. , clozapine is recom­

undergoing general psychiatric treatment23）. Apart

mended for treating treatment-resistant schizophre­from the substantial number of severely ill patients,

nia. Despite its effectiveness, there’s a global trend of

this discrepancy may be attributed to the more wide­

underutilization of clozapine12）. The rates of clozapine

spread availability of ECT equipment in designatedprescriptions for both inpatients and outpatients are

inpatient facilities compared to general psychiatric13）

hospitals. However, in contrast to the rate of clozap­

14）

4.8 ％ in the United States , 5.5 ％ in Sweden , 8.3 ％
15）

16）

in Australia , 10.1 ％ in Denmark , 10.9 ％ in South
17）

18）

Korea , 23.7 ％ in England and Wales , and 24.6 ％19）

ine utilization, the rate of ECT use was not higher
for patients under the MTSA than those under thein China . The reasons for these low prescription

Mental Health and Welfare Act. This could be at­

rates include the risks of serious side effects, such as

tributed to a higher preference among patients underagranulocytosis, myocarditis, and intestinal obstruc­the MTSA for continuous treatments such as clozap­

tion, and the requirement for continuous hematologi­

ine, especially when considering the outpatient treat­20）

cal monitoring . In Japan, the rate of clozapine pre­ment period. Further studies are warranted to ex­

scription was relatively low at 6.2 ％21） owing to theplore the optimal utilization of clozapine and ECT in

No. 2, 2024

103

Saitoh・Sasayama・Yoshizawa et al.

patients with treatment-resistant schizophrenia andFurther examination of problematic behaviors thatto actively promote the use of clozapine and ECT,

result in hospitalization is essential to improve dis­

where necessary, to enhance treatment outcomes incharge support.

these challenging cases.
Ａ

Ｖ Conclusions

Strengths and limitations
The strength of our study lies in the analysis of

The majority of difficult-to-treat patients underdata from patients hospitalized under the MTSA, a

MTSA had schizophrenia. The present findings sug­dataset that is often challenging to obtain. Addition­gest that appropriate therapeutic strategies, such as

ally, this study enhances the understanding of medi­

monotherapy with antipsychotic drugs and active

cal treatment under the MTSA by comparing theseuse of clozapine, are emphasized for inpatients underfindings with those from patients hospitalized under

the MTSA. Learning from the treatment of these dif­the Mental Health and Welfare Act.

ficult-to-treat MTSA cases has the potential to sig­

This study has several limitations that must benificantly enhance psychiatric care in Japan. In par­noted. First, owing to the stringent confidentiality

ticular, promoting the use of clozapine and ECT may

protocols, data collection was confined to difficult-to-

be beneficial for patients who experience prolonged

treat and long-term hospitalized inpatients, preclud­

hospitalization due to severe psychotic symptoms anding comparisons with more general cases. Second,

challenges in symptom improvement. Therefore, ad­clinical scales were not used to assess the illness se­ditional research in this area is warranted to further

verity. Third, the survey was originally conductedrefine and develop effective treatment strategies.

under a different framework for patients hospitalized

Conflict of interest

under the MTSA and the Mental Health and Welfare
Act. Therefore, variations in the survey items and alack of consistency existed between the two groups.

The authors declare that they have no conflict ofinterest.

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