JapanesepMental Health SystemyReformProcess and Comparisons with Australia
Yutaro Setoya
Tadashi Takeshima
National Institute of Mental Health,
Health JAPANContents• Current Situation of Mental Health andWelfare Services in Japan• Mental Health Reform Process in Japan• Comparison of key data with Australia• Implications to Japan

Japan• Population:
128M (Australia 20M)
• Area:378,000 sq km (Australia 7,687,000)• GDP per capita:
29,400US$ (Australia 28,900US$)
High population density
density.
About the same GDP per capita
Comparing the data,
data divide by six to know theequivalent size in Australia

Current S
CSituation off
Mental Health Services in Japan

Difference of health system Aus &Jpn
In Japan there is…
• No GP• No catchment area. Patient can choose
wherever they want to go• Universal health insurance with copayment
• Fee
F for
f service
i schemehffor medical
di l servicei• Private and public hospital on same scheme,with same priceM t l Health
MentalH lth S
Servicesi
iin JJapan
MedicalSocial Welfare• Mental Hospitals (80% private)• Out patient clinics (private practice)• Home visit by nurse• Daycare center• Pt. and Family Psychoeducation/Social
Skill Training/Occupational
SkillsT i i /Otil ththerapy…
• Half-way homes (rehabilitation facilities)• GroupGHome
H• Home help
• Job coaching/scoaching/supported
pported emplo
employment
ment• Care management

Mental Hospitals•MentalM t l hospitals:hit l 1
1,669.
669 N
No off B
Beds:
d 350
350,000.
000
28.1 beds per 10,000 people. (No of pt. 330,000)•Forms of the establishment:
University hospitals 5%
Public hospitals 15%
Pi t hPrivatehospitals
it l 80%
80%.
•40% of the inpatients are over 65 years old, andmore than 70% are staying longer than one year.

Mental Hospitals contcont.
• All beds of national and public mental hospitals
accepts involuntary hospitalization.
• 68% of the private mental hospitals also havebeds for involuntary hospitalization.
services, private• In Japanese mental health services
facilities are playing a central role.
Co-payment
payment of medical services are 30%30%, same• Co
in public or private. For chronic mental ill patient,co-paymentp yis 10% or less, dependingp
g on income.
• Most of the fund goes to Mental hospital. We
must allocate more fund to communityy mental
health.

Other Medical services• No. of mental clinics 3,682. Almost all oftheh clinics
li i are private.
i• About 800 mental hospitals and 300 mental
clinics provide psychiatric day care.
g byy mental hospitals:p• Home-visit nursing
total number of about 43,000 cases permonth.
• Group therapy, Occupational therapy, andother programs are conducted at hospital• Family psychoeducation is also widely
conducted.

Psychitric beds per 1,000 people（ OECD Health Data 2002

5
4.5

Finland

Luxembourg

4
35
3.5

U.S.

Sweden

S i
Switzerland
l d
U.K.

Japan

3
2.5
2

Au stralia

Germany

1.5
1
0.5

Korea

0
1960

1965

1970

1975

1980

1985

1990

1995

2000

Australia
Austria
Belgium
CanadaCzech Republic
Denmark
FinlandFranceGermany
GreeceHungary
Iceland
Ireland
Italy
Japan
Korea
L
LuxembourgbNetherlands
NorwayPolandP
Portugall
Slovak Republic
Spain
SwedenSwitzerland
TurkeyUnited Kingdom
United States

Mental Health Personnel （Full time）
at Mental Hospital
No. of person

No. of beds perpersonPsychiatrists

9,527

37.2

Nurses

53,378

6.6

Assistance Nurses

49 55449,55472
7.2

Nursing aids

35,604

10.0

OTs

3 832
3,832

92 6
92.6

PSWs

4,503

78.8

Clinical Psychologists

1,496

237.1
2002 No. of beds 354,721

We have many staff working at hospital.
We must move this workforce into community practiceLengthg of Stayy of PsychiatricyInpatients
p
600
500
400
300
200
100
0
1955

1960

1965

1970

1975

LOS

1980

1985

1990

1995

2000

2001

No. of beds per 100,000

inpatient person-day
Length of stay =1/2 (No. of admission + No. of discharge)
Length of stay is gradually becoming shorter since 1985.
However, it is still long due to long stay patients.

Survival Curves of Inpatientsp
Admitted
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
0

1

2

3

4

5

6

7

8

9

10

11

12

When seeing the inpatients admitted,• Half of the newlyy admitted patientsp
are discharged
g within 2 months.
• About 15% of the patients are still staying after a year.

No. of Inpatients by Length of Stayover 20 years
10 years - 20 years
5 years - 10 years
1 year - 5 years
6 months - 1 year
3 months
th - 6 months
th

2003
2002
2001
2000

1 month - 3 months
under 1 month0

10,00020,00030,00040,00050,00060,00070,00080,00090,000Length of stay varies; 30% stays less than ayear and remaining 70% are staying longer
year,
longer.

100,000

Ageg of Inpatients
p
2003
2002
2001
2000
1998
1996
1994
1992
1990
1988
0%

10%
under 20

20%

30%
20-40

40%

50%

60%

40-65

• About 40% of the inpatients are over 65 years oldold.
• Aging of psychiatric inpatients are advancing.

70%
20-65

80%

90%
over 65

100

Number of PsychiatricyInpatientspandLength of Stay (Summary)• Among the newly hospitalized patients at
psychiatric hospitals, 50% discharged
within about 2 months, 14% stayed longer
than 1 year.
• Of the inpatients staying at mental hospitals,
30% are staying for less than a year, and
40% are over 65 years oldold. This is because
the patients who cannot get discharged
from the psychiatric hospital and move tothe other rehabilitation facilities are aging.

Community careRehabilitation and Residential
Facilities in Community• Welfare facilities are mostly private owned (social
welfare corporations, medical corporations,NPOs).
NPOs)• Administrating finance is from public funds.
• Users can choose the facility
facility, and are registered
to the facility. Usually the database of each facility
is not linked with others.
• Entering the facilities, users must be assessedand have a care plan.

Rehabilitation facilities• Half-way
Half way homes with limit for stay(e.g.6months, 2years)• Units varies by function, from 10 to 30
users• Place to gather from home
• Offers psychosocial rehabilitation
rehabilitation, such as
ability for daily living (e.g. cooking, buying,
telephone use
use, public transporttransport…))• Some offers opportunity to work

Group Homes• Place to stay for long term, for thosewhom they can live on their own• Units are about 5-6
5 6 users• Some is a big house with many rooms,
some are apartmentstt• One staff comes on daytime

Communityy Rehabilitation Facilities
Targetg
Facility for training in daily Person without home and can notlife*
live independently
Welfare home*

No ofcapacity
5,684

Person without home

3,165

Residential vocational
facility*

Person without home and needs
vocational training

806

Outpatient vocational
facility

Person who needs vocational
training

6,271

Person who can not work because ofinterpersonal reasons462

Welfare factoryCommunity lifeC
f support
center

Provides consultation and liaison
with other facilities

452 placesGroup home
home*

Person who can live communally

6,404*residential facilities

No of Beds in Hospital and Facilities
No.
Adult acute
Adult non-acuteChild & Adolescent
Aged
Rehabilitation facilityGroup Hom e
0

50

100

150

200

250
Per 10,000 person

No. of beds for mentally ill people per 100,000 population are 28.1 inmental hospitals,
hospitals 0
0.7
7 in rehabilitation facilities and 0
0.4
4 in group home
home.
Though there are many beds in psychiatric hospitals, most of the beds areused by long staying and aged patients.
Promotion of discharge,
discharge changing hospital beds to community facilities
facilities,
and securing beds for acute care is an urgent issue.

Home-visiting (Outreach) support• The importance of visiting support has beenemphasized.
pHome-visiting
g services done byymental hospitals and clinics are increasing.
home-visiting
visiting services• Forms of home
-home visit by nurse/SW/OT/Dr
-home
h
visit
i it bby nurse b
beforefdidischargeh-home help service by home helper

C
Care
M
Managementt• Needs of integration of care is increasing
especially in community mental health.
• However,, because of the insufficient liaison
between hospitals and welfare facilities, and lackof budget to support, it was not introduced toroutine care
care.
• In 2006, new Law (Law to Support the
Independence of People with Disabilities) was
enacted. It provides funding for making careplans, so it may increase the no. of caremanagementt done.
dRecent effort in Japan:
Assertive Community Treatment• Intensive form of care management. Case load about
10• Treatment
T tt offeredff d directly
di tl fromftheth multidisciplinary
ltidi i li
team.
• The pilot study of ACT has begun in 2003.
• However, the main administration body and funding
resource for ACT is not decided.
S
Supportedt d employmentlt• “Place, then train” approach• Traditionally,
Traditionally patient were trained in special settingssettings.
• This approach, assign the patient to a actual work
place, and job coach train them on the spot.
• Still iin th
the researchh phasehCurrent Limitation (Before the reform)• Too many psychiatric beds/ lack of community support
services.
Inpatients due to the lack of support in the community =70 00070,000• Difference between disorders. Mental disorders notincluded to funding/service provision system for physicaland intellectual disorders.
• Difference of service quantity and quality between areas.
• Lack of vocational rehabilitation.
rehabilitation• High stigma and lack of understanding of mental healthamong the community.
• Increase of the use of both social welfare services andmedical expenses for outpatient/ambulatory services led
too sca
scarcityc yoof thee funding.
u d g Thee syssystem
e is
s not
o sus
sustainable.
a ab eMental Health System
Reform in JapanpReform of Mental Health and Welfare Services- Recent Developments •
•
•
•
•
•
•

2002 Future Direction of Mental Health and Welfare Policy
Report from the Sub Committee on Mental Health in the Social
Security Council (advisory board to Minister of Health)2002 Establishment of Headquarters for Mental Health andWelfare, headed by the Minister2004 Reform Vision for Health, Medical Care and Mental HealthWelfare2004 Future Policies for People with Disabilities and Community
Welfare (Grand Design for Reform)
2005 Law to Support the Independence of People with
Disabilities
2005 Revision
R i i off theth M
Mentalt lH
Healthlth anddW
Welfarelf
L
Law
2005 Revision of the Law on Promoting Employment of the
DisabledReform Vision for Mental Health and Welfare Services
Headquarters for Mental Health and Welfare, headed by the Minister“From Institution-based Care to Community-based Care”
Three main aims
public s attitude toward mental illness• Change the public’s• Reorganize and reinforce psychiatric medical services• Reorganize and reinforce community support systems

After hearing the opinions of local governments and related councils,etc., the MHLW revised the Mental Health Welfare Law in 2005.

Framework of Reform Vision for Mental Health and Welfare Services

Implement the following to promote change from hospitalization to community life over the next 10 years:(1) Better public education (2) Reform of mental health treatment (3) Greater support for community life.
Public education
Better understanding of
mental disorders and patients

Mental healthtreatment reform

Greater support forcommunity life

Advanced specialization topromote early discharge

Secure environment forformer mental patients

Stronger foundation
・Train more people to provide mental health treatment and welfare services, and develop standard care models.
・Expand benefits for better-quality home treatment services.

Basic stance: Shift from hospitalization to community-based life
The aim is to reduce the number of psychiatric hospital beds by about 70,000 over the next 10 years

(1) Goal of Public Education Reform- Like any life-style related disease, mental disorders
also affect the general public. The goal is to raise
public awareness to over 90%.
(2) Goal of Medical Treatment Reform- Efficient treatment to promote patient discharge within
a year of hospitalization.
Lower the average number of patients who remain
hospitalized to below 24% (less than 1 year group) ineach prefecture.
- Promote the return to community life of the patients
hospitalized over a year.
Raise the discharge rate (over 1 year group) to over
29% in each prefecture.
prefecture

A
Average
Rate off PatientsiWhoh Remaini Hospitalized
i li dRate of Patients(under 1 year group)
Remaining Hospitalized
100%

Average rate

Actual rate０

Average rate of patientsremaining hospitalized(under 1 year group)

１year

＝

MonthsSum of remaining patients every month

Number of hospitalized patients in previous June x 12

Discharge
sc a ge Rateate (ove(over 1 year
yea group)
g oup)100%
Di h
Discharge
ratetPatients staying
over 1 year

０

1year

Numberb off discharged
di hd patientsi(hospitalized(h i li d over 1 year)) byb monthh x 12

Discharge rate(over 1 year ＝ggroup)p)
Number of hospitalizedpppatients ((over 1 yyear)) in the yyear

Dispersion of Average Rate of Patients Remaining
Hospitalized and Discharge Rate (each prefecture)
The dots express the average rate of patients remaining hospitalized (under
1 year group)) andd theth discharge
di h
rate
t (over(
1 year group),) calculated
l l t d fromf
2000–2002 figures, by prefecture.
35.0

30.0

Disch
harge rate (%)

25.0

20.0

15 0
15.0

10.0

5.0

0.0
00
0.0

50
5.0

10 0
10.0

15 0
15.0

20 0
20.0

25 0
25.0

30 0
30.0

35 0
35.0

Average rate of pat ients who remain hospitalized (%)

40 0
40.0

45 0
45.0

Expected Transition in Number of Hospital Beds

400000Over 1-year
1 year group

350000Under 1-year group
Total

300000250000259103.4

200000150000100000146898.2112205.2

50000
02002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Assumption: Number of admitted patients grows by 2.0%

( ) Enhancement off Community(3)
C
S
Support S
Systems
1. Reorganize support system for housing,li i andlivingd activities,
i ii
suitedi d to eachh lifelif stage
2. Establish a multi-layered counseling support
system (care(management))
3. Improve the structure to supply systematic
servicesib municipalities
byi i liti→ Revisions to laws supporting the independenceof people with disabilities and promoting theiremployment

Function Differentiation of Hospital Bed
Number ofresidual patients

Present state

Making specialized acute units

Program for housing, life
support, and work

Promote discharge byintensive rehabilitation
program
Acute-phase
Patients who tend to staytreatment
for a long timepatients

Community
settings
Patients with severe
disorders

Improve inpatientcare by increasing
medical staff,, etc.

Assertive community treatment

Length of
hospitalization

Law to Support the Independence
off PeopleP
l withith DiDisabilities
bilitiChallenges
g to People
p with Disabilities
and Community Welfare• Growing difficulty in maintaining the system as
the number of users continues rising.
• Wide regional gaps (no nationwide rules; different
service supply systems fromf
one area to another,
discrepancy in municipal financial capacity).
• Broad gaps in service quality and systems bytype of disability.
• Obstacles to people with disabilities willing towork.
Inadequate systems for people with disabilities to lead normal
lives in the community.

Points of Law to Support the Independenceof People
p with Disabilities• Streamline three disorders• Service integration to more useroriented services• Enhance support for employment• Clarify benefit supply process• Secure financial source

Streamline three disorders
Current situation• Haphazard approach to 3 disorders (physical(physical,
intellectual, mental).
• Implementation by two sectors – prefecturesand municipalities.
Law aims to• Streamline the approach to 3 disorders.
• Allow the municipalities to handle theservices.

Service integration to more user
useroriented services
Current situation• Highly
Hi hl complex
l b
by di
disorderd ttype.
• Gap between aim of the facility and reality.
Law aims to• Reorganize facility systems. Create services
to support employment and help severely
handicapped.
• Use available social resources while
promoting deregulation.

Enhance support for employment
Current situation• Few users graduate facilities by gettingjjob
Law aims to• Create more job support services
services.
• Strengthen connection to employment
policiesli iClarify benefit supply process
Current situation• No objective criteria to judge need for support
pp y pprocess• Unclear benefit supply
Law aims to• Use a scale (to check disorder level) tomeasure the level of support needed.
• Clarify
Cl if theth process off supply
l ddecisioni i making.
kiSecure financial source
Current situation• Expectedprise in number of users.
• Unstable government financial support.
Law aims to• Increase the government’s financial
burden (1/2 the cost).
• StabStabilize
e tthee gogovernmentee t financea ce• Clarify users’ share of the cost.

New welfare service provision system
Care needs assessment by designated interviewer
Primary judgment by the computer
Doctors reportpCommittee for certification of need
Secondary judgment
User’s opinion
Service provision determined

Care needs is assessed in 7 categories
categories, no needs or careneeds 1 to 6
Depending on the care needs
needs, type of service and fundpaid to service provider are decided

Recent change on the national
fee schedule (2006)• The fees paid to emergency and acute psychiatric unit
are raised for those staying less than 30 days.
• Similarly, the fee usual psychiatric unit are raised for
those staying <15 days and reduced for those staying
more than 90 days
days.
• Nurse visit limited for 3 times/week but changed to
5/week for those who are less than 3 months after
discharge.
• Psychotherapy for the family was included to theschedule.
schedule• New setting of the short term (three hours) psychiatricy
was established.
daycareImage of changing the rate
new ratepreviousiratet

1 to 30

31 to 90

91 to 180 181 to 365 days

Other recent reform•••

Revision of the Law on Promoting
E l
Employmentt off theth Disabled
Di bl dAt least 1.8% of the employee must be
person with disability
disability. Mental disorder
included in 2005.
The Act for the Medical Treatment andSupervision of Insane Persons Who Caused
Serious Harm
Criminally insane treated at inpatient andoutpatient of designated hospitals
S bsidiar paid when
Subsidiaryhen mental hospitalchanges their unit into rehabilitation facility

Strategy
gy to Reduce the Psychiatricy
Beds• Difficult because most of the hospital is private• Reduce the fee for long stay pt.
pt while increasing thefee for shorter stay pt.
• Promote differentiation and specialization in function of
the units• Money are paid when hospital changes their bed into
rehabilitation facility• Setting medical goal (e.g. length of stay) for each
districtd
s c too followo o• Introduction of new antipsychotic drug
• Developingp g more community
y mental health services(home visits, half-way home…)• Most western countries closed mental hosp. without
developing community care
care. Many homelesshomeless, highreadmission rate….

A bit about Australian Mental Health Strategy• Three broad aims identified– promotet mentalt l health,
h lth preventt disorders
di d– reduce impact of disorders– assure rights of people with mental illness• Early effort was directed at restructuring public sector
specialist mental health services to:– change the service mix to be more communitybased– integrate mental health services and bring them
together with general health care (‘mainstreaming’)– reduce reliance on stand alone psychiatric hospitals– improve service responsiveness and respect ofconsumer rights

The National Mental Health Plan 2003-08• Four priority areas:– Promoting mental health and preventing mental
health problems and mental illness– Improving service responsiveness– Strengtheningggqqualityy– Fostering research, innovation and sustainability• Continuing effort required to position mental
h lth as a ''whole
healthh l off community’
it ’ mattertt b
by:– reducing stigma, particularly targeting the media– collaborating with unions and employers on
prevention in the workplace– Health promotion programs eg Mindmatters

Outcome of the NMHS in Australia• Funding increased/more fund to community• HighHi h growthth off community
it mentalt lhhealthlth
services and NGO• Closing
Cl i off standt d alonelhhospitals
it l andd nonacute beds
• RiseRi off consumers andd carers participation
ti i ti tto
services• DevelopmentDlt off public
bli awareness/education/ dti
programs

Comparison of key data between
Australia and JapanJ p

M t lH
MentalHealthlth F
FundingdiAustralia

Japan

Total spending

3 327M A$
3,327M

21 382M A$
21,382M

Per capita

166.35 A$

167.05 A$→ Almost the same spending!!

1A$=95yenMental Health Funding-Hospitalpand CommunityyHospitalCommunityAustralia

Japan

Need to allocate more fund towards community

Comparison of Psychiatric Beds

Japan

Supported public hous ing
Rehabilitation facilityy
AgedChild & Adoles cent
Adult non-acute

Aus tralia

Adult acute

0

50

100

150

200

250

300

Beds/100,000

No Professionals per 100
No.
100,000
000
p p
population
Psychiatrist
Psychiatric Nurse
Psychologist
Social Workers

Australia
14
53
5
5

Japan
p
10
59
7
16

Source: WHO Atlas

Service difference with
Victorian Service Framework
Child & Adolescent Services

Adult Services

Aged Persons Services

Statewide Services

24 hour crisis response

Crisis assessment &Treatment

Psychogeriatricassessment & treatment

Victorian Institute ofForensic Mental HealthIntensive youth support

Intensive CaseManagement

Acute Inpatient services

Personality disorderservice

Extended care
inpatient services

Brain disorders
services

Continuing care

Continuing careAcute Inpatient services

Acute inpatient services

Mother-Baby
servicesi

Rehabilitation services

Residential
Rehabilitation

Eating disorderservices

Secure/extended care
inpatient services

Dual disability
services

Psychiatric disability
Rehabilitation &support

Neuropsychiatricservices

Residential

Non-residential

Planned respite

Mutual support
Self-help

Dual diagnosis (D&A)( & )services
Transcultural psychiatry
services

Yellow: Services not available or scarce in Japan

Implications
pfrom Australia

Implications from Australia• Funding shift towards community• Development of community mental healthservices, especially the outreach type
• Care management and Individual service plan
• Specialization in services• Promotion and Prevention• Quality
Q lit improvementitFunding shift towards community• Australia have shifted the fund tocommunity in 10years, from 29.4% to51.2%.
• Japan also needs the shift towards
community.
community• More outcome based funding system
requiredDevelopment of community
mental health services• Outreach type of service is still scarce inJapan.
• Especially, there is no team that can assessin the crisis situation. Family must bring themto the hospital, sometime with the police.
• Also, more rehabilitation oriented residential
facilities are needed• Vocational and housing support

Case management and Individual
service planp
• Introducing the new law, casemanagement and individual service plany for those who are living
g inwill be a duty
the community• However quality assurance of it isnecessary, and those for SMI, directcare giving by the CM neededSpecialization in services• Both inpatient service and community
service needs specialization• Areas include CAMHS
CAMHS, personality
disorders, early psychosis, dual
diagnosis dual disability
diagnosis,
disability, etc

Promotion and Prevention• High stigma among the community andthe mental health knowledge is low• We need various types of programs,suchh as mindmatters,
i d ttLif
Life iis fforeveryone, beyond blue, national drug
strategy in Australia

Quality improvement• Community services framework is set,but contents are not defined• Training of the staff• Consumer and carer involvement• Outcome measurement

Conclusion• Japan is in the reform process toward
community mental health• Many policy
policy, law and regulation are
released• HoweverHththere are areas tto bbeconsidered more, and lessons from
Australia’s reform is valuable.