ORIGINAL ARTICLEThe Sasagawa Project: A model for deinstitutionalisationin Japan
Masafumi Mizuno,1 Kei Sakuma,2 Yonosuke Ryu,1,2 Shunichi Munakata,2 Toru Takebayashi,3Masaaki Murakami,4 Ian R.H. Falloon5 and Haruo Kashima1
1Department of Neuropsychiatry, School of Medicine, Keio University
2Asaka Hospital, Koriyama-City, Fukushima Prefecture, Japan
3Department of Preventive Medicine and Public Health, School of Medicine, Keio University
4Department of Social Welfare, Faculty of Sociology, Meiji-Gakuin University
5Department of Psychiatry, University of Auckland, New Zealand(Received for publication on November 8, 2004)(Revised for publication on January 13, 2005)(Accepted for publication on January 20, 2005)

Abstract. Japanese psychiatric services are still typically hospital-based. The Sasagawa Project is theﬁrst systematized deinstitutionalization project in Japan that aims to make the transition from hospital
to residential living while ensuring both the quality and continuity of care for the patients. Seventyeight (51 males) patients (mean age 54.6) with chronic schizophrenia, who were considered appropriate
for discharge received continuous cognitive behavioural therapies based on the Optimal Treatment
Project manualised protocol, both before and after the hospital closure. During the ﬁrst 12 months after the deinstitutionalisation was initiated on April 1st , 2002, ten people had incidents that interrupted
their stay in the residential Sasagawa Village. A common criticism of many treatment outcome trials
is that evaluation is focused on changes in clinical severity. In the Sasagawa project the transition
appeared to have been smooth and relatively few incidents occurred could be related to the transition
to a less intensive residential care. This project might be a useful model for effecting and monitoringtransition from hospital to community care in Japan and other countries where such changes have been
proposed. (Keio J Med 54 (2): 95–101, June 2005)
Key words: deinstitutionalisation, schizophrenia, outcome, psychiatric rehabilitation, psychiatrichospitals

Such reliance on hospital-based psychiatry is a barrier
to the development of community-based psychiatry.
The Sasagawa Project aims to make the transition
from a hospital to a residential facility while ensuring
both the quality and continuity of care for the patients.
The aim of this paper is to describe the rationale,methods, and recruitment of the Sasagawa project andthe community ‘‘survival’’ twelve months after thehospital closure. This is an ongoing, prospective, pragmatic, observational study that has been developed
to provide clinical and economic information about
Japanese inpatients with schizophrenia, their families,
mental health professionals and policy makers in our
attempts to develop community-based psychiatry. The
study will provide data to test additional hypotheses.

Introduction
Psychiatric care has changed considerably in mostwestern countries. Large institutional mental hospitals
have been replaced by community-based services that
focus efforts on preventing severe episodes of disorders
and the necessity for long-term hospital treatment.1,2
In Japan, health professionals and policy makers
have recognized the importance of such movements,
but changes have been slower than expected.3,4 Consequently Japanese psychiatry services remain predominantly hospital-based. A decline in hospital beds wasobserved from 1994, but the total number of inpatientsis still 2.9 per 1,000 people,5 compared to 0.9 in the
United Kingdom and 0.5 beds in the United States.6

Reprint requests to: Dr. Masafumi Mizuno, Department of Neuropsychiatry, School of Medicine, Keio University, 35 Shinanomachi, ShinjukuKu, Tokyo 160-8582, Japan, e-mail: mizuno@sc.itc.keio.ac.jp
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Mizuno M, et al: The Sasagawa ProjectIn particular, the interactions between environmental
change and the course of mental disorders, patterns oftreatment, and the association of treatment with outcomes.
Although there have been many follow-up studies ofpatients discharged from mental hospitals,7 there havebeen few long-term prospective studies with systemic
assessments. Furthermore, description of the process ofclosure has often been unclear and the results focusedon community tenure, homelessness and associatedsocial incidents such as criminal events.8 Crucial issues
about retraining of hospital-based staff and the application of manualised evidence-based treatment strategies had seldom been addressed. The most comprehensive study, the Friern Hospital Project, was carriedout in London in the 1980s.9 The extensive documentation provided enables clear comparisons to be madebetween patient relocation programmes of this kind on
a wide range of clinical and social variables. The change
from a passive lifestyle where staff made everyday
decisions for patients to one where patients wererequired to solve problems, make decisions and plans
for their daily lives might be expected to re-activate
neurocognitive functions that had been dormant for
many years of institutional care of the kind usuallyprovided in Japan.
This report will focus on the process of closure of along-stay hospital and the community tenure of patientsin the ﬁrst year after transition to residential care.
MethodA summary of the Sasagawa Project study is shownin Table 1. The study was designed to evaluate a groupof people with chronic schizophrenia over 5 years ofcontinued optimal treatment and to use a range of measures that reﬂected the broad impact of this disorder onmany aspects of peoples’ lives.
Data is being collected prospectively throughout
the 5 year period by the participating psychiatrists during treatment visits that are part of normal care. The
Institutional Review Board approved the protocol. The
study was explained to the patients by the principal
investigators. Written informed consent was obtained
from all patients.
Setting
Sasagawa Hospital was a private long-term inpatient
unit with 107 patients in the suburbs of Koriyama city;
population around 300,000. It was afﬁliated with Asaka
Hospital, a nearby acute neuropsychiatric unit. The
Sasagawa hospital was founded for the psychiatric rehabilitation for the people with chronic mental illness
by Dr. Yuju Sakuma in 1978. Most of these patients had

no relatives willing or able to provide them with a place
to live in the community. Most suffered from severe
persistent psychotic and residual symptoms and had
frequent admissions to the acute unit. Thus, a range ofintensive speciﬁc services were needed to help themadjust to living in the community.
Subject selection
Patients were selected who were considered appropriate for discharge from inpatient care. Eighty-eightpercent of the inpatients at Sasagawa Hospital weredischarged when the hospital closed on 31 st March
2002. The remaining 13 were transferred to anothermental hospital for continued inpatient care. Of the
94 discharged people, 78 (51 males) were diagnosed
as chronic schizophrenia by two psychiatrists independently. For this study, these 78 people with chronic
schizophrenia are being evaluated prospectively
throughout a 5-year period.
DesignThe project started ten months prior to closure of
the Sasagawa Hospital. A project team of twenty multidisciplinary members was recruited and a Non-Proﬁt
Organization (NPO) was founded. The following plan
was made:
1. Sasagawa Hospital would close at the end of March
2002;
2. The building would be restructured to provide (i)aresidential facility, the ‘‘Sasagawa Village,’’ and (ii)acommunity support centre called ‘‘I CAN.’’ The
refurbished buildings would provide living facilities
similar to Japanese homes, e.g. tatami ﬂooring, spabaths, etc.
3. These two facilities would be managed by the NPO.
4. A range of acute services, such as day-night hospitaland community nurse visits, would be provided asnecessary by Asaka Hospital.
5. Continuous cognitive behavioural therapies basedon the Optimal Treatment Project manualised protocols22 would be provided to patients before andafter the hospital closure.
6. An information system would be developed to document the process and outcome of the project by all
members of the multi-disciplinary team.
7. The Sasagawa Project plan would be discussed
repeatedly with patients, their families and people
who were residents in the neighbourhood of thehospital/residence.
This plan was implemented in it’s entirety without
notable problems.

Psychiatrists in charge of in the project

Demographics

Study investigators
Methods

Measures

Costs
None

Medical resource

QOL
Neurology
Neurocognition

All patient care is at the discretion of the participating psychiatrists and co-professionals
Data collection to be conducted for a minimum of 60 months
Data collection points tobe baseline assessment (before discharge), 1 month, 3 months, 6 months,
9 months, 12 months, 18 months, 24 months, 36 months, 48 months, 60 months.
Age, gender, diagnosis, diagnostic history, premorbid functions (PAS 11 ), alcohol and substancedependency/abuse
Living conditions, work, social functioning (REHAB 12 , SFS 13 )GAF 14 , PANSS 15 , CPS-50 16 , David’s Insight Scale 17 , REHAB 12
Suicide attempts, extrapyramidal symptoms, tardive dyskinesia, hyperprolactinemia
Antipsychotic medication: name, CP equivalent dosage, reason for change
Other medications: Anticholinergics, antidepressants, anxiolytics/hypnotics, mood stabilizers
Compliance: Patient and Nurse report
Community Health Record: Criminality, violence, victimization
WHO-QOL 18 , schizophrenia QOL 19
Neuroimaging (MRI), Neurophysiological study (EEG)
Neuropsychological tests: Mini-mental status (MMS) 20 , Rey’s ﬁgure test 21 , digit sapan, ﬂuency
tests, letter cancellation tests, Trail making test A, B 21
Medical resource use: Days/admissions for in-patient facilities, out-patient visits, day night carevisitsDirect costs

1 Ex-patients with chronic schizoiphrenia discharged from the Sasagawa Hospital
2 Patient consent

1 To understand the outcomes of the people with chronic schizophrenia who had been discharged
from the mental hospital after long years of inpatient cure
2 To evaluate the effects of various factors on the outcomes including premorbid factors,
psychiatric symptoms, cognitive functions, insight, drug attitude, and so on.

ICD: International Classiﬁcation for Diagnosis, QOL: Quality of Life, PAS: Premorbid Adjustment Scale, SFS: Social Functioning Scale, GAF: Global Assessment of Functioning,
PANSS: Positive and Negative Syndrome Scale, CPS: Current Psychiatric Status, CP: Chlorpromazine, REHAB: Rehabilitation Evaluation Hall and Baker.

Funding of Research

Schizophrenia diagnosed with ICD-10 10 criteria

Patients
Selection criteria

Functioning
Clinical status
Tolerability
Medication neuroleptics
Medication others
ComplianceObservational, non-interventional

A Summary of the Design of the Sasagawa Project Study

Type of study
Primary objectives

Table 1

Keio J Med 2005; 54 (2): 95–101
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Mizuno M, et al: The Sasagawa Project

Staff training

Results

All the professional staff of the ex-Sasagawa hospital
was relocated to Asaka Hospital or the afﬁliated community nursing center that applied the same treatment
without notable trouble. They were trained to implement the Optimal Treatment Project strategies formentally disordered people living in the community.
This included the full range of empirically-based
treatment strategies that have been associated withimproved clinical, social and family outcomes for psychotic disorders (optimal pharmacotherapy, assertive
community treatment, psychoeducation, carer-based
stress management, social skills training, supported
employment, and speciﬁc cognitive behavioural strategies for persistent residual psychotic and non-psychotic
symptoms and behavioural problems).22 In addition,
ten staff received three days training at the Village ISA
in Long Beach (California, USA) to study multiple
community support systems. This helped NPO staff
adjust their attitudes from those of hospital workers
to those of case managers or ‘‘life coaches’’ in thecommunity.
Patient/Resident training
A copy of the Japanese translation of the OTP
treatment manual for consumers and their carers23,24
was given to each patient, and at least 10 sessions werecompleted prior to their discharge. These initial sessions focused on education about their disorders, medication, adherence and the recognition of the early signsof a major exacerbation. After discharge the training
programme continued, with a focus on problem solving
day to day stresses and life changes associated withpatients’ efforts to achieve their personal life goals, aswell as biomedical and psychosocial strategies to copewith residual psychotic, negative and anxiety symptoms,
or antisocial behaviours. Early recognition of exacerbations resulted in assertive intensive care being provided in the residence with support from additional staff
from Asaka Hospital.
Evaluation
A wide range of standardized scales were used toassess clinical symptoms, social support, social activity,
family function, quality of life, and neuropsychological
functions (see Table 1). The assessment of clinical severity in the Sasagawa project includes not only overall
severity, measured with the Global Assessment of
Functioning (GAF) scale,14 but also speciﬁc ratings for
positive, negative, depressive and cognitive symptoms.
Tolerability assessments include mass index, extrapyramidal symptoms, hyperprolactinemia and sexual dysfunction.

Sasagawa Hospital closed as planned on the 31
March, 2002. The day after the closure, the residential
facility ‘‘Sasagawa Village’’ was opened and 94 patients,
including the 78 diagnosed with chronic schizophrenia,
took up residence in the refurbished building. Fourwere diagnosed as having epilepsy, 4 as mental retardation, 1 as a major mood disorder, 1 as schizoaffective
disorder, 1 as a behavioural disorder due to alcohol, 1
as a Kleinfelter syndrome. The remaining 4 people had
schizophrenia, but had moved from the acute unit of
Asaka hospital to Sasagawa Hospital at the end of
March without participating in the training before discharge. Therefore, the total number of the subjects withschizophrenia for this study was 78 (51 males), with amean age of 54.6 years. Table 2 shows descriptive
details of the patients included in the study.
During the ﬁrst 12 months after the deinstitutionalization, ten people had incidents that made their continuous stay in Sasagawa Village impossible. The incidents were classiﬁed in three categories: 1) physicalconditions, 2) psychotic exacerbations, and 3) accidents.
Six people were admitted to hospital with serious physical illnesses. Two did not return to Sasagawa Village;
one with complications of heart disease and the otherafter surgery for ossiﬁcation of posterior longitudinal
ligament (OPLL). The other four were admitted withacute MI, adynamic ileus, glaucoma, and pneumonia,
and returned to the Sasagawa village after a few
months. Three residents had major psychotic or affective exacerbations. Two were admitted to the acute unit
and returned to the Sasagawa Village after a few daysof intensive care. The third committed suicide at Sasagawa Village during a major depressive episode. The
last of the 10 residents who did not stay at the Village

Table 2

Details of the Patientsage (range)mean age of onset
total length of stay in life (months)
Diagnosis by ICD-10
Paranoid Schizophrenia
Residual Schizophrenia
Simple Schizophrenia
PANSS score
positive
negativegeneralGAF score
CP equivalent dosage (mg)54.6 G 7.2 (34–67)
23.1 G 5.9
312.0 G 122.7
34 (43.6%)
42 (53.8%)
2 (2.6%)9 (7–25)
19 (7–29)
26.5 (16–41)
57.5 (25–82)
587.5 (66.7–3433.5)

ICD: International Classiﬁcation for Diagnosis, PANSS: Positive and
Negative Syndrome Scale, GAF: Global Assessment of Functioning,
CP: Chlorpromazine.

Keio J Med 2005; 54 (2): 95–101

throughout the 12-month follow-up drowned in theshallow garden pool. The circumstances of his deathappeared accidental.
In summary, the outcome 12 months after hospital
closure were: successful community tenure 68 (87.2%),
physical illness 6 (7.7%), major exacerbations 2 (2.6%),
death-suicide 1, accident 1 (1.3%).
The activity of the patients appeared to have increased. In addition, the morale of the staff and theirattitudes towards residents appear to have changed in apositive way. Before discharge, patients’ everyday lives
were managed totally by hospital staff. With the moveto the Village, their life style had changed dramatically.
For example: Case K.I. a 56-year old man who had
been in hospital for the past 23 years re-started his
career as a house cleaner. He participated in the
day-night care programme three days a week and thejob coach training on the remaining two days. The daynight care programme involves sports, karaoke, playing
musical instruments, and group meetings. He was able
to take medicine by himself regularly and enjoyedcooking with his friends living in the Sasagawa Village.
His psychopathology remained stable with some persistent negative symptoms such as slightly diminishedemotional responsiveness and restricted affect. Speciﬁc
communication skills such as expressing pleasant feelings were repeatedly trained and practised and his interpersonal communication skills improved markedly
since his discharge.
Case M.N. is a 53-year old woman who had spent thepast 24 years admission in Sasagawa Hospital. She now
participates in the day-night care three days a week andenjoys playing Japanese harp together with her friends
living in the Sasagawa Village. She often had somequarrels soon after the closure, but training in problem
solving skills helped her cooperate with others andremedied her diminished social drive.
All the residents utilize various living supports in thecommunity, for example, meal delivery services, visiting
nursing services, community recreation centres, etc. On
the other hand, most manage their own possessions,daily schedules, and medication.
Discussion
This preliminary report of the Sasagawa project suggests that transition from hospital to community-basedcare of patients with severe and persistent chronic
schizophrenia is feasible in Japan. Almost all patients
who had been resident in a long-stay unit were able
to be managed in a residential programme with extensive clinical and social supports and ongoing treatment
aimed at clinical and social recovery. In the ﬁrst year
after hospital transfer only 5% suffered a major exacerbation of their mental disorders, and a similar pro-99

portion experienced severe physical illness. There wereno reported incidents of criminal or violence, or casesof homelessness. Careful planning that minimized socialand clinical dislocation may have contributed to thissuccessful transition. Education for neighbours of Sasagawa Hospital was repeated on several occasions sothat people understood the needs for accepting thechanging methods for the community care of mentallychallenged people. The agreement of the local mayor
was considered a very important step towards gaining
the cooperation of neighbourhood as a whole.
The most comprehensive study for assessing theeffects of a closure of a mental hospital, the Friern
Hospital Project,9 carried out in London in the 1980sreported the one-year outcome in the community.25 A
total of 278 patients were discharged in phases overthe ﬁrst three years. At the time of reassessment one
year after discharge, 7 (2.5%) had died, 6 (2.2%) werelost to follow-up, and 5 (1.8%) were in hospital at thefollow-up point. In total, 260 (94%) were living outside
the hospital one-year after discharge. However, many
had had their stay in the community interrupted duringthat ﬁrst year by brief admissions. The process oftreatment before and after discharge did not appear
to change in any remarkable way, with pharmacotherapy and supportive case management appearing mostprominent. An earlier study in the United States contrasted three approaches to rehabilitation in a hospital
closure programme.26 The more goal oriented behavioural intervention focusing on training patients in skills
needed to live in the community appeared to be superior to case management and milieu type strategies inmaintaining community tenure after discharge. Morerecent studies of deinstitutionalization for long-term
mental illness in Australia and Italy have shown thathigh levels of community tenure can be achieved wherea well-organised programme of hospital closure isundertaken.27,28
The current project is ongoing and subsequent reports will attempt to answer questions about whichtypes and severity levels of clinical impairments, social
disabilities, and subjective well-being factors are most
responsive to community-based treatment strategies
and how deinstitutionalization inﬂuences long-term
outcomes in terms of health status, work, and social
functioning, quality of life and costs. The ﬁndings fromthe Sasagawa project may contribute to the current debate about transition from hospital to community-based
services in Japan.
One matter worthy of special mention is that all thepatients and staff were trained and prepared for the
integrated community-based psychiatry service following the Optimal Treatment Project protocols. These include treatment manuals that provide a full range ofpharmacological and psychosocial strategies that have

100

been proven efﬁcacious in random-controlled trials.
The rehabilitation was not based on the clinical experience and ad hoc ideas of the staff, but on well-organizedgoal and problem-oriented behavioral and cognitive
methods that address clinical issues, such as adherence
to medication and early warning signs of impending
exacerbations and early crisis intervention, copingwith residual positive, negative, anxiety and affective
symptoms, as well as social and interpersonal issues,
such as friendships, intimate relationships, work, hobbies and leisure, and problems of aggressive behaviourand substance use. Earlier versions of these cognitivebehavioural strategies for cases of chronic schizophrenia were employed with very similar results in the pioneering study of Paul and Lentz.26 Thus, the Sasagawa
project has sought to update the treatment programmewith the latest evidence-based strategies, not merely
provide alternative living arrangements and social
structures for patients as has been the usual practice inother countries. The staffs were trained in the psychosocial treatment methods in a series of structured role
played practice sessions. In order to maintain their levelof technical skills for managing people with mental
illness in the community, 5-hours supervision sessions
with continued role-played practice were held every
month by psychiatrists, who had received extensive
training in the cognitive-behavioural methods.
Before the closure of the hospital, considerable attention was paid to ethical issues such as the patients’agreement for the transition, as well as relatives’ agreement for discharge of patients from the hospital. Moreover, extensive and repeated consultation meetings
were held with the neighbours of the Hospital. Some
did not totally agree with the new living facilities formentally ill patients and had high levels of stigma, butwith education on mental disorders and their modern
treatment, most ﬁnally adopted somewhat positive attitudes towards the project. However, such changes in
attitudes are often fragile so that in order to sustain anddevelop further support from the local community, it isessential to demonstrate positive results. The entrance
hall of the ex-hospital ward on the ground ﬂoor of theVillage is used now as the communication salon opened
to all people in the community. Many events are held
there and people with and without mental illness areinvited as guests. School pupils often stay in the salonand enjoy accessing the Internet using the computer
there. School teachers who had heard about this alsocome to the salon and the local communication between people in the community and ex-patients is
expanding naturally. Because this project has been
conducted at only one institution in one area where
the local community has been highly supportive, theseﬁndings might not be generalized to other hospital
relocation projects and further research is needed.

Mizuno M, et al: The Sasagawa Project
The part of this study had presented in the meeting of the 14 thInternational Symposium for the Psychological Treatment of Schizophrenia and other Psychoses. Melbourne 22–25, September, 2003.

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