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Travel Medicine and Infectious Disease (2008) xx, 1e5available at www.sciencedirect.com

journal homepage: www.elsevierhealth.com/journals/tmid

REVIEW

Mental health care of Western expatriates in Tokyo
Doug Berger*, Douglas Eames, Pablo Prados-Ruano
Meguro Counseling Center, Tokyo, Japan
Received 3 April 2008; accepted 9 April 2008

KEYWORDS
Mental health care,
Tokyo, Japan;
Therapist Tokyo, Japan;
Psychiatrist Tokyo,
Japan;
Counseling Tokyo,
Japan;
Psychiatric Medications
Tokyo, Japan

Abstract This paper describes the current state of mental health care for Western expatriates in Tokyo, Japan. Types of therapists, patient demographics, illness breakdown, andpsychiatric medications in Japan are discussed and problems in the system and potential
remedies are presented.
ª 2008 Elsevier Ltd. All rights reserved.

Western mental health therapists andcredentialing in Japan
A large number of non-Japanese English speakers in Tokyorequire psychiatric care and mental health counseling.
These persons prefer this care from fellow Western therapists vis-à-vis the local Japanese therapeutic community
because of both real and perceived cultural and language
differences.1,2This population is served by a potpourri of Westerntherapists ranging from aroma therapists, body energy
therapists, and life coaches, to Ph.D. psychologists and an
occasional M.D. psychiatrist. Psychotherapy is not regulated in Japan, and while few of the Western therapists
have any official Japanese qualifications, most all of these* Corresponding author. þ81 337166624.
E-mail address: doug@japanpsychiatrist.com (D. Berger).

therapists are qualified to practice in their country oforigin. There is the rare Westerner who may have a certificate from the Japan Clinical Psychologists Association, ora Ph.D. from a Japanese university. There are also a couple
Japanese psychiatrists who have done residency or havea medical license in the United States, and who will seesome Westerners for medication, and sometimes
psychotherapy.
Western patients who need psychiatric medicine will
either be referred by a therapist or present themselves
directly to a medical clinic. There are a handful of Western
GPs and internists in Tokyo who have either taken theJapanese medical license test or who are from a country
that once had a reciprocal treaty with Japan to accept thelicense from their country of origin to allow medical care in
Japan of non-Japanese (e.g., U.K., New Zealand) who carefor these persons. Many Western persons will also go
directly to see a Japanese physician, especially if they
are in the Japanese National Health Insurance plan.

1477-8939/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.tmaid.2008.04.004

Please cite this article in press as: Berger D et al., Mental health care of Western expatriates in Tokyo, Travel Medicine and Infectious
Disease (2008), doi:10.1016/j.tmaid.2008.04.004

ARTICLE IN PRESS+ MODEL2
It has been rare to hear of a charlatan therapist,
however, there has been the occasion of someone claiming
to have been a U.S. surgeon who had done psychotherapy,
and in the 90’s a client, whose daughter was seeing a French
therapist that seemed inappropriately close with her,investigated the therapist and found that they had skippedout on parole from San Quentin State Prison in California
where they had done time for pedophilia. Interestingly,
even when informed, for unknown reasons the Japanesepolice did not act on removing this person from Japan.
A group of therapists have formed and attempted tovalidate the credentialing paperwork of its members, however, they do not require official letters from universities orcredentialing boards; and while they will do an ethics
evaluation of a member if there is a complaint, theevaluation committee and the members in question arecompetitors in a small market, making the ethics review
process itself a conflict of interest. The ethics review also
provides a conclusion letter to the complainant, thus providing the complainant with a document they could use
against the therapist in a lawsuit, or against this organization
in a suit for accepting this therapist into the organization.
Thus, these non-governmental self-policing organizations
have huge logistic and legal issues to face in fulfilling theirmandate properly. There is also no malpractice insurance
system for non-Japan credentialed therapists leaving a legal
void in terms of malpractice responsibility.
The body energy therapists and life coaches are usuallya sink for persons who have some form of anxiety/depression or personality disorder, but who do not want toaccept that they have mental illness and they use the ‘‘nonmedical’’ paradigm as a defense to deny personal weakness.
The main risk of these therapies is if the therapist does notknow when to refer the patient with psychiatric illness toa specialist, or does not want to because of monetary
incentive. Most of the professional non-medical therapists(e.g., psychologists) do have some idea when a patientneeds to see a psychiatrist for medication; but this is notalways the case for mild illnesses like dysthymia, cyclothymia, or bipolar disorder type II, etc.

Demographics of Western patients seen
in a typical Western mental healthclinic in Tokyo
Including all nationalities, there are almost 354,000 foreign
residents in Tokyo which has a total population of about
12.6 million (Japan Ministry of Internal Affairs and Communications). There are more Western men in Japan than
women. While there is no hard demographic data available,
this intuition is reflected in the ratio of Western males tofemales attending a Western counseling clinic in Tokyo of
about three to one. This is probably because many jobs
Westerners have in Tokyo are largely with the foreign
corporations that are in industries that typically moremales gravitate toward (software and IT, law, financetrading and broking, etc.) In support of this idea, the rosterof Western lawyers at a large international law office inTokyo was reviewed and found to list 30 males and 9
females. A large portion of the Western expatriates are
single, or have married locally, as it is more difficult for an

D. Berger et al.
entire family to move out to Japan (although there arecertainly a number of corporate expatriate families incentral Tokyo). The highly demanding nature of theinternational corporate environment in Tokyo results ina large proportion of highly educated and intellectuallytalented persons attending therapy.
Another large area of employment for Westerners is thatof teaching English; and these account for a much larger
percentage of Westerners who live outside the major urban
areas of Tokyo and Osaka where the majority of international corporations are located. While it seems that the
male female ratio is near one for young teachers who haverecently graduated university and who want to gain someoverseas experience, the male proportion grows significantly as these teachers get older and the females tend toreturn to their country of origin. This is probably due toa number of males marrying or socializing locally, while forfemales, they may find that the career opportunities for
women are more limited in Japan because the culture hasstrong role expectations for men to work and for women tostay home and care for a family.
The structure of the Japanese family also has a role in thetendency for Western women to leave Japan. Traditionally,
Japanese men expect their wives to stay home and care forhousehold duties. The family itself tends to revolve aroundthe wife and child unit, the wife being closely involved inmany of the child’s scholastic activities, while the husband isusually working long hours at a company. The husband also
spends a lot of time involved with his corporate duties thatentails late evenings and may also encroach on weekend
time. So the pattern that emerges is that of a warm andmothering wife, and a husband content to leave the family to
the wife’s charge and delve into his work duties. It is evident
that if you are a Western woman you may have trouble
accepting a husband busy with so much outside activity;
while the warm household is more acceptable for theWestern man. There are of course many individual exceptions to the traditional paradigm, and tradition seems to be
slowly changing, probably less so in the countryside.
This discussion would not be complete without noting
the number of local Western persons who have started theirown companies or professional practices, those working in
Embassies, as well as a group of students who come fromabroad to study in Japan. There are also about a dozeninternational schools catering to the Expatriate community,
certainly the ratio of boys to girls in school is closer to one.

Types of disorders seen in a typical Westernmental health clinic in Tokyo
It is rare to find a Westerner with severe mental illness inJapan. This is because persons who are seriously ill withschizophrenia, psychotic depression or difficult to control
bipolar disorder, usually will not have a career which may
send them abroad, and ongoing symptoms will impair theability to travel overseas and negotiate the complex
logistics and finances of living in Japan if one tries tocome on their own accord. Highly functioning bipolar
disorder, alcoholism, and even drug abuse (cocaine,
amphetamine) are not uncommon in some successful
expatriates, particularly in the finance industry.

Please cite this article in press as: Berger D et al., Mental health care of Western expatriates in Tokyo, Travel Medicine and Infectious
Disease (2008), doi:10.1016/j.tmaid.2008.04.004

ARTICLE IN PRESS+ MODEL
Mental health care
For persons already in Japan who become seriously ill,
this may be controllable and treatable as an outpatient.
However, if psychiatric hospitalization is necessary, thenunless the person is extremely fluent in Japanese and has
the Japanese National Health Insurance, the hospital islikely to coordinate with the respective Embassy to havethe person repatriated as soon as possible. Persons who are
not easily hospitalized may be helped by SOS International
who can often escort the person (usually medicated) on
a plane back home. Unfortunately, the Japanese police will
not usually bring even floridly psychotic persons to thehospital unless there is an actual action of some damage toproperty or others. Consequently, psychiatric hospitalization in Japan, especially for a Westerner who the police
may not easily be able to communicate with, is often noteasy and these persons may fall thru the cracks in thesystem. Complex coordination with one’s employer, theembassy, the police, and significant others may eventually
result in hospitalization or outpatient stabilization andrepatriation.
The major disorders seen in Westerners attending an
outpatient psychiatric clinic are similar to any middle-classneighborhood psychiatrist’s office: depression and dysthymia, anxiety disorders, personality disorders, and couples’
conflicts being most common. Bipolar spectrum disorders,
ADD, drug and alcohol abuse are also seen, but are lesscommon. Schizophrenia is rare in Westerners in Japan as
noted above. Treatment resistant depression, drugedruginteractions, medication side-effects, reluctance to accept
the nature of one’s illness or see how one’s personality
effects their life, etc. are the standard challenges as in any
psychiatrist’s office.
While there is some stress of being in a country withanother language, many signs in Tokyo are in English andthe vast majority of Japanese will speak enough English to
help you out in the street, the subway, bank, etc. The city
is extremely modern, perhaps more so than most Westerncities, certainly violent crime is very low, and the vast
majority of the people are clean and polite. While there isa lot of underlying insularity, serious alienation anddiscrimination might only be felt in Tokyo if one is trying
to ‘‘fit-in’’ to a Japanese corporate organization where
actual responsibility and comradery may not easily beobtained. Alienation and isolation might be more common
for a Westerner living in the Japanese countryside; butdifferent people have different social supports and may
experience the stress of being a foreigner differently
depending on a number of factors.
There are some disorders, however, related to thelifestyle of living in Japan. One is due to the culture ofheavy drinking in business dinners and with one’s colleagues after work, especially for those in the financeindustry. Disturbed sleep cycles, use of harder drugs, andother consequences of binge drinking may often be seen.
Another is the development of a disorder of sexual
control in men. Some men collect a number of girlfriends
having multiple sexual partners, and some frequent the
many erotic massage parlors where manual and oral sex islegal and widely available. The mix of a high population
density, the largely young age of women in the work force,and the combination of interest in speaking English with thelure of having less social restrictions with Western men who3
are seen as a way out of the traditional Japanese lifestyle,leads to significant interest in these men among somegroups of Japanese women. Both the heavy drinking andthe sexual indiscretions are often subjectively distressing,and may lead to significant problems in work and occupational functioning, not to mention marital conflict.
An additional issue that one might say has somerelationship to being in Japan is that, because it isrelatively easy for a native English speaker to obtain
employment teaching English in a ‘‘English Conversation
School’’, some persons who otherwise have significant
talents may not reach their full potential. If one is anxious
or has low self-esteem due to a personality disorder or
depression, then it may be less anxiety provoking or less ofa challenge to one’s fear of failure to teach English than totake the risk of failure in a more challenging career pathand the studies necessary for this path which they mightotherwise have pursued if they were in their native country
and felt the pressure to strive for employment. Somepersons who have an oppositional or rebellious style may
have had trouble fitting into a conventional career path andalso gravitate to English teaching in these schools. It is also
common to see persons with untreated ADD, dysthymia, or
bipolar spectrum illness who do not want to accept they are
ill and thus they function below their potential. Not all
English teachers are below their potential of course, anda number of these persons obtain Master’s or higher level
degrees in teaching or linguistics and enjoy the challengesof language teaching in Universities, etc.
As a final note for this section, many Western-Japanese
couples (usually the husband is Western but not always)
also present for psychological help. Infidelity, power struggles, depression or personality disorder in one partner etc.,
are common themes. Most of the time these are the same
themes as seen in same-culture couples, however, there
may be some tendencies specific to these couples, discussion of which is beyond the scope of this article.

Psychiatric medications and prescribing
practices in Japan
In terms of psychiatric medications, while Japan lags
behind the West in the approval of psychiatric medications,
there are now a number of SSRIs, SNRIs, atypical antipsychotics, and mood stabilizers on the market.3 Notably
missing drugs, however, include the antidepressants mirtazepine, bupropion, and escitalopram (all of which haveclinical trial programs ongoing in Japan), and fluoxetine(Prozac which terminated a clinical program); the antipsychotics clozapine and, ziprasidone, paliperidone (clozapine
had reportedly been in development and discussion with
the Japanese Authorities since the late 70’s, ziprasidone
has discontinued its Japan development, and paliperidone
is said to be in development in Japan); the mood stabilizers
oxcarbazepine, topiramate, and lamotragine (all haveongoing clinical programs in Japan).
The reasons for the lag in drug approval includes a varietyof causes including business decisions based on development
costs and perceived market size, difficulty in conducting
clean clinical trials for psychiatric illnesses, high regulatory
hurdles and thus costs placed by the Japanese health

Please cite this article in press as: Berger D et al., Mental health care of Western expatriates in Tokyo, Travel Medicine and Infectious
Disease (2008), doi:10.1016/j.tmaid.2008.04.004

ARTICLE IN PRESS+ MODEL4authority to prevent the market from exploding, etc. Just forreference, sertraline (Zoloft) had been in development inJapan from the late 80’s until its final approval in 2006 as
J-Zoloft, and paroxetine (Paxil, Seroxat) had been indevelopment also for well over 10 years.4,5For stimulants, the situation is more dire, partly becauseof the fear by the Authorities of stimulant abuse spreading
throughout Japan. Methyphenidate (Ritalin) immediate
release was on the market in Japan since the 1950’s andapproved for intractable depression and narcolepsy, however, in 2007 a few medical clinics in Tokyo were closed fordispensing large numbers of indiscriminant prescriptions of
Ritalin (‘‘Ritalin Factories’’), and the Ministry of Healthsummarily removed the depression indication and now only
allows a few registered sleep specialists to prescribe Ritalin
for narcolepsy. Many patients with depression and ADD(given a diagnosis of depression in order to use off-label)
were now stranded without their Ritalin. Many of thesewere changed to the only other stimulant readily available
on the market indicated for narcolepsy and depression,
pemoline, however, it is often felt to have lower efficacy
than methylphenidate and there is a risk for liver toxicity (ithas been taken off the market in the US).
Concerta (sustained-release methlyphenidate) did gain
approval in late 2007, however, it is only approved forpediatric ADD and closely regulated only to be dispensed bypsychiatrists who take a course in its proper prescribing.
Thus, adults with depression or ADD are still left with taking
pemoline. It is assumed that children who had taken
Concerta will be able to continue their prescriptions asadults, but that leaves society with the paradox for adults
who did not start taking Concerta as children. Because of
the fear of stimulant abuse, tight regulations, and thus real
limitations to expected earnings for pharmaceutical companies, neither mixed amphetamine salts (Adderal), norother extended release methylphenidate compounds are indevelopment or on the market in Japan. Methamphetamine
is approved for narcolepsy, comatose states, and depression, but there is a strict procedure to obtain prescription
rights and it is almost never used.
The Authority will allow a 1-month supply of a controlled
drug like methylphenidate to be brought into airport
customs for personal use with a prescription from theoverseas doctor, and some Westerners who frequent abroad
may start doing this. The reason Ritalin is allowed to bebrought in through customs but not through the mail isprobably to avoid multiple mailing imports that could be
used on the black market.
More importantly, other non-controlled medications likeantidepressants, antipsychotics, mood stabilizers, etc, may
be imported in a 1-month supply for personal use without
a prescription by mail order (benzodiazepines, zolpidem,
etc are not allowed). Many Westerners are happy to pay
cash for their medications rather than wait in a doctor’s
office every month just for a prescription renewal where
they have to pay travel cost to/from the doctor’s office,and one-third out of pocket for the doctor visit and the
medications anyway if they use the Japanese National
Health Insurance. If there is no prescription, there is no
way to determine exactly what a 2-month supply is, and it
is assumed that the authorities are more concerned withwhat might look like an amount for reselling rather than the

D. Berger et al.
exact amount for 2 months. For Ritalin, as long as theamount is clearly just for one person the authorities will not
likely disallow a personal import for Ritalin thru airport
customs.
In terms of drug regimen and dosing, it is not uncommon
for Japanese psychiatrists to use multiple medications of
the same class at low doses. For many years polypharmacy
was anathema to many U.S. psychiatrists, but this haschanged with the understanding that hitting on multiple
neurotransmitter systems may be beneficial for manydifficult to treat patients that require a methodical addition of medications to their regimens. The problem withstarting polypharmacy simultaneously from the get-go as isoften practiced in Japan, is that one cannot be sure what
drug is bringing on effect or mal-effect, and that the doses
tend to be subtherapeutic. Japanese physicians accustomed to treating persons with low body weight orquestionable poor metabolism (Japanese have a three tofourfold increase in CYP 2C poor metabolizers-5e6% vs.
23%) often do not raise the dose adequately in Japanesepatients, and this can be a source of limited efficacy, or theneed to continue sleeping or antianxiety medication for
prolonged duration as the underlying depression is nottreated, etc. Having patients with depression on 10 mg
three times daily of a tricyclic antidepressant, starting
manic patients on 100 mg of lithium a day, having patientswith schizophrenia who are on 2 low-potency and 2 highpotency antipsychotics, and 3 different benzodiazepines
at night also take valproic acid on an as-needed basis
etc., are some concrete examples of inadequate dosing
and polypharmacy that often needs to be rationalized.
While there are many talented Japanese psychiatrists
and a number of larger universities with psychiatricresidencies,6 the problem of a high variance in practice skill
may stem from the lack of a Board-Certification program inJapan for psychiatry, as well as the practice where a new
medical graduate who finished perhaps a 1-year rotating internship then obtains employment in a psychiatric hospitalgarnering the title of psychiatrist (psychiatric residency in
the U.S. is 4 years). It is not uncommon for a psychiatricpatient in Japan with depression to be told they have‘‘autonomic nervous system dysfunction’’, either because
the doctor is (usually unreasonably) fearful of precipitatinga suicide, or because the doctor is not familiar with modern
DSM nosology, and this lack of knowing their actual diagnosis on the patient’s part may cause them to stop their
medications too early, etc.
Use of the Japanese National Health Insurance only
allows visits to licensed psychiatrists (not counselors ortherapists), and these visits are usually limited to
10e15 min long because of the crowded nature of theclinics. Even assuming no language barrier this is usually
not adequate. These factors result in a number of difficulties for the Western person to receive adequate psychiatriccare in Japan making the availability of modern Western
psychotherapy and psychiatric care all that more important
for the international community in Tokyo.
Approval of modern psychiatric drugs in stride with theWest, standardized psychiatric residencies, BoardCertification for psychiatrists, and mobile crisis teams
with on-call English staffing in urban areas would greatly
help the provision of psychiatric care in Japan. For the

Please cite this article in press as: Berger D et al., Mental health care of Western expatriates in Tokyo, Travel Medicine and Infectious
Disease (2008), doi:10.1016/j.tmaid.2008.04.004

ARTICLE IN PRESS+ MODEL
Mental health careforeseeable future, the few mental health clinics staffed byand catering to Westerners in the major cities will provide
the brunt of the care for the international community, andwith e-mail and video Internet telephony gaining popularity
these clinics can further outreach to international residents
in the Japan countryside.

Conflict of interest
No conflict of interest has been provided by the authors.

References
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2. Berger D, Fukunishi I, Wogan J, Kuboki T. Alexithymic traits aspredictors of difficulties with adjustment in an outpatient
cohort of expatriates in Tokyo. Psychological Reports 1999;85:
67e77.
3. Berger D, Fukunishi I. Psychiatric drug development in Japan.
Science July 19,1996;273:318e9.
4. Berger D. Antidepressant drug developent in Japan: current
perspectives and future horizons. Clinical Research Focus Sept
2005;16(7):32e5.
5. Berger D. Methodologic issues in the clinical trial study ofdepression. Pharma Japan March 24, 2008;2083:18e9.

56. Berger D. On the practice of medicine and on the culture andcustoms in Japan. Tokai Journal of Experimental & Clinical
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Doug Berger, M.D., Ph.D. is a graduate of New York Medical College,
and an American Board-Certified Psychiatrist. He received his Ph.D.
from Tokyo University for research in neuropsychiatry, and has held
research positions at the Keio University and the Tokyo Institute of
Psychiatry. He has run the Meguro Counseling Center in Tokyo formany years: www.japanpsychiatrist.com. Dr. Berger has also worked
for many years as a manager and consultant on clinical trials andbusiness-related issues for the pharmaceutical industry in Japan:
www.japanpsychiatrist.com/DrugDev.html.
Douglas Eames, Ph.D. has run a clinic in Tokyo using Virtual Reality
and Biofeedback to treat phobias and anxiety and has publisheda number of studies in this area. He had previously done researchat Waseda University, and has developed an internet-based 16
session Cognitive Behavioral Therapy program for Panic Disorder.
He now holds a position at Osaka Kyoiku University as a Visiting
Researcher and works with Dr. Berger in treating the international
community in Tokyo.
Pablo Prados-Ruano, Ph.D. has conducted neuropharmacology
research in Japan and received his Ph.D. in Pharmacology from
Tokyo University. Intimately knowledgeable about psychiatric
medications, he has worked with pharmaceutical companies on
research and development and business strategy on a wide-varietyof therapeutics for both Japan and Global markets and has beena close advisor for the Meguro Counseling Center in Tokyo formany years.

Please cite this article in press as: Berger D et al., Mental health care of Western expatriates in Tokyo, Travel Medicine and Infectious
Disease (2008), doi:10.1016/j.tmaid.2008.04.004