Health, 2017, 9, 763-777
http://www.scirp.org/journal/health
ISSN Online: 1949-5005
ISSN Print: 1949-4998

Health Resource Utilization and Comorbidities
in Patients with Mental Disorders: Analysis
Based on Health Insurance Claim Data
Kana Kazawa1, Susumu Iwamoto2, Md Moshiur Rahman1, Michiko Moriyama1
Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
Department of Economics, Yamaguchi University, Yamaguchi, Japan1
2

How to cite this paper: Kazawa, K., Iwamoto, S., Rahman, M.M. and Moriyama,
M. (2017) Health Resource Utilization andComorbidities in Patients with Mental
Disorders: Analysis Based on Health Insurance Claim Data. Health, 9, 763-777.
https://doi.org/10.4236/health.2017.94055
Received: March 22, 2017
Accepted: April 27, 2017
Published: April 30, 2017
Copyright © 2017 by authors andScientific Research Publishing Inc.
This work is licensed under the Creative
Commons Attribution International
License (CC BY 4.0).
http://creativecommons.org/licenses/by/4.0/
Open Access

Abstract
The number of patients with mental disorders is increasing all over the world
and they have a high prevalence of physical complications. To analyze andcompare the cost of mental disorders with the total medical costs such as
mental disorders and physical disorders, we analyzed the cost that patientswith mental disorders incurred. We investigated the distribution of medical
costs and the characteristics of diseases by using the health insurance claimsof people in City A, Japan from March 2013 to February 2014. The subjects
had one or more of 4 mental disorders: schizophrenia, alcohol related disorders, bipolar disorder, and depressive episode. As a result, the total number ofpatients who met inclusion criteria per year was 7403 (6522 outpatients and881 inpatients). It was revealed that the hospitalization rate of patients withmental disorders increased with age, and many inpatients stayed in hospitalfor a long time. Also, it was revealed that many patients with mental disorders
were in complicated condition with more than one mental or physical disorders and incurred medical costs for these comorbidities. In conclusion, thisanalysis indicated that many patients with mental disorders switch from attending the outpatient department to hospitalization as they become older.
Further, they incurred a lot of medical expenses for complication management. To improve their QOL, comprehensive assessment of their mental/
physical health, self-management education, coordination of services, andsupport for decision making regarding treatment are necessary.

Keywords
Mental Disorder, Medical Cost, Comorbidity

1. Introduction
The number of patients with mental disorders is increasing across the world. A
DOI: 10.4236/health.2017.94055

April 30, 2017

K. Kazawa et al.

report from the World Health Organization (WHO) described that lifetime prevalence of mental problems is about 20% to 35% [1] [2]. A survey conducted inJapan by the Ministry of Health, Labour and Welfare in 2014 estimated that 533
thousand patients (total of inpatients and outpatients) were diagnosed to haveany of the mental and behavioral disorders (ICD 10 Code, F00 to 99) [3]. Kawakami et al surveyed 1663 Japanese persons in the several regions and found that
2.9% and 1.6% of them had major depression and alcohol abuse/dependence, respectively, in the previous 12 months [4].
Mental problems often need long time treatment. For example, 40% to 60% of
the patients with schizophrenia suffer from lifelong disorder [5]. Regarding
health resource utilization, the rate of hospitalization in Japan is higher formental and behavioral disorders than others, and the period of hospitalization
exceeds 1 year for 12.8% of hospitalized patients. Among OECD countries, thenumber of psychiatric hospital beds is the highest and the hospitalization days
are the longest in Japan [2]. Furthermore, the social scenario indicates a highprevalence of depression and schizophrenia in the person who committed suicide [6] [7].
Many studies in and outside of Japan have analyzed the medical and societal
costs of mental disorders [8]-[14]. In these analyses, only the cost of mental disorders was analyzed. But clinically, many patients with mental disorders havephysical disorders as well. It is reported that the co-existence of mental andphysical disorders leads to poor control of mental conditions, insufficient management of physical disorders, and low QOL of the patients [15] [16] [17] [18].
In order to improve the cost/benefit of treatment and quality of medical services
for these patients, the conditions of concurrent physical disorders have to be addressed. Also, the necessity of preventing aggravation and acute phase treatment
for physical disorders can be minimized in addition to discussions about the
number of beds.
However, few reports have analyzed the physical comorbidities of the patientswith mental disorders or the places where they have received treatment. This is alimitation of the patient surveys conducted by the Ministry of Health, Labour,and Welfare and the analyses of medical cost based on health insurance claim
data.
In the present study, we analyzed the cost of mental disorders by analyzing
and comparing the cost for mental disorders with the total medical costs (including mental and physical disorders) incurred by patients who were diagnosed
with mental disorders. To analyze the medical cost of each disease, we used a
medical cost grouping technique to link disorders listed on the health insurance
claim sheets to the drugs and/or interventions administered according to their
medical indications. Based on these analyses, we tried to clarify the details of the
medical cost of patients with mental disorders.
The study population is limited to the residents who are covered by national
health insurance in one city. However, it is expected that patients with mental
disorders will continue to increase, and the improvement of QOL in these pa-764

K. Kazawa et al.

tients is an important issue. By analyzing health resource utilization and physicalcomorbidities of patients with mental disorders, our study may contribute to theimprovement of medical service and clarify the cost-benefit of treatment provided to these patients whose cost is partly paid by the insurer.

2. Methods
2.1. Subjects
The subjects analyzed in our study were the residents (age ≤ 74 years) of City A
who were covered by national health insurance and suffered from one or moreof 4 mental disorders that have the highest morbidity and lifetime prevalence
among mental disorders: alcohol related disorders (ICD10 Code, F10), schizophrenia (ICD10, Code F20), bipolar disorder (ICD 10, Code F31), and depressive episode (ICD10 Code, F32). For the analysis of diseases of the hemodialysis
patients, all persons covered by the national health insurance were included in
the study.
Outline of persons covered in the national health insurance in City A (as ofFebruary 2014)
In total, 94,380 residents in City A were covered by the national health insurance. Among them, 47,150 (50.0%) were males and 47,230 (50.0%) were females.
When grouped by age, the age group ranging 65 to 69 years accounted for thehighest percentage (11,795 persons [12.5%]) in the residents covered by the national health insurance, followed by the age group 60 to 64 years (10,726 persons[11.4%]) and the 70 to 74 years age group (9,888 persons [10.5%]). Among all
persons covered by the national health insurance, 23.2% were the elderly (age ≥65 years).
City A is a tertiary industry based local city. About 30% of the residents arecovered by the national health insurance and 19.9% of the residents are the elderly in 2015. For 100 thousand residents in City A, there are 78.58 hospitals/clinics (national average [hereinafter same will be applied in this paragraph]67.88), and among them, 12.84 (4.99) hospitals/clinics are specialized in psychiatry. Clinics have 127.73 beds (80.90), hospitals have 1012.73 beds (1215.00)
and psychiatric hospitals/clinics have 230.09 beds (259.31). Psychiatric beds account for 22.7% of the total beds [19].

2.2. Study Design
Cross-sectional study.

2.3. Data Collection and Analysis
We collected data from health insurance claim sheets issued over 12 months(March 2013 to February 2014) and extracted and analyzed data on age, sex, dateof use of health resource, disease, medical institution, days of use, and medical
cost. There are 3 types of health insurance claim sheets: sheets for hospitalization
cost, sheets for outpatient cost, and sheets for prescription cost. Each month, asheet that describes the medical service provided and its cost for the previous
765

K. Kazawa et al.

month is issued at each medical institution.
We analyzed the following particulars from the data: (1) relationship between
the number of the patients and medical costs, (2) percentage of inpatients anddays of hospitalization classified by hospital function classification, (3) details ofphysical comorbidities, and (4) diseases of patients on hemodialysis. The following 2 procedures were used for analysis. First, we used a medical cost grouping technique to analyze medical cost used for the target disorders only (4 mental disorders described above). For analysis of outpatient medical costs, medical
charge of out-patient/prescription health insurance claim sheet was linked withdiseases and summarized. If there were multiple diseases, costs were divided by
the number of diseases and assigned equally to each disease. Medical charges
that were not linked to any disease were assigned to the primary disease requiring outpatient clinic visits. The hospital costs listed on health insurance claim
sheets were linked with the disease primarily responsible for hospitalization andsummarized. If there were multiple diseases, costs were divided by the numberof diseases and assigned equally to each disease. Second, all costs on the claim
sheets of patients with target disorders were analyzed. Namely, the medical costs
were analyzed regardless of the type of disease (mental and physical disease).
Data used in this analysis were obtained from the insurer through opt-out procedure.

3. Results
The subjects included in our analysis were residents of City A who were coveredby national health insurance and suffered from one or more of 4 mental disorders: schizophrenia (F20), alcohol related disorders (F10), bipolar disorder (F31),and depressive episode (F32).

3.1. Medical Cost Used for Treatment of Target Mental Disorders(Medical Cost Grouping)First, we used a medical cost grouping technique to clarify the medical cost used
for the 4 disorders as follows (Table 1). It should be noted that some patientswere counted twice or more times because they had more than 1 disorder. The
total number of patients per year was 7403 (6522 outpatients and 881 inpatients,
with duplication). The medical cost was 1.02 billion yen for outpatients (approximately 80 thousand to 260 thousand yen per patient) and 2.24 billion yen
for inpatients (approximately 1.05 million to 2.94 million yen per patient). Schizophrenia accounts for the highest percentage of this cost both for outpatients or
inpatients.
Among the total medical costs used for the residents covered by national
health insurance in City A, 7.2% was used for outpatients and 18.9% was used
for inpatients for the above 4 mental disorders.

3.2. Total Outpatient Costs of Patients with Target Mental
Disorders
Next, the total outpatient costs of the patients with one or more of the target766

K. Kazawa et al.
Table 1. Medical cost used for treatment of the target mental disorders.
Outpatient
Rank

Disease name (ICD10)

Total medical
expenditure (yen)Average medical
fee/patient (yen)Percentage of total
medical expenditure1

Schizophrenia (F20)687,079,469

263,350

4.9%

2Depressive episode(F32)

227,718,315

80,183

1.6%

3

Bipolar disorder (F31)75,684,015

115,9020.5%

4Alcohol relateddisorders (F10)32,394,473

77,1300.2%

Inpatient
Rank

Disease name (ICD10)

Total medical
expenditure (yen)Average medical
fee/patient (yen)Percentage of total
medical Expenditure1

Schizophrenia (F20)

1,965,551,398

2,938,044

16.6%

2

Alcohol relateddisorders (F10)

121,245,783

1,289,849

1.0%

3Bipolar disorder (F31)

81,340,333

1,730,645

0.7%

4Depressive episode(F32)

74,601,997

1,050,732

0.6%

mental disorders were analyzed regardless of the disease (Figure 1 and Figure2). The total outpatient costs of 1.37 billion yen were classified by sex and age
groups.
In the period included in this analysis (1 year), 5,601 patients received treatment as outpatients (2650 males [47.3%] and 2,951 females [52.7%]). The agegroup that accounted for the highest percentage was the 60 to 69 years age groupfor both males and females (males 23.5% and females 22.3%). The age group thatused the highest amount of medical cost per patient was the 40 to 49 years age
group, which was approximately 390 thousand yen, followed by the 50 to 59
years age group and the 60 to 69 years age group. This amount was relatively
higher than the outpatient cost per patient shown in Table 1, which indicatesthat the patients had multiple diseases for which they received treatment.
Regarding the medical cost used by each age group, the 40 to 49 years age
group (20.9% of the total patients) used 33.1% of the total medical costs, followed by the 60 - 69 years age group (20.9% of the total patients) and the 50 - 59
years age group (20.9% of the total patients), which used 23.8% and 18.9%, respectively, of the total medical costs. The patients with target mental disorders
used 9.8% of the total outpatient cost of the residents covered by national healthinsurance in City A. This was 2.6% higher than the percentage of medical cost
obtained by the medical grouping technique for the 4 mental disorders.
The number of patients who were diagnosed with the target mental disorders(schizophrenia [F20], alcohol related disorders [F10], bipolar disorder [F31] ordepressive episode [F32]) is summarized in Table 2. The most frequent disorder
was depressive episode, followed by schizophrenia and bipolar disorder. Since
the total number of outpatients was 5601, it was indicated that the patients withtarget mental disorders had more than one diagnosis of mental disorder.
767

K. Kazawa et al.

Figure 1. The number of outpatients and medical cost per patient.

Figure 2. Medical cost by age of outpatient.
Table 2. Diagnosis of outpatients.
Disease name (ICD10)

No. of patients

Percentage of total outpatients

Depressive episode (F32)

3237

43.4%

Schizophrenia (F20)

2887

38.7%

Bipolar disorder (F31)

738

9.9%

Alcohol related disorders (F10)

602

8.1%

Some patients with multiple diseases

3.3. Total Inpatient Costs of Patients with Target Mental
Disorders
Next, the health insurance claim data were analyzed to determine the cost for
hospitalization due to one or more of the target mental disorders (4 ICD 10 codenames specified above) (Figure 3, Figure 4). The total hospitalization costs were
2.3 billion yen. The breakdown of this total amount by sex and age group is asfollows.
In the period included in this analysis (1 year), 1128 patients were hospitalized
in total (637 males [56.5%] and 491 females [43.5%]). The age group that768

K. Kazawa et al.

Figure 3. The number of inpatients by age group and medical cost per patient.

Figure 4. Inpatient medical cost by age group.

accounted for the highest percentage of inpatients was the 60 to 69 years age
group (males 33.1% and females 27.3%). The age group that used the highest
amount of medical cost per patient was the 60 to 69 years age group, followed by
the 50 to 59 years age group and the 40 to 49 years age group.
Regarding the medical cost used by each age group, the 60 to 69 years age
group (30.6% of the total patients) used 36.9% of the total hospitalization costs,
followed by the 50 to 59 years age group (22.8% of the total patients) and the 40 49 years age group (18.7% of the total patients), which used 24.8% and 15.8%,
respectively, of the total hospitalization costs. Of the total hospitalization costs
used by the residents covered by national health insurance in City A, 19.4% wasused for the patients with target mental disorders.
Analysis of the number of patients by each diagnosis of the 4 ICD 10 codenames specified above is summarized in Table 3. The most frequent disorder
was schizophrenia, followed by depressive episode and alcohol related disorders.
The hospitalization period was analyzed in patients with schizophrenia, a disorder which used highest hospitalization cost. As a result, 462 patients (61.2% of
the patients with schizophrenia) were hospitalized for 91 days (3 months) or
longer per year, and of them, 401 patients (53.1% of the patients with schizophrenia) were hospitalized for 180 days (6 months) or longer. The total
769

K. Kazawa et al.
Table 3. Diagnosis of inpatients.
Disease name (ICD10)

No. of patients

Percentage of total inpatients

Schizophrenia (F20)

755

66.2%

Depressive episode (F32)

192

16.8%

Alcohol related disorders (F10)

124

10.9%

Bipolar disorder (F31)

70

6.1%

Some patients with multiple diseases

hospitalization costs of the patients who were hospitalized for schizophrenia for
91 days or longer was approximately 1.72 billion yen, which accounted for 74.9%of the total hospitalization costs of the target mental disorders*.
*This cost is the total hospitalization costs of patients who were hospitalized
for schizophrenia and includes the cost used for treatment of mental disorders
other than schizophrenia and/or physical diseases.

3.4. Hospitalization Cost by Hospital Functional Classification
In Japan, each prefecture decides hospital functional classification of medical institutions matched by its medical/operational plans [20]. There are the following
bed categories of hospital functional classification: 1) beds for the advanced
acute phase = beds for highly intensive treatment for acute conditions, e.g., highcare unit and stroke care unit; 2) beds for the acute phase = beds for treatment ofconditions that are in the acute phase but do not need highly intensive treatment; 3) beds for the convalescent phase = beds for rehabilitation or preparation
for discharge after the acute phase; and 4) beds for the chronic phase = beds forlong-term treatment. One medical institution may have more than one categoryof beds. In the present study, hospitalization was analyzed by hospital functionalclassification (Table 4). When a medical institution has more than one categoryof beds, it was grouped according to the highest category.
As a result, the percentage of the hospitalization cost for target disorders was
the highest in psychiatric beds that do not belong in any of the above categories(59.1%), followed by the convalescent phase (24.2%) and the chronic phase(7.0%) categories. For these 3-bed categories that used most of the hospitalization cost as above, the hospitalization period per month was 26.2 days or longer,
which was markedly longer than the hospitalization period for beds in othercategories. Among the inpatients with the target disorders, 283 inpatients (19.6%of the total inpatients) were elderly (≥ 70 years), most of whom were hospitalized in one of these 3-bed categories. Of note, 8 patients whose deaths were recorded in the health insurance claim sheet were hospitalized in one of the above 3
bed categories having long hospitalization periods and had stayed in the hospital
until their deaths.
For the medical cost per month, the cost was the high for the advanced acutephase and acute phase categories, for which highly intensive treatments are administered.
770

K. Kazawa et al.
Table 4. Hospitalization by hospital functional classification.
Hospital functional classification

Percentage of Percentage of total Hospital days per month
total inpatients hospital costs(Mean ± SD)

Medical institution for theadvanced acute phase

11.2%

4.2%

9.3 ± 6.8

Medical institution for the acute phase

8.7%

3.8%

11.7 ± 9.0

22.8%

24.2%

28.5 ± 6.1

8.7%

7.0%

26.2 ± 8.5

40.1%

59.1%

28.6 ± 5.9

Others8.4%

1.7%

7.7 ± 3.4

Total

100.0%

100.0%

Medical institution for theconvalescent phase
Medical institution for thechronic phase
Psychiatric care institution that do notbelong in any of the above categories

3.5. Concurrent Disorders of Patients with Mental Disorders
The 30 medical conditions that are most frequently reported in the health insurance claim sheet of the patients with target mental disorders are summarizedin Table 5. To specify the condition, we used the minor classification of ICD10
disorder name. Commonly observed conditions were insomnia, a condition often observed as a complication of mental disorders, and constipation, chronic
gastroenteritis, diabetes/glucose tolerance abnormal, headache, deformation/
fracture of joint/spine, obesity, and drug-induced hepatic/renal disorders, which
are conditions often observed as adverse reactions to antipsychotics.
Frequently reported disorders included lifestyle-related diseases such as
hypertension, dyslipidemia, diabetes, hyperuricemia and obesity.

3.6. Diseases of Patients on Hemodialysis
Finally, Japan has the second highest density of patients requiring hemodialysis
therapy in the world [21]. As renal failure is possible to manage, we analyzed patients requiring hemodialysis.
For the patients on hemodialysis among the residents covered by national
health insurance in City A, risks of deterioration in renal function and complications were analyzed. Although temporal or causal relations between the hemodialysis and onset of the disease could not be analyzed in our study, we performed an analysis to identify the characteristics of this group (Table 6). Amongthese residents, 411 patients received hemodialysis, and common diseases observed among these patients were primary renal impairment, and secondary
renal impairment associated with lifestyle diseases, such as hypertension, diabetes, and dyslipidemia. Patients with mental disorders frequently received
hemodialysis as well.

4. Discussion
4.1. Long Hospitalization and Changes in Treatment
Environments for Mental Disorders
We analyzed several aspects of targeted mental disorders. It was revealed that771

K. Kazawa et al.
Table 5. Top 30 disorders that the patients with target mental disorders have.
Rank

Disease name
(Aggregated the minor classification of ICD 10 disease names)

No. of patients

1

Insomnia

2697

2

Constipation

1497

3

Neurodegenerative disease

1104

4

Chronic gastroenteritis

1069

5

Hypertension

1053

6

Dyslipidemia

926

7

Diabetes

725

8

Epilepsy694

9

Infection

647

10

Cardiovascular disease

450

11

Headache318

12Orthopedic disease (Without fracture）

240

13

Cerebrovascular disorder

228

14

Hyperuricemia

224

15

Malignant neoplasm

164

16

Chronic hepatitis

142

17

Chronic heart failure

125

18

Hyperprolactinemia

113

19

Dementia

111

20

Benign prostatic hyperplasia

109

21

Fracture

100

22

Chronic kidney disease（Without diabetic nephropathy）

89

23

Alcoholic liver injury

80

24

Viral hepatitis

67

25

Obesity64

25

Autoimmune disease64

27

Dysuria (Without benign prostatic hyperplasia)

49

28

Impaired glucose tolerance

41

29

Drug-induced liver injury

23

30

Drug-induced nephropathy

6

Some patients with multiple diseases

patients in their 40 s accounted for the highest percentage of outpatients, while
those in their 60 s accounted for the highest percentage of inpatients and were in
the hospital for a long period. Also, it was revealed that many patients withmental disorders had complications with more than one mental or physical disorders and used medical cost for these comorbidities in addition to the underly-772

K. Kazawa et al.
Table 6. Top 20 diseases observed in patients on dialysis.
Disease name (Aggregated ICD 10 disease names)
Rank
1

20

60 years of age or younger (n = 148)

No. of patients

60 years of age or older(n = 263)

No. ofpatients

Hypertension

128

Hypertension

237

Cardiovascular disease94

Orthopedic disease(Without fracture）

186

Orthopedic disease (Without fracture)84

Cardiovascular disease

159

Diabetes

72

Diabetes

158

Hyperuricemia

45

Dyslipidemia

102

Dyslipidemia

43

Chronic heart failure

98

Chronic heart failure

42

Hyperuricemia

83

Mental disorders

29

Cerebrovascular disorder70

Infection

27

Mental disorders

61

Cerebrovascular disorder

20

Infection

36

Chronic glomerulonephritis

18

Chronic glomerulonephritis

33(Renal cyst

15

Renal cyst

32

Malignant neoplasm(Without renal malignant neoplasm)

10

Fracture

22

Epilepsy

10

Epilepsy

19

Autoimmune disease10

Autoimmune disease

16

Renal malignant neoplasm

6

Malignant neoplasm(Without renalmalignant neoplasm)

8

Fracture

6

Neurodegenerative disease8

Neurodegenerative disease4

Amyloidosis

7

Amyloidosis

2

Renal malignant neoplasm

7

Renal neoplasia

2

Dementia

6

ing mental problems. Moreover, quite a few of them received treatment for thehighly acute phase.
These findings depict that some patients live with several mental and physicalproblems. From their 40s and onwards, patients tend to need hospitalization because they require inpatient management for their mental and physical disorders. Sometimes, they shift from outpatient visits to hospitalization as they havedifficulty in visiting hospitals and receiving care after being discharged, leading
to prolongation of hospitalization. In our analysis, follow-up of the outcome waslimited because it was based only on health insurance claim data and we found
few records of death. However, we estimate that actual data will show that more
end-of-life care has been administered in hospitals.
According to a report that describes the medical and societal costs for Japanese patients (age ≥ 20 years) with depression or schizophrenia, treatment costof mental disorders accounts for 9% to 28% of the total costs, while societal costassociated with absenteeism (absent from work) or presenteeism (lowered
productivity) accounts for 47% to 67% and mortality cost accounts for 45% to773

K. Kazawa et al.

47% [9] [12]. Regarding societal cost, discussions are also taking place in abroad[22] [23]. The survey by the Ministry of Health, Labour and Welfare (2014) reported that among patients who are hospitalized for an extended period, those
who need urgent support for their daily or social life in addition to disease management and care often lacks access to these supports [24]. On the other hand,the patients who need relatively less support have to spend a long time in training for jobs and self-management and can obtain few medical services in thecommunity such as home-visiting nursing care, visiting medical care, day care,or care for their physical conditions. Such lacks of medical management andcare services are leading to longer hospitalizations.
In Japan, the government has changed its policy for treatment of mental disorders from 2004 [25]. The policy encourages utilization of mental health services in the community instead of hospitalization. In order to carry out thesechanges, beds are being reduced, the treatment, care, and welfare services in thecommunity are being enhanced, and personnel who provide these services arebeing trained. Although it will depend on each patient’s mental and physicalcondition, it is desirable to organize social services and provide treatment andtraining for jobs and self-management from the early phase of the disease in order to support the patient's life in the community. Recently, the number of patients with dementia is also increasing in addition to the target mental disorders
analyzed in the present study, and education is necessary for the general public
to deepen understanding of mental disorders. From the high percentage of mortality cost disclosed in a previous study, it can be estimated that end-of-life carein hospitals is not few [9] [12]. It is reported that advanced care planning is notwidely used in Japan [26]. In order to improve the QOL of patients, medical
professionals have to provide the patients and their family with information on
the outlook of the disease and how to care for the patients at the end of life.
These suggestions will enable patients & their family in decision making with thepreferences, medical indications, and living conditions of the patients/family
considered.

4.2. Comprehensive Assessment of the Mental/Physical Health ofPatients with Mental Disorders
Our study revealed that many patients with mental disorders have physicalproblems as well. Although temporal/causal relation between diseases was notclarified in our analysis, interaction between mental and physical conditions
hinders proper control of the systemic condition and leads to lowered QOL andrisks of death. The diseases commonly observed in the patients included in our
analysis were symptoms associated with the underlying mental disorders, common adverse reactions to antipsychotics, and lifestyle-related diseases. Since wehave universal coverage and a free access healthcare system in Japan, not all patients with mental disorders are followed up by specialists. It is important for
medical professionals to comprehensively assess the mental/physical and living
conditions of the patients as well as the available social resources to help them774

K. Kazawa et al.

have access to better self-management education and medical care services. Patients with mental disorders often use several drugs. Medical professionals
should recommend them to consult specialists when they show symptoms associated with their mental disorders or common adverse reactions to antipsychotics so that they can switch to a more appropriate treatment, dose, or non-pharmaceutical therapy.
Furthermore, Japan has the highest aging rate in the world (WHO, 2010), andthe aging rate in 2015 is 26.7% (Ministry of Health, Labor and Welfare, 2015)[27] [28]. The elderly population rate is expected to rise in the future, and accordingly, an increase in the number of elderly patients with dementia is estimated[28]. It is reported that patients with dementia have high prevalence of physicaldiseases [29] [30], and the home treatment becomes more difficult as the severityof the physical diseases increases [31] [32] [33]. In order to realize the dementia
patient’s familiar living place and to improve patient's QOL, it is necessary toanalyze the cost for mental disorders further and to improve service and infrastructure in the future.
In this study, there is a limit to generalization because the subject is coveredby national health insurance in one area. However, the results of clarifying thehealth resource utilization and comorbidities in patients with mental disorders
can be implemented to improve the health services and systems. It is necessary
to expand the number of areas and sample size for further analysis.

5. Conclusion
Our study revealed that patients with mental disorders are shifting from outpatient treatment to hospitalization as they get older. Patients in general are often
hospitalized for an extended period, and they have many concurrent mental/physical problems. Therefore, comprehensive assessment of their mental/physical health, self-management education suitable for each patient, organization of services, and support for decision making regarding treatment are essential for the improvement of their QOL.

Acknowledgements
We thank City A for providing us the data and Data Horizon Corporation for
helping us with processing health insurance claim sheets. We obtained funding
from City A to conduct this study as a joint research with the city, but analysis
was approved by the ethics committee of Hiroshima University.

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