since 1960 , the rate of psychiatric beds per 100,000 residents has decreased in oecd countries due to de - institutional policies and the advent of community care support systems .
conversely , in japan , the psychiatric bed rates have increased [ 1 - 3 ] .
the average length of hospitalisation within a psychiatric ward in 2012 was 298.1 days . while this length is shorter when compared to 1998 ( 496 days ) [ 1 - 3 ] , it is still too long .
a national patient survey in 2005 , observed that  social hospitalisation , which includes baseless hospital care after a patient has become stable , accounted for 70,000 in - patients , of which about 30% were discharged less than one year after admission and about 70% were discharged after one year .
the national patient surveys from 1999 and 2002 revealed that nearly 35,000 patients were discharged within these three years [ 2 - 4 ] .
thereafter , about 63,000 patients were newly - admitted and as a result , the number of social hospitalisations virtually did not change .
the risk factors associated with long - stay hospitalisation in psychiatric hospitals in japan include diagnoses of dementia , mental retardation , and schizophrenia , and being men , and older [ 5 , 6 ] .
a long stay can directly cause problems regarding a family s acceptance , poor improvement of symptoms , and poor recovery of daily living abilities .
the present study was conducted to investigate how the length of a patient s mental health hospitalisation is related to family structure , frequency of visits , and laundry types ( self - washing , family washing , supplier washing ) , which is related to adl .
our hypotheses were that short - stay admission would be related to living with either a partner or family members , to a high frequency of visits , and/or to self - washing .
the present study included a re - examination of the medical records of 83 patients discharged between 1 july 2013 and 30 june 2014 , and the collection of data about their age , laundry type ( self - washing , family washing , and supplier washing ) , family visits per month , and family structure prior to hospitalisation .
fifty - six patients ( men 50.0% , excepting 27 patients discharged due to death ) were included in these data .
a diagnosis of a mental and/or behavioural disorder was made by mental health specialists according to the icd-10 . all patients received psychotherapy , occupational therapy , and pharmacological interventions as clinically indicated .
patients discharged between 2013 and 2014 were divided into three admission durations ( under six months , between six months and 20 years , and over 20 years ) .
the following disorder categories of the icd-10 were used : f00-f09 ( organic , including symptomatic , mental disorders ) , f10-f19 ( mental and behavioural disorders due to psychoactive substance use ) , f20-f29 ( schizophrenia , schizotypal and delusional disorders ) , f30-f39 ( mood disorders ) , and  other ( mental and behavioural disorders except for f00-f09 , f10-f19 , f20-f29 , and f30-f39 ) .
the main independent variables of interest were hospitalisation for medical care and protection , laundry type ( self - washing , family washing , and supplier washing ) , family visits per month , and family structure prior to hospitalisation ( living with a parent , with a partner , with a son / daughter / brother , alone , in a care facility , or in a medical hospital ) . these variables were calculated and compared using  tests .
we used log - transformed values for admission duration and family visits per month to account for their skewed distribution .
a length of stay of more than six months was considered the cut - off point for a long hospital stay .
bivariate logistic regression analyses were conducted to identify factors independently associated with the length of stay .
odds ratios were adjusted for age ( continuous ) , sex , and main mental disorder ( f00-f09 , f10-f19 , f20-f29 , f30-f39 , and 
statistical analyses were performed with the statistical package for the social sciences ( spss version 22.0 ; ibm corp , tokyo , japan ) .
ethics approval was obtained from five ethics committees of the hospital s institutional review board . due to the non - interventional ; retrospective design , no informed consent was required ; it was waived by the hospital s institutional review board .
the present study included a re - examination of the medical records of 83 patients discharged between 1 july 2013 and 30 june 2014 , and the collection of data about their age , laundry type ( self - washing , family washing , and supplier washing ) , family visits per month , and family structure prior to hospitalisation .
fifty - six patients ( men 50.0% , excepting 27 patients discharged due to death ) were included in these data .
a diagnosis of a mental and/or behavioural disorder was made by mental health specialists according to the icd-10 .
patients discharged between 2013 and 2014 were divided into three admission durations ( under six months , between six months and 20 years , and over 20 years ) .
the following disorder categories of the icd-10 were used : f00-f09 ( organic , including symptomatic , mental disorders ) , f10-f19 ( mental and behavioural disorders due to psychoactive substance use ) , f20-f29 ( schizophrenia , schizotypal and delusional disorders ) , f30-f39 ( mood disorders ) , and  other ( mental and behavioural disorders except for f00-f09 , f10-f19 , f20-f29 , and f30-f39 ) . the main independent variables of interest were hospitalisation for medical care and protection , laundry type ( self - washing , family washing , and supplier washing ) , family visits per month , and family structure prior to hospitalisation ( living with a parent , with a partner , with a son / daughter / brother , alone , in a care facility , or in a medical hospital ) .
we used log - transformed values for admission duration and family visits per month to account for their skewed distribution .
a length of stay of more than six months was considered the cut - off point for a long hospital stay .
bivariate logistic regression analyses were conducted to identify factors independently associated with the length of stay .
odds ratios were adjusted for age ( continuous ) , sex , and main mental disorder ( f00-f09 , f10-f19 , f20-f29 , f30-f39 , and 
statistical analyses were performed with the statistical package for the social sciences ( spss version 22.0 ; ibm corp , tokyo , japan ) .
ethics approval was obtained from five ethics committees of the hospital s institutional review board . due to the non - interventional ; retrospective design , no informed consent was required ; it was waived by the hospital s institutional review board .
table 1 shows the characteristics of the patients discharged during the study period , separated by length of stay at discharge .
the mean age for patients hospitalised between six months and 20 years was 77.111.7 years , which is nearly 10 years older than those in the other admission groups ( p = 0.040 ) . in terms of the main mental disorder , f00-f09 , f10-f19 , and
f20-f29 were the most common categories for those hospitalised between six months and 20 years ( 10.7% , 5.4% , and 17.9% , respectively ) .
f30-f39 was the most common category for those hospitalised for less than six months ( 7.1% ; p < 0.001 ) .
regarding laundry type , self - washing was the most common method for those hospitalised for over 20 years , family washing was most common for those hospitalised for less than six months , and supplier washing was most common for those hospitalised for between six months and 20 years ( p < 0.001 ) .
the bivariate - adjusted odds ratios ( 95% confidence intervals ) for in - patients hospitalised for more than six months was 0.08 ( 0.01 , 0.48 ) for family washing ( p = 0.006 ) compared with those who used supplier washing .
the number of visits per month and family structures before hospitalisation were not significantly associated ( table 2 ) .
the present study evaluated how length of hospitalisation was related to family variables ( family visits per month and living situation prior to hospitalisation ) and laundry type , which is related to adl , among in - patients with mental and behavioural disorders in a private psychiatric hospital in japan .
our results revealed that family washing was related to a reduction in the length of the patients hospital stays . in 1961 ,
when japan introduced the universal public insurance system , psychiatric hospitals began to increase in number .
furthermore , psychiatric residents began moving from home care to hospital care [ 8 - 10 ] .
although the number of psychiatric beds has decreased in recent years , the number of private hospitals with mental health wards is still high [ 1 - 3 ] , constituting about 80% of psychiatric hospitals in japan .
therefore , it is difficult to reduce the number of psychiatric beds [ 8 - 10 ] .
gigantesco , de girolamo , santone miglio and picard reported that being in a private psychiatric hospital is also a barrier to discharge in italy .
thus , psychiatric medical care has not sufficiently shifted from hospitalisation back to community care [ 1 - 3 ] . in terms of the relationship between laundry type and visit frequency per months
, family washing was observed to be at its highest peak for more than 60 visits per month , and supplier washing was observed to have two high peaks at 16 - 30 visits and over 46 - 60 visits ( fig .
1 ) . in a conventional survey , it was found that patients with dementia , mental retardation , and schizophrenia tended to experience long - stay hospitalisation [ 5 - 7 ] . in the present study , diagnostic status did not significantly influence the length of stay . likewise in italy
, no difference of diagnostic status emerged between long - stay and short - stay patients .
kawano et al . outlined various factors that relate to a long psychiatric hospitalization including  being received by the family ( 51.5% ) ,  no symptom improvement ( 48.8% ) , and limited life skills
( 44.0% ) , whereas for dementia  physical diseases ( 20.8% ) , and  no reliable administrative services ( 29.2% ) account for longer stays .
we assumed that the patient who chooses self - washing will have a short - length of stay because they have somewhat higher to adl .
the results showed that self - washing did not reduce the length of stay , but family washing was related to a short length of stay .
moriyama , et al . conducted a follow - up investigation regarding social hospitalisation processes , which included patient , family , and medical worker interviews [ 13 - 15 ] .
economy , physical functioning , and the  home environment. the factors relevant to the family were  health maintaining the health of the caregiver ,  the patient does not apply for certification of the need for long - term care and has received help from home - visit nursing , a home care worker , or a long - term care health facility , and 
caregiver burden. the factor relevant to hospitals was the  economic condition of the hospital. in other words , if beds are not full , the hospital s profit decreases , affecting the hospitalization - discharge cycle .
thus , if family members intentionally or unintentionally visit when a doctor or chief nurse is absent , the opportunity for discharge and communicative care is diminished . in the present study ,
if the family was helping with the laundry , the family visited the hospital every two or three days .
as such , the opportunity to discuss treatment with hospital staff was more frequent , increasing the probability of earlier discharge .
although one of our hypotheses was that a high frequency of visits would be related to a short length of stay , the frequency of visits was not related to a short length of stay in the present study .
conversely , if a supplier was doing the laundry , there were separate peaks during high visit frequencies ( fig .
the ratio of patients with a diagnosis of f00-f09 was highest in those hospitalised for between six months and 20 years ( table 1 ) . discharging someone to home care is reasonable for individuals with mild dementia ; however , discharge to a care facility is most likely when a patient suffers from severe dementia .
this is also the case with other mental disorders ( i.e. , f10-f19 , f20-f29 , and f30-f39 ) .
in addition , in the present study , illness severity affected the length of stay .
another of our hypotheses was that self - washing would be related to a short length of stay .
self - washing had a ratio high for the f20-f29 category ( table 1 ) , and severity of disease affected the length of stay .
it has been previously reported that family members with high care efficacy [ 18 , 19 ] and sufficient economic resources   are best able to handle a home discharge for individuals with more severe mental health issues .
another of our hypotheses was that living with a partner or family before hospitalization would be related to a short length of stay .
as the present study showed family structure before hospitalisation was not significantly related to reduced hospital stays .
tortnicroft , bebbington , and leff reported that medical staff tend to carefully discharge a patient into the home environment in italy because the severity of psychopathology had influenced the length of stay .
they showed that improvements in social networks and a less restrictive social environment promote the discharge to the community from a hospital [ 22 , 23 ] .
thus , we consider that long - stay patients who are discharged from hospital should be supported to live in the community in oecd countries . in 2015
the ministry of health , labour and welfare reported avenues of reform regarding mental health and medical care welfare . in japan community - based mental health services
the main premise is to shift individuals from hospitalisation to community care as a way to recognise and strengthen the medical health care system over the next 10 years .
individuals over the age of 65 years within psychiatric wards accounted for 29% of the patient population in 1996 .
since japan s population of individuals over 65 years of age continues to increase , further increases in disorders ( i.e. , dementia ) associated with this age group will be likely to occur . in the present study
, the private hospital has seen an increase in the number of dementia in - patients in recent years ( no data ) .
thus , there will probably be an increase in the number of in - patients requiring long - term hospitalisation .
it needs to be determined whether family washing is the result of economic concerns or if it is motivated more by the social and psychological benefits for the patient .
second , we did not assess family care efficacy , it could be the case that care efficacy is directly related to family washing behaviour and/or frequency of family visits .
finally , the present study did not assess a patient s number of a prior social hospitalisations .
further studies are needed to assess how social hospitalisations are related to the variables of interest in the present study .
in conclusion , knowing the in - patient family environments helps to encourage discharge and to provide proper care after discharge .
the present study indicated that family washing could be an important factor for decreasing the length of stay . in japan , there are still many private psychiatric hospitals .
the number of dementia cases is increasing in these psychiatric hospitals , which causes long hospitalisation . in view of this situation
further interventional studies should be conducted to investigate the relationship between discharge and communication between in - patients , their families , and hospital staff , and how we are able to help with medical treatment and care .
 background : in japan , the number of beds and average length of stay in a psychiatric ward are greater than in other developed countries.objective:the present study aimed to investigate the association between family variables and the length of stay of patients with mental and behavioural disorders in a private psychiatric hospital in japan.methods:the medical records of patients discharged during a one - year period ( n=56 : men 50.0% excepting 27 patients discharged due to death were re - examined regarding age , laundry type ( self - washing of clothes , family washing or supplier washing ) , number of family visits per one month while hospitalised , and family structure prior to hospitalisation . 
 a length of stay greater than six months was considered the cut - off point for a long hospital stay . 
 bivariate logistic regression analyses were conducted to identify factors independently associated with the length of stay , adjusted for sex , age , and mental and/or behavioural disorders according to the criteria of the international statistical classification of diseases and related health problems.results:the bivariate - adjusted odds ratio ( 95% confidence intervals ) for in - patients hospitalised for more than six months was 0.08 ( 0.01 , 0.48 ) for those who used family washing ( p = 0.006 ) compared with those who used supplier washing . 
 the number of visits per month and family structures before hospitalisation were not significantly associated.conclusion:these results suggest that within a private psychiatric hospital in japan , family washing is associated with shortened stays and frequency of family visits , while family structure is not associated with these factors . 