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By George Wehfritz

Despite efforts to reform the system, Japan still hospitalizes most of its mentally ill patients.

Japan's notorious intolerance for mental illness has given rise to a booming industry. Since the 1960s, hundreds of psychiatric hospitals--the vast majority of them private, for-profit facilities--have sprung up to house "abnormal" people deemed burdensome to society. The majority suffer from schizophrenia and have been institutionalized involuntarily--often at the behest of fearful and uninformed relatives. In the past that meant virtual imprisonment. "In some hospitals, violence and abuse were the norm," says Dr. Yoshiharu Kim, a director at Japan's National Institute of Mental Health. "Japan has a long, sad history of compulsory inpatient treatment."

That legacy lives on despite efforts to reform the system. Japan still boasts six times as many psychiatric beds per capita as the United States and has bucked a global trend toward community-based treatment. Ironically, Japan's recalcitrance is motivated precisely by what caused the United States to release thousands of psychiatric patients in the 1980s: money. Japan so efficiently warehouses its mentally ill that the alternative--intensive hospital treatment for acute patients and outpatient care for the rest--would cost more, at least in the short run, than keeping Japan's huge psychiatric population hospitalized.

To be sure, care has improved dramatically since the passage of Japan's Mental Health Act in 1987. Championed by a new generation of psychiatrists and doctors, the legislation restricted the ability of doctors or families to lock up sick people involuntarily. (Today, 70 percent enter hospitals of their own volition.) But it has thus far failed to spur a broad shift to community-based care.

Upon admission, Japanese psychiatric patients enter a world where the aim is often maintenance, not healing. They are housed, fed and medicated but routinely denied intensive treatment that could make them well because hospitals, which earn a flat fee per patient, can't afford to provide it. Under Japan's nationalized medical system, psychiatric facilities must provide one doctor for every 48 patients--merely a third of the 1 to 16 ratio required for most other fields of medicine. "The existing system promotes long-term care with little service, resulting in institutionalism," says Yasuichiro Yusa, a clinical psychologist at Hasegawa Hospital near Tokyo.

Yusa acknowledges that Japan's approach has merits as well as faults. As a student and practicing psychologist in the United States in the 1980s, he witnessed the American emphasis on discharging patients as quickly as possible. Many patients ended up homeless or otherwise "victims of the system," he says. Japan's psychiatric patients are victimized in different ways. Most are so deprived of stimulation that they develop a dependency that makes their return to society difficult. These patients can spend years--even decades--in the hospital. In 1999, for example, 43 percent of inpatients had been hospitalized for at least five years, down only slightly from the 1983 figure of 48 percent. Today, experts estimate that four in 10 inpatients are well enough to function on the outside if assisted-living facilities were available. But because they aren't, stable patients linger in psychiatric wards.

Outpatients burden their families socially as well as financially. One Osaka-based professor has supported his sister since she was diagnosed with paranoid schizophrenia 16 years ago. When that happened, he explains, her husband left, her mother considered suicide and he was called upon to quell his sister's violent, knife-wielding outbursts. She's been hospitalized on numerous occasions but now lives in a tiny apartment near her family. "My thoughts often wander to my sister," says the professor, who asked to remain anonymous. "What if my mother gets too old to care for her? What if I can no longer afford her bills?"

Japan is only beginning to construct the community-based support networks the mentally ill need to cope on the outside. Hospitals are resisting the trend for fear that they'll lose government funding. Communities, too, are highly ambivalent. When Mamoru Takuma, a 37-year-old drifter with a history of mental illness, walked into an elementary school in Osaka and stabbed 23 people last year, killing eight children, Japanese lawmakers responded with a draft of new legislation aimed at keeping potentially violent psychiatric patients off the streets. The bill was submitted to the Diet last month.

Mental-wellness advocates launched a new campaign to destigmatize schizophrenia that coincided with the Japanese premiere of "A Beautiful Mind" last week. To promote awareness, 40-year-old musician Yukio Shimomura even sings about his schizophrenia in a duet with a depression patient. "We want to live the way we are without hiding," he says. But that's much easier said than done for patients who've spent years in atrophying confinement.

Staff writer Hideko Takayama also contributed to this article.

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