Releasing 70,000 Psychiatric Patients Shows Japan Debt Task
In the hallway of St. Pierre Psychiatric Hospital north of Tokyo, an elderly woman sits on the floor next to a bulging brown duffle bag, her arms wrapped around her knees, mumbling about being taken home.
She has packed her things many times since she was admitted for schizophrenia more than 20 years ago, in the belief someone is coming to fetch her, said psychiatrist Manabu Yamazaki, the hospital’s owner.
Her hope mirrors that of the government, which wants to empty 70,000 beds to reduce the highest rate of psychiatric hospitalization among developed nations, lowering its 1.8 trillion yen ($23.5 billion) annual mental-health payments. Facing the world’s largest public debt and the fastest aging society, Prime Minister Yoshihiko Noda is trying to curtail growth in the country’s 34.8 trillion yen-a-year health bill.
“The only thing the government has in mind is cutting medical costs,” said Yugo Miyata, who runs Yokohama Camellia Hospital on the outskirts of Tokyo. “If hospitals force out 70,000 patients immediately, we must be ready for several thousand of them to be homeless on the street.”
The effort to reverse a five-decade policy of isolating psychiatric cases is unrealistic because most patients have no living relatives or have been hospitalized too long to cope outside, and because of the stigma in Japan of having a mentally ill relative, according to doctors including Yamazaki and Yuji Okazaki at Tokyo Metropolitan Matsuzawa Hospital.
Between 2004, when the health ministry set a 10-year timescale for the reduction, and September 2009, when the latest survey was carried out, the number of beds fell by only 6,806, to 348,121. In an effort to speed up the cuts, the government this year is selecting 25 psychiatric hospitals for a trial program that would require them to remove at least 10 percent of their beds within three to five years and set up teams to help care for patients released into the community.
The failure to empty wards shows the difficulty Noda faces in reducing subsidies in a nation where the burden of caring for a growing number of elderly patients is falling on a shrinking group of working-age citizens. Meeting the government’s target would save about 100 billion yen a year, according to Ludwig Kanzler, a partner at McKinsey & Co. in Tokyo.
About one in three Japanese will be over 65 by 2025, compared with 12 percent in 1990, the Paris-based Organization for Economic Cooperation and Development estimates. Seniors occupy almost two-thirds of hospital beds in Japan, the OECD said in a December 2009 report. Care of the mentally ill accounts for 5.2 percent of the nation’s 34.8 trillion yen medical bill.
While the U.S. and western Europe began closing asylums and integrating patients into the community in the 1960s, in Japan the stigma of mental illness has ensured that the nation’s 1,076 psychiatric hospitals maintain a 90 percent occupancy rate. Japan has 13.5 times more psychiatric beds per 100,000 people than the U.S. and 4.5 times more than the U.K., according to OECD data.
“There’s no question that the stigma against mental illnesses is greater in Japan,” said Nancy Andreasen, the Andrew H. Woods chair of psychiatry at the University of Iowa Carver College of Medicine, who received the President’s National Medal of Science in 2000. “There is a tendency to take an ill family member and get them out of sight and essentially out of mind.”
The mentally ill have been largely separated from society in Japan since the 1950s, when the government prohibited people from locking up sick relatives at home. To increase the availability of hospital beds, it introduced subsidies and relaxed minimum staffing requirements.
Public pressure to institutionalize the mentally ill grew after former U.S. ambassador Edwin Reischauer was attacked by a patient suffering from schizophrenia at the Tokyo embassy in 1964, causing international embarrassment.
“Many patients don’t need medical care,” said Okazaki at Tokyo Metropolitan Matsuzawa Hospital. “But they have no home to return to as their parents have died and their siblings don’t feel they have a duty to support them.”
Treating Japan’s more than 300,000 psychiatric in-patients costs about 400,000 yen per patient per month on average, according to a 2009 health ministry survey. Between 70 percent and 100 percent of that cost is covered by the government, depending on the patient’s age and relatives’ ability to pay. For seniors, the state pays as much as 90 percent of the bill.
“Few psychiatric beds have been cut at this point,” said Ken Hongo, deputy director for the health ministry’s mental welfare division said in a telephone interview. The government is still planning how to support patients in communities and deal with an increasing number of dementia patients, he said.
With the population aging, the proportion of dementia patients at mental hospitals rose to 17 percent in 2008, from 11 percent almost a decade earlier, the ministry’s survey shows.
“Other hospitals don’t take dementia patients with psychosis so they end up at mental hospitals,” said Okazaki at Tokyo Metropolitan Matsuzawa Hospital.
At Yamazaki’s St. Pierre Hospital, half the patients are elderly and many have dementia, the 70-year-old psychiatrist said as he unlocked a steel-reinforced sliding door intended to prevent patients from entering the elevator lobby. The two- to four-bed rooms, partitioned by pink curtains and wooden cabinets, are painted tan and brightly lit through hardened-glass windows that open little more than a hand’s width.
For fresh air, patients can step outside onto a rooftop herb-and-flower garden surrounded by a 3-meter-high mesh fence.
With large subsidies, psychiatric hospitals, 90 percent of which are owned by doctors, have little incentive to release patients, according to the OECD report. Government payouts for seniors had “the unintended effect of turning hospitals into de facto nursing homes,” the report said. “Keeping patients in beds is an easy way to gain revenue.”
“It should be possible to organize psychiatric treatment in Japan in similar ways as elsewhere,” said McKinsey’s Kanzler. “Whether the government succeeds will be a matter of coming up with a plan that gives the hospitals little choice.”
Japan’s mental hospital association, which represents the 88 percent of psychiatric hospitals that are privately owned, will suggest instead converting some beds by March 2012 into less medically intensive residential care in return for government compensation, said Yamazaki, who chairs the group.
“The government encouraged isolating mental patients from society for the last 50 years,” said Yamazaki, in his office in the six-story, 522-bed hospital he rebuilt five years ago for 3.5 billion yen. “It should be responsible if it wants to change that. If we let patients go, they will have nowhere to go and nothing to do.”
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