In 2001, focusing on the fact that the number of hospitalized patients born between 1945 and 1949 is consistently high, Someya et al. [14] predicted that based on the aging of psychiatric inpatients associated with aging of the above-mentioned population and the major decline in the number of patients in that generation 30 years later, the number of inpatients with schizophrenia would decrease by at least 60% by 2030. As of 2018, the number of inpatients with schizophrenia has declined exactly as predicted [18] Also, a look at the overall number of psychiatric inpatients shows that the number in the 2017 Patient Survey is nearly the same as that calculated by Someya et al. [14,17]
Why, then, was the number of hospital patients born between 1945 and 1949 always so high around that time? We believe that the answer may be related to the Seishinka Tokurei, a special measure related to hospital staffing issued in 1958 by the then Ministry of Health and Welfare. This measure permitted psychiatric wards to have only one-third as many doctors and two-thirds as many nurses as general hospital wards. Although the medical service fees were low, the ability to keep labor costs low meant that having long-term inpatients was a shortcut to stable hospital management. This state of affairs led to a vast increase in psychiatric care beds in private hospitals, which resulted in a large number of psychiatric patient admissions from the 1960s to the 1980s. The group of inpatients among these admissions whose hospital stays became long-term are considered to account for the majority of long-term inpatients today. Another special law related to psychiatric medicine, the Act on Mental Health and Welfare for the Mentally Disabled, is in place today. The psychiatric health care system operates under this system, thereby allowing psychiatric hospitals to be managed at lower costs than general hospital beds [19].
However, long-term hospitalization causes health care costs to balloon and is thus undesirable from the perspective of promoting transition to community mental health services, which emphasize quality of life. Therefore, as part of the Vision for Reform of Mental Health and Welfare, the MHLW has long strived to ensure transition to community mental health services with the stated goal of cutting back 70,000 psychiatric care beds in 10 years. Despite this goal, only approximately 25,000 beds have been eliminated in 15 years. Although Japan has been transitioning to community mental health services as other countries have, this transition has not yet led to a major reduction in long-term psychiatric care beds. According to the WHO Mental Health ATLAS 2017, the percentage of newly admitted patients whose stays become long-term (1 year or more) has decreased to roughly 12% [20]. However, more than two-thirds of all patients in psychiatric care beds overall stay for more than 1 year [12]. Factors behind the continuation of long-term hospitalizations likely include cultural and societal factors such as stigma.), a lack of use of clozapine, and a lack of resources such as outreach and home-visit nursing services [21]. Another conceivable factor is the absence of financial compensation for private hospitals. Clozapine, which was introduced in Japan in 2009, has made almost no penetration since then; in January 2018, clozapine was prescribed for only 0.1% of all patients with schizophrenia [12]. Thus, clozapine has unfortunately not led to reduced rates of treatment-resistant schizophrenia or long-term use of psychiatric care beds. Also, due to sharp increases in the incidence of dementia and mood disorders such as depression, the number of patients with mental illness has increased by 60% in the last 15 years, breaking the 4-million mark and reaching 4.193 million in 2017 [17]. Going forward, hospital stays must be further shortened, and intervention must begin earlier. Shortening hospital stays would greatly reduce the number of psychiatric care beds.
While social factors such as the increasing application of information technology are also conceivable reasons for the increase in patients with mood disorders, other factors are likely greater; specifically, a change in the concept of depression and other mood disorders, and higher frequencies of consultation due to the spread of this change. In addition, the reason that 20,000 patients with mood disorders are predicted to require long-term psychiatric care beds going forward is not because those patients have mood disorders but because 12% of patients with all diseases in Japan are chronic patients [20]. Therefore, as the overall number of patients increases, the number of patients who require long-term psychiatric care beds is also predicted to increase.
The reduction in dementia-related psychiatric care beds is thought to be due largely to the transfer of patients with dementia to aged care facilities. However, due to the absence of connections among medical, welfare, and care data, a clear conclusion cannot be drawn. Therefore, surveys investigating these issues need to be conducted in the future. However, in Japan, there is a great deal of movement back and forth between aged care facilities and psychiatric hospitals due to factors such as persons living in aged care facilities being placed in psychiatric hospitals as soon as they demonstrate psychiatric symptoms or behavioral and psychological symptoms of dementia. This high degree of movement is a factor in the predicted reduction of dementia-related long-term psychiatric care beds. The stigma attached to psychiatric patients may also play a role.
The predicted closure of 64,000 long-stay beds is likely to have substantial financial implications. Specifically, with the lack of public funding for private hospitals and a dwindling population, hospitals will be forced to downsize and focus more on outpatient care to remain operational. However, due to the lack of experience with community mental health services in Japan, preparing such services would likely take time. The Japanese government, in particular the MHLW, is currently advancing a policy of comprehensive regional care systems that can also handle psychiatric disorders. This policy aims to promote not only the development of infrastructure to facilitate transition to community mental health services but also to promote therapeutic drugs for treating treatment-resistant schizophrenia and measures for managing dementia to realize discharge and community transition. However, this policy only began in 2017 and has not yet produced structural change. In light of this present situation, we believe it is necessary to leave behind the mindset that “long-term hospitalization is bad” and adopt a multifaceted approach to the diversification of mental illness and the issue of psychiatric bed supply/availability, which are forecast to decrease going forward due to the natural decrease in long-term inpatients.
Nevertheless, the Patient Survey used in this study is conducted only once every 3 years and is not very exhaustive, with a sampling rate of only about 38%. Thus, the survey does not encompass all long-term psychiatric inpatients. Another point that must be noted regarding the Patient Survey is that it represents the number of patients at a specific point in time, not for an entire year. Furthermore, our discharge-admissions differences represent the mean differences of 5-year intervals based on data from 630 Surveys up to 2016. Consequently, it must be said that differences for 2017 onwards are uncertain. In addition, there is no publicly available data for future forecasts of mortality rates. Therefore, models are forced to incorporate the assumption that current mortality rates will remain unchanged. While it is assumed that current mortality rates will remain unchanged until 2040, advancements in medicine could extend lifespans, making it highly likely that the number of patients will increase by 2040.
We are currently striving to integrate care to create a health care system centered on community-based integrated care [22]. Several other countries, particularly in Western Europe, have already been actively transitioning from institutional care to community-based care [23-24]. Based on our findings in this study and on these efforts in other countries, we conclude that it may be pertinent to consider the comprehensive structure of future mental health care.