By Jennifer Bleak, M.D.
Clinical Director, Tokyo English Life Line (TELL) Community Counseling Service

Psychiatric hospitals in the Tokyo area

Living in a foreign country is a challenging, growth enhancing experience and we foreigners living in Tokyo are especially fortunate to be in an industrialized country with a low crime rate and modern facilities of every kind. Still, even for a Japanese speaking foreigner, accessing services, especially in a medical emergency can be a daunting experience. This article is focused on one aspect of the health care services in Tokyo, i.e. inpatient psychiatric care. Because I have practiced hospital psychiatry only in the U.S., American standards of psychiatric practice are the reference points for comparison with the Japanese system in this article. That the information in these reports was obtained almost solely from the interviews with the directors of psychiatry of six Tokyo area hospitals and visits to the psychiatric inpatient units of 5 of the 6 hospitals is important to emphasize.

We chose hospitals with a reputation for having admitted foreigners in the past and only a couple of the hospitals we contacted were not responsive. Oftentimes a hospital's motivation to treat foreigners originates with one or two psychiatrists. Once the psychiatrist(s) leaves, the hospital may lose interest in treating foreigners. So the hospitals that welcomed us were, to a certain extent, self-selected by their relative willingness to treat foreigners. A summary of information about each hospital is included at the end of this article. Normally, the goal of the hospital and the psychiatrist in treating a foreign inpatient is stabilization, hopefully within about one week, so that the individual can be escorted home and complete their treatment in their native country, where language and cultural differences are not an obstacle to recovery.

Three types of psychiatric admission exist in Japan. A voluntary admission is possible when the patient is admitted by his/her own free will and signs a consent. A compulsory admission occurs when the patient refuses admission, but two psychiatrists examine the patient and find that admission is necessary to prevent the patient from harming self or others. In Japan compulsory admissions are often the result of the police arresting and bringing the patient to one of five municipal psychiatric hospitals.

Voluntary and compulsory admissions also exist in the U.S., the difference being that, compulsory admissions may only be continued after several days by court order. The third type of admission, admission of medical protection does not exist in the U.S. This third type of admission occurs when the patient is unwilling to consent to the admission, but a family member gives consent and one psychiatrist determines that admission is necessary. If no family member is available to consent, the mayor of the town can give consent for medical protection admission.

The kind of admission determines who is responsible for payment of costs not covered by National Health Insurance. The voluntary patient is responsible for these costs. The government is responsible for payment of costs for a compulsory admission. The person signing in the patient is responsible for payment for a medical protection admission. If a patient is not covered by National Health Insurance at the time of admission, he/she may be able to purchase it retroactive to the day admission.

The first step in a voluntary admission or a medical protection admission is to make an appointment during the designated hours that patients are normally evaluated at the particular hospital. These hours are during normal business hours and vary from hospital to hospital. It is much better for the patient to come to the hospital for an appointment during business hours to be evaluated for an admission. (An additional source of information about gaining admission to a psychiatric hospital is the Himawari phone line at 03-5285-8181 weekdays from 9 am to 8 pm.

At night and holidays, contacting the police or the 119 emergency ambulance number may be the only route to admission, in which case the police and the hospital system will decide where the patient is ultimately admitted. The police will take the patient to the nearest municipal psychiatric hospital and the next day, the municipal hospital will probably transfer the patient to the next on the list of designated private hospitals in the area. (In the U.S., a person seeking emergency psychiatric admission can do so by simply coming to a hospital emergency room, any time of the day or night. But if they lack insurance coverage, they are usually transported to a State psychiatric hospital.)

The psychiatric hospitals we visited seemed to be divided according to the severity of mental illness treated. This is different from the U.S. where most psychiatric hospitals treat the entire range of severity of mental illness and mixed together on the same locked units. In the U.S. virtually no non-acute patients are kept in the hospital whereas, more non-acute patients are hospitalized in Japan where inpatient treatment is more available and hospitalizations are longer. In fact, Japan has the highest the number of psychiatric hospital beds per capita in the world.

Inpatient psychiatric care is generally much more accessible in Japan than in the United States. Because of the low levels of insurance coverage for psychiatric care in the U.S., oftentimes, needed hospitalization is unavailable, and, even when patients are admitted, they are discharged in spite of some continuing suicidal risk or inability to care for self. Japanese National Health Insurance provides much more substantial coverage for psychiatric inpatient care.

The cost per hospital day is lower partly due to lower staff/patient ratio in Japan. The amount of time spent with the patient by the attending psychiatrist is probably lower in Japan than in the U.S. For the foreign patient in a Japanese psychiatric hospital this raises particular difficulty in that the only English speaking staff members are generally the psychiatrists. Open, as opposed to locked units, are far more common in Japan than in the U.S.

The lower cost of hospitalization and the lower staff /patient ratio in Japan are probably related to a number of factors : lower frequency of malpractice suits brought by Japanese patients and their families, the Japanese emphasis on group harmony and conformity even within a psychiatric inpatient population, a tendency in Japanese psychiatry towards pacification of the patient through a heavy use of biological treatments such as medication and electroshock therapy, and the expectation that the family will be willing to do such things as stay overnight with a dangerously suicidal patient.

The frequency of overmedication and electroshock therapy in Japanese psychiatry is worth further exploration. One issue for the mentally ill in Japan seems to be the difficulty they experience in fitting into the highly refined social expectations here. I think there has been a tendency in Japanese psychiatry to sideline the mentally ill through overmedication, inpatient treatment, and the extensive use of electroshock treatment as a way of dealing with the patient's difficulty with conforming to group norms. However, the goal of social participation is becoming more of a focus of treatment. The hospitals we visited are trying to shorten inpatient treatment and provide for a transition from the hospital to normal life through passes, which allow patients to go to work while in the hospital. Day hospitals and psychological treatments such as occupational therapy are becoming more common.

Regarding electroshock treatment, this is an effective mode of treatment also used in the U.S. Over the decades the procedure has been modified and rendered safe. The only known side effect is short term memory loss which subsides after several days. However, electroshock therapy seems to be more commonly used in Japan than in the U.S. For example, one of the directors of a municipal hospital that treats mostly psychotic patients said about 500 patients per year are treated with electroshock therapy at his hospital. In the U.S., electroshock therapy is usually reserved for those with depression and mania under unusual situations, for example, acute mania in a pregnant woman in her first trimester, a situation in which she may harm herself or others and the medications that could be used are limited.

The risk of suicide is also addressed differently. Unlike Japan, a suicidal patient would never be knowingly admitted to an open unit in the U.S. In addition, each U.S. hospital has a structured, titrated set of suicide precautions. In very rare cases in the U.S., a patient actively engaged in self-violence, might require four point restraints in an isolation room. But usually, restricting the patient to the day area 24 hours a day in full view of the glassed-in nurses station is the highest level of suicide precautions. (In contrast, even the closed units we visited in Japan did not usually have a nurses' unit with a full view of the day room.) The lowest level of suicide precaution in the U.S. would be to have the nurse check on the patient every fifteen minutes.

In Japan, staff /patient ratios are too low to accommodate such intensive observation. In Japan, suicidal patients are admitted to open units. Belt restraints, sedation and enlisting the family to stay overnight with the patient appear to be some measures to control suicidal impulses on Japanese psychiatric inpatient units.

Regarding the use of isolation rooms, restraints and injections against the patients will, all of these measures are utilized in the U.S. and Japan, the purpose being to prevent patients from hurting themselves or others. In the U.S., a structure for management of a patient in restraints is in place. For example, patients must be checked each shift by a of psychiatrist. Nursing staff is required to give water and do other things for the health and comfort of the patient according to a predetermined schedule. All of the hospitals we visited said that they follow the law in their uses of restraints, which requires that a psychiatrist order restraints and that he document the reasons for them. Most of the hospitals we visited with isolation rooms had video cameras in them so the nurses could more easily observe the occupant. Likewise, injections against a patient's will are used in the U.S. to manage patients actively attempting to harm themselves or others and I was not able to determine if there were any difference in the use of injections here.

All the hospitals in the study allowed visits by family and friends. However, it is important for visitors to try and not upset the patient particularly in the late afternoon and evening since there is very little nursing coverage at night to deal with patients in distress. Also, patients need to be made aware that due to the scarcity of nursing staff, they may not get much individual attention and that the units have a lot of rules to be obeyed. In some hospitals they may not be able to have a private room.

Regarding confidentiality, I could not get a sense of how it is handled compared to the U.S. But each hospital pointed out various things they do to protect confidentiality such as refusing to release records without the patient's permission, not posting the names of patients on the unit and not revealing to callers that the patient is on the unit. Generally, psychiatric patients in Japan, unlike the U.S., are not allowed to see their own records. Most of the hospitals did say that, with the patient's permission, they would release a report to an airline and to the treating facility in the patient's native country for the purpose of transferring the patient for continued treatment.

In conclusion, based on my experience of psychiatric hospitals in the U.S. and our interviews with the directors of six psychiatric hospitals in Tokyo, there appears to be substantial differences in the admission and management of psychiatric inpatients. Although the information in this report, being from only six hospitals and based solely on staff interviews, is far from complete, I hope that it will help those faced with the need to help a foreign individual requiring an emergency psychiatric admission. As stated earlier, when a foreigner requires psychiatric admission, often the best strategy is to have the foreigner briefly admitted, during normal business hours, for stabilization and then to have a family member or friend escort the patient back to the native country for completion of treatment.


(Jennifer Bleak is an American Board Certified Psychiatrist, licensed to practice medicine in the State of Illinois. TELL consists of a free of charge phone line which provides crisis counseling and resource information in English (03-5774-0992, 9 am to 11 am every day) and a face to face counseling service (for an appointment call the English line, 03-3498-0231 or the Japanese line, 03-3498-0232) which provides psychotherapy in English, Japanese and German on a sliding fee scale based on income.

The face-to-face counseling service also carries out community service projects and can provide consultation to foreigners who need to report suspected child abuse. Through July, 2004 a limited number of child protection consultations will be funded by a grant from State Street Bank.)