Twelve-month use of mental health services in four areas in Japan: Findings from the World Mental Health Japan Survey 2002–2003
Yoichi Naganuma, PSW, MSc, Department of Mental Health Administration, National Institute of Mental Health, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8553, Japan. Email: firstname.lastname@example.org
Abstract The aim of the present study was to provide basic descriptive data regarding utilization of 12-month mental health services in the Japanese community population. Face-to-face household surveys were carried out in four areas (two urban cities and two rural municipalities), and a total of 1663 persons participated (overall response rate: 56.4%). For data collection, the structured psychiatric interview, World Mental Health version of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI) was used, allowing DSM-IV diagnoses, severity, and service utilization. It was found that 7.3% of total respondents had received any service, either professional or non-professional, in the past 12 months, including 20.0% of those with 12-month DSM-IV disorders and 6.2% of those without. Thirty-three percent of those with any mood disorder used any service, and 26.8% of those used some type of health care. The probability of people with 13–15 years of education receiving mental health treatment was fourfold higher than those with ≥16 years of education. Gender, age, or income were not found to contribute to utilization of mental health services. The results confirm that the majority of people with a recent psychiatric disorder have not used mental health care or other support systems. The mental health care system in Japan has improved over the past decade, but not enough for people suffering from mental disturbances.
Mental disorders are widespread and contribute substantially to the total burden of disease in the general population.1 The provision of adequate care as early as possible for people suffering from mental disorders or other emotional problems is one of the most pressing issues in Japan, as well as in other countries.
There is an increasing trend in the proportion of those seeking treatment. In the US Epidemiologic Catchments Area (ECA) Survey in 1980–1982, a proportion of those who used health services for mental health reasons (either general physicians or mental health specialists) in the past 6 months was 2–4% for mental health specialists and 3–4% for general physicians in a total population; and 8–12% for mental health specialists and 7–8% for general physicians among those who experienced any DSM-III2 disorder.3 According to the US National Comorbidity Survey Replication (NCS-R) conducted in 2001–2002, 14% of a total population visited mental health services and 10% visited general physicians in the past 12 months; 25% of those who experienced any DSM-IV disorder visited mental health services and 17% visited general physicians in the past 12 months.4 Similarly, according to the European Study of the Epidemiology of Mental Disorders/Mental Health Disability: a European Assessment in the year 2000 (ESEMeD/MHEDEA 2000) across six European countries, 6.4% of a total population visited any type of formal health services (e.g. psychiatrist, psychologist, nurse, medical doctor etc.) in the past 12 months and 25.7% of those who experienced any mental disorder visited any type of formal health services in the past 12 months.5 The proportion of those seeking treatment also varies among countries. The World Health Organization (WHO) established the World Mental Health (WMH) Survey Consortium in 1998 to address the current status of mental disorders and mental health service use across many countries.6 In the first report from the survey using data from 14 countries, the proportion of those who sought medical treatment for mental health reasons was lower among Asian countries and Nigeria compared with the USA and Europe both in total population and those with mental disorders.6
In Japan there were few data available to estimate the proportion of those receiving medical treatment in a general population or among those who suffered from mental disorders until recently. The most recent national patient survey in 2002 based on reports from medical service institutions estimated that a total of 2.3 million people received treatment for mental disorders in Japan, which was 1.8% of the total population in Japan.7 However, the figure may be underestimated because people may visit physicians for mental health reasons but not receive a diagnosis of mental disorder. In a community-based survey that was conducted in a town in Japan in 1992, 7% of respondents had received some type of treatment for mental disorders in their lifetime.8 However, this was a small-sized study and the findings may not be generalized to other parts of Japan. As a part of the aforementioned WMH Survey, the WMH Japan (WMHJ) Survey was conducted in four community populations in Japan in 2002–2003. The study reported that 3% of the total population visited a mental health specialty and 4% visited general physicians; 6–18% of those who experienced any DSM-IV disorder visited a mental health specialty and 5–7% visited general physicians in the past 12 months, depending on the disorder severity.9 The findings suggest that the proportion of medical treatment is certainly greater from that estimated from the National Patient Survey, but still much lower than those reported in the US NCS-R4 and in Western countries.6
It seems that there still remain many barriers to making mental health services widely accessible in Japan, despite new policies aiming to reduce the stigma of mental disorders having been recently introduced in Japan.10 To understand factors associated with the low proportion of medical treatment for mental disorders in Japan, the analysis should be done by specific disorder. In addition, services provided by non-psychiatrists have emerged worldwide, such as clinical psychologists, general practices, non-medical counseling services, or alternative therapies such as chiropractice, aroma therapy, healing, or megavitamins.11 The utilization of these services for mental health reasons should be examined. Furthermore, previous studies have not examined the proportion of those who received adequate treatment among those who visited mental health services.
The aim of the present study was to provide basic descriptive data from WMHJ 2002–2003, and to address the more detailed states of utilization of the mental health services in the Japanese community, using the same data set as a previous study.9
We first examined the proportion of those who had obtained any treatment in the 12 months before the survey, by disorder and by service provider sector. Second, we examined the average number of visits and proportions of patients receiving minimally adequate treatment. Finally, we examined the association of sociodemographic and diagnostic variables with treatment.
Four community populations in Japan were selected as study sites in 2002–2003. The sites included two urban cities (Okayama and Nagasaki) and two rural municipalities (Kushikino and Fukiage in Kagoshima prefecture). These sites were selected in consideration of both geographic variation and the availability of site investigators.9 From a voter registration list or a resident registry, a random sample was selected from residents aged ≥20 years at each survey site. Trained interviewers carried out structured face-to-face interviews with those who agreed to participate in the survey using the standardized instrument. We excluded subjects who had died, moved, or had been institutionalized. A total of 1663 interviews was obtained. The Composite International Diagnostic Interview (CIDI) questionnaire was divided into two parts. Part I, which included basic sociodemographic data, a core diagnostic assessment, and service use was administered to all respondents. Part II assessed risk factors, correlates, additional disorders (post-traumatic stress disorder and substance disorders). Part II was then administered to all part I respondents who met the criteria for any mental disorder and to a probability subsample of other respondents (n = 477).
The response rate was 56.4%. The part II respondents were weighted by the inverse of their probability of selection to adjust for the differential sampling of cases and non-cases. In addition, all samples were weighted to adjust for differential probabilities of selection and post-stratified to match the population distributions on the cross-classification for sex and age.12 The Human Subjects Committees of Okayama University (for the Okayama site), National Institute of Mental Health in Japan (for the Kagoshima site), and Nagasaki University (for the Nagasaki site) approved the recruitment, consent, and field procedures. (For details see the previous paper.9)
Diagnostic assessment of 12-month mental disorders
The DSM-IV diagnoses were made using the computer-assisted personal interview (CAPI) Japanese version of the WMH-CIDI,13 a fully structured diagnostic interview that generates DSM-IV14 diagnoses. The 12-month DSM-IV disorders considered here include anxiety (panic disorder, agoraphobia, specific phobia, social phobia, generalized anxiety disorder, post-traumatic stress disorder), mood (bipolar I and II disorders, major depressive disorder, dysthymia), and substance disorders (alcohol and drug abuse and dependence). All diagnoses are considered with organic exclusions and with diagnostic hierarchy rules, with the exception of the substance disorders, for which abuse is defined with or without dependence.
Twelve-month use of mental health services
All part II respondents were asked whether they ever received treatment for ‘problems with your emotions or nerves or your use of alcohol or drugs’. A list of types of treatment providers was presented in a respondent booklet to provide a visual recall aid. Separate assessments were made for different types of professionals, support groups, self-help groups, mental health crisis hotlines (assumed to be visits with non-psychiatrist mental health specialists), complementary and alternative (CAM) therapies, and use of other treatment settings. Other treatment settings included admissions to hospitals and other facilities (each day of admission was assumed to include a visit with a psychiatrist). Follow-up questions were first asked about age and the most recent contacts as well as the number and duration of visits in the past 12 months.
Types of 12-month service use were classified into the following categories: psychiatrist; non-psychiatrist mental health specialist (psychologist or other non-psychiatrist mental health professional in any setting, a social worker or counselor in a mental health specialty setting, use of a mental health hotline); general medical provider (general medical doctor, nurse, any other health professional not previously mentioned); human services professional (religious or spiritual advisor, social worker or counselor in a non-mental health setting); and CAM professional (any other type of healer such as chiropractors, participation in an internet support group, participation in a self-help group). The subjects who had used psychiatrist or non-psychiatrist specialist services in the previous 12 months were placed in a category labeled ‘any mental health specialty’. The subjects who had used any mental health specialty or general medical services in the previous 12 months were placed in a category labeled ‘any health care’. The subjects who had used human services or CAM services in the previous 12 months were placed in a category labeled ‘any non-health care’. The subjects who had used any of these services in the previous 12 months were placed in a category labeled ‘any treatment’. The subjects who had used any service of two or more categories in the previous 12 months were placed in each category.
Minimally adequate treatment
Minimally adequate treatment was defined as: (i) at least four visits in the prior year to any type of provider (general medical, human services, CAM etc.); or (ii) at least two visits and any type of medication (i.e. this includes medications that are known to be inappropriate for the assessed disorder); or (iii) respondent still in treatment at the time of interview.
Sociodemographic predictor variables
Sociodemographic variables included age (defined by age at interview and categorized as 20–29 years, 30–44 years, 45–59 years, 60+ years); gender; completed years of education (0–11 years, 12 years, 13–15 years, and 16+ years); marital status (married-cohabitating, previously married, never married); family income in relation to the federal poverty line15 (categorized as low, <1.5-fold below the poverty line; low average, 1.5+ −3-fold; high average, 3+ −6-fold; and high, 6+-fold higher).
Our data were weighted to adjust for differences in the probabilities of selection, differential non-response, residual differences between the sample and the site population, and over-sampling in the part II sample. Basic patterns of service use were examined by computing the proportions in treatment, mean numbers of visits among those in treatment, and proportion of treatments meeting criteria for minimal adequacy. Logistic regression analysis was used to study sociodemographic predictors for receiving any 12-month treatment in the total sample.16 Standard errors were estimated using the Taylor series method as implemented in sudaan (Research Triangle Institute, NC, USA). Multivariate significance tests in the logistic regression analyses were made using Wald χ2 tests based on coefficient variance–covariance matrices that were adjusted for design effects using the Taylor series method. Statistical significance was evaluated using two-sided design-based tests and the 5% level of significance.
Proportion of 12-month service use
It was found that 7.3% of total respondents used any services in the past 12 months, including 20.0% of those with 12-month DSM-IV disorders and 6.2% of those without any of the assessed disorders (Table 1). The majority of treatments occurred in the health care sectors (5.8% of respondents, representing 79.4% of those in treatment) and, within the health care sectors, the general medical sector (3.7% of respondents, representing 50.8% of those in treatment).
Table 1. . WMH: 12-month service usage in Japan: Percent using any service among people with 12-month mental disorder†
|GAD||–||–||–||–||–||–||–||–||–|| 18|| 16|
|Panic disorder||–||–||–||–||–||–||–||–||–|| 6|| 7|
|Agoraphobia w/o Panic||–||–||–||–||–||–||–||–||–|| 4|| 5|
|Social phobia||–||–||–||–||–||–||–||–||–|| 8|| 9|
|Specific phobia||13.1 (5.6)|| 3.4 (2.4)||14.2 (5.6)|| 8.5 (4.1)||18.6 (6.1)||0.0 (0.0)||4.6 (3.1)|| 4.6 (3.1)||20.7 (6.3)|| 47|| 45|
|Posttraumatic stress disorder¶||–||–||–||–||–||–||–|| ||–|| 6|| 2|
|Any anxiety disorder¶|| 7.7 (3.5)|| 8.7 (4.1)||15.0 (4.7)|| 9.0 (2.3)||19.1 (3.6)||2.4 (1.9)||4.2 (2.5)|| 6.6 (3.6)||21.5 (4.7)|| 66|| 23|
|Major depressive disorder||13.6 (4.9)||14.0 (6.5)||25.2 (6.5)|| 8.9 (5.2)||27.1 (7.3)||6.7 (3.7)||7.9 (5.5)||14.6 (7.3)||33.8 (8.2)|| 42|| 43|
|Dysthymia||–||–||–||–||–||–||–||–||–|| 10|| 10|
|Bipolar I or II||–||–||–||–||–||–||–||–||–|| 2|| 2|
|Any mood disorder||14.4 (4.9)||12.9 (6.1)||25.1 (6.4)||10.2 (5.2)||26.8 (7.1)||6.2 (3.5)||9.2 (5.4)||15.4 (7.1)||33.0 (8.0)|| 46|| 47|
|Alcohol abuse or dependence¶||–||–||–||–||–||–|| ||–||–|| 11|| 8|
|Alcohol dependence¶||–||–||–||–|| ||–||–||–||–|| 3|| 2|
|Drug abuse or dependence¶||–||–||–||–||–||–||–||–||–|| 2|| 1|
|Drug dependence¶||–||–||–||–|| ||–||–||–||–|| 1|| 0|
|Any substance¶||–||–||–||–||–||–||–||–||–|| 12|| 8|
|Any disorder¶|| 7.9 (2.7)|| 7.0 (2.6)||14.0 (2.9)|| 6.7 (1.8)||16.9 (2.5)||3.1 (1.8)||3.3 (1.8)|| 6.3 (2.7)||20.0 (2.8)||102|| 38|
|No disorder|| 1.3 (0.7)|| 0.3 (0.1)|| 1.5 (0.7)|| 3.5 (0.9)|| 4.8 (1.0)||1.0 (1.0)||0.5 (0.3)|| 1.5 (0.8)|| 6.2 (1.6)||375||439|
|Total part II sample|| 1.9 (0.7)|| 0.8 (0.3)|| 2.5 (0.6)|| 3.7 (0.8)|| 5.8 (1.0)||1.2 (0.8)||0.7 (0.3)|| 1.9 (0.7)|| 7.3 (1.5)||477||477|
Similarly for those with 12-month DSM-IV disorders, the majority of treatments occurred in the health-care sectors (16.9% of those with disorders, representing 84.6% of those in treatment) and, within the health-care sectors, any mental health care (14.0% of those with disorders, representing 69.9% of those in treatment), including psychiatrists (7.9% of those with disorders, representing 39.3% of those in treatment).
Those with major depressive disorder (MDD) were found to use relatively less general medical treatment (8.9% of those with MDD, representing 26.4% of those in treatment), and more than in any non-health-care sector (14.6% of those with MDD, representing 43.3% of those in treatment).
Number of visits
The mean number of 12-month visits among those receiving any treatment in total part II samples was 6.6 (SE = 1.1, n = 67).
Minimally adequate treatment
The data showed that 64.7% (SE = 8.0%, n = 477) of treated patients could be classified as receiving at least minimally adequate treatment.
Sociodemographic predictors of treatment
Receiving any 12-month mental health treatment was significantly associated with only education. The probability of people with 13–15 years of education receiving mental health treatment was fourfold higher [odds ratio (OR): 4.4, 95% confidence interval (CI): 1.4–13.9) than those with ≥16 years of education (Table 2). Gender, age, or income were not significant.
Table 2. . WMH: 12-month service usage in Japan: Sociodemographic and disorder type predictors of any treatment
| 20–29||0.2||(0.0, 7.9)|
| 30–44||0.9||(0.2, 4.6)|
| 45–59||0.4||(0.1, 1.5)|
|Overall test of effect||Wald χ2 = 2.4 d.f. = 3, P = 0.498|| |
|Any anxiety disorder|
| Yes||4.0||(0.6, 29.4)|
|Overall test of effect||Wald χ2 = 2.2 d.f. = 1, P = 0.142|| |
|Any mood disorder|
| Yes||13.4||(0.9, 190.6)|
|Overall Test of Effect||Wald χ2 = 4.2 d.f. = 1, P = 0.041|| |
|Any substance disorder|
| Yes||1.8||(0.2, 21.4)|
|Overall test of effect||Wald χ2 = 0.3 d.f. = 1, P = 0.614|| |
|No. years education|
| 0–11||1.3||(0.1, 13.7)|
| 12||0.7||(0.1, 5.2)|
| 13–15||4.4||(1.4, 13.9)|
|Overall test of effect||Wald χ2 = 8.9 d.f. = 3, P = 0.030|| |
| Low||0.6||(0.1, 2.7)|
| Low average||0.5||(0.1, 3.3)|
| High average||0.4||(0.1, 2.0)|
|Overall test of effect||Wald χ2 = 1.6 d.f. = 3, P = 0.652|| |
| Never Married||2.1||(0.1, 88.7)|
| Separated/Widowed/Divorced||6.8||(0.8, 54.6)|
|Overall test of effect||Wald χ2 = 5.4 d.f. = 2, P = 0.067|| |
|Sex|| || |
| Male||1.2||(0.4, 3.3)|
|Overall test of effect||Wald χ2 = 0.1 d.f. = 1, P = 0.738|| |
Some interesting associations were found, but they were not statistically significant (P < 0.05). It may be because of the low statistical power due to the low treatment rate. More people with any mood disorder were more likely to receive treatment than those without (Wald χ2 = 4.2, d.f. = 1, P = 0.041), and more people who were separated, widowed, or divorced were more likely to receive treatment than those who were married or cohabiting (Wald χ2 = 5.4, d.f. = 2, P = 0.067).
The present study has the following limitations. The first is a sampling bias. The survey excluded people who were institutionalized, and the sampling was done in several rural and urban areas but not in metropolitan areas, so the results do not reflect the specific features of metropolitan areas. In addition, the WMH-CIDI did not assess all the DSM-IV disorders such as schizophrenia, eating disorder, and antisocial behavior. Therefore, some respondents in treatment without a DSM-IV diagnosis considered in the present study may actually have met criteria for another type of DSM-IV disorder. And the low response rate may cause another bias. People who were treated for mental disorders may be more likely to agree to participate in this survey than those who did not use any service for their mental disorders. Because of these biases, the rates of service use may have been overestimated or underestimated.
Second, we cannot examine the validity of self-reported treatment use in the WMHJ 2002–2003 because we have no comparable data on service use. Potentially biased recall of mental health service use may have occurred,17 and we therefore have likely underestimated the unmet need for treatment, especially among those with more serious disorders.
Third, the WMH-CIDI was not fully validated against clinical diagnosis in Japan, although it was developed by an expert group with a back-translation procedure and checked though an expert review. The observed proportion of service use may have been overestimated or underestimated in the present study.
Fourth, small sample size and low prevalence9 is an important limitation. The present study failed to find significant correlates of service use because all the CI were very wide. A large sample will allow narrowing of the CI. Then the significant correlation will be clarified. Some of these limitations could be resolved by expanding the survey field and including respondents for other areas of Japan.
Even with these limitations, however, the results do highlight a very serious issue. Our results have confirmed that 80% of people with a 12-month mental disorder have not received treatment for it. As for a total sample of part II, the treatment rate was only 7.3%, meaning that more than 90% did not receive treatment. Compared with the results of a previous study by Fujihara and Kitamura carried out more than 10 years ago, the rate of health care use has modestly increased from approximately 10% to 16.9%.8 Although the mental health-care system has developed in the last 10 years, it remains insufficient for people suffering from mental disorders. Compared with other WMH collaborating countries, the utilization rate in Japan was higher than that in China, Lebanon, Nigeria, Mexico, Italy, and Ukraine, and the same as that in Colombia.6 The service use rates of Western countries are generally higher than those in Japan; in particular, those in the USA or France are twice those in Japan.
Six percent of the respondents with no disorder visited any services and 77% of them received any health care. This may be because some respondents who had a mental disorder that was not assessed in the present study, visited mental health services. This could also be because distress and impairment in social functioning can be caused not only by a mental disorder that meets the diagnostic criteria, but also by subthreshold symptoms.18 A further study should clarify the reasons for visiting mental health services among those who do not meet the diagnostic criteria for mental disorders.
As for diagnosis, the utilization rate of those with mood disorders in the past year was relatively higher than that for those with other mental disorders. In particular, it was found that 25.1% of people with any mood disorder (representing 76.1% of those in treatment) have used any mental health care as compared with 10.2% for general medical (representing 30.9% of those in treatment). Compared with the reports of other WMH collaborators, in the USA for people with 12-month MDD, 55.1% of those in treatment used mental health professionals versus 47.5% of those in treatment using general medical;19 in Colombia for people with 12-month any mood disorder, 66.1% of those in treatment used mental health professionals versus 29.4% of those in treatment using general medical.20 The primary care system by general practice was developed in the USA, so many depressive patients may easily receive treatment by general practicioners.21 Miki has reported that 59.5% of patients with primary depression visit general practitioners in Japan.22 The present study findings suggest that people with severe mental disorder such as depression are referred to mental health professionals by internists in Japan. Meanwhile, the Minister of Health, Labor and Welfare has been promoting a depression prevention campaign for the past few years, so early intervention for depression might function effectively, and the barriers to mental health service usage for the treatment of depressive mood might be reduced somewhat. Those with any substance disorder had very low usage compared with the USAs and other Western countries.5,6,23 This finding is consistent with the fact that the Japanese government has a strong justice and security policy for controlling the use of illicit and other psychotropic drugs, so the 12-month prevalence of substance disorder is remarkably low.
As for the service sector, as described above, the relatively high rate of utilization of psychiatrists was a feature of Japanese usage. In any diagnostic category, the utilization of psychiatrists was higher than that of general medical. For other countries the utilization of general medical or non-psychiatrist mental health professional was often higher than that of psychiatrists.5,20,24 The majority of people receiving treatment for mental disorder were treated by psychiatrists in Japan. As for the human service sector or CAM, some people did use these sectors. In particular, people in treatment for mood disorder are likely to use these sectors, with 16.1% utilizing human services and 27.9% utilizing CAM. In comparison, in the USA, the usage rates for those with MDD who are in treatment are 16.1% for human services and 26.7% for CAM;19 and in Colombia, the usage rates for those with any mood disorder who are in treatment are 20.9% for human services and 19.8% for CAM.20 The Japanese rate was near that of the USA. In a previous study about CAM in the USA, Eisenberg et al. found that people who use CAM do so for chronic disorders such as back problems, depression, anxiety, or headaches.11 Kessler et al. have also found that many people use CAM openly along with treatment by mental health professionals.25 The situation for Japanese people with mood disorders is probably similar, but the present small sample size and low 12-month prevalence prevent us from carrying out more detailed analysis.
As for sociodemographic variables, sex and age do not appear to significantly affect service use. Some reports have indicated that mental health service use decreases over age 65 based on the US community-sample.5,23,26 Several studies have shown that women use more mental health services than men.5,23,27 This result may be another specifically Japanese feature, so further examination is necessary. It is an unexpected result that educational background is significantly related to service use, with the utilization rate of people with 13–15 years education being higher than that for others. Those with less education may lack knowledge of mental disorders and mental health care. In contrast, those with higher levels of education are unwilling to seek help for their mental health problems because they would fear a real or perceived loss of social status.
As for the mean number of visits in the past year and the percentage of those receiving minimally adequate treatment from professionals, the present study cannot provide specific Japanese features because of the small sample size. The on-going WMHJ Survey will replicate and expand on the present findings.
The World Mental Health Japan Survey 2002–2003 was carried out in conjunction with the World Health Organization World Mental Health (WMH) Survey Initiative (http://www.hcp.med.harvard.edu/wmh/). We thank the coordinating staff members of WMH for their assistance with the instrumentation and their consultation on field procedures. These activities were supported by the United States National Institute of Mental Health (R01MH070884), the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the US Public Health Service (R13-MH066849, R01-MH069864, and R01 DA016558), the Fogarty International Center (FIRCA R01-TW006481), the Pan American Health Organization, Eli Lilly and Company, Ortho-McNeil Pharmaceutical, GlaxoSmithKline, and Bristol-Myers Squibb. The study was supported by grants from the Japan Ministry of Health, Labour, and Welfare. We would like to thank the staff members, Yuko Miyake, PhD, at the National Institute of Mental Health, Japan, and other field coordinators in the WMH Japan 2002–2003 Survey. We also thank the members of WMH services working group.