Characteristics of the names of diseases used in documents from 2000 or earlier
In 2000 or earlier, terms used to represent ‘schizophrenia’ (seishin-bunretsu-byo) differed between official and private documents (Fig. 1). The term ‘schizophrenia’ (seishin-bunretsu-byo) was used most frequently in official documents, while ‘neurosis’, ‘dysautonomia’, ‘nervous breakdown’, and ‘depressive state’ were used more often than ‘schizophrenia’ in private documents, such as medical and hospitalization certificates submitted to workplaces and insurance companies. To represent the diagnosis of ‘depression’, the terms ‘depressive state’ and ‘depression’ were used in both official and private documents. These findings indicate that it was more difficult for psychiatrists to use the term ‘schizophrenia’ (seishin-bunretsu-byo) than ‘depression’, particularly in private documents.
In 1995, Iwadate et al.7,8 conducted a questionnaire survey that asked Japanese psychiatrists about their use of the names of diseases in documents. They found that, in writing a medical certificate for a disability pension application, 59.1% of the psychiatrists would use the term ‘seishin-bunretsu-byo’ after providing the patient or family members with an explanation and obtaining their consent, 33.6% would use it regardless of the consent of the patient or family members, and 6.4% would not use it as a rule. As many as 53.6% responded that they would not use the disease name on a medical certificate submitted to a workplace, 40.9% would use the term if the people at the workplace were supportive, and 4.5% would use it regardless of the approval of the patient or family members. These findings showed that many psychiatrists were concerned that the use of the disease name ‘seishin-bunretsu-byo’ written in documents to be submitted to workplaces could prove to be a disadvantage to patients.
According to the results of a survey conducted by Linden and Chaskel9 in West Germany in 1981, schizophrenia had the highest proportion of psychiatric patients aware of the name of their disease (52%), followed by ‘nervous breakdown’ (25%). A total of 51% of these patients were informed of the name of their disease by their physicians, and about 30% were notified while completing or reading legal and administrative documents (e.g. documentation necessary for hospitalization, certificates of physical disability, and orders of hospitalization). Other sources of this information included friends, nurses, and books. That study demonstrated that patients might learn about their disease through documents.
In 1992 a study was published on the notification of mental illnesses by Japanese and North American psychiatrists.10 The results demonstrated that more than 90% of the physicians in both groups notified patients with mood and anxiety disorders of their diseases. In schizophrenia and schizophreniform disorder, however, less than 30% of the Japanese psychiatrists informed the patients of their disease, compared to more than 90% of their North American counterparts; instead, the term ‘nervous breakdown’ was used more often in Japan.
In 2000 or earlier, the disease name ‘schizophrenia’ was rarely used in private documents, probably because psychiatrists were afraid of causing their patients social disadvantage and so hesitated in notifying them of the disease.
Names of diseases in documents before and after the adoption of the new Japanese translation for schizophrenia
In both official and private documents, the term ‘togo-shitcho-sho’ (integration disorder) was used more commonly for schizophrenia in 2003 or later than ‘seishin-bunretsu-byo’ (split-mind disease) was in 2000 or earlier (Figs 1,3). According to our survey, the term ‘togo-shitcho-sho’ (integration disorder) was used in all but two official documents completed in 2003 or later. This suggests that a smooth transition to the new Japanese term was achieved within a short period.
Nishimura11 and Ono and Nishimura12 conducted a questionnaire survey involving members of the Japanese Society of Psychiatry and Neurology, to examine changes in the rate of disease notification after the adoption of the new Japanese translation for ‘schizophrenia’. During the period when the term ‘seishin-bunretsu-byo’ was used, 47.6% of psychiatrists responded that they would notify patients of the disease, 33.8% that they would not notify them, and 18.5% that they were undecided.12 Following the adoption of the term ‘togo-shitcho-sho’ to represent ‘schizophrenia’, a survey was conducted in December 2002 (immediately after the adoption), 2003 (1 year later), and 2004 (2 years later). The proportion of psychiatrists who reported that they would notify patients was 36.7%, 65.0%, and 69.7% in these successive years, and the proportion of those who would not notify patients was 44.0%, 21.0%, and 15.2%, respectively.11 As Nishimura et al. pointed out, the use of the new Japanese translation for ‘schizophrenia’ appears to have exerted a significant impact on psychiatrists’ views regarding notification of the disease.
However, these changes in the use of the ‘names of diseases’ in documents are attributable not only to the adoption of new Japanese translations but also to other factors. These include the introduction of an international classification and operational diagnostic criteria in clinical settings, introduction of a comprehensive health care system based on ICD diagnosis (2003),15 and the influences of welfare policies. In 2004, a modification was made to Japanese official documents: a field for an ICD category was added beneath the one for the disease name. Following this, in 2006, the Services and Supports for Persons with Disabilities Act came into effect, requiring psychiatrists to enter ICD-10 codes in all official medical certificates. This situation has made it difficult to enter the names of diseases, particularly in official documents, unless they are based on the ICD diagnosis. These factors have contributed to the increased use of the term ‘depression’ and decreased use of ‘depressive state’ in documents (Figs 2,4).
On the other hand, terms such as ‘nervous breakdown’ and ‘depressive state’ are still commonly used in private documents. Physicians tend to avoid using ‘schizophrenia’ in private documents, including medical certificates and applications for disability benefits submitted to workplaces, for fear of causing social disadvantage. The renaming of schizophrenia in Japan appears to have had some effect in reducing the stigma associated with the disease. However, differences in recognition of schizophrenia among physicians, patients, and society persist, and it is necessary for society as a whole to continue efforts to deepen the understanding of schizophrenia. It will accordingly be important to raise awareness of not only the disease name of schizophrenia but also its symptoms, course, treatment, and medical and welfare systems.
Schizophrenia is one of the most common psychiatric disorders. The adoption of the new Japanese translation for ‘schizophrenia’ in 2002 was an epoch-making event in the history of Japanese psychiatric medicine, 65 years after the original Japanese translation for the term schizophrenia, ‘seishin-bunretsu-byo’, was published in 1937. Revisions of the DSM and the ICD classifications are currently in progress. A marked change in the current diagnostic system may occur in the near future,16,17 thereby facilitating further changes with regard to renaming schizophrenia.18,19 The adoption of the new Japanese translation for ‘schizophrenia’ in 2002 served as a precedent in predicting the resulting impacts on physicians, patients, and society as a whole.20
It is noteworthy that physicians have not used the term ‘neurosis’, which was commonly used until 2000, in documents since 2003. Although DSM-III21 (1980) does not use the exact term, it does contain terminology such as ‘hysterical neurosis’ and ‘obsessive compulsive neurosis’. However, DSM-IV22 (1994) does not use terms that include ‘neurosis’. There appears to be an association between the revision of the DSM and the fact that the term ‘neurosis’ has not been used in documents since 2003. Changes in the use of technical terms for the classification and diagnosis of mental disorders are assumed to have an impact on both physicians and patients.
The present results were obtained at only one hospital, and may not necessarily reflect the general trends in psychiatric wards in Japan. Nonetheless, the method of classifying documents into ‘official documents’ and ‘private documents’ in this study can be considered a meaningful methodology that provides a new perspective in the field of social psychiatry.