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Keywords:

  • forensic psychiatry;
  • Japan;
  • Medical Treatment and Supervision Act;
  • mental health;
  • questionnaires

Abstract

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. ACKNOWLEDGMENTS
  7. REFERENCES

Aim:  In Japan, a new comprehensive forensic mental health service was established and enforced in 2005. However, the shortage of psychiatrists dedicated to this service is a problem. Therefore, we investigated the attitudes of general psychiatrists in Japan toward this field in order to develop measures for dealing with this issue.

Methods:  Questionnaires were sent to 3205 psychiatric facilities in Japan in January 2007. The questions explored the experience of the respondents with forensic evaluations; the respondents' recognition of, experience with, and attitude toward the Medical Treatment and Supervision (MTS) Act; and attitudes toward forensic mental health in general.

Results:  The data of 1770 respondents were analyzed in this study. Three main findings were obtained: psychiatrists generally had little experience with criminal responsibility evaluations, and a small percentage of psychiatrists tended to have conducted the majority of these evaluations; although psychiatrists widely recognized the enactment of the MTS Act, they were not sufficiently familiar with the details of the MTS Act; and in spite of a reluctance to address forensic mental health issues, the respondents harbored a general interest in these topics.

Conclusions:  Despite a general interest, general psychiatrists in Japan tend to possess insufficient knowledge of this subspecialty and lack experience in and opportunities to work in this subspecialty. The reluctance of psychiatrists to work in forensic mental health might be partly responsible for this situation. These results suggest that the enrichment of education systems for forensic psychiatry is necessary for the development of forensic psychiatry in Japan.

IN 2004, THE JAPANESE government published a report entitled, ‘Visions for the Reform of Mental Health and Medical Welfare.’ This report reflected a shift in the basic policy regarding the medical treatment and care of patients with mental disorders from treatment in psychiatric hospitals to treatment in the community involving a reduction of approximately 70 000 hospital beds over a period of 10 years. Deinstitutionalization reportedly increases the need for forensic mental health services,1 suggesting that these services should be improved in Japan.

In light of this background and the many forensic problems in psychiatric services, Japan enforced a new law in 2005 called the ‘Act on Medical Care and Treatment for Persons Who Have Caused Serious Cases under the Condition of Insanity’ (the Medical Treatment and Supervision [MTS] Act). The MTS Act provides a hybrid solution that straddles the judicial and medical systems, with the District Court serving as a gatekeeper, composed of a judge and a specially qualified psychiatrist (seishin-hoken-shinpan-in or ‘reviewer’ hereafter). The reviewer is selected from a group of mental health examiners (seishin-hoken-hanteii or ‘examiner’ hereafter) who have completed specialized training concerning the MTS Act. A comprehensive forensic mental health system was subsequently established in Japan as a result of the MTS Act.2–4

Although an urgent need for an increase in forensic mental health services exists, the number of psychiatrists who are dedicated to the forensic mental health service in Japan remains scarce.5 There are three main types of criminal responsibility evaluations in Japan: (i) a preliminary pre-trial evaluation entrusted by a public prosecutor (kan-i-kanntei); (ii) a standard pre-trial evaluation entrusted by a public prosecutor (shokutaku-kanntei); and (iii) a public trial evaluation ordered by a judge (kouhann-kanntei). Preliminary pre-trial evaluations are usually completed after an interview that typically requires a few hours to complete, whereas the other two evaluations require a few months to complete and are regarded as formal criminal responsibility evaluations. Criminal responsibility evaluations have traditionally been considered the most important focus of forensic psychiatry in Japan6 and are the procedural starting point for the MTS Act. However, the number and demographic characteristics of psychiatrists qualified to perform such evaluations have not been studied.

As part of the new law, an internal panel of the District Court orders psychiatric evaluations for medical necessity following the public prosecutor's decision not to proceed with prosecution by reason of insanity or diminished responsibility. These evaluations and assessments are performed with the aim of determining whether involuntary inpatient care in a designated inpatient facility or compulsory outpatient management at a designated outpatient facility is needed. Until now, few studies have investigated the attitudes of Japanese general psychiatrists toward forensic mental health services, including this new law. Therefore, we investigated the experiences and attitudes of general psychiatrists toward forensic mental health services in Japan.

METHODS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. ACKNOWLEDGMENTS
  7. REFERENCES

Procedure

The two-page, four-section questionnaire containing a total of 22 questions was mailed to 3205 Japanese psychiatric facilities in January 2007. Psychiatric facilities include hospitals with a psychiatry department, mental clinics, and prefectural mental health and welfare centers. No questionnaires were sent directly to individuals so that the psychiatrists received the questionnaires through the facilities where they worked. The respondents to this survey were general psychiatrists in Japan. The three main sections of the questionnaire asked about: (i) the experience of the respondent with criminal responsibility evaluations; (ii) the respondent's knowledge of and involvement with the MTS Act; and (iii) the respondent's general perspective on forensic psychiatry. The questionnaire also contained a section collecting demographic and background information. The protocol for the present research project conforms to the provisions of the 1995 Declaration of Helsinki (revised in Edinburgh, 2000).

The contents of each main section are as follows. The first section asked the respondents for their experience with criminal responsibility evaluations. The number of cases for each type of criminal responsibility evaluation that respondents had either performed or assisted with to date was requested. The second section asked the respondents about their knowledge of the MTS Act. A rating scale ranging from 1 (do not know) to 4 (definitely familiar) was provided for several statements. Specifically, questions included whether they regarded themselves as a qualified examiner (a specially qualified psychiatrist of the MTS Act), the number of psychiatric evaluations or reviews under the MTS Act they had performed, and their level of interest and eagerness to take the position of the reviewer under the MTS Act. The third section asked the respondents for their general attitude towards forensic psychiatry. In this survey, ‘forensic psychiatry’ was defined as ‘the interdisciplinary field joining psychiatric and judicial systems.’ Respondents were asked to answer questions regarding their general attitudes toward forensic psychiatry. In addition, respondents were asked to select possible educational formats that they were interested in using (workshop, case conference, video, textbook, and nothing in particular).

Participants

A summary of the demographic data of participants is shown in Table 1. Of the total questionnaires that were distributed, 1852 were returned. Respondents (n = 82) who were uncertain whether they qualified as an examiner were excluded from this study. Thus, the number of responses analyzed in this study (n = 1770) accounts for 14.2% of all the registered psychiatrists in Japan (n = 12 474).7 Of the total respondents, 17.7% (n = 313) reported that they were qualified as examiners, and this number accounts for 35.8% of all the qualified examiners in Japan (n = 875).8 Of the total respondents, 82.3% (n = 1457) were not qualified as examiners (non-examiner). The mean age and years of psychiatry practice of the examiners were greater than those of the non-examiners. The percentage of male non-examiners was significantly lower than the percentage of male examiners.

Table 1.  Demographic data
 ExaminerNon-examinerTotalP-value
  • **

    P < 0.001 according to Student's t-test or χ2-test.

  • Examiner, mental health examiner designated by the Medical Treatment and Supervision Act.

Number313 (17.7%)1457 (82.3%)1770 (100%)
Age (years ± SD)51.5 ± 9.347.2 ± 12.747.9 ± 12.3<0.001**
Years practicing psychiatry (years ± SD)23.9 ± 9.319.0 ± 12.719.8 ± 12.2<0.001**
Female/male (%)6.5/93.516.4/83.614.6/85.4<0.001**

Statistical analysis

The statistical analysis was performed using pasw Statistics 18 (spss Inc., Chicago, IL, USA). Statistical differences were determined using χ2-test for independence, two-sided Student's t-test, or Mann–Whitney U-test. Values of P < 0.05 were considered significant.

RESULTS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. ACKNOWLEDGMENTS
  7. REFERENCES

Experiences with criminal responsibility evaluations

The respondents' experiences with the evaluation of criminal responsibility are compared in Table 2. Among the total respondents, the rates of inexperience were over 60% for all types of evaluations. The examiners were significantly higher in the levels of experience with all types of evaluations than the non-examiners. These results revealed that the examiners had more experience performing all types of forensic evaluations, compared with the non-examiners. However, many of the examiners had minimal experience performing actual evaluations. In fact, more than 40% of the examiners had not conducted and approximately 80% had experience with fewer than 10 cases of all types. Approximately 70% of the non-examiners had performed no such evaluations, and about 90% had conducted fewer than 10 evaluations. Among all the examiners, 17.0% had experience only performing preliminary pre-trial evaluations, 49.3% had experience performing formal criminal responsibility evaluations (standard pre-trial or public trial evaluations), and 33.7% did not have any experience performing evaluations. Among the non-examiners, 12.0% had experience only performing preliminary pre-trial evaluations, 15.0% had experience performing formal criminal responsibility evaluations, and 73.0% did not have any experience performing evaluations (P < 0.001).

Table 2.  Percentages of respondents (examiner, non-examiner and total) by number of experienced cases (0 to 41+) in criminal responsibility evaluations
 nNumber of experienced casesP-value
01–55–1011–1516–2021–2526–3031–3536–4041+
  • **

    P < 0.001 according to Mann–Whitney U-test.

  • There are three main types of criminal responsibility evaluations in Japan: (i) a preliminary pre-trial evaluation entrusted by a public prosecutor; (ii) a standard pre-trial evaluation entrusted by a public prosecutor; and (iii) a public trial evaluation ordered by a judge. Assistant is an assistant of criminal responsibility evaluation.

  • Examiner, mental health examiner designated by the Medical Treatment and Supervision Act; n, the number of respondents.

Preliminary pre-trial evaluation            
 Examiner29242.127.79.23.13.81.42.41.41.07.9<0.001**
 Non-examiner135671.719.04.61.80.90.40.40.10.10.9
 Total164866.420.55.52.11.40.60.70.40.32.1
Standard pre-trial evaluation            
 Examiner27862.623.76.82.22.20.70.70.00.40.7<0.001**
 Non-examiner128587.011.40.90.50.10.20.00.00.00.1
 Total156382.713.61.90.80.40.30.10.00.10.2
Public trial evaluation            
 Examiner28558.633.03.93.20.00.40.40.00.40.4<0.001**
 Non-examiner131686.611.11.40.30.40.10.00.00.00.1
 Total160181.615.01.90.80.30.10.10.00.10.1
Assistant            
 Examiner28056.441.80.70.00.00.40.00.40.00.4<0.001**
 Non-examiner133577.221.31.00.20.10.10.00.10.00.0
 Total161573.624.90.90.20.10.20.00.10.00.1

Knowledge of and attitude towards the MTS Act

Table 3 shows the recognition levels of the respondents regarding the MTS Act. Of all the examiners, over 90% responded as ‘definitely familiar’ or ‘slightly familiar’ to all the questions. Among the non-examiners, 47.8% recognized the approval and enforcement of the MTS Act as ‘definitely familiar’ (Table 3a). As for the remaining questions, only about 20% of the non-examiners responded as ‘definitely familiar’ (Tables 3b–e).

Table 3.  Recognition of the MTS Act
 Definitely familiarSlightly familiarNot familiarDo not knowP-value
  • **

    P < 0.001 according to χ2-test.

  • Within the MTS Act, the District Court orders admission for psychiatric evaluations, and these evaluations and assessments are performed with the aim of determining whether involuntary inpatient care at a designated inpatient facility or compulsory outpatient management at a designated outpatient facility is warranted.

  • All numbers are percentages.

  • Examiner, mental health examiner designated by the MTS Act; MTS Act, Medical Treatment and Supervision Act.

a. Approval and enforcement of the MTS Act
Examiner86.913.100<0.001**
Non-examiner47.838.89.43.9 
Total54.834.37.83.2 
b. System under the MTS Act
Examiner76.024.000<0.001**
Non-examiner22.748.522.36.5 
Total32.144.218.45.3 
c. Admission for psychiatric evaluation
Examiner76.021.71.90.3<0.001**
Non-examiner22.544.825.67.0 
Total32.040.721.45.8 
d. Designated inpatient facility
Examiner70.026.82.60.6<0.001**
Non-examiner23.144.424.48.1 
Total31.441.320.56.8 
e. Designated outpatient facility
Examiner68.428.42.60.6<0.001**
Non-examiner21.340.128.79.9 
Total29.638.024.08.3 

Among the examiners, 51.1% (160 of 313 respondents) had experience performing psychiatric evaluations or reviews under the MTS. The percentage (34.8%, 109 of 313 respondents) of the examiners who had conducted a psychiatric evaluation under the MTS was significantly higher than that (1.5%, 21 of 1441 respondents) of the non-examiners who had assisted a psychiatric evaluation under the MTS (χ2(1) = 417.20, P < 0.001). The percentage of respondents who answered that they wanted to conduct a psychiatric evaluation was significantly higher in the examiners (33.7%, 105 of 312 respondents) than the non-examiners (9.6%, 138 of 1437 respondents) (χ2(1) = 123.94, P < 0.001). The percentage (59.3%, 64 of 108 respondents) of the examiners who had conducted a psychiatric evaluation under the MTS and answered that they wanted to conduct a psychiatric evaluation was significantly higher than that (42.9%, 9 of 21 respondents) of the non-examiners who had assisted a psychiatric evaluation under the MTS and answered that they wanted to conduct a psychiatric evaluation (χ2(1) = 1.93, P = 0.165). Actually, in the examiners, 38.8% (121 of 312 respondents) had experience acting as a reviewer. The percentage of respondents who expressed a desire to serve as a reviewer was significantly higher in the examiners (38.4%, 119 of 310 respondents) than the non-examiners (9.2%, 132 of 1432 respondents) (χ2(1) = 175.81, P < 0.001). The percentage (57.9%, 70 of 121 respondents) of the examiners who had served as a reviewer and answered that they wanted to serve as a reviewer was significantly higher than that (25.9%, 49 of 189 respondents) of the examiners who had not served as a reviewer and answered that they wanted to serve as a reviewer (χ2(1) = 31.79, P < 0.001).

General perspectives on forensic psychiatry

Of the total respondents, 69.0% (1215 of 1760 respondents) were interested in forensic psychiatry to some extent, but only 27.5% (480 of 1747 respondents) were willing to work in the field of forensic psychiatry. The percentage of respondents who were interested in forensic psychiatry was significantly higher in the examiners (86.7%, 267 of 308 respondents) than the non-examiners (65.3%, 948 of 1452 respondents) (χ2(1) = 54.43, P < 0.001). The percentage of respondents who had participated in a seminar or academic conference on forensic psychiatry was significantly higher in the examiners (62.3%, 195 of 313 respondents) than the non-examiners (19.0%, 277 of 1456 respondents) (χ2(1) = 246.63, P < 0.001). The percentage of respondents who answered that they were involved in forensic mental health was significantly higher in the examiners (43.2%, 130 of 301 respondents) than the non-examiners (8.0%, 116 of 1450 respondents) (χ2(1) = 255.61 P < 0.001). The percentage of respondents who were willing to work in the field of forensic psychiatry was significantly higher in the examiners (45.5%, 140 of 308 respondents) than the non-examiners (23.6%, 340 of 1439 respondents) (χ2(1) = 60.66, P < 0.001). Furthermore, of the total respondents, 60.7% (1067 of 1758 respondents) were interested in participating in a seminar on forensic evaluation. The percentage of respondents who answered that they wanted to participate in a seminar on forensic evaluation was significantly higher in the examiners (78.5%, 244 of 311 respondents) than the non-examiners (56.9%, 823 of 1447 respondents) of (χ2(1) = 49.97, P < 0.001). In the respondents who had conducted or assisted a psychiatric evaluation under the MTS, the percentage (95.9%, 70 of 73 respondents) of the respondents who wanted to conduct further psychiatric evaluations as part of the MTS Act and answered that they wanted to participate in a seminar was significantly higher than that (80.0%, 44 of 55 respondents) of the respondents who did not want to conduct an evaluation and answered that they wanted to participate in a seminar (χ2(1) = 149.74, P < 0.001). In the examiners who had served as a reviewer, the percentage (94.2%, 65 of 69 respondents) of the examiners who wanted to serve again as a reviewer as part of the MTS Act and answered that they wanted to participate in a seminar was significantly higher than that (81.6%, 40 of 49 respondents) of the examiners who did not want to serve as a reviewer and answered that they wanted to participate in a seminar (χ2(1) = 4.62, P < 0.05).

Table 4 summarizes the results regarding the desired education items for forensic psychiatry. Higher percentages of respondents selected workshops and case conferences, rather than videos and textbooks, as the desired education items for forensic psychiatry. Furthermore, the percentages of the examiners who selected workshops and case conferences were significantly greater than those of the non-examiners who selected these items.

Table 4.  Desired education items for forensic psychiatry
 SelectedNot selectedP-value
  • *

    P < 0.05,

  • **

    P < 0.001 according to χ2-test.

  • All numbers are percentages. Psychiatrists were asked to choose multiple items.

  • Examiner, mental health examiner designated by the Medical Treatment and Supervision Act.

Workshops   
 Examiner71.928.1<0.001**
 Non-examiner59.840.2 
 Total61.938.1 
Case conferences   
 Examiner80.519.5<0.001**
 Non-examiner66.133.9 
 Total68.631.4 
Videos   
 Examiner24.375.70.057
 Non-examiner29.670.4 
 Total28.771.3 
Textbooks   
 Examiner28.471.60.158
 Non-examiner32.567.5 
 Total31.868.2 
Nothing in particular   
 Examiner4.595.50.010*
 Non-examiner8.991.1 
 Total8.191.9 

DISCUSSION

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. ACKNOWLEDGMENTS
  7. REFERENCES

Experiences with criminal responsibility evaluations

The results clearly showed that most psychiatrists lack sufficient experience performing criminal responsibility evaluations (Table 2). On the other hand, a small proportion of psychiatrists had performed a considerable number of forensic evaluations. This result is consistent with those of previous reports.9–12 Therefore, the majority of psychiatrists have little or no experience performing forensic evaluations. That is, there is a possibility that some examiners conduct psychiatric evaluations under the MTS Act with little or no experience performing forensic evaluations. Those with little experience might feel uncomfortable with conducting forensic evaluations as they do not have enough knowledge. This could be one reason why even examiners are reluctant to perform evaluations under the MTS Act.

Knowledge of and attitude towards the MTS Act

The results showed that although the non-examiners were generally aware of the approval and enforcement of the MTS Act, they were rather unfamiliar with the details of the MTS Act (Table 3). One reason for this unfamiliarity is assumed to be that the non-examiners have had less opportunity to study the MTS Act systematically, compared with the examiners. Basic knowledge of the treatment of offenders with mental disorders is indispensable not only for forensic psychiatrists, but also for general psychiatrists. According to reports from other countries, the need for forensic mental health services increases after deinstitutionalization.1 Therefore, expanding the opportunities for general psychiatrists to study the MTS Act is important.

In particular, the percentage of non-examiners who answered that they wanted to participate in performing psychiatric evaluations or to serve as a reviewer was less than 10%. Among the examiners who had conducted a psychiatric evaluation or had served as a reviewer, about 60% answered that they wanted to conduct further psychiatric evaluations or to serve as a reviewer again. These findings suggest that many psychiatrists do not wish to be involved with the MTS Act, but that once they conduct a psychiatric evaluation or serve as a reviewer, they tend to become willing to commit themselves to the service.

Few studies have examined the stress associated with working in the field of forensic mental health.13 A previous report has suggested that knowledge regarding the MTS Act and motivation to perform evaluations under the MTS Act are closely related.5 Professional education regarding the management of offenders with mental disorders has not yet spread widely throughout Japan.6,14,15 Thus, increasing the opportunity for general psychiatrists who are interested in this field to acquire the more sophisticated skills needed to perform forensic evaluations is of great importance for improving the reliability of forensic evaluations.

General perspectives on forensic psychiatry

The results indicated that the examiners were more interested in forensic psychiatry than the non-examiners. The results also suggested that the examiners were more interested in acquiring practical skills in forensic psychiatry, rather than learning about basic concepts (Table 4). However, even among the examiners, less than half of the respondents were willing to work in the field of forensic psychiatry.

On the other hand, more than 60% of the respondents wished to participate in a seminar on forensic evaluation. Among the respondents who wanted to conduct an evaluation or to serve as a reviewer, more than 90% responded that they wanted to participate in a seminar. Similarly, among the respondents who did not wish to conduct an evaluation or to serve as a reviewer, more than 80% answered that they wished to participate in a seminar. These results suggested that many psychiatrists were interested in obtaining practical knowledge regarding forensic psychiatry, and that the respondents who actually had some experience in forensic psychiatry recognized the importance of attending seminars and workshops. Among the respondents who did not wish to work in the field of forensic psychiatry, many respondents wanted to attend a seminar or workshop. This finding might indicate that these respondents were unwilling to work in the field of forensic psychiatry not because they were merely busy, but because they had not had the opportunity to learn about forensic psychiatry.

Up until now, training for performing psychiatric evaluations has only been conducted at some universities or hospitals in Japan. This educational situation is likely responsible for the small number of psychiatrists who have conducted numerous forensic evaluations, as shown in this study. Many psychiatrists interested in forensic psychiatry may not be able to receive the necessary education and training required to perform psychiatric evaluations. After all, the population of psychiatrists who participates in performing psychiatric evaluations has not increased. Given the new situation regarding forensic mental health and the new medical treatment policies that have been initiated, there is an immediate need for an increase in the number of psychiatrists capable of working in the field of forensic mental health. Furthermore, as many former inpatients must now live within the community, more psychiatrists are needed. The present study suggests that there are a large number of general psychiatrists who could potentially serve in forensic mental health in the future once nationwide educational programs, such as post-graduate education, are established. The Japanese Society for Forensic Mental Health (JSFMH), founded in 2005, established a committee in 2009 to plan training and education programs in forensic psychiatry. Additional study is also needed to optimize educational programs and to establish a protocol for certification in forensic psychiatry.

Study limitations

The respondents in this study accounted for about 14% of all the psychiatrists in Japan and may not have been representative of this population. Furthermore, psychiatrists who were not interested in forensic psychiatry might have been less inclined to respond to this survey. The present results cannot be directly generalized to the population of psychiatrists in Japan.

ACKNOWLEDGMENTS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. ACKNOWLEDGMENTS
  7. REFERENCES

The authors are grateful to all the respondents. This study was supported by a Grant-in-Aid for Scientific Research from the Ministry of Health, Labor and Welfare of Japan.

REFERENCES

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. ACKNOWLEDGMENTS
  7. REFERENCES
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