Department of Mental Health, Tokyo University Graduate School of Medicine, Tokyo
College of Social Welfare, Osaka Prefecture University, Osaka
Miyagi Prefecture Natori Hospital, Natori, Japan
Correspondence: Dr Iwao Oshima, Department of Mental Health, Tokyo University Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan. Tel: 3 5841 3612; fax: 3 5841 3392; 58 e-mail: i-oshima{at}aurora.dti.ne.jp
Funding detailed in Acknowledgements.
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Aims To describe the current situation of psychiatric hospitals in Japan and to examine the relationship between negative symptoms of schizophrenia and social environments.
Method In-patients with schizophrenia were randomly selected from 139 hospitals. Data were obtained for 2758 participants using several scales, including the Manchester Scale and social environment scales.
Results Negative symptom scales showed a significant correlation with understimulating social environments in hospitals.
Conclusions This study confirms the results from the UK and provides evidence for the importance of community-based care and for providing more-stimulating rehabilitation environments.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Mental health care in Japan
Although many Western countries over the past two or three decades have
been trying to establish more-appropriate community mental health policies for
people with severe mental illness and have gradually decreased the number of
psychiatric beds (Leff, 1993;
Salokangas & Saarinen,
1998; Lamb & Weinberger,
2001), few attempts at deinstitutionalisation have been made in
Japan. In fact, the number of psychiatric beds had been on the rise until
recent years (Mino et al,
1990; Oshima et al,
2002). The number of psychiatric beds per 100 000 persons in 1998
was 284, which was the highest ratio in the world
(Fig. 1). In addition,
conditions within psychiatric hospitals in Japan are severe, as we describe
below. Nevertheless, serious discussion about possible plans to establish
community care programmes as a substitute for psychiatric in-patient care has
just begun.
|
The characteristics of the psychiatric inpatient population and psychiatric hospitals listed here are derived from data provided by Japans Ministry of Health and Welfare (1999) and the Zenkaren Health and Welfare Research Institute (2000). In Japan, 71% of psychiatric inpatients remain in hospital for 1 year or longer and the average length of stay is 8.5 years. In addition, there has been a gradual ageing of in-patients, with 29.5% of patients being over the age of 65 years and 64.6% over the age of 50 years. The percentage of involuntary admission cases is no less than 32%, whereas that of unlocked wards is only 40%. The in-patient wards are very restrictive environments. Specifically, in a nationwide survey, we found that the quality of life within psychiatric hospitals is much poorer than that in sheltered accommodation under the Livelihood Protection Law, which was enacted to ensure a minimum level of quality of life in Japan (Zenkaren Health and Welfare Research Institute, 1994; Oshima et al, 1996).
On the other hand, progress has been made since the mid-1980s in community mental health policy. Social rehabilitation facilities in line with the new mental health law, amended in 1987, have been established in several districts across Japan. Recently, various types of community mental health programmes have been put in place, although the provisions allocated for these programmes are as yet insufficient.
Nevertheless, such community care programmes have not been effective in solving the problems of long-stay patients in Japan. According to several nationwide surveys, 3060% of patients resident in psychiatric hospitals have been evaluated by psychiatrists as being capable of living within the community, if community support programmes were available (Zenkaren Health and Welfare Research Institute, 1998). Furthermore, approximately 60% of long-stay patients in several nationwide surveys expressed a wish to be discharged from the psychiatric hospital in which they were staying (Zenkaren Health and Welfare Research Institute, 1998).
![]() |
METHOD |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
To recruit participants into the study, each hospital made a list of all patients meeting the following criteria: a diagnosis of schizophrenia according to DSMIIIR (American Psychiatric Association, 1987) and a duration of hospital stay of at least 1 year on the day of data collection. Each hospital then sent its list to the investigator, who randomly selected 20 people from each list using patient identification numbers. For six hospitals in which the total number of cases did not reach 20, all cases that satisfied the criteria were selected. Out of the 139 hospitals that participated in this study, we randomly selected 30 patients from 20 hospitals that agreed to participate in more intensive research, the results of which are analysed elsewhere (further details available from the author upon request).
The study by Wing & Brown (1970) considered only women under the age of 60 years; however, we included male and female in-patients of all ages. Moreover, our definition of long-stay was a duration of hospitalisation of 1 year or longer, compared with a criterion of 2 or more years in the original study. Inclusion criteria were also different because the data were collected to answer several distinct research questions in this nationwide survey, such as assessing the needs for community support resources. However, we conducted an additional analysis using the same criteria as Wing & Brown (1970) to compare results (n=714).
A total of 2898 patients fulfilled the inclusion criteria, and 2758 patients (95.2%) agreed to participate. Sample characteristics are as follows: 57.8% of participants were male, and the average age and mean length of stay of all participants were 51.9 years and 13.5 years, respectively. These features are consistent with national statistics in Japan (Ministry of Health and Welfare, 1999). With regard to the features of the participating hospitals, the proportion of public hospitals (39.6%), the mean number of psychiatric beds (309 beds) and the proportion of unlocked wards (46.4%) were all higher than national averages. Other features of the hospitals, such as characteristics of inpatients and proportion of medical staff, are consistent with national data.
Procedure and measures
Two sets of measures were taken. Hospital psychiatrists assessed
psychiatric symptom scales, and nurses caring for the participants provided
information on social environments and clinical conditions other than
psychiatric symptoms. All data except hospital data were collected for each
participant.
Research kits, including the rating scales, questionnaires and research manuals, were sent to the hospitals taking part. Research was conducted according to the manuals at each hospital. Rating scale scores and completed questionnaires were collected by each hospital and returned to the investigator. The survey was conducted during January and February 1995.
Most of the scales and variables used were identical to those used by Wing & Brown (1970). Some were modified to take into account differences between Japanese and British psychiatric hospitals and some specific characteristics of this study. Standardised symptom scales such as the Manchester Scale (see below) were also included.
Clinical condition
Manchester Scale. The Manchester Scale is a five-point symptom
rating scale developed by Krawiecka et al
(1977). For this study, we used
a Japanese version of the scale (Takekawa
et al, 1994): symptoms of chronic mental illness are
evaluated with eight items, sensitive to therapeutic changes and with easily
administered sub-scales. A simplified interview schedule was prepared. Among
the eight items, four (flattened, incongruous affect,
poverty of speech, mute, incoherence and irrelevance of
speech, coherently expressed delusions) were the same as
items on the Symptom Rating Scale (SRS) used by Wing & Brown
(1970) to evaluate the primary
disabilities of schizophrenia. This allowed us to classify patients according
to Wings hierarchical clinical classification based on the SRS
(Wing, 1961;
Krawiecka et al,
1977). Although each item of the Manchester Scale is usually
scored as 04, we converted this to a range of 15, which is the
same scoring as the SRS. The following subgroups were defined by the same
clinical classification as used by Wing
(1961), based on the SRS:
Psychiatrists in charge of the participating patients evaluated this scale.
Ward Behaviour Rating Scale. The Ward Behaviour Rating Scale (WBRS) is a 12-item, three-point rating scale, developed by Wing (1961) to evaluate the primary disabilities of schizophrenia based on nurses daily observation of ward behaviours. It consists of two sub-scales: the Social Withdrawal Score (WBRSSWS), which has eight items scored from 0 to 16, and the Socially Embarrassing Behaviour Score (WBRSSES), consisting of four items scored from 0 to 8. Cronbachs coefficient for each scale was 0.77 and 0.61, respectively. Nurses in charge of the patients evaluated this scale.
Negative attitude to discharge. A single-item scale was developed by Wing & Brown (1970) to evaluate the secondary disabilities of schizophrenia. Psychiatrists interviewed and evaluated the participants using a simplified interview schedule. Anchor points of this scale are: 1, strongly desires to leave hospital; 2, desires to leave hospital in some way; 3, ambivalent or vague; 4, indifferent; 5, wishes to stay. Psychiatrists responsible for the patients evaluated this scale.
Social environment
The social environment scales were evaluated by nurses caring for the
patients.
Personal Possessions Scale. This scale measured the number of personal possessions out of 21 possible items that patients could possess on psychiatric wards in Japan, and that are necessary for daily life. The items were selected from the personal possessions list of Wing & Brown (1970), and modified to take into consideration the situation and culture in psychiatric hospitals in Japan. Cronbachs coefficient was 0.83.
Nurses Opinions about Patients Scale. Nurses evaluated a nine-item scale about patients ability to cope with certain everyday activities and responsibilities. Items were selected from the scale developed by Wing & Brown (1970), and were likewise modified to take into account the situation and culture in Japanese psychiatric hospitals. Cronbachs coefficient was 0.83.
Patients Occupation Scale. This is a single-item scale about recent occupation, contact with the outside world and physical treatment, developed by Wing & Brown (1970). This scale was completed using the questionnaire filled out by nurses about the patients ward behaviour.
Contact with the Outside World Scale. This is a single-item scale developed by Wing & Brown (1970), and was completed using the questionnaire about the patients ward behaviour.
Ward Restrictiveness Scale. This is a 30-item scale, completed by the nurse responsible for each participant, about restrictions on patients movements and their daily life, limiting autonomy and self-determination. Items were selected from the scale developed by Wing & Brown (1970), and also culturally modified. Among them, seven items about objective indices of the wards structure and function were analysed separately. Other items were rated as agree, disagree or could not decide by the nurse. One point was given to each item if it was considered restrictive (agree or disagree, depending on the item). These represented items that could be assessed objectively by the nurses, and were intended to be independent of the symptoms and social functions of the patients. Cronbachs coefficient was 0.86.
Analysis
Wing & Brown (1970)
described the adverse effects of prolonged hospital stay on people with
schizophrenia in terms of primary disabilities (clinical poverty
syndromes and florid symptoms) and secondary disabilities (a negative attitude
to discharge). By means of cross-sectional and longitudinal studies, they
found that a relationship exists between these disabilities and
understimulating social environments as well as length of stay. We aimed to
replicate the results of Wing & Brown in terms of the influence of social
environments and length of stay on clinical poverty syndromes
and negative attitude to discharge through a cross-sectional design.
Wing & Brown (1970) measured clinical poverty syndromes in terms of flatness of affect and poverty of speech using the SRS and the WBRSSWS. They assessed florid symptoms by incoherence of speech and coherently expressed delusions using the SRS and WBRSSES. We also adopted the WBRSSWS and WBRSSES, and four equivalent scales in the Manchester Scale. We defined clinical poverty syndromes as negative symptoms, and florid symptoms as positive symptoms.
First, we compared the proportions of primary and secondary disabilities of long-stay patients in Japan with those in the UK in the 1960s and 1990s (Table 1). We then analysed the influence of social environments and length of stay on these disabilities using correlations and multiple regression analysis with negative symptom scales and negative attitude to discharge as dependent variables (see Table 3). In addition, we used the five social environment scales, and four of these scales (excluding the Nurses Opinions about Patients Scale), as independent variables, and examined multiple correlation coefficients. The reason for excluding the Nurses Opinions about Patients Scale from the analysis was that it was considered to be the most subjective of the five social environment scales, and was also much influenced by poor clinical condition of the participant. We have to consider the possibility that we overestimated the effects of those scales. For the same reason we examined differences between the Ward Restrictiveness Scale and the other four scales, because it was considered to be the most objective and the least influenced by the participants clinical condition.
|
|
All statistical analyses were carried out using the Statistical Package for the Social Sciences, version 9.
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Social environments
Among social environment variables, the current research results that can
be compared with British studies are shown in the lower part of
Table 1. The mean score on the
occupation scale was 3.7, which was lower than the means for all of the
British hospitals, except for Severalls Hospital. On the other hand, the mean
score of contact with the outside world was 6.3, which was almost the same as
in the British studies. The proportions of those allowed to have matches or
lighters and to work outside were evaluated more favourably than those of
British studies.
Table 2 shows the distribution of scores on the social environment scales and variables that were not presented in the British studies. The most notable item of the Ward Restrictiveness Scale was that the proportion of high room occupancy (seven or more patients per ward) was 23%. The proportion of those with three or more prohibited possessions was also over 20%.
|
The mean score of the Nurses Opinions about Patients Scale, shown in the lower part of Table 2, was 6.1, out of a maximum score of 9. The mean score on the Personal Possessions Scale was 8.9, out of a maximum of 21, and that on the Ward Restrictiveness Scale was 14.5, out of a maximum of 35.
Relationship of length of stay to clinical condition
Correlations between clinical condition scales, negative attitude to
discharge and length of stay are shown in the upper part of
Table 3. There were significant
positive correlations between each negative symptom scale and between negative
attitude to discharge and length of stay.
Conducting the same analysis using Wing & Browns (1970) criteria demonstrated that the length of stay had a significant low association with all negative symptom scales (r=0.140.16) and negative attitude to discharge (r=0.25).
Relationship of social environment to clinical condition
The relationships between the clinical condition scales and the social
environment scales are shown in Table
3. A moderate correlation was found for each negative symptom
scale (r=0.410.63). On the other hand, a somewhat weaker
correlation was demonstrated for the three scales of positive symptoms
(r=0.300.42).
Three negative symptom scales and five social environment scales were significantly correlated. In particular, moderate to strong correlations were found for the negative symptom scales with nurses positive opinions about patients and number of personal possessions: coefficients ranged from 0.28 to 0.58 (from 0.30 to 0.54 using the criteria of Wing & Brown (1970)). The correlations with the Ward Restrictiveness Scale, which is considered to be an objective variable, relatively independent of the condition of the patients, were between r=0.13 and r=0.16 (from 0.12 to 0.12 using Wings criteria), which were significant, but did not suggest a particularly strong relationship. Multiple correlation coefficients with the five social environment scales were between 0.41 and 0.62, and those with the four scales excluding Nurses Opinions about Patients were between 0.32 and 0.49.
In contrast, positive symptom scales showed a less consistent relation with social environment scales: coefficients ranged from r=0.04 to r=0.46, R=0.170.47 (r=0.060.46, R=0.170.59, using Wings criteria). Particularly, the coefficients of coherently expressed delusions were smaller than those obtained from the negative symptom scales. However, correlations with incoherence and irrelevance of speech and WBRSSES were similar to those with negative symptom scales.
The negative attitude to discharge as an index of secondary disabilities was positively correlated with flattened, incongruous affect, poverty of speech, mute and WBRSSWS as indices of negative symptoms. However, no significant correlation was found with positive symptom scales except for incoherence and irrelevance of speech. A weak negative correlation was demonstrated with social environment variables, such as nurses positive opinions about patients, personal possessions, contact with the outside world, and patients occupation.
We obtained similar results using the criteria of Wing & Brown (1970).
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Among the measures of positive symptoms that we assessed, coherently expressed delusions correlated most weakly with social environment measures. The equivalent correlations demonstrated for WBRSSES and incoherence and irrelevance of speech were, however, of similar magnitude to those for measures of negative symptoms. One should note, however, that incoherence of thought is reported to correlate highly with negative symptoms (Bilder et al, 1985; Someya, 1990). In terms of the effects of an increase in the length of stay, we found a parallel increase in negative symptoms, and a negative attitude to discharge, whereas positive symptoms, excluding incoherence and irrelevance of speech, showed no such increase. We identified a similar influence of prolonged stay in a psychiatric hospital on the exacerbation of negative symptoms and negative attitude to discharge to that reported by Wing & Brown (1970). Our findings therefore appear to replicate those of Wing & Brown.
With regard to severe social environments, many hospitals in Japan do not provide appropriate social roles for psychiatric in-patients. The Patients Occupation Scale score was noticeably lower than that in the British studies. This raises the concern that although a relatively low proportion of long-stay patients have a negative attitude to discharge and negative symptoms, actual activities promoting the discharge of such in-patients are not encouraged.
Limitations and significance of this study
This research was conducted as a nationwide survey in Japan. The
participating hospitals were those that expressed a positive attitude toward
this project, and were thought to be hospitals with many activities available
to patients. However, we believe that we obtained a relatively representative
sample, because most features of the patients and the hospitals studied are
consistent with the national statistics in Japan.
Our intention of replicating the study reported by Wing & Brown (1970) was difficult to achieve, given that after the significant advances in deinstitutionalisation in Europe and in North America, most people with severe persistent mental illness in those areas receive community care. Therefore, we believe that it is important to have conducted the replication study in Japan, where the problems of institutionalisation are still under discussion (Zenkaren Health and Welfare Research Institute, 1998; Oshima et al, 2002). Notably, we obtained almost the same results using a cross-sectional design and national samples covering over 12% of psychiatric beds in Japan. This nationwide survey had several purposes, such as assessing the need for community support resources. Therefore, we were unable to strictly replicate the study of Wing & Brown (1970); in addition, we did not select the same criteria for samples, nor did we use the exact scales.
Implications
Psychiatric hospitals in Japan have understimulating social environments,
and although the proportions of in-patients with negative symptoms or negative
attitudes to discharge are lower than was found in the British studies
(Wing & Brown, 1970;
Curson, 1992), it is still vital to address these issues within psychiatric
hospitals and to encourage community-based treatment. Patients who do not have
severe symptoms still remain in psychiatric hospitals with poor conditions for
extended periods, since there are few alternatives to hospital-based care.
These individuals should be provided with systematic treatment in the
community, such as assertive community treatment or intensive case management,
which have been proved to be effective in evidence-based practice for people
with severe, persistent mental illness
(Mueser et al, 1998), and with other effective community programmes that have been developed
empirically from deinstitutionalisation and community mental health practices
in Europe and in the USA (Watts &
Bennett, 1991).
![]() |
Clinical Implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
ACKNOWLEDGMENTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Bilder, R. M., Mukherjee, S., Rieder, R. O., et al (1985) Symptomatic and neuropsychological components of defect states. Schizophrenia Bulletin, 11, 409419.[Medline]
Curson, D. A., Pantelis, C.,Ward, J., et al (1992) Institutionalism and schizophrenia 30 years on. Clinical poverty and the social environment in three British mental hospitals in 1960 compared with a fourth in 1990. British Journal of Psychiatry, 160, 230241.[Abstract]
Krawiecka, M., Goldberg, D. & Vaughan, M. (1977) A standardized psychiatric assessment scale for rating chronic psychotic patients. Acta Psychiatrica Scandinavica, 55, 299308.[Medline]
Lamb, H. R. & Weinberger, L. E. (eds) (2001) Institutionalization: Promise and Problems. San Francisco, CA: Jossey-Bass.
Leff, J. (ed.) (1993) The TAPS Project: evaluating community placement of long-stay psychiatric patients. British Journal of Psychiatry, 162 (suppl. 19), 156.[Abstract]
Ministry of Health and Welfare (1999) Patient Survey 1996 [in Japanese]. Tokyo: Statistics and Information Department, MHW.
Mino,Y., Kodera, R. & Bebbington, P. (1990) A comparative study of psychiatric services in Japan and England. British Journal of Psychiatry, 157, 416420.[Abstract]
Mueser, K. T., Bond, G. R., Drake, R. E., et al (1998) Models of community care for severe mental illness: a review of research on case management. Schizophrenia Bulletin, 24, 3774.[Medline]
Oshima, I., Yoshizumi, A., Inazawa, K., et al (1996) Long-stay inpatients expressed needs and hopes about community living after discharge from psychiatric hospitals in Japan: an analysis of a nationwide self-rating survey for long stay schizophrenics in about 40 000 psychiatric beds in Japan [in Japanese]. Japanese Journal of Hospital and Community Psychiatry, 38, 558567.
Oshima, I., Ito, J. & Taira, N. (2002) Need for an integrated program of case management and psychoeducation in long stay psychiatric patients in Japan. In Comprehensive Treatment of Schizophrenia: Linking Neurobehavioral Findings to Psychosocial Approaches (eds H. Kashima, I. R. H. Falloon, M. Mizuno, et al), pp. 196203. Berlin: Springer.
Salokangas, R. K. R. & Saarinen, S. (1998) Deinstitutionalization and schizophrenia in Finland: I. Discharged patients and their care. Schizophrenia Bulletin, 24, 457467.[Medline]
Someya, T. (1990) Independence and validity of negative symptoms [in Japanese]. Japanese Archives of Psychiatric Evaluation, 1, 339347.
Takekawa,Y., Hori, A., Tsunashima, K., et al (1994) Reliability and validity of Japanese version of Manchester Scale [in Japanese]. Seishinigaku, 36, 389394.
Watts, F. N. & Bennett, D. H. (1991) Theory and Practice of Psychiatric Rehabilitation. Chichester: John Wiley & Sons.
Wing, J. K. (1961) A simple and reliable subclassification of chronic schizophrenia. Journal of Mental Science, 107, 862875.
Wing, J. K. & Brown, G. W. (1970) Institutionalism and Schizophrenia. London: Cambridge University Press.
Zenkaren Health and Welfare Research Institute (1994) The Needs of Care and Support of People with Mental Disorders and Their Families (III): A Nationwide Survey of Long-stay Psychiatric Patients in Japan [in Japanese]. Zenkaren Health and Welfare Institute Monograph 7. Tokyo: Zenkaren.
Zenkaren Health and Welfare Research Institute (1998) Research on Institutional Care for Long-term Inpatients in Japan [in Japanese]. Zenkaren Health and Welfare Institute Monograph 15. Tokyo: Zenkaren.
Zenkaren Health and Welfare Research Institute (2000) Current Status of People with Severe Mental Illnesses in Japan: an Analysis of Nationwide Statistics [in Japanese]. Zenkaren Health and Welfare Institute Monograph 26. Tokyo: Zenkaren.
Received for publication October 28, 2002. Revision received January 31, 2003. Accepted for publication February 19, 2003.