Hidden From View.(Brief Article)

Japan's notorious intolerance for mental illness has given rise to a booming industry. Since the 1960s, hundreds of psychiatric hospitals-- the vast majority of them private, for-profit facilities--have sprung up to house "abnormal" people deemed burdensome to society. The majority suffer from schizophrenia and have been institutionalized involuntarily--often at the behest of fearful and uninformed relatives. In the past that meant virtual imprisonment. "In some hospitals, violence and abuse were the norm," says Dr. Yoshiharu Kim, a director at Japan's National Institute of Mental Health. "Japan has a long, sad history of compulsory inpatient treatment."

That legacy lives on despite efforts to reform the system. Japan still boasts six times as many psychiatric beds per capita as the United States and has bucked a global trend toward community-based treatment. Ironically, Japan's recalcitrance is motivated precisely by what caused the United States to release thousands of psychiatric patients in the 1980s: money. Japan so efficiently warehouses its mentally ill that the alternative--intensive hospital treatment for acute patients and outpatient care for the rest--would cost more, at least in the short run, than keeping Japan's huge psychiatric population hospitalized.

To be sure, care has improved dramatically since the passage of Japan's Mental Health Act in 1987. Championed by a new generation of psychiatrists and doctors, the legislation restricted the ability of doctors or families to lock up sick people involuntarily. (Today, 70 percent enter hospitals of their own volition.) But it has thus far failed to spur a broad shift to community-based care.

Upon admission, Japanese psychiatric patients enter a world where the aim is often maintenance, not healing. They are housed, fed and medicated but routinely denied intensive treatment that could make them well because hospitals, which earn a flat fee per patient, can't afford to provide it. Under Japan's nationalized medical system, psychiatric facilities must provide one doctor for every 48 patients--merely a third of the 1 to 16 ratio required for most other fields of medicine. "The existing system promotes long-term care with little service, resulting in institutionalism," says Yasuichiro Yusa, a clinical psychologist at Hasegawa Hospital near Tokyo.

Yusa acknowledges that Japan's approach has merits as well as faults. As a student and practicing psychologist in the United States in the 1980s, he ...