Every psychiatrist must pay careful attention to avoid violating human rights when initiating coercive treatments such as seclusion and restraint. However, these interventions are indispensable in clinical psychiatry, and they are often used as strategies in the treatment of agitated patients.
The Mental Hygiene Law was intended to protect the fundamental human rights of people with mental illness and facilitate their rehabilitation within the community. Since enactment of the law in 1950, all psychiatric medical professionals in Japan have been bound to practice psychiatry with careful consideration to avoid infringing upon human rights. There have been certain calls from a humanitarian viewpoint for the abolition of seclusion and restraint. However, in acute psychiatry, these coercive measures can be useful therapeutic strategies to ensure the safety of psychiatric patients [3–7]. In Japan, judgment regarding the necessity for involuntary psychiatric admission is entrusted to designated mental health physicians. The judicial system never becomes involved in this decision-making process. In order to admit a patient for hospitalization to provide medical care and protection, a designated physician obtains written consent from that patient's guardian [11, 14].
Article 29 of the Mental Health and Welfare Law states that if a prefectural governor recognizes that a person who has been examined is diagnosed as mentally disordered and is therefore likely to hurt himself/herself or others unless hospitalized for medical care and protection, the prefectural governor may admit the person to a mental hospital established by the national or prefectural government or a designated hospital. This form of forced hospitalization can be approved only when the person has been examined by at least two designated physicians and the examination results of each physician conclude that the person is mentally disordered and that he or she is likely to hurt himself/herself or others because of a mental disorder unless admitted to a hospital for medical care and protection.
In Japan, there is no uniform residency program in each medical specialty. Instead of standardized training programs, there is a two-tier psychiatric training system in Japan: (1) specialist certification by the Japanese Society of Psychiatry and Neurology; and (2) government designation. To become a designated mental health physician, applicants for designation must have clinical experience exceeding five years, including over three years in general psychiatry. Designated mental health physician candidates must take a three-day course of lectures and submit eight case reports of involuntary hospitalization in six categories: schizophrenia (three case reports including at least one case in which the patient was admitted by a prefectural gubernatorial order, which is the most coercive type of hospitalization), mood disorder, substance abuse, dementia, organic disorders, and child and adolescent mental health. Thus, the main purpose of this designation system is to thoroughly acquaint psychiatrists with the Mental Health Law and authorize psychiatrists to execute various involuntary interventions based on Japan's strict mental health regulations.
According to the results of the present study, the average score ranking the necessity of hospitalization was 8.91 ± 0.3 on the 9-point Likert scale, with 98.9 percent of respondents scoring a 7 or higher. With regard to the form of admission, opinions were nearly divided in half: 42.1 percent responded that hospitalization for medical care and protection would be most likely, whereas 56.8 percent said an involuntary hospitalization ordered by a prefectural governor would be a likely type of admission. In the case vignette used in this study, Mr. A. brandished a kitchen knife and threatened his neighbors. This behavior may be considered to satisfy the legal requirements for involuntary hospitalization. However, in real life situations, hospitalization for medical care and protection, a less coercive measure, is more commonly suggested. The polarization of the respondents' opinions on this point might be attributable to differences in their interpretations of the case vignette.
There was significant diversity among the respondents' estimations of hospitalization length, which ranged from four weeks (n = 4) to one year (n = 1). The majority of respondents suggested twelve weeks (n = 106), with an average of 13.53 ± 6.4 weeks. Two group comparisons between the designated mental health physicians and the non-designated physicians revealed no statistically significant difference between the two groups' estimations of hospitalization length. Further, no correlations were found between the estimated hospitalization length and the likelihood of prescribing restraint, nor were correlations discovered between the estimated hospitalization length and the length of physicians' psychiatric experience. However, the two group comparisons between psychiatrists who favored restraint and those who opposed it revealed that those practitioners who favored restraint suggested a significantly shorter hospitalization length than those who opposed restraint. We cannot provide a clear explanation for this result. The result might indicate that restraint is considered an outcome of treatments that target earlier improvement in the manifestation of psychiatric symptoms. Hoge et al. reported that most episodes of refusal to take antipsychotic medication by consumers ended with voluntary acceptance of treatment [15]. However, it takes time to persuade patients to take oral medication and often requires additional staff. To ensure minimum coerciveness in psychiatric practice, we need additional studies to explore those factors affecting psychiatrists' decisions about initiating coercive measures.
Psychiatrists in other countries may consider a three-month hospitalization to be somewhat excessively long. However, it is noteworthy that Japan has been criticized for its lengthy hospitalization periods for schizophrenic patients [11]. When considering this national mental health care backdrop, the three-month hospitalization suggested in this study certainly reflects the recent improvements in Japanese psychiatrists' awareness about shortening hospital stay durations. In the treatment case presented, the patient lives alone and has no prior history of psychotic episodes. Unfortunately, Japan still suffers from a lack of social resources enabling people with mental disorders to live within their communities. Further measures are needed to shorten the length of hospital stays.
For employing seclusion versus restraint, the score for the likelihood of prescribing seclusion showed a high concurrence rate among the respondents, with an average of 8.43 ± 1.0 on a 9-point scale. Alternatively, the score for the likelihood of prescribing restraint ranged from 1 to 9, with an average of 5.14 ± 2.5. In Japan, seclusion in a room with a certain amount of space and equipped with a bathroom is considered less restrictive than restraint. At a previously held international workshop on seclusion and restraint that we organized, we realized through discussions with psychiatrists from other countries that cultural backgrounds would influence psychiatrists' opinions about behavioral restrictions [16]. For instance, when the Czech Republic became a target of criticism because of their use of a cage bed--a bed surrounded by a metal cage used to restrain a patient--the Czechs explained that in the Czech Republic the use of a "net bed" was considered more humane than other restraint techniques, such as straps, isolation rooms, or even strong medication. It is important to understand that differences in psychiatric opinions may be due to differences between cultural backgrounds [17].
When comparing scores for estimated hospitalization lengths, according to the types of hospitals where physicians work, those who work at general hospitals suggested a significantly longer period than those who work at university hospitals or psychiatric hospitals. One reason for this result could be explained by the psychiatric departments in most general hospitals being understaffed while having a higher percentage of patients requiring restraint, for example, people who are sent to the emergency room with an altered level of consciousness or delirium patients with comorbid physical conditions. Another reason could be that there are increasing numbers of patients with behavioral and psychological symptoms of dementia (BPSD) resulting from the rapid aging of the Japanese population. Yet another reason for expecting a longer hospitalization period at general hospitals might be the nurses' working environment. It has been reported that training nurses is effective in decreasing the number of behavioral restrictions at hospitals [18, 19]. However, certain nursing system characteristics in the psychiatric wards of many general hospitals could be hindering this effect. For instance, nurses in general hospitals are routinely transferred to different wards after a certain period of time and therefore are likely to be less experienced, tending to resign sooner because of their workload.
As for limitations of this survey, the questionnaire was sent to the subjects with a brief description of an imaginary case rather than a real patient. The subjects of this study represent only a subset of psychiatrist in Japan. The latest data provided by the Japanese Ministry of Health, Labor and Welfare reports that the total number of psychiatrists was 12,474, accounting for 4.49% of all medical doctors in 2006 (on-line database of JMHLW; http://www.mhlw.go.jp/toukei/). The number of doctors under the age of 40 was 93,409 in 2006. Considering these data, we estimated the number of young psychiatrists as 4,194. Thus, the subjects of this study account for 4.36% of all young Japanese psychiatrists. Similarly, the number of designated physicians for mental health was 11,791 in 2006. Our sample included only 0.5% of those designated physicians, indicating limited representation. In regard to the 9-point scale used in this study, a 5 score indicates neither agreement nor disagreement on a 9-point Likert scale (with 9 being the highest possible score) and the significance of the deviation from the mean of 5 remains controversial. Therefore, it is difficult for us to draw firm conclusions.
