Stigmatized attitudes of medical staff toward people who use drugs and their determinants in Japanese medical facilities specialized in addiction treatment.

AIM: Stigma within healthcare settings significantly impact the lives of people who use drugs (PWUD). Given the lack of quantitative data on stigma toward PWUD in healthcare settings and the unknown factors that contribute to it in the Japanese context, this study aimed to investigate the current status of stigma toward PWUD and its determinants. METHODS: We conducted a survey in five specialized addiction medical facilities across three prefectures in Japan. The survey included questions related to stigmatizing attitudes toward PWUD, knowledge about illicit drug use, and personal and professional interactions with PWUD. RESULTS: A substantial portion of respondents rejected the notion that drug addiction can be overcome through sheer willpower or attributed it solely to moral failings. However, the majority still considered them untrustworthy and viewing drug use as unacceptable and incomprehensible. Many respondents perceived PWUD as dangerous, despite the limited occurrence of hostile behavior from PWUD in clinical practice. A considerable proportion of respondents did not seek support for their own or their relatives' drug-related issues, and less than half had collaborated with recovered PWUD, which serves as potential indicators of reduced stigma. While healthcare professionals recognized that involving law enforcement does not contribute to the recovery of PWUD, a considerable number still believed it was necessary to report them to the authorities. CONCLUSION: Healthcare professionals in specialized addiction medical facilities demonstrate strong stigmatizing attitudes toward PWUD. Comprehensive educational programs and large-scale awareness campaigns are necessary to address and mitigate stigma in this context.

How Do Psychiatrists in Japan Choose Involuntary Admission, and What Do They Think of Supported Decision Making? A Thematic Analysis of Peer to Peer Interviews.

To include people with disabilities as equal citizens, CRPD (Convention on the Rights of Persons with Disabilities) promotes direct or supported decision-making by people with disabilities. However, involuntary psychiatry admission is considered in many countries to be necessary for people with psychosocial disabilities. To overcome the tension and implement CRPD, it is essential to understand the experiences and concerns of service users, family members, and medical professionals in each country. To understand the process and the factors that make psychiatrists decide involuntary psychiatric admission in Japan, and explore their attitudes toward direct or supported decision-making by people with psychosocial disabilities. Psychiatrists who had authorized involuntary admission and who were in charge of the service users were recruited at hospitals in Japan. The interviews were individual, peer to peer, and semi-structured. The interviews were audio-recorded, transcribed verbatim, and the analysis followed reflexive thematic analysis using NVIVO 12. Six psychiatrists (five designated psychiatrists and one psychiatric resident) participated in the study at two hospitals in urban Japan. The study found that the psychiatrists assessed symptoms, behaviors, and perceptions of the service users together with supports and wishes of their families. The psychiatrists decided on involuntary admission when they saw self-harm or violence, weak insights and judgment abilities, family's wishes, or when they wanted to avoid the service users leaving the hospital with incomplete treatment. The psychiatrists felt that the service users would not understand any explanations, which made their communications minimal. The psychiatrists thought it was hard to imagine a system other than the current involuntary admission mechanism. If it was to change, they felt the essential things were to avoid abuse, clarify who is responsible, make plans medically valid and feasible, and assess and plan through everyday life, not just in crisis. During a crisis, the psychiatrists were most careful about complying with the Mental Health Act and responded to the family's wish. The psychiatrists justified involuntary admission as they believed that people in a psychiatric crisis cannot decide or understand and need protection. Related protocols, laws, and expectations from family members shapes the values and practices of psychiatrists in Japan. The paper concludes with several recommendations to regard people with psychosocial disabilities as equal citizens, and promoting the aim of reducing or ending involuntary admission.

Experiences of involuntary psychiatric admission decision-making: a systematic review and meta-synthesis of the perspectives of service users, informal carers, and professionals.

BACKGROUND: In involuntary psychiatric admission, used globally, professionals or caretakers decide upon hospitalization regardless of what the person with psychosocial disabilities decides. This raises clinical, ethical, legal, and human rights concerns, and it goes against Convention on the Rights of Persons with Disabilities (CRPD). CRPD mandates that member states respect the autonomy of people with disabilities. Through Article 12, it recognizes full enjoyment of legal capacity for persons with disabilities. Implementation of Article 12 is challenging in every country, and exploring all the stakeholders' experiences at admission decision-making will help us to understand the challenges that the current psychiatry system poses for service users to exercise their autonomy and identify the areas where service users need support to have their rights, will, and preferences respected. AIM: To describe the experiences of service users, informal carers, and professionals in involuntary psychiatric admission decision-making and throughout the subsequent involuntary admission. We explored the support that the service users need to have their rights, will, and preferences respected. METHOD: A search of twelve databases in medicine, sociology, and law in Danish, English, Japanese, Norwegian, Portuguese, Spanish, and Swedish was conducted in 2017 and 2018, limited to the past 10 years, using terms such as "involuntary," "admission," "mental illness," and "experience". The search identified 682 articles. Four researchers independently reviewed the articles to find those that completed original qualitative or mixed method studies exploring experiences of involuntary psychiatric admission among adults. We added seven publications from the articles' references, contacted experts in the field (no publications were added), and excluded two articles that were in German. Three researchers analyzed the articles' results using Thematic Analysis (PROSPERO registration number CRD42019072874). RESULTS: Overall, 37 articles were included from 11 countries; they involved 731 service users, 100 informal carers, and 291 mental health professionals. We identified a lack of communication and a power imbalance among the stakeholders, which was exacerbated by the professionals' attitudes. At admission decision-making, the service users wanted to be heard and wanted to understand the situation. The families felt responsibility for the service users, they were careful not to ruin relationships, and they struggled to obtain support from the mental health system. Professionals believed that threats or harming others should lead to admission regardless of what the service users or their families felt. Professionals sometimes felt that it was not necessary to explain the information to the service users because they would not understand. Professionals were concerned and frustrated with difficulties in coordinating among themselves. During admission, service users struggled with the ward environment and relationship with staff; they most objected to coercion, such as forced medication. Families were frustrated that they were not involved in the treatment planning, especially as the service users moved toward discharge. The professionals often rationalized that coercion was necessary, and they believed that they knew what was best for the service users. CONCLUSIONS: A lack of communication and a power imbalance among the stakeholders hindered respect for the service users' rights, will, and preferences. This was exacerbated by professionals rationalizing coercion and assuming that service users were incapable of understanding information. Services that encourage communication and overcome power imbalances (e.g. Crisis Plans, Family Group Conferencing) combined with stronger community mental health support will respect service users' rights, will, and preferences and avoid substituted decision-making on issues such as involuntary admission and forced medication.

An end to coercion: rights and decision-making in mental health care.

The United Nations Convention on the Rights of Persons with Disabilities requires a paradigm shift from a medical model of disability to a social model that emphasizes overcoming the barriers to equality created by attitudes, laws, government policies and the social, economic and political environment. The approach adopted by the social model recognizes that people with psychosocial disabilities have the same right to take decisions and make choices as other people, particularly regarding treatment, and have the right to equal recognition before the law. Consequently, direct or supported decision-making should be the norm and there should be no substitute decision-making. Although recent mental health laws in some countries have attempted to realize a rights-based approach to decision-making by reducing coercion, implementing the Convention on the Rights of Persons with Disabilities can be challenging because it requires continuous refinement and the development of alternatives to coercion. This article reviews the impact historical trends and current mental health frameworks have had on the rights affected by the practice of involuntary treatment and describes some legal and organizational initiatives that have been undertaken to promote noncoercive services and supported decision-making. The evidence and examples presented could provide the foundation for developing a context-appropriate approach to implementing supported decision-making in mental health care.

La Convention des Nations Unies relative aux droits des personnes handicapées nécessite un changement radical pour passer d'un modèle médical du handicap à un modèle social mettant l'accent sur la levée des obstacles en matière d'égalité, créés par des attitudes, des lois, des politiques gouvernementales ainsi que l'environnement social, économique et politique. L'approche adoptée par le modèle social reconnaît que les personnes présentant un handicap mental ont le même droit de prendre des décisions et de faire des choix que les autres, notamment en matière de traitement, et ont droit à une reconnaissance égale devant la loi. Par conséquent, la prise de décision directe ou accompagnée doit être la norme et il ne doit exister aucune prise de décision substitutive. Bien que certains pays aient récemment cherché, à travers des lois sur la santé mentale, à instaurer une approche fondée sur les droits en matière de prise de décision en réduisant la coercition, la mise en œuvre de la Convention relative aux droits des personnes handicapées peut poser problème, car elle exige une amélioration continue et l'élaboration de solutions autres que la coercition. Cet article examine l'impact que les tendances historiques et les cadres actuels en matière de santé mentale ont eu sur les droits lésés par la pratique du traitement involontaire et décrit plusieurs initiatives législatives et organisationnelles qui ont été prises pour promouvoir les services non coercitifs et la prise de décision accompagnée. Les données et les exemples présentés peuvent servir de fondement à l'élaboration d'une approche adaptée au contexte pour mettre en place la prise de décision accompagnée en matière de soins de santé mentale.

La Convención de las Naciones Unidas sobre los Derechos de las Personas con Discapacidad requiere un cambio de paradigma, de un modelo médico de discapacidad a un modelo social que haga hincapié en la superación de las barreras a la igualdad creadas por las actitudes, las leyes, las políticas gubernamentales y el entorno social, económico y político. El enfoque adoptado por el modelo social reconoce que las personas con discapacidad psicosocial tienen el mismo derecho a tomar decisiones y a elegir como cualquier otra persona, especialmente en lo que se refiere al tratamiento, y tienen derecho a un reconocimiento igualitario ante la ley. Por lo tanto, la toma de decisiones directa o apoyada debería ser la norma y no debería haber un responsable sustituto de la toma de decisiones. Aunque las recientes leyes sobre salud mental de algunos países han tratado de aplicar un enfoque basado en los derechos para la adopción de decisiones mediante la reducción de la coerción, la implementación de la Convención sobre los Derechos de las Personas con Discapacidad puede ser un reto, ya que requiere un continuo perfeccionamiento y el desarrollo de alternativas a la coerción. Este artículo evalúa el impacto que las tendencias históricas y los marcos actuales de salud mental han tenido sobre los derechos afectados por la práctica del tratamiento involuntario y describe algunas iniciativas legales y organizativas que se han emprendido para promover servicios no coercitivos y apoyar la toma de decisiones. La evidencia y los ejemplos presentados podrían servir de base para desarrollar un enfoque apropiado al contexto para la implementación de la toma de decisiones apoyada en la atención de la salud mental.

Comparison of characteristics of suicide attempters with schizophrenia spectrum disorders and those with mood disorders in Japan.

Suicidality in patients with schizophrenia is high. To clarify the characteristics of suicidal behavior in patients with schizophrenia, we investigated suicide attempters with schizophrenia spectrum disorders in comparison with patients with mood disorders. One hundred patients with schizophrenia spectrum disorders and 155 patients with mood disorders admitted to an emergency department after a suicide attempt were interviewed in detail on items concerning 1) demographic characteristics, 2) previous suicidal behavior, and 3) index suicidal behavior. Differences between the two groups were subsequently analyzed. Patients with schizophrenia spectrum disorders showed a lower incidence of previous deliberate self-harm, and a higher incidence of a subsequent suicide attempt more than 1 year after the previous suicide attempt as well as a higher lethality of index suicide attempt compared to patients with mood disorders. Furthermore, the most common motive for making a suicide attempt in patients with schizophrenia spectrum disorders was having a mental problem. This study revealed the factors associated with suicide attempts among Japanese patients with schizophrenia spectrum disorders, and the nature of these factors makes it difficult to predict future attempts. This makes clear the importance of continuous long-term follow-up with careful attention to the mental symptoms and psychological burden for such patients.

Attitude of young psychiatrists toward coercive measures in psychiatry: a case vignette study in Japan.

BACKGROUND: 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 to treat agitated patients. In this study, we investigated young psychiatrists' attitudes toward psychiatric coercive measures. METHODS: A total of 183 young psychiatrists participated as subjects in our study. A questionnaire with a case vignette describing a patient with acute psychosis was sent to the study subjects via the Internet or by mail. This questionnaire included scoring the necessity for hospitalization, and the likelihood of prescribing seclusion and/or restraint, on a 9-point Likert scale (with 9 indicating strong agreement). RESULTS: There was general agreement among the study subjects that the case should be admitted to a hospital (8.91 +/- 0.3) and secluded (8.43 +/- 1.0). The estimated length of hospitalization was 13.53 +/- 6.4 weeks. Regarding the likelihood of prescribing restraint, results showed great diversity (5.14 +/- 2.5 on 9-point scale); psychiatrists working at general hospitals scored significantly higher (6.25 +/- 2.5) than those working at university hospitals (5.02 +/- 2.3) or psychiatric hospitals (4.15 +/- 2.6). A two-group comparison of the length of inpatient care revealed a significant difference between those psychiatrists who scored 1-3 (n = 55, 14.22 +/- 7.4 wks) and those who scored 7-9 (n = 62, 12.22 +/- 4.0) regarding the need to use restraint. CONCLUSION: Our results may reflect the current dilemma in Japanese psychiatry wherein psychiatrists must initiate coercive measures to shorten hospitalization stays. This study prompted its subject psychiatrists to consider coercive psychiatric treatments.

Japan Young Psychiatrists Organization (JYPO) welcomes participants from overseas to the Course for Academic Development of Psychiatrists (CADP).

Japan Young Psychiatrists Organization was founded in 2002. The Course for Academic Development of Psychiatrists (CADP) held in 2001 was the momentum to establish JYPO. CADP is the course designed by Professor N. Sartorius for the purpose of developing professional and leadership skills of young psychiatrists. From then, JYPO have continued to hold CADP annually. Now we JYPO welcome the participants of CADP from overseas. We aim to introduce the detailed contents of CADP to the Asian colleague and encourage them to participate in CADP.