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Psychiatry and Clinical Neurosciences 2013; 67: 471482 doi:10.1111/pcn.

12086

Review Article

Review of mental-health-related stigma in Japan


Shuntaro Ando, MD, MScPH,1,3* Sosei Yamaguchi, PhD,2 Yuta Aoki, MD3,4 and
Graham Thornicroft, MD, PhD5
1
Department of Psychiatry and Behavioral Sciences, Tokyo Metropolitan Institute of Medical Science, 2Department of
Psychiatric Rehabilitation, National Institute of Mental Health, National Center of Neurology and Psychiatry, 3Department
of Neuropsychiatry, Graduate School of Medicine, The University of Tokyo, 4Department of Psychiatry, Tokyo Metropolitan
Health and Medical Treatment Corporation, Ebara Hospital, Tokyo, Japan, and 5Health Service and Population Research
Department, Kings College London, Institute of Psychiatry, London, UK

The aim of this study is to understand the nature contact between health professionals and individuals
and characteristics of mental-health-related stigma with mental illness and less stigmatization by these
among Japanese people. We searched relevant studies professionals. Less stigmatization by mental health
in English or Japanese published since 2001 using professionals may be associated with accumulation
MEDLINE and PsycINFO, and found 19 studies that of clinical experience and daily contact with people
examined mental-health-related stigma in Japan. who have mental illness. Stigmatizing attitudes in
Regarding knowledge about mental illness, reviewed Japan are stronger than in Taiwan or Australia, pos-
studies showed that in the Japanese general popula- sibly due to institutionalism, lack of national cam-
tion, few people think that people can recover from paigns to tackle stigma, and/or societys valuing of
mental disorders. Psychosocial factors, including conformity in Japan. Although educational programs
weakness of personality, are often considered the appear to be effective in reducing mental-health-
cause of mental illness, rather than biological factors. related stigma, future programs in Japan need to
In addition, the majority of the general public in address problems regarding institutionalism and
Japan keep a greater social distance from individuals offer direct social contact with people with mental
with mental illness, especially in close personal rela- illness.
tionships. Schizophrenia is more stigmatized than
depression, and its severity increases the stigmatizing Key words: attitudes, Japan, knowledge, mental-
attitude toward mental illness. The literature also health-related stigma, review.
showed an association between more direct social

ENTAL-HEALTH-RELATED STIGMA IS interna- ponents: problems related to (i) knowledge (igno-


M tionally a central issue for people with mental
health illness. It results in disadvantages for these
rance or misinformation); (ii) attitudes (prejudice);
and (iii) behavior (discrimination).3 Indeed, past
individuals, in particular because mental illnesses are studies have consistently reported that many people
generally more stigmatized than other conditions.13 with mental health problems suffer from a lack of
The term stigma includes the following three com- mental health literacy, the general publics misunder-
standing of mental illness, stigmatizing attitudes and
harmful discrimination, and associated problems,
*Correspondence: Shuntaro Ando, MD, MScPH, Department of including low self-esteem, loss of social opportuni-
Psychiatry and Behavioral Sciences, Tokyo Metropolitan Institute of
ties, and economic inequality.35
Medical Science, 2-1-6 Kamikitazawa, Setagaya-ku, Tokyo 156-8506,
Japan. Email: ando-st@igakuken.or.jp
Mental-health-related stigma has played an impor-
Received 8 August 2012; revised 22 January 2013; accepted 11 April tant role as a barrier to development of and access
2013. to mental health services in Japan. For example,

2013 The Authors 471


Psychiatry and Clinical Neurosciences 2013 Japanese Society of Psychiatry and Neurology
472 S. Ando et al. Psychiatry and Clinical Neurosciences 2013; 67: 471482

almost two-thirds of individuals with mental illness the current evidence for mental-health-related stigma
never seek help from a health professional because of in Japan. This study, therefore, aims to conduct a
stigma.6 In addition, mental health services in Japan narrative review of articles about mental-health-
have been internationally criticized due to the exces- related stigma in Japan and address the following
sive number of inpatients, insufficient community questions:
resources, and infringement of human rights of indi-
viduals with mental illness.7 Thus, tackling mental- 1 What types of mental illness are stigmatized in
health-related stigma has been identified as extremely Japan?
important to improving services for (and hence the 2 How is mental illness stigmatized in Japan?
lives of) individuals with mental health problems in 3 Which demographic characteristics are associated
every country, including Japan.8 with the stigma of mental illness in Japan?
A variety of efforts to decrease mental-health- 4 Why are people with mental illness stigmatized in
related stigma have been made all over the world. At Japan?
the global level, the World Psychiatric Association 5 Is stigmatization in Japan any different from
(WPA) and the World Health Organization (WHO) that in other countries (i.e. nature or severity of
conducted a global anti-stigma campaign to develop stigma)?
tools to make it easier to tackle stigma and discrimi- 6 What interventions have been introduced to
nation.9,10 Many types of interventions at the national reduce the stigma of mental illness in Japan?
and local level have also been developed to reduce
the mental-health-related stigma of people with
mental illness, including large-scale media cam-
METHODS
paigns, short education programs, social contact,
films, and simulations.1113 In terms of Japanese
Inclusion criteria
activities aimed at overcoming such stigma, the In order to collect a wide range of relevant evidence,
National Federation of Families with Mentally Ill in we included peer-reviewed studies published since
Japan requested that the psychiatric society change 2001 written in English or Japanese. Studies were
the name of the illness, which was a translation of included if they examined public or personal stig-
the German name schizophrenie (literally meaning matization (knowledge, attitudes, and behavior)
split mind).6 The new name was adopted in 2002 towards any mental illness in any population in
and became commonly used in official documents.14 Japan, including students, professionals, informal
In addition, to improve mental health literacy, caregivers, or the general public. All types of studies
facilities such as health centers have conducted except reviews were included in this review.
educational programs about mental health for local
communities.11
Despite the development of such approaches to
Search strategy
address mental-health-related stigma, it remains a MEDLINE (searched by S.A.) and PsycINFO
serious problem that adversely affects the lives of (searched by S.Y.) were searched from 2001 to
people with mental health problems in many October 2011. No restrictions were applied for
countries.1,2 Not surprisingly, there is still a harmful publication type. The following search terms were
mental-health-related stigma in Japan. For example, used: ((attitud$ OR social behavio$ OR social dis-
in a large-scale cross-sectional survey, only 5% of tance$ OR illusion$ OR stereotyp$ OR stigma$
the general public believed that people with mental OR discriminat$) AND (mental disorder$) AND
illness could recover fully from their illness through (Japan$)) ($ = truncation). In addition, MeSH terms,
professional help.14 including attitude, social behavior, discrimination,
Because the level and description of stigma are mental disorders, and Japan, were applied.
socially and culturally influenced,15 understanding
characteristics of mental-health-related stigma based
on research evidence can contribute to lessening of
Study selection and synthesis of evidence
the stigma and development of future interventions. After screening the identified titles for potential
However, to the best of our knowledge, there has relevance, full manuscripts of potentially relevant
been no review that comprehensively summarizes studies were obtained. Data were extracted, and

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Psychiatry and Clinical Neurosciences 2013 Japanese Society of Psychiatry and Neurology
Psychiatry and Clinical Neurosciences 2013; 67: 471482 Mental health stigma in Japan 473

narrative synthesis was conducted on the basis of the


research questions. Question 2. How is mental illness stigmatized
in Japan?
In this section, mental-health-related stigma is cate-
RESULTS gorized into that relating to knowledge of and atti-
tudes towards people with mental illness.
Characteristics of studies included
in the review
Knowledge of psychiatric symptoms
A total of 365 studies from MEDLINE and 95 studies
and causes
from PsycINFO were identified by the electronic data-
base search. From these, 19 met inclusion criteria A significant lack of knowledge about schizo-
for this review (Table 1).1634 There were many studies phrenia in the general public was observed in several
which were not included because their focuses studies.16,27,29,31 Approximate proportions of the
were not on public or personal stigma but on self- general population who had correct knowledge
stigma. Most of those included were cross-sectional about prevalence, onset, and characteristic symptoms
studies,1632 including five between Japan and China, of schizophrenia were 27%, 42%, and 12%, respec-
Taiwan, or Australia.19,2527,31 Two were intervention tively.16 A study involving elementary school teachers
studies.33,34 Eight studies used community samples showed that only 23% of respondents identified
as study subjects,20,21,2427,29,32 and six studies used schizophrenia correctly in a case vignette.31 Regard-
specialists whose fields were associated with mental ing the causes of mental illness, three studies found
health.1619,22,28 The other four studies used industrial that the most popular attributed causes of schizo-
workers and government employees,33 employers phrenia in the general public were psychosocial
of industries,23 elementary school teachers,31 medical factors: interpersonal relationships (65%),29 stress
students,34 or participants in lectures about mental from personal relations (79%),31 and weakness or
health.30 With regard to types of mental disorders, nervousness (73%).27
11 studies examined schizophrenia,1619,2531 four However, mental health workers and students at
studied dementia,2022,24 three studied depression,2527 a health and welfare school had some knowledge
and four studied general mental illness.23,3234 Many about mental illness.19 More than 70% of the partici-
studies used their own questionnaire to assess know- pants gave correct answers to most questions about
ledge and attitudes,1618,20,21,2327,31,34 although some psychiatric symptoms.19
used established instruments for outcome measure-
ment.19,22,2830,32,33 No studies assessed discrimination
Knowledge of treatment and recovery
(actual behavior).
Several studies examined the general publics knowl-
edge about treatment of depression and schizophre-
Question 1. What types of mental illness are nia. Although most people thought that those mental
stigmatized in Japan? illnesses could be targets of treatment, they were
There was only one study that compared stigmatiza- pessimistic about recovery from the condition. Hori
tion of different types of mental illness.25 That study et al.16 found that more than 80% of the general
examined public beliefs about depression, depres- public agreed that schizophrenia could be treated.
sion with suicidal thoughts, early schizophrenia, and On the other hand, less than 40% of the general
chronic schizophrenia.25 In general, schizophrenia public expected full recovery (with or without
was stigmatized to a greater extent than depression. relapse) of people with schizophrenia.27
In particular, a greater proportion of participants Medication was poorly recognized as a helpful
thought that individuals with schizophrenia were treatment for mental illness, and knowledge about
more dangerous and unpredictable than those with side-effects was especially poor. In addition, a psy-
depression.25 In terms of chronicity of the disorder, chiatrist was not typically chosen first by the gene-
more respondents would refuse to employ an indi- ral public as help for mental illness. In one study,
vidual with chronic schizophrenia compared to only 3041% of the general public regarded
someone with early schizophrenia: 61% versus 48%, antipsychotics as helpful for schizophrenia; 5467%
respectively.25 regarded psychotherapy as helpful.27 Similarly, only

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Psychiatry and Clinical Neurosciences 2013 Japanese Society of Psychiatry and Neurology
474 S. Ando et al. Psychiatry and Clinical Neurosciences 2013; 67: 471482

Table 1. Characteristics of included studies involving Japan


Characteristics
of participants
(Number of Length of Type of
Reference Study type participants) Intervention Comparison follow up illness Outcome scale Brief summary

Hori Cross-sectional General population NA NA NA Schizophrenia Own questionnaire Psychiatrists had the
(2011)16 study (web- (197) least negative
based survey) Psychiatric staff (100) attitudes toward
Physicians (112) schizophrenia,
Psychiatrists (36) followed by
psychiatric staff
Katakura Interview Home-visit nurses NA NA NA Schizophrenia Own questionnaire Equal footing with
(2010)17 (7) client was essential
in home visits
Mino Cross-sectional Psychiatrists (549) NA NA NA Schizophrenia Own questionnaire Psychiatrists discharge
(2009)18 study judgment affected
patients attitude
toward discharge
Haraguchi Cross-cultural Rehabilitation workers NA Chinese NA Schizophrenia Social Distance Large social distance
(2009)19 study Students at a health Scale-Japanese from schizophrenia
and welfare school version in both China and
(352/347) Knowledge of Illness Japan with different
and Drugs features
Inventory
Matsubayashi Cross-sectional Community sample NA Community 9 years Dementia Own questionnaire Perception of
(2009)20 study (2151/4862) sample dementia has
changed positively
Umegaki Cross-sectional Community sample NA Community 4 years Dementia Own questionnaire Perception of
(2009)21 study (7000/7000) sample dementia has
changed positively
Nakahira Cross-sectional Staff at facilities caring NA NA NA Dementia Attitude Toward Experience and
(2008)22 study for elderly people Aggression Scale education reduced
(752) aggressive attitudes
Ozawa Cross-sectional Employers of NA NA NA Psychiatric Own questionnaire Employers attitude
(2007)23 study industries (358) disability correlated with age
and prior experience
Umegaki Cross-sectional Community sample NA NA NA Dementia Own questionnaire Disclosure of
(2007)24 study (7000/3949 ) diagnosis of
dementia desirable
Griffiths Cross-cultural Community sample NA Australian NA Schizophrenia, Own questionnaire Negative attitudes
(2006)25 study aged 2060 years adults depression based on previous greater in Japanese
(2000/3998) studies than in Australians
Nakane Cross-cultural Community sample NA Australian NA Schizophrenia, Own questionnaire Public attributed
(2005)26 study aged 2060 years adults depression social causes for
(2000/3998) illness
Jorm Cross-cultural Community sample NA Australian NA Schizophrenia, Own questionnaire Recognition of
(2005)27 study aged 2060 years adults depression disorder and belief
(2000/3998) about treatment
different between
countries
Katsuki Cross-sectional Nurses at two NA NA NA Schizophrenia Nurse Attitude Scale Burnout resulted in
(2005)28 study psychiatric critical attitude
hospitals (189) toward patients
Tanaka Cross-sectional Community sample NA NA NA Schizophrenia Mental Disorder Majority was willing
(2005)29 study (2632) Prejudice Scale to have patient as a
neighbor
Ishige Cross-sectional Participants in lectures NA NA NA Schizophrenia Social Rejection Scale Positive contact
(2005)30 study and seminars about experiences led to
mental health (786) accepting attitude
Kurumatani Cross-cultural Elementary school NA Taiwanese NA Schizophrenia Own questionnaire Stronger stigma in
(2004)31 study teachers Japan than in
(129/150) Taiwan
Tanaka Cross-sectional Community sample NA NA NA Mental illness Mental Disorder Information and
(2004)32 study (2632) Prejudice Scale interaction with
patients important
Tanaka Intervention Industrial workers 1.5-h lecture Before the Immediately Mental illness Mental Illness and Mental health lecture
(2003)33 study (before Government about lecture after the Disorder reduced stigma of
and after study) employees (420) mental lecture Understanding Scale mental illness
health Negative Attitudes
Scale
Mino Intervention Medical students 1-h Students who Immediately Mental illness Own questionnaire Educational program
(2001)34 study (clinical (95/94) educational heard a lecture after the based on previous favorably changed
controlled program not related to program studies attitudes toward
study) mental health mental illness

Psychiatrists evaluated the feasibility of discharge of 549 patients.
The number of Japanese/Chinese.

Different samples were used in the two surveys.
Different samples were used in the two surveys.
Two different studies were included in the paper.
The number of Japanese/Australians.
The number of Japanese/Taiwanese.
The number of interventions/controls.

NA, not applicable.

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Psychiatry and Clinical Neurosciences 2013 Japanese Society of Psychiatry and Neurology
Psychiatry and Clinical Neurosciences 2013; 67: 471482 Mental health stigma in Japan 475

about 35% of respondents regarded antidepressants


as helpful for depression, while approximately 50% Attitudes: Social distance
regarded psychotherapy as helpful. In a study of All studies measuring social distance from people
rehabilitation workers and students at a health and with schizophrenia or depression among the general
welfare school, only 3560% had correct knowledge public found greater distance in closer relation-
about side-effects of psychiatric medication and the ships. In two studies using community samples, for
importance of maintenance medication, although instance, a larger proportion of the general public
more than 70% of respondents had correct knowl- showed an unwillingness to get married and become
edge regarding the effectiveness of psychiatric medi- family with someone with schizophrenia or de-
cation.19 The most commonly mentioned suitable pression compared to working closely with those
help for depression was friends/family (7072%) people.25,32 In another example from a community-
followed by counselors (6275%). Less than 50% of based survey, approximately 78% of the general
respondents mentioned psychiatrists.27 public showed understanding toward a landlord who
rejected renting to an individual with schizophrenia,
while approximately 84% of the respondents were
accepting of the patient as a neighbor.28 This trend
Attitudes: Prejudice was also similar in medical students. Mino et al.34
Significant stigmatizing attitudes towards people reported that medical students kept the greatest
with mental illness were observed among the social distance from individuals with schizophrenia
general public. In an Internet-based survey, 56% with respect to marriage of their children to former
of participants agreed that schizophrenic patients patients (94% of the respondents), followed by
could harm children.16 In another general public renting a room in their home to former patients
survey, 4861% would not employ someone with (86%).
schizophrenia, 5874% would not vote for a poli-
tician with schizophrenia, and 5458% would not
vote for a politician with depression.25 One survey Question 3. Which demographic characteristics
showed that dementia was regarded as the least are associated with the stigma of mental
desirable disease condition among four conditions illness in Japan?
(dementia, cancer, stroke, and heart disease) by Some of the studies included in this review showed a
community-dwelling elderly people in two of the difference in extent of stigmatizing attitude related to
three towns investigated.20 Another study examin- several demographic characteristics and professional
ing dementia revealed that more than 40% of the backgrounds.
general public regarded dementia as a shameful
condition.21,24
Similar stigmatizing attitudes were observed
Sociodemographics
among some professionals. One study that examined Hori et al.16 found no significant effect of sex on
stigmatization in industrial workers and govern- stigmatizing attitudes toward schizophrenia. Further-
ment employees found that only 26% of the parti- more, in a study of nurses, there was no signifi-
cipants agreed that individuals who had delusions cant difference in attitudes towards schizophrenia
and hallucinations should live in the community between men and women.28 No significant effect of
without being hospitalized.33 Even among medical age on the stigma of schizophrenia was found in a
students, the stigmatizing belief that people with web-based survey.16 Two studies, however, reported
schizophrenia are frightening because of unpredict- that older participants tended to be less socially
able behavior was held by many (82% of respon- accepting of people with schizophrenia and demen-
dents).34 The same study revealed that approximately tia than younger participants.30,32 Similarly, employ-
77% of students agreed that it was dangerous for ers in their thirties tended to express lower levels
mentally ill patients to live in an apartment by of concern about the activity limitation of people
themselves.34 A qualitative study revealed that with psychiatric disability than those in their sixties.23
home-visit nurses underestimated understanding of Furthermore, Umegaki et al.21 compared perception
surroundings and skills for daily life of patients with of dementia between younger adults (4064 years of
schizophrenia.17 age) and an older group (65 years of age or older),

2013 The Authors


Psychiatry and Clinical Neurosciences 2013 Japanese Society of Psychiatry and Neurology
476 S. Ando et al. Psychiatry and Clinical Neurosciences 2013; 67: 471482

and found that the perception was more negative of schizophrenic patients in Japan may be associated
and inaccurate in the older group. Compared with with the strong stigma of schizophrenia.31
the younger group, a greater proportion of the older
group agreed that dementia was a shameful disease:
5357% versus 3942%, respectively.21 Question 5. Is stigmatization in Japan any
In a web-based survey, no significant association different from other countries in nature
was found between academic degree and level of or severity?
stigma of schizophrenia.16 Tanaka et al.32 conversely There were five studies that compared mental-health-
reported that people in the lowest education group related stigma in Japan and other countries, includ-
showed greater rejection of people with mental ing China, Taiwan, and Australia.19,2527,31 Overall,
disorders. They also pointed out that widowed findings suggested that the stigma of mental illness
(divorced) people tended to demonstrate more nega- in Japan was less than in China and greater than in
tive attitudes towards people with mental disorders. Taiwan and Australia.
With regard to knowledge about schizophrenia,
there were more correct answers about psychiatric
Professional background symptoms and medication among rehabilitation
There is a tendency that more objective attribution workers and health-related students in Japan than in
to mental disorders is held by health professionals China. The social distance people kept from those
than by the general public.26 Hori et al.16 found that with mental illness was less in Japan than in China.19
psychiatrists and psychiatric staff showed overall Kurumatani et al.31 examined knowledge, beliefs,
less negative attitudes toward schizophrenia than and attitudes towards schizophrenia of elementary
the general public and physicians. Moreover, public school teachers in Japan and Taiwan. In response to a
health nurses and psychiatric nurses showed a higher case vignette involving schizophrenia, the propor-
acceptance of people with schizophrenia compared tion of those correctly identifying the disorder was
with other professionals, although psychiatric nurses lower in Japanese compared to Taiwanese teachers:
demonstrated less socially accepting attitudes than 23% versus 34%, respectively. A similar proportion
public health nurses.30 A negative correlation was of teachers in Japan and Taiwan believed that stress
found between years of psychiatric nursing experi- from personal relationships was a cause of schizo-
ence and negative attitude (hostility and criticism) phrenia (79% vs 78%), although Japanese compared
towards schizophrenia.28 Similarly, Nakahira et al.22 to Taiwanese teachers less often chose heredity (9%
reported that staff who had more clinical experi- vs 37%) and stress from a disaster (5% vs 61%).
ence and/or a higher position in facilities for elderly Although, compared to Taiwanese, the Japanese were
people tended to have a more positive attitude more likely to regard pediatricians/physicians (30%
towards patients aggression than their less experi- vs 11%) and school nurses (75% vs 47%) as effective,
enced counterparts. Also, Ozawa and Yaeda (2007) they were less likely to regard social workers (38% vs
reported that motivation to employ workers with 68%) and physical activity (22% vs 68%) as effective.
psychiatric disabilities was higher in employers with With respect to prejudice and social distance from
a history of employing people with disabilities.23 people with schizophrenia, significantly more stig-
matizing attitudes were observed in Japan than in
Taiwan.
Question 4. Why are people with mental illness A large-scale international cross-sectional survey
stigmatized in Japan? between Japan and Australia examined mental-
There was no study with the primary objective being health-related stigma.2527 The Japanese individuals
investigation of the mechanism of stigmatization were more likely to attribute personality of a person,
related to mental illness. One study, however, such as nervousness or weakness, as the causes of
showed that Japanese psychiatrists might be conser- schizophrenia and depression compared with Austra-
vative when considering discharge from a psychiatric lians.26 In contrast, the Japanese were less likely
hospital, with this attitude possibly due to public to view biological factors (virus or infection, allergy,
pressure that promotes admission of individuals with or inheritance) and social/demographic factors
mental illness to such hospitals.18 It was suggested in (young, poor, unemployed, or divorced/separated) as
another study that the high institutionalization rate causes than Australians.26 In terms of treatment and

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Psychiatry and Clinical Neurosciences 2013 Japanese Society of Psychiatry and Neurology
Psychiatry and Clinical Neurosciences 2013; 67: 471482 Mental health stigma in Japan 477

prognosis of schizophrenia and depression, com-


pared to the Australians, the Japanese were less likely DISCUSSION
to regard general practitioners as helpful (1930% vs
7087%), and were more likely to consider psychia-
Main findings
trists, family, self-cure, and hypnosis as helpful.27 In This review addressed six questions in an effort to
terms of long-term prognosis, the Japanese were much comprehend the nature and characteristics of mental-
less optimistic about full recovery even with profes- health-related stigma in Japan. We will now discuss
sional help than Australians (37% vs 1637%).27 the Japanese trends and significant characteristics of
In relation to attitudes towards people with schizo- stigma, considering findings from the current review
phrenia and depression, there was a tendency toward and past studies.
more negative attitudes and stronger social rejection
in Japanese people compared to Australians.25
1. What type of mental illness is stigmatized
in Japan?
Question 6. What interventions have been used All types of mental illness examined in the included
to reduce the stigma of mental illness in Japan? studies were considerably stigmatized in Japan,
There were two studies that examined effects of inter- including schizophrenia, depression, dementia, and
vention aimed at reducing mental-health-related others.1634 Schizophrenia was more stigmatized than
stigma.33,34 One study gave 1.5-h lectures to industrial depression, and severity increased the stigmatizing
workers and government employees using a 24-page attitude toward the mental illness,25 consistent with a
pamphlet.33 The educational program significantly previous study showing more stigma of people with
improved understanding of all examined aspects of schizophrenia than those with depression.35 This
mental health (treatability of mental illness, efficacy result suggests that a wide range of mental illnesses
of medication, and social recognition of illness). can be the target of programs that tackle the stigma of
About 70% of the participants, for instance, agreed mental illness.
with the statement Treatment of mental illness
requires medication after the lecture, compared to
20% at baseline. For another example, the rate of 2. How is mental illness stigmatized in Japan?
agreement with the statement I feel insecure when Knowledge of mental illness was relatively poor
people with mental illness, singly or as a group, rent among the general public in Japan. Japanese people
and live in an apartment decreased from 46% to are apt to consider psychological factors (e.g.
29% after the lecture. weakness of character) as the cause of mental illness
Another study conducted a 1-h lecture explaining rather than biological factors (e.g. genetic predispo-
mental health services in Japan and presentation of sition).26,29,31 They also tend to prefer seeking help
a case of schizophrenia to medical students.34 The from counselors and friends/family rather than
explanation highlighted higher inpatient rate, larger psychiatrists.27 These findings suggest that Japanese
proportion of long-stay (>5 years) inpatients, and a people may be more likely to regard mental health
poorer social support system in Japan compared with problems as personal problems. Nevertheless, a focus
England. In the case presentation, the importance of on biological causes of mental illness is not a sub-
development of community services for the mentally stantially effective way to reduce stigmatization in
ill was stressed. As a result of the lecture, improve- the general public, according to evidence from well-
ment was observed in the stigmatizing attitude structured reviews.36,37 What is important may be
towards mental illness. For example, in response to emphasizing that mental illness is not an individuals
the question Would you be willing to work on a job fault, rather than focusing on causes of mental illness.
with former patients?, only 41% replied positively In contrast to common views about mental illness,
before the lecture, but the rate increased to 63% after low expectations for recovery seem to be specific to
the lecture. As an example of improvement in atti- Japan. Institutionalism in Japan might prevent the
tude towards psychiatric services, although only 37% general public from seeing people with mental ill-
of students agreed that mental hospitals should be ness in their communities, and make it difficult for
open before the lecture, the rate increased to 67% them to imagine people recovering from mental
after the lecture. illness.7,18,37 We should, however, take into account

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Psychiatry and Clinical Neurosciences 2013 Japanese Society of Psychiatry and Neurology
478 S. Ando et al. Psychiatry and Clinical Neurosciences 2013; 67: 471482

the possibility that institutionalism is not the cause of correlated with the strong stigma.31 The large number
the strong mental-health-related stigma, but instead of psychiatric beds and long stays in psychiatric
is a result of the strong stigma.25 hospitals may decrease contact between the general
With respect to attitude towards mental illness, a public and patients with schizophrenia. Conse-
certain extent of negative attitudes and social rejec- quently, misperceptions held by the general public
tion were common across the studies included in may not be corrected because of few opportunities to
this review. Particularly, prejudice regarding inabili- meet patients who have recovered from the illness.
ties, dangerousness, and unpredictability of patients In addition, considering the poor knowledge
appeared to be strongly linked to negative attitudes and weaker stigma associated with specific profes-
toward schizophrenia in the general public.16,17,25,34 sionals,16,26,2931 lack of appropriate education on
Similar trends in knowledge and attitudes have been mental health literacy may be another reason for the
seen even in Western cultures.13,36,37 stigma of mental illness.

5. Is stigmatization in Japan any different from


3. Which demographic characteristics are
other countries in nature or severity?
associated with the stigma of mental
illness in Japan? Different degrees of mental-health-related stigma
were seen between Japan and other countries in the
Studies included in this review did not show a sex
included studies. Overall, stigmatization of people
difference in stigmatization of mental illness. A
with mental illness in Japan appeared to be weaker
recent systematic review on stigmatization related
than in China, but stronger than in Taiwan and
to sex among Western countries supported this
Australia. There are several possible reasons for this
finding.38 With regard to age, some of the included
difference between countries.19,2527,31 For example,
studies found that older people had more negative
different knowledge and preferences regarding treat-
attitudes towards schizophrenia, dementia, and
ments between Japan and other countries could be
general mental illness.21,23,30,32 This might be due
due to social/medical systems, as seen in Australia
to the negative social value associated with mental
and Taiwan, where people can easily access general
illness in Japan, as well as a lack of appropriate edu-
practitioners or social workers.2527,31
cation and opportunities for mentally ill people.30
Differences in attitudes and social acceptance of
There was also a tendency for a stigmatizing attitude
people with mental illness between countries are
to be greater in less educated people.32 We speculate
issues more complicated than can be attributed
that highly educated people in Japan might have
to knowledge. Haraguchi et al.19 suggested that the
opportunities to learn about mental illness, although
reason for keeping a greater social distance from
they might also be sensitive to social desirability,
those with mental illness observed in China might be
which is a typical bias in stigma research.
associated with contact with untreated schizophrenic
Meeting people who have recovered from mental
patients. This idea on the impact of contact with
illness may reduce stigmatization. Professionals who
untreated people with mental illness aligns with
had routine contact with people with mental illness,
the findings from the recent studies in Western
particularly in their communities, showed a less stig-
countries.39,40
matizing attitude towards them than those who had
On the other hand, Kurumatani et al.31 suggested
few such opportunities.16,30 This finding may reflect
that stronger stigmatizing attitudes towards schizo-
the fact that staff with more experience have more
phrenia in Japan compared to Taiwan come from
chances to meet people who have recovered from
the higher institutionalization rate of patients with
their mental illness.3 Interestingly, both the high
schizophrenia in Japan and consequent limited
quality and the frequency of contact are important in
contact with such patients in the community. The
improving stigmatization of people with mental
association between frequent contact with people
illness, even among professionals.3
with mental illness and positive attitudes towards
people with mental illness were also suggested in a
4. Why are people with mental illness previous study.41 Institutionalization in Japan may
stigmatized in Japan? have been sustained by a higher number of psychi-
It has been suggested that the high institutionaliza- atric beds per population compared with Western
tion rate of schizophrenic patients in Japan may be countries.7

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Psychiatry and Clinical Neurosciences 2013 Japanese Society of Psychiatry and Neurology
Psychiatry and Clinical Neurosciences 2013; 67: 471482 Mental health stigma in Japan 479

In addition, less social rejection in Australia com-


pared to Japan can be explained by implementa- 6. What interventions have been used to reduce
tion of national projects and campaigns to improve the stigma of mental illness in Japan?
mental health services and tackle stigma against Even brief educational programs can improve atti-
mental illness in Australia that began in 2001.42 tudes towards mental illness, as well as the under-
Indeed, recent studies, not only in Australia but also standing of mental illness and efficacy of medication,
in the UK, consistently reported that the national although the long-term effect of education has not
campaigns had positive effects on changing attitudes been examined.33,34 Tanaka et al.33 recommended that
and behavior towards people with mental illness in educational programs address problems associated
the general public.42,43 with long-term hospitalization, which would help
Further, the particular history and nature of participants understand that people with mental
Japanese culture may explain why Japanese people illness can live in their community. Future programs
have often shown stigmatizing attitudes towards should emphasize that mental illness is not an indi-
mental illness. Furnham and Murao (2000) sug- viduals fault, and include talks by those with mental
gested that it had been a taboo to discuss mental illness as well as interactions with them through
illness in public, and that family members had been recreation or collaborative activities.33 An accepting
responsible for care of people with mental illness attitude can be facilitated through positive contact
until very recent years.44 Such public ignorance of experiences, whereas a stigmatizing attitude can be
mental illness may be related to strong mental- formed through negative contact experiences, such as
health-related stigma in Japan. Moreover, in the exposure to socially deviant behavior.11,30,33
Japanese culture, it might be more socially accept- Although no studies included in this review con-
able to have a stigmatizing attitude towards mental ducted an intervention involving social contact with
illness based on honnne/tatemae.45,46 Honne refers people with mental illness or other effective strategies
to real opinions and feelings, and tatemae refers to lessen mental-health-related stigma, three system-
to those that are publicly expressed. Japanese people atic reviews comparing various types of interven-
have historically been hesitant to express their tions concluded that social contact with persons with
true feelings in public, and instead display opinions mental illness produced more change in attribution
and behaviors that will be supported by the major- of mental illness than education.4749 On the other
ity of the general public. They strongly prefer not hand, there is little clear evidence for the effectiveness
to stand out as different from others. Therefore, of interventions using video-based contact on reduc-
we should take into account that answers from the tion of mental-health-related stigma.11 In addition,
Japanese respondents might have reflected response a systematic review that examined the effectiveness
bias. of hallucination simulation showed that simulated
It is difficult to determine the primary reason why hallucinations had contradictory effects on stigma,
people in Japan often have more negative attitudes increasing empathy, but also the desire for social dis-
towards people with mental health problems than tance.12 We should exercise caution in using such
people in other countries. However, direct compari- materials to reduce mental-health-related stigma.
sons of attitudes towards people with mental illness
between Japan and other countries have emphasized Limitations
the importance of community care that provides
There are several limitations of this study. First,
opportunities to have contact with those in the
because this narrative review represents studies from
community who have mental illness, as well as the
only two electronic databases, there might be relevant
launch of a national campaign to reduce mental-
studies that were not included. Second, study selec-
health-related stigma. Further comparative studies
tion from each database was conducted by only one
between Japan and China are required, considering
researcher.
the limited representativeness of the sample in the
previous study.19 In addition, the statistical validity
and reliability of the scales used in four compara-
Recommendations for future study
tive studies were not developed, although they
and intervention
appeared to employ the appropriate back translation There was no study that investigated discrimina-
method.2527,31 tion against people with mental illness in Japan.

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Psychiatry and Clinical Neurosciences 2013 Japanese Society of Psychiatry and Neurology
480 S. Ando et al. Psychiatry and Clinical Neurosciences 2013; 67: 471482

Interventions including
direct contact with people
Attitude
Promotion of
community services Prejudice:
Decreased opportunity People with mental illness are
to have contact with dangerous, unpredictable, etc.
Institutionalism
people with mental Social distance:
illness Unwillingness to vote for or marry
Campaigns including someone with mental illness
a focus on problems
about institutionalism

Knowledge
Lack of campaigns
Cause of illness:
Attributed to individuals fault
Treatment for illness:
Lack of education Poor knowledge about efficacy and
side-effects of medication
Prognosis of illness:
Education about Pessimistic about recovery from
mental health literacy mental illness

Figure 1. Current problems associated with the stigma of mental illness and expected interventions for these problems in Japan.
Current problems and consequent stigma toward mental illness; , expected interventions.

Implementation of such a study should be considered. personality was most often seen as the cause for
We found only a few studies that compared mental- mental illness, rather than biological factors, such as
health-related stigma between Japan and Western heritability. A substantial number of Japanese people
countries. A comparison of Japan with other Western do not recognize that people with mental illness
countries, including European countries and the USA, can recover. In addition, many people have negative
could provide more global findings in terms of cul- attitudes towards people with mental illness, consid-
tural differences. We identified no randomized con- ering them dangerous and unpredictable. Not sur-
trolled trials on interventions in Japan to decrease the prisingly, the majority of the general public in Japan
stigma of mental illness. Such trials are required in the keeps greater social distance from individuals with
future to establish the effectiveness of interventions. mental illness in close relationships. Schizophrenia
In addition, research on interventions involving direct is more stigmatized than depression, and the seve-
contact with people with mental illness and cam- rity of the illness increases the stigmatizing attitude
paigns to reduce stigma should be promoted (Fig. 1). toward it.
It is also suggested that future direction for reducing In terms of professionals stigmatization, mental
mental-health-related stigma in Japan should focus on health staff who regularly and directly have contact
further de-institutionalization, as the progress of social with individuals with mental illness have less nega-
inclusion is the primary aim for overcoming stigma in tive attitudes. This may be associated with their accu-
other countries.50 Sharing the goal of reducing mental- mulation of contact with people who have recovered
health-related stigma would contribute not only to from mental illness. Compared to Taiwan and Aus-
maintaining activities tackling against stigma of men- tralia, the stigma of mental illness was stronger in
tal illness but also to developing community care. Japan, which might be due to institutionalism, the
lack of implementation of national campaigns, and
societys value of conformity. Although some educa-
CONCLUSION tion programs appeared to be effective in reducing
In Japan, the general publics knowledge of mental mental-health-related stigma, we found key implica-
illness was found to be relatively poor. Weakness of tions for future interventions. For example, both the

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Psychiatry and Clinical Neurosciences 2013 Japanese Society of Psychiatry and Neurology
Psychiatry and Clinical Neurosciences 2013; 67: 471482 Mental health stigma in Japan 481

general public and professionals need to: (i) elimi- 13. Corrigan PW, River LP, Lundin RK et al. Three strategies
nate the misunderstanding that mental illness is for changing attributions about severe mental illness.
caused by personal faults; (ii) focus on the adverse Schizophr. Bull. 2001; 27: 187195.
effects of institutionalism; (iii) stress the importance 14. Takahashi T, Tsunoda M, Miyashita M et al. Comparison
of diagnostic names of mental illness in medical docu-
of community care; and (iv) offer direct social contact
ments before and after the adoption of a new Japanese
with people with mental illness. translation of schizophrenia. Psychiatry Clin. Neurosci.
2011; 65: 8994.
15. Angermeyer MC, Buyantugs L, Kenzine D, Matschinger H.
ACKNOWLEDGMENTS Effects of labelling on public attitudes towards people
This study is not supported by any fund. All authors with schizophrenia: Are there cultural differences? Acta
Psychiatr. Scand. 2004; 109: 420425.
declare that there is no conflict of interest.
16. Hori H, Richards M, Kawamoto Y, Kunugi H. Attitudes
toward schizophrenia in the general population, psychiat-
ric staff, physicians, and psychiatrists: A web-based survey
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