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Review Article
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
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
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.
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
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.
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
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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