AIM: To clarify the components of hospitalization for assessment (HfA) and the management changes from the beginning of the scheme to the present.

METHODS: This study is composed of two surveys. In 2013 survey, we created two paper questionnaires (facility and case questionnaires) for psychiatrists working in psychiatric hospitals accepting HfA patients. Questionnaires were sent to 205 hospitals that were identified as accepting the HfA cases, and responses were requested via mail. The facility questionnaire was designed to clarify the following specifications and characteristics of each facility: the facility organizer (public sector or private hospital), and the number of beds, psychiatrists, psychiatric nurses, occupational therapists, psychiatric social workers, psychotherapists, public health nurses, and patients treated through HfA during the survey period. The case questionnaire was then used to collect data of the patients under HfA based on the Medical Treatment and Supervision (MTS) Act who were discharged between July 1, 2012 and June 30, 2013. Gathered information included: legal information of each case, demographic data, past history of the offenders, issued offense and the relationship to the victim, information regarding past psychiatric testimonies, psychiatric diagnoses, contents of the treatment during HfA, information regarding seclusion and restraint during the HfA, the verdict of the District Court panel, and so forth. Next, we compared those results with relevant data obtained in 2007. The 2007 survey comprised data of HfA patients from July 15, 2005 (the date the MTS Act was enforced) to January 15, 2007.

RESULTS: We obtained 171 cases, approximately a half of whole contemporary cases of HfA, from 134 facilities, of which 46 were national, prefectural, or semi-official hospitals, and 88 were private hospitals, in 2013 survey. The majority of subjects were male, schizophrenic, and experienced previous psychiatric treatment. The most frequent type of the offense was injury, followed by arson. Most of the subjects were medicated, and a few cases took psychotropic injection during the HfA. The frequency of injection was decreased in 2013 (χ² = 7.54, df = 1, P = 0.006) than in 2007. Psychiatric testimony was more likely to be conducted in 2013 (χ² = 8.56, df = 1, P = 0.004). The examiner psychiatrist was more likely to belong to the HfA facility to which the patient was hospitalized (χ² = 5.32, df = 1, P = 0.02). Hospitalization orders were more frequently selected in 2013 (χ² = 19.76, df = 3, P < 0.001), although the characteristics of the subjects had not changed.

CONCLUSION: Although the management of HfA has improved in recent years, structural problems remain.

Forensic mental health is a topic of great concern and controversy[1]. Thanks to the global trend toward deinstitutionalizing patients with mental disorders, the need to develop sophisticated forensic mental health systems has increased[2]. Consequently, many countries have established their own forensic mental health systems, which link different disciplines according to their cultural backgrounds[3].

For many years, Japan had no specific legal provision for offenders with mental disorders[4]. Such offenders were treated under the Mental Health and Welfare Act. Under that legislation, patients with mental disorders who were potentially dangerous, being capable of harming themselves or others, were hospitalized under a prefectural government order. This system of official involuntary hospitalization was completely independent of the criminal justice system[5], which led some lawyers to argue that the human rights of these patients were not properly guaranteed. Similarly, some psychiatrists suggested the need for special hospitals with sufficient staff to provide appropriate care for offenders with mental disorders[6].

To address these problems, the Medical Treatment and Supervision (MTS) Act (the Act on Medical Care and Treatment for the Persons Who Had Caused Serious Cases under the Condition of Insanity) was enforced in 2005[7], and the Japanese forensic mental health system underwent reform. Under this new scheme, individuals committing a serious criminal offense in a state of insanity or diminished responsibility would be dealt with in a judicial, administrative framework. The public prosecutor is responsible for making allegations to the District Court to render judgment. The offender is sent to a hospital, usually soon after the public prosecutor makes an allegation to the court. In the term of hospitalization for 2 to 3 mo, psychiatric examination and treatment are implemented; this assessment period is known as hospitalization for assessment (HfA, kantei-nyuin)[8]. The District Court forms a judgment panel consist of one judge and one mental health reviewer (seishin-hoken-shinpan-in), with the latter being selected from a group of psychiatrists who hold a judgment physician license (seishin-hoken-hantei-i), which is a national license for forensic mental health specialists. A second psychiatrist with a judgment physician license is then appointed by the panel of the District Court to be an examiner psychiatrist (kantei-i), who is required to write a report on the psychiatric evaluation of the patient. At the end of HfA, the panel makes a final decision based on the reports written by the examiner psychiatrist and the rehabilitation coordinator (shakai-fukki-chousei-kan) working in a probation office, with refererence to the opinion of the mental health advisor (seishinhoken-sanyo-in) who is a discretionary member of the panel. The panel can arrive at three possible verdicts: hospitalization orders, community treatment orders, or no treatment/release. In the case of a hospitalization order, the offender is sent to a designated inpatient facility by the government officials. If either of the first two options is selected, the offender is then obliged to submit to continuous supervision by a rehabilitation coordinator[9]. When the offender cannot adhere to treatment in the community, the probation office can make an allegation for a recall order, based on the deliberate assessment regarding the risk of recommitting.

In 2008, the Japanese Government published a list of 239 Japanese psychiatric hospitals for the purpose of HfA of mentally disordered offenders[10]. According to an official report, this has now increased to 286 hospitals[11]. However, the criteria used to elect these facilities are vague. The MTS Act provides little information on the regulation for even the minimum requirements these facilities must meet, which has led to marked variations in conditions[12]. To minimize this variation and improve the quality of assessments, we previously conducted a written mail survey of leading Japanese forensic mental health experts. This resulted in the development of expert consensus for many HfA treatment standards. We therefore concluded that these consensus statements should be widely publicized among practitioners to ensure better management during HfA[9].

Since the MTS Act was enforced some 9 years ago, several papers have been published on subsequent outcomes[13,14]. In contrast, the status of HfA is rarely reported, either officially or unofficially. Therefore, we have conducted an annual, national audit study to monitor HfA facilities and subjects.

This study aims to clarify the current situation of HfA and to examine the changes in the contents of HfA from the past to now. We first present the data obtained in the 2013 survey, and then compare the results of the obtained data in 2007.

In this study, we attempted to clarify the current focus of HfA as well as the changes in its operation. We gathered data for almost half of all cases subject to HfA in 2012-2013 and compared it with the data in 2005-2007. This revealed several important considerations for the proper management of patients under HfA.

Approximately one-third of the facilities accepting HfA cases were administered by an official state organization. Considering that more than 90% of psychiatric hospital care is administered by the private sector in Japan, and that the majority of private hospitals accept official involuntary hospitalization cases[16], private hospitals appear reluctant to participate in HfA. Moreover, there tended to be higher staffing levels in facilities accepting the HfA cases; that is, only hospitals with adequate staff could cope with the offenders with mental disorders.

In our study, men were 2.5 times more likely to be subject to HfA than women. Men are known to commit crimes 5-10 times more often than women, particularly homicide[17,18], yet a higher proportion of women (19/76 = 25%) committed homicide in our study (21/196 = 10.7%) (χ² = 6.23, df = 1, P = 0.01). This may have been due to the considerable amount of infanticide cases by mothers, which is common in Japan[19,20].

The mean age of offenders in the 2013 survey was significantly higher than that in the 2007 survey. Considering that the mean age in Japan increased from 43.7 in 2007 to 45.5 in 2013[21], this difference may be consistent with societal trends. Furthermore, most offenders had no history of marriage, which is also consistent with a questionnaire survey of mental health care users in which just 13.0% (132/1016) of the participants lived with a spouse[22]. In contrast, 80% of the responders had an occupational history. In another survey of psychiatric outpatients, we reported that 40% of patients had no current occupation[23], while a survey of mental healthcare users revealed that one-fourth earned enough money for daily living[24]. Even after accepting the limitations of combining these findings, it appears that forensic patients have superior occupational performance to standard psychiatric outpatients. The relationship between executive function and offending in patients with mental disorders remains controversial[25], and further analyses with sophisticated datasets will be required to investigate the association between occupational history and serious offending.

Almost half of all offenders in these surveys were under ongoing psychiatric treatment, and relatively few were therapy naïve. This is much different from that reported in other countries[26]. It may therefore be essential to enrich the care for patients already attached to medical practitioners, rather than to introduce a new treatment pathway for patients without a therapeutic history. This approach could reduce serious crimes by patients with mental disorders in Japan.

The percentage of HfA cases implementing the use of psychiatric testimony increased between the survey periods, suggesting that prosecutors have come to consider the criminal responsibility of offenders deliberately. This tendency is consistent with the establishment of the Lay Judge Act (2009). According to this new legislation, in the case of serious crimes where the defendant can be subjected to the MTS Act, a lay judge system is used; since its enforcement, psychiatric testimony has been more common in Japan[27,28]. Prosecutors appear to require psychiatric testimony in any cases of questionable criminal responsibility, subject to the lay judge system, leading to a higher proportion of psychiatric testimony in HfA cases. This is advantageous in terms of clarifying diagnoses, but can delay medical treatment that tends to be withheld during psychiatric testimony, which may cause the offender’s mental state to deteriorate.

Most offenders subjected to the HfA in these surveys had schizophrenia or some other psychotic disorders. This is expected considering only those considered to be irresponsible or to have diminished responsibility were subject to HfA. In contrast, dual diagnoses were identified in approximately one-fifth of the cases, which is less than that previously reported in other countries[26,29]. It was reported that 23.3% of inpatients treated under the MTS Act in designated hospitals had dual diagnosis, including intellectual disability, developmental disorders, and substance misuse[30]. This discrepancy suggests that dual diagnoses were overlooked in some cases at the HfA stage. Deeper investigation is necessary to make a precise diagnosis during HfA to determine the best treatment strategy for the subjects.

The majority of the offenders were prescribed medication, which is rational considering the fact that most of them were diagnosed with schizophrenia. Facilities accepting HfA cases seem to be disciplined in prescribing medications for the offenders in the same way as they would for other patients with mental disorders, as recommended by expert consensus[9]. However, fewer offenders received injectable psychotropic drugs during HfA in the 2013 data than that in the 2007 data. This could suggest that recent offenders were adequately treated with oral medication and did not need injections. A solid knowledge base and sophisticated HfA procedures probably help in minimizing the reliance on invasive treatment. On the other hand, accumulating evidence suggest the efficacy of LAI of antipsychotics upon patients with psychosis[31,32]. It is highly estimated that offenders with psychotic disorders are adaptable to LAI in terms of maintaining compliance and stabilizing their mental state. However, the term of HfA is limited to 2 or 3 mo. Introduction of LAI at the initial stage of HfA has some difficulties, such as the risk of misdiagnosis and acquiring informed consent. Forced LAI induction is not recommended by experts in the HfA[9]. An appropriate strategy of using LAI in the HfA should be established.

Most offenders were secluded during the HfA process, although the precise term of seclusion varied. Therefore, the likelihood of seclusion was much higher than that in acute psychiatric units in the US[33]. In Japan, the standard management of patients with schizophrenia, and therefore risk for harm to others, tends to involve physical seclusion[34]. Our surveys revealed that the proportions of secluded offenders have not changed since the MTS Act was enforced. One of the reasons for frequent seclusion in Japan seems to be a small number of nursing staff, as experts recommended rich human resource in the HfA setting[9]. The fact that the seclusion rate per bed in a year is only 0.1-0.2 in designated inpatient facilities[35] is consistent with the estimation above. Although restraint was less frequent than seclusion, it continues to be used at similar rates in 2013. Reductions are necessary in both these areas, when possible.

While this is a controversial topic, it is recommended that the examiner psychiatrist should be selected from among the psychiatrists at the hospital where the offender is hospitalized because this brings practical advantages[36]. In almost 90% of respondents in the 2013 survey, the examiner psychiatrist met this criterion, which had increased from the 2007 data. This result suggests improved processes for selecting the examiner psychiatrist.

In terms of the panel decisions, hospitalization orders were more common in the 2013 data than in the 2007 data, and community treatment orders were less frequently adopted. We assume that the panel has become more defensive over recent years. In July 2007, the Supreme Court made a verdict that it is inappropriate to withhold treatment orders for offenders who need psychiatric care as part of the MTS Act simply because adequate care can be provided through the Mental Health and Welfare Act[37]. After this verdict, offenders requiring any inpatient care were to be hospitalized in designated inpatient hospitals under the MTS Act, regardless of the severity of their mental disorders. Another possible explanation is more practical; some years after the MTS Act was brought into law, several hospitals opened new wards to accept the cases of MTS act. It is possible that bed shortages initially suppressed the decision to hospitalize patients early after the introduction of the MTS Act.

In conclusion, the characteristics of offenders with mental disorders did not change between the two survey periods. In contrast, treatment and administration of subjects under the HfA has improved to some extent. Nevertheless, several challenges must still be overcome to ensure proper treatment in the HfA setting.

The main limitation of this study is its inherent selection bias. All respondents of our survey voluntarily returned the questionnaires we sent. Therefore, it is possible that only those facilities in which the staff was willing to participate in the HfA responded to our survey. Even after confirming that the proportion of cases was consistent with that in official reports, care should be taken when generalizing our results to the broader HfA landscape.