Ben Hills 

He made the best of it as he mingled with the crowned heads of Europe at the glittering banquet to celebrate the royal wedding of 2010, the marriage of Sweden’s Crown Princess Victoria to her personal trainer, the dashing Daniel Westling. Shiny decorations the size of drink-coasters adorning his morning coat, Japan’s next emperor smiled dutifully for the cameras and chatted in English with the other royal guests.

But there was no hiding the fact that something was missing from the happy picture. While Crown Prince Naruhito enjoyed the Scandinavian pomp and ceremony, his princess was housebound in their palace in Tokyo where she has been confined for most of the past eight years with a debilitating mental illness that no-one in Japan dares discuss, let alone offer an effective treatment for.

Nineteen years ago when Masako Owada married into the imperial family she was hailed as a breath of fresh air: a high-flying diplomat, a Harvard graduate fluent in five languages, it was hoped that she would bring the ancient institution into the 20th century. Today, crushed by the oppressive palace bureaucracy, denied any meaningful role, harshly criticised for failing to produce a (male) heir, her life is a misery.

Raise medical care in Japan with knowledgeable people it and you will typically be met with a shrug and a comment such as “First world country — third world medicine.” Nowhere is this more accurate than in psychiatry. A recent survey by the World Health Organization√ of treatment for mental illness in seven Asian countries found that Japan (along with China) did worst — even the gathering of statistics was “still in its neo-natal stage.”

Princess Masako is merely the most prominent victim of the system. Officially she is suffering from tekiou shogai, an adjustment disorder. However the World Health Organisation’s publication ICD 10, the internationally-recognised Bible of psychiatry, defines this condition as ‘mild depression’ brought on by a stressful life event and says that it always resolves within six months, either by itself or with the help of counselling and mild medication. After eight years it is obvious to all but her minders in the Imperial Household Agency that Masako is actually suffering from deep depression and needs serious help.

Superficially Japanese appear to suffer far less from mental illness than people in other developed countries: only three people in 100 suffer from a ‘major depressive disorder,’ one third the rate of a country such as the United States. However, there is good reason to believe that this is due to chronic under-reporting and a reluctance by doctors to diagnose anything demanding more than a bottle of pills and a good lie down.

If you look at suicide statistics a different picture emerges. Japan has the highest rate in the world (barring the suffering countries of the former Soviet Union, Korea and war-torn Sri Lanka): 36 men and 14 women in every 10,000 kill themselves every year, a figure five times the national road toll, three times the rate of the United Kingdom and double that of the United States. Interestingly, while the rate for females has fallen slightly since World War II the male rate has almost doubled, boosted by the recent spate of schoolboys gassing themselves over charcoal braziers in chatroom suicide trysts.

Why the stigma? Etsuro Totsuka, professor of human rights law at Kyoto’s Ryokoku University, nailed it in an article for the British journal The Psychiatrist. In Japan, he wrote, mental illness has traditionally been regarded as “…genetic, incurable, impossible to understand and dangerous… the mentally ill were a disgrace to the family… the Japanese did not want to talk about them, did not want to see them, to hear about them, to get married to them and to employ them.”

Although the first chair in psychiatry was established at Tokyo University more than a century ago, until recent times treatment has been little better than medieval. Right up until the 1950s mental patients deemed a danger to society or themselves were the responsibility of their families, who walled them up in cells in their own homes by the thousand. The mentally ill were banned from public places including swimming pools, baths, ferries, art museums and historical monuments, and were barred from a range of professions including barbers, beauticians, cooks, interpreters and guides.

It is a terrible irony that by the time Japan began constructing what became a gulag of mental asylums in the 1950s, the rest of the world was already dismantling its huge, Dickensian institutions and discharging patients into society where (so the theory went) they could lead more normal lives, with the aid of modern drugs and social support. Between 1955 and 1980 the number of inmates of mental hospitals in the US fell by 80 pc (from 34 to seven per 10,000) while in Japan it rose 500 pc, from five per 10,000 to 26. Japan today still has, by a huge margin, more mental inpatients than any country on earth — about 350,000, proportionately 13 times the number in the US and four times as many as in the UK.

Daunted by the twin imperatives of having both the world’s largest public sector debt and the world’s most rapidly-aging population (older people pay less tax and suffer more mental illness) the Japanese government has attempted to reign in its crippling mental health budget. In 2004 it announced plans to empty 70,000 psychiatric hospital beds within 10 years — but halfway through the programme it was forced to admit failure, with a reduction of fewer than 7000 patients.

How did it come to this? Because the government poured tens of billions of dollars a year of tax-payers’ money into funding these patients, and allowed private entrepreneurs (many of them psychiatrists) to build the hospitals, 80 pc of which are privately-owned. The hospital-owners privately refer to their patients (the majority of whom are compulsorily committed by their families) as “treasure” and are naturally reluctant to release them. The average stay of a patient in one of Japan’s hospitals is 390 days, compared with only 10 in the US — many people with a common disorder such as schizophrenia, who in the West would be prescribed drugs and allowed to live in the community, spend their entire lives in a locked ward sedated to the eyeballs.

If the treatment they were receiving was world-standard it might be argued that a Japanese psychiatric hospital was a better place for a mental patient to be than sleeping rough on the streets or in a prison cell, which has been the fate of many of those discharged during the dismantling of western mental institutions. But that is not the case.

According to Professor Gordon Parker of the University of New South Wales, one of Australia’s most eminent psychiatrists, psychiatry in Japan is “…very unusual, very quaint, very idiosyncratic and often quite bizarre.” Doctors, who sell the drugs they prescribe (a highly-profitable sideline) “dispense them like sweets — the theory is that if one drug works two will work even better, so they will dispense three or four of them.” Extraordinarily, Japan spends more on medication than on the staple food, rice.

The Japanese media have coined a phrase to describe this — kasuri zuke shakai, or ‘drug pickled society’ and it has had particularly nasty effects on mental patients. Some years ago the medical journal The Lancet surveyed thousands of schizophrenia patients in 16 Japanese hospitals and found that half of them were taking at least three drugs and18 pc four or more . As a result many patients were suffering “extrapyramidal side effects” — movement disorders which can include paralysis. Hardly surprisingly, other surveys have found that the majority of patients want to be discharged, and between 30 and 60 pc — up to 200,000 people who are currently locked up — have been evaluated as capable of living in the community, with support.

And this One-Flew-Over-The-Cuckoo’s-Nest saga doesn’t end there. Not only are psychotropic drugs over-prescribed, many of them are only-in-Japan concoctions of doubtful benefit which have never been approved in other countries. And many Western drugs which have been shown to be useful for decades are banned or otherwise restricted in Japan.

Pfizer’s Zoloft, for example, which was once the world’s most popular anti-depressant was not approved in Japan until 2005, a decade after it began helping patients in the US. Eli Lilly’s Prozac, another useful anti-depressant, was never released in Japan at all because the company’s consultants advised that there was no market for it as “depression is not acknowledged in Japan as a mental illness.”

None of this bodes well for the woman who will be obliged to take on the arduous duties of  Japan’s next empress within a few years. Denied the benefits of modern psychiatric care, Masako — like millions of her future subjects — seems doomed to a life of unremitting and unnecessary illness.

Publishing Info

Pub: BBC Website
Pub date: 22 May 2012