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Wednesday, Feb. 20, 2008
TIME, TRAINING, COVERAGE ELUSIVE
Treating clinical depression a tall order
By TOMOKO OTAKE
Depression is no stranger to Japanese society, but only within the last decade has its "clinical" component gained currency along with the realization that the malady can affect almost anyone.
According to the Health, Labor and Welfare Ministry, one in 15 people in Japan suffers clinical depression at some point in their lives.
Depression is considered the leading cause of suicide. And in the industrialized world, Japan has the highest rate. Out of 100,000 people, 12.8 females and 35.6 males will kill themselves. This has translated into more than 30,000 suicides annually in recent years.
Public awareness of depression has grown in recent years, but treatment options are limited. Most people turn to antidepressants and other drugs. Few have access to, or seek out, psychotherapy, unlike in North America and Europe where this option is believed effective treatment.
Experts fault Japan's national health insurance system, which discourages doctors from spending a lot of time with patients, and the shortage of professionals trained in verbal forms of therapy.
However, more people are turning to professionals.
One man, who is in his early 30s and works for a Tokyo brokerage, is undergoing cognitive behavioral therapy,or CBT, through a clinical psychologist.
The man, who didn't want his name used, was diagnosed with depression in late 2006, after suffering sleep deprivation, stomachaches and headaches apparently triggered by his job.
He said his health began to deteriorate soon after he switched jobs and started at his present firm, where he encountered an extremely competitive atmosphere and workers cold and hostile to newcomers. He also had to work more than 80 hours of overtime every month.
He ultimately had to take a 10-month rest leave. During this time, he took medication, including antidepressants, but also became interested in CBT after reading that such therapy helps to prevent depression from recurring.
Recently back at work, he is now in the "assessment" stage of the 12- to 18-month program, where he spends a good portion of his one-on-one meetings with a therapist recalling in detail the circumstances that triggered his depression.
"For example, my therapist tells me to recall the circumstances right before and after a particular event that brought me to tears," he explained. "The therapist would tell me to describe in detail how I dealt with the situation, including my feelings at the time, my thoughts, actions and physical symptoms."
While seeking out cognitive behavioral therapy, the man found that the cost and nature of such treatment vary enormously among clinical psychologists, and that some practitioners may be better than others, although this is hard to gauge.
He pays ¥10,000 per 50-minute session, which he has twice a month. Full-scale psychotherapy is not covered by public insurance and clinics and hospitals are free to set their own prices.
Psychotherapy is practiced in Japan by a wide range of people with varied expertise and training, from "rinsho shinrishi" clinical psychologists to other counselors certified via one of nearly 20 private-sector groups with accreditation systems, including the Japan Industrial Counselors Association and the Japanese Association of Counseling Science.
Psychologists are calling for government accreditation, said Mariko Okumura, a clinical psychologist and member of the secretariat at the Japan Society of Certified Clinical Psychologists.
The group represents more than 13,000 psychologists certified through an exam held by a semigovernmental board. To take the qualification exam, applicants must have finished graduate-level study in clinical psychology at schools designated by the board.
Okumura said the group has pushed for government accreditation of clinical psychologists for 20 years to improve the recognition and social standing of such professionals — but to no avail.
Most psychiatrists, who are medical doctors, use only medication to treat depression, often with minimum communication with patients.
The Tokyo brokerage employee recalled how one doctor rushed to prescribe drugs after a brief exchange like this: "Hi! How have you been?" "Well, I haven't been feeling so great." "OK, let's change your prescription."
Even doctors who use psychotherapy do not have adequate time for treatment because the public health insurance system does not reward lengthy patient sessions, said Dr. Hiroko Mizushima, a former member of the House of Representatives who now offers interpersonal psychotherapy, which is also believed effective in treating depression, in Minato Ward, Tokyo.
In her calculation, doctors can afford to spend only up to 20 minutes per patient if they want to cover the therapy sessions by public health insurance and not go bankrupt, Mizushima said.
"Most other doctors would say they can only afford to spend 15 minutes. With 15 minutes per visit, there is no way you can practice any kind of psychotherapy," she said.
Mizushima provides full-scale psychotherapy, but it is not insured, which means patients must pay 100 percent of their bill. Public health insurance covers up to 70 percent in cases of insured treatments.
Psychotherapists are meanwhile in short supply in Japan and there is a shortage of professionals who can train future ranks. Experts, however, are sharing verbal therapy knowledge and knowhow.
Yoshihiko Tanno, a professor of clinical psychology at the University of Tokyo, said he and around 20 other top professionals set up the Tokyo Academy of Cognitive Behavioral Therapy in 2006.
"Ideally, graduate schools that prepare students for the clinical psychology qualification exam should be teaching CBT, which is common practice in the U.S. and U.K.," Tanno said. "But because CBT is still relatively new in Japan, very few people can teach how to practice it."
The academy has held eight workshops on CBT in Tokyo — four times a year — covering a combined 2,100 students, Tanno said, noting a third of them are doctors, including psychiatrists, pediatricians and physicians. Another third are active clinical psychologists and the rest are nurses, social workers and others, he said.
"We would like to hold our workshops in other cities, as many attendees have had to come from all over the nation. Eventually, we would like to offer e-learning on CBT as well."
Shin-ichi Suzuki, an associate professor of clinical psychology at Waseda University in Tokorozawa, Saitama Prefecture, said the need for government support for psychotherapists will only grow because more people, including cancer patients, are beginning to demand such services.
"In the near future, psychological care will transcend the boundary of psychiatry and will become a major element of Japan's health care, as needs for such care are growing among cancer patients and sufferers of chronic illnesses," he said.