Priorities for the Japanese Economy in 2016 (January 2016)

Year One in the Era of Mental Health Care

Senior Fellow, RIETI

The revised Industrial Safety and Health Act, which requires companies with 50 or more employees to perform stress checks, was enforced in December 2015. Stress checks are an annual examination of employees' stress levels including symptoms of depression and anxiety. As the first stress checks are obliged to be carried out within a year of the enforcement of the law, many businesses will be offering their first stress checks in 2016. Perhaps this will result in more frequent identification of people suffering from mental health problems and more people receiving treatment. Businesses may also start to deal more proactively with mental health than ever before. If so, then 2016 will be remembered as year one in the Era of Mental Health Care.

Current state of depression treatment

If stress checks are to be meaningful, there has to be a high rate of recovery in those cases of mental illness identified by stress checks. But will mentally ill people really recover at a high rate? I looked for the studies examining the recovery rate from depression by various treatments. According to the Japanese version of Wikipedia, treatments commonly used for depression include rest, psychotherapy, pharmacotherapy, and electroshock therapy (Note 1). The following discussion will touch on each of these with the exception of electroshock therapy.

First, a review of the use of pharmacotherapy to treat depression in children and adolescents found that 67.8% of patients recovered (Note 2). According to STAR*D research that allowed the prescribed drug to be changed up to three times and which tracked the recovery rates of each drug in sequence, 33% recovered with the first drug, 57% with the second, 63% with the third, and 67% with the fourth (Note 3). In other words, quite a few people do not recover from depression even if they take therapeutic drugs. Additionally, antidepressants have been shown to be more effective the more severe the symptoms of depression are, but their effectiveness is not so clear if the original symptoms are not very severe (Note 4).

Next, the same review (Note 2) looked at psychotherapy as well and found a recovery rate of 53.7%. While there are many types of psychotherapy, cognitive behavioral therapy (CBT) is widely known as the effective treatment of depression. However, CBT is not a panacea. First of all, there are extremely few therapists in Japan who are trained well to provide CBT. Internet CBT, which a patient can access via a computer and does not involve a therapist, can offer CBT to a large number of people but is not yet satisfactory. The limitations of internet CBT are revealed by its high dropout rates and temporary effects (Note 5). CBT can also be self-administered by reading books, also known as bibliotherapy (Note 6). As far as I know, however, there has not been any research to examine the effectiveness of bibliotherapy for depression in Japan. In addition to the above mentioned limitations, a recent study suggested that the effectiveness of CBT is diminishing over time. The researchers conjecture that the initially high level of effectiveness of CBT may be the result of the placebo effect shown in the initial stage of introduction of new therapies (Note 7).

Regarding rest, I looked for studies showing the effect of rest on depression but found nothing that really seemed to qualify as evidence. Curiously, rest is not even listed as a method of treating depression in the English version of Wikipedia (Note 8). For workers, work-related stress seems to be often the cause of depression, so depression may abate temporarily when the patient takes time off from work. In many cases, however, workers cannot stay away from work for a long time due to economic reasons. And those who take time away from the job to treat depression may face high hurdles when returning and find it difficult to find a job elsewhere. Supposing that there is still no research verifying the effectiveness of rest on depression, research really should be done that examines the long-term effects, including the impact on the person's employment status. This should be done using trustworthy methods, such as randomized controlled trials (Note 9).

Expectations of new research

It seems to me that not enough money is being spent on research on mental health in Japan. We find bright spots in medical research, such as the discovery of induced pluripotent stem (iPS) cells and cancer treatments. But research on mental health is not given a high priority in spite of its importance. Perhaps I am mistaken, but it seems we could be dedicating more resources to mental health research.

Next, I would like to point out some areas of mental health research that should be prioritized. It may seem odd, but the fields of mental health care that I find most hopeful might be folk remedies or alternative therapies. Concrete examples include the Sedona Method, The Work of Byron Katie, and the Emotional Freedom Technique (EFT). The Sedona Method uses simple questions to help the patient release negative emotions (Note 10). The Work of Byron Katie resembles CBT. It alleviates negative emotions by questioning the thoughts that cause suffering (Note 11). EFT helps the patient release negative emotions by tapping certain points on the body (Note 12).

Most psychiatrists, clinical psychologists, and other mental health professionals probably do not know these methods. However, searching online will yield plenty of information and first-hand experiential reports. These methods are becoming widespread outside the awareness of psychiatrists and clinical psychologists. Hence, they may be criticized as dubious treatment, but, in fact, I have tried them for myself and sense intuitively their effectiveness. Moreover, they seem to be cost-effective, as people can learn about them by just reading books and/or attending seminars.

I expect that these three methods and other alternative forms of mental health care will be actively studied for their effectiveness using randomized clinical trials. If research indicates that any is effective, it would help many people with mental health problems. Conversely, if they are shown to be ineffective and this fact becomes well known, many people could stop wasting time and money on questionable approaches.

Readers may be thinking RIETI could do these types of studies on its own, but it's not possible. Research to examine the effectiveness of interventions on mental health problems requires the approval from an ethical review board, such as those that exist at university medical schools and psychology departments. Mental health professionals such as psychiatrists or clinical psychologists would have to be actively involved since matters of human mental health are very delicate. Without substantial roles played by those professionals, it's almost impossible to engage in studies examining the effects of interventions on mental health problems including alternative therapy interventions.

Currently, the situation in this issue feels stuck, but change may be happening gradually. For example, the psychiatrist Hiroko Mizushima translated The Work of Byron Katie (Note 13) into Japanese. I also heard that a psychiatrist made a presentation on the Sedona Method at a meeting of the Japanese Society of Psychiatry and Neurology. Staffordshire University in the United Kingdom is reportedly researching EFT (Note 14). Hopefully, more professionals will get involved in these lines of inquiry in Japan. If that happens, 2016 indeed will be year one in the Era of Mental Health Care in the truest sense.

December 25, 2015
  1. ^ "Treatment of Depression," (2015, in Japanese). Japanese Wikipedia, (Retrieved on December 10, 2015)
  2. ^ Cox, G. R., Callahan, P., Churchill, R., Hunot, V., Merry, S. N., Parker, A. G., & Hetrick, S. E. (2014). "Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents," The Cochrane Library.
  3. ^ Gaynes, B. N., Rush, A. J., Trivedi, M. H., Wisniewski, S. R., Spencer, D., & Fava, M. (2008). "The STAR* D study: Treating depression in the real world," Cleveland Clinic Journal of Medicine, 75 (1), 57-66.
  4. ^ Fournier, J. C., DeRubeis, R. J., Hollon, S. D., Dimidjian, S., Amsterdam, J. D., Shelton, R. C., & Fawcett, J. (2010). "Antidepressant drug effects and depression severity: a patient-level meta-analysis," JAMA, 303 (1), 47-53. The following RIETI paper also takes up the issue of differences in antidepressant effectiveness by pathology. So, Mirai and Takashi Watanabe (2014), "Proposal to Promote the Entry of the Private Sector into Non-clinical Depression Related Businesses as Providers of Low-intensity Mental Health Services," RIETI Policy Discussion Paper Series14-P-001 (in Japanese). English abstract.
  5. ^ So, M., Yamaguchi, S., Hashimoto, S., Sado, M., Furukawa, T. A., & McCrone, P. (2013). "Is computerised CBT really helpful for adult depression?-A meta-analytic re-evaluation of CCBT for adult depression in terms of clinical implementation and methodological validity," BMC Psychiatry, 13 (1), 113.
  6. ^ The following book has a good reputation for use in reading therapy. Burns, David, The Feeling Good Handbook, Plume, 1990. Multiple research studies indicate this book is effective against depression.
  7. ^ Johnsen, T. J., & Friborg, O. (2015). The Effects of Cognitive Behavioral Therapy as an Anti-Depressive Treatment is Falling: A Meta-Analysis.
  8. ^ Management of depression. (2015, November 15). In Wikipedia, The Free Encyclopedia. Retrieved 12:11, December 10, 2015, from
  9. ^ I noted randomized controlled trials and their importance in the following report. Sekizawa, Yoichi, "Evidence Based Medicine Visited," Special Report, RIETI, 2015 (in Japanese).
  10. ^ Hale Dwoskin, The Sedona Method: Your key to lasting happiness, success, peace and emotional well-being, Sedona Press, 2003
  11. ^ Byron Katie, Loving What Is: Four Questions That Can Change Your Life, Harmony, 2003
  12. ^ Gary Craig, The EFT Manual (EFT: Emotional Freedom Techniques), 2008, Energy Psychology Press
  13. ^ Byron Katie, I Need Your Love - Is That True?: How to Stop Seeking Love, Approval, and Appreciation and Start Finding Them Instead, Rider, 2005.
  14. ^ Alternative tapping technique good for mental health. (Retrieved on December 4, 2015)

January 12, 2016

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