Schizophrenia is one of the leading causes of disability-
adjusted life years (DALYs) lost and years of life lived with
disability in 15-44-years-olds in the world (1). In Japan,
260,000 patients with schizophrenia were treated every
day in 1999, and 202,012 were admitted to a mental hos-
pital in 2002. Patients with schizophrenia represented
53% of all inpatients with mental disorders in 2002, and
their mean duration of hospitalization was 363.7 days in
the same year.
After the 2001 World Health Day, a series of initiatives
have been implemented in Japan to promote a communi-
ty-based care instead of hospital-centered care. While the
WPA Global Programme against Stigma and Discrimina-
tion because of Schizophrenia (2) was initiated in 1996,
the Japanese Society of Psychiatry and Neurology (JSPN)
had started its efforts to tackle the misunderstandings and
deep-rooted prejudices about schizophrenia already in
1993. Part of these efforts has been the replacement of the
old Japanese term for schizophrenia – “Seishin Bunretsu
Byo” (i.e., “mind-split-disease”) – by the new term “Togo
Shitcho Sho” (“integration disorder”). The new term was
approved by the JSPN General Assembly in August 2002.
This paper reviews the impact of the renaming on psychi-
atric practice in Japan.
BACKGROUND OF THE RENAMING
OF THE JAPANESE TERM FOR SCHIZOPHRENIA
In 1993, the National Federation of Families with Men-
tally Ill in Japan (NFFMIJ) requested the JSPN to replace
the term “Seishin Bunretsu Byo” by a less stigmatizing
one. The JSPN Committee on Concept and Terminology
started to examine the request in 1995. After a series of
questionnaire surveys, symposia and workshops at the
annual JSPN meeting, it was decided to change the old
term into a new one, provided that: a) the change did not
result in any disadvantage to the patients, and b) the term
conveyed the concept that schizophrenia is a disorder
defined by a clinically significant syndrome, but not a dis-
ease defined by a specific etiology, symptomatology, clini-
cal course and pathological findings. The Committee
examined several alternatives, and finally selected the term
“Togo Shitcho Sho” (“integration disorder”). After surveys
involving the NFFMIJ, the citizens and JSPN members on
the appropriateness of the new term and a public hearing,
the JSPN Board accepted the new term, which was finally
approved by the JSPN General Assembly in August 2002.
REASONS FOR THE RENAMING
The first reason for the renaming was the need to
remove the harmful impact of the diagnosis with the old
term on the patients and their families. In Japan, many
psychiatrists hesitated to inform the patients of the diag-
nosis of schizophrenia using the old term, because of the
possible negative consequences on treatment adherence
and outcome. For instance, Ono et al (3) reported in 1999
that 52% of JSPN Council members informed their
patients of the diagnosis of schizophrenia only occasional-
ly on a case-by-case basis, and only 7% of them informed
all their patients of the diagnosis. Thirty-seven percent of
the members informed only the patients’ families. On the
other hand, Koishikawa (4) reported in 1997 that only
16.6% of the patients and 33.9% of their families were
able to report correctly the diagnosis. This means that
approximately 167,000 patients with schizophrenia in
Japan spent in a psychiatric ward more than one year (on
average) without knowing what their diagnosis was. These
findings indicate a serious communication gap among psy-
chiatrists, patients and their families, which makes collab-
orative treatment and psychoeducation more difficult.
The old term identified the patient as a person with a dis-
organized personality even after recovery or full remission.
That is, once the diagnosis of “Seishin Bunretsu Byo” was
Renaming schizophrenia: a Japanese perspective
MENTAL HEALTH POLICY PAPER
In order to contribute to reduce the stigma related to schizophrenia and to improve clinical practice in the management of the disorder,
the Japanese Society of Psychiatry and Neurology changed in 2002 the old term for the disorder, “Seishin Bunretsu Byo” (“mind-split-dis-
ease”), into the new term of “Togo Shitcho Sho” (“integration disorder”). The renaming was triggered by the request of a patients’ families
group. The main reasons for the renaming were the ambiguity of the old term, the recent advances in schizophrenia research, and the
deep-rooted negative image of schizophrenia, in part related to the long-term inhumane treatment of most people with the disorder in the
past. The renaming was associated with the shift from the Kraepelinian disease concept to the vulnerability-stress model. A survey car-
ried out seven months after renaming in all prefectures of Japan found that the old term had been replaced by the new one in about 78%
of cases. The renaming increased the percentage of cases in which patients were informed of the diagnosis from 36.7% to 69.7% in three
years. Eighty-six percent of psychiatrists in the Miyagi prefecture found the new term more suitable to inform patients of the diagnosis as
well as to explain the modern concept of the disorder. The Japanese treatment guideline for “Togo Shitcho Sho” was developed in 2004
under the framework of the vulnerability-stress model.
Key words: Schizophrenia, stigma, renaming, vulnerability-stress model
Department of Psychiatry, Tohoku Fukushi University, 1-8-1, Kunimi, Aoba-ku, Sendai-shi, Miyagi 981-8522, Japan
W Wo or rl ld d P Ps sy yc ch hi ia at tr ry y 5 5: :1 1 - - February 2006
made, the patient was usually regarded as an essentially ill
person throughout his or her life. This was the main reason
why the NFFMIJ required the JSPN to change the old term.
Moreover, in many Japanese textbooks of psychiatry up
to the 1970s, “Seishin Bunretsu Byo” was essentially
described following the concept of dementia praecox. It was
characterized by a poor prognosis and a chronic process of
deterioration, eventually leading to decay of personality. It
required the physician to evaluate how the process of dete-
rioration was progressing. Not surprisingly, according to a
survey carried out in 1996 (5), 77.3% of JSPN Council
members thought that the general image of schizophrenia in
the community was that of an untreatable disease.
However, since the 1970s, Bleuler (6), Harding et al (7),
Ciompi (8) and others reported in long-term outcome
studies of schizophrenia that a majority of patients may
recover. Ciompi proposed a complex bio-psychosocial
view of schizophrenia (9) based upon the vulnerability-
stress model (10). Thus, schizophrenia is currently con-
ceptualized as a clinically significant syndrome, whose eti-
ology and pathophysiology are not yet firmly established.
Along with the modern advances in neurosciences and
the development of pharmacological and psychosocial
interventions, the investigation of the biological risk fac-
tors for schizophrenia and the achievement of social inte-
gration of the patients are two main themes of schizophre-
nia research in Japan. These recent research advances also
contributed to convince the JSPN to abandon the old
name as well as the old concept of the disorder.
A further reason for the stigmatization attached to the old
term is the history of inhumane treatment of patients with
“Seishin Bunretsu Byo” in the first half of the 20th century.
In those days, families were obliged to take custody of these
patients by a special legislation (“Seishin Byo Sha Kango
Ho”). Several patients were confined to a small isolated
room or a hut under restraints. This law was replaced in
1950 by a Mental Hygiene Law, subsequently revised in
1965. A Mental Health Law and a Mental Health and Wel-
fare Law were then implemented in 1987 and 1995, respec-
tively. After this continuing effort, psychiatric treatment and
care in today’s Japan has improved remarkably. Contrary to
this, the stigma caused by this long history of exclusion and
inhumane treatment remains deeply rooted even now.
The new term for schizophrenia (“Togo Shitcho Sho”)
refers to the vulnerability-stress model, and implies that
the disorder may be treated and that recovery is possible if
a combination of advanced pharmacotherapy with appro-
priate psychosocial intervention is used. In Japan, we use
this model for the investigation of biological vulnerability
for schizophrenia and in clinical practice.
SPREAD OF THE NEW TERM AFTER RENAMING
After the official approval of the new term, the frequency
of appearance of the old and new term in reports from men-
tal hospitals was examined monthly in the Miyagi Prefecture
and Sendai City (n = 1,944). Six months after the renaming,
the new term was used in 85.5% of cases in Sendai City and
74.5% of cases in the Miyagi Prefecture. A similar survey
was carried out in all prefectures of Japan seven months
after renaming. The new term was used in an average of
about 78% of cases in these reports (n = 17,108) (11).
Nishimura and Ono (12) reported that the percentage
of cases in which patients were informed of the diagnosis
increased from 36.7% in 2002 to 65.0% in 2003 and even-
tually to 69.7% in 2004. They also reported that 98.0% of
those who usually informed the patient of the diagnosis
used the new term in 2004, compared to 68.0% and
86.0%, respectively, in 2002 and 2003. However, 35.9% of
them also used the old term concomitantly. Thus, the use
of the new term clearly increased the frequency with
which patients were informed of the diagnosis.
In our survey of 136 members of the Miyagi College of
Psychiatrists carried out 13 months after the renaming
(11), 86% of the respondents found the new term easier to
inform patients of the diagnosis as well as to explain the
concept of the disorder. Eighty-two percent of them found
the new term more suitable to obtain consent to treatment
from patients, useful to improve treatment compliance,
effective to reduce stigma, and promising for achievement
of social integration.
The College of Chairman Psychiatrists of Japan published
in 2004 the Practice Guideline for the Treatment of Schizo-
phrenia (13) using the new term and the vulnerability-stress
model. This guideline recommends: a) a community-based
care instead of hospital-centered care; b) a multi-axial
assessment based on the DSM-IV-TR for the formulation of
a treatment plan including medication and psychosocial
intervention; c) a treatment plan adequately formulated for
acute, remission and stable phases; d) the establishment of a
therapeutic alliance including psychiatric social workers.
The above process is to be regarded as part of the WPA
Global Programme against Stigma and Discrimination
because of Schizophrenia. It kindled a series of anti-stigma
activities in many areas of Japan (14) and contributed to
new policies implemented by the government (15). It may
represent a useful model for other countries worldwide.
This work was supported in part by a grant from the
Ministry of Health, Labor and Welfare of Japan. The
author would like to thank Drs. K. Asai, T. Iwadate, S.
Ushijima, Y. Ono, K. Okagami, Y. Kim, T. Sakai, Y. Satsu-
mi (Nishimura), T. Someya, S. Takagi, Y. Nakane, K.
Moriyama for their excellent collaboration in the JSPN
Committee for Re-labeling the Term Schizophrenia (1994-
2000), the JSPN Special Committee for Renaming Schizo-
phrenia (2001-2003) and the Japanese Society against
Stigma for Mental Disorders.
1. World Health Organization. The world health report 2001. Men-
tal health: new understanding, new hope. Geneva: World Health
2. World Psychiatric Association. Schizophrenia – Open the doors,
the WPA Global Programme against Stigma and Discrimination
because of Schizophrenia. New York: World Psychiatric Associa-
3. Ono Y, Satsumi Y, Kim Y et al. Schizophrenia: is it time to replace
the term? Psychiatry Clin Neurosci 1999;53:335-41.
4. Koishikawa H, Kim Y, Yuzawa C et al. Investigation of the con-
sciousness of the patients and families about the given informa-
tion of the disease. In: Uchimura H (ed). Studies on clinical fea-
tures, treatment, and rehabilitation of schizophrenia. Tokyo: Min-
istry of Health and Welfare, 1997:12 (in Japanese).
5. JSPN Committee for Re-labeling the Term Schizophrenia. Report
of survey questionnaire on the term and concept of schizophre-
nia. Psychiatr Neurol Japonica 1996;98:245-65 (in Japanese).
6. Bleuler M. The schizophrenic disorders: long-term patient and
family studies. New Haven: Yale University Press, 1978.
7. Harding CM, Brooks GW, Ashikaga T et al. The Vermont study of
persons with severe mental illness. Long-term outcome of sub-
jects who retrospectively met DSM-IV criteria for schizophrenia.
Am J Psychiatry 1987;144:727-35.
8. Ciompi L. The natural history of schizophrenia in the long term.
Br J Psychiatry 1980;136:413-20.
9. Ciompi L. The dynamics of complex biological psychosocial systems
– four fundamental psychobiological mediators in the long-term evo-
lution of schizophrenia. Br J Psychiatry 1989;155(Suppl. 5):15-21.
10. Zubin J, Spring B: Vulnerability – a new view of schizophrenia. J
Abnorm Psychol 1977;80:103-26.
11. Sato M, Koiwa M. Prevalence of “Togo Shitcho Sho” (schizo-
phrenia) and the ripple effect. In: Ono Y (ed). Studies on the
effects of renaming psychiatric disorders. Tokyo: Ministry of
Health, Labor and Welfare, 2005:14-8 (in Japanese).
12. Nishimura Y, Ono H. A study on renaming schizophrenia and
informing diagnosis. In: Ono Y (ed). Studies on the effects of
renaming psychiatric disorders. Tokyo: Ministry of Health, Labor
and Welfare, 2005:6-13 (in Japanese).
13. Sato M, Inoue S. The treatment guideline of Togo Shitcho Sho
(schizophrenia). Tokyo: Igaku Shoin, 2004.
14. Sato M. The Yokohama declaration: an update. World Psychiatry
15. Sato M. Studies on removing the stigma against persons with
mental illness. Report 2002-2004. Tokyo: Ministry of Health,
Labor and Welfare, 2005 (in Japanese).