如何防止職場精神病/日本精神病保健狀況 (書評: 50年來在既得利益團體下殊少進步)

如何防止職場精神病？

2012-11-14 天下雜誌 510期

韓國，連續第八年，居經濟合作暨發展組織（OECD）會員國自殺率第一。日本，十四年來，自殺人數年年破三萬。而台灣，企業員工罹患憂鬱症、過勞死和自殺事件也不算少。
日本早已成為各國勞動安全政策的學習典範。
去年底，厚生勞動省擬訂勞動安全衛生法修正草案，規定在二○二○年以前，所有企業都有義務，對員工進行精神狀況檢查，以確實掌握勞工精神健康狀態。
還在國會審議中的這項修正案，將原本僅五○％企業需要做的事，變成所有企業的義務。並把全國六百萬家中小企業，統統納入。
修正案明訂，企業實施每年一次員工健檢時，也得做精神壓力測試。厚勞省有一份包括疲勞、焦慮和憂鬱等項目的簡易壓力檢測表，供施測參考。
過去，厚勞省根據『下一代育成支援對策推進法』，規定員工人數在三○一人以上的企業雇主，必須向所在地的勞動局，提出「行動計劃」，營造讓員工兼顧工作與育兒的工作環境。
去年四月一日起，擴大到一○一人以上的企業，也比照實施。
到今年七月止，一○一人到三○一人的企業，有九六．九％、總計近七萬家，乖乖提出行動計劃。
這一連串措施，其來有自。
每年二六○○人自殺
日本因精神疾病請求職災補償的件數，從一九九八年的四十二件，到二○一○年，暴增為一一八一件。創歷來最高紀錄，十二年成長二十七倍。

厚勞省統計，日本每年因憂鬱、過勞而自殺的上班族，達兩千六百人。因此產生的醫療支出，及勞動力損失等社會成本，一年高達十一兆日圓（約四兆台幣），相當於台灣四分之一的GDP。
○六年起，日本政府施行自殺對策基本法以來，每年花上百億日圓防治自殺。自殺人數已逐年下降，顯示已見成效。
自殺率全球第一的韓國，精神健康對策，更普及社會各層面。
由於學校及職場，均面臨激烈競爭，導致壓力產生精神疾病的案例增多。韓國保健福利部，要求明年起，韓國民眾全面接受精神健康檢查，以便早期發現、及早治療。
一生十九次精神檢查
韓國『二○一一年精神疾病流行病學調查』顯示，一四．四％的韓國十八歲以上成年人，曾有過一次以上的精神疾病經歷。但其中，僅一五．三％，接受醫院治療或專家諮詢。
報導指出，未來韓國人從小學入學前開始到七十歲，總計一生當中，將接受十九次精神健康檢查。
除了憂鬱症是共同項目外，不同年齡層有不同檢查重點：幼兒和青少年側重注意力缺陷過動（ＡＤＨＤ）、網路成癮；青壯年則是壓力、自殺、酗酒；六十歲以上高齡者，重點在壓力、自殺傾向。
韓國實際的做法是，由國民健保公司，根據對象年齡郵寄問診表，受檢者填妥表格後寄出，由健保公司評估。

在台灣，有規模的企業，幾乎都會定期給員工做健康檢查，但都只管身體，不管心理。最近兩件職災認定案，暴露出勞工心理健康受到忽略的問題。(編按：立即檢測》你的心理健康嗎？)
去年十月，台塑化一名員工自殺，被勞委會鑑定為，執行職務所致之職業病。燿華電子一名員工，以罹患憂鬱症為由，申請精神疾病職業傷病給付，歷經波折，最終鑑定獲准。
勞委會勞工安全衛生處處長傅還然表示，○九年，勞委會修正發布「勞工保險被保險人因執行職務傷病審查準則」，及「工作相關心理壓力事件引起精神疾病認定參考指引」。將精神疾病納入職業病種類表，說明台灣已有機制可以引用。
比起日、韓，動輒每十萬人有二、 三十人自殺的高自殺率國家，台灣自殺率逐年下降，去年為一五．一人。自殺連續十三年名列國人十大死因，前年起退出榜外。
然而，勞委會職業疾病鑑定委員會，受理案件卻有增加趨勢。
今年迄九月底止，受理四十八件，創歷年同期新高。其中，因工作壓力引起的精神疾病或自殺案件，有十件，佔二一％。
傅還然表示，新版職業安全衛生法，增訂雇主促進勞工身心健康之義務。未來，臨廠醫護健康服務的企業，將由現行三百人以上，逐步擴大到五十人以上的企業。
若在立法院三讀通過，「會是蠻進步的法規，與國際相比並不遜色，」傅還然說。

奇美醫院精神科主治醫師黃隆正表示，根據去年以來，支援南科園區診所駐廠經驗，發現精神健康議題漸趨重要，但投入的資源卻很少。
黃隆正建議，未來健檢項目中，也該有一套心理篩檢，以建立個人基本身心健康資料。
一來，可以作為日後身心變化的數據參考。二來，可用來參考為員工安排適當職務，例如失眠者的輪班調整等。
黃隆正語重心長地說，以公共衛生的角度，心理健康檢查、心理衛生支援，也該視為員工福利。
「雇主應該體認到，這不是花錢，而是可以讓員工生產力增加，對公司是正向的，」黃隆正說。
勞委會傅還然也強調，雇主應調整心態，「面對問題、接受事實、妥善處理。」對這些有適應障礙、需要協助的員工，應給予適才適所的工作安排。
ＥＡＰ降低離職率
目前，企業最常見的做法，就是實施ＥＡＰ員工協助方案（Employee Assistance Program）。以成立專屬單位，或引進外援方式，提供工作、生活和健康等諮詢協助。
台北捷運、台積電、統一集團、ＩＢＭ、台灣日立等企業都有類似措施。根據美國就業諮詢公司Challenger, Gray & Christmas, Inc.的成本效益研究顯示，公司每花一美元在ＥＡＰ上，可帶來三美元的成本節省效益。
 
以台灣ＩＢＭ為例，○四年實施ＥＡＰ以來，三年內，員工離職率從一○％降為八％。
奇美醫師黃隆正直言，除了企業雇主努力，政府應檢討法律面和執行面。從各層面促進，和國家競爭力息息相關的國民心理健康。

Sunday, Nov. 25, 2012

Shedding light on problems with Japan's psychiatric care

By JEFF KINGSTON

MENTAL HEALTH CARE IN JAPAN, edited by Ruth Taplin and Sandra J. Lawman. Routledge, 2012, 148 pp., $155 (hardcover)

This collection of seven chapters makes for grim reading because it details the miserable state of mental health care in Japan.

One key problem is the, "megadose culture in psychiatric care." Patients are kept sedated with massive doses of psychiatric drugs to pacify them, a situation partially due to chronic understaffing. According to these experts, this antediluvian approach fails to help these "quiet patients" and is symptomatic of wider problems.

There is a strong stigma attached to mental illness in Japan that discourages many people from seeking the help they need. But even if they do, the health care system does not cater to their needs and is skewed toward a high dosage, poly-pharmacy therapy that generates profits for the prescribing doctors.

Yayoi Imamura suggests that this problem stems from inadequate psychiatric medical education and the reimbursement system of national health insurance. These shortcomings contribute to relatively poor care (and outcomes) for patients.

Renaming the disease was undertaken to reduce the social stigma. According to Hiroto Ito, the 2002 shift in the term for schizophrenia from seishin bunretsu byo (disease of a split and disorganized mind) to togo shicchou sho (dysfunction of integration) "has been well accepted."

Perhaps, but as he and other authors acknowledge, awareness of mental illness in Japan remains low and overall public perceptions of mental disorders tend to be negative.

U.S. Ambassador Edwin Reischauer played an inadvertent role in the evolution of mental health care in Japan and a spike in social stigma. In 1964, a knife-wielding schizophrenic seriously injured Reischauer, prompting a mass media campaign highlighting the dangers poised by the mentally ill. As a result of this orchestrated public hysteria, the government introduced compulsory institutionalization. In addition, doctors were required to notify local police in cases where the patient might cause harm. In 1970, over 75,000 patients, mostly from lower income groups, were forcibly institutionalized, a figure that has dropped to 1,800 owing to concerns about patient's human rights and greater emphasis on outpatient care.

The media later became a force for reform as one Asahi reporter actually had himself committed and then reported about the mistreatment of patients.

More spectacularly, in a case that drew global attention, the media exposed gross violations and physical abuse at a mental hospital in Utsunomiya, Tochigi Prefecture, causing injuries that led to death.

Subsequently, reforms have shifted care from hospitals to rehabilitation centers and more recently to communities, with greater emphasis on outpatient care and social integration. Despite some success with anti-stigma campaigns, however, a sensationalist media is ever eager to highlight violent crimes and speculate irresponsibly about the mental health of suspects, fanning prejudice and anxieties.

According to Hajime Oketani and Hiromi Akiyama, "no major step toward fundamental and radical changes has been taken for the past 50 years."

They argue that further reform is blocked by the Japanese Association of Psychiatric Hospitals, a private industry lobby group that zealously guards its beds and profits. As a result, dysfunctional practices in Japan's mental health care system persist.

Given the high number of suicides in Japan, annually over 30,000 since 1998, there is an urgent need to improve diagnosis and treatment of mental illness, but the authors find few promising signs that the government is effectively addressing this crisis. It is encouraging, nonetheless, that a user-centered movement on mental care services is emerging, providing mutual support, mobilizing pressure against discrimination and raising awareness about problematic practices. Yet there is a long way to go.

Although this book could benefit from better editing and translation, and in some places reads like a tedious official report, it contributes to our understanding of what is wrong and what needs to be done. But at this steep price, it is one for the libraries.

Jeff Kingston is the director of Asian Studies at Temple University, Japan campus.