The “Land of the Rising Sun”…
The home of Samurai and Ninja…
The birthplace of Sony, Nintendo, and countless other technology companies which have changed our world…
The originators of Anime and Manga…
The manufacturers of Toyota, Honda and many other cars…
Japan is a country with a rich history, a strong economy, a fascinating culture, and it has a big influence on our modern world. For these reasons and others, I was very excited that I was invited to teach Japanese doctors about ADHD in early March 2012. While I was there, I presented to, and met many Japanese Child Psychiatrists and Pediatric Neurologists. I had many discussions with them about their work with ADHD.
In this blog post, I’ll share some of what I learned while I was there, and I’ll share some of my personal opinions about ADHD in Japan. Please note – this blog post really is my personal opinion. I did not see patients in Japan, I was only there for 6 days, and I did not conduct any research while I was there. Although I’ve gathered information and formed some opinions, I clearly cannot say that I have a strong grasp of Japanese culture, nor the mental health system in Japan, nor all there is to know about ADHD in Japan. That said, I hope that my thoughts can help you to understand more about ADHD in Japan. (And if you read this article, and find that my opinion has some factual inaccuracies, please let me know if the comments, and I’ll do my best to fix them.)
(and after sharing my opinions about ADHD in Japan, I’ll share about my experiences with traveling in Japan, so stay tuned…)
Firstly, you may wonder: Do kids and teens have ADHD in Japan? Do they get diagnosed, and are they prescribed medication?
The answer is: yes and yes.
Kids and teens are diagnosed with ADHD in Japan, and they are prescribed medication when they are diagnosed.
In general, to get a diagnosis of ADHD in Japan, one needs to see a Child Psychiatrist or Pediatric Neurologist. To get an assessment, a family would go directly to the specialist, as there aren’t family doctors or general practitioners in Japan. The specialists use the same assessment and diagnosis process that doctors in North America and Western Europe do.
In many ways, the challenges with getting diagnosed with ADHD are similar in Japan as they are in other parts of the world. By this I mean that there is stigma around mental health issues, and a significant reluctance for parents to give children medication. In addition to the challenges around acceptance of the diagnosis of ADHD and the use of medication which go on all over the developed world, in Japan, there have been significant issues with stimulant abuse and misuse. This has led to even more concerns around the proper use of ADHD medication in Japan. Here is a link to an article published in 1989 about stimulant abuse in Japan. There were renewed concerns about stimulant abuse in 2007, which are summarized below.
I learned about one very interesting cultural difference around ADHD diagnosis and treatment in Japan. In Japanese culture, it is important to respect other people’s personal space. When a child with ADHD has hyperactivity/impulsivity, which includes a symptom like: “interrupts and intrudes on others”, then their parents are often very concerned about this symptom, because it breaks the cultural norm. As such, parents of a child with this symptom may be more inclined to get their child diagnosed with ADHD, and they would be more inclined to give their child medication to help with ADHD. While this may be good to ensure that these children get the help that they need, it can also work against longer term treatment. In other words, when that symptom goes away (and the child is no longer interrupting and intruding on others), the parent is more likely to stop treating their child with medication. And even though that hyperactive/impulsive symptom is resolved, the child may have many other challenges with ADHD (such as inattention, restlessness, social problems, etc.).
While talking with Japanese specialists about their ADHD patients, it seemed to me that parents of kids and teens with ADHD go through issues of frustration and guilt, as they do in North America. Although I didn’t meet parents of kids and teens with ADHD in Japan to discuss this issue with them, I have a suspicion that the frustration and guilt that parents experience may be more in Japanese culture around ADHD than in Western countries.
What About Medication for ADHD in Japan?
When it comes to medication for ADHD in Japan, there are very few options. While Ritalin is available in Japan, it is illegal for it to be used for ADHD (it is currently only approved for narcolepsy). In October 2007, there was a crisis which happened in Japan over Ritalin, and a concern around its abuse. There were articles in a major Japanese newspaper – The Yomiuri (which at this point are not available on their website – and if they are, they aren’t in English). There was a significant tightening of rules around the use of stimulants for ADHD. Although I can’t access any source materials for this story, a user on ADD Forums posted a quote from the news story, when it was happening (you can find the post here). The quote said:
A panel of the Health, Labor and Welfare Ministry on Wednesday decided to remove the psychotropic drug Ritalin from its list of approved medicines to treat depression as it has become widely abused.
Following the decision by the pharmaceutical and food sanitation council, the ministry within this month will restrict the prescription of the highly addictive drug solely for the treatment of narcolepsy.
Ritalin is the brand name of methylphenidate hydrochloride, a central nervous system stimulant.
To prevent a further increase of the abuse of the drug, especially among young people, the ministry ordered Novartis Pharma K.K., the pharmaceutical company that produces and distributes the drug, to develop a system to manage its distribution.
The Minato Ward, Tokyo-based company plans to set up the system by early next year.
Under the new system, which is as strict as that applied for narcotics for medical use, doctors with expertise in diagnosing narcolepsy as well as medical institutions and pharmacies that prescribe the drug will be required to be preregistered.
Also at the panel meeting, Janssen Pharmaceutical K.K. proposed the same management system regarding the distribution of Concerta, a drug used to treat attention-deficit hyperactivity disorder.
(Oct. 19, 2007)
Prior to the release of Concerta in Japan, there were no medications officially approved for the treatment of ADHD. Doctors were treating ADHD with Ritalin, but Ritalin was only approved for the treatment of Depression and Narcolepsy. Because of the issue described above, Ritalin was only approved for Narcolepsy, and doctors are no longer allowed to use it to treat ADHD. Shortly after this issue, Concerta was released, and was approved for the treatment of ADHD.
The medications currently available in Japan for ADHD include: Concerta (OROS Methylphenidate) and Strattera (Atomoxetine).
These medicines are approved to treat ADHD from 6-18 years old.
Doctors are not allowed to prescribe the medication to anyone younger than 6 years old, and they are only allowed to prescribe ADHD medication to anyone over 18 years old if they started the medication prior to their 18th birthday. In other words, at the current time, if someone is diagnosed with Adult ADHD, and did not start medication before their 18th birthday, they would not be allowed to take an ADHD medication. I do understand that at least one of the companies which produces ADHD medication in Japan is applying for an adult indication for ADHD. If and when this is approved, it would make it easier for patients who get diagnosed with adult ADHD to receive medication for their condition.
For a published scientific article looking at the use of medications for ADHD in Japan, please view this article.
Japanese ADHD Specialists:
When I presented in Tokyo, I presented at a national ADHD meeting. There were many Japanese presenters at the meeting (which I could understand thanks to the translators). I was very impressed by the caliber of their presentations, and the wisdom and insight they shared. I have attended ADHD meetings in Canada, USA and Europe, and while all of the presentations in Tokyo were very good, there were a couple of presentations ranked in the top presentations that I’ve seen. The Japanese Psychiatrists and Pediatricians are very well trained, intelligent, they conduct great research, and they care for their patients deeply.
Prevalence of ADHD in Japan:
The prevalence of ADHD in Japan is relatively understudied. Yoshimasu published in 2006 that regarding ADHD in Japan (and Eastern countries): “the epidemiological evidence including data for incidence, prevalence, gender differences, and etiology remain insufficient.”
When it comes to the number of patients diagnosed with ADHD and the number receiving medication, my sense is that there are significantly fewer in Japan (based on population) compared to the United States or Canada. While I have no solid research upon which to base this opinion, here’s how my logic goes (from my Canadian perspective):
- Japan has a population of approximately 135 million people; Canada has a population of approximately 35 million people
- Japan has approximately 500 Child Psychiatrists; Canada has approximately 500 Child Psychiatrists
- Japan has approximately 2500 Pediatricians who treat ADHD; Canada has approximately 2500 Pediatricians who treat ADHD
In other words – for the size of the population, there is an equally sized ‘work force’ of medical specialists who assess and treat ADHD. While I don’t know the budgets of mental health treatment programs (i.e. how much money is invested in psychological treatments), based on my logic above, I suspect that overall fewer patients in Japan (based as a percentage of the population) are identified with ADHD and receive help for it than are in Canada.
Hopefully these insights and opinions are helpful to you. Please share any comments below.
Before wrapping up, I’d like to share some of my personal experiences traveling in Japan.
My Personal Experiences Traveling in Japan:
I had so many great experiences while in Japan, even though it was a very busy trip (I was there for 6 days, and I had 6 presentations in 4 cities). I hardly had time to get accustomed to the time difference, so I was always some variant of tired while I was there (except for when I was presenting, because as the saying goes: “The show must go on!”). Here are a few experiences which I enjoyed:
Grateful for the translators:
I was fortunate while I was in Japan to have two excellent medical translators. They did real time translation during my presentation, so that doctors could listen to my presentation in Japanese on headphones while I presented in English. When participants asked questions, I would listen to the question in English on headphones, while they were asking in Japanese. While most doctors could speak some English, there were few who could talk about medical issues comfortably in English (and their English was always better than my Japanese!).
When traveling between cities, I was fortunate enough to have a guide to get me to the train, or airport. Because I don’t speak or read Japanese, it is very hard to get around without help, because one can’t even read a street sign! And while many people speak some English, it is hard to get around without speaking Japanese.
Excellent Train System:
Japan has an excellent train system. It runs like clockwork, and the trains are local, express (to an adjacent city), and there are of course the “Bullet Trains”. I did take the Bullet Train from Tokyo to Nagoya. It went approximately 160 km/h, and it was smooth and comfortable. On my last day in Japan, I was supposed to take the Bullet Train from Osaka to Tokyo (so that I could go to Narita Airport to fly home), however there had been an accident earlier, and the bullet train was significantly delayed. The message we were told was that someone had slipped off the platform when the bullet train was passing through a station, so the train was not running. While it was explained as an accident, one of the psychiatrists I had spoken to expressed concerns about the high suicide rate in Japan, and how many people jump in front of trains as their method of committing suicide. While I will never know what happened to that person that day, I was certainly concerned for that person, and their family. In the end, the travel agent found me an alternate way of getting to Tokyo (via a short flight), and I got to Narita airport earlier than I would have otherwise. Interestingly, when I had no ability whatsoever to contribute to the solution of the issue, I had a surprising calm about the fact that I could potentially miss my flight. If I were in the English speaking world, I wouldn’t have had a travel agent with me, and I would have had to figure it out, or get the right help to figure it out – and in that case, I certainly would have worried more.
Expensive Taxi Ride: One of the first things I noticed when I got to Japan was the fact that the airports are quite a distance from the cities. Narita International airport is quite a drive from Tokyo, and when I arrived on a Friday afternoon, it took around 2 hours to get there. The bill for the taxi ride? The equivalent of $300! The message here is this: when you go to visit Tokyo on holidays – make sure to take the train from Narita Airport into Tokyo. It’ll probably be faster, and it will cost a lot less.
Amazing Sushi: Need I say more? As a sushi lover, I had fantastic fresh sushi in Japan. I was able to go to two different local restaurants (one in Tokyo and one in Tsu City), and the food was amazing. When I say ‘local restaurants’, I mean restaurants which aren’t tourist locations, but rather restaurants where real Japanese people eat. That’s how I love to get great food when traveling, and I loved it!
Tech Tourism: When I had time to tour in Tokyo, I went to the beautiful Asakusa temple, and then the day was getting late, and things were closing. When I was asking my guide about the different options we had, I chose to go to Ginza (a part of Tokyo), where the Sony showroom is. As a bit of a ‘tech geek’, I really enjoyed seeing the Sony showroom, which included several pieces of technology which aren’t in North America yet. I then went to ‘Bic Camera’, which was like a huge department store, with floors and floors of electronics. Although I loved seeing these great technology stores (and I didn’t spend too much), I must admit that I feel pretty geeky for visiting the tech stores in Tokyo 🙂
Wonderful People: While in Japan, I met many smart, educated, warm, caring and humble people. While I was only there a short time, I met some great medical colleagues, and made at least one good friend that I will keep in touch with.
Japan is a fascinating and complex country, and this trip has really piqued my curiosity. I look forward to my next opportunity to go back to the ‘land of the rising sun’, to experience more of what Japan has to offer.
If you are going to travel to Japan, and you take medication for ADHD, please be very mindful of the Japanese rules and laws for stimulant medication. In a future post, I will share the current rules and restrictions (hint – you can’t bring all stimulant medications into Japan…)
Here are some more of my pictures from Japan: