People with Mental Disorders and the Disability Pension System in Japan (February 2004)

Written by Emiko Kikuchi, Community Life Support Center Sora and translated by Japanese Society for Rehabilitation of Persons with Disabilities

Income security for people with disabilities

According to the 2003 White Paper on People with Disabilities, it is estimated that people aged 18 or older with physical disabilities number 3.422 million and people with intellectual disabilities number 342,000 (including people with more than one disability). People who are receiving medical treatment for psychiatric disorders (schizophrenia, depression, manic depression and other emotional disorders, neuroses, etc.; onset mostly during and after puberty) are estimated to number 2.04 million. Available data indicate that more than several million people with disabilities in Japan face the serious challenge of self-realization.

According to the " Survey on the Status of Employment of People with Disabilities in FY 1998 " published by the former Ministry of Labor, people with disabilities employed by business establishments with five or more employees (regular, part-time or other employees) were estimated to number 396,000 for those with physical disabilities , 69,000 for those with intellectual disabilities, and 51,000 for those with mental disorders. This suggests that it is unlikely they can achieve financial independence through work. We must keep in mind that many people with disabilities who are unable to achieve financial independence through work have no choice but to depend on family support or public welfare assistance under Japan's disability pension system, which has continued to leave a great number of disabled people without pension benefits. (Disability pension recipients are estimated to number approximately 1.8 million.) Having been engaged in livelihood support for people with disabilities on a daily basis, our center has witnessed the vicious cycle whereby elderly parents have kept providing daily care and economic assistance (living expenses, medical expenses, national pension premiums, nursing-care insurance premiums, etc.) to their grownup children with disabilities, whose inability to become independent of their parents in turn has made their livelihood more unstable and limited their growth and potential . The disability pension system and other income security measures for people with disabilities should be addressed, because these underlie the lives of people with disabilities, enabling independent community life and social participation based on self-determination and choice.

Disability pensions and people with mental disorders

It goes without saying that the disability pension system plays a central role in income security for people with disabilities in Japan. For people with mental disorders, who have historically lagged behind people with other disabilities in terms of receiving proper attention, disability pensions , which have long covered them, are of great importance (the system was inaugurated in 1961 and mental disorders have been covered since 1964). The Fundamental Law for People with Disabilities in 1993 legally defined people with mental disorders as "those with disabilities," and the enactment of the Mental Health and Welfare Law in 1995 led to the establishment of a system of "mental health welfare handbooks" for people with mental disorders. There is now a greater awareness of the necessity of welfare measures for disabilities caused by diseases in people with mental disorders. Also, improvements have been made, albeit partially, by amending laws from the perspective of measures already practiced in other fields of disability.

Nonetheless, a belated understanding of mental disorders as disabilities has kept these disorders outside the system (a system that includes child rearing allowance, welfare allowance for children and adults with physical and intellectual disabilities and other welfare allowances provided by local governments; discount fares, free passes and the like for Japan Railways and local transportation; recently, some local governments have begun to consider mental health welfare handbook holders as being covered by the system). In addition, the aforementioned delay has brought about disadvantages in disability assessment (underestimation), which makes for a very user-unfriendly system (e.g., special physically handicapped person allowance, welfare allowance for children with disabilities, and support and mutual aid system for people with physical and intellectual disabilities). The situation in which disability pension and welfare public assistance alone serve as the recourse to improvement or resolution of economic challenges caused by chronic diseases and prolonged disabilities remains unchanged. Disadvantages in income security pose more serious problems for people with mental disorders than for people with other disabilities.

As for the number of persons receiving disability pension due to mental disorders, recipients of the Disability Basic Pension number approximately 220,000 (70% of whom are under the noncontributory plan) and those of the Disability Employees' Pension are estimated to number about 40,000. It is estimated that the total number of such recipients, including those of the Disability Mutual Aid Pension, is below 300,000. Most people with mental disorders are without pension benefits - even those who need disability pension. Recipients of disability pension are required to satisfy two requirements: 1) a payment requirement (condition for premiums to be paid by the date of the first medical examination; this condition is not required when the date of the first medical examination comes before age 20); and 2) disability condition requirement (whether or not the degree of the disability applies to disability assessment standards as of the day the disability is diagnosed). For certification that these requirements have been satisfied, specified application documents (e.g., certificate of the date of first medical examination and medical certificate) must be submitted. Nevertheless, it is difficult for people with mental disorders to satisfy requirement 1) , and to submit application documents and fulfill the requirement stated in 2) . As a result, a great number of people with mental disorders are without pension benefits.

Mental disorders that do not fit into the disability pension system

Payment requirements and mental disorders

Since pensions are part of the social welfare insurance system, those who receive benefits must pay a specified premium. But unlike retirement, a foreseeable event, it is difficult to prepare for unpredictable injury, disease or disability. It is hard to be aware of the onset of schizophrenia and other psychiatric disorders (as is also true for internal disorders, intractable diseases and the like) and the impact (disability) on everyday life increases as the symptoms progress over the long term from prodromal to acute. Normally, patients and their families do not realize that they are mentally ill because of the way in which psychiatric disorders develop. In many cases, people reach medical institutions in serious condition and only after a long delay since onset. In a society where prejudice remains deeply rooted, the date of first medical examination can vary greatly depending on the social support systems available for patients and their families .

Disability condition requirements and mental disorders

Lagging awareness of what constitutes a disability has had a more serious impact on disability assessment for disability pension than for other types of disabilities. Although disability assessment standards and medical certificate forms have been revised, the assessment has still tended to place a disproportionate emphasis on symptoms. In other words, degrees of disability caused by diseases are not assessed in the context of individual living conditions. Also in disability recognition, lack of pension benefits and disadvantageous grades easily occur due to the nature of mental disorders as well as problems of the support system.

Problems concerning certificates of the date of first medical examination and medical certificates (used to determine the assessment day of disability)

Since the medical institutions people with mental disorders currently go to are more often than not different from those they went to for their first medical examination, they may be closed or clinical charts may have been destroyed (the statutory retention period for clinical charts is five years) if many years have passed since the date of first medical examination or the date of disability assessment. Such cases result in full loss or reduction of pension benefits (retroactive claims become impossible) because of failure to obtain a certificate of the date of first medical examination and medical certificates as of the date of disability assessment. There are cases in which applications have been accepted from an applicant who uses petitions in place of the certificate of the date of first medical examination and other evidential documents that enable the date of first medical examination to be identified (e.g., patient registration card, receipts and records in housekeeping books). Nonetheless, even when conditions 1) and 2) are satisfied, a great many people have gone without pension benefits or have received reduced benefits due to irregularities in application documents that are certainly not the responsibility of the persons in question.

The present disability pension system has countless problems: operational problems, problems that transcend each disability and problems unique to each disability. These problems can be seen through the state of individuals with mental disorders receiving pension. It is becoming clear that the disability pension system must be improved to prevent disabled people from going without pension benefits . This means not only improving the system to prevent the nonpayment of premiums and problems concerning the storage of medical charts issued by doctors, but also studying ideal disability assessment from welfare perspectives according to the objectives of disability pension (prevention of income declines and economic disadvantages due to disabilities).

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