Families’ opinions about caring for patients with psychiatric disorders after involuntary hospitalization in Japan

Abstract

Objective:

It is imperative to know families’ opinions about where patients should live after discharge from involuntary hospitalization in the era of community mental health.

Methods:

Questionnaires were sent (March–May 2011) to 808 guardians of patients who were involuntarily hospitalized in Japan (response rate = 54.2%). The final sample size was 365 family members. Whether families wanted to live with the patient after discharge from the hospital was the primary outcome variable. The associations of the demographic characteristics of the patients and families with the outcome variable were tested using logistic regression analysis.

Results:

Approximately, 19% of the family guardians wanted to live with the patient after discharge from the hospital. Their wish to cohabit was positively associated with being a female (vs male) patient, having three or more cohabitants in the home and having lived together before hospitalization, after adjusting for the other covariates. Long-term hospitalization (10 years or longer) and siblings were significantly associated with the families not wanting to cohabit, after adjusting for the other covariates.

Conclusion:

It is important to know families’ opinions about patients’ living situations after discharge from involuntary hospitalization to provide them with an effective support system.

Keywords

Involuntary hospitalization family caregiver burden community psychiatric disorder

Introduction

The mental health system in Japan is currently on the way to a substantial reform from ‘institution-based medical treatment to community-based care’ (Ministry of Health, Labour and Welfare, 2004). As the nation with the highest number of psychiatric beds per capita in the world (2.68 beds per 1,000 population in 2012) (OECD StatExtracts, 2015), Japan is now shifting its care of those with mental illness to deinstitutionalization. One of the most timely events was the 2014 revision of the Act for Mental Health and Welfare, which has been operative since April 2014 (Ministry of Health, Labour and Welfare, 2013a). Families have conventionally played an important role in caring for psychiatric patients in Japan (Kawanishi, 2006, p. xiv). Under the previous version of the Act for the Mental Health and Welfare and its precursors (Ministry of Health, Labour and Welfare, 2013b), one family member, often the parent of a patient, was officially designated as the patients’ ‘family guardian’. A family guardian, called ‘Hogosha’ in Japanese, was responsible for protecting the patient on behalf of the other family members, particularly for approving involuntary hospital admissions, called Hospitalization for Medical Care and Protection (HMCP), ‘Iryo-Hogo-Nyuin’ in Japanese. The 2014 Revision abolished the system of family guardians and allowed any family member to approve HMCP (Ministry of Health, Labour and Welfare, 2013b). Although family guardians, by law, have not existed since the 2014 Revision, HMCP has remained the main system of involuntary hospitalization, and family members are expected to be involved in caring for patients during and after involuntary hospitalization. The family guardian is regarded as the representative of a patient’s family, making it necessary to investigate the needs of patients’ families, particularly those of involuntarily hospitalized patients under the HMCP system. In Japan, many patients live with their family members in the community (The National Federation of Mental Health and Welfare Party in Japan, 2010, 2011), and in countries with community-based mental health systems, the family has become the focus of attention as a relevant caregiver for patients with psychiatric disorders (Corrigan, Mueser, Bond, Drake, & Solomon, 2009, p. 235). As living with one’s family is a form of social inclusion in Japan, knowledge of families’ opinions about where patients should live after their discharge from the hospitals is needed to create an effective community mental health system.

The primary questions of our investigation are as follows:

Where do families of patients, who were involuntarily hospitalized, want them to live after discharge from the hospital?

Which factors predict families’ choice to live with patients after hospital discharge?

Methods

Participants

We conducted a cross-sectional survey of family guardians of patients who were involuntarily admitted to hospitals in Okayama Prefecture under the HMCP system. The survey was designed to investigate the demographic characteristics of the family guardians and patients, and the family guardians’ opinions about the patients’ admission and discharge.

In all, 20 of 24 psychiatric hospitals in Okayama Prefecture agreed to participate in the survey. We asked the participating hospitals to select patients whose ID numbers were multiples of 3 according to their admissions records, which yielded a sample of approximately one-third of the total number of involuntary admissions to each participating hospital. We asked these hospitals about the demographic characteristics of the patients and whether the patients had families. Questionnaires were sent to both family and legal guardians, requesting information about demographic characteristics, the guardians’ opinions about the HMCP system and other relevant information.

The total number of family and legal guardians was 808. From March 2011 to May 2011, we sent a letter to the guardians explaining the survey’s aim and requesting their participation in it. Responses were returned from 438 guardians (response rate = 54.2%). We excluded 58 respondents with missing data related to age, sex and their type of guardianship. Legal guardians who were not part of the patients’ families comprised 3.9% of the guardians (15/380), whom we excluded from the subsequent analyses. Thus, we analyzed data from 365 family guardians.

Ethics

We explained the aim of the survey to the hospitals and informed them that they could freely decide whether to participate in it or not without sanctions. The guardians’ survey consisted of a thorough explanation about the survey’s aim on the cover of the questionnaire. The guardians were informed that they could refuse to respond to the survey without sanctions. Therefore, the participants’ return of the questionnaire was considered informed consent. The investigators obtained patient data with removed personal identifiers from the hospitals. The study’s protocol was reviewed and approved by the Ethics Committee at the National Center of Neurology and Psychiatry.

Measures

Explanatory variables

We identified explanatory variables using the demographic and clinical characteristics of the patients and their family guardians. The demographic characteristics were the patients’ and guardians’ age and gender. The patients’ clinical characteristics were diagnosis and duration of hospitalization. The family guardians’ characteristics were family relationships and the family’s sociodemographic characteristics: the number of cohabitants, employment status, health status, having or not having lived with the patient before the hospitalization, and having or not having someone to go to for advice and/or assistance. Other demographic characteristics of family guardians, including gender of guardian, family household income and family’s house ownership, were not included in the final analysis, based on the results of assessing the model fit using the stepwise selection method.

The patients’ and family’s ages were divided into four categories: 20–44 years (reference), 45–64 years, 65–74 years, and 75 years and over. Patients’ diagnoses were classified using the International Classification of Diseases, 10th revision (ICD-10) (World Health Organization (WHO), 1993) into ‘organic, including symptomatic and mental disorders (F00-09)’ (reference); ‘schizophrenia, schizotypal and delusional disorders (F20-29)’; and ‘other diagnoses’. The duration of hospitalization was classified into five categories: shorter than 100 days (reference), 100 days to 1 year, 1–5 years, 5–10 years, and 10 years and more. The family’s employment status was categorized as ‘regularly employed’, ‘irregularly employed’, ‘self-employed’ and ‘unemployed or other’ (reference). The number of cohabitants was obtained by counting the number of family members who lived in the same household, including the family guardian, with the number = 1 as the reference. The guardian’s family relationships included spouse (reference), parent, sibling, offspring, and others. We ascertained the family guardians’ health status by having them choose any number of problems from a list of nine problems in the questionnaire, including sleeplessness, loss of appetite, fatigability, stomach ache, headache, foot pain, backache, stiff shoulder and others, if present. The number of selected problems was summed to form a total score ranging from 0 to 9, with higher scores indicating poorer health status. Responses to the questions about whether a family guardian had ‘lived with the patient before admission, or not’ and had ‘someone to go to for advice and/or assistance, or not’ were dichotomous (‘yes’ or ‘no’).

Response variable

The family guardian’s opinion at the time of survey was evaluated by the question, ‘What do you want to do when the patient’s illness has improved so that she or he can be discharged from hospital?’ The family guardian was asked to choose one of the following answers: (1) ‘I want to live with and take care of the patient at home’, (2) ‘I want the patient to live by herself or himself’, (3) ‘I want the patient to be taken care of in the hospital for as long as possible’, (4) ‘I want the patient to live in a welfare accommodation’ and (5) ‘Other’. We dichotomized these five answers to two categories. We categorized answer 1 as ‘want to live together’ and collapsed answers 2–5 into one category: ‘do not want to live together’. These binary categories comprised the response variable.

Statistical analysis

We conducted logistic regression to analyze the association between the explanatory variables and the response variable. The explanatory variables included in the final model were selected by assessing model fit using the stepwise selection method (data are not shown). We entered the demographic characteristics (the age and sex of the patients and family guardians) in Model 1. Next, we added patients’ clinical characteristics (diagnosis and duration of hospitalization) in Model 2. Finally, we added family characteristics in Model 3: family relationships, employment status, the number of cohabitants and the family guardians’ health status; their ‘having lived with the patient before admission or not’; and ‘having someone to go to for advice and/or assistance or not’ in Model 3. The odds ratios (ORs) and 95% confidence intervals (CIs) for the response variable were calculated. All p values less than .05 (two-sided test) were considered statistically significant. All statistical analyses were performed using SPSS version 18 for Windows.

Results

Table 1 shows the demographic characteristics of the participants. The majority of family guardians wanted the patients to stay in the hospital or live in welfare accommodations (74.6%, 229/307), instead of independently (2.9%, 9/307) or together. Of the family guardians, 18.9% (58/307) wanted to live with the patients after discharge from the hospital.

Table 1.

Demographic characteristics of the subjects (n = 365), 2011, Okayama.

	n (%)
Demographic factors
Patient’s age, year (SD)	67.1 (16.8)
Patient’s gender
Man	174 (47.7)
Woman	191 (52.3)
Family guardian’s age, year (SD)	64.0 (11.5)
Family guardian’s gender
Man	193 (56.8)
Woman	147 (43.2)
Missing	25
Patient’s factors
Patient’s diagnosis (according to ICD-10)
F0	150 (41.1)
F1	5 (1.4)
F2	185 (50.7)
F3	14 (3.8)
F7	6 (1.6)
Other	5 (1.4)
Patient’s duration of admission
<100 days	65 (17.8)
⩾100 days and <1 year	77 (21.1)
⩾1 year and <5 years	140 (38.4)
⩾5 years and <10 years	45 (12.3)
⩾10 years	38 (10.4)
Family guardian’s factors
Family guardian’s family relationship
Spouse	63 (17.3)
Parent	66 (18.1)
Sibling	116 (31.8)
Offspring	102 (27.9)
Other relatives	18 (4.9)
Family guardian having lived together before hospitalization
Yes	196 (53.8)
No	168 (46.2)
Missing	1
Family guardian’s employment status
Regular	73 (20.2)
Irregular	49 (13.6)
Self-employed	50 (13.9)
Unemployed and other	189 (52.4)
Missing	4
Number of cohabitants
1	104 (29.1)
2	119 (33.3)
3	66 (18.5)
More than 4	68 (19.0)
Missing	8
Number of family guardian’s health problems
0	50 (13.7)
1	119 (32.7)
2	64 (17.6)
3	57 (15.7)
4	45 (12.4)
5	17 (4.7)
6	8 (2.2)
7	3 (0.8)
8	1 (0.3)
Missing	1
Family guardians having someone to go to for advice or assistance
Yes	166 (48.5)
No	176 (51.5)
Missing	23
Family guardian’s wanting to live with patient after discharge
Yes	58 (18.9)
No	249 (81.1)
Patient be taken care in hospital as long as possible	139 (45.3)
Patient to live in a welfare accommodation	64 (20.8)
Either hospital or welfare accommodation for the patient	26 (8.5)
Patient to live by herself or himself	9 (2.9)
Other	11 (3.6)
Missing	58

SD: standard deviation; ICD-10: International Classification of Diseases, 10th revision.

The results of the logistic regression are presented in Table 2. In Model 3, the following variables were significantly associated with the family guardian’s wanting to live with the patient after discharge from the hospital: patient’s female gender (OR = 3.00, CI = 1.16–7.75, p = .02); the number of cohabitants being 3 (OR = 5.28, CI = 1.33–20.90, p = .02), 4 or more (OR = 4.46, CI = 1.23–16.21, p = .02); family guardian having lived with the patient before admission (OR = 11.41, CI = 3.73–34.93, p < .001); family relationship being a sibling (OR = 0.08, CI = 0.01–0.42, p = .003); and the duration of hospitalization being 10 years or longer (OR = 0.06, CI = 0.00–0.91, p = .043).

Table 2.

Odds ratios for family guardians wanting to live with patients after patients’ discharge from the hospital under the Hospitalization for Medical Care and Protection system, 2009 Okayama.

	Model 1		Model 2		Model 3
	OR	95% CI	OR	95% CI	OR	95% CI
Demographic characteristics
Patient’s gender
Men	1.00		1.00		1.00
Women	2.26*	1.11–4.63	2.51*	1.18–5.35	3.00*	1.16–7.75
Family guardian’s gender
Men	1.00		1.00		1.00
Women	0.79	0.40–1.59	0.87	0.42–1.80	1.28	0.46–3.59
Patient’s age (years)
20–44	1.00		1.00		1.00
45–64	0.29*	0.10–0.81	0.45	0.15–1.35	0.78	0.12–5.08
65–74	0.31*	0.10–0.95	0.54	0.16–1.84	0.65	0.04–9.61
More than 75	0.24**	0.09–0.65	0.44	0.11–1.74	0.65	0.03–14.31
Family guardian’s age (years)
20–44	1.00		1.00		1.00
45–64	1.12	0.22–5.84	0.97	0.18–5.22	0.93	0.07–12.98
65–74	0.83	0.15–4.58	0.83	0.14–4.76	0.99	0.05–22.02
More than 75	1.34	0.23–7.96	1.46	0.23–9.11	0.75	0.02–28.07
Patients’ clinical characteristics
Diagnosis
F0			1.00		1.00
F2			1.43	0.49–4.13	3.77	0.85–16.73
Other			2.38	0.54–10.48	4.63	0.61–35.14
Duration of hospitalization
<100 days			1.00		1.00
⩾100 days and <1 year			0.51	0.18–1.40	0.70	0.19–2.52
⩾1 year and <5 years			0.43	0.18–1.05	0.49	0.15–1.59
⩾5 years and <10 years			0.65	0.21–1.99	1.23	0.27–5.59
⩾10 years			0.06**	0.01–0.50	0.06*	0.00–0.91
Family guardians’ characteristics
Family relationship
Spouse					1.00
Parent					0.23	0.02–2.47
Sibling					0.08**	0.01–.42
Offspring					0.31	0.05–1.85
Other relatives					0.00	0.00–NA
Lived together before hospitalization
No					1.00
Yes					11.41***	3.73–34.93
Employment status
Unemployed and other					1.00
Regularly employed					2.25	0.54–9.36
Irregularly employed					0.36	0.07–1.86
Self-employed					0.46	0.09–2.35
Number of cohabitants
1					1.00
2					2.30	0.76–6.99
3					5.28*	1.33–20.90
⩾4					4.46*	1.29–16.21
Number of health problems
Per 1 increase					0.74	0.54–1.01
Have someone to go for advice or assistance
Yes					1.00
No					0.47	0.19–1.16
−2 Log-likelihood	231.2		218.2		153.52
Cox-Snell R²	0.06		0.1		0.31
Nagelkerke R²	0.09		0.17		0.49

OR: odds ratio, 95% CI: 95% confidence interval, NA: not available.

p < .05; **p < .01; ***p < .001.

Discussion

This study is the first to investigate families’ opinions about where involuntarily hospitalized patients with psychiatric disorders should live after discharge from the hospital in Japan. We found that approximately three-fourths of the families wanted their ill relatives to stay in hospitals or welfare accommodations. Approximately one-fifth of the families wanted to live with the patients after discharge from the hospital. Their wish to live together had a significant positive association with being a female patient, living with three or more cohabitants and having prior experience living with the patients, adjusting for the other covariates. A 10-year or longer hospital duration and siblings as family guardians were significantly associated with the families not wanting to live together, adjusting for the other covariates. Only a small proportion of families wanted their ill relatives to live independently.

The results revealed that many families were not willing to live with the patients in the community. The stigma against mental illness may explain this finding, as stigma is reported to be strong in Japan (Ando, Yamaguchi, Aoki, & Thornicroft, 2013). The above finding also reveals a tendency of families to rely heavily on psychiatric hospitalization for support, and the lack of support in the community is also apparent (OECD, 2014; Oshima & Kuno, 2006). Many families’ reluctance to care for the patients in their household may reflect the difficulties of the community mental health system in Japan. A similar situation was reported in Korea, which is adjacent to Japan (Lee & Park, 2014).

Meanwhile, up to 80% of patients live with their families in communities in Japan (The National Federation of Mental Health and Welfare Party in Japan, 2010, 2011). There are wide cultural variations with regard to the proportion of patients living with families among countries. In Europe, significantly fewer patients live with their families, with rates of 24.6% (Sweden) (Flyckt, Löthman, Jörgensen, Rylander, & Koering, 2013), 20% (Copenhagen), 38.9% (Amsterdam) and 40.0% (London) (Van Wijngaarden et al., 2003). However, many patients live with their families in Southern Europe (86.9%: Verona, Italy (Van Wijngaarden et al., 2003) and 87.0%: Portugal) (Gonçalves-Pereira et al., 2013) and in Latino (42.9%) and Asian (65.0%: Korean-American) societies (Bae & Brekke, 2002). Although the proportion of families wishing to live with the patient after discharge was not high in our survey, cohabitation might meet the needs of some families of Latino, South European and Asian countries including Japan.

It would be inappropriate to force families to assume an unreasonable amount of responsibility for mentally ill relatives. Family involvement is, however, crucial for many patients with psychiatric disorders in the context of deinstitutionalization (Onwumere, Smith, & Kuipers, 2010). Because cohabitation with family can be a kind of social integration in Japan, it would be worthwhile to explore the factors that encourage families to cohabit with those who are psychiatric patients. Accordingly, we examined the factors associated with a family’s desire to live together following a patient’s discharge from the hospital in the following section.

Being a female patient was positively and significantly associated with families wanting to live together after discharge. Compared to men, women have been reported to exhibit a less severe course of illness (Usall, Ochoa, Araya, Márquez, & NEDES Group, 2003), lower severity of symptoms and deterioration (Y. L. Tang et al., 2007), less severe acts of violence (Elbogen & Johnson, 2009) and fewer seclusion and restraint incidents when they were hospitalized involuntarily (Nawka et al., 2013). Being a male patient has been associated with a higher burden of care for the family (Scazufca & Kuipers, 1996). Therefore, the lower burden of care associated with being a female patient may have contributed to the family’s choice to live with the patient.

Having three or more cohabitants was significantly associated with a family’s wanting to live together. Lin and Kleinman (1988) inferred that a nuclear family that consists of fewer members has to take care of the patient with fewer resources to rely upon. This may place an overwhelming burden of care on the family and cause high expressed emotion of its members, exacerbating stress levels of patients, leading to relapse. However, the findings are inconsistent regarding this issue. Kate, Grover, Kulhara, and Nehra (2013) reported a positive, significant association between the family being a non-nuclear family and the burden of care for 100 families with schizophrenia in India. Schene, van Wijngaarden, and Koeter (1998) did not find that caregivers in smaller households felt more burdened than those in larger households in the Netherlands. Hou, Ke, Su, Lung, and Huang (2008) found that among Asian countries, the burden of care in primary caregivers was not significantly associated with the number of cohabitants in Kaohsiung, Taiwan, although the latter was inversely related to the former. We, thus, did not find consistent associations between increased caregiver burden and the size of the household, although Lin and Kleinman’s inference that was mentioned above warrants further investigation. Because we did not ask questions about family structure (i.e. nuclear vs extended family), other relatives, friends or neighbors whom patients could rely on for social support, future studies should include these variables.

Families that lived with the patient before admission also showed a readiness for living with the patient after discharge. Parabiaghi et al. (2007) reported that the caregivers’ burden at baseline was the only significant predictor of burden in those caring for patients with schizophrenia 3 years later. This finding implies a long-term stability of burden of care; thus, the quality of the relationship between a family and a patient may be stable over an extended period. Furthermore, families’ coping strategies and subjective appraisal were predictors for caregivers’ burden (Kate et al., 2013). Judging from these findings, long-term successful experiences in coping with a patient’s behaviors before admission may reduce the burden of care on families, leading to their increased willingness to live together.

However, a long-term hospitalization exceeding 10 years was strongly associated with families not wanting to live with patients. Mitsonis et al. (2012) reported that a longer duration of illness was associated with caregivers’ distress. Hadryś, Adamowski, and Kiejna (2011) also reported that the duration of illness was positively and significantly associated with a greater burden of care on families. According to these findings, a hospitalization of more than 10 years was considered a reflection of the chronicity and severity of the patient’s illness, leading to increased caregiver burden. However, Tang, Leung, and Lam (2008) found that the family’s burden of care was not associated with the patient’s duration of hospitalization. Oshima, Mino, and Inomata (2003) reported that prolonged stays in hospitals would result in the worsening of negative symptoms and negative attitudes about discharge from the hospitals of the patients with schizophrenia in Japan. Kono et al. (2012) found that the top two reasons given for hospitalizations exceeding 1 year among hospitalized patients in Japan were ‘the family’s reluctance to accept the patient’s discharge from hospital’ (51.5%) and ‘no progress in symptom improvement’ (48.8%). These findings suggest that long-term hospitalization does not solely reflect the chronicity and severity of a patient’s illness, but may be related to the patient’s reluctance to live outside the hospital and/or the family’s unwillingness to live with the patient. We need to explore this issue in future studies.

Being a sibling in our study was also significantly associated with the family not wanting to live together. In previous studies, siblings’ involvement in the patient’s care was more likely to consist of periodic emotional support than daily instrumental support, such as housing, monitoring medication and household chores (Hatfield & Lefley, 2005; Smith & Greenberg, 2007). Although sibling relationships have been reported to be relevant to the quality of life of patients with schizophrenia (Smith & Greenberg, 2007), many siblings in our study and previous studies seemed hesitant to take responsibility for providing sustained instrumental help. A study in Italy (Carrà, Cazzullo, & Clerici, 2012) reported that almost all of the patients lived either with their parents or spouse (88.1%) or alone (11.9%), not with siblings. Our finding on siblings not wanting to cohabit is thus consistent with previous studies.

We reported preliminary findings on the demographic characteristics of the patients and families who wanted to cohabit in the community after involuntary hospitalization under the HMCP system. Our results indicated that a reduced family burden, effective coping strategies and subjective appraisals, and a shorter duration of hospitalization were associated with families’ readiness for cohabiting with the patients in the community. Possible measures to ensure the success of this living arrangement would, thus, be to establish effective support services for families, including assertive community treatment and family psychoeducation, which the previous literature has recommended (Dixon et al., 2010; Ito et al., 2011; Nishio et al., 2012; Sono, Oshima, & Ito, 2008; Sono et al., 2012).

We should provide appropriate services to meet the diverse needs of the families who have relatives with psychiatric disorders. Doing so may promote their acceptance of patients living in the community. If families want to live with their ill relatives, community-based services can help them live together. If the families do not want to live with their ill relatives, or if the patients want to live independently, the above services in the community can be utilized to promote the patients’ social integration. We must be careful not to impose too much of a burden of care on families. We have to prepare to offer diverse service choices to respond to the individualized needs of patients and families regarding ways of living in the community.

The wish to live with a family member following his or her discharge from a psychiatric hospital is a complex phenomenon. It is probably related to positive (Cohen, Colantonio, & Vernich, 2002; Kulhara, Kate, Grover, & Nehra, 2012; Lou, Lau, & Cheung, 2015; Veltman, Cameron, & Stewart, 2002) and negative aspects of caregiving, referred to as caregiver burden. Another issue is the influence of cultural factors. A study in Finland (Stengard, Honkonen, Koivisto, & Salokangas, 2000) reported that dissatisfaction among caregivers of patients with schizophrenia was significantly associated with living with them. This finding is inconsistent with our results. It may reflect cultural factors, such as collectivism in Asian countries, including Japan (Chan, 2010). Hence, we need to explore those issues from a cross-cultural perspective.

Limitations

This study has several limitations. First, the sample was restricted to one prefecture in Japan, the sample size was not large and the proportion of participants who were finally included in the analyses was about half of the target sample. Therefore, we should be cautious about generalizing the findings to the general population. Second, we did not take clinical correlates, including the patients’ symptoms and functioning into consideration. Patients’ functioning, in particular, is strongly associated with burden of care (Tang et al., 2008). Furthermore, other characteristics that might have affected the family’s opinions could be clinical correlates, including severity of illness at the time of hospitalization, history of violence to self and/or others, duration of families’ stay with the patient while the patient was ill and frequency of caregivers’ visits while the patient was in the hospital. In future studies, we should investigate the families’ opinions about the patients in relation to characteristics besides those included in our current analysis. Third, we do not know the reasons, in detail, why families wanted to live with their relatives with psychiatric disorders. We need to conduct in-depth interviews with families to elicit their opinions about the care of patients. Fourth, we regarded the family guardian’s opinions as representative of the patient’s entire family. It is quite possible, however, that other family members might have had different opinions about the patient’s living arrangements after discharge from a hospital. We should, thus, investigate diverse attitudes about patients living among family members in the future.

Conclusion

Many families wanted their relatives to remain in hospitals or welfare institutions. One-fifth of them, however, wanted to live with the patients after their discharge from the hospital. Their wish to live together had a significantly positive association with the patient being a female, the number of cohabitants being three or more and their having lived with the patient before hospitalization. A hospitalization of 10 years or longer and siblings serving as family guardians were significantly associated with the family not wanting to live with the patient. We should not impose a burden of care that is unrealistic and overwhelming on the families of patients. Yet, families are an invaluable resource for patients’ care, especially in the age of community-based care. Therefore, further exploration of the services needed to support families who care for patients in the community is needed.

Footnotes

Acknowledgements

We would like to thank Dr. J.Ota., Dr. K.Fujita. and the Okayama Psychiatric Hospital Association for their contributions. We appreciate the cooperation of the hospitals and the guardians who were involved in this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Health and Labour Science Research Grants (H24-Seishin-Ippan-008, H21-Kokoro-Ippan-009).

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