The Making of Psychiatrists in Japan

Psychiatry has witnessed significant progress in understanding and treatment modalities over the past few decades ( www.jspn.or.jp/modules/about/index.php?content_id =55 ). The field of psychiatry continues to evolve daily, emphasizing the importance of learning. Among the avenues for psychiatric education, there is the Japanese Young Psychiatrists’ Organization (JYPO) ( www.jypo.or.jp/english/ ). This organization brings together aspiring early-career psychiatrists from across Japan from North (Hokkaido) to South (Okinawa) ( Figure 1 ), actively engaging in mutual learning and skill development. We are also involved in JYPO’s activities, which include dialog with psychiatrists from various countries and participation in global conferences. In these exchanges with psychiatrists from different nations, understanding each other’s backgrounds is crucial. This involves considering how individuals pursued a career in medicine, the psychiatric training they received, and their ongoing professional development activities. In Japan, individuals typically aim at entering medical school after graduating from high school and receive a six-year length of medical education, including both classroom learning and clinical training.

After graduating from medical school, individuals must pass the national examination for medical practitioners to obtain a physician’s license. Those aspiring to specialize in psychiatry need to receive further training as residents and take examinations to obtain board certification as specialists. Throughout this entire process, organizations like the Japanese Society of Psychiatry and Neurology (JSPN) oversee training standards and promote opportunities for professional education. In this review, we describe the current status of psychiatric care in Japan, the journey to becoming a physician, psychiatric training, and the support infrastructure for specialization and educational activities.

Education and Training before Becoming a Psychiatrist

Entering a medical university

As shown in Table 1 , to specialize in psychiatry as a psychiatrist, one must first become a physician, who needs to pass the national examination for medical practitioners. According to information published on the Ministry of Health, Labor, and Welfare’s (MHLW’s) website, the pass rate for the examination done in February 2023 was 94.9% for new graduates and 91.6% overall. The number of applicants, examinees, and passers was 9,703, 9,459, and 8,972 for new graduates, respectively, and 10,586, 10,293, and 9,432 overall, respectively ( www.mhlw.go.jp/general/sikaku/successlist/2023/siken01/about.html ). This high pass rate might give the impression that becoming a physician in Japan is relatively easy. But in Japan, the challenge lies more in gaining eligibility to sit for the national examination for medical practitioners rather than passing it.

The qualification to sit in the national examination for the medical practitioner is generally acquired by completing the standard medical curriculum, a six-year program at the college of medicine in a medical school. In Japan, to gain admission to a university is generally harder than to graduate from one, and this holds true for medical schools as well. Particularly, medical school entrance examinations are known for their difficulty, with some universities having competition ratios in the tens, and it is rare for students to spend many years as ronin (repeated examination takers) before gaining admission. Medical school admissions have been criticized for overemphasizing academic achievement, leading to the introduction of alternative selection processes such as admissions office examinations and recommendation-based entrance examinations.

While the above pertains to students entering medical school after high school graduation, there are also opportunities for graduates of nonmedical universities to enter medical school through a process known as “bachelor’s degree transfer.” In 2019, 224 students entered medical school in this manner, while the number of nontransfer students (those entering through general entrance examinations, including admissions office examinations and recommendation-based entrance examinations) was 9,210 ( www.mext.go.jp/component/a_menu/education/detail/_icsFiles/afieldfile/2019/09/05/1325992_002.pdf ). Then, in Japan, the aim at entering medical school at around the age of 18 years after graduating high school is more common than going through the “bachelor’s degree transfer” process.

Receiving medical education

The medical curriculum at medical schools in Japan is a six-year program. Japanese medical education is influenced by decisions made in the United States, because the Educational Commission for Foreign Medical Graduates (ECFMG) announced that starting in 2023, applicants for ECFMG certification will be required to be a student or graduate of a medical school that is appropriately accredited by an agency recognized by the World Federation for Medical Education (WFME). Due to the COVID-19 pandemic, the implementation of the requirement has been moved to 2024, but the influence on medical education in Japan is expected to continue in the future. Japanese medical schools are being inspected and evaluated on various aspects of education in accordance with the medical education field-specific evaluation standards, aiming at obtaining international accreditation.

While the specific curriculum varies by university, mainly after completing classroom-based didactic lectures, students take a set of common examinations in their fourth year, using computer-based testing (CBT) to assess their comprehensive understanding of medical knowledge, and the objective structured clinical examination (OSCE) to evaluate their clinical skills. The OSCE, a simulation test, allows students to do mock consultations before interacting with actual patients. One of the key areas assessed in OSCE is effective (empathetic) communication with patients. This includes maintaining appropriate eye contact, using understandable language, adopting an appropriate posture and attitude, adjusting voice volume, speed, and tone according to the patient’s condition, actively listening, as well as using open-ended questions to encourage the patient to speak freely. In addition, the examination involves summarizing the patient’s complaints and medical history in students’ own words and confirming the accuracy of this summary ( www.cato.or.jp/pdf/osce_42.pdf ).

After passing the examinations, students move on to clinical practice, having the opportunity to interact with patients. The departments where clinical practice is done may vary depending on the university and the students. The training includes opportunities to see patients with mental disorders at the department of psychiatry.

At the end of the six-year program, students have the national examination for medical practitioners. According to the examination design chart created by the MHLW in 2024, about 5% of the medical-specific topics in the examination are devoted to psychiatric and psychosomatic disorders. In addition, the general medical section also covers the aspects of psychiatric symptoms ( www.mhlw.go.jp/content/10803000/001079480.pdf ).

Junior residency training

Physicians intending to engage in clinical practice must receive junior residency training. After passing the national examination for medical practitioners, they typically receive a two-year junior residency training. According to a report by the MHLW in 2020 ( www.mhlw.go.jp/content/001000358.pdf ), 55.2% at university hospitals and 64.3% at clinical training hospitals completed mandatory training in seven clinical departments (internal medicine, surgery, pediatrics, obstetrics and gynecology, psychiatry, community medicine, and emergency medicine). It means that more than half of the physicians have received junior residency training in psychiatry.

The content of the junior residency training varies among hospitals but generally includes managing patients alongside senior physicians, participating in treatment, and learning how to take medical histories, conduct psychiatric interviews, write medical records, and implement pharmacotherapy and other treatment methods. But since the training period for internal medicine occupies over nine months of the two-year training period, and the average time for psychiatric training is only one month, there is usually limited time to learn extensively. Still, it allows for an understanding of the general work of a psychiatrist.

After a two-year junior residency training, the number of physicians who choose psychiatry as their desired specialty has increased from 268 individuals (3.6%) to 353 individuals (213 males, 122 females, 4.8%). This suggests that having received a two-year training has led to a significant number of physicians newly aspiring to specialize in psychiatry.

Pathways to Be a Psychiatrist: A Curriculum for Aspiring Mental Health Experts

After completing a two-year junior residency training, most doctors choose a career path in a specific clinical department and begin specialized training. In Japan, a specialist system exists to ensure that individuals have standard medical skills and maintain health-care quality. In the field of psychiatry, the JSPN has established a specialist system of board-certified psychiatrists. In addition, in mental health care, there is a national qualification for designated mental health physicians, certifying the ability to protect basic human rights while treating and supporting individuals with mental disorders.

Generally speaking, psychiatry trainees are aimed at acquiring both essential qualifications, which, despite their different purposes and certifying bodies, are fundamental for clinical practice ^{[ 1 ]} . They initially gain experience in a wide range of clinical psychiatry settings and subsequently focus on identifying their specialty area ( Table 2 ).

Board-certified psychiatrist by the Japanese Society of Psychiatry and Neurology

History and curriculum of training

To become a board-certified psychiatrist, one must work at an accredited hospital for at least three years. The JSPN approves each hospital’s specialized training curriculum. The system of the board-certified psychiatrist is operated by the JSPN, with oversight provided by the Japanese Medical Specialty Board (JMSB) to ensure consistency and quality across the various medical departments. Historically, in Japan, beginning with anesthesiology in 1962, the specialist certification system has been established by academic societies for each medical department. Due to the proliferation of specialist systems across diverse academic societies, the establishment of the JMSB in 2014 was aimed at supervising these systems from a third-party perspective. The JMSB manages the certification process, setting standards for the accreditation and renewal of specialists, training programs, and facilities, and conducts unified evaluations and accreditations. The JSPN specialist system, revalidated in 2018, reflects these comprehensive standards.

Despite the extensive history, the JSPN specialist examination was not initiated until 2009, a relatively recent establishment. Its starting was significantly delayed by the student protests of the 1960s in Japan, targeting at the structure of mental health care among other things. The proposed specialist system within the JSPN was consequently frozen for an extended period due to these critiques ^{[ 2 ]} .

Most key training hospitals that meet the standards are university psychiatry departments or large psychiatric institutions. Around 500–600 doctors start their psychiatry training each year in Japan. Due to significant variations in doctor numbers across prefectures, the competent authority has imposed restrictions in some prefectures on the number of trainees they can accept new trainees.

Psychiatry trainees cannot complete their entire three-year training at a single facility. They must work at other affiliated hospitals for at least six months. This requirement ensures that trainees gain diverse experiences across different facilities within a short timeframe.

Trainees gain experiences across various psychiatric settings, including outpatient services, psychiatric wards, and both voluntary and involuntary hospitalizations. In addition, a specified number of cases for each mental disorder listed in the ICD-10 must be experienced. Requirements also include experiencing psychiatric emergencies, behavioral restrictions such as isolation and restraint, physical complications, and community medical care (interaction with supporters).

Examinations

After completing a three-year training while experiencing specific diseases and situations, they will take the specialist examination. This examination consists of a case report, a written examination, and an interview. About 70% of examinees pass the examination each year.

The written examination consists of 100 multiple-choice questions covering the entire field of psychiatry. Questions vary from simple knowledge queries to more complex ones that involve answering two questions based on a case description of about five lines. An example of such a question is as follows:

Q: Select the two incorrect statements regarding psychoeducation for depression.

After passing the written test, candidates will take an interview test.

The interview, which lasts about 45 minutes, comprises questions and role-playing exercises based on hypothetical cases, as well as discussions about the candidates’ case reports. Initially, each candidate is provided with a case description, spanning approximately one A4 page, detailing the patient’s life history, present illness, and current symptoms.

The examination instructions state: “You will be assessed through questions and rôle-play exercises based on the content of the case report. In the rôle-play, you are to explain the diagnosis, tests, and treatment plan in a setting where the patient and their family are present. Although the information may be incomplete, you should proceed with the explanation as if it is the totality of information available.”

When it comes to their own submitted case reports, candidates are often required to elaborate on their experiences related to the case. One or two of the eight submitted reports are selected for further discussion. When an examinee passes these examinations, one can become a board-certified psychiatrist. After obtaining certification, diverse career paths are available. According to a survey conducted by the MHLW, there are about 10,000 psychiatrists, about two-thirds are employed in hospitals (including general hospitals and psychiatric hospitals) and one-third are working at outpatient clinics ( www.mhlw.go.jp/ toukei/saikin/hw/ishi/20/dl/R02_kekka-1.pdf ).

Designated mental health physicians by the government (Ministry of Health, Labor, and Welfare)

The designation of mental health physicians certificated by the MHLW is intended to safeguard patients’ human rights on admission to psychiatric wards ^{[ 3 ]} . Their primary responsibilities involve in assessing the need for involuntary admission, often with family consent, implementing inhospital movement restrictions, and evaluating the necessity for compulsory admission as directed by the prefectural governor.

To note, Japan is different from the majority of countries in the world ^{[ 4 ]} ; a system of involuntary hospitalization is maintained where family consent allows for admission without the necessity before judicial proceedings. This framework is invoked in cases, in which the designated mental health physician deems hospitalization necessary due to mental illness, and the individual in question does not give their consent. In addition, for situations with a clear risk of harm to oneself or others, the responsibility for authorizing hospitalization rests with the prefectural governor.

Three years of clinical experience in psychiatry are required, followed by attendance at designated training sessions. Subsequently, five involuntary hospitalization cases must be submitted, spanning across specific categories. These include organic, including symptomatic, mental disorders ( ICD-10 , F0), mental and behavioral disorders due to psychoactive substance use (F1), schizophrenia, schizotypal and delusional disorders (F2), mood [affective] disorders (F3), and other mental disorders (F4-F9).

The case reports must adhere to several complex criteria, including:

If a patient is transferred to another hospital for involuntary hospitalization, the period you oversaw the treatment must exceed three months. Candidates will receive a government-conducted interview after submitting the case reports and passing the review. Successful completion of both stages results in certification.

After Becoming a Board-certified Psychiatrist

This section deals with the career of a psychiatrist after becoming a board-certified psychiatrist by the JSPN and a designated mental health physician by the MHLW. After becoming a certified psychiatrist, one must periodically renew his or her certification, but there is no career path that most psychiatrists follow.

We would like to describe some medical subspecialties that are considered to be relatively popular among them. Some medical subspecialties are certified by the Japanese Medical Specialty Board and others by the Psychiatry Subspecialty Board (PSSB) of the JSPN. Not all subspecialties are systematically covered or have a uniform training approach, and this is still in the process of being developed ( www.jspn.or.jp/modules/newspe/index.php?content_id=110 ).

Psychotherapy

As in other countries, various types of psychotherapy can be learned in Japan. Some are led by specific academic societies that certify specialists, while others do not have any official titles of specialists. Cognitive behavioral therapy (CBT) ^{[ 5 ]} , for example, is one of the most popular psychotherapies taught in Japan. CBT training is offered by the National Center of Neurology and Psychiatry (NCNP) ( www.cbt.ncnp.go.jp/ ) and the Center for the Development of CBT training ( www.cbtt.jp/ ). They regularly hold workshops to teach CBT in a wide range of fields, from general CBT to specialized CBT for specific disorders such as depression, social anxiety, obsessive-compulsive disorder, and post-traumatic stress disorder. In addition, those who wish to receive supervision in CBT for their cases can ask supervisors to train them to learn practical CBT. Then, the MHLW has established certification for CBT supervisors, and those who meet the criteria can become CBT supervisors and be involved in the training of their successors ( www.mhlw-cbt-training.ncnp.go.jp/supervisor.htm ).

Another psychotherapy for an academia-sponsored certification system that has been available is Morita therapy ^{[ 6 ]} , which originated in Japan. This is a psychotherapy that focuses on the mechanism of captivity, and helps patients, mainly in the neurotic focus, to acquire an attitude of mind as it is, and was invented by Masatake (Shoma) Morita in 1919 ^{[ 7 ]} . The Japanese Society for Morita Therapy has established a system of certified doctors for Morita therapy ( www.jps-morita.jp/accredit.html ).

Child and adolescent psychiatry

Child and adolescent psychiatry has attracted the interest of medical students in recent years, as autistic spectrum disorder and attention deficit hyperactivity disorder have become more apparent in society. In total, 552 psychiatrists have been certified by the Japanese Society for Child and Adolescent Psychiatry for this subspecialized status ( www.child-adolesc.jp/nintei/ninteii/ ). Although there are not many facilities where systematic training can be done, it is one of the most popular subspecialties.

Addiction psychiatry

In Japan, the number of patients with alcoholism is estimated to be 570,000 as of 2018 ( www.mhlw.go.jp/content/12200000/000760238.pdf ). Although the number is gradually decreasing, it is one of the most important social issues. The Japanese Medical Society of Alcohol and Addiction Studies, which was formed by merging four societies, is the main society in addiction, with more than 1,000 members, but the system of medical specialists is not yet in place officially ( www.jmsaas.or.jp/about/history/ ).

Disaster Psychiatric Assistance Team

Japan is often exposed to natural threats such as earthquakes, tsunamis , and typhoons due to its geography. Disaster psychiatric assistance teams (DPATs) are professionally trained and dedicated teams, aiming at responding to the needs for mental health care during disasters. DPAT exists in Japan as a project commissioned by the MHLW. As a background, DPAT was established in 2013 as a result of the recognition of the need to respond to psychiatric needs in the immediate aftermath of the 2011 Tohoku 3.11 Earthquake and Tsunami . As a result, 1,091 teams were dispatched for the Kumamoto Earthquake in 2016 ( www.nisseikyo.or.jp/news/topic/ detail.php?@DB_ID@=140 ), and many teams were dispatched for the Noto Peninsula Earthquake in 2024 ( www.nisseikyo.or.jp/news/topic/detail.php?@DB_ID@=665 ). As for careers, to be a designated, mental health physician is necessary to become a doctor of a DPAT advance troop.

Consultation-liaison psychiatry

Consultation-liaison psychiatry is important as one of the roles of psychiatry in general hospitals. In Japan, the Japanese Society of General Hospital Psychiatry, which has more than 1,000 members, certifies physicians in the field of GHP ( www.square.umin.ac.jp/psy/content/document/jsghp2019_content01_gakkai_02.html ). In addition to the treatment of delirium, which is a common problem in physical inpatients, the scope of practice has recently been expanding to include palliative care for cancer and heart failure, evaluation before organ transplantation, and appropriate modified electroconvulsive therapy ^{[ 8 ]} .

Forensic psychiatry

Forensic psychiatry is the field of research and practice of treatment and therapy for patients with mental illnesses that have led them to engage in illegal activities. In Japan, forensic psychiatry has been the subject of increasing social attention in recent years due to the arson case at an animation company and a bizarre murder case, both of which were the subject of psychiatric evaluation. Until recently, no university-operated medical probation wards existed, but in 2022, a judicial psychiatric center was established at Hokkaido University, which is expected to foster human resources and promote research ^{[ 9 ]} .

Epilepsy (psycho-epileptology)

Psychosis caused by epilepsy used to be one of the three major psychiatric diseases, and the culture in Japan was that patients with epilepsy were treated by psychiatrists. But the number of psychiatrists treating patients with epilepsy has been decreasing in recent years, partly because the pathophysiology of epilepsy has been found to be overexcitation and synchronous activity of neurons in the brain, and partly because the skills of EEG interpretation are different from those of general psychiatrists.

Nevertheless, the incidence of depression, psychosis, anxiety, neurodevelopmental disorders, and dementia in patients with epilepsy is higher than those in the general population. No doubt exists that psychiatrists to treat patients with epilepsy is logical and important. Even though epilepsy itself is treated by neurologists, the importance of psychiatrists’ participation in epilepsy care is well-known within the framework of psycho-epileptology. There are epileptologists certified by the Japan Epilepsy Society ( www.jes-jp.org/ ) and EEG specialists certified by the Japanese Society of Clinical Neurophysiology ( www.square.umin.ac.jp/JSCN/specialist/ ).

Others

Other subspecialties not covered in this section include geriatric psychiatry, psychosomatic medicine, neuropsychiatry, sleep medicine, emergency psychiatry, community psychiatry, psychopharmacology, and psychoanalysis, which are also important subspecialties but were omitted for reasons of space. In addition to subspecialties, there are many other career options, such as private practice, engaging in experimental research and clinical research at universities or research institutions, working for a pharmaceutical company, working as an industrial physician, or working for a government agency.

Psychiatrists have many points of contact with society, and there is an aspect in which problems become medicalized according to social trends. A range of ways exists for psychiatrists to build their careers because the nature of the problems varies.

Education of Early Career Psychiatrists

In this section, we give more detailed information on psychiatric education in Japan that extends beyond the confines of one’s affiliated institution. The scope of psychiatric care is broad, encompassing everything from the basics of general clinical psychiatry to psychotherapy, child and adolescent psychiatry, forensic psychiatry, disaster psychiatry, and psychiatric care in general hospitals (liaison psychiatry). But to cover this wide range of knowledge within the confines of one’s own department or hospital alone is often challenging. To overcome this challenge, various measures are being taken, such as participation in academic conferences held throughout Japan, study groups organized by these conferences, and seminars held by organizations focusing on the education of psychiatrists.

The Japanese Society of Psychiatry and Neurology

The JSPN is the largest psychiatric society in Japan, with a membership exceeding 20,000. As an institution that certifies specialists, the JSPN hosts various study groups and learning sessions, supporting life-long education for young physicians, those aiming at career advancement, and its members. It conducts educational activities in specialized fields where there is a large actual demand but limited specialists, such as child psychiatry training sessions, forensic psychiatry training sessions, and training courses on the appropriate use of physical treatments such as rTMS and ECT.

The Japan Young Psychiatrists Organization

The JYPO is a certified nonprofit organization, aiming at improving the quality of psychiatric care throughout Japan by fostering leadership among young psychiatrists, cultivating an international perspective, and enhancing their knowledge and academic abilities in psychiatric care ^{[ 10 ]} . More than 20 years since its establishment, its alumni are active across Japan, including those in academia and regional health-care facilities. Here, we introduce some of the activities conducted by the JYPO.

The course for the academic development of psychiatrists

The CADP is a residential academic conference aimed at helping psychiatrists to excel in the International Academic Community ^{[ 10 ]} . It has been held 20 times since 2002, with the 21st conference scheduled for March 2024 in Himeji, Japan. Bringing together 30 Japanese participants and about 10 international participants, the CADP uses English as its working language and includes practical lectures on oral and poster presentations, lectures on career development by pioneers, and small group work simulating research planning in international teams. Norman Sartorius (Switzerland) has been involved as an advisor since the first session, offering special lectures and direct guidance. The conference is characterized by its participant-led planning and operation, serving as an opportunity for young psychiatrists to gain academic motivation, develop planning skills, and become accustomed to international settings ( Figures 2 and 3 ).

Clinical research workshops

The clinical research workshops are study groups designed to equip young psychiatrists with the knowledge and practical skills necessary to translate daily clinical questions into research. Each year, the workshops are focused on timely and relevant topics, such as research using big data, the realities of clinical research, and recently, paper writing using ChatGPT.

Regional exchange meetings

Given the structure of Japan’s personnel system for doctors, which is primarily based on university and direct hospital employment, opportunities to learn about psychiatric care and treatments at different universities and hospitals are limited. To address this, regional exchange meetings are held, enhancing understanding of regional health care, improving psychiatric care techniques, and strengthening the network among psychiatrists through case study discussions and facility introductions.

Furthermore, in collaboration with the JSPN, activities such as the translation of WPA materials into Japanese and international joint meetings with young psychiatrists from overseas are conducted. These efforts are aimed at strengthening the horizontal connections among young psychiatrists and contributing to the improvement of the quality of psychiatric care.

Conclusion

Here, we have presented a review of the mental health education that Japanese medical students and early career physicians receive, from their undergraduate years to their initial training, and how psychiatry residents navigate their specialized training. In addition, we have showcased the initiatives of the JYPO, in which we have been actively involved, as a case study of the various engagements of early career psychiatrists in Japan and internationally, highlighting their benefits.

Japan, an island nation, is sometimes critiqued for its “Galapagos syndrome.” This term has positive connotations, signifying the development of a unique and valuable culture, but it also carries negative implications, suggesting a drift from global standards due to isolation.

Evaluating one’s environment can only be fully realized by having knowledge of other places. To discern what aspects are superior and which require improvement, to continue engaging and striving for excellence through domestic and international exchanges is essential. This manuscript expresses our hopes for enhancing exchanges, particularly between Japan and the world.

Data Availability Statement

Data sharing is not available to this article because no datasets were generated or analyzed during the current study.

Financial Support and Sponsorship

The authors denied any source of funding from any sponsor or agency.

Conflicts of Interest

Nakagami, Oya, Horinouchi, and Aki are the past vice president, past president, past president, and current president, respectively, of the Japanese Young Psychiatrists Organization. Besides advocating the JYPO, all authors declare no potential conflicts of interest in writing this review.