This study consists of two cross-sectional surveys in Sendai city, which is the capital of Miyagi prefecture. Sendai has a population of one million, located 300 km north from Tokyo, and neighbor to suburbs such as Natori city, which has a population of 70 thousand.

The primary survey was a self-completed questionnaire on the need and feasibility of ACT. Subjects were psychiatric hospital directors (in the case of general hospitals, the head of the psychiatry department) and psychiatric clinic directors (clinic directors) located within the city of Sendai and surrounding areas. The primary survey confirmed whether respondents would cooperate in secondary and subsequent surveys. In the secondary survey, the number of patients eligible for ACT was estimated based on primary physicians’ evaluations.

The researcher selected 17 inpatient institutions including the 14 institutions in the “Sendai Survey,” a survey of all psychiatric inpatient hospitals in the city of Sendai reported in 2005, and three psychiatric inpatient institutions belonging to municipalities neighboring Sendai.

Thirty-four outpatient only psychiatric institutions were surveyed, including all 32 institutions located within the city listed as member institutions on the Miyagi Prefecture Psychiatric Clinic Association website as of the end of December 2007 and two psychiatric clinics in neighboring municipalities. The list of outpatient medical facilities published in the 2007 Sendai Mental Health and Welfare Guidebook was checked to find clinics or general hospital psychiatry departments without inpatient beds within the city that were not members of the Miyagi Prefecture Psychiatric Clinic Association. Five clinics and one institution that provided outpatient care to mainly adults with mental disorders in a government facility were added, for a total of 40 institutions. Requests for cooperation in the survey, self-completed questionnaire forms, explanations of ACT, and other relevant materials were sent to a total of 57 institutions on January 24, 2008 and returned materials were to be postmarked by February 1, 2008.

The inpatient survey reference date was February 1, 2008. The number of patients that would be covered by ACT was ascertained from primary physicians’ inpatient evaluations. In the five psychiatric hospitals that consented to the request for this survey (four in Sendai and one in Natori which is suburb of Sendai), there were 852 inpatients in the psychiatric wards, of whom 509 patients resided in the city of Sendai. Consent was obtained from 423 of these 509 patients.

The outpatient survey reference date was February 22, 2008. Survey forms were sent to general hospital psychiatry departments, single department psychiatric hospitals, and psychiatric clinics within the city of Sendai that, in the primary survey, had expressed intention to cooperate further. The number of patients eligible for ACT was ascertained from primary physicians’ evaluations of outpatients who visited the hospital or clinic on the survey date. 945 patients underwent psychiatric outpatient examinations on the day of the survey; consent for the survey was obtained from 779 patients.

In the primary survey, collected data included the need for ACT, necessary roles for ACT, plan to establish an ACT team, and financial profitability of ATC. In the secondary survey, collected data included each client’s basic characteristics and variables related ACT eligibility such as diagnosis, severity of disability, and psychiatric symptoms.

Disability was assessed as a single item scored on a 5-point Likert scale, with higher scores indicating a more severe disability (1: Mental disorder is seen, but patient can function normally in daily life and life in the community; 2: Mental disorder is seen, and patient has certain restrictions in daily life or life in the community; 3: Mental disorder is seen, and patient has marked restrictions in daily life or life in the community, and assistance is needed at certain times; 4: Mental disorder is seen, patient has marked restrictions in daily life or life in the community, and constant assistance is needed; 5: Mental disorder is seen, and patient is almost fully unable to care for him or herself).

Symptoms were assessed as a single item scored on a 6-point Likert, with higher scores indicating more severe symptoms (1: No symptoms; 2: Psychiatric symptoms are seen, but are stable; 3: Several deficits are seen in communication and recognition; 4: Behavior is substantially affected by hallucinations or delusions; 5: There is a gross deficit in communication and constant attention is needed; 6: Marked deviant behaviors seen).

To estimate the number of potential ACT users in Japan, we used the data from government statistics, including the hospital survey by the Ministry of Health, Labor, and Welfare [16] and Census by the statistics bureau of the Ministry of Internal Affairs and Communications [17].

In addition to descriptive analyses, we estimated the number of potential ACT users in Japan based on the number of eligible clients for ACT in this survey. Eligibility for ACT was assessed using the screening criteria based on the inclusion criteria of the ACT-J team, which was established in the first adoption study of ACT in Japan [12].

The screening criteria of this study were as follows:

1. Residence: Sendai city
2. Age: 18-59 years old
3. Primary diagnosis: F2 (schizophrenia, schizotypal, and delusional disorders), F3 (mood disorders), and other mental disorders, as defined by the ICD-10 [18] (excluding primary diagnosis of intellectual impairment, dementia, drug or alcohol abuse, and personality disorder)
4. Substantial psychiatric service use in the past 2 years (two or more hospitalizations, 100 or more in-patient days, three or more psychiatric emergency department visits, or 3 months or more of no-show to out-patient clinic appointments)
5. Low level of social functioning when at best in the previous year, defined as a disability evaluation of 4 points or higher.

Based on these evaluations, we supposed three levels of criteria from criteria 1 to 3 described below:

• Criteria 1: Included those diagnosed as F2 or F3 if the patient met the criteria for either (iv) OR (v).
• Criteria 2: Included those diagnosed as F2 if the patient met the criteria for either (iv) OR (v) and those diagnosed as F3 were included if clients met criteria for both (iv) AND (v).
• Criteria 3: Included those diagnosed as F2 or F3 if the patient met the criteria for either (iv) AND (v).

According to the 2012 hospital survey by the Ministry of Health, Labor, and Welfare [16], the number of psychiatric inpatients per 100,000 people in Miyagi prefecture was 234.7. Here, using the population of Sendai and Natori (1,098,232 people), the number of psychiatric inpatients in these cities was estimated to be 2577.6. The number of psychiatric inpatients as of the survey reference date at the five institutions in this study was 416, which is equivalent to 16.1% of the total number of psychiatric inpatients in the entire city. Hence, assuming that this survey is representative, the number of psychiatric inpatients eligible for ACT in Sendai was approximately 1084.9, 998.1, and, 613.8 for Criteria 1, 2, and, 3 respectively (see C in Table 3).

According to the Survey of Medical Care Activities in Public Health Insurance (Ministry of Health, Labor, and Welfare), the number of cases in which medical treatment of outpatient psychiatric therapy (first visit), outpatient psychiatric therapy 2 (hospital), and outpatient psychiatric therapy 2 (clinic) was done in the single month of August 2006 was 4,216,910 [16]. This findings is a summation of medical acts in all of Japan. Using the populations of the city of Sendai and all of Japan, cases in which psychiatric outpatient care was given for patients residing in Sendai can be estimated as 34,329.2 per month. Assuming that this outpatient treatment was over 24 weekdays, the number of psychiatric outpatient visits per day would be about 1,430. The number of outpatients included in this study was 657; therefore, this study was equivalent to 45.9% of the total number of psychiatric outpatients care in all Sendai. Moreover, the total number of outpatients in Sendai would be 14 times more than the those in this study because the average interval of psychiatric outpatient care in Japan is 14.0 days [19]. Accordingly, the number of psychiatric outpatients eligible for ACT in Sendai would be approximately 2531.6, 2043.6, and, 305.0 for Criteria 1, 2, and, 3 respectively (see D in Table 3).

Therefore, the estimated numbers of eligible clients in Sendai were 3616.5, 3041.7, and, 918.8 respectively. Assuming that one ACT team provides services for 100 clients, the estimated number of ACT teams needed for 100,000 population are 3.5, 3.0, and, 0.9 for Criteria 1, 2, and, 3 respectively (see F and G in Table 3).