The provision of Cognitive Behavioral Therapy in Japan: an analysis using insurance claims data

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In Japan, patients can receive insurance coverage for CBT treatment of Major Depressive Disorder (MDD), social anxiety disorder (SAD), panic disorder (PD), Obsessive Compulsive Disorder (OCD), post-traumatic stress disorder (PTSD), and bulimia nervosa; however, utilization of CBT remains insufficient. This study investigated CBT provision for these disorders using Japanese health insurance claim data. Methods Data were from Detroit Employment Solutions Corporation (DeSC), spanning April 2015 to March 2022. The dataset included “Kempo” (salaried workers’ insurance; large companies) and “Kokuho” (national health insurance; self-employed and their dependents), representing 2.8% and 12% of each insured population, respectively. Patients with the aforementioned mental health conditions were identified, and analyses explored demographic characteristics, session frequencies, intervals, and prescription details. Results Overall, 0.50% of Kempo, and 0.24% of Kokuho, clients who were diagnosed with the relevant mental conditions claimed insurance for CBT. Among Kempo clients, CBT was claimed by 322 (89.2%) with MDD, 8 (2.2%) SAD, 13 (3.6%) PD, 11 (3.1%) OCD, 5 (1.4%) PTSD, and 2 (0.5%) unspecified conditions. Among Kokuho clients, CBT was claimed by 1037 (92.0%) with MDD, 11 (1.0%) SAD, 23 (2.0%) PD, 25 (2.2%) OCD, 13 (1.2%) PTSD, and 18 (1.6%) unspecified conditions. Average intervals between sessions for MDD were 34.2 days under Kempo and 71.9 days under Kokuho. Conclusion Few patients claimed insurance for CBT, and most session intervals exceeded one month. Findings underscore significant unmet medical needs in CBT provision in Japan. Medical environments that support and integrate regular CBT must be established. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1. Introduction Psychiatric conditions such as Major Depressive Disorder (MDD), anxiety, and Obsessive-Compulsive Disorder (OCD) significantly impair quality of life and are among the top ten diseases contributing to economic burdens (Baxter et al., 2014; Murray et al., 1996). Additionally, the long-term costs of illness and treatment are substantial (Cho, Mishiro, Fujimoto, et al., 2022), leading to significant social losses such as absenteeism and presenteeism (Sado et al., 2011). The first-line treatments recommended are pharmacotherapies, such as antidepressants, Cognitive Behavioral Therapy (CBT) and combination of both. CBT is a psychotherapy with robust evidence demonstrating its effectiveness, often proving to be as effective as, or even more effective than, pharmacotherapy. Moreover, unlike pharmacotherapy, which can involve the risk of adverse events, CBT carries no biological risks and is recommended for sensitive individuals such as pregnant women or children. CBT excels in preventing relapses and is essential for achieving and maintaining remission (Zhang Z et al, 2018). It has also been shown that by widely disseminating CBT, it effectively reduces societal losses by addressing presenteeism and absenteeism (Clark, 2013). Internationally recognized clinical guidelines such as the National Institute for Health and Care Excellence (NICE, 2018) and the Canadian Network for Mood and Anxiety Treatments (CANMAT) (Yatham et al., 2018) recommend CBT as a frontline treatment for mental health conditions in clinical settings. To improve health care systems, governments should implement health care policies in accordance with these guidelines. One of the most notable mental health strategies is seen in the UK's Improving Access to Psychological Therapies (IAPT) program. Initiated in 2008, this program has trained a large number of therapists and now servs one million users with recovery rates reaching 40–50% (Digital, 2019). IAPT has also surpassed the expected return-to-work rate of 4%, reaching 5% (Clark, 2013). Many countries are adapting CBT delivery methods to fit their healthcare systems and geographical characteristics (Cano-Vindel et al., 2022; Gratzer & Goldbloom, 2016), exploring various approaches to enhance the availability and efficacy of evidence-based mental health treatments. Despite the widespread recognition of CBT as a most robustly effective treatment for mental health conditions, its adoption as a mainstream medical practice remains a pressing issue in many countries. While variations in healthcare systems and geographical differences mean that the ideal model for CBT implementation can differ significantly from one country to another, common obstacles include limitations in human resources and geographical accessibility (Clark, 2013). Data on the prevalence of CBT in Japan, including regional differences, are scarce. Understanding the state of CBT dissemination in Japan can provide valuable insights for developing methods to monitor and improve CBT accessibility. Such data are crucial for estimating the unmet need for services, facilitating open discussions among policymakers and the public and guiding future mental health policy initiatives (Hayashi et al., 2020). Furthermore, understanding the medical environment for CBT implementation could lead to strategies that complement existing practices, which could provide useful information for medical policy considerations in Japan and other countries. In Japan, CBT is administered by trained psychiatrists (Kobori et al., 2014). These psychiatrists typically charge a fee of 4800 Japanese yen (~ $ 32USD) for each session lasting over 30 minutes, regardless of the frequency of visits, which does not exceed once per week. This compares to a standard psychiatric psychotherapy session, lasting between 5 and 30 minutes, typically charged at 3150 Japanese yen (~ $ 20.7USD). Therefore, the remuneration that psychiatrists receive is relatively low for CBT than a standard psychotherapy session, particularly considering the time spent on treatments (Kobori et al., 2014). Japanese healthcare integrates tightly with national insurance, allowing individuals suffering from any illness to seek treatment from any healthcare provider they choose. Healthcare providers also register the medical actions performed and medications prescribed for insured conditions according to medical policy. To tackle the systemic issues in healthcare provision in Japan, it is crucial to understand the current status of CBT provision, including the progress of strategies and the balance of supply and demand. Increasingly, insurance claim data research has become a common method to understand these dynamics and issues within psychiatric care (Cho, Mishiro, Akaki, et al., 2022; Desai et al., 2019). National databases have been used to investigate the number of CBT claims in Japan (Haraguchi et al., 2021). Although these national databases can track the overall provision of healthcare on an annual basis, they do not capture detailed individual or group characteristics. Therefore, utilizing insurance claim data is more beneficial than national database data (Nakatani E, et al 2022, Nakatsuka K, et al 2024), because it allows for the investigation of individual session counts and dropout rates. In addition, it is possible to track the frequency of sessions for each individual. While evidence-based treatment guidelines recommend CBT once a week, there is evidence that CBT is often unavailable or delivered less frequently in routine clinical care in Western countries (Gunter & Whittal, 2010; Shafran et al., 2009). In Japan, CBT for depression has been covered by health insurance since 2010. However, its use has been limited and the number of insurance claims has plateaued in recent years (Hayashi et al., 2020). Thus, we hypothesize that the proliferation of CBT in Japan still remains insufficient at present. This situation may mean that it is difficult for many patients to use CBT as their first-line treatment. We also hypothesize that CBT sessions are usually performed less frequently than once a week for three primary reasons: first, difficulty of accessibility; second, because it is not economically efficient; and third, because it is considered unrealistic for patients to attend sessions more frequently. Therefore, the aim of this study is to investigate, using health insurance claims data, ( 1 ) the number of CBT claims made for different mental health conditions that are covered by insurance, and ( 2 ) the frequency and number of sessions per individual. 2. Method 2.1 Data source Since the Japanese government established a universal health insurance system in 1961, those who live in Japan are covered by one of several public insurance systems (Yasunaga, 2019). Kokuho represents national health insurance for the self-employed, retirees, and their dependents. Kempo represents association, or union-managed, health insurance for salaried employees in large companies. Kyokai Kempo is a health insurance scheme operated by the National Health Insurance Association for salaried workers in small and medium-sized enterprises. Kyosai Kumiai are mutual aid associations that operated health insurance for other employees, including public servants. The Advanced Elderly medical service system for the elderly covers all persons aged over 75 years. As of 2019, the number of enrollees in Kokuho, Kempo, Kyokai Kempo, Kyosai Kumiai and Advanced Elderly medical service system are 28.7 million, 29.5 million, 38.9 million, 8.6 million, and 17.2 million, respectively. This study used the Detroit Employment Solutions Corporation (DeSC) database, maintained by DeSC Healthcare, Inc. This repository contains commercially available administrative claims and health examination data, details of which can be found elsewhere (Kimura et al., 2010; Sato et al., 2024). The DeSC database collects insurance claims data from three types of health insurance: Kokuho, Kempo and the Advanced Elderly medical service system. As of 2019, the number of enrollees in Kokuho and Kempo included in this claims database were approximately 12.0% and 2.8% of each population (Takeshita et al., 2024). Thus, the DeSC database encompasses approximately 14 million individuals of varying ages, including young, middle-aged, and older individuals, with an age and sex distribution closely matching Japan's population estimates (Okada & Yasunaga, 2022). The database contains anonymised and separately maintained medical claims data for outpatients and inpatients and includes the following information: (i) unique identifier; (ii) date of birth and gender; (iii) diagnosis according to International Classification of Diseases, 10th edition (ICD-10), codes; (iv) Japan-specific identification system-based procedures; (v) distribution of medicines according to the Anatomical Therapeutic Chemistry classification system; and (vi) dates of coverage and withdrawal. 2.2 Study design and participant selection This retrospective cohort study used data collected between April 2015 and March 2022. Indicator dates for each individual were defined as the date of the first CBT session. Inclusion criteria were: (i) registered in the DeSC database between April 2015 and March 2022; (ii) had continuous registration for the inclusion year, the previous year and the subsequent year; (iii) had a registered diagnosis of MDD, SAD, OCD, PD, PTSD or BN, treated using CBT and claimed using health care insurance; and (iv) entered into the DeSC database within one year prior to first CBT session. Participants were excluded if they had an incomplete registration, had insufficient insurance documentation, were registered in the DeSC database for more than one year before their first CBT session, or discontinued their insurance coverage before the study ended. The need for informed consent was waived because of the study’s retrospective, non-interventional nature and the use of anonymized data. Ethical approval for waiving informed consent was granted by an ethical committee, which confirmed that the privacy and security measures in place adequately protected participant data. Diagnoses treated using CBT were categorized as follows: If CBT was administered before March 2016, the diagnosis was designated as MDD. If the medical institution that administered CBT listed a single diagnosis at the first session, that diagnosis was used as the official diagnostic label. If the diagnosis at the medical institution where CBT was first administered was singular at the time of the first CBT session, that diagnosis was used as the official diagnostic label. If the primary diagnosis that was registered during the treatment period was singular at the time of the first CBT session, that diagnosis was used as the official diagnostic label. If the primary diagnosis registered during the treatment period matched the diagnosis at the CBT medical institution and both were singular, that diagnosis was used as the official diagnostic label. 2.3 Variables First, the first CBT session for each individual was identified. Then, the number of patients starting CBT sessions each fiscal year was tracked. Third, for each individual, the duration from the first to the last CBT session, as well as the average number of days between sessions, were calculated. Fourth, the total number of sessions and the achievement rates were calculated. These metrics provided insights into the engagement and continuity of patients within the CBT programs under the two different insurance frameworks. Demographic characteristics included age at the first session (using date of birth) and gender. 2.4 Statistical analyses The analyses were conducted using stepwise regression in IBM SPSS Statistics 20.0 (IBM Corp., 2011. When examining CBT practices within the Kempo and Kokuho insurance systems, several parameters were not compared with statistical analysis between the two insurances. This decision was made because of the high proportion of elderly individuals aged between 65 and 75 years within the Kokuho system, as highlighted by Okada and Yasunaga (2022). This demographic characteristic is significantly higher in Kokuho compared with that in the general population, leading to potential sample bias in the study. 3. Results 3.1. Participants Participants included a total of 464,377 individuals under Kokuho and 72,743 under Kempo who were registered at least once with diagnoses of MDD, OCD, SAD, PD, PTSD or BN. The distribution of diagnoses were as follows: under Kokuho, there were 1,037 cases of MDD, 25 of OCD, 11 of SAD, 23 of PD, 13 of PTSD and and 18 unidentified cases. Under Kempo, there were 322 cases of MDD, 11 of OCD, 8 of SAD, 13 of PD, 5 of PTSD and 2 unidentified cases. No cases of BN were recorded under either insurance type. 3.2 CBT Demographic analyses across the Kempo and Kokuho health insurance systems revealed distinctive patterns in the treatment of mental health conditions (Tables 1 and 2). Gender distributions predominantly favored females or were balanced, except for people with PTSD diagnoses under Kempo (Table 1). Individuals under Kokuho typically had their first CBT session in their late thirties, while those under Kempo typically had their first CBT session around thirty years of age (Table 2). This age discrepancy likely reflects the higher proportion of elderly people insured under Kokuho. Regarding treatment distributions, MDD consistently had the highest treatment incidences across both insurance systems. After MDD, OCD and PD emerged as the most prevalent conditions in Kokuho and Kempo, respectively. The data also indicated a plateau in year-on-year increases across all conditions. 3.3 Retention rates and intervals between sessions Comparing total session counts, most patients across all conditions and insurance types attended only the initial session, except for OCD patients under Kokuho (Figs. 1 to 5). Excluding those who attended only the first session, the highest claim counts for MDD, OCD, PD were for those who completed 16 sessions (the maximum number of sessions claimed). For SAD, except for one case in Kokuho, all patients dropped out within three sessions, indicating early discontinuation. The average number of days between sessions was longer among those with early dropout, and, for those undergoing more than ten sessions, the frequency of sessions was generally more than once a week, although this varied by condition. Among participants who were treated for over ten sessions, for Kokuho, the retention rates for CBT among those with MDD, OCD, SAD, PD, PTSD were 37.0%, 40.0%, 9.1%, 34.8%, and 30.8% respectively, and for Kempo, they were 21.7%, 45.5%, 0.0%, 38.5%, and 20.0%. 4. Discussion This was the first study to investigate insurance claims for CBT for several psychiatric conditions in Japan. While a portion of the population claimed CBT treatment, the findings suggest that its widespread adoption in Japan has not yet been fully realized. Additionally, the frequency and patterns of claims indicate that the recommended weekly sessions of CBT are typically not being followed; instead, treatments are being administered on a bi-weekly to monthly basis. As hypothesized, an increase in the number of CBT claims was not observed. Previous studies investigating the trends from 2010 to 2015 also reported that the number of CBT claims for depression remained stable (Haraguchi et al., 2021; Hayashi et al., 2020). Furthermore, even after the inclusion of other psychiatric conditions that were covered by insurance since 2016, there was no significant increase in claims between 2015 and 2022. This suggests that the integration of CBT into insurance coverage for numerous disorders did not substantially expand CBT utilization for depression or other conditions in Japan. Among the 464,377 individuals registered under Kokuho insurance and 72,743 under Kempo insurance with diagnoses of MDD, OCD, SAD, PD, PTSD, or BN, only 1,127 individuals (approximately 0.24%) under Kokuho and 361 individuals (approximately 0.50%) under Kempo received at least one CBT session. These low rates of CBT utilization suggest that many patients with these conditions might be receiving pharmacotherapy, the other primary treatment option, or no treatment at all. Furthermore, issues with CBT accessibility and utilization might significantly impact its use as an intervention. There is a notable preference for psychotherapy over pharmacotherapy, being three times more favored (McHugh et al., 2013). Many individuals remain skeptical about pharmacotherapy and current treatment methods, leading to an overall reluctance to seek treatment. In Japan, there has been a longstanding issue with reluctance to consult psychiatrists for psychiatric conditions. Indeed, patients with MDD and anxiety disorders only make up 27.3% and 17.8%, respectively, of those who consult psychiatric specialists within a 12-month period (Ishikawa et al., 2016). This study revealed that, among patients who received CBT, approximately 40% or fewer were also undergoing pharmacotherapy. This may be partly because a substantial proportion of patients either prefer not to receive pharmacotherapy or find it ineffective, possibly owing to issues with tolerability or skepticism. Furthermore, the presence of adverse events, particularly in treatments involving SSRIs, has been highlighted in prior work (Bar-Oz et al., 2007, Hetrick et al., 2007). In Japan, many antidepressants are noted in the prescribing information as having relative contraindications for use in minors. Therefore, efficiently identifying and providing CBT to individuals with psychiatric conditions is crucial because it represents a significant opportunity to enhance mental health treatment options and outcomes. Several patterns emerged regarding demographic characteristics of those claiming CBT within the Kempo and Kokuho health insurance systems. A higher proportion of women than men were found to claim CBT. This may be attributed to the generally higher help-seeking behavior observed in women, suggesting that they may be more likely to engage appropriately in treatment activities, including CBT (Oliver MI et al., 2005). While caution is necessary because of the limited sample size, one third of the patients with SAD under Kempo were children and adolescents. Developing effective methods to deliver CBT to specific populations in need remains a critical challenge. The average frequency of CBT sessions was found to be less than once per week. Evidence suggests that CBT is most effective when administered weekly over a 10–12 week period (Bennett-Levy et al., 2010). This recommendation balances the limited availability of human resources with maintaining patient adherence (Laynard et al., 2007). These constraints significantly shape treatment protocols and can affect the delivery of effective healthcare. However, in areas with a shortage of CBT therapists, or in rural areas where weekly visits to medical facilities are impractical, the standard weekly sessions over 10–12 weeks does not align with clinical realities (Bennett-Levy et al., 2010). In Japan, the medical billing system accommodates less frequent CBT sessions, which has led to an established practice of scheduling sessions less often than once a week. This adjustment is not solely due to medical system limitations but is also heavily influenced by patient-specific factors. For patients engaged in daily commutes for school or work, attending weekly therapy sessions poses a significant logistical challenge. Data from the Kokuho system indicate that the typical frequency of CBT for MDD patients was approximately once a month. In contrast, the Kempo system showed greater variability, likely influenced by a higher proportion of employed individuals in this group. This study also found that, except individuals who only attended an initial session, the greatest frequency of sessions were observed in patients who completed the maximum of 16 sessions. OCD patients exhibited the highest retention rates among all disorders, which might be attributed to the nature of CBT techniques applied. For example, Exposure-Response Prevention for OCD often moves quickly through the psychoeducation phase to the exposure tasks, facilitating early noticeable treatment effects that likely bolster adherence (Ale et al., 2015). This may contribute to the higher continuation rates observed in OCD. Conversely, in SAD, many patients dropped out at earlier stages, possibly owing to disorder-specific comorbid symptoms, such as avoidance behaviors, which might make continued attendance challenging. In summary, this study highlights that the dissemination of CBT in Japan is insufficient, and that the current healthcare framework may not support its widespread adoption. While promoting and implementing evidence-based CBT is essential, adapting these interventions to suit the existing medical environment is equally important. Innovations such as developing low-intensity CBT options and enhancing the training of psychologists and healthcare professionals are crucial. Additionally, utilizing technology, such as internet platforms and mobile applications, could broaden access to CBT. It is critical to recognize the study's limitations, which could impact the interpretation and generalizability of the findings. Firstly, the sample may not necessarily be representative of the population in Japan. Secondly, in Japan, psychologists are not covered by insurance for conducting CBT within the medical system, though some may provide CBT alongside medical treatments privately; therefore, some people might have been receiving CBT but not claimed for it on their insurance. Thirdly, the absence of data from Kyokai Kempo beneficiaries suggests that the findings might not fully reflect the broader Japanese population, limiting the generalizability. Fourthly, focusing primarily on session frequency without directly assessing treatment outcomes restricts the study’s capacity to thoroughly evaluate the effectiveness of CBT interventions. Future research should aim to overcome these limitations to gain a more comprehensive understanding of the factors influencing CBT provision and its impact on patient outcomes. 5. Conclusion This study highlights significant challenges in integrating CBT within the Japanese healthcare system. Our findings indicate that, despite the recognized effectiveness of CBT and its inclusion in insurance coverage, its adoption and the frequency of sessions are insufficient. Key systemic barriers, such as policy limitations and resource constraints, may impede the widespread provision of CBT. To improve mental health services and treatment options, policies must align more closely with evidence-based practices, focusing on expanding access to CBT through improving training for providers, and innovative delivery models such as digital platforms. Addressing these issues is crucial for improving the quality and effectiveness of mental health care in Japan, and to ensure that individuals with mental health conditions receive the necessary treatment efficiently. Abbreviations CBT Cognitive Behavioral Therapy MDD Major Depressive Disorder SAD Social Anxiety Disorder PD Panic Disorder OCD Obsessive Compulsive Disorder PTSD Post-Traumatic Stress Disorder DeSC Detroit Employment Solutions Corporation NICE National Institute for Health and Care Excellence CANMAT Canadian Network for Mood and Anxiety Treatments IAPT Improving Access to Psychological Therapies Declarations Acknowledgments We thank Katherine East, PhD, from Edanz (https://jp.edanz.com/ac) for editing drafts of this manuscript. Ethics approval and consent to participate This study was reviewed and approved by the Ethics Committee of Hyogo Medical University (approval ID: 4906). The requirement for informed consent was waived due to the retrospective and anonymized nature of the data. Consent for publication Not applicable. Availability of Data and Materials The data that support the findings of this study are not publicly available due to contractual agreements with the data provider. As per the terms of use, these data cannot be shared with third parties. Funding This study received partial funding from the Japan Agency for Medical Research and Development (Grant Numbers: 23hma922015h0001 and 24hma322035h0001). No additional financial support was provided for the conduct of this research or the preparation of this article. Competing Interests The authors declare that there are no conflicts of interest. Author Contributions K.M. and Y.H. designed the study and wrote the protocol and conducted the statistical analysis. Y.H., M.S., S.O., K.Y., and K.H. provided summaries of previous research studies. K.M. and H.M. wrote the first draft of the manuscript and all authors contributed to and have approved the final manuscript. Authors' information Not applicable. Clinical trial number Not applicable. References Baxter AJ, Vos T, Scott KM, Ferrari AJ, Whiteford HA. The global burden of anxiety disorders in 2010. 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J Clin Psychiatry. 2013;74(6):595–602. https://doi.org/10.4088/JCP.12r07757 . Ishikawa H, Kawakami N, Kessler RC. Lifetime and 12-month prevalence, severity and unmet need for treatment of common mental disorders in Japan: results from the final dataset of World Mental Health Japan Survey. Epidemiol Psychiatr Sci. 2016;25(3):217–29. https://doi.org/10.1017/s2045796015000566 . Bar-Oz B, Einarson T, Einarson A, Boskovic R, O'Brien L, Malm H, Bérard A, Koren G. (2007). Paroxetine and congenital malformations: meta-Analysis and consideration of potential confounding factors. Clin Ther. May;29(5):918–926. 10.1016/j.clinthera.2007.05.003 . PMID: 17697910. Hetrick S, Merry S, McKenzie J, Sindahl P, Proctor M. (2007). Selective serotonin reuptake inhibitors (SSRIs) for depressive disorders in children and adolescents. Cochrane Database Syst Rev. Jul 18;(3):CD004851. 10.1002/14651858.CD004851.pub2 . Update in: Cochrane Database Syst Rev. 2012;11:CD004851. doi: 10.1002/14651858.CD004851.pub3. PMID: 17636776. Oliver MI, Pearson N, Coe N, Gunnell D. (2005). Help-seeking behaviour in men and women with common mental health problems: cross-sectional study. Br J Psychiatry. Apr;186:297–301. 10.1192/bjp.186.4.297 . PMID: 15802685. Bennett-Levy J, Richards DA, Farrand P, Christensen H, Griffiths K, Kavanagh DJ, Klein B, Lau MA, Proudfoot J, Ryden C, Williams C. Oxford guide to low intensity CBT interventions. Oxford University Press; 2010. https://doi.org/10.1093/med/9780199590117.001.0001 . Laynard R, Clark D, Knapp M, Mayraz G. Cost-benefit analysis of psychological therapy. Natl Inst Econ Rev. 2007;202(1):90–8. https://doi.org/10.1177/0027950107086171 . Ale CM, McCarthy DM, Rothschild LM, Whiteside SP. Components of Cognitive Behavioral Therapy Related to Outcome in Childhood Anxiety Disorders. Clin Child Fam Psychol Rev. 2015;18(3):240–51. https://doi.org/10.1007/s10567-015-0184-8 . Tables Table 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1demographicdata20250325.xlsx Table2demographicdata20250325.xlsx Cite Share Download PDF Status: Published Journal Publication published 29 Sep, 2025 Read the published version in BMC Psychiatry → Version 1 posted Editorial decision: Revision requested 24 Jun, 2025 Reviews received at journal 24 Jun, 2025 Reviews received at journal 27 May, 2025 Reviewers agreed at journal 10 May, 2025 Reviewers agreed at journal 09 May, 2025 Reviewers invited by journal 08 May, 2025 Editor invited by journal 07 May, 2025 Editor assigned by journal 05 May, 2025 Submission checks completed at journal 05 May, 2025 First submitted to journal 25 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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10:12:33","extension":"xlsx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":12376,"visible":true,"origin":"","legend":"","description":"","filename":"Table2demographicdata20250325.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6530172/v1/e4ead3ec160e91acab0b4c9e.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The provision of Cognitive Behavioral Therapy in Japan: an analysis using insurance claims data","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003ePsychiatric conditions such as Major Depressive Disorder (MDD), anxiety, and Obsessive-Compulsive Disorder (OCD) significantly impair quality of life and are among the top ten diseases contributing to economic burdens (Baxter et al., 2014; Murray et al., 1996). Additionally, the long-term costs of illness and treatment are substantial (Cho, Mishiro, Fujimoto, et al., 2022), leading to significant social losses such as absenteeism and presenteeism (Sado et al., 2011). The first-line treatments recommended are pharmacotherapies, such as antidepressants, Cognitive Behavioral Therapy (CBT) and combination of both. CBT is a psychotherapy with robust evidence demonstrating its effectiveness, often proving to be as effective as, or even more effective than, pharmacotherapy. Moreover, unlike pharmacotherapy, which can involve the risk of adverse events, CBT carries no biological risks and is recommended for sensitive individuals such as pregnant women or children. CBT excels in preventing relapses and is essential for achieving and maintaining remission (Zhang Z et al, 2018). It has also been shown that by widely disseminating CBT, it effectively reduces societal losses by addressing presenteeism and absenteeism (Clark, 2013).\u003c/p\u003e \u003cp\u003e Internationally recognized clinical guidelines such as the National Institute for Health and Care Excellence (NICE, 2018) and the Canadian Network for Mood and Anxiety Treatments (CANMAT) (Yatham et al., 2018) recommend CBT as a frontline treatment for mental health conditions in clinical settings. To improve health care systems, governments should implement health care policies in accordance with these guidelines. One of the most notable mental health strategies is seen in the UK's Improving Access to Psychological Therapies (IAPT) program. Initiated in 2008, this program has trained a large number of therapists and now servs one million users with recovery rates reaching 40\u0026ndash;50% (Digital, 2019). IAPT has also surpassed the expected return-to-work rate of 4%, reaching 5% (Clark, 2013). Many countries are adapting CBT delivery methods to fit their healthcare systems and geographical characteristics (Cano-Vindel et al., 2022; Gratzer \u0026amp; Goldbloom, 2016), exploring various approaches to enhance the availability and efficacy of evidence-based mental health treatments.\u003c/p\u003e \u003cp\u003eDespite the widespread recognition of CBT as a most robustly effective treatment for mental health conditions, its adoption as a mainstream medical practice remains a pressing issue in many countries. While variations in healthcare systems and geographical differences mean that the ideal model for CBT implementation can differ significantly from one country to another, common obstacles include limitations in human resources and geographical accessibility (Clark, 2013).\u003c/p\u003e \u003cp\u003eData on the prevalence of CBT in Japan, including regional differences, are scarce. Understanding the state of CBT dissemination in Japan can provide valuable insights for developing methods to monitor and improve CBT accessibility. Such data are crucial for estimating the unmet need for services, facilitating open discussions among policymakers and the public and guiding future mental health policy initiatives (Hayashi et al., 2020). Furthermore, understanding the medical environment for CBT implementation could lead to strategies that complement existing practices, which could provide useful information for medical policy considerations in Japan and other countries.\u003c/p\u003e \u003cp\u003eIn Japan, CBT is administered by trained psychiatrists (Kobori et al., 2014). These psychiatrists typically charge a fee of 4800 Japanese yen (~\u003cspan\u003e$\u003c/span\u003e32USD) for each session lasting over 30 minutes, regardless of the frequency of visits, which does not exceed once per week. This compares to a standard psychiatric psychotherapy session, lasting between 5 and 30 minutes, typically charged at 3150 Japanese yen (~\u003cspan\u003e$\u003c/span\u003e20.7USD). Therefore, the remuneration that psychiatrists receive is relatively low for CBT than a standard psychotherapy session, particularly considering the time spent on treatments (Kobori et al., 2014).\u003c/p\u003e \u003cp\u003eJapanese healthcare integrates tightly with national insurance, allowing individuals suffering from any illness to seek treatment from any healthcare provider they choose. Healthcare providers also register the medical actions performed and medications prescribed for insured conditions according to medical policy.\u003c/p\u003e \u003cp\u003eTo tackle the systemic issues in healthcare provision in Japan, it is crucial to understand the current status of CBT provision, including the progress of strategies and the balance of supply and demand. Increasingly, insurance claim data research has become a common method to understand these dynamics and issues within psychiatric care (Cho, Mishiro, Akaki, et al., 2022; Desai et al., 2019). National databases have been used to investigate the number of CBT claims in Japan (Haraguchi et al., 2021). Although these national databases can track the overall provision of healthcare on an annual basis, they do not capture detailed individual or group characteristics. Therefore, utilizing insurance claim data is more beneficial than national database data (Nakatani E, et al 2022, Nakatsuka K, et al 2024), because it allows for the investigation of individual session counts and dropout rates. In addition, it is possible to track the frequency of sessions for each individual. While evidence-based treatment guidelines recommend CBT once a week, there is evidence that CBT is often unavailable or delivered less frequently in routine clinical care in Western countries (Gunter \u0026amp; Whittal, 2010; Shafran et al., 2009).\u003c/p\u003e \u003cp\u003eIn Japan, CBT for depression has been covered by health insurance since 2010. However, its use has been limited and the number of insurance claims has plateaued in recent years (Hayashi et al., 2020). Thus, we hypothesize that the proliferation of CBT in Japan still remains insufficient at present. This situation may mean that it is difficult for many patients to use CBT as their first-line treatment. We also hypothesize that CBT sessions are usually performed less frequently than once a week for three primary reasons: first, difficulty of accessibility; second, because it is not economically efficient; and third, because it is considered unrealistic for patients to attend sessions more frequently.\u003c/p\u003e \u003cp\u003eTherefore, the aim of this study is to investigate, using health insurance claims data, (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) the number of CBT claims made for different mental health conditions that are covered by insurance, and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) the frequency and number of sessions per individual.\u003c/p\u003e"},{"header":"2. Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Data source\u003c/h2\u003e \u003cp\u003eSince the Japanese government established a universal health insurance system in 1961, those who live in Japan are covered by one of several public insurance systems (Yasunaga, 2019). Kokuho represents national health insurance for the self-employed, retirees, and their dependents. Kempo represents association, or union-managed, health insurance for salaried employees in large companies. Kyokai Kempo is a health insurance scheme operated by the National Health Insurance Association for salaried workers in small and medium-sized enterprises. Kyosai Kumiai are mutual aid associations that operated health insurance for other employees, including public servants. The Advanced Elderly medical service system for the elderly covers all persons aged over 75 years. As of 2019, the number of enrollees in Kokuho, Kempo, Kyokai Kempo, Kyosai Kumiai and Advanced Elderly medical service system are 28.7\u0026nbsp;million, 29.5\u0026nbsp;million, 38.9\u0026nbsp;million, 8.6\u0026nbsp;million, and 17.2\u0026nbsp;million, respectively.\u003c/p\u003e \u003cp\u003eThis study used the Detroit Employment Solutions Corporation (DeSC) database, maintained by DeSC Healthcare, Inc. This repository contains commercially available administrative claims and health examination data, details of which can be found elsewhere (Kimura et al., 2010; Sato et al., 2024). The DeSC database collects insurance claims data from three types of health insurance: Kokuho, Kempo and the Advanced Elderly medical service system. As of 2019, the number of enrollees in Kokuho and Kempo included in this claims database were approximately 12.0% and 2.8% of each population (Takeshita et al., 2024). Thus, the DeSC database encompasses approximately 14\u0026nbsp;million individuals of varying ages, including young, middle-aged, and older individuals, with an age and sex distribution closely matching Japan's population estimates (Okada \u0026amp; Yasunaga, 2022).\u003c/p\u003e \u003cp\u003eThe database contains anonymised and separately maintained medical claims data for outpatients and inpatients and includes the following information: (i) unique identifier; (ii) date of birth and gender; (iii) diagnosis according to International Classification of Diseases, 10th edition (ICD-10), codes; (iv) Japan-specific identification system-based procedures; (v) distribution of medicines according to the Anatomical Therapeutic Chemistry classification system; and (vi) dates of coverage and withdrawal.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Study design and participant selection\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study used data collected between April 2015 and March 2022. Indicator dates for each individual were defined as the date of the first CBT session. Inclusion criteria were: (i) registered in the DeSC database between April 2015 and March 2022; (ii) had continuous registration for the inclusion year, the previous year and the subsequent year; (iii) had a registered diagnosis of MDD, SAD, OCD, PD, PTSD or BN, treated using CBT and claimed using health care insurance; and (iv) entered into the DeSC database within one year prior to first CBT session. Participants were excluded if they had an incomplete registration, had insufficient insurance documentation, were registered in the DeSC database for more than one year before their first CBT session, or discontinued their insurance coverage before the study ended. The need for informed consent was waived because of the study\u0026rsquo;s retrospective, non-interventional nature and the use of anonymized data. Ethical approval for waiving informed consent was granted by an ethical committee, which confirmed that the privacy and security measures in place adequately protected participant data.\u003c/p\u003e \u003cp\u003eDiagnoses treated using CBT were categorized as follows:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIf CBT was administered before March 2016, the diagnosis was designated as MDD.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIf the medical institution that administered CBT listed a single diagnosis at the first session, that diagnosis was used as the official diagnostic label.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIf the diagnosis at the medical institution where CBT was first administered was singular at the time of the first CBT session, that diagnosis was used as the official diagnostic label.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIf the primary diagnosis that was registered during the treatment period was singular at the time of the first CBT session, that diagnosis was used as the official diagnostic label.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIf the primary diagnosis registered during the treatment period matched the diagnosis at the CBT medical institution and both were singular, that diagnosis was used as the official diagnostic label.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Variables\u003c/h2\u003e \u003cp\u003eFirst, the first CBT session for each individual was identified. Then, the number of patients starting CBT sessions each fiscal year was tracked. Third, for each individual, the duration from the first to the last CBT session, as well as the average number of days between sessions, were calculated. Fourth, the total number of sessions and the achievement rates were calculated. These metrics provided insights into the engagement and continuity of patients within the CBT programs under the two different insurance frameworks.\u003c/p\u003e \u003cp\u003eDemographic characteristics included age at the first session (using date of birth) and gender.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Statistical analyses\u003c/h2\u003e \u003cp\u003eThe analyses were conducted using stepwise regression in IBM SPSS Statistics 20.0 (IBM Corp., 2011. When examining CBT practices within the Kempo and Kokuho insurance systems, several parameters were not compared with statistical analysis between the two insurances. This decision was made because of the high proportion of elderly individuals aged between 65 and 75 years within the Kokuho system, as highlighted by Okada and Yasunaga (2022). This demographic characteristic is significantly higher in Kokuho compared with that in the general population, leading to potential sample bias in the study.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Participants\u003c/h2\u003e \u003cp\u003eParticipants included a total of 464,377 individuals under Kokuho and 72,743 under Kempo who were registered at least once with diagnoses of MDD, OCD, SAD, PD, PTSD or BN. The distribution of diagnoses were as follows: under Kokuho, there were 1,037 cases of MDD, 25 of OCD, 11 of SAD, 23 of PD, 13 of PTSD and and 18 unidentified cases. Under Kempo, there were 322 cases of MDD, 11 of OCD, 8 of SAD, 13 of PD, 5 of PTSD and 2 unidentified cases. No cases of BN were recorded under either insurance type.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.2 CBT\u003c/h2\u003e \u003cp\u003eDemographic analyses across the Kempo and Kokuho health insurance systems revealed distinctive patterns in the treatment of mental health conditions (Tables\u0026nbsp;1 and 2). Gender distributions predominantly favored females or were balanced, except for people with PTSD diagnoses under Kempo (Table\u0026nbsp;1). Individuals under Kokuho typically had their first CBT session in their late thirties, while those under Kempo typically had their first CBT session around thirty years of age (Table\u0026nbsp;2). This age discrepancy likely reflects the higher proportion of elderly people insured under Kokuho. Regarding treatment distributions, MDD consistently had the highest treatment incidences across both insurance systems. After MDD, OCD and PD emerged as the most prevalent conditions in Kokuho and Kempo, respectively. The data also indicated a plateau in year-on-year increases across all conditions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Retention rates and intervals between sessions\u003c/h2\u003e \u003cp\u003eComparing total session counts, most patients across all conditions and insurance types attended only the initial session, except for OCD patients under Kokuho (Figs.\u0026nbsp;1 to 5). Excluding those who attended only the first session, the highest claim counts for MDD, OCD, PD were for those who completed 16 sessions (the maximum number of sessions claimed). For SAD, except for one case in Kokuho, all patients dropped out within three sessions, indicating early discontinuation. The average number of days between sessions was longer among those with early dropout, and, for those undergoing more than ten sessions, the frequency of sessions was generally more than once a week, although this varied by condition. Among participants who were treated for over ten sessions, for Kokuho, the retention rates for CBT among those with MDD, OCD, SAD, PD, PTSD were 37.0%, 40.0%, 9.1%, 34.8%, and 30.8% respectively, and for Kempo, they were 21.7%, 45.5%, 0.0%, 38.5%, and 20.0%.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis was the first study to investigate insurance claims for CBT for several psychiatric conditions in Japan. While a portion of the population claimed CBT treatment, the findings suggest that its widespread adoption in Japan has not yet been fully realized. Additionally, the frequency and patterns of claims indicate that the recommended weekly sessions of CBT are typically not being followed; instead, treatments are being administered on a bi-weekly to monthly basis.\u003c/p\u003e \u003cp\u003eAs hypothesized, an increase in the number of CBT claims was not observed. Previous studies investigating the trends from 2010 to 2015 also reported that the number of CBT claims for depression remained stable (Haraguchi et al., 2021; Hayashi et al., 2020). Furthermore, even after the inclusion of other psychiatric conditions that were covered by insurance since 2016, there was no significant increase in claims between 2015 and 2022. This suggests that the integration of CBT into insurance coverage for numerous disorders did not substantially expand CBT utilization for depression or other conditions in Japan.\u003c/p\u003e \u003cp\u003eAmong the 464,377 individuals registered under Kokuho insurance and 72,743 under Kempo insurance with diagnoses of MDD, OCD, SAD, PD, PTSD, or BN, only 1,127 individuals (approximately 0.24%) under Kokuho and 361 individuals (approximately 0.50%) under Kempo received at least one CBT session. These low rates of CBT utilization suggest that many patients with these conditions might be receiving pharmacotherapy, the other primary treatment option, or no treatment at all. Furthermore, issues with CBT accessibility and utilization might significantly impact its use as an intervention.\u003c/p\u003e \u003cp\u003eThere is a notable preference for psychotherapy over pharmacotherapy, being three times more favored (McHugh et al., 2013). Many individuals remain skeptical about pharmacotherapy and current treatment methods, leading to an overall reluctance to seek treatment. In Japan, there has been a longstanding issue with reluctance to consult psychiatrists for psychiatric conditions. Indeed, patients with MDD and anxiety disorders only make up 27.3% and 17.8%, respectively, of those who consult psychiatric specialists within a 12-month period (Ishikawa et al., 2016). This study revealed that, among patients who received CBT, approximately 40% or fewer were also undergoing pharmacotherapy. This may be partly because a substantial proportion of patients either prefer not to receive pharmacotherapy or find it ineffective, possibly owing to issues with tolerability or skepticism. Furthermore, the presence of adverse events, particularly in treatments involving SSRIs, has been highlighted in prior work (Bar-Oz et al., 2007, Hetrick et al., 2007). In Japan, many antidepressants are noted in the prescribing information as having relative contraindications for use in minors. Therefore, efficiently identifying and providing CBT to individuals with psychiatric conditions is crucial because it represents a significant opportunity to enhance mental health treatment options and outcomes.\u003c/p\u003e \u003cp\u003eSeveral patterns emerged regarding demographic characteristics of those claiming CBT within the Kempo and Kokuho health insurance systems. A higher proportion of women than men were found to claim CBT. This may be attributed to the generally higher help-seeking behavior observed in women, suggesting that they may be more likely to engage appropriately in treatment activities, including CBT (Oliver MI et al., 2005). While caution is necessary because of the limited sample size, one third of the patients with SAD under Kempo were children and adolescents. Developing effective methods to deliver CBT to specific populations in need remains a critical challenge.\u003c/p\u003e \u003cp\u003eThe average frequency of CBT sessions was found to be less than once per week. Evidence suggests that CBT is most effective when administered weekly over a 10\u0026ndash;12 week period (Bennett-Levy et al., 2010). This recommendation balances the limited availability of human resources with maintaining patient adherence (Laynard et al., 2007). These constraints significantly shape treatment protocols and can affect the delivery of effective healthcare. However, in areas with a shortage of CBT therapists, or in rural areas where weekly visits to medical facilities are impractical, the standard weekly sessions over 10\u0026ndash;12 weeks does not align with clinical realities (Bennett-Levy et al., 2010).\u003c/p\u003e \u003cp\u003eIn Japan, the medical billing system accommodates less frequent CBT sessions, which has led to an established practice of scheduling sessions less often than once a week. This adjustment is not solely due to medical system limitations but is also heavily influenced by patient-specific factors. For patients engaged in daily commutes for school or work, attending weekly therapy sessions poses a significant logistical challenge. Data from the Kokuho system indicate that the typical frequency of CBT for MDD patients was approximately once a month. In contrast, the Kempo system showed greater variability, likely influenced by a higher proportion of employed individuals in this group.\u003c/p\u003e \u003cp\u003eThis study also found that, except individuals who only attended an initial session, the greatest frequency of sessions were observed in patients who completed the maximum of 16 sessions. OCD patients exhibited the highest retention rates among all disorders, which might be attributed to the nature of CBT techniques applied. For example, Exposure-Response Prevention for OCD often moves quickly through the psychoeducation phase to the exposure tasks, facilitating early noticeable treatment effects that likely bolster adherence (Ale et al., 2015). This may contribute to the higher continuation rates observed in OCD. Conversely, in SAD, many patients dropped out at earlier stages, possibly owing to disorder-specific comorbid symptoms, such as avoidance behaviors, which might make continued attendance challenging.\u003c/p\u003e \u003cp\u003eIn summary, this study highlights that the dissemination of CBT in Japan is insufficient, and that the current healthcare framework may not support its widespread adoption. While promoting and implementing evidence-based CBT is essential, adapting these interventions to suit the existing medical environment is equally important. Innovations such as developing low-intensity CBT options and enhancing the training of psychologists and healthcare professionals are crucial. Additionally, utilizing technology, such as internet platforms and mobile applications, could broaden access to CBT.\u003c/p\u003e \u003cp\u003eIt is critical to recognize the study's limitations, which could impact the interpretation and generalizability of the findings. Firstly, the sample may not necessarily be representative of the population in Japan. Secondly, in Japan, psychologists are not covered by insurance for conducting CBT within the medical system, though some may provide CBT alongside medical treatments privately; therefore, some people might have been receiving CBT but not claimed for it on their insurance. Thirdly, the absence of data from Kyokai Kempo beneficiaries suggests that the findings might not fully reflect the broader Japanese population, limiting the generalizability. Fourthly, focusing primarily on session frequency without directly assessing treatment outcomes restricts the study\u0026rsquo;s capacity to thoroughly evaluate the effectiveness of CBT interventions. Future research should aim to overcome these limitations to gain a more comprehensive understanding of the factors influencing CBT provision and its impact on patient outcomes.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study highlights significant challenges in integrating CBT within the Japanese healthcare system. Our findings indicate that, despite the recognized effectiveness of CBT and its inclusion in insurance coverage, its adoption and the frequency of sessions are insufficient. Key systemic barriers, such as policy limitations and resource constraints, may impede the widespread provision of CBT. To improve mental health services and treatment options, policies must align more closely with evidence-based practices, focusing on expanding access to CBT through improving training for providers, and innovative delivery models such as digital platforms. Addressing these issues is crucial for improving the quality and effectiveness of mental health care in Japan, and to ensure that individuals with mental health conditions receive the necessary treatment efficiently.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCBT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCognitive Behavioral Therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMDD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMajor Depressive Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSAD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSocial Anxiety Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePanic Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOCD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eObsessive Compulsive Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePTSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePost-Traumatic Stress Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDeSC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDetroit Employment Solutions Corporation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNICE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Institute for Health and Care Excellence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCANMAT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCanadian Network for Mood and Anxiety Treatments\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIAPT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eImproving Access to Psychological Therapies\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Katherine East, PhD, from Edanz (https://jp.edanz.com/ac) for editing drafts of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed and approved by the Ethics Committee of Hyogo Medical University (approval ID: 4906). The requirement for informed consent was waived due to the retrospective and anonymized nature of the data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are not publicly available due to contractual agreements with the data provider. As per the terms of use, these data cannot be shared with third parties.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received partial funding from the Japan Agency for Medical Research and Development (Grant Numbers: 23hma922015h0001 and 24hma322035h0001). No additional financial support was provided for the conduct of this research or the preparation of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eK.M. and Y.H. designed the study and wrote the protocol and conducted the statistical analysis. Y.H., M.S., S.O., K.Y., and K.H. provided summaries of previous research studies. K.M. and H.M. wrote the first draft of the manuscript and all authors contributed to and have approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBaxter AJ, Vos T, Scott KM, Ferrari AJ, Whiteford HA. The global burden of anxiety disorders in 2010. Psychol Med. 2014;44(11):2363\u0026ndash;74. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S0033291713003243\u003c/span\u003e\u003cspan address=\"10.1017/S0033291713003243\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurray CJ, Lopez AD, Jamison DT. 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Clin Child Fam Psychol Rev. 2015;18(3):240\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10567-015-0184-8\u003c/span\u003e\u003cspan address=\"10.1007/s10567-015-0184-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6530172/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6530172/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eCognitive Behavioral Therapy (CBT) is a first-line treatment for many mental health conditions. In Japan, patients can receive insurance coverage for CBT treatment of Major Depressive Disorder (MDD), social anxiety disorder (SAD), panic disorder (PD), Obsessive Compulsive Disorder (OCD), post-traumatic stress disorder (PTSD), and bulimia nervosa; however, utilization of CBT remains insufficient. This study investigated CBT provision for these disorders using Japanese health insurance claim data.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData were from Detroit Employment Solutions Corporation (DeSC), spanning April 2015 to March 2022. The dataset included \u0026ldquo;Kempo\u0026rdquo; (salaried workers\u0026rsquo; insurance; large companies) and \u0026ldquo;Kokuho\u0026rdquo; (national health insurance; self-employed and their dependents), representing 2.8% and 12% of each insured population, respectively. Patients with the aforementioned mental health conditions were identified, and analyses explored demographic characteristics, session frequencies, intervals, and prescription details.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOverall, 0.50% of Kempo, and 0.24% of Kokuho, clients who were diagnosed with the relevant mental conditions claimed insurance for CBT. Among Kempo clients, CBT was claimed by 322 (89.2%) with MDD, 8 (2.2%) SAD, 13 (3.6%) PD, 11 (3.1%) OCD, 5 (1.4%) PTSD, and 2 (0.5%) unspecified conditions. Among Kokuho clients, CBT was claimed by 1037 (92.0%) with MDD, 11 (1.0%) SAD, 23 (2.0%) PD, 25 (2.2%) OCD, 13 (1.2%) PTSD, and 18 (1.6%) unspecified conditions. Average intervals between sessions for MDD were 34.2 days under Kempo and 71.9 days under Kokuho.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eFew patients claimed insurance for CBT, and most session intervals exceeded one month. Findings underscore significant unmet medical needs in CBT provision in Japan. Medical environments that support and integrate regular CBT must be established.\u003c/p\u003e","manuscriptTitle":"The provision of Cognitive Behavioral Therapy in Japan: an analysis using insurance claims data","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-15 10:12:29","doi":"10.21203/rs.3.rs-6530172/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-24T07:35:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-24T06:52:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-27T06:48:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"260010188785893023429178371332511242826","date":"2025-05-10T12:54:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"17933709145722350929574406340718590115","date":"2025-05-10T02:56:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-08T23:21:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-07T11:28:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-05T06:10:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-05T06:09:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2025-04-25T15:16:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c5b59cc1-22ae-4238-bbed-94c382776480","owner":[],"postedDate":"May 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-06T16:10:29+00:00","versionOfRecord":{"articleIdentity":"rs-6530172","link":"https://doi.org/10.1186/s12888-025-07316-y","journal":{"identity":"bmc-psychiatry","isVorOnly":false,"title":"BMC Psychiatry"},"publishedOn":"2025-09-29 15:58:05","publishedOnDateReadable":"September 29th, 2025"},"versionCreatedAt":"2025-05-15 10:12:29","video":"","vorDoi":"10.1186/s12888-025-07316-y","vorDoiUrl":"https://doi.org/10.1186/s12888-025-07316-y","workflowStages":[]},"version":"v1","identity":"rs-6530172","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6530172","identity":"rs-6530172","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}