In psychiatric practice, involuntary treatment may be recommended when patients refuse treatment due to a lack of insight. However, there is a growing demand for transparency regarding the use of involuntary treatment and the processes involved. In 2012, Yamanashi Prefectural Kita Hospital introduced a review system for involuntary treatment exclusively in the psychiatric emergency ward. In 2016, this initiative was expanded to encompass all psychiatric wards following a successful trial. The review system involves the participation of the director, chief nurse from each psychiatric ward, and a psychologist. It assesses the patient's competency and best interests, and subsequently determines the appropriateness of involuntary treatment for patients whose psychiatrists in charge deem such treatment necessary, 72 hours or more after hospitalization.
 Between December 2016 and March 2023, a total of 169 reviews (an average of 2.2 per month) were conducted. The median time from hospitalization to review was 21 days, and the median time from the application for involuntary treatment to review was 1 day. Over 70% of the reviews were conducted in psychiatric emergency wards, and 115 cases (68.0%) were related to modified electroconvulsive therapy. Among all reviews, nine (5.3%) were not approved, of which four were not approved because the patients had complete competency. Finally, 50 cases (29.6%) underwent involuntary treatment under manual restraint.
 The introduction of this review system has provided us with a deeper insight into involuntary treatment within our hospital. The review offers several advantages, such as preventing inappropriate involuntary treatment, facilitating the implementation of necessary involuntary treatment, and enabling transitions to less invasive treatments with greater confidence. However, the system has problems such as the absence of involvement of an independent third party.
 To improve trust in psychiatric practice in Japan, it is essential to illuminate the process of involuntary treatment, which has been underrepresented in deliberations, and to explore the appropriate review process.
 Authors' abstract