Clinical effects of online cognitive behavioral group therapy for chronic pain patients and developing a therapeutic alliance: A pre-post pilot trial.

Background and Aims: Research suggests that various psychosocial factors influence chronic pain, with psychotherapies like cognitive behavioral therapy  proving effective. However, the limited availability and accessibility have prolonged suffering among patients with chronic pain. This challenge has led to a growing demand for accessible online interventions. We developed an online cognitive behavioral group therapy (CBGT) program, building upon our existing face-to-face CBGT program. We compared the scores obtained by patients during the treatment-as-usual (TAU) period with those collected at the beginning and at the end of the intervention. Methods: Patients with chronic pain (N = 22) agreed to participate in the online CBGT program, which was conducted once a week for 12 sessions. The sample size was decided based on the effect sizes of our past face-to-face CBGT. We assessed pain intensity [Visual Analogue Scale (VAS)], pain catastrophizing [pain catastrophizing scale (PCS)] and psychiatric assessment [Beck Depression Inventory-Second Edition (BDI)-II], State-Trait-Anxiety Inventory (STAI), and Short Form Health Survey (SF-36) at three points: entry, pretreatment, and posttreatment. We also evaluated the participants' therapeutic alliance with the treatment staff [short-form version of the Working Alliance Inventory (WAI-S)]. We utilized analyses of variance, Friedman test, paired t-tests, Wilcoxon signed-rank test, and Pearson correlation analysis for data evaluation. Results: Results indicated a significant posttreatment improvement in VAS, PCS, and BDI-II scores compared to the TAU period. Furthermore, posttreatment WAI-S scores increased significantly compared to pretreatment scores. Also, positive correlations were observed among pre- and posttreatment changes in WAI-S, pain intensity, and pain catastrophizing scores. Conclusion: There is a possibility that a therapeutic alliance can be established, and therapeutic effects achieved through an online CBGT intervention; however, additional research is required to substantiate this potential. We have registered this clinical trial in UMIN-CTR on 04/21/2021 with the number UMIN000043982.

Verification of the brain network marker of major depressive disorder: Test-retest reliability and anterograde generalization performance for newly acquired data.

BACKGROUND: Recently, we developed a generalizable brain network marker for the diagnosis of major depressive disorder (MDD) across multiple imaging sites using resting-state functional magnetic resonance imaging. Here, we applied this brain network marker to newly acquired data to verify its test-retest reliability and anterograde generalization performance for new patients. METHODS: We tested the sensitivity and specificity of our brain network marker of MDD using data acquired from 43 new patients with MDD as well as new data from 33 healthy controls (HCs) who participated in our previous study. To examine the test-retest reliability of our brain network marker, we evaluated the intraclass correlation coefficients (ICCs) between the brain network marker-based classifier's output (probability of MDD) in two sets of HC data obtained at an interval of approximately 1 year. RESULTS: Test-retest correlation between the two sets of the classifier's output (probability of MDD) from HCs exhibited moderate reliability with an ICC of 0.45 (95 % confidence interval,0.13-0.68). The classifier distinguished patients with MDD and HCs with an accuracy of 69.7 % (sensitivity, 72.1 %; specificity, 66.7 %). LIMITATIONS: The data of patients with MDD in this study were cross-sectional, and the clinical significance of the marker, such as whether it is a state or trait marker of MDD and its association with treatment responsiveness, remains unclear. CONCLUSIONS: The results of this study reaffirmed the test-retest reliability and generalization performance of our brain network marker for the diagnosis of MDD.

Oral theophylline augmentation for patients with missed or inadequate seizures with electroconvulsive therapy.

AIM: An inadequate seizure occasionally occurs during a course of acute electroconvulsive therapy (ECT) under the maximum approved electrical stimulation in Japan of 504 mC. This retrospective study was conducted to determine the effectiveness and adverse reactions of an oral theophylline augmentation technique. METHODS: A retrospective review of medical records was conducted of patients admitted to the Department of Psychiatry, Hiroshima Citizens Hospital, who received acute phase ECT from October 2014 to March 2017. RESULTS: A theophylline augmentation technique was instituted in 13 patients (7 males, 6 females; 56-79 years old). The total number of ECT sessions per patient ranged from 9 to 20 and the number of those with theophylline augmentation per patient ranged from 1 to 17. An augmentation effect was noted in all patients and each finished the scheduled ECT course, except for 1 who developed memory disturbance. The maximum dose of theophylline ranged from 200 to 700 mg/day, and the serum level at 06:00 on the day of the ECT session ranged from 5.3 to 23.6 mg/L in 12 patients, as 1 missed the examination. CONCLUSION: Oral theophylline augmentation can be considered as an effective treatment option for patients undergoing ECT with inadequate seizures.

Clinical practice guidelines for the care of psychologically distressed bereaved families who have lost members to physical illness including cancer.

The Japanese Psycho-Oncology Society and the Japanese Association of Supportive Care in Cancer developed evidence-based clinical practice guidelines for the care of psychologically distressed bereaved families who have lost members to physical illness including cancer. The guideline development group formulated two clinical questions. A systematic literature review was conducted. The level of evidence and the strength of the recommendations were graded and recommendation statements validated using the modified Delphi method. The recommendations were as follows: non-pharmacological interventions were indicated for serious psychological distress (depression and grief); antidepressants were indicated for depression; however, psychotropic medications including antidepressants were not recommended for 'complicated' grief. These guidelines will facilitate the provision of appropriate care to distressed bereaved family members and highlight areas where further research is needed.

Decreased physical activity with subjective pleasure is associated with avoidance behaviors.

The main hypothesis for the relation between physical activity and mental health is that autonomous motivation, such as subjective pleasure for the activity, plays an important role. However, no report has described empirical research designed to examine the role of subjective pleasure in the relation between objectively measured physical activity and psychological indexes. We used accelerometers to collect data indicating participants' physical activity intensity during a week. Participants recorded their subjective pleasure of activity per hour. In 69% of them, the individual correlation coefficients between physical activity and pleasure in an hour (an index of Physical Activity-Pleasure; PA-PL) were positive (r = 0.22, 95%Cl = [0.11-0.38]), indicating that pleasant sensations increased concomitantly with increasing physical activity. Conversely, 31% participants exhibited negative values of PA-PL, which means that the increase in physical activity had the opposite effect, decreasing pleasure. Multiple linear regression analysis showed that avoidance/rumination behaviors decreased significantly with increased PA-PL (ß = -6.82, 95%CI: [-13.27 to -0.38], p < .05). These results indicate that subjective pleasure attached to the PA is more important than the PA amount for reducing depressive behavior.

Kynurenic acid is a potential overlapped biomarker between diagnosis and treatment response for depression from metabolome analysis.

Since optimal treatment at an early stage leads to remission of symptoms and recovery of function, putative biomarkers leading to early diagnosis and prediction of therapeutic responses are desired. The current study aimed to use a metabolomic approach to extract metabolites involved in both the diagnosis of major depressive disorder (MDD) and the prediction of therapeutic response for escitalopram. We compared plasma metabolites of MDD patients (n = 88) with those in healthy participants (n = 88) and found significant differences in the concentrations of 20 metabolites. We measured the Hamilton Rating Scale for Depression (HRSD) on 62 patients who completed approximately six-week treatment with escitalopram before and after treatment and found that kynurenic acid and kynurenine were significantly and negatively associated with HRSD reduction. Only one metabolite, kynurenic acid, was detected among 73 metabolites for overlapped biomarkers. Kynurenic acid was lower in MDD, and lower levels showed a better therapeutic response to escitalopram. Kynurenic acid is a metabolite in the kynurenine pathway that has been widely accepted as being a major mechanism in MDD. Overlapping biomarkers that facilitate diagnosis and prediction of the treatment response may help to improve disease classification and reduce the exposure of patients to less effective treatments in MDD.

Real-World Effectiveness of Ramelteon and Suvorexant for Delirium Prevention in 948 Patients With Delirium Risk Factors.

OBJECTIVE: The aim of this study was to examine the effectiveness of ramelteon and suvorexant for delirium prevention in real-world practice. It explored whether ramelteon and/or suvorexant would affect delirium prevention among both patients at risk for but without delirium (patients at risk) and those with delirium the night before a consultation. METHODS: This multicenter, prospective, observational study was conducted by trained psychiatrists at consultation-liaison psychiatric services from October 1, 2017, to October 7, 2018. Patients who were aged 65 years or older and hospitalized because of acute diseases or elective surgery, had risk factors for delirium, and had insomnia or delirium on the night before the consultation were prescribed ramelteon and/or suvorexant. The decision to take medication was left to the discretion of each patient. The primary outcome was incidence of delirium based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, during the first 7 days. RESULTS: Among 526 patients at risk, those taking ramelteon and/or suvorexant developed delirium significantly less frequently than those who did not, after control for the effects of risk factors on the estimate of an independent association between the effects of ramelteon and/or suvorexant and the outcome of developing delirium (15.7% vs 24.0%; odds ratio [OR] = 0.48;, 95% CI, 0.29-0.80; P = .005). Similar results were found among 422 patients with delirium (39.9% vs 66.3%; OR = 0.36; 95% CI, 0.22-0.59; P < .0001). CONCLUSIONS: Ramelteon and suvorexant appear to be effective for delirium prevention in real-world practice.

Psychological and psychiatric symptoms of terminally ill patients with cancer and their family caregivers in the home-care setting: A nation-wide survey from the perspective of bereaved family members in Japan.

OBJECTIVE: The psychological and psychiatric symptoms of terminally ill cancer patients are highly problematic and have been associated with greater burden among caregivers. Until now, the extent of these problems in the home care setting was unclear. METHODS: This retrospective study was conducted as part of a nationwide survey from the perspective of bereaved family members in Japan (J-HOPE3). The bereaved family members rated the symptoms of delirium and suicidal ideation of patients with cancer, and the sleeplessness and depressed mood of family caregivers utilizing home care services in the one month before the patients' deaths. Regression analyses were performed to identify factors associated with caregivers' sleeplessness or depressed mood. RESULTS: Of the 532 subjects analyzed, between 17% and 65% of patients experienced various symptoms of delirium, and 27% suicidal ideation. Among family caregivers, 60% experienced sleeplessness and 35% experienced depressed mood at least once during the week. Caregivers' psychological symptoms were associated with their own poor health status, being the spouse of the patient, and the patients' psychological or psychiatric symptoms. To manage patients' symptoms, 11% of caregivers had consulted psychiatrists or psychologists while another 11% wanted to do so. CONCLUSION: Psychological problems assessed were common among patients with cancer and their family caregivers in the one month of home care prior to the patient's death. An effective complementary care system, run by home-visit physicians, nurses, and experts in mental disorders, is needed.

Preventive Effects of Suvorexant on Delirium: A Randomized Placebo-Controlled Trial.

OBJECTIVE: No highly effective pharmacologic interventions to prevent delirium have been identified. We examined whether suvorexant, a potent and selective orexin receptor antagonist, is effective for the prevention of delirium. METHODS: We conducted a multicenter, rater-blinded, randomized, placebo-controlled clinical trial in intensive care units and regular acute wards between April 2015 and March 2016. Eligible patients were 65 to 89 years old, newly admitted due to emergency, and able to take medicine orally and had an expected stay or life expectancy of 48 hours or more. Seventy-two patients were randomly assigned using the sealed envelope method to receive suvorexant (15 mg/d; 36 patients) or placebo (36 patients) every night for 3 days. The primary outcome measure was incidence of delirium as determined by the DSM-5. Trained psychiatrists assessed for delirium. RESULTS: We found that delirium developed significantly less often among patients taking suvorexant than among those taking placebo (0% [n/N = 0/36] vs 17% [6/36], respectively, P = .025). Comparison by log-rank test also showed that delirium developed significantly less often among patients taking suvorexant than among those taking placebo (χ² = 6.46, P = .011). Analysis of variance revealed a tendency for main effect of treatment (F = 3.79, P = .053) on the sleep-wake cycle disturbance score (item 1) of the Japanese version of the Delirium Rating Scale-Revised-98 (DRS-R-98-J). There were no significant differences in adverse events. CONCLUSIONS: Suvorexant administered nightly to elderly patients admitted for acute care may provide protection against delirium. Larger studies are needed to show the potential of suvorexant to improve the circadian core domain of delirium. TRIAL REGISTRATION: UMIN Clinical Trials Registry identifier: UMIN000015681​.

Disrupted Brain Activation and Deactivation Pattern during Semantic Verbal Fluency Task in Patients with Major Depression.

BACKGROUND: Patients with major depressive disorder (MDD) exhibit cognitive impairment, and evidence suggests that the semantic version of the verbal fluency task is a reliable cognitive marker of the disorder. Here, using functional magnetic resonance imaging (fMRI), we investigated the dysfunction of neural processing in acute depression and examined the effects of a 6-week pharmacological intervention. METHODS: Sixteen patients with MDD participated in 2 fMRI sessions, and 16 healthy control (HC) subjects participated in 1 fMRI session. During each fMRI session, the participants performed a semantic verbal fluency task. Brain activity during the task was compared between groups (MDD 1st fMRI vs. HC) and times (MDD 1st fMRI vs. 2nd fMRI). RESULTS: Significant brain hypoactivation was observed in MDD patients at the prefrontal, lateral parietal, and limbic regions compared to HC, and MDD patients exhibited hyperactivation at the left precuneus compared to HC. Hypoactivity of the left dorsolateral prefrontal cortex (DLPFC) and hyperactivity of the precuneus were normalized with treatment. CONCLUSIONS: Hypoactivation of the left DLPFC and hyperactivation of the precuneus should be considered as dysregulation of anticorrelated brain networks during a cognitive demanding task. This failure of network regulation may be an important factor in the pathophysiology of MDD.

[Epigenetic mechanism of depression].

Numerous epigenetic studies have revealed that the acetylated status of histone as well as methylated status of cytosine is closely involved in gene transcription. Preclinical and clinical studies demonstrate that changes in levels of various genes in the brain including BDNF, play a role in the pathophysiology of depression. It is well known that the levels of BDNF mRNA and protein in the rat brain, such as frontal cortex and hippocampus, was decreased in response to stress, but the precise mechanism of stress-induced downregulation of BDNF has yet to be characterized. In this context, we examined the influence of a single immobilization stress (SIS) on the levels of total BDNF mRNA with each exon mRNA by real-time PCR and acetylated histone at the promoters of the BDNF gene by chromatin immunoprecipitaion assay in the rat hippocampus. SIS significantly decreased the levels of total BDNF mRNA with significant reduced levels of exon I and IV mRNA. Significant decreases in acetylated histone H3, but not H4, were found at the promoters of exons I, IV, and VI. On the other hand, antidepressant-like effects has been reported with sodium butylate (SB), a histone deacetylase (HDAC) inhibitor, promoting gene transcription. We also found antidepressant-like effect of repeated administration of SB in the forced swim test using rats. In addition, we found that upregulation in transthyretin mRNA in the rat hippocampus is, at least in part, associated with this effect using DNA microarray and real-time PCR. Based on these findings, it is postulated that epigenetic regulation of the BDNF gene by stress and antidepressants may be involved in the pathophysiology of depression.

Maternal postpartum learned helplessness (LH) affects maternal care by dams and responses to the LH test in adolescent offspring.

It is known that the early environment affects the mental development of rodent and human offspring. However, it is not known specifically whether a postpartum depressive state influences the depressive state in offspring. Using learned helplessness (LH) in rats as an animal model of depression, we examined the influence of maternal postpartum LH on responses to the LH test of offspring. Dam rats were judged as LH or non-helpless (nLH) on postnatal days (PN) 2-3, and maternal behavior was recorded during PN2-14. On PN 45-46, offspring were subjected to the LH test. Plasma corticosterone (CORT) levels, hippocampal levels of glucocorticoid receptor (GR) and brain-derived neurotrophic factor (BDNF) mRNA were measured before and after the LH test in offspring. Active nursing in LH dams was significantly lower than that in nLH dams. Susceptibility to LH in the offspring of LH dams was significantly higher than in those of nLH dams, and was negatively correlated with active nursing by LH dams. The GR mRNA levels before and after the LH test were lower in the offspring of LH dams than in those of nLH dams, and the reduced basal GR mRNA and protein might have resulted in the higher CORT response after the LH test. There was no significant difference in BDNF mRNA in the offspring of LH and nLH dams. These findings suggest that early postpartum LH decreased active nursing and increased depression-like behavior in the adolescent offspring via dysfunction of the hypothalamic-pituitary-adrenal axis.

Single immobilization stress differentially alters the expression profile of transcripts of the brain-derived neurotrophic factor (BDNF) gene and histone acetylation at its promoters in the rat hippocampus.

Decreased levels of brain-derived neurotrophic factor (BDNF) in the hippocampus are implicated in the pathophysiology of major depression, although the mechanism has yet to be characterized. Epigenetic studies revealed that DNA methylation and histone modifications at the promoter of exons of the BDNF gene are the pivotal factors in the regulation of BDNF transcription. Histone acetylation regulates gene transcription through chromatin remodelling. We examined the influence of a single immobilization stress (SIS) at 2 h and 24 h afterwards on the levels of total BDNF mRNA with each exon mRNA by quantitative real-time PCR, acetylated histone at the promoters of the BDNF gene by chromatin immunoprecipitation followed by real-time PCR, and BDNF protein by ELISA in the rat hippocampus. SIS significantly decreased the levels of total BDNF mRNA with significantly reduced levels of exons I and IV mRNA followed by a significant reduction in BDNF protein 4 h after SIS. Significant decreases in the levels of acetylated histone H3, but not H4, were found at the promoters of exons I, IV, and VI. In contrast, no marked changes in the levels of either acetylated histone or BDNF mRNA and protein were found 24 h after SIS. This study demonstrated the involvement of histone acetylation in the regulation of BDNF transcription by SIS, and the plastic change in histone acetylation after SIS. These findings suggest that stress affects BDNF gene transcription via epigenetic regulation, and glucocorticoid may be involved in this regulation.

Effects of single prolonged stress and D-cycloserine on contextual fear extinction and hippocampal NMDA receptor expression in a rat model of PTSD.

Although the impaired extinction of traumatic memory is one of the hallmark symptoms of posttraumatic stress disorder (PTSD), the underlying mechanisms of impaired extinction are unclear and effective pharmacological interventions have not yet been developed. Single prolonged stress (SPS) has been proposed as an animal model of PTSD, since rats subjected to SPS (SPS rats) show enhanced negative feedback of the HPA axis and increased contextual fear, which are characteristics similar to those observed in patients with PTSD. In this study, using SPS rats, we examined (a) the ability of SPS to impair fear extinction, (b) whether D-cycloserine (DCS) can alleviate impaired fear extinction in SPS rats, and (c) the effect of SPS and/or DCS on the levels of N-methyl-D-aspartate (NMDA) receptor subunit mRNAs in the rat hippocampus during extinction training. SPS rats exhibited impaired fear extinction in the contextual fear test, which was alleviated by the repeated administration of DCS. The effect of enhanced extinction, induced by the administration of DCS to SPS rats, was maintained for one week following extinction training. SPS induced significant upregulation of the levels of NMDA receptor subunit mRNAs before and during the period of extinction training, while repeated administration of DCS eliminated the enhanced mRNA levels of NMDARs. Behavioral analyses indicated that SPS is an appropriate animal model of PTSD and that DCS may be effective in the treatment of PTSD. These findings suggest that DCS, irrespective of its mechanistic involvement in the enhancement of fear extinction, may help to reverse hippocampal plasticity, and thus reverse the NMDA compensatory alterations.

Risk factors of preterm delivery at less than 35 weeks in patients with renal transplant.

BACKGROUND: To identify prenatal events associated with preterm delivery at less than 35 weeks of gestation in women with renal transplant. METHODS: A case-control study of 53 pregnancies in 42 renal transplant recipients, at a single center from 1984 to 2003 was analyzed. Preterm delivery cases (n=23) at less than 35 weeks of gestation were compared with the controls (n=30). RESULTS: Preterm delivery at less than 35 weeks of gestation occurred in 23 cases (43.4%). Hypertension (> or =140/90 mmHg) prior to pregnancy (odds ratio (OR) 6.3, 95% confidence interval (CI) 1.0-38.6), proteinuria (> or =0.3g/day) prior to delivery (OR 11.7, CI 2.7-51.8) and serum creatinine (> or =1.5mg/dl) prior to delivery (OR 4.4, CI 1.0-19.5) were significantly associated with increased risk of preterm delivery. Perinatal or neonatal deaths were not found. Fetal anomaly was seen in one case (polydactyly), and periventricular leukomalacia was found in two cases. CONCLUSION: In this case-control study, hypertension prior to pregnancy, proteinuria and serum creatinine (> or =1.5mg/dl) prior to delivery were related to the occurrence of preterm delivery at less than 35 weeks in renal transplant pregnancies.

Quetiapine treatment for behavioral and psychological symptoms in patients with senile dementia of Alzheimer type.

The purpose of this study was to assess the effect of quetiapine in the treatment of behavioral and psychological symptoms of dementia (BPSD) in patients with senile dementia of Alzheimer type (SDAT). Sixteen SDAT patients with BPSD were recruited and quetiapine (25- 200 mg/day) was prescribed for 8 weeks. BPSD were evaluated with the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD) and Cohen-Mansfield Agitation Inventory (CMAI) at week 0 (baseline) and week 8 (endpoint). The severity of the extrapyramidal symptoms was also assessed by the Drug-Induced Extrapyramidal Symptoms Scale (DIEPSS) at baseline and endpoint. Significant improvements were seen in the CMAI total score and in the BEHAVE-AD subscales of delusions, activity disturbances, aggressiveness, diurnal rhythm disturbances and in the BEHAVE-AD overall severity. There was no significant difference between the baseline and endpoint in the DIEPSS score. These data indicate that quetiapine is effective in controlling BPSD with favorable adverse-event profiles.