The Paradoxical Clinical Course of Persons with Gambling Disorder and Comorbid Attention-Deficit/Hyperactivity Disorder (ADHD).

The co-occurrence of gambling disorder (GD) and attention-deficit/hyperactivity disorder (ADHD) has been widely reported. In this study, we aimed to investigate the social background, clinical characteristics, and clinical course of initial-visit GD patients with and without ADHD in a Japanese psychiatric hospital. We recruited 40 initial-visit GD patients and collected comprehensive information by self-report questionnaires, direct interviews, and medical records. 27.5% of the GD patients had comorbid ADHD. Compared to the GD patients without ADHD, those with ADHD had significantly higher comorbidity rates of autism spectrum disorder (ASD), lower rates of marriage, slightly less years of education and marginally lower employment rates. On the other hand, the GD patients with ADHD showed higher treatment retention rates and participation rates in the mutual support group. Despite presenting with disadvantageous characteristics, GD patients with ADHD exhibited a more favourable clinical course. Therefore, clinicians should be mindful of the possibility of ADHD comorbidity and the potential for better clinical outcomes among GD patients with ADHD.

Efficacy of disulfiram for the treatment of alcohol dependence assessed with a multicenter randomized controlled trial.

BACKGROUND: The efficacy of disulfiram in preventing an alcoholic relapse has been controversial. The aim of our study was to assess the efficacy of supervised disulfiram for the treatment of alcohol dependence with a multi-institutional study in Japan. METHODS: In a single-blinded, randomized placebo-controlled study, we recruited 109 patients diagnosed with alcohol dependence under ICD-10 criteria. The patients were randomly allocated to 4 treatment groups, depending on whether they took disulfiram (200 mg daily) or a placebo or whether they received adjunctive therapy consisting of mailed letters which delineated and emphasized the harmful effect of alcohol and the management of alcohol craving. The proportion of abstinence among the 4 groups at 26 weeks after discharge was the primary outcome measure. The proportion of abstinence was compared with the severity of alcohol dependence and craving. Furthermore, we examined the proportion of abstinence in patients with inactive aldehyde dehydrogenase-2 (ALDH2). RESULTS: There were no significant differences among the 4 groups in terms of abstinent patients or study dropouts. The ratio of abstinence was not related to the severity of alcohol dependence or the degree of alcohol craving. Patients with inactive ALDH2 significantly sustained abstinence with the use of disulfiram (p = 0.044). CONCLUSIONS: Supervised oral disulfiram use followed by intervention via letters seems to be ineffective for increasing abstinence. Further studies are necessary to prove the efficacy of disulfiram for the pharmacological treatment of alcohol dependence. We indicated the effectiveness of disulfiram for the maintenance of abstinence in patients with inactive ALDH2.

[Significance of SBIRT and countermeasures for its dissemination].

This article reviews the literatures on screening, brief intervention, and referral to treatment(SBIRT). SBIRT is an intervention model that identifies at-risk alcohol users and then provides them a patient-centered intervention. This literatures include publications on advice, intervention, minimal intervention, brief intervention, screening and intervention, and SBIRT. SBIRT evaluation is important for the following reasons. SBIRT is one of the most clinically effective and cost-effective preventive services. SBIRT prevents the progress to alcohol dependence, avoids stigma, treats all spectrums of drinking behavior, is evaluated high by patients and their families, strengthens a positive therapeutic atmosphere in medical settings, and has different importance in different medical settings. Next, we present concrete evidence for the effectiveness of SBIRT. Many clinical trials have been conducted to evaluate the efficacy and cost-effectiveness of SBIRT in primary care, emergency departments, and trauma centers. In addition, we summarize barriers to the dissemination of SBIRT. Of particular importance is the lack of necessary knowledge, skill, financial incentive, time, and structured systems for SBIRT. Therefore, medical treatment fees, recommendation of the medical society, concrete countermeasure, and education of medical staff are important factors related to the dissemination of SBIRT. Finally, we present the costs factors associated with implementing SBIRT for the introduction of medical treatment fees.

Significant Weight Gain With the Administration of Lurasidone and Valproic Acid in Schizophrenia and Bipolar Disorder Patients.

Antipsychotics are frequently used to treat psychiatric disorders and have been associated with weight gain. Mental disorders are likely to reduce patients' quality of life. Unhealthy lifestyles such as reduced physical activity, sleep disturbances, and irregular diets can lead to weight gain. Herein, we report two cases of schizophrenia and bipolar disorder who had a 10-kg gain in weight in six months with the administration of lurasidone and valproic acid. Lurasidone has fewer side effects, such as weight gain and somnolence. However, concomitant use of sedating antipsychotics or mood stabilizers in the acute phase and multiple doses increase the risk of weight gain. Additionally, various factors, including psychiatric symptoms and lifestyle changes, are believed to contribute to weight gain, and a comprehensive approach should be followed.

Sex differences in risk factors for suicidality among Japanese substance use disorder patients: association with age, types of abused substances, and depression.

AIM: The aim of this study was to identify risk factors for suicide in Japanese substance use disorder (SUD) patients, adjusting for age and sex, and to examine sex differences in suicide risk among these patients. METHODS: A self-reporting questionnaire on age, sex, types of abused substances, current depression, and suicidality was administered to 1420 SUD patients who consecutively visited seven hospitals specializing in SUD treatment during the month of December 2009. Unadjusted/adjusted odds ratios of factors associated with suicidality were calculated for each sex. RESULTS: The multivariate analysis using the total sample identified younger age, female sex, and current depression as risk factors for severe suicidality in SUD patients. The multivariate analysis by each sex demonstrated that younger age and current depression were associated with severe suicidality in male SUD patients. Only current depression was associated with severe suicidality in female patients. CONCLUSION: Current depression is a risk factor for suicide in SUD patients common in both Western countries and Japan, although in Japanese SUD patients both younger age and female sex were more closely associated with severe suicidality than aspects of SUD. Additionally, young male SUD patients are speculated to have psychosocial features associated with suicidality in common with female SUD patients.

[Investigation of patients suspected of drinking, who visited emergency department, and their negative influence on emergency medical system].

We investigated the nature of patients who have a pathological drinking problem visiting the emergency department (ED). During the investigation period, 107 (1.2%) of 8,812 referred patients, including children, were suspected of having consumed alcohol by the medical staff in the ED on the basis of the interview, the smell of alcohol on the patient's breath, pre-hospital information, etc. One hundred and seven patients were divided into either of the two groups, "problem drinkers" or "others". When the patient fulfilled at least one of the following conditions, he/she was categorized as a "problem drinker". The conditions were either drunken patients who did not cooperate with the staff in the ED, who came to the ED after drinking more than two times during the investigation period, who usually consumed over 60 g of ethanol in a day, or who injured themselves intentionally after having consumed alcohol. Statistical significance was revealed with regard to "arrival time" and "diagnosis" between both groups. In the "problem drinkers" group, a larger number of patients visited the ED during the day (08:00-18:00 hrs.) and almost half the illness were diagnosed as trauma-related. The tendency of statistical significance was noted with regard to "sex" and "transportation". There was no statistical significance with regard to "age", "health insurance", "severity of illness", "opportunity to drink", or "CAGE questionnaire.

[Investigation of patients suspected of drinking, who visited emergency department, and their negative influence on emergency medical system].

We investigated the drunken patients visiting the emergency department (ED) to determine their negative influence on emergency medical system in our community. One hundred seven (1.2%) of 8,812 referred patients, including children, was suspected of drinking by the medical stuffs in the ED on the basis of the interview, smell of alcohol on breath, pre-hospital information, and so on. Objective analysis of drinking, such as blood alcohol concentration measurement, was not performed. Both the mean age and the median of the patients were 45 years old. The number of male was 4 times higher than female. Three fourths visited ED during the period from the evening to early morning, when it tends to be confused in ED. Eighty percents were delivered by ambulance service. Over 90% visited ED within 12 hours after drinking. Half of them were classified as moderate or more severe alcohol intoxication level on visiting ED. The medical practice was significantly disturbed by some patients, who were restless, violent, or uncooperative with the medical stuffs. Seven patients attempted suicides during drinking before visiting ED. Two thirds of the patients were diagnosed as mild, and left ED after simple medical treatment. Only 6.5% were indicated to admission and the urgent operations were performed on three patients. The CAGE was obtained from 55 patients, and half of them were positive to two or more questions, indicating suffering from alcohol disorder. Half of the patients drank over 60g of alcohol in one day, and 61% drank in four or more days in one week. Result of the investigation of the drunken patients visiting ED reveals negative influence on emergency medical system.

Depression and suicide risk of outpatients at specialized hospitals for substance use disorder: comparison with depressive disorder patients at general psychiatric clinics.

The present study used a self-reporting questionnaire to compare suicide risk in outpatients being treated for substance use disorder at specialized hospitals to suicide risk in outpatients being treated for depressive disorder at general psychiatric clinics. Although patients in both groups exhibited an equal severity of depression, the patients with drug use disorder had a higher suicide risk than those with depressive disorder. These findings indicate that drug-abusing patients at specialized hospitals may have a severe risk of committing suicide, suggesting that carefully assessing the comorbidity of depression with drug abuse may be required for preventing suicide in drug-abusing patients.

[A study on differences of suicide risk in substance use disorder patients by types of an abused substance: a comparison among alcohol, amphetamine, and sedative, hypnotic or anxiolytic use disorder patients].

BACKGROUND AND PURPOSE: Substance use disorder is one of the important mental health problems related to suicide, nearly equal with depressive disorder. However, it is unclear how differences of abused substances influence the suicide risk of individuals with substance use disorder in Japan. The purpose of the present study is to compare an estimated suicide risk among patients with alcohol, amphetamine, and sedative, hypnotic or anxiolytic use disorders. METHODS: Subjects were 1082 outpatients with alcohol use disorder (AUD), 191 with amphetamine-like use disorder (AMUD), and 63 with sedative, hypnotic or anxiolytic use disorder (SUD), all of whom consecutively had consulted seven medical facilities specialized for treatment of substance use disorder during a month of December 2009. A self-reporting questionnaire including the items of Kessler 10 (K10) and the Mini International Neuropsychiatric Interview (M.I.N.I.) was administered, and scores of the K10 and M.I.N.I., and the other clinical information were compared among the patients with AUD, AMUD, and SUD. RESULTS: Patients with AMUD and SUD showed significantly higher score on the M.I.N.I. than those with AUD, while those with SUD showed highest score on the K10, followed by those with AMUD. In either of patients with AUD, AMUD, or SUD, approximately 60% of the subjects who attempted suicide within a month reported to take any psychoactive substance in the attempted suicide. Additionally, a remarkable difference was found in histories of general psychiatric treatment before consulting medical facilities specialized for treatment of substance use disorder between these three groups. Most of outpatients with SUD reported such histories. CONCLUSIONS: Outpatients with SUD appeared to involve the highest risk for suicide of all patients with substance use disorder, probably because of the comorbid-severe depression. In our speculation, SUD which our subjects suffered from might be induced or accelerated by pharmacotherapy performed in general psychiatric facilities. Education on dependency of prescribed psychotropic drugs to general psychiatrists is required.

Changes of clinical symptoms in patients with new psychoactive substance (NPS)-related disorders from fiscal year 2012 to 2014: A study in hospitals specializing in the treatment of addiction.

AIMS: The use of new psychoactive substances (NPS) has become increasingly widespread over the last decade, in Japan and internationally. NPS are associated with a range of increasingly serious clinical, public, and social issues. Political measures to ameliorate the effects of NPS in Japan have focused on tightening regulation rather than establishing treatment methods. The current study sought to compare the neuropsychiatric symptoms of patients with NPS-related disorders across several years. We examined patients who attended specialized hospitals for treating addiction, to elucidate the impacts of legal measures to control NPS. METHODS: Subjects (n = 864) were patients with NPS-related disorders who received medical treatment at eight specialized hospitals for treating addiction in Japan between April 2012 and March 2015. Clinical information was collected retrospectively from medical records. RESULTS: Among psychiatric symptoms, the ratio of hallucinations/delusions decreased over time across 3 years of study (first year vs second year vs third year: 40.1% vs 30.9% vs 31.7%, P = 0.037). Among neurological symptoms, the ratio of coma/syncope increased over the 3-year period (7.8% vs 11.0% vs 17.0%, P = 0.002), as did the ratio of convulsions (2.8% vs 4.3% vs 9.7%, P = 0.001). CONCLUSION: The symptoms associated with NPS were primarily psychiatric in the first year, while the prevalence of neurological symptoms increased each year. The risk of death and the severity of symptoms were greater in the third year compared with the first year, as regulation of NPS increased.

Development of MHFA-based 2-h educational program for early intervention in depression among office workers: A single-arm pilot trial.

OBJECTIVE: In the workplace depression and suicide are serious mental health problems. A lack of knowledge and mental health skills along with the stigma toward mental health problems often results in delays in seeking professional help. Interventions targeting not only persons with mental health problems but also people around the individual are warranted in order to encourage supporting behavior within entire workplace. In the present study, we investigated the efficacy of our newly developed educational training program in the management with depression and suicidal risk in the workplace as a single-arm pilot trial. METHODS: The program is a two-hour (2-h) training course for employees based on the Mental Health First Aid (MHFA) program which aims to increase public mental health literacy. We conducted this program at a company workplace among 91 employees, and ultimately 83 participants completed the self-rated questionnaires. Changes in confidence and practical skills in early intervention of depression and suicide-prevention, and stigma toward mental health problems were evaluated using self-rated questionnaires at 3 time-points; pre-program, immediately post-program, and 1 month after the program. RESULTS: Confidence and practical skills were significantly improved even 1 month after the program, and stigma reduced just after the program. CONCLUSIONS: Our pilot study suggests that the program has a positive impact on encouraging employees to support their co-workers with mental health problems, and is applicable for busy workers due to its short duration. A single-arm design, evaluation using self-rated questionnaire and short-term follow up period are the main limitations of the present study. Hence, future research is required to validate the effects of this program with control groups, and also to assess long-term effectiveness and objective changes such as absenteeism and sick leave. TRIAL REGISTRATION: UMIN Clinical Trials Registry (UMIN-CTR) R000023258.

Development of a 2-h suicide prevention program for medical staff including nurses and medical residents: A two-center pilot trial.

BACKGROUND: Suicide is a crucial global health concern and effective suicide prevention has long been warranted. Mental illness, especially depression is the highest risk factor of suicide. Suicidal risk is increased in people not only with mental illness but also with physical illnesses, thus medical staff caring for physically-ill patients are also required to manage people with suicidal risk. In the present study, we evaluated our newly developed suicide intervention program among medical staff. METHODS: We developed a 2-h suicide intervention program for medical staff, based on the Mental Health First Aid (MHFA), which had originally been developed for the general population. We conducted this program for 74 medical staff members from 2 hospitals. Changes in knowledge, perceived skills, and confidence in early intervention of depression and suicide-prevention were evaluated using self-reported questionnaires at 3 points; pre-program, immediately after the program, and 1 month after program. RESULTS: This suicide prevention program had significant effects on improving perceived skills and confidence especially among nurses and medical residents. These significant effects lasted even 1 month after the program. LIMITATIONS: Design was a single-arm study with relatively small sample size and short-term follow up. CONCLUSIONS: The present study suggests that the major target of this effective program is nurses and medical residents. Future research is required to validate the effects of the program with control groups, and also to assess long-term effectiveness and actual reduction in suicide rates.

[Alcohol dependence syndrome and Before-Discharge Intervention Method (BDIM)--No. 5. Patients' evaluation of BDIM by questionnaire survey].

One (A.I) of the authors has developed BDIM (Before-Discharge Intervention Method) for the purpose of making alcoholics aware of their drinking problems. 153 patients were treated by BDIM. After the practiced BDIM, the patients underwent a 52 month observational period. 82 patients (53.6%) continued with either treatment as outpatient or inpatients, or attendance of a self-help group. We administered these 82 patients our questionnaire that asked for their assessment about the therapeutic effects of BDIM. 76 patients (49.7%) completed our questionnaire. Regarding the impression of family members' letters in BDIM, 70 patients (92.1% of 76) answered that the letter have had a positive impression on them. 52 patients (68.4% of 76) answered that they have had very strong or strong impressions. The numbers of patients who have [very strong or strong] impression are significantly more in the abstinence group than in the drinking group. Also, we asked patients about which messages of spouses, daughters and sons in BDIM gave the strongest impression to these patients. The result showed that their daughter gave the strongest impression to many patients. We believe that their children, especially the patients' daughter's messages, have therapeutic effects as impact messages even though alcoholics have cognitive or memory disorder. Patients positively assessed that BDIM strengthened motivation for treatment or attendance of self-help group meetings, for abstinence and for the consequence to their lives. Many patients assessed that BDIM has effect on awareness of their drinking problems. But the ratio of positive answers about motivation of awareness of drinking problem is smaller than the ratio of positive answers about other questions. As a result, we surmised that BDIM will have the effect of empowerment, including the effect of awareness.

Two-year prognosis after residential treatment for patients with alcohol dependence: three chief guidelines for sobriety in Japan.

BACKGROUND: In Japan, the three chief traditional guidelines for sobriety (3CGS) are regular medical checkups, participation in self-help groups, and pharmacotherapy with antidipsotropics. However, the official record of the origins of 3CGS is not clear. The aim of this current study was to assess 3CGS by an examination of the prognosis of patients with alcohol dependence 2 years after their discharge from a residential treatment program. SUBJECTS AND METHODS: The association between subjects' abstinence from alcohol and their regular medical checkups, participation in self-help groups, and treatment with antidipsotropics were prospectively examined. Two years after discharge, the relationship between the 3CGS compliance and abstinence rates was investigated as the primary outcome. In addition, the following were examined as secondary outcomes: the time taken till the first drink after discharge, whether the participants were readmitted to residential treatment, the number of days to readmission, the number of heavy drinking days, and recovery. RESULTS: A total of 98 patients participated. The perfect and partial abstinence rates for patients who followed all the principles of 3CGS were significantly higher than those for patients who followed no guidelines (P<0.05 and P<0.01, respectively). The perfect abstinence rates for patients who had continued attending checkup sessions (P<0.001) and who were taking antidipsotropics (P<0.05) were significantly higher than those for patients who did not follow these components of 3CGS. However, the perfect abstinence rates were not higher for patients who had continued to participate in self-help groups. In addition, the perfect abstinence rate was statistically associated with regular medical checkups (adjusted odds ratio =5.33, 95% confidence interval =1.35-21.0) and participation in self-help groups (adjusted odds ratio =3.79, 95% confidence interval =1.17-12.3). CONCLUSION: This study, reports the effectiveness of 3CGS for the first time. The recovery rate of alcoholics 2 years after discharge from residential treatment was examined. However, due to the chronic nature of alcoholism, further studies are required to investigate the efficacy of 3CGS beyond 2 years.

[Alcohol dependence syndrome and BDIM (before-discharge intervention method)--report 4, the family members' self-reports about BDIM].

One hundred fifty-three inpatients with alcohol dependence syndrome were treated with the structured BDIM (Before-Discharge Intervention Method). 82 patients of them have participated to self-help group meetings or kept having therapy as our outpatients or inpatients during the study period. We chose the families of the 82 patients as our study subject Out of the study subjects who took part in BDIM, 64 families (117 persons) answered our questionnaire. Among them 63 families (101 persons) gave their described answers of impressions and opinions about BDIM, which were summarized as follows. (1) Through BDIM the family members gained second thought on their alcoholic family member (IP: identified patient) and they could tell their new view to IP. BDIM enabled them to tell IP their sincere feeling and hope for recovery of IP. BDIM empowered both IP and IP's family members. (2) The family members became to know IP's orientation on his or her disease. They came to know IP's denial and understand him or her as he or she was. (3) The family members felt emotional ties among themselves and IP through BDIM. When the family members of a dysfunctional family took part together in BDIM, they could know the feelings, thoughts, experiences and hopes one another. The family members had a precious experience of mutual understanding among themselves and IP to hope for recovery together. (4) The family members appreciated BDIM as a effective therapy. In BDIM many of them regarded highly of giving their letters to IP as a useful method to convey their feeling and thoughts calmly to IP. (5) On the other hand some family members pointed out the difficulty for themselves to write on BDIM. For family members who are not good at writing a letter or tend only to blame IP through their letters, writing and giving letters to IP is not appropriate as a therapy. If family members feel strong anxiety or fear, it is safe not to practice BDIM.

[Physical and imaging properties of heavy metal filter combinations in chest radiography]

We have investigated the performance characteristic of the heavy metal filters with higher atomic numbers by comparing their patient exposures, tube loadings, radiographic contrasts, and noise Wiener spectra with those of a combination of copper and aluminum filter which has been used widely in chest radiography. Seven heavy metal filters were used for this study. As for a tungsten filter, two filters different in thickness were used. One is 0.05 mm thick, and the other 0.10 mm. The other metal filters were respectively combined with a tungsten filter with a thickness of 0.05 mm. Among the all filters investigated, tube loading of tungsten filter with 0.05 mm thick is minimum. Tungsten with 0.1 mm thick and tungsten with 0.05 mm+ barium show the larger advantages in patient exposure than those of the other filters. It was found that the magnitude of patient exposure varied slightly with the difference of image receptor used. The use of heavy metal filters showed the small advantages in the patient exposure reduction ( approximately 20%) compared with that of conventional copper filter. The use of heavy metal filters showed increasing tube loading ( approximately 5 times) compared with that of conventional copper filter. Noise Wiener spectra of heavy metal filters showed comparable with those of conventional copper filter. In conclusion, the use of heavy metal filter combinations offer no significant advantages over optimal conventional filters.