Factors affecting psychiatrist hesitation towards epilepsy care and care for patients with epilepsy transitioning from pediatric to adult care: A survey by the Japanese Society of General Hospital Psychiatry.

OBJECTIVE: This study was undertaken by the Epilepsy Subcommittee of the Japanese Society of General Hospital Psychiatry (JSGHP) to explore the challenges faced by psychiatrists in treating epilepsy and the difficulties encountered during the transition of patients with epilepsy (PWE) from pediatric to adult care. METHODS: An online survey targeting 1,980 JSGHP-affiliated psychiatrists was conducted from May to July 2022. The participants were asked to complete a questionnaire on epilepsy care. We analyzed the factors associated with participant hesitancy to treat epilepsy and their professional characteristics. RESULTS: Responses were obtained from 545 of the 1,980 solicited psychiatrists (response rate: 27.5 %). The mean number of years of clinical experience in psychiatry was 20.9 ± 10.3 years. A majority of the psychiatrists were hesitant toward treating epilepsy (89.2 %) and managing the transition of PWE from pediatric services to adult care (83.3 %). Logistic regression analysis showed that the absence of hesitation toward epilepsy treatment was significantly associated with years of clinical experience in psychiatry (OR: 1.05, p = 0.002), being a board-certified epileptologist (OR: 4.36, p = 0.037), having colleagues who are specialists in epilepsy care that may be consulted in the workplace (OR: 2.12, p = 0.027), and general confidence in managing PWE transition from pediatric to adult care (OR 3.54, p < 0.001). Confidence in managing the transition was positively correlated with being a board-certified psychiatrist of the Japanese Society of Psychiatry and Neurology (OR: 4.55, p = 0.048), being a board-certified psychiatrist of the JSGHP (OR: 1.75, p = 0.034), treating six or more PWE per month (OR: 3.54; 95 % CI, p < 0.001), and overall confidence in treating epilepsy (OR: 3.38, p < 0.001). CONCLUSIONS: Alleviation of reluctance to providing epilepsy care and managing the process of transition are correlated; however, the factors influencing each are distinct. To reduce resistance to epilepsy treatment, enhancing the knowledge of epilepsy and creating an environment conducive to consultations are essential. Improving transition-related outcomes, having substantial psychiatric expertise, and increasing opportunities to treat PWE are of great significance. The integration of these approaches may enable psychiatrists to alleviate hesitancy towards epilepsy care and enhance both treatment and transitional care modalities.

Seizure-related stress and arousal responses mediate a relationship between anxiety trait and state in epilepsy.

BACKGROUND: Epilepsy causes substantial psychological distress and anxiety, primarily due to seizures. However, the impact of stress responses and changes in arousal and their association with anxiety patterns in patients with epilepsy (PWE) remains unclear. This study aimed to investigate the relationships among seizures, stress and arousal characteristics, and trait and state anxiety characteristics in PWE. METHODS: Our sample consisted of 159 outpatients with epilepsy recruited from five institutions in Japan in 2020. Participants completed the State-Trait Anxiety Inventory-Form JYZ (STAI) and the Japanese-Stress Arousal Check List (J-SACL). We analyzed the correlations between inventory scores and clinical information. Using principal component analysis (PCA), we derived epilepsy-specific stress/arousal characteristics, which accounted for high arousal and low-stress levels, termed epilepsy-specific stress or arousal response (ESAR), from the J-SACL scores. We conducted a mediation analysis to assess the mediating role of ESAR in the relationship between traits and state anxiety. RESULTS: We found significant correlations between J-SACL stress and arousal factors (r = -0.845, p < 0.001), ESAR and seizure frequency (r = -0.29, p < 0.001), ESAR and trait anxiety scores on the STAI (r = -0.77, p < 0.0001), and ESAR and state anxiety scores on the STAI (r = -0.60, p < 0.0001). Mediation analysis supported by the Monte Carlo method revealed that ESAR significantly mediated the association between trait and state anxiety. CONCLUSIONS: These findings elucidate the epilepsy-specific stress and arousal characteristics and their roles in mediating traits and state anxiety. These results may reflect the long-term clinical course and unique emotion recognition tendencies in epilepsy.

Serine Racemase Expression by Striatal Neurons.

D-serine is synthesized by serine racemase (SR) and is a co-agonist at forebrain N-methyl-D-aspartate receptors (NMDARs). D-serine and SR are expressed primarily in neurons, but not in quiescent astrocytes. In this study, we examined the localization of D-serine and SR in the mouse striatum and the effects of genetically silencing SR expression in GABAergic interneurons (iSR-/-). iSR-/- mice had substantially reduced SR expression almost exclusively in striatum, but only exhibited marginal D-serine reduction. SR positive cells in the striatum showed strong co-localization with dopamine- and cyclic AMP-regulated neuronal phosphoprotein (DARPP32) in wild type mice. Transgenic fluorescent reporter mice for either the D1 or D2 dopamine receptors exhibited a 65:35 ratio for co-localization with D1and D2 receptor positive cells, respectively. These results indicate that GABAergic medium spiny neurons receiving dopaminergic inputs in striatum robustly and uniformly express SR. In behavioral tests, iSR-/- mice showed a blunted response to the hedonic and stimulant effects of cocaine, without affecting anxiety-related behaviors. Because the cocaine effects have been shown in the constitutive SR-/- mice, the restriction of the blunted response to cocaine to iSR-/- mice reinforces the conclusion that D-serine in striatal GABAergic neurons plays an important role in mediating dopaminergic stimulant effects. Results in this study suggest that SR in striatal GABAergic neurons is synthesizing D-serine, not as a glutamatergic co-transmitter, but rather as an autocrine whereby the GABAergic neurons control the excitability of their NMDARs by determining the availability of the co-agonist, D-serine.

Hippocampal calcification and its effects on cognitive function and symptoms in dementia.

BACKGROUND: Hippocampal calcification (HC), highly prevalent in older people, has not attracted attention until recently. Despite its potential effects on cognition and behaviour, and its possible impact on the diagnosis and severity of dementia, it has not been investigated. This study aimed to evaluate the prevalence of HC and its influence on cognition and behavioural symptoms in patients with dementia. METHODS: Data from consecutive patients who visited a medical centre for dementia, for the first time between April 2016 and September 2018, were extracted and analysed. These data included the patients' demographics, the presence of HC and hippocampal thickness as measured on computed tomography, the diagnosis of dementia and its type, cognitive function measured using the Mini-Mental State Examination and the Clock Drawing Test, and the chief complaints or symptoms prompting the visit. RESULTS: A high incidence of HC (85/267 patients) was observed. There was no significant difference in the ages of patients with and without HC. Patients with HC had higher cognitive function than those without HC at their first visit. This result was contrary to our expectations as it was not explained by the chief complaints recorded at the first visit. CONCLUSIONS: Our study showed a high prevalence of HC in older patients with dementia. Patients with HC had better cognitive function than did those without HC during their first hospital visit. This study suggests that HC may not affect the cognitive functions related to dementia. However, further research is needed to evaluate the long-term consequences of dementia with HC.

Very early-onset of RBD with ADHD: a case report study.

We experienced a case of very early-onset REM sleep behavior disorder (RBD) with ADHD. This case showed typical RBD symptoms with REM sleep without atonia on polysomnography. Methylphenidate, which enhances the dopamine system, attenuated his ADHD symptoms but not RBD symptoms. We speculate that the dysfunction of the laterodorsal tegmental nucleus in the pontine was responsible for the symptoms of RBD and ADHD in this case. Very early-onset RBD is rare, and its profile is not well known. ADHD with dysfunction in the laterodorsal tegmental nucleus may form asubtype of ADHD that is commonly comorbid with very early-onset RBD.

N-Methyl-d-aspartate receptor co-agonist availability affects behavioral and neurochemical responses to cocaine: insights into comorbid schizophrenia and substance abuse.

Both schizophrenia (SZ) and substance abuse (SA) exhibit significant heritability. Moreover, N-methyl-d-aspartate receptors (NMDARs) have been implicated in the pathophysiology of both SZ and SA. We hypothesize that the high prevalence of comorbid SA in SZ is due to dysfunction of NMDARs caused by shared risk genes. We used transgenic mice with a null mutation of the gene encoding serine racemase (SR), the enzyme that synthesizes the NMDAR co-agonist d-serine and an established risk gene for SZ, to recreate the pathology of SZ. We determined the effect of NMDAR hypofunction resulting from the absence of d-serine on motivated behavior by using intracranial self-stimulation and neurotransmitter release in the nucleus accumbens by using in vivo microdialysis. Compared with wild-type mice, SR-/- mice exhibited similar baseline intracranial self-stimulation thresholds but were less sensitive to the threshold-lowering (rewarding) and the performance-elevating (stimulant) effects of cocaine. While basal dopamine (DA) and glutamate release were elevated in the nucleus accumbens of SR-/- mice, cocaine-induced increases in DA and glutamate release were blunted. γ-Amino-butyric acid efflux was unaffected in the SR-/- mice. Together, these findings suggest that the impaired NMDAR function and a consequent decrease in sensitivity to cocaine effects on behavior are mediated by blunted DA and glutamate responses normally triggered by the drug. Projected to humans, NMDAR hypofunction due to mutations in SR or other genes impacting glutamatergic function in SZ may render abused substances less potent and effective, thus requiring higher doses to achieve a hedonic response, resulting in elevated drug exposure and increased dependence/addiction.

Short- and long-term evaluation of cognitive functions after electroconvulsive therapy in a Japanese population.

AIM: While electroconvulsive therapy (ECT) is a well-established, safe, and effective treatment for mental illnesses, the potential for adverse effects on cognitive functions remains controversial. We aimed to evaluate multiple cognitive functions in different time periods before and after ECT in a Japanese population. METHODS: A battery of five neurocognitive tests was administered to patients who underwent a course of ECT treatment at three time points: before, immediately after, and 4 weeks after ECT. RESULTS: A transient but significant decline in letter fluency function was observed immediately after ECT, but had recovered well by 4 weeks. We also observed a significant improvement in the trail-making task at 4 weeks after ECT. CONCLUSION: In a Japanese population, adverse effects of ECT on verbal fluency function-related and other cognitive impairments were transient. Over the longer term, we detected significant improvements in the performance of tasks that presumably reflected information processing speed and executive functions.

Identification of Mitosis-Specific Phosphorylation in Mitotic Chromosome-Associated Proteins.

During mitosis, phosphorylation of chromosome-associated proteins is a key regulatory mechanism. Mass spectrometry has been successfully applied to determine the complete protein composition of mitotic chromosomes, but not to identify post-translational modifications. Here, we quantitatively compared the phosphoproteome of isolated mitotic chromosomes with that of chromosomes in nonsynchronized cells. We identified 4274 total phosphorylation sites and 350 mitosis-specific phosphorylation sites in mitotic chromosome-associated proteins. Significant mitosis-specific phosphorylation in centromere/kinetochore proteins was detected, although the chromosomal association of these proteins did not change throughout the cell cycle. This mitosis-specific phosphorylation might play a key role in regulation of mitosis. Further analysis revealed strong dependency of phosphorylation dynamics on kinase consensus patterns, thus linking the identified phosphorylation sites to known key mitotic kinases. Remarkably, chromosomal axial proteins such as non-SMC subunits of condensin, TopoIIα, and Kif4A, together with the chromosomal periphery protein Ki67 involved in the establishment of the mitotic chromosomal structure, demonstrated high phosphorylation during mitosis. These findings suggest a novel mechanism for regulation of chromosome restructuring in mitosis via protein phosphorylation. Our study generated a large quantitative database on protein phosphorylation in mitotic and nonmitotic chromosomes, thus providing insights into the dynamics of chromatin protein phosphorylation at mitosis onset.

Multiple risk pathways for schizophrenia converge in serine racemase knockout mice, a mouse model of NMDA receptor hypofunction.

Schizophrenia is characterized by reduced hippocampal volume, decreased dendritic spine density, altered neuroplasticity signaling pathways, and cognitive deficits associated with impaired hippocampal function. We sought to determine whether this diverse pathology could be linked to NMDA receptor (NMDAR) hypofunction, and thus used the serine racemase-null mutant mouse (SR(-/-)), which has less than 10% of normal brain D-serine, an NMDAR coagonist. We found that D-serine was necessary for the maintenance of long-term potentiation in the adult hippocampal dentate gyrus and for full NMDAR activity on granule cells. SR(-/-) mice had reduced dendritic spines and hippocampal volume. These morphological changes were paralleled by diminished BDNF/Akt/mammalian target of rapamycin (mTOR) signaling and impaired performance on a trace-conditioning memory task. Chronic D-serine treatment normalized the electrophysiological, neurochemical, and cognitive deficits in SR(-/-) mice. These results demonstrate that NMDAR hypofunction can reproduce the numerous hippocampal deficits associated with schizophrenia, which can be reversed by chronic peripheral D-serine treatment.

[An Adolescent Case of ASD Presenting with Persistent Catatonia and Epileptic EEG Discharge].

A 26-year-old man developed a catatonic state after his grandmother's death and the Great East Japan Earthquake. He was admitted to hospital because of the prolonged severe stupor. Electroencephalography (EEG) revealed focal (F3 electrode) and generalized epileptic abnormalities. He was administered antiepileptic agents and benzodiazepines, but his stupor did not improve in spite of a reduced frequency of epileptic EEG abnormalities. His clinical his- tory did not suggest any psychotic disorders. Thereafter, extensive physical examinations were performed, but an organic cause of the stupor was not determined. For about two years, he was unable to intake food without tubal feeding, have a conversation, or move spontaneously. One day, a generalized tonic-clonic seizure (GTC) occurred spontaneously for the first time in his life, and then his stupor markedly improved. Thereafter, he could eat food spontaneously, have a fluent conversation, and move actively. After his condition had improved, we asked his parents about his developmental history, clinical history, and present state. According to clini- cal interviews including the use of PARS (Pervasive Developmental Disorders Autism Society Japan Rating Scale), DISCO (Diagnostic Interview for Social and Communication Disorders), and WAIS-III (Wechsler Adult Intelligence Scale-third edition), he was diagnosed with autistic spectrum disorder (ASD) and mild intellectual disability. It was considered that his stupor had occurred secondary to ASD. Wing et al. reported that catatonia occurred in about 17% of ASD adolescents and young adults as a later complication. It is possible that this case, without any psychotic disorders and with ASD that has been undiagnosed until young adult, progress to such a severe and prolonged catatonic state. We report this case to show that severe catatonia is possible in adolescents and young adults during the carry-over period in ASD patients.

D-serine and serine racemase are localized to neurons in the adult mouse and human forebrain.

D-Serine, a co-agonist at the NMDA receptor (NMDAR), is synthesized from L-serine by the enzyme serine racemase (SR), which is heavily expressed in the forebrain. Although SR was originally reported to be localized exclusively to astrocytes, recent conditional knock out results demonstrate that little SR is expressed in forebrain astrocytes. As a consequence, the cellular location of its product, D-serine, in the brain is also uncertain. Immunocytochemistry now indicates that SR is expressed primarily in forebrain glutamatergic neurons with the remainder in GABAergic interneurons. We utilized SR deficient (SR-/-) mice, which have <15 % of normal D-serine levels, to validate and optimize a D-serine immunohistochemical method. Nearly all of the D-serine in neocortex and hippocampus (HP) is found in neurons, with virtually no D-serine co-localizing with two astrocyte markers. Interestingly, only a subset of the D-serine positive neurons contained SR in the neocortex and HP. Greater than half of the D-serine positive neurons were GABAergic interneurons, with a majority of these neurons containing parvalbumin and/or somatostatin. Only ~25-40 % of interneurons expressed SR in the neocortex and HP. Finally, we demonstrate in human post-mortem neocortex that SR is found in both excitatory and inhibitory neurons, but not in S100ß-containing astrocytes. In sum, these findings conclusively demonstrate that the majority of D-serine is both synthesized and stored in neurons. It will be important to determine the functional significance for the separation of synthesis and storage of D-serine in neurons, as well as the presence of this NMDAR co-agonist in GABAergic interneurons.

[Models of community care for people with severe mental illness: an evaluation of assertive community treatment].

Today's psychiatric treatment system in Japan is hospital-based. It is supported by mental hospitals established after 1960. However, the psychiatric treatment system has already changed to community-based treatment in other developed countries. So, we need to change to the community-based system for those who are suffering from severe mental illness such as schizophrenia to realize deinstitutionalization. Assertive Community Treatment (ACT) is one of the effective community support programs to improve this situation. It is important to develop a program like "ACT" for clinical and cost effectiveness.

Effectiveness of vortioxetine for winter depression in bipolar disorder: A case report.

Background: We present a case report on the efficacy of the short-term application of vortioxetine in managing winter depression in patients with seasonal bipolar disorder (BP). Standard treatment strategies for BP may not adequately address seasonal depressive symptoms during winter in patients with seasonal BP patterns. Depressive symptoms during winter may be linked to seasonal changes in serotonin transporter binding, such as a decrease in synaptic serotonin levels, necessitating alternative approaches. Although antidepressants, including vortioxetine, are effective in treating seasonal monopolar depression, their efficacy and safety in treating depression in patients with seasonal BP patterns remain unclear. Case Presentation: This case report focuses on a 44-year-old male patient diagnosed with seasonal BP who had recurrent depressive episodes, specifically during winter. Notably, the patient had a significant decrease in recurrent episodes after short-term seasonal vortioxetine use without inducing mania or rapid cycling. Conclusion: Our study highlights the potential effectiveness of a seasonal, short-term treatment strategy with antidepressants, including vortioxetine, for winter depression in individuals with BP.

Synthesis and Characterization of Octacyano-Cu-Phthalocyanine.

Octacyano-metal-substituted phthalocyanine MPc(CN)8 is a promising n-type stable organic semiconductor material with eight cyano groups, including a strong electron-withdrawing group at its molecular terminals. However, most MPc(CN)8 have not been thoroughly investigated. Therefore, CuPc(CN)8 was synthesized in this study and its crystal structure, chemical and electronic states, thermal stability, and electrical properties were investigated. This article discusses the various properties of CuPc(CN)8, as compared to those of CuPc and FePc(CN)8. The previously reported FePc(CN)8 is an organic semiconductor molecule with a molecular structure similar to that of CuPc(CN)8. X-ray diffraction (XRD) measurements revealed that CuPc(CN)8 has a crystalline structure in the P1̅ space group. The crystal structure forms an in-plane network parallel to the molecular plane through multiple hydrogen bonds by the cyano groups at the molecular terminals. Interestingly, the crystal structure, especially the molecular stacking, of CuPc(CN)8 differs from that of FePc(CN)8. The absorption edge observed in the ultraviolet-visible spectrum of CuPc(CN)8 shifted to a longer wavelength than that of CuPc, which was attributed to the energy gap of CuPc(CN)8 being smaller than that of CuPc owing to the influence of the cyano groups at the molecular terminals, according to the molecular orbital calculation results using density functional theory. Ultraviolet photoelectron spectroscopy measurements confirmed that CuPc(CN)8 had a stronger n-type character than CuPc because of the orbital energy stabilization by the cyano groups. Thermogravimetry/differential thermal analysis measurements revealed that the thermal stability of CuPc(CN)8 was significantly higher than that of FePc(CN)8. CuPc(CN)8 exhibited photoconduction upon visible-light irradiation, and its electrical conductivity was higher than that of CuPc, which was attributed to a reduction in the electron injection barrier at the electrode interfaces.

Factors associated with hypnotics polypharmacy in the Japanese population.

OBJECTIVE: Insomnia disorder is a global public health issue, commonly treated with hypnotics. However, long-term use of benzodiazepine derivatives (BZDs), especially polypharmacy with this kind of drug, carries risks for dependence and abuse. This study using large-scale medical insurance records investigated the causes of polypharmacy through the treatment of insomnia disorder. METHODS: A cross-sectional study analyzed anonymized medical record data from July 2014 to March 2018 provided by a nationwide Japanese health insurance association covering 405,952 individuals. Outpatients prescribed at least one sleep medication were included. Demographic data, pharmacological classification of the drugs, and comorbidities were assessed using hierarchical logistic regression analysis to explore their associations with polypharmacy. RESULTS: Of the 33,212 outpatients who were prescribed sleep medications, 32.5 % were prescribed multiple types. After adjusting for demographics and type of sleep medications as covariates, hypnotic polypharmacy was significantly associated with younger age, the presence of certain kinds of comorbidities, and using BZD anxiolytics before bedtime with the highest adjusted odds ratios (8.01-9.39) when referenced with BZD hypnotics. On the other hand, usage of orexin receptor antagonists, melatonin receptor agonists, and Z-drugs indicated lower odds ratios (0.74-0.87). CONCLUSIONS: Hypnotic polypharmacy is relatively common in the Japanese general population. With the introduction of non-pharmacological therapy in mind, assessing patients' comorbidities and avoiding the use of benzodiazepines, especially BZD anxiolytics, before bedtime would be recommended to prevent polypharmacy.

Temporal patterns of sleep latency in central hypersomnia and attention deficit hyperactivity disorder: a cluster analysis exploration using Multiple Sleep Latency Test.

Introduction: Excessive daytime sleepiness (EDS) is a crucial symptom that diminishes the quality of life. The primary causes of EDS are central hypersomnia, including narcolepsy type 1 (NT1), type 2 (NT2), and idiopathic hypersomnia (IH). EDS is often associated with other psychiatric disorders, particularly attention deficit hyperactivity disorder (ADHD). The Multiple Sleep Latency Test (MSLT) is the standard assessment tool for EDS. Although the MSLT yields numerous parameters, most are not employed in clinical practice. In this study, we leveraged novel MSLT parameters to discern central hypersomnia and ADHD presence. Our analysis focused on sleep latency variability and employed cluster analysis to identify unique temporal patterns. Methods: We examined the MSLT data from 333 patients; of these, 200 (aged 14-54, mean: 24.9 ± 8.1, years; 114 females) met the inclusion criteria comprising comprehensive data an Apnea-Hypopnea Index (AHI) below 5, and no prior diagnosis of sleep apnea syndrome. We employed a time-course cluster approach that specifically targeted sleep latency variability during the MSLT. Results: Considering both multiple clustering quality evaluations and the study's objectives, we identified 9 distinct clusters. Clusters 1 and 3 predominantly had MSLT-positive results; Cluster 2 was entirely MSLT-positive; Clusters 4, 5, 6, 8, and 9 were mainly MSLT-negative; and Cluster 7 had mixed results. The diagnosis of hypersomnia varied notably among Clusters 1, 2, 3, and 7, with Cluster 2 demonstrating a pronounced tendency towards NT1 and NT2 diagnoses (p < 0.005). However, no significant correlation was observed between ADHD diagnoses and specific sleep latency patterns in any cluster. Conclusions: Our study highlights the value of time-course clustering in understanding sleep latency patterns of patients with central hypersomnia.