Examining the usefulness of the brain network marker program using fMRI for the diagnosis and stratification of major depressive disorder: a non-randomized study protocol.

BACKGROUND: Although many studies have reported the biological basis of major depressive disorder (MDD), none have been put into practical use. Recently, we developed a generalizable brain network marker for MDD diagnoses (diagnostic marker) across multiple imaging sites using resting-state functional magnetic resonance imaging (rs-fMRI). We have planned this clinical trial to establish evidence for the practical applicability of this diagnostic marker as a medical device. In addition, we have developed generalizable brain network markers for MDD stratification (stratification markers), and the verification of these brain network markers is a secondary endpoint of this study. METHODS: This is a non-randomized, open-label study involving patients with MDD and healthy controls (HCs). We will prospectively acquire rs-fMRI data from 50 patients with MDD and 50 HCs and anterogradely verify whether our diagnostic marker can distinguish between patients with MDD and HCs. Furthermore, we will longitudinally obtain rs-fMRI and clinical data at baseline and 6 weeks later in 80 patients with MDD treated with escitalopram and verify whether it is possible to prospectively distinguish MDD subtypes that are expected to be effectively responsive to escitalopram using our stratification markers. DISCUSSION: In this study, we will confirm that sufficient accuracy of the diagnostic marker could be reproduced for data from a prospective clinical study. Using longitudinally obtained data, we will also examine whether the "brain network marker for MDD diagnosis" reflects treatment effects in patients with MDD and whether treatment effects can be predicted by "brain network markers for MDD stratification". Data collected in this study will be extremely important for the clinical application of the brain network markers for MDD diagnosis and stratification. TRIAL REGISTRATION: Japan Registry of Clinical Trials ( jRCTs062220063 ). Registered 12/10/2022.

Development and validation of the Japanese version of the Hyperarousal Scale.

BACKGROUND: The objectives of this study were to develop a Japanese version of the Hyperarousal Scale (HAS-J) and investigate its factor structure, reliability, and validity, as well as to calculate a cutoff score for the HAS-J and assess different levels of hyperarousal in insomnia patients and community dwellers. METHODS: We recruited 224 outpatients receiving insomnia treatment (56.3% women; mean age 51.7 ± 15.6 years) and 303 community dwellers aged 20 years or older (57.8% women; mean age 43.9 ± 15.2 years). Exploratory and confirmatory factor analysis was performed to examine the factor structure of the HAS-J. Cronbach's α and McDonald's ω were then used to test internal consistency. To examine the scale's validity, we determined correlations between the HAS-J and other indexes and compared HAS-J scores between insomnia patients and community dwellers. We also compared HAS-J scores between two community-dweller groups (normal and poor sleepers) and two insomnia patient groups (with and without alleviation after treatment). RESULTS: Following exploratory and confirmatory factor analysis, a 20-item measure emerged comprising three factors: "Introspectiveness and Reactivity," "Neuroticism," and "Insomnia." Confirmatory factor analysis showed a generally good fit for the model of the three-factor structure suggested by the exploratory factor analysis loadings (χ2 (163) = 327.423, (p <  0.001), CFI = 0.914, GFI = 0.872, AGFI = 0.835, RMSEA = 0.067). In insomnia patients, internal consistency indicated sufficient reliability of the HAS-J. Correlation analysis showed weak to moderate positive correlations of the HAS-J score with other indexes, indicating concurrent validity of the HAS-J. All HAS-J subscale scores were significantly higher in insomnia patients than in community dwellers. Additionally, the total score in patients with alleviation of insomnia was comparable to that in poor sleepers and significantly higher than that in normal sleepers. CONCLUSIONS: This study demonstrated the reliability and validity of the HAS-J, indicating that it is useful as a clinical scale of hyperarousal. The high level of hyperarousal in insomnia patients who were assessed to be in remission by the Insomnia Severity Index suggests a risk of insomnia recurrence in these patients.

The right hemisphere is important for driving-related cognitive function after stroke.

Considering quality of life (QOL) after stroke, car driving is one of the most important abilities for returning to the community. In this study, directed attention and sustained attention, which are thought to be crucial for driving, were examined. Identification of specific brain structure abnormalities associated with post-stroke cognitive dysfunction related to driving ability would help in determining fitness for car driving after stroke. Magnetic resonance imaging was performed in 57 post-stroke patients (51 men; mean age, 63 ± 11 years) who were assessed for attention deficit using a standardized test (the Clinical Assessment for Attention, CAT), which includes a Continuous Performance Test (CPT)-simple version (CPT-SRT), the Behavioral Inattention Test (BIT), and a driving simulator (handle task for dividing attention, and simple and selective reaction times for sustained attention). A statistical non-parametric map (SnPM) that displayed the association between lesion location and cognitive function for car driving was created. From the SnPM analysis, the overlay plots were localized to the right hemisphere during handling the hit task for bilateral sides (left hemisphere damage related to right-side neglect and right hemisphere damage related to left-side neglect) and during simple and selective reaction times (false recognition was related to damage of both hemispheres). A stepwise multiple linear regression analysis confirmed the importance of both hemispheres, especially the right hemisphere, for cognitive function and car driving ability. The present study demonstrated that the right hemisphere has a crucial role for maintaining directed attention and sustained attention, which maintain car driving ability, improving QOL for stroke survivors.

Neuroanatomic pathways associated with monoaminergic dysregulation after stroke.

OBJECTIVE: We examined the complex relationship between lesion location, symptoms of depression (affective and apathetic), and monoamine dysfunction after stroke. METHODS: Magnetic resonance imaging was performed on 48 post-stroke patients that had been assessed for affective and apathetic symptoms using the Hospital Anxiety and Depression Scale and the Apathy Scale, respectively. Noradrenalin (NA), dopamine (DA), their metabolites, and a metabolite of serotonin (5-HT) were measured using 24-h urine samples, and 5-HT and 3-methoxy-4-hydroxyphenylglycol were measured using blood samples. We developed a statistical parametric map that displayed the associations between lesion location and both positive and negative alterations of monoamines and their metabolites. RESULTS: Multivariate analysis indicated that basal ganglia lesions and 5-HT showed relationships with affective symptoms, whereas homovanillic acid was related to apathetic symptoms. Univariate analysis showed no such relationships. However, decreases in NA and DA and increases in NA and DA turnover were related to lesions in the brainstem, whereas increases in NA and DA as well as decreases in NA and DA turnover were related to cortical and/or striatum lesions. 5-HT turnover data showed a pattern opposite to that seen for NA and DA turnover. CONCLUSIONS: Monoaminergic neuronal pathways are controlled by both receptor-mediated feedback mechanisms and turnover; thus, depletion of monoamines is not the only cause of depression and apathy. Moreover, the monoamine neuronal network might be divided into two branches, catecholamine (NA and DA) and 5-HT, both of which are anatomically and functionally interconnected and could respectively influence apathetic and affective symptoms of depression.

Association of sleep habits with blood pressure in elderly people.

We investigated the impact of sleep habits on blood pressure (BP) in cross-sectional analyses of 1533 participants aged ≥ 70 without cardiovascular disease or treatment for hypertension, diabetes mellitus, and dyslipidemia. We assessed sleep habits [time in bed (TIB), bed time, and taking sleeping pills], using the Pittsburgh Sleep Quality Index. For groups where TIB was >8 h and <6 h, systolic BP was significantly higher than the group where TIB ranged 6-8 h (134.2 ± 17.5, 134.8 ± 19.6 vs. 130.1 ± 17.7, p < 0.05, p < 0.001, respectively). Systolic BP was significantly higher in the group whose bed time was before 21:00 than that whose bed time was 21:00 or later (136.6 ± 18.6 vs. 132.0 ± 18.4, p < 0.01). Both systolic and diastolic BPs were lower in the group taking sleeping pills (133.2 ± 18.6 vs. 128.1 ± 17.3, p < 0.0001; 75.3 ± 11.5 vs. 73.3 ± 10.7, p < 0.05). Multiple regression analyses revealed that after adjusting for age, gender, body mass index, smoking, and alcohol intake, taking sleeping pills and short or long TIB were significantly associated with systolic BP, whereas bed time was not. These results suggested that inappropriate TIB and sleeping pills were associated with BP in elderly people.

Effectiveness of group cognitive behavioral therapy for somatoform pain disorder patients in Japan: A preliminary non-case-control study.

AIMS: Somatoform pain disorder is associated with psychosocial dysfunction, and psychotherapies, such as cognitive behavioral therapy (CBT), are thought to provide useful interventions to address such dysfunction as well as the pain itself. However, little is known about whether CBT for somatoform pain disorder is effective, including the long-term course of the illness, in non-Western populations. We therefore tailored such a program based on an existing CBT protocol and examined its effectiveness in Japan. METHODS: Thirty-four Japanese participants (22 women; mean age = 52.5 years) enrolled in a weekly 12-session group treatment, with 32 completing both wait-list and treatment conditions. The primary outcome measure was pain intensity. Secondary outcome measures included pain characteristics, as measured by pain catastrophizing and psychometric evaluations, including depression, anxiety, and quality of life. The patients were followed up for 12 months after treatment. RESULTS: We found that pain intensity, anxiety, depressive symptoms, and social functioning all significantly improved after treatment compared with the wait-list period, and the improvements in pain intensity, depressive symptoms, and social functioning were sustained at 12 months following the completion of CBT. There were strong positive correlations (P < 0.01) among pre- and post-treatment changes in the affective dimension of pain, depression, anxiety, and pain catastrophizing. CONCLUSIONS: These results show that the present CBT program was effective for Japanese patients with somatoform pain disorder and that gains were maintained over the long term. More work is needed to further clarify the effects of CBT interventions on somatoform symptoms, particularly in Japan.

[Complementary and alternative medicine for insomnia].

Frequency of insomnia is increasing with age. Benzodiazepine receptor agonist has been prescribed for insomnia in the elderly, but there are some patients who complain the effect is not sufficient. Adherence for sleeping pills is very low in elderly Japanese, because there has been strong stigma against sleeping pills. Complementary and alternative medicine for insomnia is widely used in elderly Japanese. Sedative antidepressants, novel antipsychotics, anti-histamine drugs, and supplements are used for insomnia as complementary and alternative medicine. But evidence of these drugs for insomnia is insufficient. In this paper, we outline the previous reports such as the advantages and disadvantages of these drugs for the treatment of insomnia in the elderly.

Psychosocial functioning is correlated with activation in the anterior cingulate cortex and left lateral prefrontal cortex during a verbal fluency task in euthymic bipolar disorder: a preliminary fMRI study.

AIM: Cognitive impairment may account for functional and occupational disability in patients with bipolar disorder even during periods of euthymia. While imaging suggests structural, neurochemical, and functional abnormalities in bipolar disorder patients, the pathophysiology of these deficits has not been elucidated. It was hypothesized that euthymic bipolar patients would have different cortical activation during a verbal fluency task compared to healthy controls, and that psychosocial functioning would be associated with prefrontal cortical activation during the task in the bipolar group. METHODS: Ten euthymic bipolar patients and 10 healthy control participants (matched for age, gender, and years of education) underwent functional magnetic resonance imaging (fMRI) during a verbal fluency task, tapping task and visual task. Correlational analysis between the fMRI brain activation and clinical variables of the participants, including Global Assessment of Functioning (GAF) score, was performed. RESULTS: Compared to the controls, euthymic bipolar patients had significantly greater activation in the bilateral precuneus with similar behavioral performance during the verbal fluency task. There were no significant differences between the groups for the visual task or the simple motor task. Activation in both the left anterior cingulate cortex (ACC) and the left dorsolateral prefrontal cortex (PFC) were significantly positively correlated with GAF score in the euthymic bipolar patients. CONCLUSION: Both the ACC and lateral PFC regions are components of a neural network that plays a critical role in psychosocial functioning, and are often found to be affected in bipolar patients.

Treatment strategies for insomnia in Japanese primary care physicians' practice: A Web-based questionnaire survey.

BACKGROUND: It is unclear how primary care physicians manage insomnia after the introduction of novel hypnotics such as orexin receptor antagonists and melatonin receptor agonists. This Web-based questionnaire survey aimed to examine treatment strategies for insomnia in Japanese primary care practice. METHODS: One-hundred-and-seventeen primary care physicians were surveyed on the familiarity of each management option for insomnia on a binary response scale (0 = "unfamiliar"; 1 = "familiar") and how they managed insomnia using a nine-point Likert scale (1 = "I never prescribe/perform it"; 9 = "I often prescribe/perform it"). Physicians who were unfamiliar with a management option were deemed to have never prescribed or performed it. RESULTS: Regarding medication, most physicians were familiar with novel hypnotics. Suvorexant was the most used hypnotic, followed by lemborexant and ramelteon. These novel hypnotics averaged 4.8-5.4 points and 4.0-4.7 points for sleep onset and sleep maintenance insomnia, respectively. By contrast, most benzodiazepines were seldom used below two points. Regarding psychotherapy, only approximately 40% of the physicians were familiar with cognitive behavioral therapy for insomnia (CBT-I) and they rarely implemented it, at an average of 1.5-1.6 points. More physicians were familiar with single-component psychotherapies (i.e., relaxation, sleep restriction therapy, and stimulus control) compared to CBT-I, and 48-74% of them implemented it slightly more often, with scores ranging from 2.6 to 3.4 points. CONCLUSION: This study suggests that Japanese primary care physicians seldom use CBT-I to treat insomnia. In addition, they use novel sleep medications more frequently than benzodiazepines in terms of pharmacotherapy. The use and availability of CBT-I in Japanese primary care might be facilitated by: educating primary care physicians, implementing brief or digital CBT-I, and/or developing collaborations between primary care physicians and CBT-I specialists.

Neuroanatomic pathways associated with poststroke affective and apathetic depression.

OBJECTIVES: Our goal was to localize lesions in poststroke depression patients using magnetic resonance imaging, based on the statistical parametric maps image analysis technique that can be used to combine image data from multiple participants and correlate these images with other data sets. METHODS: Magnetic resonance imaging acquisitions were obtained from 149 poststroke patients, who were assessed for affective and apathetic symptoms using the Hospital Anxiety and Depression Scale and the Apathy Scale, respectively. We created a statistical parametric map that displayed an association between lesion location and affective and apathetic symptoms. RESULTS: Among the patients with higher depressive scores, the lesion overlap centered on the brainstem, left basal ganglia, and left frontal cortex. Among the patients with higher apathy scores, the lesion overlap centered on the brainstem and bilateral striatum. The overlap lesion for both affective and apathetic depression centered mainly on the brainstem; however, the two types of depression often did not overlap. CONCLUSIONS: Two core symptoms that can occur after stroke, affective and apathetic symptoms, appear to be associated with different monoaminergic neuroanatomic pathways (serotonergic and dopaminergic).

Negative correlation between affective symptoms and prefrontal activation during a verbal fluency task: a near-infrared spectroscopy study.

Only a few studies have examined the relationships between affective symptoms, cognitive function (e.g. verbal fluency), quality of life (QOL), and brain activation in a nonclinical population. The aim of the present study was to assess these relationships and examine the underlying cortical mechanisms in a nonclinical population. Fifty-two healthy male volunteers were assessed for depressive symptoms using the Zung Self-Rating Depression Scale (SDS), for apathy using the Apathy Scale, and QOL using the Medical Outcomes Study short-form 36-item questionnaire (SF36). The volunteers also performed a verbal fluency test (VFT) while hemoglobin concentration changes were assessed on the surface of the frontal cortex using 24-channel near-infrared spectroscopy (NIRS). The SDS and Apathy Scale scores showed significant negative correlations with the scores of most of the SF36 subscales. Frontal activation had a significant negative correlation with the SDS scores and the Apathy Scale. These results suggest that the degree of affective symptoms is associated with a lower QOL in a nonclinical population, and that cortical hypoactivation during a VFT measured by NIRS may objectively identify individuals with a high degree of affective symptoms.

Automatic and intentional brain responses during evaluation of face approachability: correlations with trait anxiety.

BACKGROUND: The judgment of the approachability of others based on their facial appearance often precedes social interaction. Whether we ultimately approach or avoid others may depend on such judgments. METHOD: We used functional magnetic resonance imaging to determine the neural basis for such approachability judgments and the relationship between these judgments and trait anxiety. Participants viewed ambiguous (i.e. neutral) or relatively unambiguous (i.e. angry, happy) faces, assessing either the approachability or the sex of the person depicted. RESULTS: Neutral faces elicited more inconsistent responses within participants only during approachability judgment, suggesting ambiguous property as signals. The contrast pertaining to the interaction between task and face valence demonstrated activation in several areas, such that the left amygdala and medial, middle and inferior frontal gyri were responsive to angry faces when subjects were asked to recognize the sex (implicit task) and to neutral faces when required to discern the approachability (explicit task). Moreover, the blood oxygenation level-dependent change within the left amygdala in response to neutral faces during the judgment of approachability was positively correlated with participant trait anxiety. CONCLUSIONS: These findings extend a proposed model of social cognition by highlighting the functional engagement of the amygdala in approachability judgments, which underlie an individual's sensitivity to ambiguous sources of probable threat.

Treatment strategy for insomnia disorder: Japanese expert consensus.

Purpose: There is a lack of evidence regarding answers for clinical questions about treating insomnia disorder. This study aimed to answer the following clinical questions: (1) how to use each hypnotic and non-pharmacological treatment differently depending on clinical situations and (2) how to reduce or stop benzodiazepine hypnotics using alternative pharmacological and non-pharmacological treatments. Methods: Experts were asked to evaluate treatment choices based on 10 clinical questions about insomnia disorder using a nine-point Likert scale (1 = "disagree" to 9 = "agree"). The responses of 196 experts were collected, and the answers were categorized into first-, second-, and third-line recommendations. Results: The primary pharmacological treatment, lemborexant (7.3 ± 2.0), was categorized as a first-line recommendation for sleep initiation insomnia, and lemborexant (7.3 ± 1.8) and suvorexant (6.8 ± 1.8) were categorized as the first-line recommendations for sleep maintenance insomnia. Regarding non-pharmacological treatments for primary treatment, sleep hygiene education was categorized as the first-line recommendation for both sleep initiation (8.4 ± 1.1) and maintenance insomnia (8.1 ± 1.5), while multicomponent cognitive behavioral therapy for insomnia was categorized as the second-line treatment for both sleep initiation (5.6 ± 2.3) and maintenance insomnia (5.7 ± 2.4). When reducing or discontinuing benzodiazepine hypnotics by switching to other medications, lemborexant (7.5 ± 1.8) and suvorexant (6.9 ± 1.9) were categorized as first-line recommendations. Conclusion: Expert consensus indicates that orexin receptor antagonists and sleep hygiene education are recommended as first-line treatments in most clinical situations to treat insomnia disorder.

Predictors of quality of life in inpatients with schizophrenia.

Shortening hospital stays has become a key focus in psychiatric care in recent years. However, patients with schizophrenia account for about 60% of inpatients in psychiatry departments in Japan. This study was designed to investigate the relationship between quality of life (QOL) and key indicators for long-term hospital stays among schizophrenia inpatients. A further aim was to elucidate the clinical determinants of QOL among long-stay inpatients. The study sample consisted of 217 inpatients with schizophrenia. Age, duration of illness, duration of hospitalization, years of education, body mass index, neurocognitive function, drug-induced extrapyramidal symptoms, involuntary movements, psychiatric symptoms, and dose equivalents of antipsychotics and anticholinergic agents were used as index factors. Pearson linear correlation and regression analyses were performed to examine the associations between QOL and the above-mentioned factors. Negative symptoms, psychological discomfort, and resistance as rated on the Brief Psychiatric Rating Scale (BPRS) were correlated with all subscale scores of the Japanese version of the Schizophrenia Quality of Life Scale (JSQLS). Stepwise regression showed that negative symptoms, psychological discomfort, and resistance predicted the dysfunction of psycho-social activity score and the dysfunction of motivation and energy score on the JSQLS. This study shows that active treatment for negative symptoms, psychological discomfort, and resistance should be recommended to improve QOL among inpatients with schizophrenia.

Depressive symptoms and apathy are associated with psychomotor slowness and frontal activation.

Affective symptoms, such as depression and apathy, and cognitive dysfunction, such as psychomotor slowness, are known to have negative impacts on the quality of life (QOL) of patients with mental and physical diseases. However, the relationships among depressive symptoms, apathy, psychomotor slowness, and QOL in a non-clinical population are unclear. The aim of the present study was to assess these relationships and examine the underlying cortical mechanisms in a non-clinical population. Fifty-two healthy male volunteers were assessed for depressive symptoms using the Zung Self-rating Depression Scale (SDS), for apathy measured using the Apathy Scale, and QOL using the Short-Form 36 item questionnaire (SF36). The volunteers also performed the Trail Making Test Part A (TMT-A) while undergoing assessment of hemoglobin concentration changes in the frontal cortical surface using 24-channel near-infrared spectroscopy (NIRS). The scores of the SDS and Apathy Scale showed significant negative correlations with the scores of most of subscales of the SF36. In addition, the SDS score had a significant positive correlation with the time to complete the TMT-A. Further, activation of several frontal cortical areas had a significant positive correlation with the scores of the SDS and Apathy Scale. These results suggest that the degree of depressive symptoms and apathy are associated with a lower QOL in a non-clinical population and that cortical hyperactivation during a psychomotor task measured by NIRS may identify objectively individuals with a high degree of depressive symptoms and apathy.

The neurocognitive effects of aripiprazole compared with risperidone in the treatment of schizophrenia.

Aripiprazole is a D2 and D3 receptor partial agonist that is unlike other second generation antipsychotics. The effectiveness of aripiprazole with regard to neurocognitive function and its adverse effects is unclear. The present study evaluates the comparative efficacy, effects on neurocognitive function, and adverse effects of aripiprazole and risperidone in the treatment of hospitalized patients with schizophrenia. This double-blind, cross-over study included 23 patients with schizophrenia who were randomly assigned to be treated first with either aripiprazole or risperidone. After eight weeks on one medication, the patients were switched to the other medication for eight weeks. The patient assessment included the Positive and Negative Syndrome Scale (PANSS), neurocognitive assessments, and adverse events including extrapyramidal symptoms, vital signs, electrocardiogram, and clinical laboratory tests. The study findings indicated that psychopathology assessed with the PANSS, extrapyramidal symptoms and other adverse effects did not differ between aripiprazole and risperidone for the subjects remaining in treatment. In the neurocognitive assessments, the score for disinhibition with aripiprazole was significantly lower than with risperidone (p < 0.05). In addition, serum prolactin levels were significantly lower with aripiprazole (p < 0.001). The treatment drop-out rate was higher for patients receiving aripiprazole than risperidone. In comparing aripiprazole and risperidone, risperidone is better from the viewpoint of treatment continuation. On the other hand, some adverse effects, such as hyperprolactinemia and disinhibition, are less severe with aripiprazole. Thus, for certain applications, aripiprazole may be a beneficial new treatment option for schizophrenia.

[Effects of serotonin on delay discounting for rewards--an application for understanding of pathophysiology in psychiatric disorders].

In our daily life, we constantly make such choices between actions leading to rewards of various sizes after different delays. "Delay discounting" is a theoretical concept in which the "value" of reward R after delay. A steep rate of discounting results in impulsive choice, defined by an abnormally frequent choice of the more immediate reward. Our behavioral and neuroimaging results suggest that serotonin may adjust the rate of delayed reward discounting via the modulation of striatum in cortico-basal ganglia circuits in human. Our proposed role of serotonin may explain certain aspects of impulsivity in psychiatric disorders such as major depression, panic disorder or obsessive-compulsive disorder, that are known to effectively relieve symptoms by selective serotonin reuptake inhibitors. Future experiments using delayed reward paradigms could be designed to study impulsivity in these patients.

Development and acceptability of a decision aid for chronic insomnia considering discontinuation of benzodiazepine hypnotics.

AIM: To describe the development and acceptability of a decision aid (DA) for chronic insomnia considering discontinuation of benzodiazepine (BZD) and benzodiazepine receptor agonist (BZRA) hypnotics, and if discontinuing, tapering with or without cognitive behavioral therapy for insomnia (CBT-I). METHODS: We reviewed relevant literature describing chronic insomnia to identify options. We used the results of the systematic review and meta-analysis conducted previously to determine the related outcomes of two options: discontinuation of BZD/BZRA hypnotics by gradual tapering alone and discontinuation of BZD/BZRA hypnotics by gradual tapering with CBT-I. We then developed a prototype of DA following the International Patient Decision Aid Standards. A mixed methods survey was conducted to assess the acceptability among patients and healthcare providers. RESULTS: The prototype consisted of a description of insomnia, options of continuing or discontinuing BZD/BRZA hypnotics (if discontinuing, the options of tapering hypnotics with or without CBT-I), pros and cons of each option, and a value clarification exercise. Patients (n = 24) reported that the DA had acceptable language (79%), adequate information (71%), and well-balanced presentation (91%). Healthcare providers (n = 20) also provided favorable feedback. CONCLUSION: We developed a DA for chronic insomnia considering discontinuation of BZD/BRZA hypnotics, which was acceptable for stakeholders. The developed DA was designed to support patients and healthcare providers to make a decision about whether to discontinue BZD/BRZA hypnotics.

Post-stroke depression and apathy: Interactions between functional recovery, lesion location, and emotional response.

Depression and apathy are often observed after stroke and are often confused with one another. In the present review, we argue that the current concept of 'post-stroke depression' (PSD) in fact consists of two core symptoms or syndromes: (i) affective (depressive) PSD; and (ii) apathetic PSD. We argue that these two core symptoms are each associated with a different underlying neuroanatomical mechanism, a pattern that influences functional recovery. Post-stroke disabilities can provoke several distinct emotional responses, some of which are associated with severe depression. We examined one of these emotional responses previously, namely 'insistence on recovery', which was believed to be a negative indicator of functional improvement in disabled stroke patients. However, an appropriate level of insistence on recovery may, in fact, be associated with reduced depression and apathy, resulting in enhanced recovery from stroke-related disabilities. Improvements in physical disabilities (trunk stability or activities of daily living, such as walking) also reduce depression and apathy. Therefore, the experience of PSD/apathy may be intertwined with various initial emotional responses and improvements in physical functioning. Effective treatment of PSD/apathy requires a multidisciplinary approach, such that neuroanatomical/neurobiological, emotional, and physical (rehabilitation) domains are all addressed.

Understanding the process for developing sleep disorders among Japanese workers: a qualitative study.

Background: Sleep disorders have an enormous impact on occupational health and are counterproductive from an economic perspective. However, the processes of causing sleep disorders from psychosocial aspects have not yet been known. The purpose of this study was to describe how sleep disorders develop among workers with respect to different psychosocial conditions. Methods: A conventional qualitative content analysis was conducted with a semi-structured interview among twenty-seven workers (14 males and 13 females) who were diagnosed with sleep disorders or had a self-reported history of sleep difficulties. Study participants were recruited from a specialized clinic and communities using snowball sampling. This paper adhered to the Standards for Reporting Qualitative Research (SRQR) checklist. Results: The results showed that there were four steps involved in the sleep disorders development process. Firstly, participants with sleep disorders developed 'early warning signs' with 11 categories of triggers; secondly, 'aggravating factors' on top of these early warning signs; thirdly, workers tried to 'cope with' their sleep disorders in the ways they thought would be effective. Finally, when coping failed to improve the quality of sleep, it led to the onset of sleep disorders. Conclusion: The development of sleep disorders and triggers of psychosocial factors were revealed. An occupational health nurse can bring these findings in practice for preventing worker's sleep disorders.