[The Basic Act on Measures against Alcohol-related Health Harm and Role of General Psychiatrists--With focus on SBRIT and Deadly Triangle].

Japan has just enacted a national law for alcohol, that named "Basic Act on Measures Against Alcohol-related Health Harm". This article includes 5 topics; i) General psychiatrists have the roles and responsibilities in this law, ii) All psychiatrists need to know about alcohol-related health harm and alcohol-related problem, iii) Alcohol dependence is attributed to change of neurotransmitter in the brain, iv) Mood disorder is more likely to be complicated by alcohol dependence and/or hazardous drinking. Some of the patients with the above-mentioned complicated disease have alcohol-induced mood disorder, v) If the patient has alcohol-induced mood disorder, it will place priority on alcoholism treatment and will be important to quickly resolve with abstinence. Finally, the proposals are made as follows; i) Making a guideline, ii) Physicians skilled at SBIRT (Screening, Brief Intervention, and Referral to Treatment) should be qualified as a certifying physician, and having the qualification should allow reimbursing medical institutions for the alcohol related service provided.

Reliability and validity of the alcohol use disorders identification test - consumption in screening for adults with alcohol use disorders and risky drinking in Japan.

BACKGROUND: Alcohol is well established as a risk factor for cancer development in many organ sites. To assess the reliability and validity of the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) for detecting alcohol use disorders or risky drinking in Japanese adults the present study was conducted. MATERIALS AND METHODS: A test-retest method was applied with a 2-week interval with 113 health care employees. The κ coefficient, Cronbach's coefficient alpha, Spearman's correlation coefficient, and intraclass correlation coefficient (ICC) were determined and the validity of the AUDIT-C was analyzed using the data from a nationwide survey on adult alcohol use conducted in 2008 (n=4,123). RESULTS: The reliability of the AUDIT-C score was high (??coefficient=0.63, Cronbach's alpha=0.98, correlation coefficient=0.95, and ICC=0.95). According to the likelihood ratio and Youden index, appropriate cutoffs for the AUDIT-C were ≥ 5points in men and ≥4 points in women. The sensitivity and specificity of these cutoffs for identifying ≥8 points on the AUDIT were 0.88 and 0.80, respectively, for men (positive likelihood ratio [LR+]=4.5) and 0.96 and 0.87, respectively, for women (LR+=7.7). The sensitivity and specificity of the cutoffs for identifying ≥ 12 points on the AUDIT were 0.90 and 0.84, respectively, for men (LR+=5.8) and 0.93 and 0.94, respectively, for women (LR+=15.8). The sensitivity and specificity of the cutoffs for identifying ≥ 16 points on the AUDIT were 0.93 and 0.80, respectively, for men (LR+=4.7) and 0.92 and 0.98, respectively, for women (LR+=55.6). With higher scores on the AUDIT, the specificity decreased and false-positives increased. The appropriate cutoffs for identifying risky drinking were the same for both genders. CONCLUSIONS: The reliability and validity of the AUDIT-C are high, indicating that it is useful for identifying alcohol use disorders or risky drinking among the general population in Japan, a group at high risk of cancer development.

[Alcohol related problem in the workplace: trial of a screening and brief intervention program for risky drinking in the workplace, via the Internet].

This report describes the effect of a screening and brief intervention via the Internet (6-month Total health Management Program: TMP, a kind of life evolution program), for improvement of alcohol related problem in the workplace. At a certain company, 2,096 employees were screened.using AUDIT-C and CAGE via the Internet (electronic screening). From those screened, 17 risky drinkers were picked up. The classification of "risky drinker" was determined based on employees scoring over six points on AUDIT-C and over two points on_ AGE. These employees were then called to one-day practical seminar program (including the program of food education, music therapy, aro-atherapy, body conditioning etc.). After which, during 6 months, they were followed up via e-mail every month. After the 6-month follow up, their results of AUDIT-C were significantly decreased. Additionally, aside from the frequency of drinking at bedtime, maximum alcohol consumption per day was also significantly decreased. The Visual Analogue Scale for anxiety captured the initial screen and then again after follow-up was reduced significantly. Moreover, quality-of-life index for sleep and dinner were both significantly improved as well..These results suggest that the SBI (screening and brief intervention: TMP) is effective for reducing drinking behavior, can be used to effectively elevate quality of life.

[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.

[Comparison between alcoholic patients and primary care patients for the use of the ambulance].

OBJECTIVE: Though heavy drinkers and patients with alcohol dependence make use of the ambulance more frequently as compared with the general population, there are few data on the alcohol-related use of the emergency department (ED) in Japan. METHOD: A cross sectional study was conducted. 170 patients with alcohol dependence in one clinic and 306 primary care patients across two clinics provided demographic data and answered some questions about the use of emergency ambulance services over the age of 20. The questions asked included whether use of the ambulance caused injuries, as well as AUDIT-C (primary care patients only). In this study, multiple logistic regression analysis was used. RESULT: The use of emergency ambulance services by patients with alcohol dependence was 4.68 times more than primary care patients, and the occurrence of ambulance-caused injuries was 6.03 times higher, as determined by multiple logistic regression. Among primary care patients, AUDIT-C positive patients (male; 5 points or more, female; 3 points or more) were 37 (12.2%), and the occurrence of ambulance-caused injuries was 3.32 times higher. CONCLUSION: Like with other countries, in Japan, heavy drinkers and patients with alcohol dependence lead to a significant increase in the use of emergency ambulance services as well as ambulance-caused injuries.

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.

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.

[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.

[Tools for brief intervention--the national norms charts of alcohol consumption (for adult men and women)--, report No1].

We made out two ranking tables of alcohol consumption norms for Japanese adult men and women based on National Health and Nutrition Survey Japan. 2005. and Nationalwide Survey of Alcohol Drinking and Alcoholism among Japanese adults. From the tables, we drew Ranking Lists, which rank subjects out of 100 Japanese men or women in the frequency and quantity of drinking, and visually indicate heavier drinkers as higher and less degree. In the UK or US, such tables and charts already have been made out from their norms, and carried on the websites and used in the PROJECT MATCH by NIAAA. So we attempt- ed to make them out from Japanese norms, and intend to use these charts for brief intervention at medical examinations in the workplace and at medical institutions, in order to motivate heavy drinkers to receive treatment and modify their drinking behavior according to self-regulation model by Agostinelli, G. et al., as well as to encourage them to recognize their danger of overdrinking objectively.

[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.

Verification of the addiction severity index Japanese version (ASI-J) as a treatment-customization, prediction, and comparison tool for alcohol-dependent individuals.

OBJECTIVE: To demonstrate the usefulness of the Addiction Severity Index Japanese Version (ASI-J) in Japanese alcohol-dependent individuals. The ASI is a frequently used clinical and research instrument that measures severities in seven functional domains in people with substance abuse disorders. METHODS: A total of 370 male inpatients with a history of alcohol dependence participated in the study. Forty-nine participants were excluded in the final analysis due to lack of reliability (i.e., patient misrepresentation or inability to understand). We used the ASI-J and a series of indexes that determined patient states during and post-treatment. RESULTS: The correlations between ASI Composite Scores (CSs), which were calculated through a weighted formula and indicated the severity of each problem area, were significant but low in eight relations and not significant in 13 relations, indicating substantial independence of the problem areas. Significant differences were found in Family/Social CSs between abstinent and relapsed alcohol-dependent individuals. The questions of undesirable attitude were significantly related to the CSs of Employment, Drug use, Family/Social, and Psychiatric sections. Significant differences were observed in patient demographics, CS, and ASI Severity Rating (SR) and interviewer's subjective scoring between alcohol-dependent individuals and drug abusers. CSs in Japanese alcohol-dependent individuals were generally similar to corresponding CSs in individuals from other countries, with the exception of The Netherlands. CONCLUSIONS: This study demonstrated that the ASI-J is useful for understanding individual profiles of problems for each patient and planning customized treatment. The ASI-J served as a predictive tool for relapse and compliance to treatment afterward and was shown to be useful as a comparison tool in clarifying similarities and differences between substance abuser groups.

[Present and future situations of support systems for the treatment of alcohol dependence].

In 1996, Mie Association for the Study of Alcohol-related Diseases (MASAD) started, which was consisted of 21 hospitals and have been conducted by managers constituted of doctors, nurses, and medical social workers with following backgrounds. Before the opening, there were a small number of physicians who recognized necessity for cooperative medical care of alcohol dependence, whereas the ratio of alcoholics to inpatients of general hospitals was 17.8%. It took 7.4 years for alcoholics to admit the mental care center after their first arrival of general ones. Ino noticed that the physicians or medical stuffs had not performed secondary prevention of progressing alcohol dependence. MASAD have been held every 6 months at the district general hospitals. After the first meeting, the members have been screening for patients with a brief intervention steadily. We accumulated actual results for eight years and developed a cooperative network for the treatment of alcohol dependence. The number of new patients per year who were introduced to the special center from the general hospitals increased naturally, such as 7 patients in 1993 and 104 ones in 2003. Since 1998, we have had educational meetings for patients with alcohol-related problems and their families 3 times a year periodically in our hospital. The every meeting consisted of two lectures by Ino and one of the heads of the departments before a free talk session. Most of the doctors happened to recognize alcohol-related problems through preparing data for their presentation, which had been overlooked in their clinical practice. We have learned one important fact that alcohol dependence is recoverable. Development of MASAD and the educational meeting in the hospital is the lifework of Ino and our aim. If similar support systems for the treatment of alcohol dependence spread in every place, our society will become healthier and more peaceful.

[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.

[Alcohol dependence syndrome and BDIM (before-discharge intervention method)--Report 3. The patients' self-reports about BDIM].

The purpose of this study is to identify how the effects of BDIM are evaluated by patients who were practiced BDIM. 153 patients were treated by the structured BDIM (Before-Discharge Intervention Method) program. Among them, 82 patients (53.6%) have attended self-help group meetings or maintained the therapeutic relationship (as outpatients or inpatients) in the 4 months' study period. To identify the maintenance of the effects of BDIM, we made our questionaire that consist of the patients' choice of answer and the patients' self-reporting. 76 of 82 patients answered our questionaire. After 76 patients discharged from hospital, 4 1/3 years have passed on the average. Their positive answers are as follows. (1) I became aware that my drinking had bad effect on my beloved family. (2) I became aware that my family have kept compassion, expectation and appreciation for me. Their message treated me and strengthened my self-esteem. In addition, I accepted the reality of my drinking problems. (3) I recognized all my family members want my abstinence and functional communication. (4) I was extremely impressed by my family members' tears. Their tears made me decide strong abstinence. (5) I was empowered by my family members. Through BDIM, I felt a sense of security, self-esteem and freedom. (6) I thought that BDIM was a good treatment program. And I thought that the application of letters is useful to recover the patients from alcohol dependence syndrome. Their negative answers are as follows. (1) I thought it was impossible for me to be abstinent. (2) I couldn't keep the motivation of abstinence. (3) I thought BDIM was a negative treatment method. Some findings of this study are as follows: First, the letters which was handed from family members to the patient were read again and again, also preserved with much care. Therefore we get know that BDIM is useful for the patient to get and remember some good memories of the family members for a long time. Second, BDIM is helpful for the patients to become aware of their own drinking problems and realize the necessity of recovery.

[Alcohol dependence syndrome and before-discharge intervention method (BDIM)--Report 1. The process to develop the constructed BDIM].

Many alcoholics come to the hospital denying their own drinking problems. So, in the initial treatment stage for alcoholics, it is very important to bring patients' attention to their denial. In those days, there were many kinds of treatment method to help them aware of patients' denial. For example, psycho-educational therapy, Japanese Naikan therapy, attendance to self-help group meetings, and so on. But I don't think that these are effective enough to help them aware of their drinking problems, especially denial. The purpose of my study is to develop the therapeutic intervention method (Before discharge Intervention Method: BDIM). It is for being aware of patient's denial, stimulating his/her motivation for abstinence and attendance to medical follow-up sessions or self-help group meetings. To achieve these purposes, I apply Picard's initial intervention method that is a very useful therapy for alcohol dependence syndrome patients who reject consultation. The subjects of this study are 175 alcohol dependence syndrome inpatients and their family members. The period of BDIM practices is for about 1 week before discharge. BDIM's concrete programs are prepared by medical team under the therapist's guidance. Beforehand the therapist has to ask the patient whether he/she agree to practicing BDIM program or not. Then to obtain his/her family's approval of joining to BDIM, nurses talk by telephone or directly consult with the patient's family members. The therapists requires the patient's family members to write letters to him/her. In advance, the therapist has to take preliminary examination the letters not to be traumatic but spiritual. There are good memories about him/her and merits of the period without his/her drinking problems. Also, they write his/her drinking problems and their hope for abstinence and follow-up therapy after discharge and attendance of self-help group meetings. In BDIM session, the patients shall listen to his/her family members' messages by their letters with tears and receive their letters. Then the patient has an opportunity to talk his/her opinion about the letters and give his/her answer later. All the letters should be copied and kept with their medical file, because the therapists will talk about the letters with the patient and his/her family members in the follow-up session. Talking about letters after discharge helps him/her revive BDIM's memories and motivate abstinence, recovery and participation in self-help group. Even though alcohol dependence syndrome patient has some cognition and (or) memory disorders, I think that BDIM practices using some letters written by the patient and his/her family members are not only so useful for the patient to correct their cognition, but also helpful to be aware of denial and maintain motives to recovery. Owing to the deep emotion and warm heart from his/her family members, the patient can be aware of his/her family's sufferings and maintain abstinence for a long time.

[Alcohol dependence syndrome and before-discharge intervention method (BDIM)--Report 2. Statistical analysis of BDIM].

The present author has developed the structured Before-Discharge Intervention Method (BDIM), a modified version of the intervention methods by Johnson and Picard in an effort to achieve the patient's awareness of his/her problem drinking. The BDIM first involves the patient's family members and helps them recover from co-dependence on the patient's alcoholism and secondly, instructs them to write structured letters to the patient. Each letter should include a few episodes of recent and past drinking problems, and family members' concern and love for the patient, and family members' hope for his/her patient's abstinence. Family members read the letter with emotion and tears in a joint therapist, patient, family members session. We have reported the two-year-post-treatment outcome of group I (the BDIM-treated group) and group II (the BDIM-untreated group) here. Patients living with their spouse or significant other in group I of the series of new patients did significantly better than their counterpart in group II on two treatment outcome variables, that is, family members' attendance at hospital follow-up sessions and/or self-help group meetings, abstinence of the patients who and whose family members attended hospital follow-up sessions and/or self-help group meetings. Patients living with their spouse or significant other in group I of the series of all patients did significantly better than their counterpart in group II on three treatment outcome variables, that is, patients' attendance at hospital follow-up sessions and/or self-help group meetings, family members' attendance at hospital follow-up sessions and/or self-help group meetings, abstinence of the patients who attended hospital follow-up sessions and/or self-help group meetings. But we noted no other statistically significant difference between groups I and II in any of the other two subgroups of discharged patients or in any of the treatment outcome variables. In group I in the series of new patients, 49% of the patients who lived with their spouse and/or significant other attended hospital follow-up sessions and/or self-help group meetings, and 41% of them showed abstinence. In group I in the series of all patients, 49% of inpatients who lived with their spouse and/or significant other attended hospital follow-up sessions and/or self-help group meetings, and 40% of them showed abstinence. We grant that the current study was not conducted in a random patient assignment design and, therefore, needs to be interpreted with some caution. Further research is appropriate.