Clinical guide for women with mental health problems during the perinatal period.

Pregnancy and childbirth have various effects on the physical as well as mental aspects of women. Therefore, appropriate considerations must be given to the mental health of pregnant women. The Guideline Review Committee of the Japanese Society of Psychiatry and Neurology launched a liaison meeting for the Japanese Society of Psychiatry and Neurology and the Japan Society of Obstetrics and Gynecology, with a view to creating a "Clinical guide for women with mental health problems during the perinatal period" by cooperation of these two fields. After repeated discussions with input from both academic societies, they jointly formulated the "Clinical guide for women with mental health problems during the perinatal period: Overview" in May 2020, and reported its "Detailed Contents" in April 2021. We hope that this guide, which is the English overview of the detailed guide, will contribute to the mental health of pregnant women, facilitating healthy pregnancies and childbirth.

[Higher Brain Dysfunction].

The technical term "higher brain dysfunction" is used widely in Japan. However, it is not always clear what "higher" means. The author thinks that the term "higher" is understood as being associated with a meaning. In this article, the differences between higher brain dysfunctions and elementary brain dysfunctions are discussed from the point of view of lesion localization and the consistency of symptoms. The psychiatric approach is indispensable for the assessment of higher brain dysfunction. A simple test for mild Alzheimer-type dementia is also introduced.

[Mind and brain "Kasane-egaki (Oomori, S.)"].

A mind-brain problem might be explainable by the concept "Kasane-egaki (Oomori, 1994)". Kasane-egaki of the mind and brain is crucial and meaningful in medical treatment. For Kasane-egaki, it is important to note that the mind (psychiatric symptoms) must be translated into an expression which could be connected with the brain function, and vice versa As a case of Kasane-egaki, a patient with left frontal infarction showing mild obsessive-compulsive-like symptoms is introduced. However, there are two situations in which Kasane-egaki of the mind and brain cannot be applied: visual agnosia and auditory hallucination of schizophrenia The author discusses visual experiences of patients with associative visual agnosia, and the relation between auditory hallucination of schizophrenia and activation of the temporal lobe from the viewpoint of language function.

Symptoms overlooked in hospitalized cancer patients: Impact of concurrent symptoms on oversight [corrected] by nurses.

OBJECTIVE: Physical and psychological symptoms in cancer patients are frequently overlooked by medical staff. However, little is known regarding the potential impacts of concurrent physical and psychological symptoms on the overlooking of other symptoms. The aim of this study was to examine the impact of concurrent symptoms on the overlooking of other symptoms in cancer inpatients. METHOD: A total of 255 cancer inpatients in the general wards of one university hospital, who were referred to the palliative care team, were included. On the day of referral, nurses and patients were independently assessed for the presence of the following eight symptoms: pain, fatigue, nausea and vomiting, shortness of breath, lack of appetite, dry mouth, sleep problems, and distressed feelings. The presence of delirium was also separately assessed by nurses and psychiatrists on the team. A total of nine symptoms detected by nurses and those reported by patients or psychiatrists were compared, and logistic regression analysis was performed to identify the variables associated with the overlooking of these symptoms. RESULTS: The most frequently reported symptom was pain (76.5%), followed by distressed feelings (49.8%), sleep problems (34.1%), and delirium (25.1%). The proportion of those overlooked was more than one quarter (25.0-63.6%) for all symptoms except pain (12.8%). Significant associations were found between the overlooking of shortness of breath and concurrent delirium (odds ratio [OR] = 110.9); the overlooking of sleep problems and concurrent lack of appetite (OR = 9.1); and the overlooking of distressed feelings and concurrent dry mouth (OR = 27.7). No patient demographic characteristic was associated with the overlooking of any other symptoms. SIGNIFICANCE OF RESULTS: The presence of some specific concurrent symptoms is likely to lead to the overlooking of other symptoms in cancer inpatients by nurses. Comprehensive assessments of physical and psychological symptoms in daily clinical practice are needed.

Suicide intervention skills among Japanese medical residents.

OBJECTIVES: Patient suicide is a tragic occurrence, and it can be a demoralizing experience for medical residents. Few studies, however, have assessed suicide management skills among these front-line healthcare professionals. This study evaluated the self-assessed competence and confidence of medical residents with regard to the management of potentially suicidal patients and assessed the correlation with the residents' background characteristics. METHOD: The authors conducted a multicenter, cross-sectional survey of 114 medical residents in Japan, using a modified version of the Suicide Intervention Response Inventory (SIRI-2), the Medical Outcomes Study 8-Item Short-Form Health Survey (SF-8), and a 5-point Likert scale to assess confidence in suicide management. RESULTS: A majority (89.5%) of the residents rated their confidence in managing suicidal patients as Not At All Confident or Rather Not Confident, although most were close to completing their psychiatric rotation. Results on the SIRI-2 suggested intermediate competence in managing suicidal behavior, as compared with that of other healthcare professionals. Competence as indicated by the SIRI-2 score was weakly and negatively correlated with the score for self-perceived Vitality on the SF-8 scale. CONCLUSION: Insufficient skills and lack of confidence in the management of suicidal patients was observed in this sample of Japanese medical residents, thus highlighting the need for improved suicide-management programs for junior medical residents in Japanese hospitals.

Lower subjective quality of life and the development of social anxiety symptoms after the discharge of elderly patients with remitted schizophrenia: a 5-year longitudinal study.

OBJECTIVES: Remitted schizophrenic patients living in the community often encounter difficulties in their daily lives, possibly leading to the development of social anxiety symptoms. Although several studies have reported the significance of social anxiety as a comorbidity in patients with schizophrenia, few longitudinal data are available on the development of social anxiety symptoms in patients with remitted schizophrenia, especially in association with the process of "deinstitutionalization." The aims of this study were to assess the social anxiety symptoms in remitted outpatients with schizophrenia and to examine whether the development of social anxiety symptoms was associated with psychotic symptoms, social functioning, or subjective quality of life. METHODS: Fifty-six people with schizophrenia who were discharged through a deinstitutionalization project were enrolled in this longitudinal study and prospectively assessed with regard to their symptoms, social functioning, and subjective quality of life. The severity of social anxiety symptoms was measured using the Liebowitz Social Anxiety Scale (LSAS). Global/Social functioning and subjective quality of life were evaluated using the Global Assessment of Functioning Scale, the Social Functioning Scale, and the World Health Organization-Quality of Life 26 (WHO-QOL26). RESULTS: Thirty-six patients completed the reassessment at the end of the 5-year follow-up period. The mean LSAS total score worsened over time, whereas other symptoms improved from the baseline. The mean WHO-QOL26 score in the worsened LSAS group was significantly lower than that in the stable LSAS group. At baseline, WHO-QOL26 scores were associated with an increase in the severity of social anxiety symptoms. CONCLUSION: In community-dwelling patients with remitted schizophrenia, a lower subjective quality of life might lead to the development of social anxiety symptoms, both concurrently and prospectively. To achieve a complete functional recovery, additional interventions for social anxiety may be needed.

Object relations in adolescence: a comparison of normal and inpatient adolescents.

AIMS: We aimed to study the development of object relations in adolescents and their correlation with their mothers' defense styles in inpatient and normal adolescents. METHODS: We administered the Thematic Apperception Test to adolescents in the adolescent unit (junior high, n = 16; senior high, n = 22) and normal controls (junior high, n = 16; senior high, n = 16). Results were analyzed using the Complexity of Representations Scale (CRS). We administered the Defense Style Questionnaire (DSQ(40)) to the subjects' mothers (patients, n = 38; controls, n = 32) to determine whether adolescents' CRS scores correlated with mothers' DSQ scores. RESULTS: There was a nearly significant interaction for group-by-school-year for the children's CRS scores. In the control group, senior high school students' scores (mean [SD] = 3.52 [0.49]) were significantly higher (F [1,66] = 12.3, P = 0.001) than those of junior high school students' (mean [SD] = 3.03 [0.31]). In the patient group, no significant difference was observed between senior high and junior high. For mothers' DSQ(40), mature defense scores were significantly higher in the control group than in the patient group (mean [SD] = 10.8 [1.89] vs 9.35 [1.40] in junior high, and 11.8 [1.67] vs 9.36 [1.81] in senior high, F [1,66] = 22.1, P < 0.001, two-way ANOVA). A significant, positive correlation (r = 0.37, P = 0.04) was observed between the mothers' mature defense and the children's CRS scores in the control group only. CONCLUSIONS: Whatever diagnoses are provided, the problems of adolescents with non-psychotic pathologies are related to the arrest of object relations development. A patient's mother cannot employ mature mechanisms to alleviate signals of anxiety sent by her child.

How successful are physicians in eliciting the truth from their patients? A large-scale Internet survey from patients' perspectives.

OBJECTIVE: How honestly patients report their symptoms and medication adherence to their physicians has not been adequately addressed in patients with depression. We therefore conducted a large-scale Internet survey in an effort to discover how successful physicians are in eliciting the truth from their patients and also to examine reasons for patients' truth-concealing behaviors. METHOD: 2,354 participants who had received treatment for depression within the past year and had been diagnosed with depression by Patient Health Questionaire were identified from 323,226 registrants at the Macromill database through screening procedures. Participants were asked to complete a questionnaire regarding their treatment for depression with a special focus on patient-physician relationship. This study was conducted from December 7 to 13, 2010, in Japan. RESULTS: 2,020 participants successfully completed the questionnaire. Overall, 70.2% of responders reported that they had withheld the truth from their physicians. A logistic regression model found significant associations of such a behavior with female sex (95% CI, 1.15-1.74; P = .001), younger age (95% CI, 0.49-0.97; P = .030), and a lower degree of satisfaction in mutual communication (95% CI, 3.17-6.58; P < .001). 69.2% and 52.6% of the participants refrained from telling about their "daily activities" and "symptoms," respectively. Female participants were more likely to hide the facts concerning "adherence to prescribed medication" and "figures such as body temperature and weight." 31.9% of participants had discontinued the treatment without consulting their physician, which was again more frequent in females, younger persons, and those who were not satisfied with communication with their physician. CONCLUSIONS: While the findings obtained herein need to be replicated in other patient populations, a majority of patients with depression were reluctant to uncover the truth, which emphasizes the need for more fine-tuned suspicion among physicians about symptoms and medication adherence.

Aberrant sense of agency in patients with schizophrenia: forward and backward over-attribution of temporal causality during intentional action.

Self-disturbances in schizophrenia have been explained and studied from the standpoint of an abnormal sense of agency. We devised an agency-attribution task that evaluated explicit experiences of the temporal causal relations between an intentional action and an external event, without any confounding from sense of ownership of body movement. In each trial, a square piece appeared on the bottom of a computer screen and moved upward. Subjects were instructed to press a key when they heard a beep. When the key was pressed, the piece jumped with various temporal biases. Subjects were instructed to make an agency judgment for each trial. We demonstrated that an excessive sense of agency was observed in patients with schizophrenia compared with normal controls. Moreover, patient groups had a greater tendency to feel a sense of agency even when external events were programmed to precede their action. Therefore, patients felt both forward and backward exaggerated causal efficacy in the temporal event sequence during the intentional action. Confusion in the experience of temporal causal relations between the self and the external world may underlie self-disturbances in schizophrenia.

Is switching antidepressants following early nonresponse more beneficial in acute-phase treatment of depression?: a randomized open-label trial.

RATIONALE: Treatment guidelines for major depressive disorder (MDD) recommend a continuous use of antidepressants for several weeks, while recent meta-analyses indicate that antidepressant efficacy starts to appear within 2 weeks and early treatment nonresponse is a predictor of subsequent nonresponse. OBJECTIVES: We prospectively compared 8-week outcomes between switching antidepressants and maintaining the same antidepressant in early nonresponders, to generate a hypothesis on possible benefits of early switching strategy. METHOD: Patients with MDD without any treatment history for the current episode were included. When subjects failed to show an early response (i.e., ≥20% improvement in the Montgomery-Åsberg Depression Rating Scale (MADRS)) to the initial treatment with sertraline 50mg at week 2, they were randomly divided into two groups; in the Continuing group, sertraline was titrated at 50-100mg, whereas sertraline was switched to paroxetine 20-40 mg in the Switching group. A primary outcome measure was a response rate (i.e., ≥50% improvement in the MADRS) at week 8. RESULTS: Among 132 subjects, 41 subjects showed early nonresponse. The Switching group (n=20) showed a higher rate of responders than the Continuing group (n=21) (75% vs. 19%: p=0.002). Further, the Switching group was also superior in the rate of remitters (total score of ≤10 in the MADRS) (60% vs. 14%: p=0.004) and continuous changes in the MADRS (19.0 vs. 7.5: p<0.001). CONCLUSIONS: Our preliminary findings suggest that patients with MDD who fail to show early response to an initial antidepressant may derive benefits from the early switching antidepressants in the acute-phase treatment of depression.

Cost of depression among adults in Japan in 2005.

AIM: Major depression is expected to become the leading contributor to disease burden worldwide by 2020. Previous studies have shown that the societal cost of depression is not less than that of other major illnesses, such as cardiovascular diseases or AIDS. Nevertheless, the cost of depression in Japan has never been examined. The goal of the present study was to estimate the total cost of depression in Japan and to clarify the characteristics of this burden. METHODS: A prevalence-based approach was adopted to measure the total cost of depression. The total cost of depression was regarded as being comprised of the direct cost, morbidity cost and mortality cost. Diagnoses included in this study were depressive episodes and recurrent depressive disorder according to the ICD-10 or major depressive disorder according to the DSM-IV. Data were collected from publicly available statistics and the World Mental Health Japan Survey database. RESULTS: The total cost of depression among adults in Japan in 2005 was estimated to be ¥2.0 trillion. The direct cost was ¥0.18 trillion. The morbidity cost was ¥0.92 trillion, while the mortality cost was ¥0.88 trillion. CONCLUSION: The societal costs caused by depression in Japan are enormous, as in other developed countries. Low morbidity costs and extremely high mortality costs are characteristic in Japan. Effective interventions for preventing suicide could reduce the societal costs of depression.

Successful aging in individuals with schizophrenia dwelling in the community: a study on attitudes toward aging and preparing behavior for old age.

AIM: 'Successful aging' in individuals with schizophrenia has been attracting attention. We examined two forward-looking factors of successful aging among schizophrenia patients: 'attitude toward aging' and 'preparing behavior for old age'. METHODS: Fifty-seven middle-aged and elderly schizophrenia patients with successful aging were identified using the Attitude toward Aging Scale, the Preparing Behavior for Old Age Scale, and assessments of their cognitive function, psychiatric symptoms, social functioning and quality of life. A multiple regression analysis was used to detect determinants of attitude toward aging/preparing behavior for old age at that time ('present': community dwelling). We also analyzed predictors of successful aging using demographic/clinical data assessed 3 years previously ('past': residential care). RESULTS: The multiple regression analysis revealed that quality of life was a significant determinant: a higher quality of life was related to a more positive attitude toward aging and less active preparing behavior. The significant predictors of preparing behavior were quality of life and the length of the hospital stay: a longer hospital stay and a higher quality of life were related to less active preparing behavior. CONCLUSION: Quality of life and the length of the hospital stay significantly contributed to forward-looking factors of successful aging. Avoiding long hospitalization periods for patients with schizophrenia may lead to more active preparing behavior, but the improvement of quality of life may not be a sufficient condition. As schizophrenia patients have an optimistic attitude and insufficient preparing behavior, support to prepare such individuals for old age is required as part of community-based psychiatric care strategies.

Plasma substance P level in patients with schizophrenia: a cross-sectional study.

Aspiration pneumonia is a serious health concern in older patients with schizophrenia. In this study, we examined clinical and demographic variables that could impact the plasma substance P level, which is a useful predictive biomarker of aspiration. Thirty-four patients were included (mean age ± SD: 70.9 ± 10.8 years). A greater number of cigarettes/day and a higher antipsychotic dosage were found to be associated with a lower plasma substance P level, while age showed a trend-level effect. This finding suggests the need for intensive observation for prevention of aspiration pneumonia in heavy smokers who are receiving a higher antipsychotic dose in this senior population.

Lack of association between psychosis-like experiences and seeking help from professionals: a case-controlled study.

BACKGROUNDS: It still remains unclear whether individuals who experience attenuated psychotic symptoms are likely to seek help, whereas depressive symptoms are more likely to be associated with help-seeking behavior than these symptoms themselves. The aims of our study were to compare the profile of these symptoms between clinical and community samples and to investigate to what extent help-seeking behavior depends on the severity of psychosis-like symptoms and/or depressive symptoms. METHODS: The clinical sample consisted of help-seeking outpatients aged 16-30 years who had approached a community mental health clinic (N=750, mean age: 23.3±4.2 years, 62.4% females). The community sample was comprised of students from two universities and two high schools (N=781, mean age: 18.1±1.7 years, 59.2% females). Psychosis-like experiences were assessed using the PRIME Screen-Revised (PS-R), a self-reported screening instrument for assessing the risk of psychosis. Depressive symptoms were assessed using the Zung Self-rating Depression Scale (ZSDS), a 20-item self-reported questionnaire. RESULTS: Among the clinical and community samples, 27% and 10% had positive PS-R results respectively. No significant difference in the PS-R total score or the frequency of PS-R-positive items was observed between the clinical and community samples. A logistic regression analysis revealed that none of the psychosis-like experiences were significantly associated with help-seeking behavior, after controlling for the effect of depressive symptoms. CONCLUSIONS: Our findings showed that attenuated psychotic symptoms do not contribute significantly to help-seeking behavior, suggesting that the relationships among PLEs, depressive symptoms, and help-seeking behavior should be reconsidered.

Subjective recognition of adverse events with antidepressant in people with depression: a prospective study.

BACKGROUND: While it has been reported that physicians may under-recognize adverse effects of antidepressants thoroughly in clinical settings, subjective bias in recognition of adverse effects (AEs) with antidepressants has not been specifically investigated. METHODS: Four-hundred ninety-three participants with depressive disorders (ICD-10) were assessed for the severity of 20 common AEs and their inferred causal relationship with antidepressants, together with the Quick Inventory for Depressive Symptoms (QIDS). These assessments occurred twice at the 1st visit (when they were antidepressant free) and 2nd visit (10 days after the initiation of antidepressants). 'Possible AEs' and 'under-recognized AEs' were defined as 'events with exacerbation in the severity' and 'events with negative causal attribution to antidepressants' at the time of the 2nd visit, respectively. RESULTS: Three-hundred sixty-three participants (73.6%) experienced ≥ 1 under-recognized AEs. Flu like symptoms (96.5% of participants who experienced possible AEs), sexual dysfunction (94.2%), blurred vision (93.4%), anxiety/tension (91.1%) and sweating (89.2%) were found to be prevalent as under-recognized AEs. Participants with under-recognized AEs had less improvement in the QIDS than those without (27.1% vs. 11.1% decrease, p<0.001). LIMITATIONS: It is intrinsically challenging to exactly differentiate between antidepressant AEs and symptoms of depression. And the severity of depression, that of AEs and causal relationship between AEs and antidepressants were assessed not by objective but subjective scales. CONCLUSIONS: An overall trend to under-recognize AEs of antidepressants was found and people with a lesser degree of early improvement tend to understate the causality, which has an implication in interpreting voluntarily expression of AEs.

Is antipsychotic polypharmacy associated with metabolic syndrome even after adjustment for lifestyle effects?: a cross-sectional study.

BACKGROUND: Although the validity and safety of antipsychotic polypharmacy remains unclear, it is commonplace in the treatment of schizophrenia. This study aimed to investigate the degree that antipsychotic polypharmacy contributed to metabolic syndrome in outpatients with schizophrenia, after adjustment for the effects of lifestyle. METHODS: A cross-sectional survey was carried out between April 2007 and October 2007 at Yamanashi Prefectural KITA hospital in Japan. 334 patients consented to this cross-sectional study. We measured the components consisting metabolic syndrome, and interviewed the participants about their lifestyle. We classified metabolic syndrome into four groups according to the severity of metabolic disturbance: the metabolic syndrome; the pre-metabolic syndrome; the visceral fat obesity; and the normal group. We used multinomial logistic regression models to assess the association of metabolic syndrome with antipsychotic polypharmacy, adjusting for lifestyle. RESULTS: Seventy-four (22.2%) patients were in the metabolic syndrome group, 61 (18.3%) patients were in the pre-metabolic syndrome group, and 41 (12.3%) patients were in visceral fat obesity group. Antipsychotic polypharmacy was present in 167 (50.0%) patients. In multinomial logistic regression analyses, antipsychotic polypharmacy was significantly associated with the pre-metabolic syndrome group (adjusted odds ratio [AOR], 2.348; 95% confidence interval [CI], 1.181-4.668), but not with the metabolic syndrome group (AOR, 1.269; 95%CI, 0.679-2.371). CONCLUSIONS: These results suggest that antipsychotic polypharmacy, compared with monotherapy, may be independently associated with an increased risk of having pre-metabolic syndrome, even after adjusting for patients' lifestyle characteristics. As metabolic syndrome is associated with an increased risk of cardiovascular mortality, further studies are needed to clarify the validity and safety of antipsychotic polypharmacy.

Patient's trust in their psychiatrist: a cross-sectional survey.

Investigating and characterizing the degree and correlates of patient's trust in their treating psychiatrists across a range of psychiatric disorders is of a great clinical relevance to enhance our therapeutic alliance, which has not been addressed in the literature. In this study, outpatients who visited one of the participating psychiatric clinics in Tokyo, Japan between October and November, 2010 were asked to complete the Trust in Physician Scale (TPS), an 11-item self-report questionnaire. A univariate general linear model was used to examine the effects of the following variables on the TPS total score: age, sex, diagnosis, Global Assessment of Functioning score, educational background, physician's years of practice as a psychiatrist, duration of treatment with their current psychiatrists, sex concordance between patients and their psychiatrists, and whether patients were older than their psychiatrists. Five hundred and four patients were enrolled (mean ± SD age = 42.8 ± 13.6 years; 176 men; Psychiatric diagnoses (ICD-10): F0 [N = 8], F2 [N = 72], F3 [N = 252], F4 [N = 147], F6 [N = 22]). A duration of treatment with their current psychiatrist of ≥ 1 year and a duration of their physician's clinical expertise as a psychiatrist for ≥ 10 years were associated with a greater degree of patient's trust in their psychiatrist. Furthermore, patients with a F3 diagnosis showed a significantly higher TPS total score than those with F4. These findings underscore an importance of paying close attention to patients who are relatively new and are not treated by well-experienced psychiatrists in terms of subjective trust. Furthermore, this likely holds more true for patients with neurotic disorders.

How long to wait before reducing antipsychotic dosage in stabilized patients with schizophrenia? A retrospective chart review.

OBJECTIVE: Antipsychotic dose reduction is generally recommended to occur after six months of clinical stabilization despite inadequate evidence. This timing issue was addressed in this study. METHODS: This is an observational, retrospective and medical chart-based study. Inclusion criteria were (1) diagnosis of schizophrenia (DSM-IV), (2) being acutely psychotic at their first outpatient visit from May, 2002 to April, 2003, (3) having responded to antipsychotics and achieved clinical stabilization of acute symptoms, indexed as a fixation of regimen for four or more weeks, and (4) having one or more years of follow-up. Patients who had their antipsychotic doses reduced were then identified, and they were divided into two groups based on the waiting period before dose reduction: <24 weeks (Early Group) and ≥24 weeks (Standard Group). The rate of dose escalation for ≥20% during follow-up period was investigated as a proxy of clinical worsening. RESULTS: After excluding stable patients at baseline, 211 patients met inclusion criteria. The mean ± SD waiting period before reducing antipsychotics was 122 ± 102 days. The rates of patients needing dose escalation were not significantly different between patients whose dose was reduced (N = 83) and those who was not (N = 128) (57.8% vs. 59.4%), and between Early Group (N = 59) and Standard Group (N = 24) (61.0% vs. 50.0%) although the reduction rate in antipsychotic dosage was significantly greater in Early Group (58.7% vs. 43.3%, p < 0.05). CONCLUSION: These findings may indicate that timeline until antipsychotic reduction in stable patients with schizophrenia could be earlier than recommended, although caution is needed in interpreting our retrospective results.