Increased brain gyrification and cortical thinning in winter-born patients with schizophrenia spectrum.

Introduction: The findings of epidemiological studies suggest that a relationship exists between the risk of schizophrenia and winter births in the Northern Hemisphere, which may affect the process of fetal neurodevelopment. However, it remains unclear whether birth seasons are associated with the brain morphological characteristics of patients within the schizophrenia spectrum. Methods: The present magnetic resonance imaging study using FreeSurfer software examined the effects of birth seasons (i.e., summer-born vs. winter-born) on the comprehensive brain surface characteristics of 101 patients with schizophrenia (48 summer- and 53 winter-born), 46 with schizotypal disorder (20 summer- and 26 winter-born), and 76 healthy control subjects (28 summer- and 48 winter-born). Results: In comparisons with summer-born patients, winter-born patients, particularly those with schizophrenia, showed significantly increased gyrification mainly in the left lateral occipital and inferior temporal regions and right fronto-parietal region as well as cortical thinning in the right superior frontal region. Birth seasons did not significantly affect the local gyrification index or cortical thickness in healthy controls. Discussion: The present whole-brain surface-based analysis demonstrated that brain morphological characteristics reported in the schizophrenia spectrum were more pronounced in winter-born patients than in summer-born patients, suggesting the contribution of early neurodevelopmental factors associated with birth seasons to the pathophysiology of the schizophrenia spectrum.

Efficacy of Preventing Relapse Evaluated by a Multicenter Randomized Double-Blind Placebo-Controlled Withdrawal Study of Escitalopram in Japanese Adolescents with Major Depressive Disorder.

Objective: To evaluate the efficacy and safety of escitalopram (ESC) in a 48-week relapse prevention study in Japanese adolescents with major depressive disorder (MDD). Methods: This was a 48-week multicenter randomized double-blind placebo-controlled parallel-group study of patients aged 12-17 years with MDD. Patients received ESC for 12 weeks as an open-label treatment period (open-label period). Patients who achieved criteria for remission or response in the open-label period received either ESC or placebo for 36 weeks as a double-blind treatment period (double-blind period). The primary endpoint was the time to relapse during the double-blind period. Safety was evaluated in terms of type, incidence, and severity of adverse events. Results: Of the 128 patients who entered the open-label period, 80 patients entered the double-blind period, all of whom were in the primary analysis population. The primary endpoint, time to relapse, was marginally less than statistically significant between the ESC and placebo groups (p = 0.051, log-rank test). In the Cox proportional hazards model, the estimated hazard ratio [two-sided 95% confidence interval] for relapse in the placebo group versus the ESC group was 2.96 [0.94, 9.30]. There were statistically significant differences between the ESC and placebo groups in several secondary endpoints (change in Children's Depression Rating Scale-Revised, change in Clinical Global Impressions-Severity Scale, etc.). No notable safety/tolerability issues were observed in this study compared with the results of studies in Japanese adults with MDD. Conclusions: Superiority of ESC over placebo for relapse prevention in Japanese adolescents aged 12-17 years with MDD could not be verified with time to relapse evaluated by log-rank test. However, secondary endpoint results and a post hoc analysis of time to relapse suggest that ESC may be effective in preventing MDD relapse. No notable safety/tolerability issues were observed compared with the results of studies in Japanese adults with MDD. Study Registry Number: jRCT2080224520.

Clinical characteristics of child and adolescent psychiatric outpatients engaging in fireplay or arson: a case-control study.

BACKGROUND: Fireplay and arson incidents among children and adolescents have gained attention because of their potentially severe consequences and societal impacts. Understanding the underlying psychiatric characteristics of individuals engaging in fireplay or arson is crucial for early identification and targeted intervention. However, there is a lack of research conducted in clinical psychiatric populations in this context. This study compared the clinical characteristics of child and adolescent psychiatric outpatients who engaged in fireplay or arson with those without such behaviors. METHODS: A retrospective case-control study was conducted using data collected from patients who visited the Department of Child and Adolescent Psychiatry at Kohnodai Hospital, National Center for Global Health and Medicine in Japan, between April 2014 and March 2022. Medical records were checked to see if the patient had practically committed behaviors that corresponded to fireplay or arson. The case group was identified using this process. After identifying the case and control groups, sex, diagnosis, antisocial behavior, abuse history, and children-to-parent violence were assessed and compared by careful review of medical records. RESULTS: The study identified 64 patients who engaged in fireplay or arson, representing approximately 1.1% of the total 5,587 patients (case group). The median age of the patients' first fire-related behavior was 13 years (range, 6-18 years). In the case group, 14.1% of the cases involved arson, resulting in substantial damage. Of the remaining 5523 patients, 2268 patients had datasets for the first consultation (control group). The most prevalent diagnosis in the case group was attention-deficit hyperactivity disorder (ADHD), present in 57.8% of the cases. The study revealed a significant association between fire-related behaviors and ADHD as well as antisocial behavior. Gender differences were observed, with boys being more likely to engage in fireplay or arson than girls. CONCLUSIONS: This study suggests that clinicians and mental health professionals should closely consider male sex, ADHD, and antisocial behaviors as potential risk factors for fire-related behaviors. Monitoring the case group for the development of psychiatric disorders, including the use of illegal drugs, is recommended to prevent future arson incidents.

Birth season and gross brain morphology associated with early neurodevelopment in schizophrenia spectrum patients and healthy subjects.

This MRI study examined the effects of birth seasons on gross brain characteristics, such as the prevalence/size of midline brain structures (cavum septi pellucidi and adhesio interthalamica), orbitofrontal surface morphology, and insular gross anatomy, in 135 patients with schizophrenia, 47 with schizotypal disorder, and 88 healthy controls. Birth seasons only affected the insular anatomy. Summer-born subjects (N = 110) were characterized by more developed left insular gyri than winter-born subjects; however, this effect had no diagnostic specificity. The present results do not support birth seasons affecting the neurodevelopmental pathology of schizophrenia spectrum.

Anatomical variations in the insular cortex in individuals at a clinical high-risk state for psychosis and patients with schizophrenia.

Introduction: Since the number of insular gyri is higher in schizophrenia patients, it has potential as a marker of early neurodevelopmental deviations. However, it currently remains unknown whether the features of the insular gross anatomy are similar between schizophrenia patients and individuals at risk of psychosis. Furthermore, the relationship between anatomical variations in the insular cortex and cognitive function has not yet been clarified. Methods: The gross anatomical features (i.e., the number of gyri and development pattern of each gyrus) of the insular cortex were examined using magnetic resonance imaging, and their relationships with clinical characteristics were investigated in 57 subjects with an at-risk mental state (ARMS) and 63 schizophrenia patients in comparison with 61 healthy controls. Results: The number of insular gyri bilaterally in the anterior subdivision was higher in the ARMS and schizophrenia groups than in the control group. The schizophrenia group was also characterized by a higher number of insular gyri in the left posterior subdivision. A well-developed right middle short insular gyrus was associated with symptom severity in first-episode schizophrenia patients, whereas chronic schizophrenia patients with a well-developed left accessory gyrus were characterized by less severe cognitive impairments in motor and executive functions. The features of the insular gross anatomy were not associated with clinical characteristics in the ARMS group. Discussion: The features of the insular gross anatomy that were shared in the ARMS and schizophrenia groups may reflect a vulnerability to psychosis that may be attributed to anomalies in the early stages of neurodevelopment. However, the contribution of the insular gross anatomy to the clinical characteristics of schizophrenia may differ according to illness stages.

Implementations of an evidence-based assertive case management intervention for suicide attempters: Post-ACTION-J Study (PACS).

Aim: An assertive case management intervention program, ACTION-J, proved effective for preventing suicide attempters from reattempting suicide within 6 months. The ACTION-J randomized trial was conducted as part of the "National Strategic Research Projects." The program has been covered by the national medical payment system of Japan since 2016. The aim of the Post-ACTION-J Study (PACS) was to examine the current implementation status of assertive case management in a real-world clinical setting. Methods: PACS was a prospective, multicenter registry cohort study. The participants were suicide attempters admitted to the emergency departments of 10 participating medical facilities from October 2016 to September 2018. The assertive case management intervention developed by the ACTION-J Study was offered to all patients, and the primary outcome was the duration and frequency of use of the intervention at 6 months. Results: A total of 1159 patients were admitted to emergency departments after a suicide attempt during the study period, 144 of whom were included in our analysis. The proportion of participants who received the intervention for 6 months was 72.2% (104/144), and 63.9% (92/144) of the patients completed ≥7 case management interviews within 6 months. Conclusion: The findings of this study indicate successful implementation of an assertive case management intervention program based on the ACTION-J Study in a real-world clinical setting, following its integration with the national medical payment scheme in Japan. The study provided the useful information that could improve the implementation of assertive case management interventions in future.

Decision aid development and its acceptability among adults with attention-deficit/hyperactivity disorders regarding treatment discontinuation after remission.

Aim: Current clinical guidelines for attention-deficit/hyperactivity disorder (ADHD) put shared decision making (SDM) at the center of care. However, there remain challenges in SDM in ADHD management, particularly regarding the decision to continue or discontinue medication after ADHD remission in adult patients. We aimed to develop a decision aid (DA) for adult patients with ADHD regarding the continuation or discontinuation of their ongoing ADHD medications after they have attained remission. Method: We systematically developed a DA according to the International Patient Decision Aid Standard (IPDAS). First, we created a DA prototype using the results of our previous systematic review and meta-analysis that identified the consequences of continuing and discontinuing ADHD medications. Second, we administered a mixed-method questionnaire (alpha acceptability testing) to adult patients with ADHD and healthcare providers to improve the DA prototype and develop it into a final version that is acceptable for clinical settings. Results: Our DA consisted of ADHD description, the option to continue or discontinue ADHD medications, the advantages and disadvantages of the consequences, as well as value clarification exercises for each option. Patients (n = 20) reported that the DA had acceptable language (85%), adequate information (75%), and a well-balanced presentation (53%). Healthcare providers (n = 19) provided favorable feedback. The final DA met all six IPDAS requisite criteria. Conclusions: Our results could facilitate the SDM process between patients and healthcare providers on the continuation or discontinuation of ADHD medication following remission. Further studies should verify the effects of using the DA during the SDM process among patients across the age spectrum with ADHD and healthcare providers.

Efficacy and Safety of Medication for Attention-Deficit Hyperactivity Disorder in Children and Adolescents with Common Comorbidities: A Systematic Review.

INTRODUCTION: Comorbid psychiatric conditions in children and adolescents with attention-deficit hyperactivity disorder (ADHD) occur frequently, complicate management, and are associated with substantial burden on patients and caregivers. Very few systematic reviews have assessed the efficacy and safety of medications for ADHD in children and adolescents with comorbidities. Of those that were conducted, most focused on a particular comorbidity or medication. In this systematic literature review, we summarize the efficacy and safety of treatments for children and adolescents with ADHD and comorbid autism spectrum disorders, oppositional defiant disorder, Tourette's disorder and other tic disorders, generalized anxiety disorder, and major depressive disorder. METHODS: We searched MEDLINE, Embase, and ClinicalTrials.gov (to October 2019) for studies of patients (aged < 18 years) with an ADHD diagnosis and the specified comorbidities treated with amphetamines, methylphenidate and derivatives, atomoxetine (ATX), and guanfacine extended-release (GXR). For efficacy, placebo-controlled randomized controlled trials (RCTs) or meta-analyses of RCTs were eligible for inclusion; for safety, all study types were eligible. The primary efficacy outcome measure was ADHD Rating Scale IV (ADHD-RS-IV) total score. RESULTS: Of 2177 publications/trials retrieved, 69 were included in this systematic literature review (5 meta-analyses, 37 placebo-controlled RCTs, 16 cohort studies, 11 case reports). A systematic narrative synthesis is provided because insufficient data were retrieved to combine ADHD-RS-IV total scores or effect sizes. Effect sizes for ADHD-RS-IV total scores were available for ten RCTs and ranged from 0.46 to 1.0 for ATX and from 0.92 to 2.0 for GXR across comorbidities. The numbers and types of adverse events in children with comorbidities were consistent with those in children without comorbidities, but treatment should be individualized to ensure children can tolerate the lowest effective dose. CONCLUSION: Limited information is available from placebo-controlled RCTs on the efficacy (by ADHD-RS-IV) or safety of medication in children with ADHD and psychiatric comorbidities. Further studies are required to support evidence-based drug selection for these populations.

Current use of attention-deficit hyperactivity disorder (ADHD) medications and clinical characteristics of child and adolescent psychiatric outpatients prescribed multiple ADHD medications in Japan.

BACKGROUND/AIM: Patients with attention-deficit hyperactivity disorder (ADHD) manifest symptoms of hyperactivity, impulsivity, and/or inattention. ADHD medications available in Japan are limited compared with those in Western countries. Prescribing status has not been sufficiently evaluated in clinical settings in Japan. This study investigated the current use of ADHD medications and characteristics of patients who received multiple ADHD medications in a clinical setting in Japan. METHODS: Study participants were those who visited the Department of Child and Adolescent Psychiatry, Kohnodai Hospital between April 2015 and March 2020. We investigated patients who received osmotic-controlled release oral delivery system methylphenidate, atomoxetine, or guanfacine. A retrospective case-control design was used to evaluate the characteristics of patients who received multiple ADHD medications. Patients who were given three ADHD medications were defined as the case group. Randomly sampled sex- and age-matched patients diagnosed with ADHD were defined as the control group. We compared data for child-to-parent violence, antisocial behavior, suicide attempt or self-harm, abuse history, refusal to attend school, and two psychological rating scales (the ADHD-Rating Scale and Tokyo Autistic Behavior Scale). RESULTS: Among the 878 patients who were prescribed any ADHD medications, 43 (4.9%) received three ADHD medications. Logistic regression revealed that children with severe ADHD symptoms, autistic characteristics, or tendency of child-to-parent violence were more likely to have been prescribed three medications during their treatment. CONCLUSIONS: Our findings suggest the approach to prevent the use of multiple ADHD medications. A prospective study to investigate the causality between prescribing status and clinical characteristics is warranted.

Right prefrontal function and coping strategies in patients with remitted major depressive disorder.

BACKGROUND: Patients with remitted major depressive disorder (rMDD) generally rely on maladaptive coping strategies for stressful situations. These maladaptive copings are associated with an elevated relapse risk of rMDD; however, their neural basis remains poorly understood. METHODS: We enrolled (1) 45 patients with rMDD (17-item Hamilton Depression Rating Scale [HRSD17] total score ≤ 3) and (2) 56 healthy controls (HCs). Coping styles were measured using the Coping Inventory for Stressful Situations (CISS) according to three coping dimensions: avoidance-, emotion-, and task-oriented copings. The cognitive strategic processes of the prefrontal cortex were measured using a verbal fluency task (VFT). Furthermore, regional frontotemporal hemodynamic responses were monitored by near-infrared spectroscopy (NIRS). RESULTS: Patients with rMDD had significantly lower task-oriented coping scores and significantly higher avoidance- and emotion-oriented coping scores than HCs. Predominantly in the left frontotemporal region, patients with rMDD had lower frontotemporal hemodynamic responses during a VFT than HCs. Hemodynamic responses in the right inferior frontal gyrus of patients with rMDD were significantly and negatively associated with avoidance-oriented coping scores, but not of HCs. Conversely, those responses of HCs were significantly and positively associated with task-oriented coping scores, but not of patients with rMDD. DISCUSSION: Alteration in the right inferior frontal cortex plays an important role in dysfunction to stress response in patients with rMDD. Differential functioning patterns of the right inferior frontal cortex associated with coping strategies may link to MDD recurrence vulnerability.

Current situation and challenges for mental health focused on treatment and care in Japan and the Philippines - highlights of the training program by the National Center for Global Health and Medicine.

BACKGROUND AND PURPOSE: Mental health has emerged as an important public health concern in recent years. With a high proportion of children and adolescents affected by mental disorders, it is important to ensure that they are provided with proper care and treatment. With the goal of sharing the activities and good practices on child and adolescent mental health promotion, care, and treatment in Japan and the Philippines, the National Center for Global Health and Medicine conducted a training program on the promotion of mental health focused on treatment and care in Japan and the Philippines in September and November 2019. KEY HIGHLIGHTS: The training program comprised of a series of lectures, site visits, and round table discussions in Japan and the Philippines. The lectures and site visits focused on the current situation of child and adolescent psychiatry, diagnosis of childhood mental disorders, abuse, health financing for mental disorders, pharmacotherapy, psychotherapy, and disaster child psychiatry in both countries. Round table discussions provided an opportunity to explore the similarities and differences between the two countries in terms of the themes discussed during the lectures.The training program identified the need to collaborate with other professionals to improve the diagnosis of mental disorders in children and adolescents and to increase the workforce capable of addressing mental health issues among children and adolescents. It also emphasized the importance of cooperation between government efforts during and after disasters to ensure that affected children and their families are provided with the care and support that they need.

Aggressiveness is associated with excitement on the five-factor model of the positive and negative syndrome scale and prefrontal function in patients with stable schizophrenia.

Aggressiveness is a clinical concern in the stable phase of schizophrenia, as well as in the acute phase. The factors that affect aggressiveness during the stable phase remain unclear. This study investigated factors associated with aggressiveness in patients with stable schizophrenia. Sixty-six patients with schizophrenia who were in the stable phase without acute exacerbation were assessed for aggressiveness using the Buss-Perry Aggression Questionnaire; impulsivity using the Barratt Impulsiveness Scale Version 11, psychotic symptoms using the five-factor model of the Positive and Negative Syndrome Scale (PANSS) including positive symptoms, negative symptoms, disorganization, excitement, and emotional distress; and prefrontal hemodynamic responses using near-infrared spectroscopy. Multivariate regression analyses showed that the excitement factor of the PANSS five-factor model, which comprised four PANSS items (poor impulse control, hyperactivity, hostility, and uncooperativeness), and delayed prefrontal hemodynamic responses were associated with elevated aggressiveness. These findings suggest that in patients with stable schizophrenia, excitement symptoms and prefrontal dysfunction are associated with elevated aggressiveness. Furthermore, the impact of impulsive traits on aggressiveness is less relevant. Our results shed light on a specific aspect of aggressiveness in patients with stable schizophrenia and may indicate factors to consider in the clinical setting.

Hopelessness is associated with repeated suicidal behaviors after discharge in patients admitted to emergency departments for attempted suicide.

BACKGROUND: Hopelessness may be associated with an increased risk of suicide. However, findings regarding the long-term predictive ability of the Beck Hopelessness Scale (BHS) for suicide are inconsistent. This study investigated the long-term predictive ability of BHS scores for subsequent self-harm episodes in individuals admitted to an emergency department after attempting suicide. METHODS: The BHS was administered to 805 adult patients with a DSM-IV-TR axis I disorder admitted to an emergency department following a suicide attempt. The patients were followed for at least 18 months and up to 5 years. The incidence of the first subsequent suicidal behavior (attempt or dying by suicide) was examined and the numbers per person-year of overall repeat self-harm episodes, suicide attempt episodes, and non-suicidal self-harm episodes were evaluated. RESULTS: The total BHS scores showed significant associations with the overall number of self-harm episodes per person-year (incidence rate ratio [IRR], 1.05; 95% confidence interval [CI], 1.03-1.07; p < 0.0001), the number of suicide attempt episodes per person-year (IRR, 1.05; 95%CI, 1.03-1.08; p < 0.0001), and the number of non-suicidal self-harm episodes per person-year (IRR, 1.05; 95%CI, 1.03-1.07; p < 0.0001). LIMITATIONS: The study excluded children and adolescents. The sample size, while large, was insufficient to ensure generalizability, or to allow subanalyses based on specific disorders. CONCLUSIONS: Hopelessness scores assessed in the emergency department after a self-harming episode were associated with a rate of repetition of suicidal behaviors after discharge. Additional strategies to address hopelessness of these patients are warranted.

Effect of Continuing and Discontinuing Medications on Quality of Life After Symptomatic Remission in Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis.

OBJECTIVE: This study aimed to compare the effect of continuing and discontinuing medications on quality of life of patients with attention-deficit/hyperactivity disorder (ADHD). DATA SOURCES: PubMed, Cochrane Library, and Embase databases were searched using generic terms for ADHD, discontinuing, continuing, pharmacotherapy, and randomized controlled trials without date or language restrictions. STUDY SELECTION: Of the 3,672 screened studies, 9 met the predefined inclusion criteria on patients with ADHD; 5 of these 9 studies reporting on 1,463 patients (children and adolescents, n = 894; adults, n = 569) measured quality of life and were included in this meta-analysis. Only randomized, double-blind, placebo-controlled withdrawal trials of ADHD medications were included. DATA EXTRACTION: Data were independently extracted according to the Cochrane Handbook for Systematic Reviews of Interventions. Analyses were based on random-effects models. RESULTS: Compared with continuing medications, discontinuing them significantly worsened quality of life score in patients with ADHD (standardized mean difference [SMD] = 0.19; 95% CI, 0.08 to 0.30]). Moreover, discontinuing medications worsened this score in children and adolescents with ADHD (SMD = 0.21; 95% CI, 0.06 to 0.36) but not in adults with ADHD (SMD = 0.02; 95% CI, -0.46 to 0.50). CONCLUSIONS: Discontinuing medications was associated with a small but statistically significant decrease in quality of life among children and adolescents with ADHD but not in adults with ADHD. Quality of life can be applied in pharmacologic interventions regarding continuing and discontinuing medication because this concept is related to individuals' appraisal of their situation. Quality of life is an important factor for planning individualized ADHD medication treatment.

Mitochondrial DNA Copy Number Raises the Potential of Left Frontopolar Hemodynamic Response as a Diagnostic Marker for Distinguishing Bipolar Disorder From Major Depressive Disorder.

Background: Given a lack of markers, diagnoses of bipolar disorder (BD) and major depressive disorder (MDD) rely on clinical assessment of symptoms. However, the depressive mood states of BD and depressive symptoms of MDD are often difficult to distinguish, which leads to misdiagnoses, which in turn leads to inadequate treatment. Previous studies have shown that the hemodynamic responses of the left frontopolar cortex measured by near-infrared spectroscopy (NIRS) differ between BD and MDD; these hemodynamic responses are associated with altered mitochondrial metabolism; and mitochondrial DNA copy number (mtDNAcn), an index of mitochondrial dysfunction, tends to decrease in BD and increase in MDD patients. In this study, we confirmed that mtDNAcn trends in opposite directions in BD and MDD. We then determined whether mtDNAcn could enhance the utility of NIRS as a diagnostic marker to distinguish between BD and MDD. Methods: We determined mtDNAcn in peripheral blood samples from 58 healthy controls, 79 patients with BD, and 44 patients with MDD. Regional hemodynamic responses during a verbal fluency task (VFT) in 24 BD patients and 44 MDD patients, matched by age and depression severity, were monitored using NIRS. Results: Measurements of mtDNAcn were lower in BD patients and higher in MDD patients than in controls. The left frontopolar region exhibited the most significant differences in mean VFT-related oxy-Hb changes between the BD and MDD groups. Multivariate logistic regression analysis with variables including age, sex, hemodynamic response of the left frontopolar region, and mtDNAcn showed high accuracy for distinguishing BD from MDD (area under the curve = 0.917; 95% confidence interval = 0.849-0.985). For the BD group, we observed a positive correlation between hemodynamic responses in the left frontopolar region and mtDNAcn, while for the MDD group, we observed a negative correlation. Conclusions: Our findings suggest that the association between hemodynamic response and mitochondrial dysfunction in BD or MDD plays an important role in differentiating the pathophysiological mechanisms of BD from those of MDD.

Capturing spontaneous activity in the medial prefrontal cortex using near-infrared spectroscopy and its application to schizophrenia.

Near-infrared spectroscopy (NIRS) is an optimal imaging modality used to examine spontaneous brain activity because it can quietly measure blood flow changes with less physical restriction during the resting state. Here, NIRS was used at rest to measure spontaneous activity in the medial prefrontal cortex (mPFC), a main locus of default mode network. Consistent with previous fMRI studies, magnitude of the spontaneous activity in this region declined with increasing age in healthy subjects. The magnitude reduced in the mPFC of patients with schizophrenia. Additionally, in the mPFC of patients with schizophrenia, the spontaneous activity did not show any age-related decline; the activity was already low in younger patients. Further analysis using fractional amplitude of low-frequency fluctuations confirmed the reduction of spontaneous activity in the mPFC of patients with schizophrenia, consistent with the findings of fMRI studies. Our findings demonstrate the ability of NIRS to evaluate the spontaneous activity in the mPFC of patients with schizophrenia, particularly younger patients. Considering the safety and ease of the NIRS measurements, the current NIRS study of the resting-state activity indicates its utility for clinical applications to schizophrenia, which may facilitate chronological assessment of larger cohorts of patients with schizophrenia in further studies.

Protocol for a prospective multicentre registry cohort study on suicide attempters given the assertive case management intervention after admission to an emergency department in Japan: post-ACTION-J Study (PACS).

INTRODUCTION: Suicide attempt is the most important risk factor for later suicide. A randomised-controlled, multicentre trial of postsuicide attempt case management for the prevention of further suicide attempts in Japan, named ACTION-J, has established effective interventions for prevention of suicide reattempts. The ACTION-J assertive case management intervention programme was adopted by the Japanese Ministry of Health, Labour and Welfare in 2016, when medical fees were revised. This nationwide programme is provided to patients who attempt suicide and who are admitted to emergency departments in Japan.The aim of the present study is to examine the current implementation status of the ACTION-J programme. The present study also aims to clarify which patients' and hospitals' factors affect the implementation of the programme. METHODS AND ANALYSIS: This is a prospective, multicentre, patient registry cohort study. Participants will be suicide attempters admitted to the emergency departments of medical facilities with both psychiatry and emergency departments. The assertive case management programme will be delivered to participants by a case manager for up to 24 weeks, based on psychiatric diagnoses, social risks and patient needs. The core feature of the programme is to encourage patients to participate in psychiatric treatment.The primary outcome will be the proportion of patients still participating in the case management intervention at 24 weeks after registration. The secondary outcomes will include measures of the fidelity of the case management intervention. The fidelity will be evaluated using a fidelity assessment manual developed by the study group. ETHICS AND DISSEMINATION: This observational study has been approved by the ethics board of Sapporo Medical University. Enrolment began in October 2016 and will continue until December 2018. Dissemination plans include presentations at scientific conferences and scientific publications. TRIAL REGISTRATION: UMIN000024474.

Discrepancies between self- and observer-rated depression severities in patients with major depressive disorder associated with frequent emotion-oriented coping responses and hopelessness.

PURPOSE: The rating discrepancy for patients with major depressive disorder (MDD) is believed to be associated with hopelessness, risk of suicidal behavior, and personality characteristics, such as high neuroticism. However, it remains to be elucidated whether the discrepancy is also mediated by coping styles, which are conceptualized as personality characteristics. PATIENTS AND METHODS: We enrolled 154 participants and divided them into three groups: patients with MDD with a rating discrepancy (MDD-WD; n=46), patients with MDD without a rating discrepancy (MDD-WoD; n=50), and healthy controls (HCs; n=58). A rating discrepancy was defined as a high Beck Depression Inventory score and low Hamilton Depression Rating Scale score. Coping styles and hopelessness were compared among the groups. RESULTS: The MDD-WD group exhibited a higher level of hopelessness than those in the MDD-WoD and HC groups. They also demonstrated a significantly increased number of suicide attempts compared with the MDD-WoD group. Both the MDD-WD and MDD-WoD groups exhibited lesser task-oriented and greater emotion-oriented coping styles than those in the HC group, with the MDD-WD group demonstrating even greater emotion-oribented coping than that in the MDD-WoD group. Overall, high levels of hopelessness, a history of suicide attempts, and frequent use of emotion-oriented coping mechanisms were associated with rating discrepancy. CONCLUSION: Patients with MDD who showed rating discrepancy tended to use emotion-oriented coping. Planning for minimal use of emotion-oriented coping may be a psychotherapeutic intervention for such patients. Reduced emotion-oriented coping may also reduce the feeling of hopelessness and risk of developing suicidal behavior.

Delayed hemodynamic responses associated with a history of suicide attempts in bipolar disorder: a multichannel near-infrared spectroscopy study.

Bipolar disorder (BD) is associated with a high risk of suicide compared with other psychiatric disorders. Recent studies using near-infrared spectroscopy (NIRS) reported frontotemporal functional abnormalities in BD. However, it remains unclear whether NIRS signal changes are associated with vulnerability toward suicide in BD. We recruited 20 patients with depressed BD with a history of suicide attempts (suicide attempters; SAs) and 28 control patients with BD who did not have a history of suicide attempts (non-attempters; NAs). Regional hemodynamic responses during a verbal fluency task were monitored using NIRS. Compared with the NA group, the SA group exhibited significantly reduced activation during VFT in the bilateral precentral and superior temporal gyri and left supramarginal, inferior frontal, postcentral, and middle temporal gyri. Furthermore, compared with the NA group, the SA group exhibited delayed activation timing of the NIRS signal in the prefrontal region. In BD patients, current suicide risk was noted to be significantly and positively associated with delayed activation timing of the NIRS signal in the prefrontal region. The findings of this study suggest that the observed specific NIRS signal pattern in BD patients is associated with vulnerability toward suicide.