Analysis of the hikikomori phenomenon - an international infodemiology study of Twitter data in Portuguese.

BACKGROUND: Hikikomori refers to the extreme isolation of individuals in their own homes, lasting at least six months. In recent years social isolation has become an important clinical, social, and public health problem, with increased awareness of hikikomori around the globe. Portuguese is one of the six most spoken languages in the world, but no studies have analysed the content regarding this phenomenon expressed in Portuguese. OBJECTIVE: To explore the hikikomori phenomenon on Twitter in Portuguese, utilising a mixed-methods approach encompassing content analysis, emotional analysis, and correlation analysis. METHODS: A mixed methods analysis of all publicly available tweets in the Portuguese language using a specific keyword (hikikomori) between 1st January 2008 and 19th October 2022. The content analysis involved categorising tweets based on tone, content, and user types, while correlation analysis was used to investigate user engagement and geographical distribution. Statistical analysis and artificial intelligence were employed to classify and interpret the tweet data. RESULTS: Among the total of 13,915 tweets generated, in terms of tone 10,731 were classified as "negative", and 3184 as "positive". Regarding content, "curiosities" was the most posted, as well as the most retweeted and liked topic. Worldwide, most of the hikikomori related tweets in Portuguese were posted in Europe, while "individuals with hikikomori" were the users most active posting. Regarding emotion analysis, the majority of tweets were "neutral". CONCLUSIONS: These findings show the global prevalence of the discourse on hikikomori phenomenon among Portuguese speakers. It also indicates an increase in the number of tweets on this topic in certain continents over the years. These findings can contribute to developing specific interventions, support networks, and awareness-raising campaigns for affected individuals.

Using Nudges to Reduce Missed Appointments in Primary Care and Mental Health: a Pragmatic Trial.

BACKGROUND: Missed appointments ("no-shows") are a persistent and costly problem in healthcare. Appointment reminders are widely used but usually do not include messages specifically designed to nudge patients to attend appointments. OBJECTIVE: To determine the effect of incorporating nudges into appointment reminder letters on measures of appointment attendance. DESIGN: Cluster randomized controlled pragmatic trial. PATIENTS: There were 27,540 patients with 49,598 primary care appointments, and 9420 patients with 38,945 mental health appointments, between October 15, 2020, and October 14, 2021, at one VA medical center and its satellite clinics that were eligible for analysis. INTERVENTIONS: Primary care (n = 231) and mental health (n = 215) providers were randomized to one of five study arms (four nudge arms and usual care as a control) using equal allocation. The nudge arms included varying combinations of brief messages developed with veteran input and based on concepts in behavioral science, including social norms, specific behavioral instructions, and consequences of missing appointments. MAIN MEASURES: Primary and secondary outcomes were missed appointments and canceled appointments, respectively. STATISTICAL ANALYSIS: Results are based on logistic regression models adjusting for demographic and clinical characteristics, and clustering for clinics and patients. KEY RESULTS: Missed appointment rates in study arms ranged from 10.5 to 12.1% in primary care clinics and 18.0 to 21.9% in mental health clinics. There was no effect of nudges on missed appointment rate in primary care (OR = 1.14, 95%CI = 0.96-1.36, p = 0.15) or mental health (OR = 1.20, 95%CI = 0.90-1.60, p = 0.21) clinics, when comparing the nudge arms to the control arm. When comparing individual nudge arms, no differences in missed appointment rates nor cancellation rates were observed. CONCLUSIONS: Appointment reminder letters incorporating brief behavioral nudges were ineffective in improving appointment attendance in VA primary care or mental health clinics. More complex or intensive interventions may be necessary to significantly reduce missed appointments below their current rates. TRIAL NUMBER: ClinicalTrials.gov, Trial number NCT03850431.

Hikikomori: A perspective from bibliometric analysis.

AIMS: Hikikomori is a common phenomenon reported in Japan and many other countries. However, the broad trends of the research publications on hikikomori are unclear. Therefore, this study examined the patterns of research on hikikomori using bibliometric analysis. METHODS: Relevant publications were searched in Web of Science. Bibliometric analyses were performed with CiteSpace, R and VOSviewer. RESULTS: In total, 297 publications on hikikomori met the eligibility criteria. The International Journal of Social Psychiatry (IF = 10.461) published the most papers (K = 17, or 5.7%) on hikikomori. Takahiro A. Kato from Kyushu University (41; 13.8%; H-index = 18) was the most influential author, while Takahiro A. Kato (total link strength [TLS]: 235), Alan R. Teo (TLS: 157), and Masaru Tateno (TLS: 153) separately had the strongest research collaboration with other researchers. Of all countries that published on hikikomori, Japan had the highest number of publications (K = 91). The keywords "United States" and "psychiatric diagnosis" received the most attention between 2013 and 2015, whereas "health" and "autism spectrum disorder" received the most attention in 2021 and 2022. CONCLUSIONS: Peer-reviewed research publications on hikikomori are growing rapidly and the research trends in this field are also changing.

Patient Sense of Belonging in the Veterans Health Administration: A Qualitative Study of Appointment Attendance and Patient Engagement.

BACKGROUND: Health care systems have increasingly focused on patient engagement in efforts to improve patient-centered care. Appointment attendance is an integral component of patient engagement, and missed appointments are an ongoing problem for health care systems. Virtually no studies have examined how the sense of belonging is related to patient engagement within a health care system. OBJECTIVE: To examine patient experiences in the Veterans Health Administration (VA) with outpatient appointment attendance to identify factors that affect sense of belonging and patient engagement. RESEARCH DESIGN AND PARTICIPANTS: This study draws from qualitative data collected as part of a study to reduce missed appointments through use of enhanced appointment reminder letters. We conducted semistructured interviews with 27 VA patients with primary care or mental health clinic visits, using deductive and inductive analysis to develop themes. More than half of the participants were Vietnam veterans, 24 were over 40 years old, 21 were White, and 18 were men. RESULTS: We identified 3 factors that influence sense of belonging within the VA: (1) feelings of camaraderie and commitment toward other veterans were relevant to patient experience in the VA; (2) interactions with all staff influenced the engagement a patient felt with a particular clinic, care team, and the VA; (3) personalized communication and messaging could humanize the VA and demonstrate its interest in engaging with veterans. Lastly, we found (4) sense of belonging appeared to promote appointment attendance and patient engagement. CONCLUSIONS: There are multiple opportunities to strengthen patients' sense of belonging within the health care system that serves them. For veterans, strategies that build their sense of belonging may be a novel approach to increase appointment attendance and patient engagement in their health care.

Examining Tweet Content and Engagement of Users With Tweets About Hikikomori in Japanese: Mixed Methods Study of Social Withdrawal.

BACKGROUND: Hikikomori is a form of severe social withdrawal that is particularly prevalent in Japan. Social media posts offer insight into public perceptions of mental health conditions and may also inform strategies to identify, engage, and support hard-to-reach patient populations such as individuals affected by hikikomori. OBJECTIVE: In this study, we seek to identify the types of content on Twitter related to hikikomori in the Japanese language and to assess Twitter users' engagement with that content. METHODS: We conducted a mixed methods analysis of a random sample of 4940 Japanese tweets from February to August 2018 using a hashtag (#hikikomori). Qualitative content analysis included examination of the text of each tweet, development of a codebook, and categorization of tweets into relevant codes. For quantitative analysis (n=4859 tweets), we used bivariate and multivariate logistic regression models, adjusted for multiple comparisons, and estimated the predicted probabilities of tweets receiving engagement (likes or retweets). RESULTS: Our content analysis identified 9 codes relevant to tweets about hikikomori: personal anecdotes, social support, marketing, advice, stigma, educational opportunities, refuge (ibasho), employment opportunities, and medicine and science. Tweets about personal anecdotes were the most common (present in 2747/4859, 56.53% of the tweets), followed by social support (902/4859, 18.56%) and marketing (624/4859, 12.84%). In the adjusted models, tweets coded as stigma had a lower predicted probability of likes (-33 percentage points, 95% CI -42 to -23 percentage points; P<.001) and retweets (-11 percentage points, 95% CI -18 to -4 percentage points; P<.001), personal anecdotes had a lower predicted probability of retweets (-8 percentage points, 95% CI -14 to -3 percentage points; P=.002), marketing had a lower predicted probability of likes (-13 percentage points, 95% CI -21 to -6 percentage points; P<.001), and social support had a higher predicted probability of retweets (+15 percentage points, 95% CI 6-24 percentage points; P=.001), compared with all tweets without each of these codes. CONCLUSIONS: Japanese tweets about hikikomori reflect a unique array of topics, many of which have not been identified in prior research and vary in their likelihood of receiving engagement. Tweets often contain personal stories of hikikomori, suggesting the potential to identify individuals with hikikomori through Twitter.

Enhancing Usability of Appointment Reminders: Qualitative Interviews of Patients Receiving Care in the Veterans Health Administration.

BACKGROUND: No-shows are a persistent and costly problem in all healthcare systems. Because forgetting is a common cause of no-shows, appointment reminders are widely used. However, qualitative research examining appointment reminders and how to improve them is lacking. OBJECTIVE: To understand how patients experience appointment reminders as part of intervention development for a pragmatic trial of enhanced appointment reminders. DESIGN: Qualitative content analysis PARTICIPANTS: Twenty-seven patients at a single Department of Veterans Affairs hospital and its satellite clinics APPROACH: We conducted five waves of interviews using rapid qualitative analysis, in each wave continuing to ask veterans about their experience of reminders. We double-coded all interviews, used deductive and inductive content analysis to identify themes, and selected quotations that exemplified three themes (limitations, strategies, recommendations). KEY RESULTS: Interviews showed four limitations on the usability of current appointment reminders which may contribute to no-shows: (1) excessive information within reminders; (2) frustrating telephone systems when calling in response to an appointment reminder; (3) missing or cryptic information about clinic logistics; and (4) reminder fatigue. Patients who were successful at keeping appointments often used specific strategies to optimize the usability of reminders, including (1) using a calendar; (2) heightening visibility; (3) piggybacking; and (4) combining strategies. Our recommendations to enhance reminders are as follows: (1) mix up their content and format; (2) keep them short and simple; (3) add a personal touch; (4) include specifics on clinic location and contact information; (5) time reminders based on the mode of delivery; and (6) hand over control of reminders to patients. CONCLUSIONS: Appointment reminders are vital to prevent no-shows, but their usability is not optimized for patients. There is potential for healthcare systems to modify several aspects of the content, timing, and delivery of appointment reminders to be more effective and patient-centered.

The Importance of "Being There": a Qualitative Study of What Veterans with Depression Want in Social Support.

BACKGROUND: Social connectedness exerts strong influences on health, including major depression and suicide. A major component of social connectedness is having individual relationships with close supports, romantic partners, and other trusted members of one's social network. OBJECTIVE: The objective of this study was to understand how individuals' relationships with close supports might be leveraged to improve outcomes for primary care patients with depression and at risk for suicide. DESIGN: In this qualitative study, we used a semi-structured interview guide to probe patient experiences, views, and preferences related to social support. PARTICIPANTS: We conducted interviews with 30 primary care patients at a Veterans Health Administration (VA) medical center who had symptoms of major depression and a close support. APPROACH: Thematic analysis of qualitative interview data examined close supports' impact on patients. We iteratively developed a codebook, used output from codes to sort data into themes, and selected quotations that exemplified themes for inclusion in this manuscript. KEY RESULTS: "Being there" as an important quality of close supports emerged as a key concept. "Being there" was defined in three ways: physical proximity, frequent or responsive contact, or perceived availability. Close supports who were effective at "being there" possessed skills in intuitively sensing the patient's emotional state and communicating indirectly about depression. Three major barriers to involving close supports in depression care were concerns of overburdening the close support, a perception that awareness of the patient's depression would make the close support unnecessarily worried, and a desire and preference among patients to handle depression on their own. CONCLUSIONS: "Being there" represents a novel, patient-generated way to conceptualize and talk about social support. Suicide prevention initiatives such as population-level communication campaigns might be improved by incorporating language used by patients and addressing attitudinal barriers to allowing help and involvement of close supports.

Social connectedness, depression symptoms, and health service utilization: a longitudinal study of Veterans Health Administration patients.

PURPOSE: Our study explored whether aspects of veterans' social connectedness (social support, interpersonal conflict, loneliness, social norms, number of confidants) are associated with change in their depression symptoms and health services utilization over 1 year. METHODS: We conducted a prospective, longitudinal study of 262 military veterans who obtained primary care and other services at a Veterans Health Administration (VHA) facility and screened positive for depression. Participants completed surveys at baseline and 12-month follow-up. We measured social connectedness variables using the NIH Toolbox Adult Social Relationship Scales. We used the Patient Health Questionnaire to assess depression symptoms and suicidal ideation and administrative medical record data for health services utilization. We calculated change scores to model outcomes over time using multivariable regressions. RESULTS: We found that higher levels of baseline loneliness were associated with decreased depression severity over 1 year (B = - 1.55, 95% CI [- 2.53, - .56], p < .01). We found a similar association for suicidal ideation. In contrast, higher baseline number of confidants was associated with increased depression (B = .55, 95% CI [.18, .92], p < .01). Higher levels of emotional support were associated with decreased mental health visits (B = - 3.88, 95% CI [- 6.80, - .96], p < .01). No significant associations were found between social connectedness variables and primary care visits. CONCLUSIONS: Emotional support may play an important role in reducing mental health treatment utilization among VHA-using veterans. Additional investigation as to how and why loneliness and number of confidants might be paradoxically associated with depression symptoms remains necessary.

Responses to Concerning Posts on Social Media and Their Implications for Suicide Prevention Training for Military Veterans: Qualitative Study.

BACKGROUND: A "concerning post" is a display of a user's emotional crisis on a social media platform. A better understanding of concerning posts is relevant to suicide prevention, but little is known about social media users' attitudes and responses to concerning posts. Military veterans in the United States are disproportionately affected by suicide, often use social media, and may have exposure to individuals with elevated suicide risk via concerning posts. OBJECTIVE: The objective of the study was (1) to obtain insight into whether and how US military veterans respond to members of their social network on social media (ie, "friends") who are experiencing substantial emotional distress, and (2) to identify potential interventions that could assist in users' response to concerning posts. METHODS: We recruited veterans through Facebook and conducted semistructured interviews with 30 participants between June and December 2017. We used a summary template for rapid analysis of each interview, followed by double-coding using a codebook based on topic domains from the interview guide. Members of the research team met regularly to discuss emerging patterns in the data, generate themes, and select representative quotes for inclusion in the manuscript. RESULTS: Veterans were reluctant to disclose emotional and health issues on Facebook, but they were open to reaching out to others' concerning posts. There was a complex calculus underlying whether and how veterans responded to a concerning post, which involved considering (1) physical proximity to the person posting, (2) relationship closeness, (3) existing responses to the post, and (4) ability to maintain contact with the person. Veterans desired additional training, backed by community-based veteran organizations, in how to respond to concerning posts from peers. CONCLUSIONS: There is a need to incorporate features that will help veterans effectively respond to concerning posts from peers into suicide prevention training and to expand access for veterans to such training.

Using Skype to Beat the Blues: Longitudinal Data from a National Representative Sample.

OBJECTIVES: This study aimed to determine whether use of certain types of online communication technology is associated with subsequent depressive symptoms. DESIGN: Nationally representative, population-based prospective cohort. SETTING: Data were obtained from the 2012 and 2014 waves of the Health and Retirement Study (HRS). PARTICIPANTS: 1,424 community-residing older adults (mean age, 64.8) in the United States. MEASUREMENTS: We examined associations between use of four communication technologies (email, social networks, video chat, and instant messaging) in 2012 and depressive symptoms (eight-item Center for Epidemiologic Studies Depression scale) at two-year follow-up. RESULTS: 564 participants (39.6%) did not use any communication technologies, 314 (22.1%) used email only, and 255 (17.9%) used video chat (e.g., Skype). Compared to non-users (13.1%, 95% CI: 9.5-16.7%) or those who used only email (14.3%, 95% CI: 10.1-18.5%), users of video chat had approximately half the probability of depressive symptoms (6.9%, 95% CI: 3.5-10.3%, Wald Chi2 test, Chi2(1)=13.82, p < 0.001; 7.6%, 95% CI: 3.6-11.6, Wald Chi2 test, Chi2(1)=13.56, p < 0.001). Use of email, social media, and instant messaging were not associated with a lower risk of depression. CONCLUSIONS: Older adults who use video chat such as Skype, but not other common communication technologies, have a lower risk of developing depression.

Using Facebook for Qualitative Research: A Brief Primer.

As Facebook continues to grow its number of active users, the potential to harness data generated by Facebook users also grows. As much of Facebook users' activity consists of creating (and commenting on) written posts, the potential use of text data for research is enormous. However, conducting a content analysis of text from Facebook users requires adaptation of research methods used for more traditional sources of qualitative data. Furthermore, best practice guidelines to assist researchers interested in conducting qualitative studies using data derived from Facebook are lacking. The purpose of this primer was to identify opportunities, as well as potential pitfalls, of conducting qualitative research with Facebook users and their activity on Facebook and provide potential options to address each of these issues. We begin with an overview of information obtained from a literature review of 23 studies published between 2011 and 2018 and our own research experience to summarize current approaches to conducting qualitative health research using data obtained from Facebook users. We then identify potential strategies to address limitations related to current approaches and propose 5 key considerations for the collection, organization, and analysis of text data from Facebook. Finally, we consider ethical issues around the use and protection of Facebook data obtained from research participants. In this primer, we have identified several key considerations that should aid health researchers in the planning and execution of qualitative studies involving content analysis of text data from Facebook users.

Hikikomori : Multidimensional understanding, assessment, and future international perspectives.

Hikikomori, a severe form of social withdrawal, has long been observed in Japan mainly among youth and adolescents since around the 1970s, and has been especially highlighted since the late 1990s. Moreover, hikikomori-like cases have recently been reported in many other countries. Hikikomori negatively influences not only the individual's mental health and social participation, but also wider education and workforce stability, and as such is a novel urgent global issue. In this review, we introduce the history, definition, diagnostic evaluation, and interventions for hikikomori and also the international prevalence of hikikomori outside Japan. We propose a hypothesis regarding the globalization of hikikomori based on domestic and international perspectives. In addition, we introduce our latest assessment system for hikikomori (including the latest version of the 'proposed diagnostic criteria of hikikomori for the future DSM/ICD diagnostic systems') and propose therapeutic strategies, including family approaches and individualized therapies. Finally, we present future challenges that may lead to solutions for an internationalized hikikomori.

Development and validation of the 22-item Tarumi's Modern-Type Depression Trait Scale: Avoidance of Social Roles, Complaint, and Low Self-Esteem (TACS-22).

AIM: Understanding premorbid personality is important, especially when considering treatment selection. Historically, the premorbid personality of patients with major depression in Japan was described as Shuchaku-kishitsu [similar to Typus melancholicus], as proposed by Shimoda in the 1930s. Since around 2000, there have been increased reports in Japan of young adults with depression who have had premorbid personality differing from the traditional type. In 2005, Tarumi termed this novel condition 'dysthymic-type depression,' and more recently the condition has been called Shin-gata/Gendai-gata Utsu-byo [modern-type depression (MTD)]. We recently developed a semi-structured diagnostic interview to evaluate MTD. Development of a tool that enables understanding of premorbid personality in a short time, especially at the early stage of treatment, is desirable. The object of this study was to develop a self-report scale to evaluate the traits of MTD, and to assess the scale's psychometric properties, diagnostic accuracy, and biological validity. METHODS: A sample of 340 participants from clinical and community settings completed measures. Psychometric properties were assessed with factor analysis. Diagnostic accuracy of the MTD traits was compared against a semi-structured interview. RESULTS: The questionnaire contained 22 items across three subscales, thus we termed it the 22-item Tarumi's Modern-Type Depression Trait Scale: Avoidance of Social Roles, Complaint, and Low Self-Esteem (TACS-22). Internal consistency, test-retest reliability, and convergent validity were all satisfactory. Among patients with major depression, the area under the curve was 0.757 (sensitivity of 63.1% and specificity of 82.9%) and the score was positively correlated with plasma tryptophan. CONCLUSION: The TACS-22 possessed adequate psychometric properties and diagnostic accuracy in an initial sample of Japanese adults. Additional research on its ability to support clinical assessment of MTD is warranted.

Help-Seeking on Facebook Versus More Traditional Sources of Help: Cross-Sectional Survey of Military Veterans.

BACKGROUND: The media has devoted significant attention to anecdotes of individuals who post messages on Facebook prior to suicide. However, it is unclear to what extent social media is perceived as a source of help or how it compares to other sources of potential support for mental health problems. OBJECTIVE: This study aimed to evaluate the degree to which military veterans with depression use social media for help-seeking in comparison to other more traditional sources of help. METHODS: Cross-sectional self-report survey of 270 adult military veterans with probable major depression. Help-seeking intentions were measured with a modified General Help-Seeking Questionnaire. Facebook users and nonusers were compared via t tests, Chi-square, and mixed effects regression models. Associations between types of help-seeking were examined using mixed effects models. RESULTS: The majority of participants were users of social media, primarily Facebook (n=162). Mean overall help-seeking intentions were similar between Facebook users and nonusers, even after adjustment for potential confounders. Facebook users were very unlikely to turn to Facebook as a venue for support when experiencing either emotional problems or suicidal thoughts. Compared to help-seeking intentions for Facebook, help-seeking intentions for formal (eg, psychologists), informal (eg, friends), or phone helpline sources of support were significantly higher. Results did not substantially change when examining users of other social media, women, or younger adults. CONCLUSIONS: In its current form, the social media platform Facebook is not seen as a venue to seek help for emotional problems or suicidality among veterans with major depression in the United States.

Prevalence rate of Internet addiction among Japanese college students: Two cross-sectional studies and reconsideration of cut-off points of Young's Internet Addiction Test in Japan.

AIM: Due to variation in estimates of the prevalence of Internet addiction (IA) in prior research, we conducted two cross-sectional studies over 2 years investigating the prevalence rate of IA in college students in Japan and reconsidered appropriate cut-off points of a self-rating scale to screen possible IA. METHODS: This study was composed of two parts: survey I in 2014 and survey II in 2016, which were conducted in the same schools with an interval of 2 years. The study questionnaire included questions about demographics and Internet use, and Young's Internet Addiction Test (IAT). Additionally, the subjects in survey II were asked about self-reported IA. RESULTS: There were 1005 respondents in total with a mean age (± SD) of 18.9 ± 1.3 years. The mean IAT scores remained stable between 2014 and 2016: 45.2 ± 12.6 in survey I and 45.5 ± 13.1 in survey II (overall mean IAT score of 45.4 ± 13.0). With respect to self-reported IA in survey II, a total of 21.6% admitted to having IA (score of 5 or 6 on a 6-point Likert scale). We categorized these subjects as IA, and the remainder as non-IA. The mean IAT score showed a significant difference between these two groups (57.8 ± 14.3 vs 42.1 ± 10.7, P < 0.001). CONCLUSION: The severity of IA symptoms among Japanese college students has appeared stable in recent years, with mean IAT scores of over 40. Our results suggest that a screening score cut-off of 40 on the IAT could be reconsidered and that 50 might be proposed for the cut-off.

Development and validation of the 25-item Hikikomori Questionnaire (HQ-25).

AIM: Hikikomori, a form of severe social withdrawal, is an emerging issue in mental health, for which validated measurement tools are lacking. The object was to develop a self-report scale of hikikomori, and assess its psychometric properties and diagnostic accuracy. METHODS: A sample of 399 participants from clinical and community settings completed measures. Psychometric properties were assessed with factor analysis; diagnostic accuracy was compared against a semi-structured diagnostic interview. RESULTS: The Hikikomori Questionnaire contained 25 items across three subscales representing socialization, isolation, and emotional support. Internal consistency, test-retest reliability, and convergent validity were all satisfactory. The area under the curve was 0.86 (95% confidence interval, 0.80-0.92). A cut-off score of 42 (out of 100) was associated with a sensitivity of 94%, specificity of 61%, and positive predictive value of 17%. CONCLUSION: The 25-item Hikikomori Questionnaire (HQ-25) possesses robust psychometric properties and diagnostic accuracy in an initial sample of Japanese adults. Additional research on its psychometric properties and ability to support clinical assessment of hikikomori is warranted.

Brief gatekeeper training for suicide prevention in an ethnic minority population: a controlled intervention.

BACKGROUND: Suicide is a critical public health problem around the globe. Asian populations are characterized by elevated suicide rates and a tendency to seek social support from family and friends over mental health professionals. Gatekeeper training programs have been developed to train frontline individuals in behaviors that assist at-risk individuals in obtaining mental health treatment. The purpose of this study is to assess the efficacy of a brief, multi-component gatekeeper intervention in promoting suicide prevention in a high-risk Asian community in the United States. METHODS: We adapted an evidence-based gatekeeper training into a two-hour, multi-modal and interactive event for Japanese-Americans and related stakeholders. Then we evaluated the intervention compared to an attention control using mixed methods. RESULTS: A sample of 106 community members participated in the study. Intervention participants (n = 85) showed significant increases in all three types of intended gatekeeper behavior, all four measures of self-efficacy, and both measures of social norms relevant to suicide prevention, while the control group (n = 48) showed no significant improvements. Additional results showed significantly higher satisfaction and no adverse experiences associated with the gatekeeper training. The separate collection of qualitative data, and integration with the quantitative survey constructs confirmed and expanded understanding about the benefits of the intervention. CONCLUSIONS: A brief, multi-modal gatekeeper training is efficacious in promoting positive gatekeeper behaviors and self-efficacy for suicide prevention in an at-risk ethnic minority population of Japanese Americans.

Multidimensional anatomy of 'modern type depression' in Japan: A proposal for a different diagnostic approach to depression beyond the DSM-5.

Japan's prototype of depression was traditionally a melancholic depression based on the premorbid personality known as shuchaku-kishitsu proposed by Mitsuzo Shimoda in the 1930s. However, since around 2000, a novel form of depression has emerged among Japanese youth. Called 'modern type depression (MTD)' by the mass media, the term has quickly gained popularity among the general public, though it has not been regarded as an official medical term. Likewise, lack of consensus guidelines for its diagnosis and treatment, and a dearth of scientific literature on MTD has led to confusion when dealing with it in clinical practice in Japan. In this review article, we summarize and discuss the present situation and issues regarding MTD by focusing on historical, diagnostic, psychosocial, and cultural perspectives. We also draw on international perspectives that begin to suggest that MTD is a phenomenon that may exist not only in Japan but also in many other countries with different sociocultural and historical backgrounds. It is therefore of interest to establish whether MTD is a culture-specific phenomenon in Japan or a syndrome that can be classified using international diagnostic criteria as contained in the ICD or the DSM. We propose a novel diagnostic approach for depression that addresses MTD in order to combat the current confusion about depression under the present diagnostic systems.

Internet addiction and self-evaluated attention-deficit hyperactivity disorder traits among Japanese college students.

AIM: Internet addiction (IA), also referred to as Internet use disorder, is a serious problem all over the world, especially in Asian countries. Severe IA in students may be linked to academic failure, attention-deficit hyperactivity disorder (ADHD), and forms of social withdrawal, such as hikikomori. In this study, we performed a survey to investigate the relation between IA and ADHD symptoms among college students. METHODS: Severity of IA and ADHD traits was assessed by self-report scales. Subjects were 403 college students (response rate 78%) who completed a questionnaire including Young's Internet Addiction Test (IAT) and the Adult ADHD Self-Report Scale-V1.1. RESULTS: Out of 403 subjects, 165 were male. The mean age was 18.4 ± 1.2 years, and mean total IAT score was 45.2 ± 12.6. One hundred forty-eight respondents (36.7%) were average Internet users (IAT < 40), 240 (59.6%) had possible addiction (IAT 40-69), and 15 (3.7%) had severe addiction (IAT ≥ 70). Mean length of Internet use was 4.1 ± 2.8 h/day on weekdays and 5.9 ± 3.7 h/day on the weekend. Females used the Internet mainly for social networking services while males preferred online games. Students with a positive ADHD screen scored significantly higher on the IAT than those negative for ADHD screen (50.2 ± 12.9 vs 43.3 ± 12.0). CONCLUSION: Our results suggest that Internet misuse may be related to ADHD traits among Japanese youth. Further investigation of the links between IA and ADHD is warranted.