The effect of education regarding treatment guidelines for schizophrenia and major depressive disorders on psychiatrists' hypnotic medication prescribing behavior: a multicenter study.

BACKGROUND: To examine whether the "Effectiveness of Guideline for Dissemination and Education in psychiatric treatment (EGIUDE)" project affects the rate of prescriptions of hypnotic medication and the type of hypnotic medications prescribed among psychiatrists, for schizophrenia and major depressive disorder in Japan. METHODS: The EGUIDE project is a nationwide prospective study of evidence-based clinical guidelines for schizophrenia and major depressive disorder in Japan. From 2016 to 2021, clinical and prescribing data from patients discharged from hospitals participating in the EGUIDE project were used to examine hypnotic medication prescriptions The prescribing rate of hypnotics and the prescribing rate of each type of hypnotic (benzodiazepine receptor agonist, nonbenzodiazepine receptor agonist, melatonin receptor agonist, and orexin receptor antagonist) were compared among patients who had been prescribed medication by psychiatrists participating in the EGUIDE project and patients who had been prescribed medication by nonparticipating psychiatrists. Multivariate logistic regression analysis was performed to examine the effect of the EGUIDE project on the prescription of hypnotic medications. RESULTS: A total of 12,161 patients with schizophrenia and 6,167 patients with major depressive disorder were included. Psychiatrists participating in the EGUIDE project significantly reduced the rate of prescribing hypnotic medication and benzodiazepine receptor agonists for both schizophrenia (P < 0.001) and major depressive disorder (P < 0.001) patients. CONCLUSION: This is the first study to investigate the educational effects of guidelines for the treatment of psychiatric disorders on psychiatrists in terms of prescribing hypnotic medications to patients. The EGUIDE project may play an important role in reducing hypnotic medication prescription rates, particularly with respect to benzodiazepine receptor agonists. The results suggest that the EGUIDE project may result in improved therapeutic behavior.

Intracranial aneurysm as a possible complication of osteogenesis imperfecta: a case series and literature review.

Osteogenesis imperfecta (OI) is an inherited disease characterized by bone fragility due to impaired type I collagen. Although orthopedic management is improving, other complications are poorly understood. We describe three patients with OI with unruptured intracranial aneurysm (IA) detected by magnetic resonance angiography (MRA) screening of 14 patients. Case 1 was a 73-year-old woman with type 1 OI with blue sclera, vertebral compression fractures, and impaired hearing. Lumbar spine bone mineral density (BMD) was preserved (young adult mean (YAM): 86%). MRA revealed an IA in the right internal carotid artery. Case 2 was a 43-year-old man with type 4 OI and leg-length discrepancy due to left femoral neck fracture. Lumbar spine BMD was decreased (YAM: 61%). MRA showed an IA in the left anterior cerebral artery. Case 3 was a 35-year-old woman with type 3 OI with blue sclera, dentinogenesis imperfecta, deformity of the long bones, and severe scoliosis. She had undergone spine surgery and needed wheelchair assistance. The YAM of the femoral neck BMD was 71%. MRA indicated an IA in the right posterior communicating artery. The prevalence of IA in our series of patients with OI was 21%, which is higher than the reported prevalence of unruptured IA in the Japanese general population (2.2%), suggesting that IA may be a complication of OI. Our literature review revealed no cases of OI with unruptured IA, but 11 cases of OI with subarachnoid hemorrhage. IA seems unrelated to OI type, sex, or age. We recommend MRA of adults with OI.

Effects of electroconvulsive therapy on the use of anxiolytics and sleep medications: a propensity score-matched analysis.

AIM: We investigated the association of electroconvulsive therapy (ECT) with anxiolytic and sleep medication use in patients with major depressive disorder (MDD) and schizophrenia (SZ). METHODS: This nationwide observational study analyzed data from 3483 MDD inpatients and 6663 SZ inpatients. Patients with MDD and SZ were classified into those who underwent ECT during hospitalization and those who did not. A propensity score-matching method was performed to adjust for preadmission characteristics and clinical information, which were expected bias between the two groups. Rates of anxiolytic and sleep medication use at discharge were compared in the matched sample. RESULTS: 500 MDD patients were assigned to both groups. In the matched MDD sample, the rate of anxiolytic and sleep medication use at discharge was significantly lower in the ECT group than in the non-ECT group (64.9% vs. 75.8%, P = 1.7 × 10-4 ). In the ECT group, the rate of anxiolytic and sleep medication use at discharge was significantly lower than that prior to admission (64.9% vs. 73.2%, P = 1.2 × 10-14 ). 390 SZ patients were allocated. In the matched SZ sample, the ECT group was not significantly different from the non-ECT group in the rate of anxiolytics and sleep medications use at discharge (61.3% vs. 68.2%, P = 4.3 × 10-2 ). In the ECT group, the rate of anxiolytics and sleep medications use at discharge was significantly lower than that before admission (61.3% vs. 70.5%, P = 4.4 × 10-4 ), although this was not the primary outcome. CONCLUSION: Reduction of anxiolytic and sleep medication use may be considered positively when ECT is indicated for treatment of MDD.

Evaluating the safety and efficiency of robotic dispensing systems.

BACKGROUND: Although automated dispensing robots have been implemented for medication dispensing in Japan, their effect is yet to be fully investigated. In this study, we evaluated the effect of automated dispensing robots and collaborative work with pharmacy support staff on medication dispensing. METHODS: A robotic dispensing system integrating the following three components was established: (1) automated dispensing robot (Drug Station®), which is operated by pharmacy support staff, (2) automated dispensing robot for powdered medicine (Mini DimeRo®), and (3) bar-coded medication dispensing support system with personal digital assistance (Hp-PORIMS®). Subsequently, we evaluated the incidences of dispensing errors and dispensing times before and after introducing the robotic dispensing system. Dispensing errors were classified into two categories, namely prevented dispensing errors and unprevented dispensing errors. The incidence of dispensing errors was calculated as follows: incidence of dispensing errors = total number of dispensing errors/total number of medication orders in each prescription. RESULTS: After introducing the robotic dispensing system, the total incidence of prevented dispensing errors was significantly reduced (0.204% [324/158,548] to 0.044% [50/114,111], p < 0.001). The total incidence of unprevented dispensing errors was significantly reduced (0.015% [24/158,548] to 0.002% [2/114,111], p < 0.001). The number of cases of wrong strength and wrong drug, which can seriously impact a patient's health, reduced to almost zero. The median dispensing time of pharmacists per prescription was significantly reduced (from 60 to 23 s, p < 0.001). CONCLUSIONS: The robotic dispensing system enabled the process of medication dispensing by pharmacist to be partially and safely shared with automated dispensing robots and pharmacy support staff. Therefore, clinical care for patients by pharmacists could be enhanced by ensuring quality and safety of medication.

Responding to the COVID-19 outbreak as a therapeutic community in a forensic psychiatric ward in Japan-A reconsideration of the role of therapeutic community in disasters.

The global impact of COVID-19 outbreak on psychiatric hospitals and prisons is unfathomable and unprecedented, and information is needed on how best to mitigate widespread infection whilst safeguarding the community's well-being. This study reports on how the staff and patients in a forensic psychiatric ward in Japan worked together during the COVID-19 outbreak as a "therapeutic community." The "Non-Three Cs" Karaoke Project, with infection prevention guidelines designed by inpatients, was safely conducted and its humor released the staff and patients' anxiety and tension. Through these discussions, the patients and staff gained a better understanding of viruses, transmission routes, countermeasures, and coping with stress. The study highlights the importance of disclosing information to inpatients, conducting open discussions, and involving patients in the prevention and management of infectious diseases. This report is the world's first report showing a concrete example of the therapeutic community's significance during the COVID-19 outbreak. It is an experience that offers an opportunity to reconsider the significance of the therapeutic community, in which patients are seen as a presence that brings change, strength, growth, and creativity into the therapeutic setting. We believe that such an approach in a future disaster would lead to an increase in the patients' problem-solving ability, and recovery and autonomy after discharge could be promoted. A shared difficult situation can be an opportunity to build a therapeutic alliance and make a difference.

Prescription of Anticholinergic Drugs in Patients With Schizophrenia: Analysis of Antipsychotic Prescription Patterns and Hospital Characteristics.

In several clinical guidelines for schizophrenia, long-term use of anticholinergic drugs is not recommended. We investigated the characteristics of the use of anticholinergics in patients with schizophrenia by considering psychotropic prescription patterns and differences among hospitals. A cross-sectional, retrospective prescription survey at the time of discharge was conducted on 2027 patients with schizophrenia from 69 Japanese hospitals. We examined the relations among psychotropic drug prescriptions regarding anticholinergic prescription. We divided the hospitals into three groups-low rate group (LG), medium rate group (MG), and high rate group (HG)-according to their anticholinergic prescription rates, and analyzed the relationship between anticholinergic prescription rates and antipsychotic prescription. Anticholinergic drugs were prescribed to 618 patients (30.5%), and the prescription rates were significantly higher for high antipsychotic doses, antipsychotic polypharmacy, and first-generation antipsychotics (FGAs) use. The anticholinergic prescription rate varied considerably among hospitals, ranging from 0 to 66.7%, and it was significantly higher in patients with antipsychotic monotherapy, antipsychotic polypharmacy, and normal and high doses of antipsychotics in HG than in those LG and MG. The anticholinergics prescription rate in patients with second-generation antipsychotic monotherapy in HG was also significantly higher than in those LG and MG; however, the difference was no longer significant in patients with FGA monotherapy. Conclusively, in addition to high antipsychotic doses, antipsychotic polypharmacy, and FGA use, hospital characteristics influence the prescribing of anticholinergic drugs.

Characteristics of the treatments for each severity of major depressive disorder: A real-world multi-site study.

PURPOSE: In the treatment guidelines for major depressive disorder (MDD), the recommended treatment differs based on the severity. However, the type of treatment provided based on the severity of MDD in real-world clinical practice has not been investigated. In this study, we clarified the actual situation of MDD treatment in clinical practice and compared the treatment based on the severity of MDD. METHODS: We used data from 1484 patients with MDD at discharge from October 2016 to March 2020. RESULTS: The number of psychotropic prescriptions tended to be lower in those diagnosed with MDD in the severe group compared to in the non-severe group. There were significant differences among the three groups (mild, moderate/severe, and psychotic) in the percentage of patients who were not prescribed antipsychotics (p = 1.9 ×10-6), a combination of antipsychotics and antidepressants (p = 5.0 ×10-4), and the implementation rate of modified electroconvulsive therapy (m-ECT) (p = 3.4 ×10-9). The percentage of patients with a severe diagnosis who underwent m-ECT was higher, which corresponded to the severity. CONCLUSION: Our findings showed that the use of psychotropics decreased when the severity of MDD was diagnosed, and the rate of a combination of antipsychotics and antidepressants and the implementation rate of m-ECT increased with the severity. However, this study suggests that there is still an evidence-practice gap in the treatment of MDD in Japan, and guidelines are only partially adhered to in the treatment of depression.

Clozapine Treatment Is Associated With Higher Prescription Rate of Antipsychotic Monotherapy and Lower Prescription Rate of Other Concomitant Psychotropics: A Real-World Nationwide Study.

BACKGROUND: Although clozapine is effective for treatment-resistant schizophrenia (TRS), the rate of clozapine prescription is still low. Whereas antipsychotic monotherapy is recommended in clinical practice guidelines, the rate of antipsychotic polypharmacy is still high. There is little evidence on whether a clozapine prescription influences changes in the rate of monotherapy and polypharmacy, including antipsychotics and other psychotropics. We therefore hypothesized that the rate of antipsychotic monotherapy in patients with TRS who were prescribed clozapine would be higher than that in patients with schizophrenia who were not prescribed clozapine. METHODS: We assessed 8306 patients with schizophrenia nationwide from 178 institutions in Japan from 2016 to 2019. We analyzed the psychotropic prescription data at discharge in patients diagnosed with TRS and with no description of TRS (ND-TRS) based on the diagnosis listed in the discharge summary. RESULTS: The rate of antipsychotic monotherapy in the TRS with clozapine group (91.3%) was significantly higher than that in the TRS without clozapine group (45.9%; P < 2.0 × 10-16) and the ND-TRS without clozapine group (54.7%; P < 2.0 × 10-16). The rate of antipsychotic monotherapy without any other concomitant psychotropics in the TRS with clozapine group (26.5%) was significantly higher than that in the TRS without clozapine group (12.6%; P = 1.1 × 10-6) and the ND-TRS without clozapine group (17.0%; P = 5.9 × 10-6). CONCLUSIONS: Clozapine prescription could be associated with a high rate of antipsychotic monotherapy. Patients will benefit from the correct diagnosis of TRS and thus from proper clozapine prescription.

Neurocognitive features, personality traits, and social function in patients with schizophrenia with a history of violence.

Recent literature examining associations between cognitive function, clinical features, and violence in patients with schizophrenia has been growing; however, the results are inconsistent. Reports on social function and personality are limited. These studies are yet to be reflected in risk assessment tools and management plans. The aim of this study is to provide a resource for risk assessment and intervention studies by conducting multifaceted well-established assessments in a large population. Data from 355 patients with schizophrenia (112 patients with a history of violence; 243 patients without a history of violence) and 1265 healthy subjects were extracted from a large database of individuals with mental disorders in a general psychiatric population in Japan. The associations between violence in patients with schizophrenia and intellectual function, cognitive function (memory function, executive function, attentional function, verbal learning, processing speed, social cognition), clinical variables, personality traits, social function, and quality of life (QOL) were analyzed. Compared with healthy subjects, the schizophrenia group had broadly impaired cognitive function and social cognition, and their personality traits showed similar differences as those reported previously. Patients with schizophrenia with a history of violence showed significantly more impaired visual memory function (P = 1.9 × 10-5, Cohen's d = 0.34), longer hospitalization (P = 5.9 × 10-4, Cohen's d = 0.38), more severe excited factor on Positive and Negative Syndrome Scale (P = 1.6 × 10-4, Cohen's d = 0.47), higher self-transcendence personality construct on the Temperament and Character Inventory (P = 1.8 × 10-4, Cohen's d = 0.46), and shorter total working hours per week (P = 4.8 × 10-4, Cohen's d = 0.53) than those with schizophrenia without a history of violence. New findings, including impaired visual memory, a high self-transcendence personality trait, and shorter total working hours, could be focused on in future interventional research.

Hypnotic medication use among inpatients with schizophrenia and major depressive disorder: results of a nationwide study.

STUDY OBJECTIVES: To investigate the proportion of inpatients with schizophrenia and major depressive disorder prescribed hypnotic medication, and the association between such medication and the use of other antipsychotic agents. METHODS: This was a nationwide cross-sectional study performed as part of the 'Effectiveness of Guidelines for Dissemination and Education in Psychiatric Treatment' (EGUIDE) project. Data from 2146 inpatients with schizophrenia and 1031 inpatients with major depressive disorder were analyzed. All types and dosages of psychotropic drugs were recorded and the data at the time of discharge were analyzed. Associations between the use of hypnotic medication and other antipsychotic agents were evaluated using multivariate logistic regression analyses. RESULTS: The proportions of schizophrenia patients who were prescribed any and two or more hypnotic agents were 55.7% and 17.6%, respectively, and the corresponding proportions for patients with major depressive disorder were 63.6% and 22.6%, respectively. In schizophrenia patients, multivariate logistic regression analyses showed that two or more antipsychotics, anticholinergic drugs, anxiolytics, and mood stabilizers/antiepileptic drugs were positively associated with the use of any hypnotic agent. In patients with major depressive disorder, multivariate logistic regression analyses revealed that two or more antidepressants, two or more antipsychotics, anxiolytics, and mood stabilizers/antiepileptic drugs were positively associated with the use of any hypnotic agent. CONCLUSIONS: Prescription of hypnotic agents was found to be highly frequent among inpatients with psychiatric disorders. Prescription of two or more main antipsychotic agents was commonly associated with the use of hypnotic medication for both schizophrenia and major depressive disorder.

Switching from conventional therapy to burosumab injection has the potential to prevent nephrocalcinosis in patients with X-linked hypophosphatemic rickets.

OBJECTIVES: X-linked hypophosphatemic rickets (XLH) is a congenital fibroblast growth factor (FGF)23-related metabolic bone disease that is treated with active vitamin D and phosphate as conventional therapies. Complications of these therapies include nephrocalcinosis (NC) caused by excessive urine calcium and phosphate concentrations. Recently, an anti-FGF23 antibody, burosumab, was developed and reported to be effective in poorly-controlled or severe XLH patients. This study aimed to reveal the impact of switching treatments in relatively well-controlled XLH children with the Rickets Severity Scale less than 2.0. METHODS: The effects of the two treatments in eight relatively well-controlled XLH children with a mean age of 10.4 ± 1.9 years were compared retrospectively for the same treatment duration (31 ± 11 months) before and after the baseline. RESULTS: Actual doses of alfacalcidol and phosphate as conventional therapy were 150.9 ± 43.9 ng/kg and 27.5 ± 6.3 mg/kg per day, respectively. Renal echography revealed spotty NC in 8/8 patients, but no aggravation of NC was detected by switching treatments. Switching treatments increased TmP/GFR (p=0.002) and %TRP (p<0.001), and improved the high urine calcium/creatinine ratio to the normal range (p<0.001) although both treatments controlled disease markers equally. Additionally, low intact parathyroid hormone during conventional therapy was increased within the normal range by switching treatments. CONCLUSIONS: Our results suggest that a high dose of alfacalcidol was needed to control the disease, but it caused hypercalciuria and NC. We concluded that switching treatments in relatively well-controlled XLH children improved renal phosphate reabsorption and decreased urine calcium extraction, and may have the potential to prevent NC.

Criminal victimization of people with epilepsy: Sixteen criminal judgments in Japan between 1990 and 2019.

Criminal behavior by people with epilepsy (PWE) has often been discussed. However, there are limited studies on criminal victimization of PWE-in particular, how such victimizations occur. We identified criminal cases involving victims with epilepsy using databases containing criminal judgments and found 16 such cases between 1990 and 2019. Seven were homicide cases, including four filicide cases. In the four filicide cases, all the perpetrators had the intention of homicide-suicide; all the victims had intellectual disabilities or cerebral palsy; two of these victims had acted violently toward the family; and two mothers who perpetrated the crime against the victims had depression. It seemed that the comorbidities and problem behaviors of the victims were more strongly related to serious crimes by family caregivers than the epilepsy itself. To prevent victimization caused by family caregivers, reducing their stress levels is important. Defendants sometimes argued against objective evidence of a crime, claiming that epileptic seizure of PWE caused or was related to the death of victims. Legal and medical professionals involved in determining the manner of death need careful evaluation when sudden deaths of PWE occur.

The relationship between plasma clozapine concentration and clinical outcome: a cross-sectional study.

OBJECTIVE: There is no report that statistically evaluates the therapeutic reference (350-600 ng/ml) and adverse drug reaction (ADR) range (>1000 ng/ml) of clozapine (CLZ) recommended by the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) consensus guidelines in an isolated and large sampling study. METHODS: We administered CLZ to 131 Japanese patients with treatment-resistant schizophrenia in a multicenter cross-sectional study. Plasma CLZ concentrations were assayed by high-performance liquid chromatography using trough sampling. The Brief Psychiatric Rating Scale (BPRS) and severe dose-dependent ADR (sedation, myoclonus, and seizures) were analyzed statistically after adjusting for possible confounders. RESULTS: The daily CLZ dosage showed a moderately positive relationship with the plasma concentration (r = 0.49, p < 0.001). Every 100 ng/ml increase in plasma CLZ concentration improved the total BPRS score 1.95% (95% CI: 0.89-3.01, p < 0.001) and the odds ratio (OR) 1.38 (95% CI: 1.14-1.66, p = 0.001) for BPRS response. Compared with concentrations below 350 ng/ml CLZ, 350-600 ng/ml (11.12%; 95% CI: 2.52-19.72, p = 0.012) and 600-1000 ng/ml (11.05%; 95% CI: 2.40-19.71, p = 0.013) showed significant improvement in the total BPRS score. Dosages above 1000 ng/ml showed greater improvement (25.36%; 95% CI: 13.08-37.64, p < 0.001) of the total BPRS score but more severe ADRs than dosages below 1000 ng/ml (OR: 31.72; 95% CI: 1.04-968.81, p = 0.048). CONCLUSION: The AGNP therapeutic reference range (350-600 ng/ml) is useful, and a dose above 1000 ng/ml is potentially more effective but carries the risk of severe ADRs in the central nervous system.

The Perspective of Forensic Inpatients With Psychotic Disorders on Protective Factors Against Risk of Violent Behavior.

Background: Little is known about the opinions of forensic inpatients with psychotic disorders like schizophrenia on factors likely to prevent or decrease future violent behavior. Aims: To understand the perspectives of forensic inpatients with psychotic disorders on protective factors against risk of violent behavior and compare them to factors identified by professional staff. Method: Using the Structured Assessment of Protective Factors (SAPROF) checklist for self-appraisal of violence risk, we conducted semi-structured interviews with 32 inpatients of the Medical Treatment and Supervision Act Ward and compared the results with those of professionals. Results: Inpatients scored higher in the SAPROF total score, the motivational factors of "life goals" and "motivation for treatment," and the protective level in general. Inpatients scored themselves lower in risk level than professionals. The degree of agreement between service users' and professionals' evaluations was low for all categories except external factors. Inpatients prioritized "life goals," "self-control," and "medication" as the top three key strengths currently preventing violent behavior, whereas the professionals selected "life goals" less often. The top three important future goals for preventing future violence selected by inpatients were "work," "intimate relationships," and "life goals," with the former two being selected significantly less often by the professionals. Conclusions: This is the first study to shed light on Japanese forensic inpatients' perspectives about preventing future violent behavior. Despite professionals' underestimation, inpatients viewed themselves as having high motivation for treatment and positive life goals. Inpatients prioritized personal values such as life goals, work, and intimate relationships, whereas professionals prioritized understanding, treating, and observing the disease. Our findings are consistent with past reports on patients' and clinicians' perspectives. Awareness of such gaps in perceptions can help build fruitful therapeutic alliances. We discuss the implications in terms of treatment, how to address the gap therapeutically, and how to design treatment accordingly. Directions for future research are also discussed.

Monthly intravenous alendronate treatment can maintain bone strength in osteogenesis imperfecta patients following cyclical pamidronate treatment.

Objectives Osteogenesis imperfecta (OI) is a skeletal dysplasia characterized by recurrent fractures due to congenital bone fragility. The only bisphosphonate approved for OI in Japan is pamidronate (PAM). To investigate whether monthly intravenous alendronate (ALN) infusions can maintain bone strength in OI children following cyclical PAM treatment. Methods A prospective and non-inferiority study was conducted. Eight school-age OI patients aged 8.5±2.0 years who were treated with cyclical PAM for 6.0±2.3 years were enrolled and switched to monthly intravenous ALN (0.030 mg/kg/month). Changes in L1-4 bone mineral density (BMD) Z-scores, fracture rates, and bone turnover markers for 12 months were analyzed. Results Average BMD Z-scores were -3.0±1.9, -2.9±2.0, and -2.2±2.0 in 12 months before enrollment, at enrollment, and after 12 months of ALN treatment, respectively. BMD Z-scores increased significantly during treatment with both PAM and ALN (p=0.012), and the effect of ALN was not inferior to that of PAM (p=0.67). There was no change in fracture rates (p=0.86) and bone turnover markers during the 12 months before and after enrollment. Additionally, ALN showed no remarkable side effects. Conclusions Our results suggest that monthly intravenous ALN can maintain bone strength after primary usage of cyclical PAM. We concluded that monthly intravenous ALN as a maintenance treatment following cyclical PAM administration can be an option for OI children.

Employment-Related Factors of Forensic Psychiatric Outpatients with Psychotic Disorders.

PURPOSE: Employment is important for forensic psychiatric patients with psychotic disorders, in terms of reduction in symptoms, improving the quality of life, and preventing re-offenses. However, few detailed studies on employment status in such patients exist. We aimed to determine the employment rate among forensic psychiatric outpatients with psychotic disorders and identify the factors associated with employment. PATIENTS AND METHODS: The study population comprised 406 patients with psychotic disorders who completed a forensic outpatient treatment order, were aged <65 years at discharge from a forensic psychiatric ward and provided written informed consent. Psychotic disorders were defined as psychiatric disorders classified into F2 in the International Statistical Classification of Diseases and Related Health Problems, 10th edition. Demographic data were collected from the medical records of the inpatient treatment period. Prognostic data during the outpatient treatment order period was provided by the reintegration coordinators responsible for coordinating the patients' social environment during this period. Exploratory univariate and multivariable logistic regression analyses identified the factors associated with employment. RESULTS: The mean age at discharge was 44.4±10.8 years. The mean follow-up period was 2.69±1.01 years. There were 4.6 times more men (n=334) than women (n=72). During the outpatient treatment order period, 56 of 406 participants achieved employment (13.8%). Participants who committed serious crime, including homicide, arson, robbery, and sexual assault, had a lower employment rate compared to participants who committed bodily injury crimes (multivariable odds ratio, 0.421; 95% confidence interval, 0.220-0.807). History of substance use and living with family after discharge from a forensic psychiatric ward positively contributed to employment. CONCLUSION: The employment rate among forensic psychiatric outpatients with psychotic disorders was low and was similar to that reported in previous studies on general psychiatric patients with schizophrenia. Furthermore, serious criminal behavior negatively impacted employment.

Mortality and suicide rates in patients discharged from forensic psychiatric wards in Japan.

BACKGROUND: Japanese forensic mental health services for patients with psychiatric disorders under the Medical Treatment and Supervision Act was initiated in 2005; however, the prognosis of those patients is not well-known, particularly regarding mortality and suicide. This study aimed to evaluate the all-cause mortality and suicide rate in forensic psychiatric outpatients who had been discharged from forensic psychiatric wards in Japan. METHODS: Participants included 966 patients who had been discharged from forensic psychiatric wards. Data were collected from July 15, 2005 to July 15, 2018 at 29 of the 33 forensic psychiatric wards in Japan. Only the patients who provided written informed consent were included. We and collaborators at each forensic psychiatric ward identified demographic data of participants from the medical records for the inpatient treatment period. The reintegration coordinators, who belonged to the Ministry of Justice, investigated the prognosis of the participants during the outpatient treatment order period. We then connected demographic data and participants' prognosis for analysis. The crude rates (CRs) and standardized mortality ratios (SMRs) were calculated to analyze all-cause mortality and suicide rates. Univariate analysis was performed to examine the factors associated with all-cause mortality and suicide rates using the Cox proportional hazards ratio model. RESULTS: The participants included 3.3 times as many men (n=739) compared to women (n=227), and their combined mean age was 47.3 (SD=12.9). The most common primary psychiatric diagnosis was psychotic disorders (81.3%). The mean follow-up period was 790.2 days (SD=369.6). The total observation period was 2091.2 person-years. The CR for all-cause death was 812.9 per 100,000 person-years (95% CI [426.5, 1199.4]), while the SMR for all-cause death was 2.2 (95% CI [1.3, 3.5]). The CR for completed suicide was 478.2 per 100,000 person-years (95% CI [181.8, 774.6]). The suicide SMR was 17.9 (95% CI [8.6, 32.9]) overall, 7.7 (95% CI [2.5, 18.0]) for men, and 79.4 (95% CI [25.8, 185.2]) for women. Univariate analysis showed that women had higher completed suicide risk than men (hazard ratio=3.599, 95% CI [1.041, 12.445]). CONCLUSION: The all-cause mortality and completed suicide rates were higher in participants than observed in the general population consistent with the results of previous international studies.

Death Penalty and Psychiatric Evaluation in Japan.

Japan recently ordered a string of death sentences for offenders with mental illness. Based on the verdicts, we describe cases where one or more psychiatrists conducted psychiatric evaluations for several months and testified in lay judge courts. We compared these cases with those in which the death penalty was avoided, or the mandating treatment order was applied. Additionally, we discuss a trend toward more severe punishment and Japanese cultural background seen in a public opinion survey. Moreover, we introduce a research report that concluded a strong correlation between the number of victims and death penalty verdict. In Japan, lay judge trials determine the sentencing of the defendant and the verdict of guilty or not guilty, and it can be difficult for psychiatrists to help lay judges understand psychiatric symptoms and the relationship between symptoms and criminal responsibility through their testimony. We believe the right to life is the most fundamental of human rights and that the death penalty is inhumane. The death penalty also eliminates the possibility of treatment or rehabilitation, despite the fact that psychiatrists should support the possibility of treatment or rehabilitation in all cases. Further, the Japanese Penal Code does not permit execution for those mentally ill deemed unable to receive sentence; however, it is unclear who will conduct these evaluations and how they will do so. We describe our beliefs of how psychiatrists should act in these situations.

A case of perinatal hypophosphatasia with a novel mutation in the ALPL gene: clinical course and review of the literature.

Hypophosphatasia (HPP) is a metabolic bone disease characterized by failure of bone calcification and vitamin B6 dependent seizures. It is caused by loss-of-function mutations in the ALPL gene. A newborn girl required respiratory support by nasal-directional positive airway pressure at birth, and pyridoxine hydrochloride administration for vitamin B6-dependent seizures observed from day two. Umbilical cord blood showed low alkaline phosphatase (ALP) activity and high pyridoxal phosphate levels. Radiographs showed severe rickets-like appearance of the bones. Genetic analysis of the ALPL gene revealed compound heterozygous mutations, c.1559delT/p.Ser188Pro. We diagnosed her with perinatal severe HPP, and started the patient on asfotase alfa from day six. Following enzyme replacement therapy (ERT), skeletal mineralization and respiratory insufficiency improved with no remarkable side-effects. Crying vital capacity (CVC) was used to evaluate respiratory status, which continuously improved from 13.3 mL/kg (day 22) to 20.6 mL/kg (day 113). Since no seizures occurred, pyridoxine hydrochloride was tapered off at one year of age. Strategies to manage perinatal severe HPP cases following ERT have not been established till date. A review of the literature shows that CVC may be a good indicator for weaning from ventilatory support. In addition, ERT will most likely enable withdrawal of pyridoxine treatment.