Correlation between brain damage, associated biomarkers, and medication in psychiatric inpatients: A cross-sectional study.

BACKGROUND: We clarified the correlation between brain damage, associated biomarkers and medication in psychiatric patients, because patients with schizophrenia have an increased risk of stroke. METHODS: The cross-sectional study was performed from January 2013 to December 2015. Study participants were 96 hospitalized patients (41 men and 55 women) in the Department of Psychiatry at Kohnodai Hospital, National Center for Global Health and Medicine, Ichikawa, Chiba, Japan. Patients were classified into schizophrenia (n=70) and mood disorders (n=26) by psychiatric diagnoses with DSM-IV-TR criteria. RESULTS: The incidence of brain damage [symptomatic and silent brain infarctions (SBIs) and white matter hyperintensity (WMH)] was correlated more with mood disorders than with schizophrenia. It has been previously shown that the concentrations of protein-conjugated acrolein (PC-Acro) and interleukin-6 (IL-6) increased in plasma of brain infarction patients together with C-reactive protein (CRP). The concentration of PC-Acro was significantly higher in patients with mood disorders than in those with schizophrenia. The concentration of IL-6 in both groups was nearly equal to that in the control group, but that of CRP in both groups, especially in mood disorders, was higher than that in the control group. Accordingly, the relative risk value for brain infarction was higher in patients with mood disorders than with schizophrenia. Medication with atypical antipsychotics reduced PC-Acro significantly in all psychiatric patients and reduced IL-6 in mood disorder patients. CONCLUSION: Measurement of 3 biomarkers (CRP, PC-Acro and IL-6) are probably useful for judgement of severity of brain damage and effectiveness of medication in psychiatric patients.

Increased Silent Brain Infarction Accompanied With High Prevalence of Diabetes and Dyslipidemia in Psychiatric Inpatients: A Cross-Sectional Study.

OBJECTIVE: Patients with schizophrenia have increased risk of atherosclerotic diseases. It is already known that lifestyle-related disorders and the use of antipsychotics are closely related with the progression of atherosclerosis in psychiatric patients. Stroke as well as coronary heart disease play an important role in the cause of death in Asia and Japan. Thus, we studied the prevalence of cerebrovascular disease in psychiatric inpatients in Japan using brain magnetic resonance imaging (MRI). METHOD: This cross-sectional study was performed from January 2012 to December 2013. Study participants were 152 hospitalized patients (61 men and 91 women) in the Department of Psychiatry at Kohnodai Hospital, National Center for Global Health and Medicine, Ichikawa City, Japan. Mean ages were 50.0 and 57.1 years old for men and women, respectively. The diagnoses (DSM-IV-TR criteria) of participants were schizophrenia (69.1%), mood disorder (18.4%), and other mental disorders (12.5%). We checked physical status, metabolic status of glucose and lipid levels, and brain MRI within 1 week of admission. RESULTS: The study group showed a significantly high prevalence of diabetes and low high-density lipoprotein (HDL) cholesterolemia in both sexes (n = 61 in men, n = 91 in women, P < .05). In the study group, serum fasting plasma glucose and hemoglobin A1c levels were significantly high (n = 152, P < .05), but serum HDL cholesterol and total cholesterol were significantly low in both sexes (n = 61 in men, n = 90 in women, P < .05), and triglycerides were low in men (n = 61, P < .05). Silent brain infarction was recognized at a higher rate (n = 98, P < .05) compared with healthy controls. CONCLUSIONS: Participants in this study had an increased ratio of silent brain infarction compared with Japanese healthy controls, accompanied with higher ratios of diabetes and low HDL cholesterol.

[Clinical experience with clozapine in 55 cases of treatment-resistant schizophrenia].

Up until October 2012, Kohnodai Hospital had introduced clozapine treatment for 55 cases of treatment-resistant schizophrenia. In all cases, previous antipsychotic medication was discontinued the day before clozapine administration began. Of the 55 cases, 45(85%)are continuing clozapine administration, and 40 cases (73%) are receiving outpatient treatment. The average dose of clozapine was 373.1 mg/day (SD : 160.5). Clozapine was administered for a month or more in 51 cases (93%). BPRS scores improved 20% or more in a month's administration of clozapine in 18 of the cases (35%). The average clozapine dose in the improvement cases was 176 mg/day. The average BPRS score had significantly decreased from the baseline at months 1, 3, 6, and 12 after the start of clozapine administration. Of the 33 cases receiving clozapine treatment for 12 months or more, BPRS improved 20% or more in 27 (82%). BPRS improved 20% or more for the first time after clozapine administration within a month in 12 cases (44%), 3 months in 8 cases (30%), 6 months in 5 cases (19%), and 12 months in 2 cases (7%). These results suggest that clozapine should be administered continuously for over 6 months at the least and 12 months if possible to evaluate the efficacy of clozapine treatment. Of the 43 cases receiving outpatient clozapine therapy, the average GAF score improved significantly from the time of ward admission to discharge (20.6 and 42.0, respectively). Clozapine had to be discontinued in 2 cases of leukopenia, 2 cases of neutropenia, 1 case of reduced left ventricular ejection due to pericardial effusion, 1 case of drug eruption, and 1 case of marked hunger. When introducing clozapine for treatment-resistant schizophrenia, it is important to administer it as a monotherapy, slowly increase the dosage to reduce side effects, and achieve a treatment effect at the minimum required dosage.

Preliminary outcome study on assertive community treatment in Japan.

AIMS: The beneficial effects of assertive community treatment (ACT), which has been widely acclaimed as being successful in several foreign countries, must also be objectively evaluated with respect to the transition from inpatient to community-based mental health treatment in Japan. This was the first study that examined effects of the ACT program in Japan using pre/post design data of the pilot trial of the ACT program in Japan project. METHODS: The study included 41 subjects hospitalized at Kohnodai Hospital, National Center of Neurology and Psychiatry between May 2003 and April 2004 for severe mental illness and who met inclusion criteria for entry regarding age, diagnosis, residence, utilization of mental health services, social adjustment, and ability to function in daily activities. All subjects provided informed consent for study participation and were followed for 1 year after hospital discharge. RESULTS: Comparison of the number of days and frequency of inpatient psychiatric hospitalization and frequency of emergency psychiatric visits between the 1-year period before hospitalization and 1-year period after hospital discharge showed a significant decrease in number of days and frequency of hospitalization. Comparison at 1 year after discharge with baseline showed no change in satisfaction with overall quality of life or Brief Psychiatric Rating Scale scores, but the Global Assessment of Functioning score significantly increased, and the antipsychotic dose (chlorpromazine equivalent) significantly decreased. CONCLUSION: Despite some limitations in methodology and conclusions, this study suggests that ACT enables persons with severe mental illness to live for longer periods in the community, without worsening of symptoms, decreased social function, or deterioration in quality of life.

Family support in assertive community treatment: an analysis of client outcomes.

Assertive Community Treatment (ACT) is an outreach-based case management model that assists people with severe mental illness through an intensive and integrated approach. In this program, a multidisciplinary team provides medical and psychosocial services. The purpose of this study was to examine the effectiveness of the following two ACT intervention strategies: "replacement" (supporting the clients) versus "backup" (supporting family members who provide care to clients). Admission days, psychiatric symptoms, quality of life, self-efficacy, and service satisfaction ware evaluated as outcome variables. To identify effective methods of supporting family members, clients living with family were divided into two groups based on the amount and types of services received-the backup group and the replacement group. ANCOVA was used to compare the outcomes between the two groups. The replacement group displayed significantly better psychiatric symptoms, social functioning, self-efficacy, and service satisfaction scores. No differences in admission days or quality of life were found. Clients provided more support directly to clients themselves than to family members was found to have better client outcomes in improving psychiatric symptoms, social functioning, and self-efficacy, resulting in higher levels of service satisfaction. This indicates that society should reduce the responsibility of the family and share responsibility for the care of people with mental illness to effectively improve outcomes for people with mental illnesses.

Development of the Nurse Attitude Scale short form: factor analysis in a large sample of Japanese psychiatric clinical staff.

The Nurse Attitude Scale (NAS) measures nurses' Expressed Emotion. A short form of the NAS was developed and its reliability and validity examined. After performing factor analysis using 1252 samples, three factors were extracted. Cronbach's alpha for individual subscales was 0.852 for Hostility, 0.846 for Criticism and 0.645 for Positive Remarks. There was a significant correlation between individual subscales in the NAS short form and corresponding subscale in the Maslach Burnout Inventory (P < 0.001). The NAS short form seems to have acceptable reliability and validity.

The quality of life among persons with severe mental illness enrolled in an assertive community treatment program in Japan: 1-year follow-up and analyses.

BACKGROUND: Toward effective community care for persons with severe mental illness and deinstitutionalization in Japan, we assessed the impact of the first trial of an assertive community treatment program on the lives and subjective perceptions of persons with mental illness without closing hospitals. METHODS: Forty-three subjects were enrolled from the newly admitted patients of a hospital, who met our criteria of problematic hospital use, severity of psychiatric disorders, and behavioral problems. The intervention team aimed to intensively support them in various life domains in their communities to decrease clients' admissions. The Quality of Life Interview was administered at baseline and after 12 months. Data were analyzed to assess the pre-post changes in their QOL, and were explained in association with other descriptive variables. RESULTS: The objective changes included increase in persons whose longest residence in a year were in communities, increase in income, and decrease in family contacts. Most subjective items were not changed except the decrease in satisfaction with family relationships. Satisfaction with family relationships was negatively correlated with hospital days at 1 year follow-up after controlling for symptoms, but was not so at baseline. Also, correlation between satisfaction with family relationships and global well-being was attenuated. A change in the positioning of family by clients and the autonomy of clients were suggested. However, previous studies showed that dissatisfaction with family relationships predicted rehospitalizations independently from symptoms, and our findings suggest our subjects' characteristics and a possible improvement in community-based care. CONCLUSION: Our program predominantly fulfilled the primary goal, but it must be further refined to reflect the detailed characteristics of the target population and resource distribution. Assessing subjective perceptions, or the QOL of clients is useful for evaluating the program localization.

[Preliminary reports on psychiatric practice in correctional facilities].

In October 2001, Nanashakon, a council composed of seven psychiatry-related organizations in Japan, decided to launch an investigation into forensic psychiatry in Japan, and established a working team (WT) for this purpose. From its establishment to March 2004, the WT performed surveys and analyses of the current situation of preliminary reports by psychiatric experts (preliminary reports) and of psychiatric practice in correctional facilities. Based on the results, the WT has presented proposals including guidelines for preliminary reports. In January 2002, the WT conducted an awareness survey on the status quo of testimony by psychiatric experts and forensic psychiatry, targeting the members of the Japanese Society of Psychiatry and Neurology, and obtained 666 replies. The survey revealed various critical opinions such as skepticism over the current punishment imposed on criminal patients with mental disorders. In February 2002, the WT obtained data on preliminary reports (2,042 cases) compiled prior to prosecution in FY2000 from the Japanese Ministry of Justice. Reviewing the details and differences between the evaluation by psychiatrists and the decision by public prosecutors, the WT pointed out the ambiguity of criteria used for the evaluation of competency of weak-minded persons and the criteria for criminal punishment. Around the same time, the WT was also asked by a news agency to analyze the preliminary reports of 50 district public prosecutor offices. The results revealed marked regional differences in the operation of the preliminary evaluation system for competency. In January 2003, the WT collected 146 preliminary reports from around the country for comparison and review, and again found conspicuous individual and regional discrepancies in the format and content. Based on these results, the WT conducted a hearing of 41 expert opinions on preliminary reports, and in January 2004, proposed guidelines outlining a format model of preliminary reports, and a training and authorizing system for forensic psychiatrists, to standardize preliminary reports and enhance their reliability. In February 2004, the WT conducted a questionnaire survey on the current situation of psychiatry in correctional facilities, targeting doctors with experience working under these circumstances. Fifty-one replies were obtained. Most of the respondents approved of the current system. However, to incite arguments in this area, attempts were made to draw critical responses and discussion by presenting data on the current situation of psychiatric practice in correctional facilities.