Training types associated with knowledge and experience in public health workers.

BACKGROUND: Training non-specialist workers in mental healthcare improves knowledge, attitude, confidence, and recognition of mental illnesses. However, still little information is available on which type of mental health training is important in the improvement of these capacities. METHODS: We studied web-based survey data of 495 public health workers to examine training types associated with knowledge and experience in supporting individuals with mental illness. Multivariable logistic regression analysis was conducted to evaluate the association between a lack of knowledge and experience (outcome) and mental health training (exposure). We fitted three regression models. Model 1 evaluated unadjusted associations. Model 2 adjusted for age and sex. Model 3 adjusted for age, sex, years of experience, mental health full-time worker status, and community population. Bias-corrected and accelerated bootstrap confidence intervals (CIs) were used. RESULTS: For all training types, the association between a lack of knowledge and experience and mental health training attenuated as the model developed. In Model 3, a lack of knowledge and experience was significantly associated with training in specific illness (OR, 0.54; 95% CI, 0.32-0.93) and screening and assessment (OR, 0.63; 95% CI, 0.39-0.99). Non-significant results were produced for training in counseling, psychosocial support, collaborative work, and law and regulation in Model 3. CONCLUSIONS: We believe that the present study provides meaningful information that training in specific illness and screening and assessment may lead to knowledge and experience of public health workers. Further studies should employ a longitudinal design and validated measurements.

Number of long-term inpatients in Japanese psychiatric care beds: trend analysis from the patient survey and the 630 survey.

BACKGROUND: The number of psychiatric care beds and the mean length of stay in psychiatric care beds in Japan have decreased over the past 10 years. However, as has long been indicated here and elsewhere, Japan lags behind other countries in terms of deinstitutionalization. Furthermore, the population of inpatients in psychiatric care beds is aging dramatically. In addition to the diversification of mental illness, the question of what measures to implement going forward regarding current psychiatric bed resources has emerged as a new challenge. METHODS: Using data from the Patient Survey and the 630 Survey, we examined trends in the number of long-term inpatients in psychiatric care beds in Japan through 2040. Population estimation was used for estimating long-term hospital bed demand because of small fluctuations in the admission and discharge of long-term inpatients. RESULTS: In 2017, nearly one-third of all long-term hospitalized patients were aged ≥75 years, and an estimated 47% of the total are expected to die by 2040. Thus, the overall demand for long-term hospitalization is forecast to decrease sharply due to aging of currently hospitalized long-term inpatients. The number of long-term inpatients in 2017 was 167,579, and this is projected to decrease to 103,141 in 2040. CONCLUSIONS: We believe it is necessary to adopt a multifaceted approach to promote hospital discharge and transition to the community, and to address the diversification of mental illness and the issue of psychiatric care bed supply/availability, which are forecast to decrease due to the natural decrease in long-term inpatients.

National database study on the use of long-acting antipsychotic injections and hospital readmission proportions in patients with schizophrenia in Japan.

AIM: It is important to investigate the current prescription status and clinical outcomes of patients with schizophrenia receiving long-acting antipsychotic injections. We aimed to determine the prescription proportion of long-acting antipsychotic injections and hospital readmission proportions of patients with schizophrenia in Japan. METHODS: An open dataset was created using data from the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Patient records with the term 'schizophrenia' were included. In Analysis 1, antipsychotic prescription proportions were determined for outpatients who had visited psychiatric facilities between 1 February 2015 and 31 March 2017. In Analysis 2, patients who had been discharged from a psychiatric facility and had received a long-acting antipsychotic injection prescription within 90 days after initial discharge were selected; then, their readmission proportion was examined for 365 days after the initial discharge. RESULTS: The long-acting antipsychotic injection prescription proportion was 3.5% for outpatients with schizophrenia receiving antipsychotics. The readmission proportion was 41.0% in the entire patient population, 36.2% in patients receiving typical long-acting antipsychotic injections alone, and 23.5% in patients receiving atypical long-acting antipsychotic injections alone. CONCLUSION: Long-acting antipsychotic injections are not yet widely used in Japan. The readmission proportion was lower in the patients receiving atypical than typical long-acting antipsychotics injections. The results may provide important basic information to develop new future research questions but should be interpreted with caution because generalizability may be limited by the use of aggregated data and the data structure of the database used.

Switching to antipsychotic monotherapy vs. staying on antipsychotic polypharmacy in schizophrenia: A systematic review and meta-analysis.

BACKGROUND: While recent meta-analyses have reported the superiority of antipsychotic polypharmacy (APP) over antipsychotic monotherapy (APM) in schizophrenia, switching to APM can be beneficial in terms of side effects. To determine whether patients receiving APP should switch to APM or stay on APP, we conducted a systematic review and meta-analysis. METHODS: Randomized controlled trials (RCTs) examining a switch from APP to APM vs. staying on APP were systematically selected from a previous meta-analysis comparing APP with APM in patients with schizophrenia. In addition, we conducted an updated systematic literature search using MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Data on study discontinuation, relapse, psychopathology, neurocognition, extrapyramidal symptoms, and body weight/body mass index (BMI) were extracted and synthesized. RESULTS: A total of 6 RCTs involving 341 patients were included. All studies examined a switch from 2 antipsychotic agents to a single agent. Clozapine-treated patients were included in 3 studies. There was a significant difference in study discontinuation due to all causes in favor of staying on APP (N = 6, n = 341, RR = 2.28, 95% CI = 1.50-3.46, P < 0.001). There were no significant differences in relapse, any psychopathology, neurocognition, extrapyramidal symptoms, or body weight/BMI between the 2 groups. The quality of evidence was low to very low. CONCLUSIONS: The findings suggest that clinicians should closely monitor patient condition when switching to APM after receiving 2 antipsychotics. Given the low to very low overall quality of the evidence, the findings should be considered preliminary and inconclusive.

Relationship between the use of seclusion and mechanical restraint and the nurse-bed ratio in psychiatric wards in Japan.

The relationship between the number of nurses in psychiatric wards and frequency of use of seclusion and restraint has been unclear. We aimed to clarify this relationship in Japanese general psychiatric wards while controlling for patient and ward-level characteristics. We hypothesized that seclusion and mechanical restraint are less likely to be used in a ward with more nurses. We used data for individual admissions from April 2015 to March 2017 in hospitals participating in the Psychiatric Electronic Clinical Observation (PECO) system, which extracted data from each hospital's electronic health record system. We analyzed the data of 10,013 admissions in 113 wards of 23 hospitals. We examined the relationships between the number of nurses per 10 beds in each ward and the use of seclusion and mechanical restraint, controlling for the patients' age, sex, diagnosis, voluntary versus involuntary admission, prescribed dose of antipsychotics, severity of symptoms, and length of stay, in addition to ward-level characteristics including ward size, location (urban or rural), and type of ward (acute ward or not), using multilevel multivariate logistic regression analyses. The fraction of admissions exposed to at least one episode of seclusion or mechanical restraint was 36.7% and 14.9%, respectively. The odds ratios of the number of nurses per 10 beds for the use of seclusion and mechanical restraint were 2.36 and 1.74, respectively, indicating that both seclusion and mechanical restraint were actually used more frequently in wards with more nurses. A possible explanation is that patients anticipated to need coercive measures are more likely to be admitted to wards with many nurses. Increasing the number of nurses in a ward may not contribute to reducing the use of seclusion and restraint.

A prospective naturalistic multicenter study on choice of parenteral medication in psychiatric emergency settings in Japan.

AIM: To provide information about psychiatric emergency situations in Japan, we examined psychiatrists' preference among parenteral medication since intramuscular (IM)-olanzapine became available and clinical characteristics in patients given IM-olanzapine compared to those given other parenteral medication. METHODS: We conducted a naturalistic study proceeding over a 1-year period in 9 psychiatric emergency departments. RESULTS: Among 197 patients, the distribution of IM-injections (n = 89) was as follows: IM-olanzapine, 66 patients (74.2%), IM-levomepromazine, 17 patients (19.1%), IM-haloperidol, 5 patients (5.6%), and IM-diazepam, 1 patient (1.1%). The distribution of intravenous (IV)-injections (n = 108) was as follows: IV-haloperidol, 78 patients (72.2%), and IV-benzodiazepines (diazepam, flunitrazepam, or midazolam), 30 patients (27.8%). Advantages of IM-olanzapine over other parenteral medications in efficacy were found as follows: less frequent needs of an additional injection despite no difference in duration until a patient became cooperative for oral administration, and less frequent needs of restraint after the injection. Furthermore, advantages of IM-olanzapine over other injections in safety were found as follows: less frequent appearance of extrapyramidal symptoms, no occurrence of ECG abnormality and other serious adverse events except a fall, less frequent needs of an adjunctive anticholinergic drug, and less frequent needs of another kind of drug additionally injected. CONCLUSIONS: Olanzapine has rapidly become the first choice of intramuscular medication in psychiatric emergency situations since it became available in Japan, probably due to the advantages in both efficacy and safety. This study reflecting psychiatric emergency practice in Japan may contribute to periodic international comparison of psychiatric emergency practice.

Trends in the prevalence of psychological distress and the use of mental health services from 2007 to 2016 in Japan.

BACKGROUND: Little is known regarding trends of psychological distress and use of mental health services in Japan during recent years. METHODS: This study examined trends in severe and moderate psychological distress and the use of mental health services among adults (≥18 years old), using the Comprehensive Survey of Living Conditions in Japan from 2007, 2010, 2013, and 2016 (Total N = 2,159,005, all survey years combined). We defined a score of ≥13 on Kessler Psychological Distress Scale (K6) as severe distress and a K6 score between 5 and 12 as moderate distress. Age- and sex-specific trends of psychological distress and the use of mental health services were also examined. RESULTS: As compared with 2007, those with severe distress slightly increased in 2016 (4.01%-4.15%, p = 0.02) while those with moderate distress remained mostly unchanged (24.61%-24.69%, p = 0.61). The use of mental health services steadily increased in this decade for both with severe distress (11.95%-15.76%, p < 0.01) and with moderate distress (2.60%-3.56%, p < 0.01). The prevalence of severe distress among women aged 25-29 years old was highest in 2016 among all the age groups although the use of mental health services was not particularly high among women in this age group. LIMITATIONS: Cross-sectional nature of the data did not allow us to examine the causal relationship between psychological distress and the use of mental health services. CONCLUSIONS: In spite of an observed increase in the use of mental health services, the prevalence of psychological distress slightly increased. Further studies are necessary to identify sources of treatment gap especially for vulnerable demographic subgroups.

Personal lifestyle as a resource for work engagement.

OBJECTIVES: Personal lifestyle, including diet, exercise, and sleep, might have an impact on work engagement, though previous studies have not focused on these relationships. The aim of this study was to examine whether dietary intake of fish, regular exercise, sufficient sleep, abstinence from alcohol, and abstinence from tobacco were positively associated with work engagement. METHODS: We recruited adults aged 40-74 years who attended the health checkups with a particular focus on the metabolic syndrome in central Tokyo. In December 2015, 797 people responded to a questionnaire and 592 (74.3%) who had regular jobs were selected for this study. Work engagement was assessed on the 9-item Utrecht Work Engagement Scale (UWES-9). Bivariate and multivariate regression analyses were performed to examine the relationships between lifestyle and UWES-9. RESULTS: Dietary intake of fish, regular exercise, sufficient sleep, and abstinence from tobacco were significantly correlated with the total UWES-9 score, even after adjusting for age, sex, and depressive and anxiety symptoms. The results suggested a dose-response relationship between dietary fish intake and work engagement. CONCLUSIONS: Dietary fish intake, regular exercise, sufficient sleep, and abstinence from tobacco might be lifestyle factors that can serve as resources for work engagement. These findings could be useful in motivating employees to make lifestyle improvements and convincing employers and managers that lifestyle is important not only for health but also for productivity.

[The Report of the Survey to the Members of the Society about the Functional Dissociation of the Psychiatric Hospital beds].

In 2014, Japanese Ministry of Health, Labour and Welfare published the guideline on the policy of the psychiatric hospitals. We executed a survey to the members of "The Japanese Society of Psychiatry and Neurology" about the impression of this guideline, especially about "The functional differentiation of psychiatric hospital beds". Nine questions were notified on the home page of the society. 862 answers (5.3% of the members) were corrected by website from 1st to 30th of May in 2015. Attribution of the answers : doctors working at the psychiatric hospitals (70.9%), the psychiatric clinics (20%), the others (9.1%). The questions which more than 80% of the answers agreed were "The reduction of the psychiatric beds should be stepwise under the rule of check & balance in the improvement of the psychiatric community treatment", "Improve the function of the recovery phase treatment" and "The adequate treat- ment for the patients of the severe and chronic phases". The questions more than 55% of the answers agreed were "The reduction of the chronic phase beds for the improvement of the function of the acute phase beds". The questions which opposites exceeded (almost 47%) were "The assessment of the psychiatric symptoms in the patients of the chronic phase should be done by the third party" and "The facility for social skill treatment should be placed in the community". We could know the mind of the members about the revolution of the psychiatric.

[Individually Safe and Realistic Correction of Antipsychotic Polypharmacy and High-dose Regimens in Japanese Patients with Chronic Schizophrenia: The SCAP method].

Compared with other countries, Japan exhibits prominent levels of antipsychotic polypharmacy and high-dose regimens. In view of these circumstances, the Safe Correction of Antipsychotic Polypharmacy and high-dose regimens (SCAP) method was developed based on previous findings as a realistic way to reduce medication consumption in patients already experiencing polypharmacy and high-dose regimens. In the SCAP method, "clinicians can reduce medications one by one, gradually, with occasional breaks permitted." A clinical study conducted to evaluate this method found no change in clinical symptoms, side effects, or quality of life (QOL), and the number of withdrawals due to aggravation was also small. A leaflet describing these results, and which is designed to support efforts to reduce medications, has been released. Future research will involve the examination and analysis of data from this study, taking into account its limitations, with a view toward developing guidelines applicable to clinical settings. The pragmatic, gradual correction of polypharmacy and high-dose regimens that goes beyond the "multiple drugs or single agent" dichotomy can decrease the burden experienced by patients. This is a practical approach that can be applied when developing comprehensive plans for the future psychiatric care of aging patient populations.

Evaluation of the individual safe correction of antipsychotic agent polypharmacy in Japanese patients with chronic schizophrenia: validation of safe corrections for antipsychotic polypharmacy and the high-dose method.

BACKGROUND: Polypharmacy for schizophrenia treatment is not justified by the available clinical evidence. We evaluated a treatment reduction approach that reduces the dose and number of antipsychotic medications simultaneously prescribed to patients. METHODS: In a randomized open study of the Safe Correction of Antipsychotic Polypharmacy and High-Dose Prescriptions program funded by the Japanese Ministry of Health, Labour, and Welfare, we evaluated a drug reduction method consisting of a dose reduction intervention performed on 163 patients with schizophrenia for twelve or 24 weeks. One antipsychotic medication was removed each week from each patient's treatment regimen by reducing the dose by 0 to 50 chlorpromazine equivalents. Data on health-related indices of quality of life, clinical symptoms, and risk of side effects were analyzed using a two-way repeated-measures mixed linear model. RESULTS: Despite a 23% reduction in antipsychotic dose, no differences in outcomes were observed between the dose reduction and observation groups (effect size = 0.001 - 0.085, P = .24-.97), despite high statistical power (1-ß = 0.48-0.97). The findings are limited by the nonuniformity of the participants' treatment history, duration, and dose reduction amount. Dose reduction protocol patients exhibited no difference in psychotic symptoms or adverse events compared with the observation group. CONCLUSIONS: Importantly, the low dropout rate in our study (6.9% of participants withdrew because of patient factors and 23.8% for all secondary reasons) indicates that our "slowly" method is well tolerated. We hope that this approach will result in therapeutic improvements.

[Community cooperation initiatives pertaining to concomitant physical illnesses].

In the field of psychiatric care, while there is increasing demand related to concomitant physical illnesses (particularly during the emergency stage of such illnesses), this area is associated with several issues. As injuries resulting from attempted suicide among elderly patients with mood disorders increase, there has been a coordinated effort to improve mental healthy policies through government intervention (i. e., improving general practitioners' ability to deal with depression, and the establishment of psychiatric beds in concomitant illness wards). However, in addition to infrastructure issues, such as the location of, and access to, medical resources, communication loss and mutual unease are occurring between emergency medical services and psychiatric care providers. There is also a sense of distance between mental health professionals and the general medical community; timely and functional cooperation is not the norm. Fujita Health University Hospital has an emergency medical care center and psychiatric beds. For quite some time, the hospital has been dealing with over 100 cases a year, necessitating the emergency admission of patients with mental and concomitant physical illnesses from neighboring areas. The hospital provides continuous medical care in collaboration with psychiatrists and other mental health professionals. In light of this, within the Aichi prefectural regional health-care revitalization plan from 2011, this hospital has been commissioned to provide emergency psychiatric services for concomitant physical illness. Furthermore, Fujita has been upgrading its facilities with the aim of improving its response capabilities. However, it is impossible for this hospital to accept all emergent cases with concomitant illnesses within the whole of Aichi Prefecture, which has a population of over 7 million people. Thus, this does not reflect true medical collaboration with the community. In the debate over the formulation of a health-care plan commencing in the 2013 fiscal year, the issue of concomitant illnesses was highlighted when the subject of psychiatric emergency services was raised. There is some debate regarding the level of collaboration between emergency medical services, psychiatric hospitals, and general practices, with emergency medical care centers within the prefecture as the catchment area. A specific policy measure was then developed that included the creation of model pairs to facilitate concrete and effective collaboration between emergency units and psychiatric hospitals, the building of a support system for clinical management, and putting in place mechanisms to operate the system. Such efforts will hopefully promote the collaboration between psychiatric care centers and general medical treatment geared toward local circumstances.

Study protocol: safety correction of high dose antipsychotic polypharmacy in Japan.

BACKGROUND: In Japan, combination therapy with high doses of antipsychotic drugs is common, but as a consequence, many patients with schizophrenia report extrapyramidal and autonomic nervous system side effects. To resolve this, we proposed a method of safety correction of high dose antipsychotic polypharmacy (the SCAP method), in which the initial total dose of all antipsychotic drugs is calculated and converted to a chlorpromazine equivalent (expressed as milligrams of chlorpromazine, mg CP). The doses of low-potency antipsychotic drugs are then reduced by ≤ 25 mg CP/week, and the doses of high-potency antipsychotics are decreased at a rate of ≤ 50 mg CP/week. Although a randomized, case-controlled comparative study has demonstrated the safety of this method, the number of participants was relatively small and its results required further validation. In this study of the SCAP method, we aimed to substantially increase the number of participants. METHODS/DESIGN: The participants were in- or outpatients treated with two or more antipsychotics at doses of 500-1,500 mg CP/day. Consenting participants were randomized into control and dose reduction groups. In the control group, patients continued with their normal regimen for 3 months without a dose change before undergoing the SCAP protocol. The dose reduction group followed the SCAP strategy over 3-6 months with a subsequent 3-month follow-up period. Outcome measures were measured at baseline and then at 3-month intervals, and included clinical symptoms measured on the Manchester scale, the extent of extrapyramidal and autonomic side effects, and quality of life using the Euro QOL scale. We also measured blood drug concentrations and drug efficacy-associated biochemical parameters. The Brief Assessment of Cognition in Schizophrenia, Japanese version, was also undertaken in centers where it was available. DISCUSSION: The safety and efficacy of the SCAP method required further validation in a large randomized trial. The design of this study aimed to address some of the limitations of the previous case-controlled study, to build a more robust evidence base to assist clinicians in their efforts to reduce potentially harmful polypharmacy in this vulnerable group of patients. TRIAL REGISTRATION: UMIN Clinical Trials Registry 000004511.

Comparative clinical profile of mirtazapine and duloxetine in practical clinical settings in Japan: a 4-week open-label, parallel-group study of major depressive disorder.

No studies have compared mirtazapine with duloxetine in patients with major depressive disorder (MDD). Fifty-six patients were nonrandomly assigned to a 4-week treatment with either 15 to 45 mg/day of mirtazapine (n = 22) or 20 to 60 mg/day of duloxetine (n = 34). The primary efficacy measurements were the Hamilton Rating Scale for Depression (HRSD) and the Montgomery-Åsberg Depression 6-point Rating Scale (MADRS) scores. The second efficacy measurements were the response and remission rates of treatment. Tolerability assessments were also performed. Fifty-six patients (43 male; age, 43.6 years) were recruited. There was no significant difference in the discontinuation rate between the mirtazapine and duloxetine treatment groups (P = 0.867). Both mirtazapine and duloxetine significantly improved the HRSD and MADRS scores from baseline (P < 0.0001-0.0004). While mirtazapine was superior to duloxetine in the reduction of HRSD scores (P = 0.0421), there was no significant change in MADRS scores in terms of between-group differences (P = 0.171). While more somnolence was observed with mirtazapine (P = 0.0399), more nausea was associated with duloxetine (P = 0.0089). No serious adverse events were observed for either antidepressant. Mirtazapine and duloxetine were safe and well-tolerated treatments for Japanese patients with MDD. Double-blind controlled studies are needed to further explore the efficacy and safety of mirtazapine and duloxetine in Japanese patients with MDD.

An evaluation of polymorphisms in casein kinase 1 delta and epsilon genes in major psychiatric disorders.

Disturbances of the circadian rhythm are involved in the pathophysiology of bipolar disorder (BD), schizophrenia (SCZ) and major depressive disorder (MDD). Specifically, because clock gene dysfunction is good candidate for enhancing the susceptibility to these psychiatric disorders, we selected two circadian rhythm-related genes (CSNK1D and CSNK1E) and investigated genetic associations of the genes with these three disorders. None of the SNPs showed a significant association with MDD, but a SNP (rs2075984) in CSNK1E and SNP (rs6502097) in CSNK1D were associated with SCZ (P=0.0091, uncorrected) and BD (P=0.030, uncorrected), respectively. To confirm these findings, we analyzed an independent dataset (maximum N=3815) but found a lack of association (P=0.63 for rs2075984 and P=0.61 for rs6502097). The final meta-analysis showed no association between these SNPs with SCZ (P=0.21) and BD (P=0.53). These results do not support that genetic variation in CSNK1D and CSNK1E is a susceptibility factor for major psychiatric disorders in the Japanese population.

[How everyone recognize about polypharmacy?].

Some investigations report that dosage amount and number of antipsychotics in Japan were higher than those in the other country. This problem was discussed as quality of psychiatric medication by "the conference of the future about psychiatric health, medicine and welfare" (Japanese ministry of health, labor and welfare; 2009). The report of this conference said "In order to accelerate improvement to single dosage and loss in quantity, we should be grasped of the actual condition about the polypharmacy and extensive medication of antipsychotics for schizophrenic patients, and we should be discussed about the methods of information and evaluation". But there is no evidence about the polypharmacy is good or bad, and no one knows actual condition about the Japanese antipsychotics medications. In order to answer this question, we are undergoing "the clinical study about safety and effective correction of polypharmacy and agent extensive medication of antipsychotics".