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.

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.

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.

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.

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.

Strength-based assessment for future violence risk: a retrospective validation study of the Structured Assessment of PROtective Factors for violence risk (SAPROF) Japanese version in forensic psychiatric inpatients.

BACKGROUND: The Structured Assessment of PROtective Factors for violence risk (SAPROF) was recently developed as a strength-based addition to the risk assessment of future violent behavior. We examined the interrater reliability and predictive accuracy of the SAPROF for violence in forensic mental health inpatient units in Japan. METHODS: This retrospective record study provides an initial validation of the SAPROF in a Japanese sample of 95 forensic psychiatric inpatients from a complete 2008-2013 cohort. Violent outcomes were assessed 6 and 12 months after hospitalization. RESULTS: We observed moderate-to-good interrater reliability for the SAPROF total score and the internal factors, motivational factors, external factors, and the Final Protection Judgment scores. According to a receiver operating characteristic analysis, the SAPROF total score and all subscale scores predicted violence at both 6 and 12 months after hospitalization with high accuracy. Furthermore, the predictive validity of a combination of the SAPROF with the Historical Clinical Risk Management-20 (HCR-20) outperformed that of the HCR-20 alone. CONCLUSIONS: The results provide evidence of the value of considering protective factors in the assessment of future violence risk among Japanese forensic psychiatric inpatients. The SAPROF might allow for a more balanced assessment of future violence risk in places where the population rates of violent crime are low, such as Japan, but a validation study in a different setting should confirm this. Moreover, future studies should examine the effectiveness of treatment and promoting community re-integration on motivating patients and treatment staff.

Brain structure differences among male schizophrenic patients with history of serious violent acts: an MRI voxel-based morphometric study.

BACKGROUND: The biological underpinnings of serious violent behaviors in patients with schizophrenia remain unclear. The aim of this study was to identify the characteristics of brain morphometry in patients with schizophrenia and a history of serious violent acts, who were being treated under relatively new legislation for offenders with mental illness in Japan where their relevant action should be strongly associated with their mental illness. We also investigated whether morphometric changes would depend on types of serious violent actions or not. METHODS: Thirty-four male patients with schizophrenia who were hospitalized after committing serious violent acts were compared with 23 male outpatients or inpatients with schizophrenia and no history of violent acts. T1-weighted magnetic resonance imaging (MRI) with voxel-based morphometry was used to assess gray matter volume. Additionally, patients with violent acts were divided based on whether their relevant actions were premeditated or not. The regional volumes of these two groups were compared to those of the control patient group. RESULTS: Patients with schizophrenia and a history of serious violent acts showed significantly smaller regional volumes of the right inferior temporal area expanded to the middle temporal gyrus and the temporal pole, and the right insular area compared to patients without a history of violence. Patients with premeditated violent acts showed significantly smaller regional volumes of the right inferior temporal area, the right insular area, the left planum polare area including the insula, and the bilateral precuneus area including the posterior cingulate gyrus than those without a history of violence, whereas patients with impulsive violent acts showed significantly smaller volumes of only the right inferior temporal area compared to those without a history of violence. CONCLUSIONS: Patients with schizophrenia and a history of serious violent acts showed structural differences in some brain regions compared to those with schizophrenia and no history of violence. Abnormalities in the right inferior temporal area were relatively common but did not depend on whether the violent actions were premeditated or not, and abnormalities in a wider range may be attributed to not only planning the violent action against others but also to maintaining that plan. TRIAL REGISTRATION: UMIN.ac.jp UMIN000008065 . Registered 2012/05/31.

Final adult height in long-term growth hormone-treated achondroplasia patients.

The objective of this study was to evaluate the gain in final height of achondroplasia (ACH) patients with long-term growth hormone (GH) treatment. We analyzed medical data of 22 adult patients (8 males and 14 females) treated with GH at a dose of 0.05 mg/kg/day. Optionally, tibial lengthening (TL) was performed with the Ilizalov method in 15 patients and TL as well as femoral lengthening (FL) in 6 patients. Concomitant gonadal suppression therapy with buserelin acetate was applied in 13 patients. The mean treatment periods with GH were 10.7 ± 4.0 and 9.3 ± 2.5 years for males and females, respectively. GH treatment augmented the final height +0.60 ± 0.52 SD (+3.5 cm) and +0.51 ± 1.29 SD (+2.8 cm) in males and females compared to non-treated ACH patients, respectively. Final height of ACH patients that underwent GH and TL increased +1.72 ± 0.72 SD (+10.0 cm) and +1.95 ± 1.34 SD (+9.8 cm) in males and females, respectively. GH, TL, and FL increased their final height +2.97 SD (+17.2 cm) and +3.41 ± 1.63 SD (+17.3 cm) in males and females, respectively. Gonadal suppression therapy had no impact on final height. CONCLUSIONS: Long-term GH treatment contributes to 2.6 and 2.1% of final adult height in male and female ACH patients, respectively.

Neurocognitive features in male patients with schizophrenia exhibiting serious violence: a case control study.

BACKGROUND: The relationship between violence and neurocognitive function in schizophrenia is unclear. We examined the backgrounds and neurocognitive functions of violent and nonviolent patients with schizophrenia to identify factors associated with serious violence. METHODS: Thirty male patients with schizophrenia who were hospitalized after committing serious violent acts were compared with 24 hospitalized male patients with schizophrenia and no history of violence. We evaluated psychiatric symptoms using the Positive and Negative Syndrome Scale (PANSS) and neurocognitive functions using the Brief Assessment of Cognition in Schizophrenia (BACS)-Japanese version. RESULTS: Repeated-measures analyses of variance on BACS subcomponents z-scores showed that the violent and control groups had different neuropsychological profiles at trend level (p = 0.095). Post hoc analyses of variance indicated that the violent group had significantly better working memory and executive function than the control group. In post hoc ANOVAs also controlling for the effect of the presence of substance abuse on cognitive function, violent or nonviolent group had a significant main effect on executive function but not on working memory. CONCLUSIONS: Patient with violent or non-violent schizophrenia have distinct neuropsychological profiles. These results may help develop improved psychosocial treatments.

The usefulness of monitoring sleep talking for the diagnosis of Dementia with Lewy bodies.

BACKGROUND: Dementia with Lewy bodies (DLB) is the second most common type of neurodegenerative dementia. It is frequently difficult to differentiate DLB from Alzheimer's disease (AD) and other types of dementia. This study examined the usefulness of monitoring sleep talking for the diagnosis of DLB. METHODS: A total of 317 patients with dementia were selected from a consecutive series at the Dementia Clinic of Kumamoto University Hospital. Diagnostic categories consisted of probable DLB (n = 55), probable AD (n = 191), frontotemporal lobar degeneration (FTLD) (n = 16), vascular dementia (VaD) (n = 18), and other/unspecified dementia (n = 37). We evaluated sleep talking in all dementia patients and normal elderly subjects (n = 32) using an originally designed sleep talking questionnaire. RESULTS: Sleep talking occurred most frequently in the DLB group (61.8%), followed by the VaD group (33.3%), other/unspecified dementia group (27.0%), AD group (18.8%), FTLD group (12.5%), and normal elderly subjects group (6.3%). The prevalence of sleep talking in the DLB group was significantly higher than in other groups, except in the VaD group. The sleep talking yielded high specificity (81.2%) and some sensitivity (61.8%) for the differential diagnosis of DLB from AD. Furthermore, loud sleep talking may improve the specificity (96.9%). For the differentiation of DLB from all other dementia types, the specificity of sleep talking and loud sleep talking was also high (79.4% and 95.8% respectively). CONCLUSIONS: Assessing sleep talking, especially the volume of sleep talking, may be useful in the clinical discrimination of DLB from not only AD but also from all other types of dementia.

A case of autosomal dominant osteopetrosis type II with a novel TCIRG1 gene mutation.

Osteopetrosis is a rare genetic disorder characterized by increased bone mineral density (BMD) due to osteoclast failure. T-cell immune regulator 1 (TCIRG1) plays crucial roles on osteoclast function, and its mutation causes autosomal recessive osteopetorosis. However, mutations in TCIRG1 have never been identified in autosomal dominant osteopetrosis (ADO). A 3-year-old boy was first presented to the clinic because of spontaneous radius and femur fractures. He has optic atrophy. The areal BMD at the lumbar spine was 1274 g/cm2 (233% of normal). Laboratory tests revealed no remarkable abnormal findings, including anemia, except for extremely elevated serum tartrate-resistant acid phosphatase-5b (14,600 mU/dL). Radiographically, the skull base, pelvis, and vertebrae showed a focal sclerosis. Genetic analysis revealed a novel de novo heterozygous missense mutation (His242Arg). Taken together with the mutation, his mild clinical features were diagnosed as ADO. This case implies that TCIRG1 could become a genetic candidate for ADO in addition to malignant forms such as ARO.

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.

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.

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.

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.

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.