Post-Disaster Community Transition of Psychiatric Inpatients: Lessons from the Fukushima Nuclear Accident.

This study sought to explore factors related to community transition after the mandatory evacuation of psychiatric inpatients to other hospitals owing to the Fukushima Daiichi Nuclear Power Plant accident. A retrospective cohort design was adopted and 391 psychiatric patients were examined. Univariate and multivariate analyses were conducted to confirm the association between the achievement or non-achievement of discharge to community living and their backgrounds (age, gender, evacuation destination, psychiatric diagnoses, and physical complications). Multivariate analysis indicated that patients with psychiatric diagnoses of schizophrenia, schizotypal, and delusional disorders (International Statistical Classification of Diseases and Related Health Problems 10th revision, F20-29), and those with physical diagnoses of the circulatory (I00-95) and digestive (K00-93) systems showed a significant association with the non-attainment of community transition. From these results, we hypothesized that difficulties in the management of medication during and immediately after the extremely chaotic settings of evacuation could have negative effects on the community transitions. Furthermore, another possible concern was that individuals' persistent psychotic status before the accident had been carried over to the destination hospitals. Therefore, pre-disaster daily cooperation across hospitals and challenges for vulnerable psychiatric patients' future community lives are also essential.

[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.

Effects of risperidone and aripiprazole on neurocognitive rehabilitation for schizophrenia.

AIM: Methods to improve neurocognitive impairments are of important research interest. This study sought to examine the synergistic effects of neurocognitive rehabilitation and antipsychotics for schizophrenia. METHODS: Subjects were 43 patients diagnosed with schizophrenia or schizoaffective disorder in a randomized trial of the effects of neurocognitive rehabilitation or a quasi-randomized experimental trial of supported employment with neurocognitive rehabilitation. We compared the effects of risperidone and aripiprazole in neurocognitive rehabilitation for schizophrenia. Subjects were divided into the following groups: (i) the control-risperidone group (CR group) (n = 13); (ii) the rehabilitation-risperidone group (RR group) (n = 9); (iii) the control-aripiprazole group (CA group) (n = 10); and (iv) the rehabilitation-aripiprazole group (RA group) (n = 11). Subjects in the rehabilitation group were engaged in computer-based cognitive exercises (24 sessions) with bridging group (12 sessions) over 12 weeks. Psychiatric symptoms, neurocognitive functioning and social functioning assessments were evaluated at baseline and at 12 weeks. RESULTS: A two-way anova with neurocognitive rehabilitation and antipsychotic medication as factors revealed a significant interaction effect on motor speed. Working memory and motor speed significantly improved in the RA group compared with the CA group. We found no significant improvements between the CR group and the RR group. CONCLUSION: A synergistic effect of neurocognitive rehabilitation and aripiprazole was observed as improvement of motor speed. In patients treated with aripiprazole, neurocognitive rehabilitation appeared to improve working memory and motor speed. Further studies of synergistic effects of neurocognitive rehabilitation and antipsychotic medication are necessary to verify these findings.

Post-evacuation return of psychiatric hospital inpatients evacuated to hospitals outside the Fukushima prefecture after the nuclear accident: A Retrospective Cohort Study.

BACKGROUND: Post-evacuation return after mandatory hospital evacuation due to complicated disasters is often overlooked and not well-discussed. AIMS: In this study, we explored the factors which are related to the ease or difficulty of the post-evacuation return to Fukushima prefecture of psychiatric inpatients who had been evacuated to hospitals outside the prefecture because of the Great East Japan Earthquake (GEJE) and subsequent Fukushima Daiichi Nuclear Power Plant (FDNPP) accident. METHOD: This retrospective cohort study included evacuated psychiatric hospital inpatients who were registered in the Matching Project for Community Transition (MPCT) and had been traced until July 31, 2019. A total of 531 patients were included for the analyses. Univariable and multivariable analysis were conducted to detect the patients' traits including their psychiatric/physical backgrounds which were associated with their outcome - the time from GEJE to the date of return to Fukushima. RESULTS: Over half of the patients returned to Fukushima. In the multivariable analysis, the patients' gender (male), age (older), and psychiatric diagnoses of schizophrenia, schizotypal and delusional disorders (ICD-10, F20-29) showed lower hazard ratio (HR) and statistically significant association with the difficulties of post-evacuation return. Meanwhile, disorders of psychological development (F80-89), diseases of the nervous (G00-99, except G40-41) and genitourinary (N00-99) systems showed higher HR and statistically significant association with the ease of return. CONCLUSIONS: The specific characteristics of the psychiatric inpatients including their psychiatric and physical status are associated with their post-evacuation return to their hometown. These results indicated that the evacuated hospitals' practitioners and staffs from the MPCT understood the necessity of the earlier return of inpatients to their hometown. Moreover, clinicians should pay more attention to some symptoms unique to psychiatric patients which contributed to their difficulties in returning safely or expressing their hope to return.

Effects of psychosocial program for preparing long-term hospitalized patients with schizophrenia for discharge from hospital: randomized controlled trial.

AIM: The aims of the present study were to revise the Community Re-entry Program-Japanese version and to review the effectiveness of the revised Program, named the Discharge Preparation Program. METHODS: This study was a randomized controlled trial. The Discharge Preparation Program (DPP) was the intervention condition (n = 26), and the usual rehabilitation program was the control condition (n = 23). Outcome indicators included factors that make patient discharge difficult (which nurses evaluated), psychiatric symptom, knowledge about the illness or medication, and the number of patients who were discharged within 6 months after the end of a program. RESULTS: Significant improvements were found in the score of the 'Issues on treatment compliance' factor and the score of the 'Autistic life' factor, which are subscales of the Discharge Difficulty Scale, for the DPP group, on two-way ANOVA ('Issues on treatment compliance': F = 3.818, P < 0.10; 'Autistic life': F = 4.155, P < 0.05) These factors affected discharge outcome. Thus, the program may be capable of promoting discharge of long-term hospitalized psychiatric patients. With regard to the number of patients discharged in 6 months after the end of a program, there was no significant difference between both groups. CONCLUSION: The present result is in agreement with past studies, and the DPP is useful in discharge support for patients with schizophrenia in Japan.

Long-term observation of mortality among inpatients evacuated from psychiatric hospitals in Fukushima prefecture following the Fukushima nuclear disaster.

The debate regarding the need for hospital evacuation and the evacuation distance remains rather chaotic. Furthermore, the relationship between hospital evacuation and the prognoses of psychiatric inpatients has not yet been investigated. We aimed to reveal the association between the long-term prognosis of psychiatric inpatients evacuated immediately following the Fukushima Daiichi Nuclear Power Plant accident and their backgrounds. In this retrospective cohort study, 777 psychiatric inpatients who were immediately evacuated from their hospitals following the accident were included for analysis. Survival time was the primary outcome. We conducted univariable and multivariable analyses to examine the associations between mortality and linear distance of evacuation and different backgrounds, including psychiatric/physical traits. Univariable analysis showed that the estimated survival time among patients was significantly associated with their evacuation distance. A multivariable analysis showed that a longer evacuation distance had a significantly lower hazard ratio (HR) and resulted in lower mortality. In contrast, older patients with physical complications of respiratory disease (International Statistical Classification of Diseases and Related Health Problems 10th revision, J00-99) and genitourinary disease (N00-99) showed a significantly higher HR and had a higher mortality than patients without these complications. To prevent death among elderly psychiatric inpatients with physical comorbidities during disasters, the evacuation destination should be determined taking into consideration the evacuees' tolerance for long-distance transportation and the availability of post-evacuation care in the destination hospitals.

Development of a clinical pathway for long-term inpatients with schizophrenia.

Clinical pathways have been defined as an optimal sequencing and timing of interventions by staff for a particular diagnosis or procedure, designed to better utilize resources, maximize quality of care and minimize delays. The aim of the present study was to develop a clinical pathway for long-term inpatients with schizophrenia. A review of clinical records was conducted for 17 patients with schizophrenia who had stayed in one psychiatric hospital for >1 year, and who remained in the community >3 months after hospital discharge. A review of clinical routine records was conducted. The discharge process of each patient was expressed in a clinical pathway around phases and care components. They were integrated into one clinical pathway. The discharge process was divided into assessment and goalsetting, preparation, and discharge phases. Care components included discharge planning, daily activity, living environment, health management, and basic life skills. Discharge planning was an important care component that was combined with all three phases. A clinical pathway was developed from reviewing past patient records, and discharge planning was found to be an important care component, which was combined with all three phases: assessment and goalsetting, preparation, and discharge. Further study is needed to examine the validity of the pathway for use in other hospitals.

[What impedes discharge support for persons with schizophrenia in psychiatric hospitals?].

OBJECTIVE: This study examines the factors that may impede discharge support for persons with schizophrenia who are receiving standard psychiatric services in Japan. SUBJECTS: Two hundred and ninety-two in-patients from nine psychiatric hospitals diagnosed with schizophrenia agreed to participate in this study. The mean duration of hospitalization at the time of the survey was approximately 10 years. METHODS: Variables that were evaluated in the baseline assessment were as follows: demographic features such as age and duration of hospitalization, primary psychiatrist's evaluation (the Brief Psychiatric Rating Scale, Global Assessment of Functioning, Assessing List of Patients' Needs of Psychiatric Rehabilitation, and so on), ward nurses' evaluation (the Discharge Difficulty Scale and the Hall and Baker's Rehabilitation Evaluation), and self administered questionnaires (the Self-Efficacy for Community Life Scale, Client Satisfaction Questionnaire, MOS Short-Form 36-Item Health Survey, and Drug Attitude Inventory Short Form). In the follow-up one year later, the subjects were divided into two groups: patients discharged and patients still hospitalized. RESULTS: Eight factors were identified by factor analysis of the Discharge Difficulty Scale. They were insight and treatment compliances, anxieties over discharge, activities of daily living (ADL), problem behaviors, autistic behaviors, medical complications, suicidal behaviors, and family problems. Five clusters were found on cluster analysis; cluster 1 (multiple factors of discharge difficulty), cluster 2 (insight, adherence, and autistic behavior factors of discharge difficulty), cluster 3 (few factors of discharge difficulty), cluster 4 (anxiety and autistic behavior of discharge difficulty), and cluster 5 (insight and adherence, anxiety, and deviant behavior factors of discharge difficulty). In the follow-up one year later, 60 and 157 subjects were divided into the discharge and continued-hospitalization groups, respectively. Six factors were detected by factor analysis that examined the variables which showed significant differences between the two groups in the baseline assessment: 1) discharge difficulties observed by ward nurses, 2) interpersonal difficulties attributed to negative symptoms, 3) hostility, excitement, and suspiciousness, 4) self-efficacy of patients in the community, 5) possible exacerbation of medical diseases, and 6) physical complaints related to the adverse effects of medication. On logistic regression analysis, the hostility, excitement, and suspiciousness and self-efficacy of patients in the community were found to be the two significant contributing factors to the outcome. DISCUSSION: Effective treatments promoting discharge support for long-term in-patients with schizophrenia are discussed according to the five clusters found. By clustering discharge difficulties, the treatment team will be provided with the necessary medical and social resources. In conclusion, a desirable supportive relation between patients and the team, basic skills to motivate the patients, and cooperative relations among the members of the treatment team are crucial in order to improve the outcomes of patients with discharge difficulties.

Training persons with schizophrenia in illness self-management: a randomized controlled trial in Japan.

Despite the worldwide shift from inpatient to community-based treatment for individuals with severe mental illness, Japanese psychiatric services remain hospital based. In 1998, Japan had 29 psychiatric beds per 10,000 persons, twice as many as in most European countries and five times as many as in the United States (1). The reasons for Japan's slow transition to a community-based mental health system are both economic and cultural. For instance, 90 percent of psychiatric beds are in private for-profit hospitals. There is little incentive for inpatient facilities to discharge patients promptly, because the Japanese health care system provides universal coverage with virtually unlimited reimbursement for inpatient services, and the government does not have a mechanism for financing the relocation of resources from hospitals to communities (2). In addition, the stigma associated with mental illness in Japanese families is high (3). Thus a patient's primary residence is the psychiatric hospital, and opportunities are provided for periodic visits from the family.However, psychiatric rehabilitation principles and practices are beginning to take root in Japan. Anzai and his colleagues at the Matsuzawa Psychiatric Hospital in Tokyo have adapted an empirically validated skills training program to prepare patients with schizophrenia for life in the community after discharge from the hospital. In this column, they report the results of a randomized controlled trial of this approach in an inpatient facility serving a large urban center.

Symptom dimensions and needs of care among patients with schizophrenia in hospital and the community.

The purpose of the present paper was to examine the psychiatric symptom dimensions related to needs of care among patients with schizophrenia in hospital and in the community. Subjects were 217 patients with F2 ICD-10 diagnoses. Hospital patients included 102 inpatients (47.0%) in psychiatric long-term care units. Community patients included 115 outpatients (53.0%) living in their homes or residential facilities. Psychiatrists used the Brief Psychiatric Rating Scale (BPRS) to assess patients' psychiatric symptoms. Formal care providers assessed needs of care using a scale developed by the Committee on Case Management Guidelines for People with Mental Disabilities in Japan. Instrumental Activities of Daily Living (IADL) self-performance and difficulty were also measured using a scale from the Minimum Data Set-Home Care (MDS-HC). Multiple regression analyses were applied, using the symptom dimensions as dependent variables and needs of care as independent variables. Patient group (hospital or community) was also used as an independent variable. Hospital patients demonstrated more severe psychiatric symptoms and greater needs of care than community patients. Multiple regression analyses showed that the total needs of care were greater among male patients (B = 0.142, P = 0.005), hospital patients (B = 0.310, P < 0.001), patients with poor IADL self-performance (B = 0.217, P = 0.047), and patients with severe negative symptoms (B = 0.240, P = 0.002; R(2) = 0.515). The present results suggested an association between negative symptoms and needs of care in schizophrenia. Hospital patients had greater needs of care, even though their psychiatric symptoms were controlled for. Further research should examine the relationships between psychiatric symptoms and needs of care in a cohort study following patients when hospitalized and when living in the community.