Seishin shinkeigaku zasshi = Psychiatria et neurologia Japonica最新文献

Drug overdose is a serious public health issue and fatal cases have been reported from various fields of medicine. This case-control analysis assessed the comparison between fatal overdose cases in the special wards of Tokyo Metropolitan area and prescribed psychotropic drugs in Tokyo in 2009-2010. It was suggested that the prescribed drugs serve as a direct cause of death in overdose cases. Furthermore, pentobarbital calcium, chlorpromazine-promethazine-phenobarbital, levomepromazine and flunitrazepam were identified as drugs with a high risk of fatal overdose. It is encouraged to prudently verify the intended application and usage of such psychotropic drugs in each case upon their prescription. This is the first study in Japan to identify psychotropic drugs with a high risk of fatal overdose by case-control study.

The Japanese suicide rate is still high compared with other countries. Worker suicide especially leads to marked social and economic losses and severely affects the bereaved. There is an urgent need to devise a system to prevent suicide at a very early stage. Generally, it is considered very difficult to intervene and prevent suicide in cases in which individuals kill themselves suddenly. However, according to some studies on suicide attempts, even those who killed themselves suddenly had experienced some kind of conflict or a desire to die for a long period. Therefore, it is essential to analyze the risk factors at an early stage when individuals have vague thoughts of suicide. This will help reduce the risk of suicide in such cases. In this article, I first survey the data related to workers' mental health in Japan. Second, I introduce the results of our pilot study in which we investigated mental health issues related to suicide among workers who have taken leave from work for more than two months. In this study, workers who do not exhibit help-seeking behavior are suggested to be a high-risk group for suicide. It is speculated that this behavior is related to several factors such as the sex, age, social status, education, personal stigma, and perceived stigma. Therefore, we must focus on both clinical and social solutions for the prevention of suicide. I believe that psychiatrists will come to play a more important role as liaisons between workplaces and social resources for the prevention of suicide.

Clozapine-induced cardiomyopathy is a rare but fatal complication with a reported incidence of 0.4% in Japan. Clozapine-induced cardiomyopathy develops at an average of 14.4 months after initiating clozapine, and to our knowledge, has a duration no longer than seven years. We present a patient who developed dilated cardiomyopathy after 17 years of clozapine treatment and made a full recovery of cardiac function at 40 weeks after clozapine treatment cessation. A 43-year-old male with a 24-year history of schizophrenia was treated with clozapine (600 mg/day) for 17 years. No abnormal findings were revealed at follow up until he pre- sented with dyspnea with no accompanying symptoms while walking. He was suspected of worsening asthma due to his past history and lack of abnormalities of ECG and CXR. However, as he experienced gradually worsening dyspnea accompanied by listlessness and lightheaded- ness, he was referred to a cardiologist. The echocardiogram revealed left ventricular dilatation and systolic dysfunction (left ventricular ejection fraction, LVEF=40%), which made a diagno- sis of dilated cardiomyopathy. We excluded cardiac ischemia and other possible causes of dilated cardiomyopathy with cardiac catheterization and endomyocardial biopsy. Clozapine treatment was stopped and switched to olanzapine along with standard heart failure medica- tions. The symptoms and left ventricular function improved following clozapine discontinua- tion. The symptoms resolved and echocardiogram showed a LVEF of 50% within 11 weeks after treatment with clozapine was ended. LVEF was reported at 59% 40weeks after cessation of clozapine. At the present time, 32 months since ceasing clozapine treatment, no worsening of symptoms has been presented. After ceasing clozapine and inducing standard heart failure medications, the patient presented the excellent recovery and the normalization of his echocar- diogram. Despite this outcome, there is currently insufficient evidence to conclusively establish a causal relationship between clozapine and cardiomyopathy in this case. In addition, this case demonstrates that we cannot exclude cardiomyopathy due to lack of abnormal findings of ECG and CXR. Therefore, we recommend that echocardiograms should be performed annually. The mortality associated with clozapine-induced cardiomyopathy is high, so if patients undergoing therapy with clozapine develop new symptoms or signs suggestive of cardiac dysfunction such as dyspnea, a focused cardiovascular examination should be considered.

The prospective payment system in the psychiatric acute care ward began in 1996 in Japan. This was up-graded to the psychiatric emergency ward in 2002. Chiba Psychiatric Med- ical Center, the model institute of these wards, has been leading the transformation from asylums to therapeutic apparatus. Although emergency/acute care wards occupy only 8% of the total psychiatric beds in Japan, they cover 41% of annual admissions onto psychiatric wards because of their high bed turnover rate. Therefore, they contributed to reduce the aver- age length of stay to two-thirds, and for the numbers of inpatients to decrease by 11% up until 2012. The Ministry of Health, Labor and Welfare presented an image of future types of psychi- atric bed-emergency, acute, recovery, and severe chronic beds, and a plan to reduce long- stay patients. Outcomes and improvements of patients with severe mental illness in the emer- gency/acute care wards may be a determinant of the future design. We propose three plans to turn it into reality: increasing the number of psychiatric emergency wards/units in general hospitals, requiring some residency program in emergency wards to become a certified psychi- atric specialist, and limiting new admissions onto psychiatric emergency wards to involuntarily hospitalized patients. These plans could facilitate deinstitutionalization in Japan, sustaining the provision of continuous and responsible care.

The role of mental symptomatology is to describe various clinical symptoms without refer- ring to their pathogenesis. This may be because of the influence of K. Jasper's General Psycho- pathology. However, from the mid-19th to early 20th century, when modern psychiatry was estab- lished, some excellent hypotheses concerning the pathogenesis of mental symptoms were pro- posed, although it was difficult to verify these hypotheses because of technical limitations. The purpose of this article was to review the historical development of symptomatology in psycho- sis with reference to the pathogenesis. W. Griesinger (1845, 1861) distinguished between the etiology and pathogenesis of a disease, and stated that every mental disease is a manifestation of brain disease. Subsequent investigators elaborated on this view : C. Wernicke (1894, 1906) proposed the disconnection of the association tracts, and P. Flechsig (1894, 1920) regarded the late myelinating "association areas"' (this term was from Flechsig) as the field of the mind. J. H. Jackson (1895) proposed the evolutionary and hierarchical organization of the nervous system. E. Kraepelin (1913) speculated on the hypoactivity of the frontal cortex-the highest cerebral centers according to Jackson's terminology-and hyperactivity of the temporal speech cortex as the pathogenesis of psychotic symptoms in dementia praecox, which were found to be the case based on neuroimaging methods over sixty years later. Currently, the pathogenesis of mental symptoms is being investigated from the viewpoint of the dysfunctions of neural cir- cuits, such as cortico-limbic, cortico-thalamic, or cortico-striatal circuitry.

Birth cohort studies are conducted by prospectively following the participants with a spe- cific characteristic background from their birth or prenatal birth, and can explore the causal relationship of various factors with outcomes. In the UK, birth cohort studies with long-term follow-ups have been launched every ten years, which have provided many significant results and related useful policy recommendation. However, these have not necessarily intended to be launched as the national project with long-term observations, rather existing birth cohorts are accept to continue because of the excellent results and survey condition. In 1990s, birth cohort studies have been revalued as national resources, and widely used by domestic and international researchers. As the contribution to psychiatry and mental health, most of the cohort studies have been conducted to identify risk factors for onset of psychiatric diseases such as schizophrenia. Nowadays, broader studies were conducted and highly evaluated for the relationships between physical and psychological illnesses, and biological studies. Recent cohort studies also showed that cognitive abilities in childhood or adolescence was similar between those who later developed schizophrenia and those who experienced psychotic symptoms, sug- gesting that a spectrum in psychiatric diseases would be useful for elucidating the pathophysiology. In Japan, birth cohort studies which findings could be reflected on policy implications have been required as national resources. However, as there have been no birth cohort studies that have conducted for long-term follow-ups, there are little techniques and knowledge for launching and continuing a birth cohort study with low attrition, and providing evidences to society. It is necessary to establish these techniques and knowledge by learning from the UK cases within the cultural and social contexts in Japan. High quality routine studies including examination have been implemented in Japan in various fields such as perinatal and infant care, schools, work places, medical care, and the central and local governments. Supplementation of those data will be needed for high quality birth cohort studies. Until now, there has been no relevant law to conduct any data linkage between the data from various fields in research settings and it is necessary to be prepared.

The Psychiatric Care and Mental Health and Welfare System Committee surveyed the contents of mental disorder medical care plans established by the 47 prefectures in Japan. Based on the "opinions of the Japanese Society of Psychiatry and Neurology Board of Directors following the official recognition of mental disorders as important diseases under the Medical Service Law's medical care plan" (September 28, 2011), investigations were conducted focusing on three aspects : locations of medical care plan discussions, public awareness of medical care information, and target values. Medical care plans of the 47 prefectures were collected. A ques- tionnaire regarding the mental disorder care plan decision process was sent to each prefecture, and answers were received from -those in charge of each jurisdiction. Among the 45 prefec- tures that responded, the mental disorder care planning groups held an average of 3 meetings. The largest number of meetings held was 7 (in 3 prefectures), and 2 meetings or fewer were held in 15 prefectures. No meeting was held in 7 prefectures. Locations in which the promotion of regional medical care cooperation regarding mental disorders was discussed were recorded by less than half of the medical care plans. The names of the medical facilities that were recorded in many of the medical care plans included various functions, such as "facilities for emergency psychiatric care" and "dementia medical centers." However, medical care functions specific to various mental disorders and medical facility names including these functions were only recorded in approximately half of the medical care plans. Regarding target values for promoting medical care plans, the vast majority of prefectures recorded that the "average in- patient discharge rates occurred in under 1 year."A relatively large number of prefectures also recorded "suicide mortality rates". and the "number of dementia medical centers" ; however, there were hardly any records concerning "rates of in-patient hospitalization for medical care and protection lasting more than 1 year." Moreover, there were few records regarding the "number of patients (per 100,000 of population) hospitalized for medical care and protection each year" and the "percentage of patients receiving care in protective room isolation." While prefectural medical care plan contents are varied, definite improvements of psychiatric care through medical care planning are finally underway. Mental disorder medical care plans based on the Medical Service Law operate together with related documents such as the guideline based on the Mental Health and Welfare Act, Article 41 ; disability welfare plans based on the Comprehensive Support for Persons with Disabilities Act ; and long-term care plans based on the Long-term Care Insurance Act. Further implementation and assessment, and continued revision based on this assessment, are needed with regard to these related plans and guidelines.

In the JSPN postgraduate training guideline for certified psychiatrists, cognitive-behav- ioral therapy (CBT) is to be referred to, understood, and explained in psychotherapeutic treatments of certain mental disorders. The Japanese Association for Cognitive Therapy has annually sponsored the Cognitive Therapy Workshop for mental health professionals since 2000. The Japan Psychotherapy Week (JPW) has been a dream project of the present author to provide opportunities to learn such psychotherapies as psychoanalysis, Morita therapy, and CBT at the same place during the same periods of time, simultaneously or sequentially. The idea of the JPW has two sources: Differential therapeutics in psychiatry on one hand, and the Japan Digestive Disease Week on the other hand. The JPW2015 "East Meets West" was held at a traditional hotel in Kobe in the evenings of February 21 and 28, 2015. As described in Plato's Symposium, the audience was served food and drinks while listening to the speaker talk about psychoanalysis, Morita therapy, and CBT. The first evening began with making a toast, followed by opening remarks about the author's intentions regarding the JPW, based on excerpts from Zeami's Fushihaden (the Flowering Spirit). Two well-known psychiatrists majoring in CBT and Morita therapy gave an address, entitled: "What is a desirable encounter of East with West?" and "On psychotherapy having roots", respectively. In the second evening, a prominent psychiatrist in the field of psychoanal- ysis gave a lecture on"The power of words in psychotherapy". After drinking a toast, excerpts from Plato's Symposium were presented to identify Eros as a "great daimon" mediating between immortal gods and mortal human beings. The cognitive therapist showed how cognitive therapy has the power of incorporating ele- ments of interpersonal, behavioral, and psychodynamic approaches. The JPW has nothing to do with psychotherapy integration. Instead, cognitive therapy, as an intermediary, will vanish in the process of the JPW. When established, the JPW will further develop the psychotherapeutic competence of psychiatrists.

We report the activity of the initial-phase intensive support team for dementia in Kobe City. The severity of dementia of the people who received the support was moderate in two-thirds of them. It took more than one year for over 50% of the people to receive support from the initial identification of dementia to involvement by the support team. Approximately three- quarters of the individuals were admitted to long-term care services facilities after receiving the service provided by the support team. A diagnosis of dementia was obtained for only about half of the people. Although there are many issues regarding the support team, we concluded that this activity is very beneficial for dementia people and their families, and it should be extended everywhere in Japan.

The mortality risk of long-term and new antipsychotic drug use in Alzheimer's disease (AD) patients in Japan was studied to determine improved treatment protocols. One of the main findings was that newly prescribed users showed increased mortality. Therefore, the new use of antipsychotic drugs represents a distinct mortality risk, while those on long-term anti- psychotic therapy are suggested to be relatively safe.