Seishin shinkeigaku zasshi = Psychiatria et neurologia Japonica最新文献

The UK National Institute for Health and Care Excellence (NICE) is a non-departmental public body accountable to the Department of Health. NICE was established in 1999 in an attempt to reduce variability in the availability and quality of medical services in NHS to end the so-called postcode lottery. Since its establishment NICE has acquired an international reputation for the development of high quality, evidence-based clinical guidelines. NICE also makes cost-benefit assessments of certain technologies on the basis of effectiveness and cost effectiveness. In order to develop a NICE guideline related to psychiatry, the National Collaborating Centre for Mental Health establishes a Guideline Development Group that consists of technical experts, health and/or social care professionals, and lay representatives. The group searches for and evaluates the available evidence and formulates a series of clinical recommen- dations following which stakeholders are consulted and revisions occur. As well as providing treatment recommendations for healthcare professionals, the guidelines are also intended to inform patients, helping them make decisions and improving communication between patients and healthcare staff, and also to direct the focus of research. To date, NICE has published guidance on antenatal and postnatal mental health, antisocial personality disorder, attention deficit hyperactivity disorder, bipolar disorder, borderline personality disorder, dementia, depression, depression in children and young people, drug misuse (opioid detoxification and psychological interventions), eating disorders, obsessive-compulsive disorder, PTSD, schizophrenia, and the management of self-harm. We describe how, both directly through education and effects on clinical pathways, and indirectly through effects on health providers and patient behavior, NICE guidance has had an impact on psychiatrists working in UK.

At present, there are a variety of guidelines for psychiatric and other departments. In general, guidelines are positioned as specific documents of reference suggested for clinical settings that state appropriate health care services to be provided. However, since many types of guidelines with varying characteristics are often published by academic societies and organiza- tions, it is difficult to assess clinical guidelines unambiguously. The Medical Information Net- work Distribution Service, operated by the Japan Council for Quality Health Care with the support of a Grant-in-Aid for Scientific Research from the Ministry of Health, Labour, and Welfare, collects, assesses, and selects clinical guidelines published in Japan. On the other hand, in medical lawsuits filed to determine whether malpractice has occurred, guidelines serve as evidence that provides reference standards for principally judging faults or negligence. When courts make decisions regarding duties of care imposed on physicians and their violations, they tend to emphasize clinical guidelines developed by medical societies and other organizations, and establish the norm of conduct of "these guidelines". This is significantly different from the medical community's view of clinical guidelines. The medical and judicial communities are cur- rently being advised to deepen mutual understanding of these guidelines.

In recent years, novel antidepressants and mood stabilizers for major depressive disorder and bipolar disorder have arrived on the market, and older psychiatric medications have also come to be indicated for these disorders as well. For this reason, pharmacotherapy treatment strategies for said diseases have become increasingly diverse and complex. With this fact in mind, this paper reviews the combination of medications that are the most evidence-based and logical for polypharmacy in the following cases: combined antidepressants for major depres- sion, combined antidepressants and mood stabilizers for bipolar depression, and combined mood stabilizers in maintenance therapy for bipolar disorder. In addition, I attempt here to clearly define treatment-resistant depression and detail some of the most important considerations for avoiding cases of false treatment-resistant depression. Finally, I proffer a few personal suggestions for simplifying polypharmacy in the two disorders.

The major role of occupational physicians is to facilitate workers' communication with managers and primary physicians. In other words, occupational medicine is similar to consulta- tion-liaison psychiatry. Psychiatrists should not decide whether patients can return to the workplace solely based on their symptoms of mental disorder; their work performance and potential to cooperate with other workers in the workplace should also be considered. In order to achieve this, it is important to promote close cooperation between occupational physicians and psychiatrists. The aim of the stress check system in Japan is the primary prevention of mental disor- ders. However, it is necessary to provide care for groups and individuals, which is in accor- dance with the concept of first aid. It is useful for occupational physicians to liaise with psychi- atrists when they encounter the critical case of a patient with mental health problems.

The certified public psychologist (tentative name) was introduced as a versatile profession, which covers the fields of medical, healthcare, welfare services, industry, and law. In this study, I report the process of how certified public psychologists were introduced, indicate their char- acteristics in the medical field, and make proposals on their expected roles and associated tasks. Since their professional involvement in psychiatric care, healthcare, and welfare settings has shifted from hospital- to community-based care, the care system has also changed from a team-based care approach to a multi-professional collaborative system. Experts involved in the multi-professional collaborative system are required to exert their skills based on professional knowledge and experience, and also to be equipped with human strengths as a generalist based on experience accompanied with wide-ranging education. Responding to such a trend, in addition to the payments made for each of their services, such as psychological assessment, treatment, and education, I would like to request financial reimbursement by the medical fee system for professionals working in team-based medical and multi-professional collaborative settings. I strongly hope that certified public psychologists, who have been involved in the medical field for more than half a century, will become financially secure upon being certified through a national qualification, and play an active and worthwhile role as full-time employees in each setting while responding to the needs and expectation of patients, clients, and other medical workers.

In Japan, Clinical Practice Guidelines are defined as a document that presents appropriate recommendations to assist patients and practitioners in making decisions regarding clinical practice of marked importance, based on the body of evidence evaluated and integrated by systematic reviews and the balance between benefits and harm outlined by the Medical Information Network Distribution Services (Minds). Their successful implementation should improve the quality of care by decreasing inappropriate variation and expediting the application of effective advances to everyday practice. The process of developing CPGs includes dissemination, implementation, and assessment after publication. Some of the countries or guideline developers conducted research on factors of facilitators and barriers influencing the imple- mentation of CPGs. In Japanese mental health, little is known about the influence of CPGs. To gain an understanding of the current status of CPGs for mental health, we collected all published CPGs using the following databases: Minds website, Toho University and ICHUSHI Clinical Practice Guidelines Database, and J-GLOBAL. As a result, we found 1,117 articles. Because of the overlap among the 3 databases, trans- lated versions of foreign CPGs, commentaries, and review articles, 78 CPGs were extracted. We categorized the 78 CPGs into the following types : disease, writers, publication year, method of development, publication type, and revised or not. Through this survey, we found that there are many CPGs, they are difficult to identify, and their implementation and dissemination rates are unclear. CPGs are one type of medical information, and their use causes some challenges. When we develop CPGs, we have to per- form a systematic review of the evidence. It is known that there is a gap between evidence and practice in healthcare research. Also, multimorbidity is now very common. CPGs are gen- erally developed for a single disease, and so the application of CPGs is difficult when a patient has more than one disease. Although CPGs for mental health are being developed in Japan, there have been few studies on the influence, barriers, and facilitators of dissemination and implementation. Further research is needed on how to utiliz medical information effectively in order to improve the quality of health care.

This paper considers what psychological support should be provided for children and ado- lescents with gender dysphoria based on lessons learnt as a member of a comprehensive medi- cal care team for patients with Gender Identity Disorder (GID), and as a school counselor (SC). The characteristics of adult patients with GID and the results of psychological tests, together with the issues and problems these patients experienced in childhood are analyzed. The need to provide care in consideration of their low self-esteem caused by the inconsiderate remarks of others, how to lessen the conflicts arising from the stereo-typed gender images imposed at school, and the capability to face gender dysphoria and build their future are pointed out Based on actual school cases, ideas for the support needed for these children and adolescents with gender dysphoria are presented. This takes a developmental viewpoint of a clinical psychologist who endeavors to provide children and adolescents with a safe place to talk about gender dysphoria problems, and serve as a liaison between the school and home.

Background: Burnout is a psychological condition that may occur after being exposed to excessive and prolonged work-related stresses. Previous studies have demonstrated that the rate of burnout among physicians may be higher compared to other occupations ; and espe- cially psychiatric trainees would have a higher risk of burnout because of limited clinical expe- rience, the burden of heavy duties and longer work-hours etc. In this study, we report the findings from Japanese data obtained as part of the international study of burnout syndrome among psychiatric trainees (BoSS International).

Methods: This study was initiated by members of the European Federation of Psychiatric Trainees (EFPT) and the European Psychiatric Association-European Early Career Psychia- trists (EPA-EECP). The total number of participating nations was 22 countries. A national coordinator recruited study collaborators all over Japan and psychiatric trainees working at their medical institutes were invited to participate in BoSS International by e-mail. The sub- jects were requested to answer the on-line questionnaire anonymously. Consent was obtained when making a list of potential participants at each institute and reconfirmed on the first page of the on-line questionnaire. Answering the questionnaire was deemed to constitute consent.

Results: Total number of participants to BoSS International was 7,525 from 22 countries and regions. Of them, 1,980 psychiatric trainees fully completed answering the questionnaire (response rate (RR) 26.0%) including 95 Japanese trainees (RR 41.5%). The mean age of 95 Japanese psychiatric trainees (male rate 67.4%) enrolled in BoSS International was 31.8?4.8 year-old. Their mean clinical experience was 2.9 ?4.4 years. The mean weekly working hours were 72.3?27.1, which was the longest of the 22 participating countries/regions ; while weekly clinical supervision by a mentor was only 3.8?9.0 hours. Regarding the severity of burnout, assessed by using the Maslach Burnout Inventory-General Survey (MBI-GS) consisting of three factors (emotional exhaustion, cynicism, and low sense of professional efficacy): 41 Japanese psychiatric trainees (42.0%) meet the criteria of severe burnout syndrome in this study ; with emotional exhaustion scores of 2.20 and higher, and cynicism of 2.00 and higher. Signifi- cant differences were found on the PHQ-9 score and mean length of supervision between those participants with presence and absence of severe burnout syndrome by using Student's t-test.

Conclusion: Statistical analyses of the whole data (n=1,980) revealed that the risk of burnout was higher for trainees who were younger, without children, and had not opted for psychiatry as a first career choice. Further analyses after adjustment for socio-demographic characteristics and country difference still demonstrated severe burnout was associated with long working hours, le

Some children who have had gender dysphoria since early childhood experience distress at the first signs of their secondary sex characteristics. This might have a strong negative effect on their emotional and social functioning as well as on their school lives. Physical inter- vention should be considered for such adolescents ; however, gender identity can also fluctuate during that period. Therefore, it is difficult to use cross-sex hormone therapy as a way to mas- culinize or feminize the body for early adolescents, because such hormones have partially irre- versible effects. Worldwide, puberty suppression therapy is recommended for such pubescent children, as it is recognized as reversible physical intervention. For puberty suppression, gonadotropin-releasing hormone agonists (GnRHa), which stop luteinizing hormone secretion, are used. This consequently stops the secretion of testosterone in genetically male patients and production of estrogens and progesterone in genetically female patients ; as a result, the physi- cal changes of puberty are delayed. When GnRHa is stopped, the progress of puberty restarts. This therapy is also mentioned in the 4th edition of the Diagnostic and Therapeutic Guidelines for Patients with Gender Identity Disorder (The Japanese Society of Psychiatry and Neurol- ogy). According to those guidelines, we can use this therapy for early adolescents after they have reached Tanner Stage 2. Although this intervention is new to Japan, there is some evi- dence from other countries supporting such applications. Furthermore, in Japan, pediatric endocrinologists have used GnRHa for young patients with precocious puberty for a long period of time, and this has proved the safety of this treatment for children. More experience and data in this area are needed. Furthermore, we have to establish closer cooperation with child mental health specialists, such as pediatric psychiatrists, school counselors, and teachers, so that proper treatment may begin at the right time for more patients. Psychotherapy or psy- chosocial support, on its own, is sometimes not enough to reduce the physical dysphoria of transgender patients, and the innate sex steroids also have irreversible effects on gender dys- phoric children. When we decide not to intervene in cases of gender dysphoric children with hormonal treatments including puberty suppression, we are actually deciding to intervene by leaving them with their inherent hormones. We have to be conscious of the fact that"withhold- ing puberty suppression and subsequent feminizing or masculinizing hormone therapy is not a neutral option for adolescents (Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7)."

The committee of conflict of interest of the Japanese Society of Psychiatry and Neurology has been promoting awareness of Conflict of Interest (COI) among society members. The soci- ety publishes two academic journals: "Psychiatria et Neurologia Japonica(Seishin Shinkeigaku Zasshi)" in Japanese and "Psychiatry and Clinical Neurosciences (PCN)" in English. The integrity and fairness of the content should be guaranteed in medical journals. Inadequate dec- laration of COI may damage the reliability of a study. If the authors have a financial relation- ship with any providers, the reader may doubt the impartiality of the analysis of the data and discussion of the results. If the authors intentionally hide COI, the study may be viewed nega- tively by the society, even if it was carried out correctly. "Seishin Shinkeigaku Zasshi" requires authors to disclose their COI according to the COI guideline of the society. In most cases, they obtain grant support from the government, dona- tions from industry, or a speaker's honoraria. All authors of the paper must disclose their own COI. The corresponding author must bear in mind that all authors are responsible for the sub- mitted paper. It is important for the authors to determine whether there are any COI from a third party's point of view. In the PCN journal, COI must be declared according to the ICMJE form for COI disclo- sure. This form is different from the COI guideline of the society. In the ICMJE form, minor financial interests do not need to be declared, but if there are any non-financial COI, they should be declared.