Seishin shinkeigaku zasshi = Psychiatria et neurologia Japonica最新文献

The pharmacokinetics of drugs vary markedly among patients. It is also necessary to aware that pharmacokinetics can change within the same patient. A typical example is drug interactions. Psychotropic drugs generally have a high plasma protein binding rate, which may increase the effects of medications taken concomitantly. Furthermore, psychotropic drugs often competitively inhibit the enzymes metabolizing drugs, and thereby increase the blood levels of concomitantly administered medications. On the contrary, there are also psychotropic drugs, which induce metabolic enzymes and thereby lower the blood levels of concomitant medications. As the number of drugs administered increases, these interactions become more complicated, creating increasing difficulty in estimating clinical effects. Therefore, multidrug combination therapy is not, based on pharmacokinetic considerations, recommended.

The problem of high-dose psychotropic polypharmacy has been pointed out for a longtime in schizophrenia, being referred to at the Annual Meeting of the Society in 2011. The fre- quency of high-dose psychotropic polypharmacy is much higher in Japan compared with other countries. The polypharmacy rate is about 65% for anti-psychotic drugs, and rates of high- dose antipsychotics are 30% or higher. The rates of combination therapy using anti-Parkinson drugs, anti-anxiety drugs/sleeping pills, and mood stabilizers with antipsychotics have also been reported to be 30-80% or higher. In 2014, a reduction of medical fees for multi-drug prescriptions of psychotropic drugs was made, but it is still too early to assess its impact. Against this background, we introduced the Guidelines for Pharmacological Therapy of Schizophrenia, created by The Japanese Society of Neuropsychopharmacology. We describe how high-dose psychotropic polypharmacy has been used to treat schizophrenia in Japan in these guidelines, being the first evidence-based guidelines using the Minds method. Further- more, a schizophrenic case with cognitive decline who received polypharmacy is presented. In addition, the EGUIDE project for the purpose of education and dissemination of these guide- lines is considered. It is our hope that patients with schizophrenia can receive more appropriate treatment.

Jungian Psychology was introduced to Japan in 1931 by Kokyo Nakamura for the first time in Sekai Daishiso Zenshu ("The Complete Works of Thoughts in the World") vol. 33. (Shunjusha Publishing Company). Yoshitaka Takahashi and others made Jungian Psychology more accessible to the Japanese public in the mid-1950s although they did not succeed in full repre- sentation of the fundamental ideas of C. G. Jung. It was Hayao Kawai who truly understood those ideas and initiated the Jungian movements in Japan in 1967. In my opinion, however, there are hardly any Jungian Analysts who develop Jung's ideas further enough to reach a new awareness of the human psyche except a very few people such as Neumann, E., and Gug- genbtihl-Craig, A., Kalff, D. M., Spiegelman, M., Meier, C. A. and Hillman, J., Giegerich, W, in the West and H. Kawai and me in Japan. Kawai develops and deepens Jungian thoughts to a cer- tain extent in his book, The Buddhist Priest Myoe : A Life of Dreams (Shohakusha Publishing Company), while his understanding of Buddhism does not exceed what D. T. Suzuki describes in his work, An Introduction to Zen Buddhism. That is to say the ideas of both Zen and Shin Buddhism are abstracted and assimilated in general Buddhism in his work, resulting in losing their unique features which could have been pursued further. Moreover, although Kawai translates Jung's idea of SynchronizitAt to "kyoji-sei" (synchronicity), I claim that "engi-ritsu" (the pratitya-samutpada principle) would be a more appropriate term to reflect the original concept as it would imply the opposite principle to"inga-ritsu" (the causal principle). It should be noted that the pratitya-samutpada principle is different from the Buddhist concept of pratitya- samutpada which includes causality. In addition I transcribed the Avatamsaka sutra, which originated in India and was developed in China. I also attended to the 2"d international confer- ence featuring the Avatamsaka sutra at Belesbat on the outskirts of Paris. Eventually I have reached an idea that when combined with the concept of the pratitya-samutpada principle, the Avatamsaka sutra could be considered as a-product of Eastern wisdom which would provide an insight beyond Jung. What was originally comprehended by Gautama Buddha was crystallised in abstract images of Amitabha and Vairocana in China during the second and fourth centuries. Amitabha is a celestial buddha that Shinran, the founder of Shin Buddhism, established his own understanding of in his school whereas Vairocana is a celestial buddha that appears in the Avatamsaka sutra. Vairocana could be taken as an image of the"rising sun", the creator of all things, while Amitabha as the "sinking sun", the saviour of all creatures. This picture of psychological cosmology gives a new perspective on the human psyche that would succeed Jungian Psychology. I believe this unique conception is equivalent to the findings in modern physical cosmology, such as Einstein's theories a

The new certificate psychiatrist system of the Japanese Board of Psychiatry is discussed from the viewpoint of the improvement of the current certificate psychiatrist system. In the new system, training items are applied each year for three years. Actually general items and particular disease items of the current training book are rearranged in the new sys- tem. The results of training psychiatrists are evaluated multi-dimensionally and two-way com- municatively. The instructing doctor evaluates the performance of training psychiatrists at the time of completing the program at all training hospitals and gives some feedback to the psy- chiatrists. Staff with multiple occupations also evaluate the training psychiatrists. The training psychiatrists also evaluate the instructing doctors and training program. The program man- agement committee of each basic training hospital collaborates with the training committee of the cooperative training hospitals to examine and evaluate the training results, and improve the program.

One of the main problems in the training of psychiatrists in Japan is psychotherapy. What is meant by "psychotherapy" in this context is not some special form of therapy, but the skills regarding constructing and sustaining therapeutic relationships in order to carry out daily medical practice smoothly. Those with skills in medical practice, in the case of psychiatric practice, will meet difficulties when facing patients' pathologies and personalities, and thus require professional training. In other countries, as a condition for acquiring the qualification of a psychiatrist, experi- ences on individual supervison are included. Supervision is productive in the sense of receiving evaluations on therapeutic relationships from the eyes of a detached observer and obtaining advice accordingly, and also in the sense of contributing to establishing identities as psychia- trists through one-to-one affective relationships with senior psychiatrists. In Japan, however, it is difficult to provide trained supervisors who can meet the needs of initial psychiatric training. The absolute number of supervisors is limited and they are not evenly distributed. Against this situation in Japan, for example, in the psychiatric departments of university hospitals and psychiatric offices of hospitals, they have made attempts to provide group consul- tations by inviting external consultants a few times a year. Although those attempts have a certain significance, they have demerits such as each resident can give a case presentation only once a year at the most, there are no chances to continually receive advice, and relation- ships with the consultants are not intense. In the Neuropsychiatry Department, University of Tokyo Hospital, a new training pro- gram, TPAR (Training in Psychotherapeutic Approaches for Residents), is in operation in order to overcome this situation. Residents form groups of 2 to 3 and visit a number of exter- nal consultants to receive continuous advice once a month. After 6 months, they rotate to other consultants. The advantages of this program are discussed from the perspectives of continuity, individuality, and subjectivity of the residents.

I have discussed BPSD, especially who should treat BPSD and who can treat them, from the viewpoint of the New Orange Plan. It is desirable for all the doctors to have extensive knowledge about dementia and engage in treatment in cooperation with other departments and, more comprehensively, with nursing-care insurance fields. During the period when a patient has mild BPSD and the burden on caretakers is light, it is possible for his or her family doctor to treat BPSD. However, when a patient has severe BPSD and is in a situation where care is difficult, non-drug therapy often becomes the first choice for the treatment and drug therapy second. In the case that neither of them are effective enough for treatment, short- term hospitalization on a dementia treatment ward (closed ward) in the psychiatric depart- ment is necessary. The doctors who are specialists in dementia consist mainly of psychiatrists, neurophysicians, brain surgeons, geriatricians, and doctors who belong to the Department of General Medicine. If we consider the characteristics of the role psychiatrists play in treating dementia, it can be said that psychiatrists are specialists in treating psychic symptoms, which constitute the core of BPSD. Since psychiatrists use antipsychotics far more often than doctors in other departments, they are specialized in prescribing an antipsychotic according to the symptom. In the case of severe BPSD, psychiatrists can hospitalize the patient on a closed ward and give treatment to him or her if necessary but at the minimum. In other words, psy- chiatrists are in an important position in treating dementia that is different from doctors of other departments, and a psychiatric department seems to be the only department which can follow dementia patients through all the stages of their dementia. I strongly hope that not only dementia-specialized doctors but also all other doctors will develop an interst in dementia, and that dementia patients can access effective services any- where in Japan. The problem of dementia concerns not only people engaged in medical and care businesses but also all people in the community, and I think that it is the most important for the whole of society to try to treat dementia.

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.

Since there is a growing need for psychiatric treatment in general hospitals, the decreas- ing number of treatment beds has become a marked problem in Japan. One of the financial reasons is a difference in the reimbursement of medical fees between medical treatments in physical departments of the same hospital. Our neuropsychiatry department has accepted patients with psychiatric disorders suffering from various physical complications in order to meet local or hospital demand ; however, it is the case that the psychiatric ward has been required to decrease the number of beds from the aspect of management rationalization. According to the comparative analysis of four practical cases treated on our ward, the reim- bursement of medical fees was much lower than medical fees for the same treatment if patients had been treated on general physical wards. This result is considered to show one of the difficulties of maintaining psychiatric wards in general hospitals. It is essential to improve the reimbursement of medical fees for psychiatric wards. Moreover, we propose introducing the DPC (Diagnostic Procedure Combination) into treatment, especially on psychiatric wards. The demand for psychiatric treatment at general hospitals will increase in the future due to Japan having the world's most rapidly aging society. Maintaining a clinical budget equal to the available resources will help avoid a decreasing number of beds.

The clinical introduction of rTMS for the treatment of depression is now progressing in Japan. On the basis of the successful results of a large-scale RCT, the US FDA approved an rTMS device in 2008, and four rTMS devices are now approved and used in several countries and the EC. The results of the meta-analysis of RCTs and the real-world naturalistic observa- tional studies show beneficial effects on treatment-resistant depression. The rTMS is generally well-tolerated and safe, but has a risk of seizure, with an estimated rate of approximately one in 1,000 patients. The rTMS is thought to be an effective treatment for those unable to benefit from initial antidepressant medication.