Seishin shinkeigaku zasshi = Psychiatria et neurologia Japonica最新文献

Generalized, persistent, and free-floating anxiety was first described by Freud in 1894. The diagnostic term generalized anxiety disorder (GAD) was not in classification systems until the publication of the diagnostic and statistical manual for mental disorders, third edition (DSM-III) in 1980. Initially considered a residual category to be used when no other diagnosis could be made. The term GAD is not accepted as a distinct diagnostic category yet. Since 1980, revisions to the diagnostic criteria for GAD in the DSM-III-R, DSM-IV and DSM-5 classifica- tions have slightly redefined this disorder. The classification is fluid. This article reviews the development of diagnostic criteria for defining GAD from Freud to DSM-5. Excessive worry- ing impairs the individual's capacity to do things quickly and efficiently, whether at home or at work. The worrying takes time and energy; associated symptoms of feeling keyed up or edge, tiredness, difficulty concentrating, and depression. Individuals whose presentation meets crite- ria for GAD are likely to have met, or currently meet, criteria for unipolar depressive disor- ders. Comorbid depression are common in GAD and negatively impact treatment outcome.

The system of the specialty certification of psychiatry of the Japanese Society of Psychiatry and Neurology (JSPN) was established in 2005, and certification examination has been conducted since 2009. The Japanese Medical Specialty Board was established in 2014 in order to develop a new common specialty certification system encompassing 19 medical fields, and the training under the new system will be initiated in 2017. Under the new system, a core medical institution heads a group of medical institutions that consist of some hospitals and clin- ics for the specialty training program, and the core institution is responsible for the training and education of each resident. The committee of the certification examination of psychiatry in JSPN is responsible for administration of the examination. The aims of the examination, consisting of written and oral tests, are to assess knowledge, skills, and the attitude as a psychiatrist and decide whether or not an examinee meets the standards. Because the missions of the specialists are to treat severe and serious cases appropriately as well as to provide people with standard treatment, the role of the oral examination to assess clinical skills is important. However, there is not enough time or manpower to enrich the oral examination under the existing circumstances. Therefore, it is indispensable to assess the skills and attitudes of residents regu- larly and objectively in the training program. We need to discuss the specialty certification examination thoroughly in order to gain an image of the future of psychiatry in Japan.

Now, the psychiatric departments of general hospitals are unpopular workplaces for psy- chiatrists in Japan. However, I think there is a constant need for psychiatric departments of general hospitals, because the number of psychiatric departments of general hospitals with no psychiatric beds is increasing, even though the number of psychiatric departments of general hospitals with psychiatric beds is decreasing. Recently, there has been a trend of reevaluating psychiatry in medical care, such as in the medical treatments fees or in health care planning, so we cannot talk about medical care without involving psychiatry. The participation of gen- eral hospital psychiatry with a medical cooperation function is necessary for psychiatric reform from hospital-based to community-based psychiatry, as well as for the promotion of self-suffi- cient medical care in local communities based on medical cooperation. For psychiatry corre- sponding to high-grade acute medical care, the existence of general hospital psychiatry is nec- essary which has close contact with medical care and has a psychiatric acute care function, and adequate measures should be adopted in the national medical care fee and medical policies for the enhancement of general hospital psychiatry.

Various classes of antidepressants have been used in the treatment of major depressive disorder (MDD) ; however, treatment efficacy is inadequate, as 30-40% of patients do not expe- rience response even after sufficiently long treatment period with adequate dose of antidepressant. For the treatment-resistant patient to the therapy based on the generalized evidence, is it possible to provide an appropriate and improved treatment based on personalized medicine, taking into account predictable candidates such as sub-symptoms of depression and genetic factors instead? There is only little evidence for this in Japanese MDD, and consequently we use the evidence of Caucasians as reference, however, could we use the evidence of the popu- lation whose genetical, social, and cultural background are very different from Japanese popu- lation? In this review, I will refer to our randomized controlled studies that have some predict- able candidates including genetic factors designed for personalized medicine in MDD patients, and present an overview of procedures for making predictions of current treatment and pro- ceeding towards personalized medicine.

Drug combination therapy is sometimes used in clinical situations. CYP has been intensely studied numerous times ; thus, its pharmacokinetic interactions have been predicted to some extent. Basically, a drug interaction is defined as competitive inhibition of an enzyme by two drugs. We are concerned that fluvoxamine may have a drug interaction with paroxetine. Flu-voxamine inhibits CYPlA2 and CYP2C9 activity, and paroxetine inhibits CYP2D6 activity. However, recently, new drug targets have been identified, such as P-glycoprotein, a drug transporter. Fluvoxamine and paroxetine inhibit not only CYP but also P-glycoprotein. Additionally, there is an increased risk of upper gastrointestinal tract bleeding with the combination of a SSRI and NSAIDs. There are also individual differences in the pharmacokinetics of drugs due to genetic factors and individual differences in drug receptors, which have not yet been investigated for fluvoxamine or paroxetine. Obtaining clinical diagnoses of drug interactions is necessary in all patients.

This article describes the situation of psychiatric medicine and the system of dispatching medical doctors half a century ago in Okinawa, based on the author's knowledge and experi- ence gained as an expert participating in the mental health survey of Okinawa in 1966 (herein- after referred to as the Okinawa survey) and as the responsible officer of the Ministry of Health and Welfare in Japan in charge of dispatching medical personnel from mainland Japan to Okinawa. The Okinawa survey adopted the same high-level statistical methods as its counterpart mental health surveys in Japan. The survey clearly illustrated the situation of psychiatric dis- orders and psychiatric medicine in Okinawa, and influenced subsequent psychiatric medicine in Okinawa. After rejoining mainland Japan in 1972, the situation of psychiatric medicine in Okinawa changed markedly. In the Okinawa survey, the prevalence of mental disorders was 25.7 per 1,000 of the popu- lation, and the number of persons with mental disorders was estimated to be 24,060. Approximately 17,000 persons (71%) with mental disorders did not receive treatment or guidance. In 1966, mental institutions in Okinawa consisted of five mental hospitals and one clinic. The num- ber of psychiatric beds was 915. The Ryukyu Mental Health Law came into effect in Okinawa before rejoining mainland Japan. The characteristics of this law were the confinement of per- sons with mental disorders in private residences and the waiver of psychiatric medical fees using public resources. After rejoining mainland Japan, the confinement of persons with mental disorders in private residences was discontinued, but the waiver of psychiatric medical fees was continued. The Okinawa Mental Health Association contributed to psychiatric medicine and mental health services in Okinawa before rejoining mainland Japan. Taking the opportunity of the Okinawa survey, officers in charge of mental health services and public health nurses started mental health activities in public health centers. The dispatch of medical doctors is one of the medical supports for Okinawa. Psychiatrists are dispatched mainly from public mental hospitals such as the Shimofusa National Mental Hospital. Compared with 1966, the present situation regarding the quantity of psychiatric medicine, in Okinawa, such as the number of beds, has improved. It is expected hereafter that comprehensive psychiatric rehabilitation and stress care sys- tems will improve psychiatric medicine in Okinawa.

A deliberately crafted setting of intensive Naikan therapy has its base in traditional Japa- nese culture that attaches importance to practical and procedural knowledge. Whereas a ratio- nal explanation by using descriptive knowledge is valued in western society, Japanese society tends to value procedural knowledge. The contrast between these two values can be explained by a difference in understanding transcendent existences. In Western society, it has been understood in relation to logos related to logical orderliness. On the other hand, it has been understood in relation to WAZA, which has to do with a magical or hands-on knowledge. Both types of knowledge involve two phases in a process of development; construction and deconstruction. The deconstructive phase in which reformation and renovation of knowledge is induced consists of intuitive and holistic experience, which in Western Christian society is related to hypostasis-persona of the Trinity, while it is related to "sumu" from Shintoism in Japan. Both are symbols of the Creation, coming from the precipitative phenomenon, symbolized in liquid. Insight in psychotherapy is one with a person's experience of deconstructing procedural knowledge. Max Weber has discussed over these two kinds of knowledge and its construction/deconstruction moments. Reconsidering Weber's theory from a psychotherapeutic viewpoint will therefore give us a new key to understand the core of legitimacy of domination and a Tenno system of Japan.

Beginning in March 2013 and following again in May of the same year, warnings on the potential for medication-related impairment during the operation of motor vehicles were issued by the Ministry of Internal Affairs and Communication as well as the Ministry of Health, Labour, and Welfare. These notices have proven to be confusing for staff at psychiatric departments and pharmacies alike, as many widely prescribed psychotropic medications were included on the list. In response.to this issue, here I reviewed the aforementioned proscriptions as well as equivalent pronouncements from other countries and provided a brief overview on the subject from the point of view of pharmaceutical companies and regulatory agencies. The results showed that drug safety regulations in Japan were significantly more restrictive than the other countries surveyed for driving automobiles and operating machinery, and that the tone of the language used differed greatly from country to country. Additionally, observation of the current situation in the EU specifically reveals that, compared to Japan, the issue is being confronted much more proactively. Moving forward, it is recommended that Japan also, through the combined effort of regulatory agencies, academia, medical facilities, pharmaceutical companies and patients and their families, make greater efforts to adopt standards that assure traffic safety for the general public at large while concurrently respecting patients' right to freedom of movement and autonomy, even when receiving medical treatment.

In 2012, the Japanese government announced the Five-Year Plan for Promotion of Demen- tia Measures (Orange Plan). This plan was developed in the context of the realization of a community-based integrated care system to support the lives of persons with dementia and their family caregivers. The community-based integrated care system allows various services to be provided in an integrated manner, and is created in each community in accordance with the local circumstances and participation of local residents. The first pillar of the Orange Plan is the development and popularization of the standard Integrated Care Pathway (ICP) for dementia. Although few municipalities have developed ICP for dementia to date, the philosophy such as "Dementia-friendly Community" could be shared among residents and professionals in the process of development. Under the second pillar "Early Diagnosis and Intervention", the Initial- phase Intensive Support Team for Dementia (IPIST) was introduced and three types of Medical Center for Dementia were developed. However, to realize quality diagnosis and post- diagnostic integrated care throughout Japan each prefecture and municipality should consider the service-providing system for dementia depending on the local circumstances along with utilization of the national system. In 2015, Tokyo Metropolitan Government planned to deploy the MCD in all municipalities. Dementia Support Coordinators were also deployed in each municipality to facilitate access to diagnosis and provide post-diagnostic support in collabora- tion with the Dementia Outreach Team arranged at each MCD. In 2015, the government revised the Orange Plan and introduced the Comprehensive Strategy to Accelerate Dementia Measures (New Orange Plan). The most important point of this plan is to prioritize the standpoint of persons with dementia and their families when creating measures. Now we are enter- ing a new stage of the National Dementia Strategy.

Neurodevelopmental disorders, including attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD), are commonly associated with sleep disturbances. The etiology of sleep disorders is multifactorial, such as congenital vulnerability of the quality and quantity of sleep, congenital abnormality of the sleep-wake pattern, comorbid sleep problems with developmental disorders, and sleep disturbances associated with pharmacological treat- ment. Obstructive sleep apnea disorder (OSAS) and restless legs syndrome (RLS) are closely associated with ADHD. OSAS in children not only presents with symptoms of sleep distur- bances, but also with associated symptoms such as growth failure, neurocognitive and behav- ioral symptoms, ADHD-like symptoms, and enuresis. The first-line treatment is adenotonsillec- tomy. ADHD and RLS show high rates of comorbidity with common etiologies like iron defi- ciency and the alternation of dopamine transporter expression. Hypnotics are not effective for RLS, and a precise diagnosis is vital to treat RLS associated with ADHD. ASD is also associated with a high frequency of sleep disorders, especially insomnia, para- somnia, and sleep-wake disorders. The first strategy against sleep disturbances is behavioral intervention ; however, pharmacological treatment is sometimes needed. In clinical practice, excessive daytime sleepiness was reported in children with ADHD or ASD, which might lead to a deficit in alertness. Alertness deficits associated with neurodevel- opmental disorders remain uncertain, and so they should be assessed. The effect of stimulants on sleep in patients with ADHD differed among individuals, which might be the cause of insomnia and also treatment for ADHD and sleep hygiene. Non-stimu- lants are often effective for insomnia. Neurodevelopmental and sleep disorders are complex and bidirectional. Sleep disturbances should be taken into consideration in daily clinical practice.