Seishin shinkeigaku zasshi = Psychiatria et neurologia Japonica最新文献

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.

The author outlined Morita therapy-based living-guidance (yojo) and inpatient treatment for depressed patients. He further discussed commonalities and differences between Morita therapy and "the third generation" of cognitive-behavioral therapies, such as behavioral activa- tion (BA) and mindfulness-based cognitive therapy (MBCT). Both Morita therapy and BA share at least a common view that it is effective to activate patients' constructive behavior at a certain point in depression treatment. In a corresponding manner, as MBCT emphasizes the "being" mode and Morita therapy, "arugamama, or being as is," they both state that the turn- ing point to break the vicious cycle (or "doing" mode) is accepting thoughts and emotions as they are. However, Morita therapists, compared with BA therapists, seem to pay more attention to the necessity of resting and appropriate timing for introducing behavioral activation. MBCT has patients concentrate their attention on their own aspirations and bodily sensations (medita- tion), while in Morita therapy, their attentions are naturally diverted through the practice of daily life. Besides the differences of cultural backgrounds, there seem to be differences in depression models between Morita therapy and "the third generation" of CBT. In the BA model, the cause of depression lies in a lack of positive reinforcement, and negative reinforcement resulting from the avoidance of the experience of discomfort. The cognitive theory of depression places the model of the vicious cycle among the elements of cognition, emotion, and behavior. In this regard, MBCT shares a common assumption regarding the pathogenesis of depression with conventional cognitive therapy. As BA and MBCT are based on psychological models of depression, both treatments have been primarily practiced by clinical psychologists. On the other hand, medical doctors mainly offer a psychotherapeutic approach with medication treat- ments for depressive patients in Japan. In this context, the practice of treating depression is based primarily on medical models of endogenous depression. This is also true of Morita ther- apy, but in a broad sense. While those who follow medical models in a narrow sense try to identify the cause of illness and then to remove it, Morita therapists pay more attention to the recovery process rather than the pathogeneses of depression and attempt to promote patients' natural healing-power. Therefore, it may be more appropriate to refer to the model used in Morita therapy as "a resilience model".

While long-acting injections (LAI) have arrived in Japan as a second-generation antipsy- chotic drug and LAI therapy for the symptom-stabilization phase is garnering attention, deaths associated with paliperidone (PAL) -LAI were sensationally reported, attracting interest regarding the safety of LAIs. In writing this report, an opportunity to oppose LAI usage was provided, so we raise the following three issues concerning the usage of the second-generation antipsychotic LAI for the symptom-stabilization phase. 1) Particularly notable adverse reactions of LAI are those acutely developed and in some cases fatal, including malignant syndrome, diabetic ketoacidosis, torsade de pointes due to pro- longed electrocardiogram QT, and leukopenia. All antipsychotic drugs come with the risk of such adverse reactions, and since the occurrence of adverse reactions cannot be predicted prior to administration, once they have developed, the offending drugs should be immediately reduced or discontinued to remove the drug from the body ; however, since this process can- not be followed with LAIs, such fatal adverse reactions may be protracted. Moreover, in the US, adverse reactions from post injection delirium/sedation syndrome (PDSS) have been reported in relation with olanzapine (OLZ) -LAI. This is a disease state in which the drug rap- idly flows into the blood following LAI intramuscular administration along with an acute increase in blood level, leading to significant sedation (lethargy in some cases) and/or serious symptoms accompanied by delirium ; therefore, in order to minimize these risks, the US FDA has made it mandatory to use a monitoring system referred to as REMS (Risk Evaluation and Mitigation Strategy)for OLZ-LAI. Whether or not the phenomenon occurs only with OLZ-LAI remains to be seen, so careful attention must be paid. 2) In Japanese psychiatric clinical sites, the current situation is that monitoring of adverse reactions for antipsychotic drugs, particularly with outpatients, is not sufficiently carried out Under such circumstances, there remain doubts when it comes to advocating -looking to replace oral drugs with LAI in the symptom-stabilization phase. 3) Replacing oral drugs with LAI in the symptom-stabilization phase significantly increases treatment costs as well as increasing the number of hospital visits. This increase in treatment cost and number of visits may have a large impact on the adherence of the patients to the drugs.

The objective of this article (and the corresponding symposium) was to assume an "oppo- sition" stance and argue against the presumed usefulness of long-acting injections (LAI) for the treatment of patients with schizophrenia. Here, LAI demonstrated limited patient applica- bility and were found to be used infrequently in Japan, with insufficient evidence to their effi- cacy suggesting that LAI would be more appropriate playing a supplementary role in the pharmacotherapy guidelines for schizophrenia. Additionally, any potential benefits of LAI have yet to be fully realized in Japan due to the fact that 80% of patients treated with LAI for schizophrenia are also prescribed antipsychotics orally, and a hesitance towards LAI by psy- chiatrists is likely to be reflected in their limited usage nationwide, an attitude which may present an ethical problem in terms of just principles.

"Guidelines for medical treatment and its safety in the elderly 2015" are the guidelines that position safety as the principal objective when a non-specialist performs medical therapy for elderly persons older than 75 years old, or an elderly person who is frail or needs nursing care younger than 75 years. When the guidelines were announced in April 2015, many public comments were received from patients, caregivers, care staff, medical doctors, and the medical society. The majority of the comments were regarding behavioral and psychological symptoms of dementia (BPSD). Many opinions about antipsychotics were from non-specialists, such as primary care doctors. This suggests that many non-specialists treat severe BPSD using antipsychotics, and that the further promotion of cooperation between non-specialists and psychiatrists is necessary.

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.

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.

I was dispatched to Okinawa Ishigaki Island in 1976 and, then after about thirty years, to Touhoku to provide medical aid due to a shortage of psychiatrists. On Ishigaki, I participated in outreach activities for local islands and was deeply impressed by the public health nurses and community mental health services. I also recognized important points of view about culture and psychiatry. I spent five years in Touhoku and then the East Japan Disaster hit area. At that time, many psychiatrists from throughout Japan supported our hospital, and we supported the disaster area. I describe my experiences in both places. I hope someday that young psychiatrists will join medical dispatch programs to such areas.

A diagnosis of drug-induced long QT syndrome is made when the QT interval corrected for heart rate (QTc) is 500 msec or above or is prolonged 60 msec or more after initiating, substituting, or increasing the dose of the drug, and it is considered that the risk of severe ventricular arrhythmia, referred to as torsade de pointes (TdP), increases under these condi- tions. Long QT syndrome is divided into the two broad categories of congenital or secondary, and among drug-induced long QT syndrome, which is classified as secondary, antipsychotic drugs are considered to be the most frequent cause of TdP, excluding anti-arrhythmic drugs. At the same time, escitalopram, which became commercially available in 2011, garnered attention in Japan due to administration contraindication in patients with prolonged QT. The guidelines of the International Conference on Harmonization of Technical Requirements for Regis- tration of Pharmaceuticals for Human Use (ICH) (E14) requires a detailed QT prolongation effect evaluation study (Thorough QT/QTc study) for new drugs, and in Japan, this has been adapted to drugs applied for on and after Nov 1, 2010. As a result of the study, escitalopram demonstrated a maximum of 11.8 msec prolongation from baseline when administered at 30 mg, which is the approved dosage overseas, and thus became contraindicated in patients with prolonged QT ; however, since the approved dosage of escitalopram in Japan is 20 mg/day, and since the study at our site indicated that other antipsychotic drugs may have a QT prolongation effect greater than escitalopram, our findings suggest the necessity to determine inter- drug differences and dose dependency of the antidepressant drugs and antipsychotic drugs that were commercially available before 2010 and are still used today, by conducting QT prolongation effect evaluation studies. Furthermore, the factors prolonging the QT intervals include a female sex, hypokalemia, hypomagnesaemia, bradyarrhythmia, various cardiac diseases, central nerve system diseases, drug interactions, and gene mutations; wherein, drug-induced long QT syndrome occurs due to the additive and synergistic effects of these factors, making it difficult to predict QT prolongation. Therefore, careful electrocardiogram monitoring is required in clinical settings.