Seishin shinkeigaku zasshi = Psychiatria et neurologia Japonica最新文献

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".

About half of inpatients in psychiatric hospitals in Japan are over 65 years old. Most of them are long-term inpatients with schizophrenia. The number of beds in psychiatric hospitals will probably decrease in 10-15 years. Local shift means that those long-term inpatients leave hospital and spend their lives more fully and more comfortably. Most of them are over 65 years old. However, the motivation of the government and mental hospitals to promote this local shift seems to be low. Most men- tal hospitals in Japan are private, and so such a shift may be against their interests. The gov- ernment wants to decrease the number of beds in mental hospitals due to international criti- cism and for financial reasons. But I'm afraid some may think that in 10-15 years, regardless of whether local shift goes good or bad, many long-term inpatients eventually die and beds at mental hospitals will subsequently decrease. So local shift is a 'time limited problem'. However, if many long-term inpatients leave mental hospitals, they will use mental clinics or other community-based mental health care. Also, cooperation with other agencies will be very important. If such community support fails, a revolving door phenomenon will develop.

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.

Shared decision making (SDM) is being considered increasingly important in today's medical practice. This approach should also be promoted in the field of mental health. We developed a question prompt sheet (QPS) for persons with schizophrenia as a decision aid to empower them with autonomy. We published it on the website as a free download available to the general public. The therapeutic relationships respecting otherness between mental health service users and professionals can be the basis of recovery-oriented support. This article aims to introduce the background and process of making a QPS and to rethink recovery and growth from the viewpoint of dialogism.

Context: Children and adolescents with intellectual disability often have various mental disorders and behaviour problems. Despite the limited evidence on the efficacy and safety of psychotropic medication use to children and adolescents with intellectual disability, clinicians often prescribes psychotropic medications for the management of problem behaviours.

Objective: We aimed to clarify the psychotropic prescribing practices for children and adolescents with intellectual disability.

Design: We conducted a 1-year cohort study of patients with intellectual disability aged 3-17 years using a large health insurance claims database in Japan.

Outcome measures: Psychotropic prescription, prescription duration, polypharmacy, and average dosage.

Results: Of 2,035 patients, the most prevalently prescribed psychotropic medications were antipsychotics (12.5%), anxiolytics/hypnotics (12.4%), stimulants (4.8%), mood stabilizers (2.4%), and antidepressants (1.8%). The prescription prevalences of anxiolytic/hypnotic and antipsychotics increased with age. Patients aged 6 years or older had around 2-fold higher prescription duration of antipsychotics (median duration of over 300 days per year) than those aged 3 to 5 years. The likelihood of polypharmacy and excessive dosage (defined as chlorpromazine equivalents of >300 mg/day) of antipsychotics increased with age.

Conclusion: We observed a higher prescription prevalences of anxiolytics/hypnotics and antipsychotics and a longer prescription duration of antipsychotics in the present study than those in previous studies. Our results suggest a need for developing clinical practice guidelines for the management of problem behaviours among children and adolescents with intellectual disability.

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.

In Japan, healthcare professionals and healthcare workers typically practice a culture of self-assessment when it comes to managing their own health. Even where this background leads to instances of mental health disorders or other serious problems within a given organization, such cases are customarily addressed by the psychiatrists or psychiatric departments of the facilities affected. Organized occupational mental health initiatives for professionals and workers within the healthcare system are extremely rare across Japan, and there is little recognition of the need for such initiatives even among those most directly affected. The author has some experience designing and operating a comprehensive health management system to support students and faculty at a university in the Tokyo Metropolitan Area that contains a medical school and university hospital. At this university, various mental health-related problems were routinely being allowed to develop into serious cases, while the fundamental reforms required by the health management center and the mental health management scheme organized through the center had come to represent a challenge for the entire university. From this initial situation, we undertook several successive initiatives, including raising the number of staff in the health management center and its affiliated organizations, revising and drafting new health management rules and regulations, launching an employment support and management system, implementing screenings to identify people with mental ill-health, revamping and expanding a counselling response system, instituting regular collaboration meetings with academic affairs staff, and launching educational and awareness-raising activities. This resulted in the possibility of intervention in all cases of mental health crisis, such as suicidal ideation. We counted more than 2,400 consultations (cumulative total number; more than half of consultations was from the medical school, postgraduate medical course, or hospitals) on a campus comprising 8,700 people, in which our problem-solving approach was able to achieve a certain degree of success in a majority of cases. Amid the increasing prevalence of mental ill-health and signs of worsening mental health problems in all areas of society, I look forward to the establishment of occupational mental health systems that are suited to medical institutions.

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.

"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.

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.