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.
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.
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.
Minds (Medical Information Network Distribution Service) is an information service provided by the Japan Council for Quality Health Care (JCQHC), a public interest incorporated foundation. The Minds guide for developing clinical practice guidelines was published in 2014. The aim of the Minds project is to help medical practitioners fully utilize information related to evidence-based medicine (EBM) in their practice. Minds also provides patients and the public with information to help understand the basics of diseases and share up-to-date evi- dence with doctors, on which modern medical practices are based. Overall, clinical practice guidelines are made up as follows : 1) a three-layered structure of guideline committees con- sisting of a managing committee, guideline creation team, and a systematic review team, 2) a clear description of the basis for an individual's judgment and COI, 3) evaluation of the body of evidence summarized for every outcome and study design in all selected research reports for each Clinical Question (CQ), and 4) not only the "benefit" but also the "harm" in the patient outcome caused by intervention are to be included in the evaluation. According to the Minds method, the Japanese Society of Neuropsychopharmacology has created a "Guidelines for Pharmacological Therapy of Schizophrenia." These guidelines were introduced to explain the characteristics of the Minds method in this paper. The Effectiveness of GUIdelines for Dissemination and Education in psychiatric treatment project (EGUIDE proj- ect) was also introduced to disseminate and evaluate these guidelines.
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.
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.
Our study mainly focused on summarizing the history and issues of the Sports for People with Mental Health Problems in Japan. Since it had been shifted from inpatients activity to a community based sport activity, it was the matter of great urgency for us to expand and rein- force its organizational foundation. The first competition of volleyball for people with mental health problems was held on 2001, and since 2008 the Sports for People with Mental Health Problems was officially admitted to participate in the National Sports Festival for People with an Impairment. The basic principal required protecting participants' privacy at the same level of other disabilities. We needed clearly define the qualification for participants, such as restricting participants only with disability certification issued by Japan Federation for Mental Health and Welfare. Furthermore, the first International Symposium/Meeting on Sport for People with Mental Health Problems was held in Tokyo in 2013, and the first international sports competi- tion for people with mental health problems was held in Japan, which was a milestone for the internationalization of World sport championship for people with mental health problems. For the upcoming the Japan Olympic and Paralympic in 2020, we recognize the public interests for sports for people with mental health problems. It is the great opportunity for us to trigger to popularize it. Since the activities with all three types of disability will grow not only in sports but also in other fields, it is very important to bring information together.
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, less supervision, and not having regular rest. The analyses of Japanese data showed similar tendencies, although statistical significance was not observed. Burnout among psychiatry trainees may be linked to drop-out from the training program and malprac- tice in clinical settings. We should be aware of the higher risk of burnout in residents and the importance of regular and sufficient supervision to prevent burnout.
In this thesis, the historic circumstancs of enactment of and the forthcoming issues related to "the Certified Public Psychologists Act" are reported."The Certified Public Psychologists Act" was established thanks to the united efforts of a great number of the persons concerned, and the Act is scheduled to take effect in September 2017."The Certified Public Psychologist" is an occupational register: it is a qualification without which a person is allowed to deliver relevant services, but not permitted to feign a "Certified Public Psychologist". And since the Certified Public Psychologist is a general qualification, psychologists with the qualification are allowed to work in various fields such as educational area, medical/clinical area, forensic/criminal area, and industrial/occupational area. Mental problems in the modern society arise, in many cases, from various multidimensional factors which are intertwined and mutually related. Psychologists, in offering professional support in actual settings, need to be aware of their accountability that theories and skills are right for the supports. In addition, a sense of balance is required in collaboration, or team approach. It is emphasized that enhancing the systems for training and education is an urgent issue because continuous exertion to improve the compre- hensive capacity as professionals for future is indispensable.
The certified psychologist is a cross-disciplinary profession ; thus, the qualification test and curriculum should cover not only medical but also non-medical areas. The number of men- tal health professionals working in medical areas is high. Knowledge and skills in the health care area are necessary for certified psychologists and candidates. Knowledge covers laws and systems of medical services, including medical safety and infection control, and medical knowledge at the non-professional/patient level. In the general medical area, skills of: 1) having multilevel perspectives, 2) understanding dynamics and collaborating, and 3) facilitating com- munication with difficulties, are necessary. When going down the clinical river, holding an OAR [Open, Available, Responsible] is significant, not only for those who working in the medical area but for everyone, because every certified psychologist is obligated to cooperate.
It is considered that professionalism is a virtue as a personal attribute, competency is an observable behavior, and professional identity formation is a form of socialization. Social accountability is believed to be an important attribute of medical professionalism. A true professional struggles with complicated and/or ambiguous clinical problems of our modern society, and he/she grows up in the course of managing such difficult cases with iterative reflection. A reflective practitioner is someone who can practice in such a way. A reflective practitioner dealing with social problems is a true professional. Significant Event Analysis (SEA) is one of most valuable learning strategies to become a reflective practitioner.
The legally defined certified psychologist is going to enter into the medical care system in 2019. In Germany, where the medical insurance is obligatory like in Japan, the authorized psy- chological psychologists are already functioning. There are similarities and differences between these psychological practitioners. German psychological psychologists are permitted both to have their own practices and to work in hospitals. Patients are allowed to visit them directly to be treated if they wish. The psychological psychologists are also authorized to claim medical treatment fee on medical insurance. The amount of their medical treatment fee is so much as that of psychiatric specialists on the whole. They are neither permitted to prescribe medicines nor to issue a medical certificate. They must ask them to a medical doctor. Like German's, neither prescription nor issue of a medical certificate are included in the authority of Japanese certified psychologists. They are not permitted to have a practice. It seems to be reasonable that every doctor can give them orders of psychotherapeutic treat- ments, as mentally sick patients are increasing in every field of clinical medicine. However it may probably be only psychiatrists who can understand and evaluate their profession appro- priately, therefore it would be suitable that psychiatrists participate somewhere in this order- ing and evaluating system. The medical treatment fee should be paid enough to the certified psychologists.
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 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), Gender dysphoria (GD) is defined as a marked incongruence between one's experienced/expressed gender and assigned gender. Clinical pictures of GD in children show marked diversity. Because of their limited ability to express themselves verbally, children with GD might not be able to describe their discomfort or distress about this incongruence. In contrast to GD in adulthood, GD in children could be alleviated in the natural course. Thus, the clinical diagnosis of GD in children should be made carefully. Distortion of gender identity is equal to prominent confusion of identity, and has a huge psychological burden on children with GD. In addition to the distress due to dysphoria about gender, children with GD could suffer from bullying at school, loneliness among school peers or even in their family, and feelings of disgust about their physical appearance that could cause decreased self-esteem and a sense of worthlessness. In 2015, the Ministry of Education, Culture, Sports, Science and Technology (MEXT) in Japan encouraged all school teachers to provide appropriate support at school to sexual minor- ity students, including students with GD. Furthermore, MEXT published a manual for school teachers to promote necessary interventions for such students at school. There are several papers reporting child cases of GD and comorbid psychiatric disorders. Among them, autism spectrum disorder (ASD) is one of the common comorbidities. Reflecting these conditions, recent review articles discuss possible associations between GD and ASD. In this paper, based on the first author's clinical experience, we describe the clinical symp- toms and diagnosis of GD in children, the relationship between GD and ASD, gender-related manifestations observed in ASD, and practical support for children with GD entering primary school.
In 2010, the Ministry of Education, Culture, Sports, Science and Technology (MEXT) in Japan strongly recommended that students with gender identity disorder (GID) who had behavioral health concerns should consult a professional in their schools. Furthermore, in 2015, MEXT subsequently announced that it is important for sexual minority students, including students with GID, to receive more support from professionals through cooperation with medical institutions. However, there has been no nationwide clinical research done on sexual minority youth, so little is known about how to optimally care for them in medical practice. This study assessed the current status of medical care for children and adolescents with GID and other atypical sexual development. The authors surveyed certifying physicians and councilors (315 people in total) of The Japanese Society for Child and Adolescent Psychiatry. The question obtained basic demographic and practice information and allowed for free responses on topics such as opinion on consultation and medical care for GID and atypical sex- ual development in childhood and adolescence. One hundred twenty-seven, or 40.3%, of those surveyed responded. The average number of years of total clinical experience was 23.9, and the average number of years of child psychiatric clinical experience was 18.8 years. The number of child psychiatrists who provided con- sultation for GID and other sexual development including transvestism and gender dysphoria were 88 (68.5%) and 105 (81.9%), respectively. The consultants' most frequent clients, in descending order, were: individuals, parents, and school officials. Seventy-four (57.5%) child psychiatrists provide medical care for patients with GID. In the preschool and elementary school age groups, consultants served many more (assignment) males than (assignment) females with GID, whereas in the higher elementary school and later ages, consultants served more females than males with GID equally often. In junior high school and later ages, consultants served more females than males with GID. Eighty-seven (67.7%) of the child psychiatrists provided medical care for patients with other sexual development. Before and during the mid- dle elementary school ages and in the high school ages, consultants served more males than females with other typical development, whereas in higher grade elementary and junior high school ages, consultants served more females than males with other typical development. The free response sections revealed a diversity of opinions, clinical course, and cooperation with other institutions. At present, among child psychiatrists, there are many different perspectives on clinical care for GID and other sexual development. Therefore, it will be necessary to systematically examine current scientific evidence and to establish consensus on best practices for clinical management.
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 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 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.
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.
