[Cooperation with primary care physicians on the issue of suicide prevention].

The "General Outline of Comprehensive Suicide Prevention Measures," formulated in 2007, places heavy emphasis on the role of primary care physicians (hereinafter "PC physicians") in preventing suicide, calling for improvements to their diagnostic and treatment capabilities, as well as for increased availability of appropriate psychiatric care. The following are study findings from Shimane Prefecture, Japan. 1. Among PC physicians, 38.4% had experienced the suicide of outpatients. For internists, the figure was 55.6%, while for physicians in other specialties it was 17%. 2. In the greater Matsue area, of the 948 new patients seen at psychiatric hospitals and clinics between June and August, 2009, 29.6% had been referred from PC physicians. Of the referred patients, 25.3% exhibited suicidal ideation (17.8% classified as mild, 5.7% as moderate, and 1.8% severe), while 12.5% had attempted suicide (6.4% classified as minor attempts, 3.9% as moderate, and 2.1% as serious). 3. In the greater Izumo area, although 73% of family doctors are treating patients with symptoms of depression, 38% of physicians noted the absence of specialists with whom they can consult. This highlights the need for greater availability of local psychiatric consultation services. 4. In the greater Masuda area, which had a very high suicide rate, a model suicide prevention project was implemented over two years, beginning in 2004. The project put great emphasis on cooperation between numerous concerned entities and organizations. Notable aspects of this project included cooperation between medical institutions and psychiatric hospitals, as well as efforts to promote the use of self check mental health assessments at the time of regular health checkups, after which persons with mental health issues were provided with support at the checkup site, as well as at medical and other facilities. Another element of the program consisted of the proactive implementation of home visits by public health nurses. These approaches are believed to have contributed to the decline seen in the suicide rate, from 48.9-58.1 per 100,000 population in 2001-2003, to 19.8-36.7 per 100,000 population in 2008-2010. 5. The findings of this study illustrate the fact that many PC physicians have experienced the suicide of outpatients, and endeavor to refer patients with mental health issues-including suicidal ideation and attempted suicide-to psychiatrists. Findings also show, however, that PC physicians are struggling due to a lack of psychiatric specialists available for consultation. Comprehensive measures to prevent suicide, including efforts by PC physicians and cooperation with psychiatrists, are effective. It is therefore necessary that plans for local medical services include cooperation between a wide variety of consulting organizations and medical services, as well as construction of a framework that organically links non-psychiatric medical institutions with departments of psychiatry.

A disynaptic pathway from the central amygdaloid nucleus to the paraventricular hypothalamic nucleus via the parastrial nucleus in the rat.

The organization of projections from the central amygdaloid nucleus (CeA) to the paraventricuilar hypothalamic nucleus (PVH) has been studied in order to understand the anatomical substrates of amygdaloid modulation of endocrine and autonomic functions, and a hypothesis that the bed nucleus of the stria terminalis (BST) may act as a relay site between the CeA and PVH has been proposed. Using anterograde and retrograde tract-tracing methods, in the rat, we first indicated that neurons in the parastrial nucleus (PS), where projection fibers from the central amygdaloid nucleus (CeA) terminated, sent their axons to the paraventricular hypothalamic nucleus (PVH). We further demonstrated that the CeA terminals formed symmetrical synaptic contacts with somata and dendrites of the PVH-projecting PS neurons, and that the PS received CeA fibers predominantly from the lateral part and sent large numbers of projection fibers to almost all the subdivisions of the PVH. Using anterograde tracing combined with the postembedding immunogold method, we finally revealed that nearly all the CeA terminals in the PS were immunoreactive for gamma-aminobutyric acid. The present data suggest that output signals from the CeA are transmitted disynaptically to the PVH neurons via the PS neurons and modulate PVH neuron activity by way of disinhibition.

Breath-holding spells in somatoform disorder.

Breath-holding spells (BHS) are commonly seen in childhood. However, there are no case reports of BHS occurring in adolescents or young adults. We report two young adult cases and discuss the pathogensis, both physically and psychologically. BHS occurred for 1-2 minutes after hyperventilation accompanied by cyanosis in both cases. Oxygen saturation was markedly decreased. Each patient had shown distress and a regressed state psychologically. These cyanotic BHS occurred after hyperventilation, and we considered that a complex interplay of hyperventilation followed by expiratory apnea increased intrathoracic pressure and respiratory spasm. Breath-holding spells can occur beyond childhood.

Korsakoff syndrome following chronic subdural hematoma.

We describe a patient who developed Korsakoff syndrome following a spontaneous chronic subdural hematoma. The present case demonstrates persistence of both amnesia and confabulation long after recovery from the acute phase of spontaneous chronic subdural hematoma. There are few reports describing persistent amnesia with confabulation following brain damage. We considered that chronic subdural hematoma in the bilateral frontal and temporal lobes caused amnesia and confabulations, and these conditions persisted as a result of organic atrophic changes of both the frontal and temporal lobes due to long-term compression by chronic subdural hematoma.

Successful electroconvulsive therapy in major depression with fluvoxamine-induced bruxism.

SUMMARY: A 61-year-old patient with major depression and selective serotonin reuptake inhibitor-induced bruxism was successfully treated with a course of bilateral electroconvulsive therapy. Both the depressive symptoms and bruxism completely remitted after six treatments. Possible mechanisms of this effect are discussed.

Sleep disturbances and depression in the elderly in Japan.

UNLABELLED: The purpose of the present study was to evaluate the relationship between sleep disturbances and depression in the Japanese elderly. METHODS: These investigations in the Japanese elderly were carried out with the Geriatric Depression Scale, the Pittsburgh Sleep Quality Index, and questions on restless legs syndrome and nocturnal eating disorder. A total of 2023 people (male: 1008; female: 1015; average age: 74.2 +/- 6.3 years) were analyzed by chi2 test and simple and multiple logistic regression. The prevalence of sleep disturbance was 37.3% and that of depression was 31.3%. Female gender and/or older (> or =75 years) age were significantly associated with depression. Characteristics in depressive elderly were poor sleep efficiency, sleep disturbances due to difficulty of initiating sleep (DIS), breathing discomfort, coldness and pain, poor subjective sleep quality and lack of enthusiasm for activities. Sleep disturbances due to using the bathroom, breathing discomfort and coldness and long sleep latency were associated with depression in younger (65-74 years) men. Sleep disturbance due to DIS was associated with depression in older (> or =75 years) men. Sleep disturbance due to pain was associated with depression in younger and older women. Poor sleep efficiency was associated with depression in older women. Poor subjective sleep quality was associated with depression in younger and older men and younger women. Lack of enthusiasm was associated with depression in younger and older men and older women. Restless legs syndrome was statistically significantly associated with depression in younger men. It is concluded that sleep disturbance and depression among the Japanese elderly are closely related symptoms. The features of sleep disturbance with depression differed with sex and age.

Successful treatment of nocturnal eating/drinking syndrome with selective serotonin reuptake inhibitors.

Nocturnal eating/drinking disorder (NE/DS) is a rare syndrome that includes disorders of both eating and sleeping. It is characterized by awakening in the middle of the night, getting out of bed, and consuming large quantities of food quickly and uncontrollably, then returning to sleep. This may occur several times during the night. Some patients are fully conscious during their nocturnal eating, while some report total amnesia. The aetiology of NE/DS is still unclear, and there is no satisfactory treatment. Four patients with NE/DS are described. Treatment with a selective seroronin reuptake inhibitor (SSRI) was effective in controlling their episodes of nocturnal eating. To our knowledge, this is the first published case report of successful treatment with SSRIs in NE/DS.

Echocardiographic investigation of pericardial effusion in a case of anorexia nervosa.

OBJECTIVE: Pericardial effusion has recently been reported as a complication of anorexia nervosa. A distinct pathophysiological cause of it could not be revealed. In some reports, there was a probable correlation between weight gain and reduction of pericardial effusion in anorexia nervosa cases. We encountered a case in which pericardial effusion remitted completely along with body weight increase and normalization of low T3 syndrome. These findings suggest that the reduction of pericardial effusion may correlate with both weight gain and low T3 normalization. Plasma brain natriuretic peptide (BNP) levels were increased in this case despite heart failure, and plasma BNP decreased as pericardial effusion remitted. The measurement of serum BNP level may be a clinical parameter in such a case of pericardial effusion.

Late onset anorexia nervosa: two case reports.

OBJECTIVE: Some patients develop an eating disorder at a late age. It is worth investigating why this syndrome develops at such widely different ages. METHODS: Two Japanese cases of late onset anorexia nervosa are reported. RESULTS: In these late onset cases, anorexia developed out of sadness over a loss such as bereavement, divorce, and fear or anxiety for the future. In addition, these two patients didn't demonstrate a fear of aging or of losing their attractiveness and sexuality, nor did they develop a dissociative disturbance based on an early traumatic history of sexual abuse in PTSD. CONCLUSION: Although the clinical features are similar, there appear to be differences between late onset and adolescent cases in psychological mechanisms.