[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.

[Naikan therapy for prolonged depression: psychological changes and long-term efficacy of intensive Naikan therapy].

OBJECTIVE: Many studies have shown that a considerable number of patients with prolonged depression are refractory to drug therapy or supportive psychotherapy. A few studies have shown the short-term effectiveness of intensive Naikan therapy for prolonged depression, but the long-term effects have not been reported. For other psychotherapies also, few studies have demonstrated their long-term effectiveness for prolonged depression. The purpose of the present study was to assess the long-term efficacy of intensive Naikan therapy for patients with prolonged depression and to investigate the factors contributing to its efficacy. METHOD: At Tottori University Hospital, 23 inpatients with prolonged depression were treated with intensive Naikan therapy. The age, sex, age at onset, number of depressive episodes, duration of the present episode, diagnosis and family history were investigated. The Tokyo University Egogram (TEG), Yatabe-Guiltora personality inventory (YG test) and Rosenzweig picture-frustration (PF) study were conducted before and after intensive Naikan therapy to investigate psychological changes. The long-term efficacy (average: 24.5 +/- 10.6 months) of intensive Naikan therapy for prolonged depression was assessed with Global Assessment of Functioning scale (GAF). "Improvement" was defined as a post-therapy GAF score of 61 or higher. The Hamilton Depression Rating Scale (HAM-D) was applied to confirm the GAF results. Whether the patient achieved awareness of other's viewpoint, awareness of egocentricity, feeling of love, breaking out from self and sense of fulfillment after intensive Naikan therapy was investigated. RESULTS: Fifteen patients (65.2%) showed improvement in GAF and HAM-D (improved group) and eight patients showed no improvement (non-improved group). The average GAF score changed from 46.1 (before Naikan therapy) to 81.8 (at outcome assessment) in the improved group and from 45.3 to 52.8 in the non-improved group. The improved group had significantly shorter average duration of the present depressive episode and significantly less depressive episodes compared to the non-improved group. Only the improved group showed significantly lower scores on the critical parent (CP) scale of TEG, cyclic tendency (C) on the YG test and extraggression (E-A) in PF study. In the improved group, significantly more patients achieved deep insight (Naikan); and significantly more patients achieved awareness of other's viewpoint, awareness of egocentricity, feeling of love, breaking out from self and sense of fulfillment after intensive Naikan therapy. CONCLUSIONS: Our results suggested that intensive Naikan therapy for prolonged depression was equally as effective as Morita therapy, interpersonal therapy or group psychotherapy, and the effects of intensive Naikan therapy continued for a long term. Attainment of deep Naikan brought psychological changes in patients showing improvement, motivating them to continue Naikan therapy in daily life. We consider that this is the key factor that maintains the long-term efficacy of intensive Naikan therapy.

[Psychiatric symptoms related to interferon treatment for chronic hepatitis].

Psychiatric symptoms related to interferon (IFN) treatment for chronic hepatitis have been a crucial issue in consultation liaison psychiatry. In this report we present a hypothesis regarding the development of psychiatric symptoms. There were marked differences in the incidence of psychiatric symptoms among studies. This may be because psychiatric symptoms are readily overlooked in routine practice in the Department of Internal Medicine, and because IFN treatment frequently causes transient depression. It was speculated that psychiatric intervention was required in 10-19% of the patients. We found that among psychiatric symptoms related to IFN treatment, depression with irritation and anxiety was commonly observed. In many case reports, mood disorder was noted as a precursory or residual symptom of delirium and hallucination/delusion. We present management guidelines for psychiatric symptoms in IFN treatment, and propose that self-assessment scaling should be performed before and during treatment to detect psychiatric symptoms in the early stage, and that patients with suspected symptoms should be promptly referred to the Department of Psychiatry. We introduce an open study of antidepressant treatment for depression related to IFN treatment, and recommend aggressive administration of antidepressants. IFN treatment should be discontinued in patients with: moderate or severe suicidal ideation or suicide attempt, depression that does not respond to antidepressant treatment, manic state, hallucination/delusion, or delirium.

Hyperviscoelasticity of epipharyngeal mucus may induce globus pharyngis.

Detailed observation reveals a lump of translucent sticky mucus standing in the epipharynx of most globus patients, suggesting that the mucus adherent to the epipharynx causes a globus sensation. The epipharyngeal mucus of 70 consecutive globus patients was sampled via the nasal cavity. Fucose and sialic acid, the determinants of the viscoelasticity of mucus, were measured. Twenty-three patients were also asked to complete the Throat Questionnaire so we could evaluate the correlation between the degree of globus sensation and the viscoelasticity of the mucus. The mucus of 10 healthy subjects was sampled, analyzed, and compared with the data of the patients. The fucose and sialic acid concentrations found in the patients with globus pharyngis were significantly higher than those in the control subjects (Mann-Whitney U test, p < .01). The fucose concentrations correlated significantly with the globus pharyngis scores (Spearman correlation, p < .05). We conclude that there is a close association between stagnant mucus in the epipharynx and globus sensation.