Treatment Persistence Between Long-Acting Injectable Versus Orally Administered Aripiprazole Among Patients with Schizophrenia in a Real-World Clinical Setting in Japan.

INTRODUCTION: Persistence with antipsychotic treatment is critical in managing patients with schizophrenia. To evaluate whether aripiprazole long-acting injection (aripiprazole once-monthly, AOM) can contribute to longer treatment persistence compared with daily orally administered aripiprazole (OA) in real-world clinical settings in Japan, treatment persistence in patients with schizophrenia was compared between patients treated with AOM and those with OA, using a claims database compiled by JMDC Inc., Tokyo, Japan. METHODS: Data of patients with schizophrenia who newly initiated AOM or OA treatment between May 2015 and November 2017 were analyzed. The Cox proportional hazard model was used to estimate the hazard ratio (HR) for treatment discontinuation of AOM vs. OA treatment, adjusted for age, sex, chlorpromazine-equivalent dose of antipsychotics, and the number of psychiatric hospitalizations. RESULTS: The analysis included 198 patients in the AOM group and 1240 patients in the OA group (mean age 38.4 ± 11.9 years and 39.3 ± 12.4 years, respectively). The AOM group was significantly less likely to discontinue treatment than the OA group (adjusted HR 0.54, 95% confidence interval [CI] 0.43-0.68). When using the tolerable patients extracted from the OA group (i.e., patients with at least two OA prescriptions; n = 983) vs. the whole AOM group, AOM users were again significantly less likely to discontinue treatment (adjusted HR 0.67, 95% CI 0.53-0.86). CONCLUSION: AOM was associated with longer treatment persistence than OA in the antipsychotic treatment of patients with schizophrenia in real-world clinical settings in Japan, suggesting that the use of AOM may contribute to longer antipsychotic treatment.

Budget impact analysis of long acting injection for schizophrenia in Japan.

Aims: To estimate the budgetary impact of providing additional reimbursement for long acting injections for schizophrenia patients in psychiatric hospital settings in Japan to improve patient outcomes in schizophrenia.Methods: Budget impact analysis of change in reimbursement policy using a prevalence-based model over a five-year time horizon. The results are reported as net change in expenditure and consequent cost/savings in Japanese yen at the time of analysis.Results: The budget impact analysis shows that an increase in reimbursement for LAIs could lead to cumulative savings of an estimated 36.6 billion JPY over five years. These savings result from a decrease in hospitalization costs and an increased usage of LAI (assumed to be 10%). Based on the sensitivity analysis, the saving estimates are most sensitive to change in market share of generic and branded oral antipsychotics.Limitations: Historical data were used to estimate the future costs of drug and hospitalization; however, it is not the best predictor of future, hence a source of potential bias. A good level of treatment adherence with oral antipsychotics was assumed, which is generally not the case; therefore, we might have overestimated the effectiveness of oral atypical antipsychotics. Additionally, the drug cost due to reimbursement might have also been overestimated because in clinical setting, the increase of LAI use may not have reached 10% of the market share. Lastly, patients' behavior was derived from models, which may have loosely approximated the reality.Conclusions: An additional reimbursement for the use of LAI in schizophrenia patients is likely to be cost neutral/cost saving and should be considered as a policy option to improve patient outcomes and budget sustainability.

Associations between readmission and patient-reported measures in acute psychiatric inpatients: a study protocol for a multicenter prospective longitudinal study (the ePOP-J study).

BACKGROUND: Several previous observational studies have reported the risk factors associated with readmission in people with mental illness. While patient-reported experiences and outcomes have become increasingly important in healthcare, only a few studies have examined these parameters in terms of their direct association with readmission in an acute psychiatric setting. This project will investigate multiple factors associated with readmission and community living in acute psychiatric patients in Japan. This study will primarily investigate whether patient-reported experiences at discharge, particularly quality of life (QoL), are associated with future readmission and whether readmission after the index hospitalization is associated with changes in patient-reported outcomes during the study period. Here, we describe the rationale and methods of this study. METHODS: This multicenter prospective cohort study is being conducted in 21 participating Japanese hospitals, with a target sample of approximately 600 participants admitted to the acute psychiatric ward. The study has four planned assessment points: time of index admission (T1), time of discharge (from the index admission) (T2), 6 months after discharge from the index admission (T3), and 12 months after discharge from the index admission (T4). Participants will complete self-reported measures including a QoL scale, a subjective disability scale, and an empowerment- and self-agency-related scale at each assessment point; additionally, service satisfaction, subjective view of need for services, and subjective relationships with family members will be assessed at T2 and T3. We will assess the participants' hospitalization during the study period and evaluate several potential individual- and service-level factors associated with readmission and patient-reported experiences and outcomes. Multivariate analyses will be conducted to identify potential associations between readmission and patient-reported experiences and outcomes. DISCUSSION: The present study may produce evidence on how patient-reported experiences at discharge influence readmission and on the influence of readmission on the course of patient-reported outcomes from admission to community living after discharge. The study may contribute to improving care for both patients' subjective views of their own health conditions and their community lives in an acute psychiatric setting.Trial registration University Hospital Medical Information Network-Clinical Trials Registry (UMIN-CTR) UMIN000034220. Registered on September 20, 2018.

[Safety of Long-acting Injectable Antipsychotics Is Long-acting Injection a High-risk Treatment Option?].

Early post-marketing phase vigilance (EPPV) of paliperidone palmitate (PAL-P) revealed a mortality of at least 32 (0.29%) out of approximately 11,000 patients with schizophrenia administered PAL-P between November 2013 and May 2014 (average administration period of four months). Since then, many psychiatrists may have become distrustful of PAL-P, as well as of other long-acting injectable antipsychotics (LAI). This study reviewed the mortality data observed in several premarketing clinical trials of antipsychotics, including PAL-P, post-mar- keting surveillances (PMS) of antipsychotics conducted in Japan, and several large-scale cohort studies performed in developed countries, and re-evaluated the mortality risk of PAL-P. The results of the literature review were as follows: 1) the mortality of the patients on LAI in clinical trials was 3.56-7.95/1,000 person-years. This number was not higher than that of those on oral antipsychotics (5.00-8.55/1,000 person-years) ; 2) the mortality of those on PAL-P in clinical trials (3.56/1,000 person-years) was not higher than that on the other LAIs (6.34-7.95/ 1,000 person-years); 3) the mortality of those on PAL-P observed in the EPPV (equivalent to 0.22% per three months) was similar to the three-month mortality observed in the PMSs of risperidone LAI, oral paliperidone, or oral blonanserin (0.19-0.31%); and 4) based on data of the cohort studies, the four-month mortality of those with schizophrenia was estimated at 0.35-0.68%. Therefore, the mortality observed in the EPPV of PAL-P did not seem to be of clinical significance, even allowing for the possibility of underestimating the mortality in the EPPV.

[Individually Safe and Realistic Correction of Antipsychotic Polypharmacy and High-dose Regimens in Japanese Patients with Chronic Schizophrenia: The SCAP method].

Compared with other countries, Japan exhibits prominent levels of antipsychotic polypharmacy and high-dose regimens. In view of these circumstances, the Safe Correction of Antipsychotic Polypharmacy and high-dose regimens (SCAP) method was developed based on previous findings as a realistic way to reduce medication consumption in patients already experiencing polypharmacy and high-dose regimens. In the SCAP method, "clinicians can reduce medications one by one, gradually, with occasional breaks permitted." A clinical study conducted to evaluate this method found no change in clinical symptoms, side effects, or quality of life (QOL), and the number of withdrawals due to aggravation was also small. A leaflet describing these results, and which is designed to support efforts to reduce medications, has been released. Future research will involve the examination and analysis of data from this study, taking into account its limitations, with a view toward developing guidelines applicable to clinical settings. The pragmatic, gradual correction of polypharmacy and high-dose regimens that goes beyond the "multiple drugs or single agent" dichotomy can decrease the burden experienced by patients. This is a practical approach that can be applied when developing comprehensive plans for the future psychiatric care of aging patient populations.

Psychotropic dose equivalence in Japan.

Psychotropic dose equivalence is an important concept when estimating the approximate psychotropic doses patients receive, and deciding on the approximate titration dose when switching from one psychotropic agent to another. It is also useful from a research viewpoint when defining and extracting specific subgroups of subjects. Unification of various agents into a single standard agent facilitates easier analytical comparisons. On the basis of differences in psychopharmacological prescription features, those of available psychotropic agents and their approved doses, and racial differences between Japan and other countries, psychotropic dose equivalency tables designed specifically for Japanese patients have been widely used in Japan since 1998. Here we introduce dose equivalency tables for: (i) antipsychotics; (ii) antiparkinsonian agents; (iii) antidepressants; and (iv) anxiolytics, sedatives and hypnotics available in Japan. Equivalent doses for the therapeutic effects of individual psychotropic compounds were determined principally on the basis of randomized controlled trials conducted in Japan and consensus among dose equivalency tables reported previously by psychopharmacological experts. As these tables are intended to merely suggest approximate standard values, physicians should use them with discretion. Updated information of psychotropic dose equivalence in Japan is available at http://www.jsprs.org/en/equivalence.tables/. [Correction added on 8 July 2015, after first online publication: A link to the updated information has been added.].

Evaluation of the individual safe correction of antipsychotic agent polypharmacy in Japanese patients with chronic schizophrenia: validation of safe corrections for antipsychotic polypharmacy and the high-dose method.

BACKGROUND: Polypharmacy for schizophrenia treatment is not justified by the available clinical evidence. We evaluated a treatment reduction approach that reduces the dose and number of antipsychotic medications simultaneously prescribed to patients. METHODS: In a randomized open study of the Safe Correction of Antipsychotic Polypharmacy and High-Dose Prescriptions program funded by the Japanese Ministry of Health, Labour, and Welfare, we evaluated a drug reduction method consisting of a dose reduction intervention performed on 163 patients with schizophrenia for twelve or 24 weeks. One antipsychotic medication was removed each week from each patient's treatment regimen by reducing the dose by 0 to 50 chlorpromazine equivalents. Data on health-related indices of quality of life, clinical symptoms, and risk of side effects were analyzed using a two-way repeated-measures mixed linear model. RESULTS: Despite a 23% reduction in antipsychotic dose, no differences in outcomes were observed between the dose reduction and observation groups (effect size = 0.001 - 0.085, P = .24-.97), despite high statistical power (1-ß = 0.48-0.97). The findings are limited by the nonuniformity of the participants' treatment history, duration, and dose reduction amount. Dose reduction protocol patients exhibited no difference in psychotic symptoms or adverse events compared with the observation group. CONCLUSIONS: Importantly, the low dropout rate in our study (6.9% of participants withdrew because of patient factors and 23.8% for all secondary reasons) indicates that our "slowly" method is well tolerated. We hope that this approach will result in therapeutic improvements.

Influence of patient characteristics on care time in patients hospitalized with schizophrenia.

BACKGROUND: In the current Japanese payment system for the treatment of psychiatric inpatients, the length of hospital stay and nurse staffing levels are key determinants of the amount of payment. These factors do not fully reflect the costs of care for each patient. The objective of this study was to clarify the relationship between patient characteristics and their care costs as measured by "care time" for patients with schizophrenia. METHODS: Patient characteristics and care time were investigated in 14,557 inpatients in 102 psychiatric hospitals in Japan. Of these 14,557 inpatients, data for 8,379 with schizophrenia were analyzed using a tree-based model. RESULTS: The factor exerting the greatest influence on care time was "length of stay", so subjects were divided into 2 groups, a "short stay group" with length of stay ≦104 days, and "long stay group" ≧105 days. Each group was further subdivided according to dependence with regard to "activities of daily living", "psychomotor agitation", "verbal abuse", and "frequent demands/repetitive complaints", which were critical variables affecting care time. The mean care time was shorter in the long-stay group; however, in some long-stay patients, the mean care time was considerably longer than that in patients in the short-stay group. CONCLUSION: The results of this study suggest that it is necessary to construct a new payment system reflecting not only length of stay and nurse staffing levels, but also individual patient characteristics.

[Metabolic and lithium monitoring in Japanese psychiatric outpatient clinics].

OBJECTIVE: Various guidelines recommend that the risks of diabetes mellitus, dyslipidemia, and lithium intoxication should be appropriately managed by regular monitoring of blood sugar and serum lipid levels in patients treated with atypical antipsychotics, and regular monitoring of serum lithium concentrations in patients treated with lithium carbonate. However, in Japan, these recommendations are not always observed. The present study used a database, constructed from research on medical policies performed in 2006, to investigate the frequencies of blood sugar, serum lipid, and serum lithium monitoring in psychiatric outpatients in Japan. METHODS: This database contained the health insurance claims of 3,674 psychiatric outpatients extracted from the 47 prefectures throughout Japan. The present study examined two subordinate surveys: 1) the frequency of monitoring blood sugar and serum lipid levels in those on atypical antipsychotics during a period of one month (February) in 2006; 2) the frequency of monitoring the serum lithium concentration in those on lithium carbonate, also obtained during February 2006. RESULTS: In Survey 1, the subjects were 228 male and 271 female recipients, with an average age of 45.1 years; 86.8% of these subjects suffered from psychosis. In Survey 2, the subjects were 70 male and 64 female recipients, with an average age of 49.9 years; 57.5% of these subjects suffered from mood disorder and 36.6% suffered from psychosis. In Survey 1, the blood sugar level, HbA1c, and urinary sugar were monitored in 28 (5.6%), 5 (1.0%), and 8 (1.6%) subjects, respectively. At least one of these three tests was performed in 32 subjects (6.4%). The serum lipid level was monitored in 40 subjects (8.0%). In Survey 2, no serum lithium concentrations were measured. The frequency of monitoring the serum lithium concentration per month was estimated to be below 2.2%. CONCLUSIONS: The Maudsley Prescribing Guidelines recommend that both blood sugar and serum lipid levels should be monitored at least once a year (equivalent to a measurement frequency of 8.3% per month). Survey 1 revealed that, although the actual frequency of monitoring the serum lipid level agreed with the recommendation, that of monitoring the blood sugar level was lower than recommended. However, when compared with the results of a study in the U.S.(equivalent to a measurement frequency of 2-17% per month), the frequency of monitoring the blood sugar level was not that low in Japan. The frequency of monitoring the serum lithium concentration per month was estimated to be below 2.2%. The guidelines and package inserts recommend that the serum lithium concentration should be monitored once every 2-6 months. Therefore, the frequency of monitoring the serum lithium concentration in psychiatric outpatients treated in Japan was considered to be too low from the standpoint of medical safety.

Study protocol: safety correction of high dose antipsychotic polypharmacy in Japan.

BACKGROUND: In Japan, combination therapy with high doses of antipsychotic drugs is common, but as a consequence, many patients with schizophrenia report extrapyramidal and autonomic nervous system side effects. To resolve this, we proposed a method of safety correction of high dose antipsychotic polypharmacy (the SCAP method), in which the initial total dose of all antipsychotic drugs is calculated and converted to a chlorpromazine equivalent (expressed as milligrams of chlorpromazine, mg CP). The doses of low-potency antipsychotic drugs are then reduced by ≤ 25 mg CP/week, and the doses of high-potency antipsychotics are decreased at a rate of ≤ 50 mg CP/week. Although a randomized, case-controlled comparative study has demonstrated the safety of this method, the number of participants was relatively small and its results required further validation. In this study of the SCAP method, we aimed to substantially increase the number of participants. METHODS/DESIGN: The participants were in- or outpatients treated with two or more antipsychotics at doses of 500-1,500 mg CP/day. Consenting participants were randomized into control and dose reduction groups. In the control group, patients continued with their normal regimen for 3 months without a dose change before undergoing the SCAP protocol. The dose reduction group followed the SCAP strategy over 3-6 months with a subsequent 3-month follow-up period. Outcome measures were measured at baseline and then at 3-month intervals, and included clinical symptoms measured on the Manchester scale, the extent of extrapyramidal and autonomic side effects, and quality of life using the Euro QOL scale. We also measured blood drug concentrations and drug efficacy-associated biochemical parameters. The Brief Assessment of Cognition in Schizophrenia, Japanese version, was also undertaken in centers where it was available. DISCUSSION: The safety and efficacy of the SCAP method required further validation in a large randomized trial. The design of this study aimed to address some of the limitations of the previous case-controlled study, to build a more robust evidence base to assist clinicians in their efforts to reduce potentially harmful polypharmacy in this vulnerable group of patients. TRIAL REGISTRATION: UMIN Clinical Trials Registry 000004511.

Cost of anxiety disorders in Japan in 2008: a prevalence-based approach.

BACKGROUND: The societal burden caused by anxiety disorders has likely been underestimated, while those for schizophrenia and depression have received more attention. Anxiety disorders represent a significant illness category that occurs at a high prevalence and poses a considerable burden. However, the cost of anxiety disorders in Japan has not yet been well researched. The goal of the present study was to estimate the total cost of anxiety disorders in Japan and to clarify the characteristics of this burden. METHOD: A prevalence-based approach was adopted to measure the total cost of anxiety disorders. Anxiety disorders were defined as diagnosis code F40.0-F41.9 according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision. The cost was comprised of the following components: medical treatment costs and social service costs as direct costs, and morbidity and mortality costs as indirect costs. Data were collected from publicly available statistics. RESULTS: The total cost of anxiety disorders in Japan in 2008 was JPY 2.4 trillion (US$ 20.5 billion at the current exchange rate of US $1 = JPY 116.8). The direct cost was JPY 50 billion. The morbidity cost was JPY 2.1 trillion, while the mortality cost was JPY 0.24 trillion. CONCLUSIONS: The social burden caused by anxiety disorders in Japan is tremendous and is similar to that of other mental disorders. Productivity loss in the workplace represents the largest portion of all the cost components. Because the medical examination rate is quite low, the improvement of healthcare access might contribute to cost mitigation.

An open-label study of algorithm-based treatment versus treatment-as-usual for patients with schizophrenia.

OBJECTIVE: The use of an algorithm may facilitate measurement-based treatment and result in more rational therapy. We conducted a 1-year, open-label study to compare various outcomes of algorithm-based treatment (ALGO) for schizophrenia versus treatment-as-usual (TAU), for which evidence has been very scarce. METHODS: In ALGO, patients with schizophrenia (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) were treated with an algorithm consisting of a series of antipsychotic monotherapies that was guided by the total scores in the positive and negative syndrome scale (PANSS). When posttreatment PANSS total scores were above 70% of those at baseline in the first and second stages, or above 80% in the 3rd stage, patients proceeded to the next treatment stage with different antipsychotics. In contrast, TAU represented the best clinical judgment by treating psychiatrists. RESULTS: Forty-two patients (21 females, 39.0 ± 10.9 years-old) participated in this study. The baseline PANSS total score indicated the presence of severe psychopathology and was significantly higher in the ALGO group (n = 25; 106.9 ± 20.0) than in the TAU group (n = 17; 92.2 ± 18.3) (P = 0.021). As a result of treatment, there were no significant differences in the PANSS reduction rates, premature attrition rates, as well as in a variety of other clinical measures between the groups. Despite an effort to make each group unique in pharmacologic treatment, it was found that pharmacotherapy in the TAU group eventually became similar in quality to that of the ALGO group. CONCLUSION: While the results need to be carefully interpreted in light of a hard-to-distinguish treatment manner between the two groups and more studies are necessary, algorithm-based antipsychotic treatments for schizophrenia compared well to treatment-as-usual in this study.

The cost of schizophrenia in Japan.

INTRODUCTION: Schizophrenia is a disorder that produces considerable burdens due to its often relapsing/remitting or chronic longitudinal course. This burden is felt not only by patients themselves, but also by their families and health care systems. Although the societal burden caused by this disorder has been evaluated in several countries, the magnitude of the societal cost of schizophrenia in Japan has never been estimated. The aim of this study is to clarify the societal burden of schizophrenia by estimating the cost of schizophrenia in Japan in 2008. METHODS: A human capital approach was adopted to estimate the cost of schizophrenia. The total cost of schizophrenia was calculated as the sum of the direct, morbidity, and mortality costs. Schizophrenia was defined as disorders coded as F20.0-F20.9 according to the International Classification of Diseases-10. The data required to estimate the total cost was collected from publicly available statistics or previously reported studies. RESULTS: The total cost of schizophrenia in Japan in 2008 was JPY 2.77 trillion (USD 23.8 billion). While the direct cost was JPY 0.770 trillion (USD 6.59 billion), the morbidity and mortality costs were JPY 1.85 trillion (USD 15.8 billion) and JPY 0.155 trillion (USD 1.33 billion), respectively. CONCLUSION: The societal burden caused by schizophrenia is tremendous in Japan, similar to that in other developed countries where published data exist. Compared with other disorders, such as depression or anxiety disorders, the direct cost accounted for a relatively high proportion of the total cost. Furthermore, absolute costs arising from unemployment were larger, while the prevalence rate was smaller, than the corresponding results for depression or anxiety in Japan.

Prescription profiles for pharmacological treatment of Japanese inpatients with schizophrenia: comparison between 2007 and 2009.

BACKGROUND AND OBJECTIVE: Pharmacological treatment of schizophrenic patients in Japan is characterized by polypharmacy with high doses of antipsychotics. In this study, we examined the profiles of antipsychotic drug therapy in 2007 and 2009 to determine if there have been any recent shifts in treatment strategy. METHOD: The subjects were schizophrenic inpatients (ICD-10-F20) admitted to 100 hospitals in 2007 and 152 hospitals in 2009. Information on the psychotropic agents prescribed on specified days in November 2007 and 2009 was acquired for each patient. RESULTS: Although no changes were observed in the rate of antipsychotic medications being prescribed, the rate of antipsychotic monotherapy in 2009 increased significantly. In 2007, among 15,761 patients, 4977 (31.6%) received antipsychotic monotherapy (i.e., administration of a single antipsychotic medication). In 2009, among 22,911 patients, 7741 (33.8%) received antipsychotic monotherapy. CONCLUSION: The rate of use of antipsychotic monotherapy has gradually increased, although the total dose has not changed significantly. The increase in the concomitant use of two or more second-generation antipsychotics is a recent trend in Japan, despite the lack of information on the efficacy and safety of this treatment strategy.

[Survey on the actual condition of psychiatrists and psychiatric services in Japan. (Part 1): Basic data on number and distribution of psychiatrists].

BACKGROUND: To ensure that psychiatric services adequately meet the needs of the Japanese people, planning a prospective design based on a needs analysis is required. Presently, the distribution of medical resources in Japan is skewed and the priorities of psychiatric services are unclear. OBJECTIVE: To determine the current status of psychiatric services. METHOD: The definition of a psychiatrist was determined by qualified specialists of the Japanese Society for Psychiatry and Neurology (JSPN). Of the 11,169 candidates who applied for the specialist psychiatry examination, 246 were excluded due to a lack of personal information and 4 due to refusal. The remaining 10,919 agreed to allow the verification of their personal data. This study was conducted with the approval of the JSPN. The total number of psychiatrists, their demographic backgrounds, the number of psychiatrists by prefecture, and the number of psychiatrists in each secondary medical care block in Japan were calculated. RESULTS: Of the 10,919 psychiatrists included in this analysis, 2,124 were female and 8,790 were male. Approximately 90% were < 65 years old, and 42% were < 45 years old. Their primary work places were as follows: psychiatric hospitals (n = 5,233, 47.9%); university departments of psychiatry (n=1,353, 12.4%); general hospitals (n = 1,064, 9.7%); psychiatric clinics (n = 2,456, 22.5%); nonpsychiatric clinics (n = 687, 6.3%); and nonclinical work places such as basic science departments (n = 124, 1.1%). The number of psychiatrists per 100,000 inhabitants in each prefecture was determined. The highest numbers of psychiatrists were from Kochi (13.20), Tokyo (12.76), and Tokushima (12.24), and the lowest numbers were from Ibaraki (5.34), Aomori (5.36), and Saitama (5.67). The number of psychiatrists per 100,000 inhabitants in Kochi was 1.48 per area (100 km square), and Tokyo showed the highest at 75.99 psychiatrists per area, followed by Osaka and Kanagawa. The five Tohoku prefectures and Hokkaido had the fewest psychiatrists per area. CONCLUSION: For planning the future management of psychiatric services, continuous investigation of the actual number of psychiatrists and the status of psychiatric services in Japan is required with the constant cooperation of the JSPN.

[Survey on the actual condition of psychiatrists and psychiatric services in Japan. (Part 2): Change in geographical working area and setting of each psychiatrist].

BACKGROUND: The shortage of psychiatrists has recently become a public concern; however, the reason for this shortage has not been clearly discussed or explained on the basis of real data. We assumed that it is not only due to the lack of the absolute number of psychiatrists, but also due to an imbalance in their distribution in geographical working areas and settings. OBJECTIVE: To evaluate the change in distribution of Japanese psychiatrists. METHOD: We analyzed the change in the geographical working area and setting of each psychiatrist from September 2006 to March 2009 using data obtained from psychiatrists who applied for the Board Certification Examination of the Japanese Psychiatric Association. Our data included 6,881 psychiatrists. RESULTS: With regard to the geographical working area, the number of psychiatrists in ordinance-designated cities (urban areas) increased by 2.2%, whereas that in other areas decreased by 3.0%. On examination of work settings, we noted a 16.0% decrease in the number of psychiatric departments in general hospitals and a 20.0% increase in the number of psychiatric clinics. Surprisingly, more than 10% of middle-aged psychiatrists (10.3% of 36 45-year-olds and 12.2% of 46-55-year olds) who worked in general hospitals moved to clinics. CONCLUSION: The present study revealed that, although psychiatrists did not tend to move from rural to urban areas, they showed a tendency to move from general hospitals to psychiatric clinics.

The inter-rater reliability of the Japanese version of the Inventory of Depressive Symptomatology, clinician version.

The Inventory of Depressive Symptomatology, clinician version (IDS­C), was developed by Rush et al. to evaluate the severity of major depressive episodes. The aim of the present study was to establish the inter­rater reliability of the Japanese version of the IDS­C. A total of 16 subjects with DSM­IV major depressive episode were evaluated. Two psychiatrists, who had completed a training session for evaluating the IDS­C before starting this reliability study, attended systematic interview sessions with each subject to evaluate the IDS­C independently, using the Japanese version of the structured interview guide for combined rating of the IDS­C and the Hamilton Depression Rating Scale. The severity of the 30 IDS­C items assessed by the two raters ranged from 0 to 4 for 27 items and from 0 to 3 for 3 items. The analysis of variance intra­class correlation inter­rater reliability values for the individual scale items ranged from 0.874 to 1.000. The present results suggest that the Japanese version of the IDS­C is a potentially useful rating instrument with high inter­rater reliability for measuring the severity of depressive symptoms in the hands of psychiatrists with sufficient evaluation training.