Akiko Kikuchi

Cognitive processing therapy (CPT) is one of the most widely tested evidence-based treatments for posttraumatic stress disorder (PTSD). However, most studies on CPT have been conducted in Western cultural settings. This open-label, single-arm trial investigated the feasibility, acceptability, and preliminary efficacy of CPT for treating Japanese patients with PTSD. A total of 25 outpatients underwent 12 CPT sessions. The primary outcome was the assessment of PTSD symptoms using the Clinician-Administered PTSD Scale for DSM-IV (CAPS-IV); secondary outcomes included the assessment of subjective PTSD severity, depressive and anxiety symptoms, trauma-related cognitions, and subjective quality of life. All outcomes were evaluated at pretreatment (i.e., baseline), posttreatment, and 6- and 12-month follow-ups. On average, participants attended 13 sessions of CPT (SD = 1.38), with a completion rate of 96.0%. One serious adverse event (hospitalization) occurred. Significant within-subjects standardized mean differences in CAPS-IV scores were found from baseline to treatment completion, g = -2.28, 95% CI [-3.00, -1.56]; 6-month follow-up, g = -2.95, 95% CI [-3.79, -2.12]; and 12-month follow-up, g = -2.15, 95% CI [-2.89, -1.41]. Moderate-to-large effects, gs = -0.77 to -2.45, were found on secondary outcomes. These findings support the feasibility, acceptability, and preliminary efficacy of CPT in a Japanese clinical setting.

本研究では英国で実施されたDangerous and Severe Personality Disorder(DSPD)事業の構想から終焉までを概説し、本邦の対応困難患者の処遇への示唆について考察した。DSPDはパーソナリティ障害者による重大事件をきっかけとして提案された行政的基準である。DSPD事業はパーソナリティ障害に有効な治療を開発すると期待されたが、治療法の無作為化比較試験は実施されず、費用対効果も否定された。実施施設では必ずしも高密度の処遇がされず、有効な治療のないまま患者を長期間拘禁する事業であると批判された。結果としてDSPD事業は廃止され、医療・刑務所・保護観察の連携によるサービスに後継された。これらの経過から、本邦において対応困難な精神科患者の高規格病棟を検討する際には、(1)包含基準として精神医学的に妥当な定義が存在すること、(2)エビデンスに基づく治療法が存在すること、(3)退院基準が明確であること、(4)退院後の地域移行をサポートするシステムが存在すること、(5)第三者評価が入ること、が重要であり、当事者との協働および人権保護に配慮した慎重な議論が求められることが示唆された。(著者抄録)

本研究では英国で実施されたDangerous and Severe Personality Disorder(DSPD)事業の構想から終焉までを概説し、本邦の対応困難患者の処遇への示唆について考察した。DSPDはパーソナリティ障害者による重大事件をきっかけとして提案された行政的基準である。DSPD事業はパーソナリティ障害に有効な治療を開発すると期待されたが、治療法の無作為化比較試験は実施されず、費用対効果も否定された。実施施設では必ずしも高密度の処遇がされず、有効な治療のないまま患者を長期間拘禁する事業であると批判された。結果としてDSPD事業は廃止され、医療・刑務所・保護観察の連携によるサービスに後継された。これらの経過から、本邦において対応困難な精神科患者の高規格病棟を検討する際には、(1)包含基準として精神医学的に妥当な定義が存在すること、(2)エビデンスに基づく治療法が存在すること、(3)退院基準が明確であること、(4)退院後の地域移行をサポートするシステムが存在すること、(5)第三者評価が入ること、が重要であり、当事者との協働および人権保護に配慮した慎重な議論が求められることが示唆された。(著者抄録)

This study aimed to evaluate the predictive validity and reliability of the Short-Term Assessment of Risk and Treatability (START) in the context of the Japanese forensic probation service. START is a structured professional judgement guide for risk domains concerning negative behaviors such as violence, self-harm, suicide, substance abuse, unauthorized leave, victimization, and self-neglect. In this study, rehabilitation coordinators evaluated community-dwelling patients who were treated under the Medical Treatment and Supervision Act at baseline and followed-up for 6 months. The results revealed that START vulnerability scores significantly predicted self-harm, suicide, physical aggression, substance abuse, and self-neglect. START strength scores predicted physical violence and unauthorized leave. Specific risk estimates predicted physical violence and self-neglect. Risk judgement for future substance use may require adjustments for cultural differences, because of the lower prevalence in Japan. These results suggest that START offers a feasible and valid tool that allows clinicians to plan treatment and promote recovery of forensic patients in Japan.

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.

Background: Schizophrenia is a disabling illness. Social cognition and interaction training (SCIT) seeks to improve patients' social functioning by alleviating deficits in social cognition. SCIT has shown promise in improving social cognition in patients with schizophrenia, but has not yet been studied in Japan. Design: An assessor-masked, randomized, parallel-group clinical trial was conducted to compare the feasibility and efficacy of SCIT with treatment as usual (TAU). Setting: Participants were recruited from outpatient clinics at the National Center of Neurology and Psychiatry and four other hospitals in Japan. Participants: Seventy-two patients diagnosed with schizophrenia or schizoaffective disorder consented to participate in the trial. Procedure: Participants were randomly allocated to either a SCIT subgroup or a TAU subgroup. SCIT is a manual-based group intervention that is delivered in 20-24-h-long weekly sessions. Groups include two to three clinicians and four to eight patients. Hypotheses: We hypothesized that SCIT would be found to be feasible and that patients who were randomized to receive SCIT would exhibit improvements in social cognition. Results: Data from 32 participants in each subgroup were entered into analyses. The persistence rate in the SCIT subgroup was 88.9%, and the average attendance rate was 87.0%. Intrinsic motivation was significantly higher in the SCIT subgroup than the TAU group during the first half of the program. Mixed effects modeling of various outcome measures revealed no significant interaction between measurement timepoint and group in any measures, including social cognition, neurocognition, symptom severity, and social functioning. In the case of the social cognition measure, significant change was observed only in the SCIT subgroup; however, the interaction between timepoint and group failed to reach significance. In an exploratory subgroup analysis, a shorter duration of illness was found to be associated with significantly better improvement on the social cognition measure in the SCIT subgroup compared with the TAU subgroup. Conclusions: In terms of the primary objective, the relatively low dropout rate observed in the present study suggests that SCIT is feasible and well tolerated by patients with schizophrenia in Japan. This view is also supported by participants' relatively high attendance and intrinsic motivation.

Background: The Structured Assessment of PROtective Factors for violence risk (SAPROF) was recently developed as a strength-based addition to the risk assessment of future violent behavior. We examined the interrater reliability and predictive accuracy of the SAPROF for violence in forensic mental health inpatient units in Japan. Methods: This retrospective record study provides an initial validation of the SAPROF in a Japanese sample of 95 forensic psychiatric inpatients from a complete 2008-2013 cohort. Violent outcomes were assessed 6 and 12 months after hospitalization. Results: We observed moderate-to-good interrater reliability for the SAPROF total score and the internal factors, motivational factors, external factors, and the Final Protection Judgment scores. According to a receiver operating characteristic analysis, the SAPROF total score and all subscale scores predicted violence at both 6 and 12 months after hospitalization with high accuracy. Furthermore, the predictive validity of a combination of the SAPROF with the Historical Clinical Risk Management-20 (HCR-20) outperformed that of the HCR-20 alone. Conclusions: The results provide evidence of the value of considering protective factors in the assessment of future violence risk among Japanese forensic psychiatric inpatients. The SAPROF might allow for a more balanced assessment of future violence risk in places where the population rates of violent crime are low, such as Japan, but a validation study in a different setting should confirm this. Moreover, future studies should examine the effectiveness of treatment and promoting community re-integration on motivating patients and treatment staff.

The Cognitive Bias Questionnaire for Psychosis (CBQp) is a valid selfreport instrument for assessing cognitive biases in psychosis. To validate the Japanese version of the CBQp, and to investigate the relationships between CBQp and various schizophrenia symptoms, such as positive symptoms, negative symptoms, and disorganized/autistic preoccupation. Patients with schizophrenia (n = 111), patients with depression (n = 40), and healthy controls (n = 35) were recruited. Using these samples, the psychometric properties of the Japanese version of CBQp were tested. The CBQp total scores had good reliability while the two subscales had moderate reliability. Furthermore, the scales had adequate concurrent validity, given that it had significant correlations with positive symptoms, and could accurately distinguish between schizophrenia patients and healthy controls. Novel findings were that the CBQp total scores were positively correlated with disorganized/autistic preoccupation. Furthermore, this study using a Japanese sample showed marginally significant correlations between the cognitive biases of threating event and severity of delusions, while this relationship was not seen in a previous study that used a Western sample. This difference could be because of the 'shame culture', which is explained as a characteristic of Japanese. The Japanese version of the CBQp was as reliable and valid as the original.

AimsFacial emotion perception is considered to provide a measure of social cognition. Numerous studies have examined the perception of emotion in patients with schizophrenia, and the majority has reported impaired ability to recognize facial emotion perception. We aimed to investigate the correlation between facial expression recognition and other domains of social cognition and neurocognition in Japanese patients with schizophrenia. MethodsParticipants were 52 patients with schizophrenia and 53 normal controls with no history of psychiatric diseases. All participants completed the Hinting Task and the Social Cognition Screening Questionnaire. The Brief Assessment of Cognition in Schizophrenia was administered only to the patients. Facial emotion perception measured by the Facial Emotion Selection Test (FEST) was compared between the patients and normal controls. ResultsPatients performed significantly worse on the FEST compared to normal control subjects. The FEST total score was significantly positively correlated with scores of the Brief Assessment of Cognition in Schizophrenia attention subscale, Hinting Task, Social Cognition Screening Questionnaire Verbal Working Memory and Metacognition subscales. Stepwise multiple regression analysis revealed that verbal working memory function was positively related to the facial emotion perception ability in patients with schizophrenia. ConclusionsThese results point to the concept that facial emotion perception and some types of working memory use common cognitive resources. Our findings may provide implications for cognitive rehabilitation and related interventions in schizophrenia.

日本の司法精神医療のなかでも特に社会内処遇に焦点を当て、医療観察制度における通院処遇の実態について調査した。全国の指定通院医療機関のうち本研究への協力の同意が得られた388施設を対象施設とし、平成17年7月15日から平成25年7月15日を調査期間とした。調査期間内に調査対象となった指定病院医療機関で通院処遇をうけていた1190名(男性865名、女性325名、平均44.1歳)についてデータを分析した。通院処遇に至るまでの形式は当初審判により「入院によらない医療」の決定を受けてただちに通院処遇が開始される形式(直接通院)が393名、当初審判により「入院による医療」の決定を受けて、指定入院医療機関での入院処遇を経たのちに通院処遇に至る「移行通院」が797名であった。診断分類では統合失調症などが918名で最も多かった。対象行為は、殺人351名、傷害388名、強盗52名、強姦・強制わいせつ68名、放火331名であった。

東京都における医療観察法の指定通院機関が抱える運用上の課題を精神保健福祉士(PSW)の視点から把握するために11名のPSWおよびその所属長に研究協力を依頼し、フォーカスグループインタビューを行った。通院処遇関連業務に従事しているPSWが直面している困難とは何か、困難に対して現状ではどのように対処しているのか、困難に対してどのような条件整備や施策が望まれているのか、といった内容について焦点化したグループインタビューを実施した。分析の結果、通院処遇業務においてPSWが直面する困難は、スタッフの理解不足や受入に向けた意思の統一上の課題などの「医療機関内の受入体制」、業務の多さやスキルの習熟に関連した課題である「ケース対応関連」、地域体制や行政に関連した課題である「地域連携関連」があげられた。医療機関の受入体制やケース対応については情報収集や院内調整の工夫などで対処が可能だが、地域連携については行政や地域の視点からの介入が必要なことが指摘された。

都内で協力が得られた医療観察法指定通院医療機関を対象に、通院治療を受けている患者への医療提供の時間を調査し、業務にかかる費用の推計を行い、関連する要因について検討した。さらに診療報酬も把握し、医療観察法下での通院治療を継続して実施について検討した。14施設から協力が得られ、72名の患者を分析対象とした。業務内容別の業務時間を対象者1人あたりとして算出した。前期、中期、後期ともデイケアの時間が最も長く、前期1446分、中期1145分、後期998分であった。職種としては、精神保健福祉士および看護師の業務が多く、個別の患者に関する業務では記録のための時間が多くかかっていることが分かった。これらの業務時間より1ヵ月にかかる人件費の平均は64000円で、前期に若干多くかかっていたが中期・後期とも大きな差は見られなかった。診療報酬は現在の点数でも医療観察法下での通院治療に取り組むことで採算は取れるが、中期、後期と進むにつれて業務量は減少しないのに診療報酬が下がり、必ずしも業務量を直接反映したものでないことが指摘できた。

Aim: The present study aimed to test the construct validity and internal consistency of the Social Cognition Screening Questionnaire (SCSQ) (Japanese version). Methods: We first tested whether the subscale scores and the total score of the SCSQ could discriminate patients with schizophrenia from normal controls. Next, we tested the internal consistency. Finally, we investigated the relation between the subscale scores and other measures of social cognition and social functioning that were presumed to correspond to the subscale's scores, including the Hinting Task, the Ambiguous Intentions Hostility Questionnaire (AIHQ), the Beck Cognitive Insight Scale and the Social Functioning Scale. Results: The subscale scores and the total score appeared to show more robust between-group differences than other measures of social cognition, such as the AIHQ and the Hinting Task. The total score distinguished the patients from normal controls with an area under the receiver-operator curve of 0.84, which indicated a high level of discrimination. The Cronbach's alpha for the four subscales was 0.72, which was considered acceptable. In terms of criterion-related validity, theory of mind, metacognition and hostility bias subscale scores showed significant correlations with the Hinting Task, Beck Cognitive Insight Scale and AIHQ, respectively. Moreover, the theory of mind subscale score showed a significant correlation with four domain scores of the Social Functioning Scale. The present results indicated good construct validity and internal consistency of the SCSQ. Conclusions: Although this is an interim report with a small sample size, the SCSQ holds promise as an efficient measure for social cognition.

Background: Until the recent enactment of the Medical Treatment and Supervision Act (MTSA) in 2005, neither legislations nor facilities for mentally disordered offenders were available in Japan. The aim of the country's forensic mental health services, based on this new law, is to improve the social reintegration of mentally disordered offenders. In order to provide optimal psychiatric care to these individuals, specialised court proceedings, treatment facilities, and concrete guidelines have been established. The aim of this study was to review the current status of the new system and to clarify future challenges for improving services. Methods: The authors collected official statistics regarding the new system published separately by the Ministry of Health, Labour and Welfare, the Ministry of Justice, and the Supreme Court of Japan. We aggregated the data and examined the system's current implementation status, nationwide. Results: There were 2,750 requests for enrolment in the MTSA system between its initiation in 2005 and 31 December 2012. Of those requests, 2,724 cases had been concluded in court. In 63.1% of the cases, an inpatient treatment order had been made; 82.4% of those inpatients were diagnosed with schizophrenia. By the end of March 2012, two patients completing treatment under the MTSA had re-committed a serious offense. While overall designated inpatient and outpatient treatment facilities have reached national targets in terms of resources and beds available, a regional gap in MTSA designated facilities remains and the number of patients under inpatient treatment order is on the increase. Conclusions: Overall, the MTSA system has been running smoothly without encountering any serious problems. However, several concerns have emerged, such as the accumulation of patients under inpatient treatment order and insufficient regional resources. To more successfully promote the reintegration of mentally disordered offenders, improvements in outpatient treatment and welfare services are crucial. In order to install effective measures to help improve the system, a nationwide database of patients being treated under order of the MTSA should be properly built and maintained.

Aim: Insight in schizophrenia is considered to have a multidimensional construct, and cognitive insight is thought to be an important dimension of insight: an ability to evaluate and correct one's own distorted beliefs and misinterpretations. The Beck Cognitive Insight Scale (BCIS) was developed to measure cognitive insight, and studies have shown that cognitive insight is associated with several clinical features in schizophrenia. The aim of the present study was to develop a Japanese version of the BCIS (BCIS-J) and assess the psychometric properties of this instrument. Methods: The BCIS-J was completed by university students (n = 183) and patients with schizophrenia (n = 30). The Japanese version of the Schedule for the Assessment of Insight was used to measure clinical insight in patients with schizophrenia, and its association with the BCIS-J was investigated. Results: Factor analysis in the university students indicated that the BCIS-J was composed of two factors, self-reflectiveness and self-certainty, as was seen in the original BCIS. The relation between the specific dimensions of clinical insight and each component of the BCIS-J in patients with schizophrenia indicated that overconfidence in their belief or judgment may be involved in their attitude to treatment and openness to feedback, and objectivity might be essential to attribute one's symptoms as part of mental illness. Conclusions: The BCIS-J is a reliable and valid instrument to measure cognitive aspects of insight and appears to complement clinical insight scales.

SIDES(Structured Interview for Disorders of Extreme Stress)の日本語版を作成し、その信頼性と妥当性を検討した。健常群60例と児童虐待や家庭内暴力などの被害者から成る臨床群53例を対象とした。臨床群のうち複数回にわたる対人間のトラウマの被害が確認された者を「トラウマあり群」、健常群のうち自記式の質問紙で児童虐待や家庭内暴力などを「経験したことがない」とした者を「トラウマなし群」とした。トラウマあり群の方がSIDESの自記式および面接で「他に特定されない極度のストレス障害」(DESNOS)の生涯診断を満たす者が有意に多かった。DES(Dissociative Experiences Scale)および身体症状尺度を外的基準とした併存的妥当性の検討では、十分な妥当性を確認した。SIDES日本語版はDESNOSの評価尺度として一定の信頼性と妥当性が示唆された。

Background: A new forensic mental health law was enacted in Japan in 2003, enabling development of specialist services. Before their establishment, it is important to determine the nature, frequency and correlates of the problems they are designed to ameliorate. Aims: To establish rates of violent recidivism among mentally disordered offenders before the new legislation, and examine associated risk factors. Method: Data were extracted from one complete annual (1980) national cohort of people judged by the Court or prosecutor to be without responsibility for a criminal offence, or of sufficiently diminished responsibility for it to be diverted for psychiatric treatment. The outcome measure was violent recidivism after community discharge and before 1991. Results: Fifty-two (10%) of 489 in the cohort were arrested or convicted of further violent offences. Violent recidivism was most strongly associated with a substance-related disorder, but histories of violence, homelessness and short index admissions were independently related. Conclusions: Violent recidivism was so unusual that, on this outcome, it could take many years to show any effect of the new service. Desistance from substance use, compliance with treatment and maintenance of stable housing may be better indicators of success, and their achievement a good preventive strategy. Copyright © 2007 John Wiley &amp Sons, Ltd.

多数の中学生を対象に,学童期の注意欠陥/多動性障害(AD/HD)にみられるような問題行動と自尊感情の関係について調査した.日本語版Wender Utah Rating Scale(WURS)を用いて学童期のAD/HDにみられるような問題行動をどれくらい経験したか評価し,併せて,日本語版WURSの信頼性を検討した.中学校2年生および3年生計486例を対象とした.WURSは,「易怒性・易興奮性」「衝動性」「情緒不安定性」「学業不振」「対人関係障害」という5つの因子からなることが示唆された.WURSのいずれの因子も自尊感情得点と中程度の相関があり,学童期のAD/HDにみられるような問題行動と思春期における自尊感情の低さの間には密接な関係があることを示唆された.日本語版WURSの内部一貫性および因子的妥当性の一部を確認した

The present study aimed to explore the status of deliberate self-harm (DSH) among junior high-school students, and investigate the relationship between DSH and substance use and childhood hyperactivity. Subjects were 239 boys (mean age=14.16 years, SD=0.67) and 238 girls (14.22, 0.68) from a junior high-school in Kanagawa, Japan. A self-reporting questionnaire consisting of original questions on self-cutting, self-hitting, and tobacco and alcohol use was employed with the Wender Utah Rating Scale (WURS) for assessing childhood hyperactivity. Overall, 8.00% and 27.70% of males and 9.30% and 12.20% of females reported self-cutting and self-hitting, respectively. Regarding substance use, 33.10% and 74.10% of males and 14.30% and 63.40% of females reported tobacco and alcohol use, respectively. Comparisons of WURS scores between those with and without experience of problematic behaviors revealed that with all problematic behaviors in both genders, scores of those with experience were significantly higher than those without (P < 0.01 except for self-cutting in females, P < 0.05). The present study indicated that DSH is an important problem, even among children as young as junior high-school age. An association between DSH and childhood hyperactivity was also suggested.