Characteristics of discharge prescriptions for patients with schizophrenia or major depressive disorder: Real-world evidence from the Effectiveness of Guidelines for Dissemination and Education (EGUIDE) psychiatric treatment project

BACKGROUND

Monopharmacy with antipsychotics and antidepressants is the first-line treatment for schizophrenia and major depressive disorder (MDD) in most clinical guidelines, while polypharmacy with psychotropic agents in the treatment of schizophrenia is common in clinical practice. There are no detailed data on the prescription patterns for inpatients with mental illness with reliable diagnoses made by treating psychiatrists.

METHODS

We gathered prescription data at discharge from 2177 patients with schizophrenia and 1238 patients with MDD from October 2016 to March 2018.

RESULTS

The patients with schizophrenia aged between 60 and 79 were prescribed lower doses of antipsychotics and hypnotics/anxiolytics than those aged between 40 and 59. There were significant differences between the prescription rate of antipsychotics in the patients with schizophrenia and that of antidepressants in the patients with MDD. The frequency of concomitant drugs such as anti-Parkinson drugs, anxiolytics/hypnotics and mood stabilizers in the subjects with schizophrenia prescribed antipsychotic polypharmacy was significantly higher than that with monotherapy. For the patients with schizophrenia, olanzapine, risperidone, aripiprazole, quetiapine, and blonanserin were the five most prescribed antipsychotics. For the patients with MDD, mirtazapine, duloxetine, escitalopram, trazodone and sertraline were the five most prescribed antidepressants.

CONCLUSIONS

Our results showed the use of high doses of antipsychotics, high percentages of antipsychotic polypharmacy and concurrent use of hypnotics/anxiolytics in patients with schizophrenia. Notably, these data were collected before intensive instruction regarding the guidelines; therefore, we need to assess the change in the prescription pattern post guideline instruction.

Improvements in the degree of understanding the treatment guidelines for schizophrenia and major depressive disorder in a nationwide dissemination and implementation study

BACKGROUND

To implement clinical practice guidelines (CPGs), it is necessary for psychiatrists to deepen their understanding of the CPGs. The Effectiveness of Guidelines for Dissemination and Education in Psychiatric Treatment (EGUIDE) project is a nationwide dissemination and implementation study of two sets of CPGs for schizophrenia and major depressive disorder (MDD).

METHODS

A total of 413 psychiatrists (n = 212 in 2016; n = 201 in 2017) learned the two CPGs in the education program of the EGUIDE project, and clinical knowledge of these CPGs was evaluated at baseline and after the programs. To improve the correct answer rate for clinical knowledge after the programs, we revised the lecture materials associated with items that had a low correct answer rate in 2016 and used the revised lecture materials with the CPGs in 2017. The rates of correct answers after the programs between the 2016 and 2017 groups were compared.

RESULTS

The correct answer rate of one item on the schizophrenia CPG and one item on the MDD CPG tended to be improved (S-D5 and D-C6) and that of one on the MDD CPG was significantly improved (D-D3, P = 0.0008) in the 2017 group compared to those in the 2016 group.

CONCLUSIONS

We reported improvements in clinical knowledge of CPGs after the EGUIDE program in the 2017 group following revision of the lecture materials based on results from the 2016 group. These attempts to improve the degree of understanding of CPGs may facilitate the successful dissemination and implementation of psychiatric guidelines in everyday practice.

Prescription patterns in patients with schizophrenia in Japan: First-quality indicator data from the survey of "Effectiveness of Guidelines for Dissemination and Education in psychiatric treatment (EGUIDE)" project

Background

Guideline for Pharmacological Therapy for Schizophrenia was published by the Japanese Society of Neuropsychopharmacology in 2015. “Effectiveness of Guidelines for Dissemination and Education in psychiatric treatment (EGUIDE)” project aimed to standardize medical practice using quality indicators (QIs) as indices to evaluate the quality of medical practice. In this study, we have reported the quality indicator values of prescription before the beginning of the guideline lectures in the EGUIDE project to ascertain the baseline status of treating patients with schizophrenia.

Methods

A cross‐sectional, retrospective case record survey was conducted, involving 1164 patients with schizophrenia at the time of discharge. We checked all types and dosage of psychotropic drugs.

Results

Forty‐three percent of patients had antipsychotic polypharmacy, and substantial concomitant medication was observed (antidepressants; 8%, mood stabilizers: 37%, anxiolytics or hypnotics: 68%).

Conclusions

In the results obtained in this study, we plant to report changes in the effectiveness of education in the EGUIDE project near the future.

This study reports the prescription pattern in schizophrenia in Japan from EGUIDE (Effectiveness of Guideline for Dissemination and Education in psychiatric treatment) project. A cross‐sectional, case record survey conducted, involving 1164 patients with schizophrenia at the time of discharge. Forty‐three percent of patients received antipsychotic polypharmacy. Based on the results, we plan to report changes in the effectiveness of education in the EGUIDE project in the future.

A composite measure of sleep health is associated with symptoms of depression among Japanese female hospital nurses

BACKGROUND

Individual dimensions of sleep health, including satisfaction, sleepiness/alertness, timing, efficiency, and duration, are associated with depression. We investigated whether a composite sleep health score is associated with symptoms of depression among Japanese female hospital nurses.

METHODS

Participants were nurses (n = 2482, all women, age 31.2 ± 8.9 years) working at three general hospitals in Tokyo, Japan. A cross-sectional survey, conducted in 2015, assessed self-reported sleep and symptoms of depression. Sleep health was categorized as "good" or "poor" across five dimensions: satisfaction, daytime sleepiness, mid-sleep time, efficiency, and duration. A composite sleep health score was calculated by summing the number of "poor" dimensions. Depression was defined by depressed mood, loss of interest, or at least one of those symptoms ("depression symptoms"). Associations between sleep health and symptoms of depression were evaluated with multivariate logistic regression analyses, adjusting for sociodemographic factors and hypnotic medication use.

RESULTS

In multivariate logistic regression analyses, sleep health symptoms of poor satisfaction, efficiency, and duration were significantly associated with depressed mood; daytime sleepiness and poor efficiency were significantly associated with loss of interest; and poor satisfaction, daytime sleepiness, mid-sleep time, and efficiency were significantly associated with having at least one depressive symptom. The composite sleep health score was associated in a graded fashion with greater odds of depression symptoms.

CONCLUSION

Individual and composite sleep health scores were associated with symptoms of depression. Assessing composite measures of multidimensional sleep health may help to better understand the well-known associations between poor sleep and depression and lead to improved intervention strategies.

Effect of Enterococcus faecalis 2001 on colitis and depressive-like behavior in dextran sulfate sodium-treated mice: involvement of the brain-gut axis

BACKGROUND

Patients with inflammatory bowel disease (IBD), including those with ulcerative colitis and Crohn's disease, have higher rates of psychiatric disorders, such as depression and anxiety; however, the mechanism of psychiatric disorder development remains unclear. Mice with IBD induced by dextran sulfate sodium (DSS) in drinking water exhibit depressive-like behavior. The presence of Lactobacillus in the gut microbiota is associated with major depressive disorder. Therefore, we examined whether Enterococcus faecalis 2001 (EF-2001), a biogenic lactic acid bacterium, prevents DSS-induced depressive-like behavior and changes in peripheral symptoms.

METHODS

We evaluated colon inflammation and used the tail suspension test to examine whether EF-2001 prevents IBD-like symptoms and depressive-like behavior in DSS-treated mice. The protein expression of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), X-linked inhibitor of apoptosis protein (XIAP), and cleaved caspase-3 in the rectum and hippocampus was assessed by western blotting. Hippocampal neurogenesis, altered nuclear factor-kappa B (NFκB) p65 morphometry, and the localization of activated NFκB p65 and XIAP were examined by immunohistochemistry.

RESULTS

Treatment with 1.5% DSS for 7 days induced IBD-like pathology and depressive-like behavior, increased TNF-α and IL-6 expression in the rectum and hippocampus, activated caspase-3 in the hippocampus, and decreased hippocampal neurogenesis. Interestingly, these changes were reversed by 20-day administration of EF-2001. Further, EF-2001 administration enhanced NFκB p65 expression in the microglial cells and XIAP expression in the hippocampus of DSS-treated mice.

CONCLUSION

EF-2001 prevented IBD-like pathology and depressive-like behavior via decreased rectal and hippocampal inflammatory cytokines and facilitated the NFκB p65/XIAP pathway in the hippocampus. Our findings suggest a close relationship between IBD and depression.

Improvement of psychiatrists' clinical knowledge of the treatment guidelines for schizophrenia and major depressive disorders using the 'Effectiveness of Guidelines for Dissemination and Education in Psychiatric Treatment (EGUIDE)' project: A nationwide dissemination, education, and evaluation study

AIM

Although treatment guidelines for pharmacological therapy for schizophrenia and major depressive disorder have been issued by the Japanese Societies of Neuropsychopharmacology and Mood Disorders, these guidelines have not been well applied by psychiatrists throughout the nation. To address this issue, we developed the 'Effectiveness of Guidelines for Dissemination and Education in Psychiatric Treatment (EGUIDE)' integrated education programs for psychiatrists to disseminate the clinical guidelines. Additionally, we conducted a systematic efficacy evaluation of the programs.

METHODS

Four hundred thirteen out of 461 psychiatrists attended two 1-day educational programs based on the treatment guidelines for schizophrenia and major depressive disorder from October 2016 to March 2018. We measured the participants' clinical knowledge of the treatment guidelines using self-completed questionnaires administered before and after the program to assess the effectiveness of the programs for improving knowledge. We also examined the relation between the participants' demographics and their clinical knowledge scores.

RESULTS

The clinical knowledge scores for both guidelines were significantly improved after the program. There was no correlation between clinical knowledge and participant demographics for the program on schizophrenia; however, a weak positive correlation was found between clinical knowledge and the years of professional experience for the program on major depressive disorder.

CONCLUSION

Our results provide evidence that educational programs on the clinical practices recommended in guidelines for schizophrenia and major depressive disorder might effectively improve participants' clinical knowledge of the guidelines. These data are encouraging to facilitate the standardization of clinical practices for psychiatric disorders.

Seasonal changes in sleep duration and sleep problems: A prospective study in Japanese community residents

Background

A scientific understanding of the effects of seasonal changes on sleep duration and sleep problems such as insomnia and hypersomnia has yet to be elucidated; however, such an understanding could aid the establishment of an optimal sleep hygiene program to treat such problems.

Methods

We investigated the effects of seasonal changes on sleep duration and sleep problems in Japanese community residents. Data on 1,388 individuals aged 15–89 years who participated in the Survey of Seasonal Variations in Food Intakes conducted by the National Institute of Health and Nutrition of Japan (2004–2007) were analyzed. Participants completed a questionnaire including items on sleep duration and sleep problems (difficulty initiating sleep [DIS], difficulty maintaining sleep [DMS]/early morning awakening [EMA], and excessive daytime sleepiness [EDS]). Data were prospectively collected at four time points (spring, summer, fall, and winter).

Results

Seasonal changes in sleep duration were found, with the longest in winter and the shortest in summer (winter–summer difference: 0.19 h). The seasonality of sleep duration was influenced by age, sex, and residential area. In terms of age, seasonal changes in sleep duration were found in the middle and old age groups, but not in the young age group. Seasonal changes in the frequencies of sleep problems were found for some items in the young age group (DMS/EMA and EDS) and middle age group (DIS and DMS/EMA); however, no such changes were observed in the old age group.

Conclusion

Seasonal effects on sleep and sleep problems were found in Japanese community residents, but these varied between age groups. Furthermore, seasonal changes in sleep duration were influenced by sex and residential area.

Stressful events and coping strategies associated with symptoms of depression: A Japanese general population survey

BACKGROUND

The following question remains open: what has the strongest impact on symptoms of depression, experiencing multiple stressful events, being exposed to a specific stressful event, or having a maladaptive coping style?

METHOD

We conducted a cross-sectional survey with face-to-face interviews. Data from 2559 randomly-sampled adults living in Japan were analyzed. The participants were asked about stressful events (12 items) experienced in the previous month and their stress-coping strategies (16 items). Presence of symptoms of depression was defined using the Center for Epidemiologic Studies Depression scale. Logistic regression analysis was used to assess the associations of stressful events and stress-coping strategies with symptoms of depression.

RESULTS

The prevalence of symptoms of depression increased with the number of stressful events. Eight stressful events and five stress-coping strategies were positively associated with symptoms of depression. In the multiple logistic regression analysis for the items that showed a significant association with symptoms of depression, two stressful events ("Health/illness of self" and "Trouble with family members") and two stress-coping strategies ("Smoking" and "Bearing without action") remained significantly associated with symptoms of depression; however, the "dose effect" of the number of stressful events disappeared, suggesting that these stressful events and stress-coping strategies have a stronger association with symptoms of depression compared with experiencing multiple stressful events.

LIMITATIONS

Since this study was cross-sectional in design, causal relationships could not be determined.

CONCLUSION

Our findings may indicate the importance of focusing on types of stressful events and coping styles in developing preventive strategies for major depression.

Association of serum BDNF levels and the BDNF Val66Met polymorphism with the sleep pattern in healthy young adults

BACKGROUND

Brain-derived neurotrophic factor (BDNF) is widely expressed in the brain and plays an important role in neuronal maintenance, plasticity, and neurogenesis. Prior studies have found that decreased serum BDNF levels are associated with perceived stress, depression, or sleep disturbances in humans.

STUDY OBJECTIVES

To elucidate whether the serum BDNF levels and BDNF genotype were associated with the sleep pattern in healthy young adults.

METHODS

The study group consisted of 79 healthy paid volunteers (45 men, 34 women) aged 20 to 29 years. Serum BDNF levels were measured with an enzyme-linked immunosorbent assay, and a single-nucleotide polymorphism (Val66Met) in the BDNF gene was assessed with a TaqMan assay. Details of the sleep pattern were obtained from 1-week sleep/wake records.

RESULTS

Serum BDNF levels were significantly associated with sleep parameters on weekends, whereas no such association was found on weekdays. On weekends, longer total sleep time and time in bed, and later mid-sleep time were associated with lower serum BDNF levels. The difference between mid-sleep time on weekdays and that on weekends, otherwise known as social jetlag, was negatively associated with serum BDNF levels. Met/Met homozygotes of the BDNF Val66Met polymorphism had significantly longer time in bed on weekends than Val/Val homozygotes. Heterozygotes did not differ from Val/Val homozygotes.

CONCLUSIONS

We first found that serum BDNF levels and the BDNF Val66Met polymorphism in healthy young adults were associated with the sleep pattern on weekends but not with that on weekdays, suggesting that the systems involved in BDNF control may be linked to endogenous sleep characteristics rather than the socially constrained sleep schedule in healthy young adults.

An Aggregate Measure of Sleep Health Is Associated With Prevalent and Incident Clinically Significant Depression Symptoms Among Community-Dwelling Older Women

Objectives

Sleep can be characterized along multiple dimensions. We investigated whether an aggregate measure of sleep health was associated with prevalent and incident clinically significant depression symptoms in a cohort of older women.

Methods

Participants were older women (mean age 80.1 years) who completed baseline (n = 6485) and follow-up (n = 3806) visits, approximately 6 years apart, in the Study of Osteoporotic Fractures (SOF). Self-reported sleep over the past 12 months was categorized as "good" or "poor" across 5 dimensions: satisfaction with sleep duration, daytime sleepiness, mid-sleep time, sleep onset latency, and sleep duration. An aggregate measure of sleep health was calculated by summing the number of "poor" dimensions. Clinically significant depression symptoms were defined as a score ≥6 on the Geriatric Depression Scale. Relationships between sleep health and depression symptoms were evaluated with multivariate logistic regression, adjusting for health measures and medications.

Results

Individual sleep health dimensions of sleep satisfaction, daytime sleepiness, mid-sleep time, and sleep onset latency were significantly associated with prevalent depression symptoms (odds ratios [OR] = 1.26-2.69). Sleep satisfaction, daytime sleepiness, and sleep onset latency were significantly associated with incident depression symptoms (OR = 1.32-1.79). The number of "poor" sleep health dimensions was associated in a gradient fashion with greater odds of prevalent (OR = 1.62-5.41) and incident (OR = 1.47-3.15) depression symptoms.

Conclusion

An aggregate, multidimensional measure of sleep health was associated with both prevalent and incident clinically-significant depression symptoms in a gradient fashion. Future studies are warranted to extend these findings in different populations and with different health outcomes.

The association between sleep problems and perceived health status: a Japanese nationwide general population survey

OBJECTIVE

Sleep problems in humans have been reported to impact seriously on daily function and to have a close association with well-being. To examine the effects of individual sleep problems on physical and mental health, we conducted a nationwide epidemiological survey and examined the associations between sleep problems and perceived health status.

METHODS

Cross-sectional surveys with a face-to-face interview were conducted in August and September, 2009, as part of the Nihon University Sleep and Mental Health Epidemiology Project (NUSMEP). Data from 2559 people aged 20 years or older were analyzed (response rate 54.0%). Participants completed a questionnaire on perceived physical and mental health statuses, and sleep problems including the presence or absence of insomnia symptoms (i.e., difficulty initiating sleep [DIS], difficulty maintaining sleep [DMS], and early morning awakening [EMA]), excessive daytime sleepiness (EDS), poor sleep quality (PSQ), short sleep duration (SSD), and long sleep duration (LSD).

RESULTS

The prevalence of DIS, DMS, and EMA was 14.9%, 26.6%, and 11.7%, respectively, and 32.7% of the sample reported at least one of them. At the complaint level, the prevalence of EDS, PSQ, SSD, and LSD was 1.4%, 21.7%, 4.0%, and 3.2%, respectively. Multiple logistic regression analyses revealed that DMS, PSQ, SSD, and LSD were independently associated with poor perceived physical health status; DIS, EDS, and PSQ were independently associated with poor perceived mental health status.

CONCLUSIONS

This study has demonstrated that sleep problems have individual significance with regard to perceived physical or mental health status.

Self-help behaviors for sleep and depression: a Japanese nationwide general population survey

OBJECTIVE

The aim of this study was to examine the relationship between self-help behaviors for sleep (SHBS) and depression among the general adult population in Japan.

METHODS

The survey was conducted in June 2000 using self-administered questionnaires for subjects living in 300 communities randomly selected throughout Japan. A total of 24,686 responses were analyzed from individuals aged 20 years or older. The Center for Epidemiologic Studies Depression Scale was used to assess the prevalence of depression with two cut-off points: 16 and 25. Details of 6 types of SHBS were asked, based on given examples of actual behavior and frequency.

RESULTS

After adjusting for sociodemographic variables, sleep problems and other SHBS, multiple logistic regression analyses revealed that "snacking on food and/or beverages" was independently associated with an increased odds ratio for depression, whereas "maintaining lifestyle regularity" was independently associated with a decreased odds ratio for depression. "Drinking alcoholic beverages," "having a bath," and "reading books or listening to music" were associated with an increased odds ratio for depression in crude analyses, but the significance of the association disappeared after adjusting for sociodemographic variables, sleep problems and other SHBS.

LIMITATION

Complex constructs are being correlated.

CONCLUSIONS

These results suggest that individual SHBS are differentially associated with depression, thus providing important clues for establishing sleep hygiene for treatment and prevention of depression.

[Management of insomnia and hypersomnia associated with psychiatric disorders]

Most psychiatric disorders, such as schizophrenia, mood disorders, or neurotic disorders are associated with sleep disorders of various kinds, among which insomnia is most prevalent and important in psychiatric practice. Almost all patients suffering from major depression complain of insomnia. Pharmacological treatment of insomnia associated with major depression shortens the duration to achieve remission of depression. Insomnia has been recently reported to be a risk factor for depression. Hypersomnia is also a major sleep problem in patient suffering from depression. There have been no clinical guide to treat the symptoms of hypersomnia in depression, but some clinical trials treating them with NDRI or adjunctive administration of psychostimulants. In patients with schizophrenia, insomnia is often an early indicator of the aggravation of psychotic symptoms. Electroencephalographic sleep studies have also revealed sleep abnormalities characteristic to mood disorders, schizophrenia and anxiety disorders. A shortened REM sleep latency has been regarded as a biological marker of depression. Reduced amount of deep Non-REM sleep has been reported to be correlated with negative symptoms of schizophrenia. Recently, REM sleep abnormalities were found in teenagers having post-traumatic stress disorder after a boat accident. Although these facts indicate that insomnia plays an important role in the development of psychiatric disorders, there are few hypotheses explaining the cause and effect of insomnia in these disorders. Here, we reviewed recent articles on insomnia and hypersomnia associated with psychiatric disorders together with their clinical managements.

[Insomnia associated with psychiatric disorders]

Most psychiatric disorders, such as schizophrenia, mood disorders, or neurotic disorders are associated with sleep disorders of various kinds, among which insomnia is most prevalent and important in psychiatric practice. Almost all patients suffering from major depression complain of insomnia. Pharmacological treatment of insomnia associated with major depression shortens the duration to achieve remission of depression. Insomnia has been recently reported to be a risk factor for depression. In patients with schizophrenia, insomnia is often an early indicator of the aggravation of psychotic symptoms. Electroencephalographic sleep studies have also revealed sleep abnormalities characteristic to mood disorders, schizophrenia and anxiety disorders. A shortened REM sleep latency has been regarded as a biological marker of depression. Reduced amount of deep non-REM sleep has been reported to be correlated with negative symptoms of schizophrenia. Recently, REM sleep abnormalities were found in teenagers having post-traumatic stress disorder after a boat accident. Although these facts indicate that insomnia plays an important role in the development of psychiatric disorders, there are few hypotheses explaining the cause and effect of insomnia in these disorders. Here, we reviewed recent articles on insomnia associated with psychiatric disorders together with their clinical managements.

Determination of aromatization of 19-oxygenated 16 alpha-hydroxyandrostenedione with human placental microsomes by high-performance liquid chromatography coupled with coulometric detection

A sensitive assay of aromatization of 16 alpha-hydroxylated androgens, 16 alpha-hydroxyandrostenedione (16 alpha-OHA), 16 alpha,19-dihydroxyandrostenedione [16 alpha,19-(OH)2A], and 16 alpha-hydroxy-19-oxo androstenedione (16 alpha-OH-19-oxo A), was developed using reversed phase high-performance liquid chromatography with a coulometric detector. The estrogens, estriol and 16 alpha-hydroxyestrone, were simultaneously detected in quantities as low as 300 pg of the estrogens formed in an assay by an internal standard method. Apparent Km and Vmax of the microsomal aromatase for 16 alpha-OHA, 16 alpha,19-(OH)2A or 16 alpha-OH-19-oxo A were 1.06, 4.00 or 571 microM and 0.014, 0.087 or 1.67 pmol/min/micrograms protein, respectively. The results show that the 19-oxo steroid has extremely low affinity for aromatase relative to the other substrates.