Early psychosis in Asia: Insights from Japan

Nomenclature for psychosis risk in Japan: Survey results from high-risk individuals, caregivers, and mental health professionals

BACKGROUND

Labeling terms for high-risk state for psychosis, such as 'ultra-high risk' (UHR), 'attenuated psychosis syndrome' (APS), and 'at-risk mental state' (ARMS), have been criticized for their potential to lead to stigma. Hence, mental health service users in Melbourne recently proposed new terms illustrating the at-risk concept ['pre-diagnosis stage' (PDS), 'potential of developing a mental illness' (PDMI), and 'disposition for developing a mental illness' (DDMI)]. We aimed at testing the suitability of these existing and new terms in the clinical settings of early psychiatric intervention in Japan.

METHODS

At two centers of early intervention (Toyama and Tokyo), a questionnaire on the understanding and opinion of high-risk terminology was administered to 62 high-risk patients, 44 caregivers, and 64 clinicians. The questionnaire contained the existing and new terms, where the term ARMS was translated into two different Japanese terms ARMS-psychosis and ARMS-kokoro. Participants' opinion on the disclosure of high-risk status was also obtained.

RESULTS

ARMS-kokoro was most preferred, least stigmatizing, and best explaining the patients' difficulties for all groups, while UHR and other terms including the Japanese word 'psychosis' (i.e., APS and ARMS-psychosis) were not preferred. New labeling terms were generally not well received. All groups preferred full disclosure of high-risk terms by the psychiatrist with or without the presence of family members.

CONCLUSION

The term ARMS-kokoro was commonly accepted as a favorable labeling term for the high-risk state for psychosis in Japan. However, another translation ARMS-psychosis was considered stigmatizing, demonstrating the importance of appropriate translation of high-risk terminology into local languages.

Perceptions and attitudes of users and non-users of mental health services concerning mental illness and services in Japan

Objectives

There is a global movement to develop and implement community-based integrated mental health systems. The present study attempted to clarify the perceptions and attitudes of users and non-users of mental health services concerning mental illness and services in Japan.

Methods

A new questionnaire was developed for this internet survey. Data from 500 outpatients with depression and 500 healthy subjects were sampled according to the demographics of the Japanese population.

Results

Over 90% of healthy subjects and over 70% of patients were unaware of the common age of onset or lifetime prevalence of mental illness. Over 90% of the healthy subjects and about 70% of the patients could not describe any services where they would feel comfortable discussing mental health problems. In both groups, "adolescents and young adults" were ranked first as a target population for mental health and illness policies. The top requirement for the integrated care systems was the promotion and awareness of correct knowledge of mental illness in both the healthy subjects and patients.

Conclusion

Societal requirements could include disseminating correct knowledge, awareness-raising actions for society, and implementing services where people, especially young people, can easily consult and receive support in the community.

An integrated youth mental health service in a densely populated metropolitan area in Japan: Clinical case management bridges the gap between mental health and illness services

AIMS

A global movement, including in Asia, is seeking to establish integrated youth mental health services that provide early intervention in the continuum from mental health to mental illness. Clinical case management (CCM), in which a case manager becomes not only a coordinator of services but also a provider of psychosocial support, can establish a 'one-stop network' that supports youth in densely populated areas with various social resources. In 2019, we opened a community-based centre called 'SODA' in front of a metropolitan railway station, which was designed to be highly accessible, stigma-free and youth-friendly to provide CCM. We aimed to clarify its services and effectiveness of CCM.

METHODS

Data from 105 youths were investigated in a case-controlled study, dividing them into two groups: those who had received CCM for 6 months, and those whose needs were met in fewer sessions.

RESULTS

Twenty-one subjects who received CCM for 6 months had difficulties in more domains than the others. The mean of the total service minutes for the subjects who received CCM for 6 months was 491.3 min: psychological support (accounted for 24.8% of the time), support for community living (31.2%), work support (13.8%), family support (10.5%) and support for cooperation with other organizations (19.8%). Global Assessment of Functioning (GAF) score improved significantly, from 46.6 at baseline to 59.3 at 6 months.

CONCLUSION

Even in metropolitan areas with numerous medical facilities, young people can face high barriers to access. CCM can be effective as an early intervention for subjects developing mental illness.

Mindlink: A stigma-free youth-friendly community-based early-intervention centre in Korea

AIM

In many Asian countries, youth mental health services are not well-developed and access to treatment is generally delayed. Here, we present a community-based service model based on our experience with Mindlink, the first early-intervention centre of its kind in Korea.

METHODS

We describe the history of this mental health early-intervention service and the characteristics of users, as well as its intervention programmes and research directions. We also propose ways to further develop youth mental health services.

RESULTS

A community-based early-intervention service for youth was first introduced in 2012, when a special team was formed in a community mental health centre of Korea. As the numbers of young clients increased, a youth-friendly, early-intervention centre called Mindlink was opened in 2016. Mindlink targets those aged 15-30 years with mental illness less than 5 years in duration. Its goal is to detect mental illness in young people early and provide comprehensive multidisciplinary interventions. It provides intensive case management and group programmes including cognitive-behavioural therapy, family intervention, psychoeducation, behavioural activation and physical health promotion. The Korean government has officially announced that the Mindlink model is effective and is currently in the process of scaling it up on a national level.

CONCLUSION

An accessible, youth-friendly, stigma-free, community mental health centre such as Mindlink allows early detection and appropriate management of mental illness in young patients.

Federated multi-site longitudinal study of at-risk mental state for psychosis in Japan

There has been recent accumulation of evidence and clinical guidance regarding the at-risk mental state (ARMS) for psychosis. However, most studies have been observational cohort and intervention studies of Western populations. To assess the validity of the ARMS concept and the transition rate to psychosis in a non-Western nation, we retrospectively combined and analyzed clinical data of individuals diagnosed with ARMS who were prospectively followed-up at three specialized clinical services for ARMS in Japan. In total, we included 309 individuals with ARMS, of whom 43 developed overt psychosis. We estimated cumulative transition rates to psychosis with the Kaplan-Meier method, obtaining rates of 12% at 12, 16% at 24, 19% at 36, and 20% at 48 months. Only two individuals reported past cannabis use. Despite several differences among the three sites, transition rates did not differ among them. Furthermore, the transition rate of children aged between 14 and 17 years did not differ from that of individuals aged 18 years or older. Regression analysis revealed that meeting the brief limited intermittent psychotic symptoms (BLIPS) criterion was associated with an increased risk of transition to psychosis, whereas genetic risk factors were not. Although antipsychotic prescription was relatively frequent in this cohort, there was no evidence supporting frequent use of antipsychotics for this population. In conclusion, our findings support the assertion that the current concept of ARMS is applicable in Japan. Development of local clinical guidelines and training for clinicians is necessary to disseminate this concept to more clinical settings.

Open-label study of cognitive behavioural therapy for individuals with at-risk mental state: Feasibility in the Japanese clinical setting

AIM

To date, most cognitive behavioural therapy (CBT) trials for individuals with at-risk metal state (ARMS) have been conducted in few Western countries and its feasibility in other regions, including Japan, has not been established.

METHODS

We designed an open-label pilot study. Fourteen ARMS participants received CBT over 6 months and were followed-up for 6 months.

RESULTS

Thirteen individuals completed the CBT intervention and assessments. The mean total score on the Positive and Negative Syndrome Scale improved from 60.2 to 46.0 after the intervention (Cohen's d = 1.1). The effects were maintained at the follow-up assessment. One participant transitioned to psychosis after the CBT intervention, and was the only patient who received antipsychotics.

CONCLUSIONS

We confirmed the feasibility of the provision of CBT for ARMS in Japan. Since overprescription of antipsychotics is a matter of great concern in Japan, CBT could be a valuable alternative treatment strategy.

Early intervention in psychosis: From clinical intervention to health system implementation

AIM

Early intervention in psychosis (EIP) is a well-established approach with the intention of early detection and treatment of psychotic disorders. Its clinical and economic benefits are well documented. This paper presents basic aspects of EIP services, discusses challenges to their implementation and presents ideas and strategies to overcome some of these obstacles.

METHODS

This paper is a narrative review about the evidence supporting EIP, with examples of successful implementation of EIP and of cases where major obstacles still need to be overcome.

RESULTS

Experience from successfully implemented EIP services into the mental healthcare system have generated evidence, concepts and specific strategies that might serve as guidance or inspiration in other countries or systems where EIP is less well developed or not developed at all. Previous experience has made clear that evidence of clinical benefits alone is not enough to promote implementation, as economic arguments and political and social pressure have shown to be important elements in efforts to achieve implementation.

CONCLUSIONS

Users' narratives, close collaboration with community organizations and support from policy-makers and known people within the community championing early intervention (EI) services are just a few of the approaches that should be considered in campaigns for implementation of EI services. Fast progress in implementation is possible.

Survey of recognition and treatment of at-risk mental state by Japanese psychiatrists

AIM

The importance of early intervention in psychiatry is widely recognized among psychiatrists. However, it is unknown whether precise knowledge of at-risk mental state has been disseminated. With this survey, we aimed to reveal how Japanese psychiatrists diagnose patients with at-risk mental state and prescribe treatment strategies for them.

METHODS

Using fictional case vignettes, we conducted a questionnaire survey of psychiatrists (n = 1399) who worked in Tokyo. We mailed study documents to all eligible participants in November 2015 with a requested return date in December.

RESULTS

Two hundred and sixty (19.3%) psychiatrists responded to the survey. Their correct diagnosis rates for the patients in the at-risk mental state vignettes were low (14.6% for the vignette describing at-risk mental state with attenuated positive symptom syndrome; 13.1% for the vignette describing at-risk mental state with brief intermittent psychotic syndrome). Many psychiatrists selected pharmacotherapy and antipsychotics to treat patients in the at-risk mental state vignettes. The psychiatrists who correctly diagnosed patients in the at-risk mental state vignettes had significantly fewer years of clinical psychiatric experience than did those who diagnosed them as having a non-at-risk mental state (12.5 years vs 22.7 years for the vignette describing at-risk mental state with attenuated positive symptom syndrome, P < 0.01; 14.3 years vs 22.2 years for the vignette describing at-risk mental state with brief intermittent psychotic syndrome, P < 0.01).

CONCLUSION

This study suggests that precise knowledge of at-risk mental state has not been disseminated among Japanese psychiatrists.

Is it possible to implement community care based on mental health in Japan? A comparison between decade ago and present on Duration of Untreated Psychosis (DUP)

INTRODUCTION

In recent years, the early detection and treatment of the first episode of schizophrenia (FES) has attracted worldwide attention. In Japan, psychiatric care has changed to an open and accessible framework over the past decade. Therefore, the duration of untreated psychosis (DUP) is thought to have been shortened. The purposes of this study were to investigate whether recent DUP periods are shorter than they were 10 years ago and whether the DUP at present differs among psychiatric facilities. We investigated the recent DUP at a psychiatric hospital and its satellite clinic.

MATERIAL AND METHODS

We examined the differences in DUP, age, sex, referral pathway, living companions, social participation, and schooling history among 3 groups of FES patients: (i) a psychiatric hospital during 1999-2001 and (ii) during 2009-2011, and (iii) a psychiatric clinic during 2009-2011.

RESULTS

The average DUP was 14.3 (SD = 17.5) months for the psychiatric hospital during 1999-2001, 16.0 (SD = 18.7) months for the psychiatric hospital during 2009-2011, and 24.4 (SD = 30.0) months for the psychiatric clinic during 2009-2011. No significant differences were found in the DUP for each facility and during this decade. Also, the differences in the DUP could not be attributed to factors such as living companions or social participation.

DISCUSSION

Increases in the numbers of patients and psychiatric clinics have not led to the early detection of FES. To shorten the DUP in the future, closer cooperation among the medical field, the educational field, and the health and welfare will be needed.

Early intervention services in psychosis: from evidence to wide implementation

AIM

Early intervention (EI) in psychosis is a comprehensive and evidence-based approach aimed at detection and treatment of psychotic symptoms in their early stages. This paper presents core features and noteworthy aspects of the evidence basis and limitations of EI, the importance of programme fidelity, challenges for its widespread dissemination and economic perspectives related to it.

METHODS

This paper is a narrative review about the evidence supporting EI and the challenges to its widespread dissemination.

RESULTS

In spite of evidence of a wide range of benefits, widespread dissemination has been slow, and even currently implemented programmes might be threatened. This reflects in part the shortcomings of mental health care in general, such as low priority for funding, stigma and structural problems. Successful examples of advocacy, mobilization and destigmatization campaigns have overcome these difficulties.

CONCLUSIONS

Funding for mental health in general and for EI services appears low relative to need. One key argument for better funding for EI can be found in its favourable cost-effectiveness, but not all stakeholders beyond mental health administrators are aware of this. Positive impacts of EI programmes on excess unemployment and tax forgone suggest that social affairs and labour ministries - and not only health ministries - could be more involved in governance of mental health issues; ministries of justice and education are other sector stakeholders than can benefit. Wider dissemination of EI services will probably benefit from better integration of potential funders, promotion of joint targets and shared financial or budgetary incentives.

Criticism and Depression among the Caregivers of At-Risk Mental State and First-Episode Psychosis Patients

Expressed emotion (EE), especially criticism, is an important predictor of outcomes for the patient for a wide range of mental health problems. To understand complex links between EE and various relevant variables in early phase psychosis, this study examined criticism, distress of caregivers, other patients’, and caregivers’ variables, and links between criticism and these variables in those with at-risk mental state (ARMS) for psychosis and first-episode psychosis (FEP). The participants were 56 patients (mean age 18.8 ± 4.2 years) with ARMS and their caregivers (49.4 ± 5.8 years) and 43 patients (21.7 ± 5.2 years) with FEP and their caregivers (49.3 ± 7.4 years). We investigated criticisms made by caregivers using the Japanese version of the Family Attitude Scale and caregiver depressive symptoms via the self-report Beck Depression Inventory. We also assessed psychiatric symptoms and functioning of the patients. Approximately one-third of caregivers of patients with ARMS or FEP had depressive symptoms, predominately with mild-to-moderate symptom levels, whereas only a small portion exhibited high criticism. The level of criticism and depression were comparable between ARMS and FEP caregivers. The link between criticism, caregivers’ depression, and patients’ symptoms were observed in FEP but not in ARMS caregivers. These findings imply that the interaction between criticism and caregivers’ and patients’ mental states may develop during or after the onset of established psychosis and interventions for the caregivers should be tailored to the patient’s specific stage of illness. Interventions for FEP caregivers should target their emotional distress and include education about patient’s general symptoms.

A naturalistic longitudinal study of at-risk mental state with a 2.4 year follow-up at a specialized clinic setting in Japan

OBJECTIVE

The notion of at-risk mental state (ARMS) is valuable for identifying individuals in a putative prodromal state of psychosis and for reducing conversion risk by pharmacological and psychological interventions. However, further systematic study is required because 1) diagnostic reliability in various clinical settings is not yet established; 2) predictive ability is insufficient; 3) optimal interventions in diversified populations are elusive; and 4) little evidence from non-Western regions exists.

METHODS

A naturalistic longitudinal study was conducted at a specialized clinic for early psychosis at a university hospital in Sendai, Japan. Individuals with ARMS (n=106) were recruited and followed up with case-by-case treatment.

RESULTS

Two-thirds of the participants were psychiatrist referrals, and 83 were followed up for at-least 1 year (mean follow-up=2.4 years). Fourteen developed psychosis and the estimated (by Kaplan-Meier) cumulative transition rate was 11.1% at 12, 15.4% at 24, and 17.5% at 30 months. At the end-point, about 30% of the 83 followed-up participants including 11 converters received antipsychotic medication. Compared to non-converters, converters showed more severe attenuated psychotic symptoms, including ego-boundary disturbance, formal thought disorder, and emotional disturbance.

CONCLUSIONS

The present study replicated previous major Western longitudinal studies, in terms of clinical characteristics, psychosis transition rate, and antipsychotic prescription rate. Our results emphasize the importance of phenomenological assessment of ARMS and intensive care in a clinical setting.

Prevention and recovery in early psychosis (PREP(®)): building a public-academic partnership program in Massachusetts, United States

Recently, there has been increasing emphasis on early intervention (EI) for psychotic disorders. EI programs in public mental health settings have been established in countries such as Australia, the United Kingdom, and Canada. However, there are relatively few EI programs in the United States (U.S.). Here we describe the conceptual origins and practical development of the PREP program, i.e., Prevention and Recovery in Early Psychosis, as it evolved in a public academic psychiatry setting in Boston, Massachusetts, U.S. PREP developed over a decade through a partnership between the Massachusetts Department of Mental Health and academic institutions within the Harvard Department of Psychiatry. We discuss the evolution, programmatic features, funding mechanisms, staffing, and the role of clinical training in PREP. The key principles in developing the PREP Program include the focus on early, evidence based, person-centered and phase-specific, integrated and continuous, comprehensive care. This program has served as a foundation for the emergence of related services at our institution, including a research clinic treating those at clinical high risk or within the putative "prodromal" period preceding frank psychosis. This account offers one possible blueprint for the development of EI programs despite the lack in the U.S. of a national mandate for EI or prevention-based mental health programs.