Effective use of yokukansan for Caucasian patient with panic disorder: A case report

Background

Yokukansan is a traditional Japanese herbal medicine that is widely administered to individuals of various age groups as an effective drug for anxiety, with few side-effects. While animal studies have yielded promising results concerning yokukansan's potential in treating anxiety disorders, comprehensive validation has remained incomplete. Moreover, most of the clinical investigations regarding yokukansan have primarily focused on Japanese subjects, and its impact on non-Asian ethnicities remains unverified.

Case Presentation

We present the case of a 17-year-old Caucasian female with panic disorder (PD). Following her relocation to Japan, she experienced panic attacks due to environmental changes, which subsequently prompted her to visit to our clinic. Various medical examinations revealed no abnormalities, which ruled out the possibility of any physical illness other than PD. Significantly, the administration of yokukansan resulted in a notable reduction in panic attacks, as well as in anticipatory anxiety, accompanied by discernible enhancements in psychosocial functioning and overall quality of life. Furthermore, it is imperative to underscore the fact that no noteworthy adverse events took place.

Conclusion

Panic attacks and profound anxiety in a Caucasian patient with PD were successfully treated with the use of yokukansan. This case study suggests that yokukansan may be effective in treating PD in Caucasians as well as in Asians. However, to substantiate this preliminary observation, further investigations are required.

Effectiveness and safety of the co-administration of Yokukan-San (Japanese herbal medicine) with antipsychotics in hospitalized older patients with pneumonia

AIM

Behavioral and psychological symptoms and delirium frequently occur in hospitalized older patients with pneumonia and are associated with longer hospital stays. Yokukan-San (YKS, traditional Japanese [Kampo] medicine) and antipsychotics are often used to treat delirium and behavioral and psychological symptoms in Japan. Hence, this study aimed to assess the effectiveness and safety of the co-administration of YKS with atypical antipsychotics in older patients with pneumonia.

METHODS

We used the Japanese Diagnosis Procedure Combination inpatient database to retrospectively identify older patients (≥65 years) hospitalized for pneumonia who received antipsychotics within 3 days of hospitalization. The patients were divided into two groups: those who received atypical antipsychotics alone (control group) and those who received both atypical antipsychotics and YKS (YKS group). We compared length of hospital stay, in-hospital mortality, bone fractures, and administration of potassium products between the two groups using propensity score overlap weighting.

RESULT

We identified 4789 patients in the YKS group and 61 641 in the control group. After propensity score overlap weighting, length of hospital stay was statistically significantly shorter in the YKS group (percentage difference -3.0%; 95% confidence interval -5.8% to -0.3%). The proportion of patients who received potassium products was higher in the YKS group (odds ratio 1.34; 95% confidence interval 1.15-1.55). In-hospital death and bone fractures were not significantly different.

CONCLUSION

Co-administration of YKS with atypical antipsychotics could be a reasonable treatment option for hospitalized older patients with pneumonia and aggressive psychiatric symptoms. Geriatr Gerontol Int 2023; 23: 849-854.

Assessment of Risk Factors for Postoperative Delirium in Older Adults Who Underwent Spinal Surgery and Identifying Associated Biomarkers Using Exosomal Protein

PURPOSE

With an increase in the aging population, the number of patients with degenerative spinal diseases undergoing surgery has risen, as has the incidence of postoperative delirium. This study aimed to investigate the risk factors affecting postoperative delirium in older adults who had undergone spine surgery and to identify the associated biomarkers.

METHODS

This study is a prospective study. Data of 100 patients aged ≥ 70 years who underwent spinal surgery were analyzed. Demographic data, medical history, clinical characteristics, cognitive function, depression symptoms, functional status, frailty, and nutritional status were investigated to identify the risk factors for delirium. The Confusion Assessment Method, Delirium Rating Scale-R-98, and Nursing Delirium Scale were also used for diagnosing delirium. To discover the biomarkers, urine extracellular vesicles (EVs) were analyzed for tau, ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), neurofilament light, and glial fibrillary acidic protein using digital immunoassay technology.

RESULTS

Nine patients were excluded, and data obtained from the remaining 91 were analyzed. Among them, 18 (19.8%) developed delirium. Differences were observed between participants with and without delirium in the contexts of a history of mental disorder and use of benzodiazepines (p = .005 and p = .026, respectively). Tau and UCH-L1-concentrations of urine EVs-were comparatively higher in participants with severe delirium than that in participants without delirium (p = .002 and p = .001, respectively).

CONCLUSION

These findings can assist clinicians in accurately identifying the risk factors before surgery, classifying high-risk patients, and predicting and detecting delirium in older patients. Moreover, urine EV analysis revealed that postoperative delirium following spinal surgery is most likely associated with brain damage.

Yokukansan (TJ-54) in patients undergoing surgery: A systematic review and meta-analysis

OBJECTIVES

To evaluate the efficacy and safety of Yokukansan (TJ-54) in patients undergoing surgery.

METHODS

Efficacy was assessed by the onset of delirium, delirium rating scales, anxiety evaluated by Hospital Anxiety and Depression Scale-Anxiety (HADS-A) score, and safety was assessed by any reported adverse events.

RESULTS

Six studies were included. There were no significant differences between the groups in the onset of delirium (risk ratio 1.15, 95% confidence interval [CI] 0.77-1.72), delirium rating scales (early postoperative period: standardized mean difference [SMD] -0.24, 95% CI -1.11 to 0.63; late postoperative period: SMD -0.06, 95% CI -1.56 to 1.45), HADS-A score (mean difference -0.47, 95% CI -1.90 to 0.96), and any adverse events (risk ratio 1.18, 95% CI 0.35-4.00).

CONCLUSIONS

The use of TJ-54 in patients undergoing surgery is not an effective strategy for postoperative delirium and anxiety. Further research considering target patients and durations of administration should be conducted.

Traditional uses, chemical compounds, pharmacological activities and clinical studies on the traditional Chinese prescription Yi-Gan San

ETHNOPHARMACOLOGICAL RELEVANCE

A widely used traditional prescription, Yi-Gan San (YGS) is a remedy for neurodegenerative disorders. The formulation consists of seven Chinese medicinal materials in specific proportions, namely Uncariae Ramulus cum Uncis (Uncaria rhynchophylla (Miq.) Miq. ex Havil.), Bupleuri Radix (Bupleurum chinense DC.), Angelicae Sinensis Radix (Angelica sinensis (Oliv.) Diels), Chuanxiong Rhizoma (Ligusticum wallichii Franch.), Poria (Poria cocos (Schw.) Wolf), Atractylodis Macrocephalae Rhizoma (Atractylodes macrocephala Koidz.) and Glycyrrhizae Radix et Rhizoma (Glycyrrhiza uralensis Fisch.). Using YGS has been shown to alleviate various behavioural and psychological symptoms of dementia (BPSD).

AIM OF THIS REVIEW

The goal of this review is to give up-to-date information about the traditional uses, chemistry, pharmacology and clinical efficacy of YGS based on the scientific literature and to learn the current focus and provide references in the next step.

MATERIALS AND METHODS

The database search room was accessed using the search terms "Yi-Gan San" and "Yokukansan" to obtain results from resources such as Web of Science, PubMed, Google Scholar and Sci Finder Scholar. We not only consulted the literature of fellow authors for this review but also explored classical medical books.

RESULTS

YGS has been used to cure neurosis, sleeplessness, night weeping and restlessness in infants. Its chemical components primarily consist of triterpenes, flavonoids, phenolics, lactones, alkaloids and other types of compounds. These active ingredients displayed diverse pharmacological activities to ameliorate BPSD by regulating serotonergic, glutamatergic, cholinergic, dopaminergic, adrenergic, and GABAergic neurotransmission. In addition, YGS showed neuroprotective, antistress, and anti-inflammatory effects. The majority of cases of neurodegenerative disorders are treated with YGS, including Alzheimer's disease and dementia with Lewy bodies.

CONCLUSIONS

Based on previous studies, YGS has been used as a traditional prescription in East Asia, such as Japan, Korea and China, and it has diverse chemical compounds and multiple pharmacological activities. Nevertheless, few experimental studies have focused on chemical and quantitative YGS studies, suggesting that further comprehensive research on its chemicals and quality assessments is critical for future evaluations of drug efficacy.

Kampo Formulae for the Treatment of Neuropathic Pain ∼ Especially the Mechanism of Action of Yokukansan ∼

Kampo medicine has been practiced as traditional medicine (TM) in Japan. Kampo medicine uses Kampo formulae that are composed of multiple crude drugs to make Kampo formulae. In Japan, Kampo formulae are commonly used instead of or combined with Western medicines. If drug therapy that follows the guidelines for neuropathic pain does not work or cannot be taken due to side effects, various Kampo formulae are considered as the next line of treatment. Since Kampo formulae are composed of two or more kinds of natural crude drugs, and their extracts contain many ingredients with pharmacological effects, one Kampo formula usually has multiple effects. Therefore, when selecting a formula, we consider symptoms other than pain. This review outlines the Kampo formulae that are frequently used for pain treatment and their crude drugs and the basic usage of each component. In recent years, Yokukansan (YKS) has become one of the most used Kampo formulae for pain treatment with an increasing body of baseline research available. We outline the known and possible mechanisms by which YKS exerts its pharmacologic benefits as an example of Kampo formulae's potency and holistic healing properties.

Hospital Admission to a Window-Side Bed Does Not Prevent Delirium: A Retrospective Cohort Study of Older Medical Inpatients in General Wards

Background: Delirium in older inpatients is a serious problem. The presence of a window in the intensive care unit has been reported to improve delirium. However, no study has investigated whether window-side bed placement is also effective for delirium prevention in a general ward. Objectives: This study aims to clarify the association between admission to a window-side bed and delirium development in older patients in a general ward. Design: This research is designed as a retrospective cohort study of older patients admitted to the internal medicine departments of Shinshu University Hospital, Japan. Participants: The inclusion criteria were the following: (1) admitted to hospital internal medicine departments between April 2009 and December 2018, (2) older than 75 years, (3) admitted to a multi-patient room in a general ward, and (4) unplanned admission. The number of eligible patients was 1,556. Exposure: This study is a comparison of 495 patients assigned to a window-side bed (window group) with 1,061 patients assigned to a non-window-side bed (non-window group). When patients were transferred to the other type bed after admission, observation was censored. Main Measures: The main outcome of interest was "delirium with event" (e.g., the use of medication or physical restraint for delirium) within 14 days after admission as surveyed by medical chart review in a blinded manner. Key Results: The patients had a median age of 80 years and 38.1% were female. The main outcome was recorded in 36 patients in the window group (10.7 per thousand person-days) and 84 in the non-window group (11.7 per thousand person-days). Log-rank testing showed no significant difference between the groups (p = 0.78). Multivariate analysis with Cox regression modeling also revealed no significant association for the window group with main outcome development (adjusted hazard ratio 0.90, 95% confidence interval of 0.61-1.34). Conclusions: Admission to a window-side bed did not prevent delirium development in older patients admitted to a general ward.

Effects of multimedia-based fall prevention education on the knowledge, attitudes, or behaviors of patients

OBJECTIVES

Patient safety is regarded as a critical quality monitoring indicator for medical institutions. The effects of a multimedia-based patient education intervention on knowledge, attitudes, and behaviors regarding fall prevention were observed.

METHODS

The study had a quasi-experimental research design and enrolled 140 participants. Seventy participants in the experimental group received multimedia-based patient education and a health education leaflet, while those in the control group received only the health education leaflet. A structured questionnaire was used for data collection at baseline, and a posttest was applied after the intervention.

RESULTS

The participants were predominantly treated in the gastroenterology department (45.7%), followed by the pulmonology department (33.6%). A total of 86.4% of patients had not experienced a fall within 3 months. After the intervention, the average scores for all variables in the experimental group were higher than those in the control group. The results indicate that attitudes, knowledge, and behaviors regarding fall prevention among patients in the pulmonology department were higher than those among patients in the gastroenterology department; the differences were statistically significant.

CONCLUSION

The individualized health education content was of substantial significance for patients with different disease backgrounds and facilitated changes in their knowledge, attitudes, and behaviors regarding falls.

RELEVANCE TO CLINICAL PRACTICE

Multimedia-based patient education influenced inpatients' knowledge, attitudes, and behaviors for preventing falls.

Yokukansan for Treatment of Preoperative Anxiety and Prevention of Postoperative Delirium in Cancer Patients Undergoing Highly Invasive Surgery. J-SUPPORT 1605 (ProD Study): A Randomized, Double-Blind, Placebo-Controlled Trial

CONTEXT

No standard preventive or therapeutic methods have been established for preoperative anxiety and postoperative delirium in patients with cancer.

OBJECTIVES

To clarify the therapeutic effect of yokukansan for perioperative psychiatric symptoms in patients with cancer as well as to confirm its safety profile.

METHODS

This is a randomized, double-blind, and placebo-controlled trial conducted at a single center in Tokyo, Japan. About 195 patients with cancer scheduled to undergo tumor resection took one packet of the study drug, which was administered orally. Coprimary outcomes were change in preoperative anxiety assessed with the Hospital Anxiety and Depression Scale-Anxiety and incidence of postoperative delirium assessed with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Interim analysis was performed with one-third (n = 74) of the target number of registered patients.

RESULTS

Because this trial was canceled based on the results of the interim analysis and the protocol treatment was discontinued in patients who were already registered, conclusions were based on the full analysis set of 160 participants. There were no significant differences between groups in the change of mean Hospital Anxiety and Depression Scale-Anxiety score (intervention group [SD] 0.4 [3.0] vs. placebo group 0.5 [3.0]; P = 0.796) or the incidence of postoperative delirium (32% vs. 30%; P = 0.798). There were no serious adverse events in either group.

CONCLUSION

In patients with cancer undergoing highly invasive surgeries, yokukansan demonstrated no significant efficacy for the treatment of preoperative anxiety or the prevention of postoperative delirium. Yokukansan is already used in daily practice in Japan, but we should be careful with its future use.

Preoperative anxiety in Chinese colorectal cancer patients: The role of social support, self-esteem and coping styles

BACKGROUND

Relatively little is known about preoperative anxiety and its associated factors with colorectal cancer, which is one of the most prevalent cancers. We aimed to investigate preoperative anxiety and its associated social, psychological and coping factors based on the disclosure/nondisclosure of cancer diagnosis.

METHODS

A cross-sectional study was conducted in consecutive colorectal cancer inpatients (N = 434), whose anxiety was assessed based on semi-structured interview, demographic-clinical variables, social support, self-esteem and coping styles (acceptance-resignation, confrontation, avoidance). Hierarchical regression analyses were conducted to explore the relationships between social, psychological, coping factors and preoperative anxiety.

RESULTS

There was no significant difference in preoperative anxiety (χ² = 1.031, p = .31) between the disclosure and nondisclosure groups. Social, psychological and coping factors together accounted for an additional variance of preoperative anxiety (disclosure: 22%; nondisclosure: 20.8%). Social support (β = -0.17, p = .004), self-esteem (β = -0.22, p = .001) and coping styles (acceptance-resignation: β = 0.32, p < .001; confrontation: β = 0.13, p = .06; avoidance: β = -0.17, p = .04) were associated with preoperative anxiety in the nondisclosure group. For the disclosure group, acceptance-resignation was the only significantly associated factor of preoperative anxiety (β = 0.37, p < .001).

CONCLUSIONS

Coping styles, such as acceptance-resignation and confrontation, could aggravate preoperative anxiety. Avoidance, social support and self-esteem might be helpful in preventing preoperative anxiety. These findings highlight the importance of providing psychological interventions for cancer patients by integrating social support, self-esteem and coping styles when disclosing a cancer diagnosis.

Yokukansan for perioperative psychiatric symptoms in cancer patients undergoing high invasive surgery. J-SUPPORT 1605 (ProD Study): study protocol for a randomized controlled trial

Background

Preoperative anxiety and postoperative delirium affect both short- and long-term prognoses in patients with cancer; therefore, these conditions require early prevention and treatment. However, no standard preventive or therapeutic methods have been established for them. Yokukansan, a Japanese herbal medicine for the treatment of insomnia and anxiety, causes relatively few adverse drug reactions and effectively improves the behavioral and psychological symptoms of dementia. Thus, it is expected to be useful for treating and/or preventing perioperative psychiatric symptoms in patients with cancer. The objective of this study is to clarify the therapeutic effect of Yokukansan for preoperative anxiety and its preventive effect on postoperative delirium in cancer patients, as well as to confirm its safety profile.

Methods

This study is a randomized, double-blind, placebo-controlled study in cancer patients scheduled to undergo tumor resection. Patients who provide consent are randomly allocated to receive oral administration of Yokukansan or placebo, and study drug administration is continued for 4 days or longer prior to surgery. We defined two primary endpoints, change in preoperative anxiety and incidence of postoperative delirium. Secondary endpoints are severity score of postoperative delirium, duration of postoperative delirium, amount of benzodiazepines used prior to surgery, amount of antipsychotic agents used after surgery, and number of postoperative hospitalization days. We plan to complete the analysis on March 31, 2021. The target number of registered patients is 110 per group, or 220 in total.

Discussion

This study is the first randomized, double-blind, placebo-controlled study intended to clarify the effects of a Japanese herbal medicine, Yokukansan, in the prevention and treatment of perioperative psychiatric symptoms in patients with cancer. The trial was initiated on August 14, 2017, with 195 subjects randomized by October 5, 2018.

Trial registration

UMIN Clinical Trials Registry (UMIN-CTR), UMIN000027561. Registered on 31 May 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3202-1) contains supplementary material, which is available to authorized users.

Yokukansan, a traditional Japanese herbal medicine, enhances the anxiolytic effect of fluvoxamine and reduces cortical 5-HT2A receptor expression in mice

ETHNOPHARMACOLOGICAL RELEVANCE

Yokukansan is a traditional Japanese herbal medicine that has been approved in Japan as a remedy for neurosis, insomnia, and irritability in children. It has also been reported to improve behavioral and psychological symptoms in patients with various forms of dementia.

AIM OF THE STUDY

To evaluate the usefulness of co-treatment with an antidepressant and an herbal medicine in the psychiatric field, the current study examined the effect of yokukansan on the anxiolytic-like effect of fluvoxamine in mice.

MATERIALS AND METHODS

The anxiolytic-like effect in mice was estimated by the contextual fear conditioning paradigm. Contextual fear conditioning consisted of two sessions, i.e., day 1 for the conditioning session and day 2 for the test session. The expression levels of 5-HT_1A and 5-HT_2A receptor in the mouse brain regions were quantified by western blot analysis.

RESULTS

A single administration of fluvoxamine (5-20 mg/kg, i.p.) before the test session dose-dependently and significantly suppressed freezing behavior in mice. In the combination study, a sub-effective dose of fluvoxamine (5 mg/kg, i.p.) significantly suppressed freezing behavior in mice that had been repeatedly pretreated with yokukansan (0.3 and 1 g/kg, p.o.) once a day for 6 days after the conditioning session. Western blot analysis revealed that the expression level of 5-HT_2A receptor was specifically decreased in the prefrontal cortex of mice that had been administered yokukansan and fluvoxamine. Furthermore, microinjection of the 5-HT_2A receptor antagonist ketanserin (5 nmol/mouse) into the prefrontal cortex significantly suppressed freezing behavior.

CONCLUSION

The present findings indicate that repeated treatment with yokukansan synergistically enhances the anxiolytic-like effect of fluvoxamine in the contextual fear conditioning paradigm in mice in conjunction with a decrease in 5-HT_2A receptor-mediated signaling in the prefrontal cortex. Therefore, combination therapy with fluvoxamine and yokukansan may be beneficial for the treatment of anxiety disorders.

Older Patients' Worries in Connection With General Anesthesia and Surgery-A Qualitative Study

PURPOSE

To examine anxiety and what older patients worry about related to anesthesia and colorectal surgery, and their perceptions regarding nurses' ability to ease preoperative worry.

DESIGN

Qualitative individual face-to-face interviews.

METHODS

The study included 18 patients aged between 62 and 91 years with lower abdominal tumors. The study was conducted in two day-surgery wards in Sweden. Interview data were analyzed with Malterud's systematic text condensation.

FINDINGS

Four themes were identified: (1) losing control of one's body, leaving one's life in someone else's hands, and the feeling that there is no going back, (2) claustrophobia and anticipated pain in an unknown environment, (3) unknown and frightening vocabulary concerning the surgery, and (4) what can happen if something goes wrong.

CONCLUSIONS

Patients worry about a number of things. If preoperative worry could be identified, actions taken to reduce worry could be personalized and patients' own strategies to reduce worries may be helpful for them.