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Objective To investigate the utility of the voxel-based specific regional analysis system for Alzheimer’s disease (VSRAD). Methods Clinical data from patients who underwent screening for dementia using VSRAD and the Japanese version of COGNISTAT, the Neurobehavioral Cognitive Status Examination, were retrospectively investigated to specify the domains of cognitive function that correlate with the statistical mean value of positive Z-scores in the target volume-of-interest (VOI). A receiver operating characteristic (ROC) curve was constructed to assess the mean value of positive Z-scores in discriminating patients with AD. Results A total of 72 patients were included (18 male and 54 female; 15 patients with AD). The mean value of positive Z-scores in the target VOI was significantly correlated with standardized COGNISTAT scores for Orientation and Memory in all patients (r = –0.35 and –0.38, respectively). ROC curve analysis revealed that a cut-off of 1.57 for mean value of positive Z-scores in the target VOI provided 69.4% accuracy in discriminating patients with AD, with a sensitivity of 0.80 and specificity of 0.67. Conclusions The results evinced the value of VSRAD in diagnosing AD. The degree of atrophy represented by the target VOI may reflect impairments in Orientation and Memory, which are early stage symptoms observed in AD.

Individuals with schizophrenia exhibit cognitive impairments, which are related to impairments in social functions. This study investigated the effects of cognitive remediation on cognitive, social, and daily living impairment. Participants were individuals with schizophrenia between 20 and 60 years old (N = 44). Participants were randomly assigned to two groups: a cognitive remediation intervention group and a non-intervention control group. The control group was provided with conventional drug therapy and either day care or occupational therapy. The intervention group was provided with the "neuropsychological educational approach to cognitive remediation" developed by Medalia and co-workers. We assessed cognitive functions using the brief assessment of cognition in schizophrenia (BACS), and evaluated social and daily living functions using the global assessment of functioning (GAF) scale. Significant group by time interaction effects indicated that verbal memory, working memory, attention, and executive function showed significantly greater improvement at post-intervention for the intervention group than the control group. Social and daily living function also improved in the intervention group and improvements were maintained one year after intervention. These preliminary findings indicate that the combination of cognitive remediation and psychiatric rehabilitation is effective for facilitating improvements in cognitive function and social and daily living functions in individuals with schizophrenia.

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. METHODS: An assessor-masked, randomized, parallel-group clinical trial was conducted to compare the feasibility and efficacy of SCIT with treatment as usual (TAU). Seventy-two patients diagnosed with schizophrenia or schizoaffective disorder consented to participate in the trial. The subjects were randomly allocated to either a SCIT or a TAU subgroup. SCIT is a manual-based group intervention that is delivered in 20–24 hour-long weekly sessions. 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: 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. 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. DISCUSSION: 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. The effect of SCIT on social cognition was no different from that of TAU, however, there is a possibility that it may show efficacy in those with short duration of illness.

Aim The aim of this study was to clarify whether improvement of cognitive functioning by cognitive remediation therapy can improve work outcome in schizophrenia and other severe mental illnesses when combined with supported employment. Methods The subjects of this study were persons with severe mental illness diagnosed with schizophrenia, major depression, or bipolar disorder (ICD-10) and cognitive dysfunction who participated in both cognitive remediation using the Thinking Skills for Work program and a supported employment program in a multisite, randomized controlled study. Logistic and multiple linear regression analyses were performed to clarify the influence of cognitive functioning on vocational outcomes, adjusting for demographic and clinical variables. Results Improvement of cognitive functioning with cognitive remediation significantly contributed to the total days employed and total earnings of competitive employment in supported employment service during the study period. Any baseline demographic and clinical variables did not significantly contribute to the work-related outcomes. Conclusion A cognitive remediation program transferring learning skills into the real world is useful to increase the quality of working life in supported employment services for persons with severe mental illness and cognitive dysfunction who want to work competitively.

BackgroundLittle is known about the economic benefits of cognitive remediation and supported employment (CR + SE). The present study aimed to investigate the cost-effectiveness of CR + SE compared with traditional vocational services (TVS).MethodIndividuals with mental illness and low cognitive function were recruited at six sites in Japan. A total of 111 participants were randomly allocated to the CR + SE group or the TVS group. Clinical and vocational outcomes were assessed at baseline and 12-month follow-up. Service utilization data were collected monthly. The data on outcomes and costs were combined to examine cost-effectiveness.ResultsThe data were obtained from a total of 92 participants. The CR + SE group resulted in better vocational and clinical outcomes (employment rate, 62.2%; work tenures, 78.6 days; cognitive improvement, 0.5) than the TVS group (19.1%, 24.9 days and 0.2). There was no significant difference in mean total costs between the groups (CR + SE group: $9823, s.d. = $6372, TVS group: $11 063, s.d. = $11 263) with and without adjustment for covariates. However, mean cost for medical services in the CR + SE group was significantly lower than that in the TVS group after adjusting covariates (Β = −$3979, 95% confidence interval −$7816 to −$143, p = 0.042). Cost-effectiveness acceptability curves for vocational outcomes illustrated the high probabilities (approximately 70%) of the CR + SE group being more cost-effective than TVS when society is not willing to pay additional costs.ConclusionsCR + SE appears to be a cost-effective option for people with mental illness who have low cognitive functioning when compared with TVS.

Devising new methods to improve neurocognitive impairment through cognitive remediation is an important research goal. We developed an original computer programme termed the Japanese Cognitive Rehabilitation Programme for Schizophrenia (JCORES) that provides cognitive practice across a broad range of abilities. The current study examined for the first time whether a cognitive remediation programme, including both computerised cognitive training using JCORES and group intervention such as enhancing meta-cognition and teaching strategies, is more effective than treatment as usual for improving neurocognitive and social functioning. Sixty-two outpatients with schizophrenia were randomised to either a cognitive remediation group or a control group. Participants engaged in two computerised cognitive training sessions and one group meeting per week for 12 weeks. The average number of total sessions attended (computerised cognitive practice + group intervention) was 32.3 (89.7%). The cognitive remediation group showed significantly more improvements in verbal memory, composite score of the Brief Assessment of Cognition in Schizophrenia, Japanese version (BACS-J), and general psychopathology on the Positive and Negative Syndrome Scale (PANSS) than the control group. These findings demonstrate that a cognitive remediation programme is feasible in Japan and is a more effective way to improve neurocognitive functioning and psychiatric symptoms.

Methamphetamine, a potent psychostimulant, may cause a condition of mood disorder among users. However, arguments concerning methamphetamine-induced mood disorder remain insufficient. This case study describes a male with methamphetamine-induced bipolar disorder not accompanied by psychotic symptoms, who twice in an 11-year treatment period, manifested an ultra-rapid cycler condition alternating between manic and depressive mood states with 3- to 7-day durations for each. The conditions ensued after a bout of high-dose methamphetamine use and shifted to a moderately depressive condition within 1 month after the use under a treatment regimen of aripiprazole and mood stabilizers. The cycler condition may be characteristic of a type of the bipolar disorder and a sign usable for characterization. Further efforts are needed to seek distinctive features and to improve diagnostic assessment of methamphetamine-induced mood disorders.

Robert P. Liberman introduced "Personal Support Specialists" as a role of psychiatrists who support patients' lives and help them discover the meaning of life, as well as helping with daily activities and personal difficulties. They need to have multiple perspectives on medical, subjective, social, and life recoveries. Important areas to help patients practically are job-assis- tance, supporting love and marriage, and independent living in the community. I usually use Seikatsu-Rinsho (The way of Living Learning), cognitive behavioral therapy, and Seikatsu-ryouhou (Life-centered Therapy) by Hiroshi Utena as basic principles in my practice. Recently, I shed light on an -individual value system to evolve these principles. Reflecting on two recovery stories I co-encountered, contents of psychiatric interviews and roles of psychiatrists are discussed. There remain many difficulties which modern psychiatry has not resolved, such as negative symptoms and marked disabilities in social life. We as psy- chiatrists should know how to evolve and maintain hope and intrinsic motivation to support a patient's life.

Objectives: Examining the pharmacotherapy of patients who have attempted suicide by overdose could be useful in developing treatment and suicide prevention plans. We surveyed the drugs taken by psychiatric prescription overdose patients who received inpatient treatment and sought to determine the characteristics of patients who repeatedly attempt suicide. Methods: Subjects were 116 patients who attempted suicide by overdose with prescription psychiatric drugs and received inpatient treatment at the Intensive Care Unit of the Emergency and Critical Care Center of Teikyo University Hospital from August 2009 to July 2010. We retrospectively surveyed clinical characteristics, including prescriptions prior to hospitalization and psychiatric diagnosis, divided subjects into a first-admission (FA) and repeatadmission (RA) groups, and compared their clinical characteristics. Results: All subjects were prescribed benzodiazepine-receptor agonists (BZDRAs), whereas antidepressants and antipsychotics were prescribed to 58.6% and 49.1% of subjects, respectively. Emotionally unstable personality disorder, borderline-type (EUPD-B) was found to be significantly more common in the RA group. Comparing prescriptions in the FA and RA groups indicated that the prescribed dosage and prescription rate for antipsychotics were significantly higher for RA group patients. Conclusion: This study revealed that repeat-admission attempted suicide patients had a significantly higher rate of EUPD-B and were more frequently using antipsychotic prescription drugs. Further, in these patients, more frequent use of antipsychotics is believed to correspond to patient impulsivity. The excessive prescription of BZDRAs is a serious problem requiring urgent measures. Research on the prescriptions for overdose patients may lead to clinically significant findings and should be promoted in the future.

Aims Facial 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. Methods Participants 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. Results Patients 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. Conclusions These 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.

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: In Japan, Job assistance for SMI have been not active. Compared with mental retardation, employment rate of SMI was low. The needs of the effective job assistance for SMI are growing. The purpose of this study was to determine the effectiveness of the combination approach of Cognitive Remediation (CR) and Supported Employment (SE) in clinical outcomes, including cognitive functioning and psychiatric symptoms besides vocational outcomes. Methods: The participants diagnosed with schizophrenia or schizoaffective disorder were assigned to CR+SE group (n=52) and SE group (n=57). CR comprised computer based trainings using COGPACK and group works. SE was individualized vocational support provided by employment specialists. Outcome measures included cognitive functioning, psychiatric symptoms, social functioning, performance of tasks as clinical outcomes, employment rate, duration of employment, and earned wage as vocational outcome. Results: CR+SE group displayed significantly better psychiatric symptoms (F=3.490, pDiscussions: This is the first controlled study to determine the effectiveness of CR on vocational outcomes in Japan. The results showed that CR and SE programs were feasible in Japan and that CR using COGPACK had favorable effects on cognitive functioning, psychiatric symptoms, and social functioning, which is consistent with previous researches.

OBJECTIVE Cognitive impairment is common in schizophrenia, and is associated with poor psychosocial functioning. Previous studies had inconsistently shown improvement in cognitive functions with cognitive remediation therapy. This study examined whether cognitive remediation is effective in improving both cognitive and social functions in schizophrenia in outpatient settings that provide learning-based psychiatric rehabilitation. This study is the first randomized controlled trial of cognitive remediation in Japan. METHOD Study participants were individuals with schizophrenia from 6 outpatient psychiatric medical facilities who were randomly assigned either a cognitive remediation program or treatment as usual. The cognitive remediation intervention includes Cognitive training using computer software (CogPack; Japanese version) administered twice a week and a weekly group over 12 weeks and was based on the Thinking Skills for Work program. Most study participants were attending day treatment services where social skills training, psychoeducation for knowledge about schizophrenia, group activities such as recreation and sport, and other psychosocial treatment were offered. Cognitive and social functioning were assessed using the Brief Assessment of Cognition in Schizophrenia (BACS) and Life Assessment Scale for Mentally Ill (LASMI) at pre- and postintervention. RESULTS Of the 60 people with schizophrenia enrolled, 29 were allocated to the cognitive remediation group and 31 were allocated to the treatment as usual group. Processing speed, executive function, and the composite score of the BACS showed significantly greater improvement for the cognitive remediation group than the treatment as usual group. In addition, there was significant improvement in interpersonal relationships and work skills on the LASMI for the cognitive remediation group compared with the treatment as usual group. Changes from pretreatment to posttreatment in verbal fluency and interpersonal relationships were significantly correlated, as well as changes in attention and work skills. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE The present findings showed that providing cognitive remediation on addition to psychiatric rehabilitation contributed to greater improvement in both cognitive and social functioning than psychiatric rehabilitation alone. Cognitive remediation may enhance the efficacy of psychiatric rehabilitation improving social functioning. (PsycINFO Database Record

Pharmaco-psychosocial treatment (PPST) refers to a treatment paradigm combining pharmacotherapy with psychosocial therapy. We conducted an 18-month randomized controlled tracking study to evaluate the efficacy of social skills training (SST) in 11 individuals with schizophrenia on risperidone monotherapy. They were randomized to either SST or non-SST group, and Global Assessment Functioning (GAF) and Brief Psychiatric Rating Scale (BPRS) scores in the 2 groups showed gradual improvement. In the SST group, Digit Span Distraction Test (DSDT) at 12 and 18 months showed significant improvement. The Subjective Deficit Syndrome Scale (SDSS) scores in the SST group showed significant improvement after 6 months and showed a significant difference in comparison between the groups. After the subjective feeling of health was recovered, the items of motivation were recovered as a direct effect of SST. Some items of the Life Assessment Scale for the Mentally Ill (LASMI) score showed significant improvement (or significant trend) in only the SST group after 6 months. Items of daily life, work skills, and self-recognition were continuously improved. We report 2 cases in the SST group that had DSDT improvement in parallel with change of action and communication as a change of social function. This study is only exploratory due to the small number of cases. However, we have demonstrated potential improvement in cognitive function due to learning experiences that required working memory and attention, thus providing improvement in social life.

The aim of this study was to clarify whether improvement of cognitive functioning by cognitive remediation therapy can improve work outcome in schizophrenia and other severe mental illnesses when combined with supported employment.The subjects of this study were persons with severe mental illness diagnosed with schizophrenia, major depression, or bipolar disorder (ICD-10) and cognitive dysfunction who participated in both cognitive remediation using the Thinking Skills for Work program and a supported employment program in a multisite, randomized controlled study. Logistic and multiple linear regression analyses were performed to clarify the influence of cognitive functioning on vocational outcomes, adjusting for demographic and clinical variables.Improvement of cognitive functioning with cognitive remediation significantly contributed to the total days employed and total earnings of competitive employment in supported employment service during the study period. Any baseline demographic and clinical variables did not significantly contribute to the work-related outcomes.A cognitive remediation program transferring learning skills into the real world is useful to increase the quality of working life in supported employment services for persons with severe mental illness and cognitive dysfunction who want to work competitively.

Aim The aims of the present study were to revise the Community Re-entry Program–Japanese version and to review the effectiveness of the revised Program, named the Discharge Preparation Program. Methods This study was a randomized controlled trial. The Discharge Preparation Program (DPP) was the intervention condition (n = 26), and the usual rehabilitation program was the control condition (n = 23). Outcome indicators included factors that make patient discharge difficult (which nurses evaluated), psychiatric symptom, knowledge about the illness or medication, and the number of patients who were discharged within 6 months after the end of a program. Results Significant improvements were found in the score of the ‘Issues on treatment compliance’ factor and the score of the ‘Autistic life’ factor, which are subscales of the Discharge Difficulty Scale, for the DPP group, on two-way ANOVA (‘Issues on treatment compliance’: F = 3.818, P

Aims: Prospective follow-up studies of high-risk children may help clarify the etiological factors in schizophrenia. While studies from North America, Europe and Israel have estimated the risk of schizophrenia at 7–16% in the offspring of an affected parent, no data have been reported for Asian populations. Method: We started a follow up of the offspring of Japanese schizophrenia patients in 1978. We investigated the estimated risk of schizophrenia in 51 high-risk offspring at the 24-year follow up. The effects of the parents' status, including history of psychiatric hospitalization and social functioning, on the risk in the offspring were also investigated. Results: The cumulative incidence of schizophrenia was 13.7 % and the lifetime prevalence was estimated to be 13.5 ± 4.8%. The association between the psychiatric hospitalization in the probands and the risk of schizophrenia in the offspring was not significant, and the Global Assessment of Functioning score was significantly lower in the probands with a history of psychiatric hospitalization than in those without such a history. Conclusions: The risk of developing schizophrenia in Japanese high-risk offspring might be comparable with the Western results. The present study suggests that the severity of the disease or the level of social functioning may not significantly affect the risk in Japanese offspring.

Persons with schizophrenia and their families have strong interests and hopes for love, marriage, pregnancy, and child-rearing. These experiences often lead to recovery from schizophrenia. There are many partners with schizophrenia who enjoy fruitful lives even with their disability. However, only some persons can enter into such lives in the real world in Japan and other countries. This leads persons with schizophrenia to develop a discouraged and disappointed attitude, and also causes professionals of mental health to develop indifference or pessimism about these issues. Schizophrenics are thought to have interests in love and sexual behavior just as strong as the general population. I discuss with my patients about these issues and working life early in the course of treatment. Because they lose their chance to learn adult behavior in social lives with peers due to the beginning of schizophrenia, they need an opportunity to participate in a social situation to learn knowledge and skills of dating and related behaviors, and systematic education such as psycho-education and social skills training should be provided. Continuing married life and child-rearing require more support from experts with rich experience and knowledge. Psychiatrists are required to participate in shared decision-making about medication during pregnancy and breast-feeding, as well as provide knowledge on the benefits and risks of antipsychotics. Net-working with the family, professionals of child welfare, and the community is necessary to support child-rearing. Urakawa Bethel's House was introduced as a pioneering concept to support love, marriage, and child-rearing. Finally, professionals' negative or indifferent attitudes toward these issues are discussed in the setting of treatment. I hope that professionals of mental health will think about these issues from the standpoints of persons with schizophrenia and their families.

Background: Persons with schizophrenia show deficits across a broad range of social domains, and their social skill deficits are thought, to some extent, to be caused by cognitive dysfunction. We conducted a review and concluded that both nonsocial and social cognition were strongly related to social skills in schizophrenia. However the relationship between social and nonsocial cognition and the pathways to social skills remain unclear.Aims: In this study, we attempted to investigate how nonsocial and social cognitive functioning and psychiatric symptoms determine social skills in persons with schizophrenia.Method: Sixty-four subjects who met the ICD-10 criteria for schizophrenia were evaluated with a semi-structured role-play test, BPRS, and a psychological test battery for attention, verbal fluency, and executive functioning.Results: The ability to recognize the goal of the situation was partly determined by attention and social cognition independently. The processing of problem-solving and planning alt...

The negative symptoms of schizophrenia are usually treatment-refractory, and considered to be a major cause of a poor outcome. Recently, it has become an important issue to elucidate the etiology of and develop treatment for negative symptoms in order to improve the outcome of schizophrenia patients. Firstly, the history of negative symptoms was reviewed. Several lines of factor-analysis studies have suggested that negative symptoms are independent from other symptoms of schizophrenia, and consist of two factors, the poverty of expression and avolition, while the results depend upon the assessment scale employed in each analysis. Anhedonia, a part of avolition, may be considered as the impairment of pleasure-seeking behavior, the impairment of remembering non-current feelings, and a person's belief that he/she cannot experience pleasure, rather than the loss of pleasure itself. As neurological bases for avolition, decreases in reward expectancy, value representation, and the behavior to seek uncertain reward were observed, which resulted in poor social functioning due to the difficulties of initiating adaptive behaviors for the future. These impairments are the bases of decreased intrinsic motivation. The negative symptoms were considered to result in poor social functioning mediated by neuro-and social cognitive dysfunction and dysfunctional cognition, such as low self-efficacy and self-stigma. Pharmacotherapy for negative symptoms remains to be established due to a lack of evidence. Several psycho-social interventions in self-efficacy, self-stigma, intrinsic motivation, and environmental contexts are now being developed, while their effects are rather limited. The principles of psychiatric rehabilitation, i.e., respecting one's own value system and preference, self-determination, and motivation, are worth revisiting from the viewpoint of neuro-cognitive science. Furthermore, a hope-oriented approach, the presence of peers, and reconstructing social values as barrier-free may be considered to be of marked help not only for treating negative symptoms through re-establishing self-esteem, but also to aid the general population.

Facial 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.Participants 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.Patients 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.These 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.

We previously demonstrated that event-related potentials (ERPs), such as N1/N2b amplitudes in an auditory selective attention task, were significantly associated with communication skills of schizophrenia. The present study investigated the relationship between N1/N2b amplitudes and the quality of life (QOL) 5 years after ERP measurement. QOL of 15 patients with schizophrenia was assessed using the quality of life scale (QLS). Correlational analyses revealed a significant relationship between N2b, but not N1, amplitude and specific domains of QOL. N2b amplitude, an electrophysiological index of orienting response, may be associated with longitudinal social functioning outcome in schizophrenia.

Zolpidem (ZOL) and zopiclone (ZPC) are non-benzodiazepine hypnotics, with unique effects on sleep architecture compared with conventional benzodiazepines. The two compounds have different profiles in action to two major subtypes of the GABA-A receptors, therefore different effects on sleep structure may be expected. In the present study, the effects of ZOL (10mg) and ZPC (7.5mg) were compared in nine healthy young male subjects during nine-night sessions, employing a crossover design. Time courses during the sessions were significantly different between the compounds in the ratio (%) of S2 and S1. Compared to the baseline, an increase of S2 and a decrease of S1 and SR were caused by ZPC, not by ZOL. SWS was increased by both ZPC and ZOL. Significant changes by ZOL were found during the first 150-min, while changes by ZPC were mostly observed during the second 150-min. This might be related to their half-lives. ZOL did not affect sleep latency in the morning, while ZPC caused a significant decrease. Subjective sleepiness, however, was not increased in the ZPC or ZOL mornings. It was speculated that difference in the action to the GABA-A receptor subtypes might be related to the differences in the effects on the sleep architecture between the compounds.

A cluster analysis of the Life Assessment Scale for Mental Illness revealed 11 categories, including social adaptation, personal hygiene, basic conversation skills, using social resources, and coping with changes at work. Nine of these 11 clusters or categories differentiated persons with schizophrenia who were institutionalized from those who were participating in community-based rehabilitation or work activities, thereby providing discriminative validity to the Scale. In addition, gender was a discriminating factor for 3 of the clusters. Shorter lengths of hospitalization were positively related to levels of social adjustment.

Persons with schizophrenia show deficits across a broad range of cognitive domains, and their social skill deficits are thought, to some extent, to be caused by cognitive dysfunction. In this study, we attempted to replicate the correlation between the early stages of information processing and non-verbal skills. Subjects for the study included 22 men and six women who met DSM-IV criteria for the diagnosis of schizophrenia. All subjects were attending a rehabilitation program at the day-treatment centers of their hospitals. Social skills were assessed using a structured role-play test. The Degraded-Continuous Performance Test (CPT) and Span of Apprehension Test (SPAN) were used. Non-verbal skills were significantly correlated with CPT-False Alarm Rate (the rate of commission errors of all trials) in multiple regression analysis, but the receiving-processing skills did not have any relation to CPT or SPAN score. Non-verbal skills may be related to early information-processing deficiency, especially the response-inhibiting system. Receiving and processing skills may be related to later stages of information processing, or may reflect not only `molecular' stages of information processing (less complex and less integration task in a continuum of complexity of cognitive processes) but also other factors such as social learning.

Psychiatric rehabilitation has been slow to develop in Japan, in part because of traditional stigma against community-based treatment of the seriously mentally ill and a prevailing biological approach to schizophrenia. In the past decade, however, rehabilitation methods have been introduced, spearheaded by social skills training. The rapid dissemination of social skills training in Japan has been promoted by the publication of a national newsletter, the development of a Japanese Social Skills Training Association, reimbursement of social skills training by the national health insurance, and an active schedule of workshops, seminars, lectures and training programs. Research on social skills training has paralleled its development as a clinical modality. When skills training has been delivered with fidelity, it has been possible to measure the acquisition of skills by persons with schizophrenia. A role-play test has been validated after its cultural adaptation to Japan and correlations have been found betwe...

The present study aimed to test the construct validity and internal consistency of the Social Cognition Screening Questionnaire (SCSQ) (Japanese version).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.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.Although this is an interim report with a small sample size, the SCSQ holds promise as an efficient measure for social cognition.

Measuring social functioning of schizophrenics is becoming an important clinical issue in the era of community care, where persons with mental illness can live in the community. Neuro- and social-cognitive function studies on the outcome of schizophrenia focus on researching brain functioning, and social functioning is a co-primary outcome measure of intervention. In this review, the viewpoint of measuring social functioning is clarified, typical and recommended assessment scales are introduced, methods to be developed for measurement are discussed, and how to measure social functioning in clinical and research settings is summarized. The axes of classifying measures include functional capacity/real-world functioning, subjective/objective evaluation, and rating/observing behaviors. Six social functioning scales were chosen as recommended scales in the study of real-world functioning as a co-primary measure in NEMH-MATRICS. Almost all scales are objective rating with the interviewing of informants. The functional capacity or competence is evaluated in performance tasks. While the scale of processing tasks of everyday functioning (UPSA) was recommended in many studies, there is no standard for assessing social skills or social problem-solving skills, because these skills differ greatly depending on the sex, age, and culture. Intervening variables among neuro/social cognitive functioning, functional capacity, and real-world functioning are intrinsic motivation, meta-cognition, self-efficacy, expected support, and the environment and support which might decrease the association of basic cognition and the functional outcome. In a clinical setting, these intervening variables, hope and subjective evaluation of support needs, and life history regarding the previous capacity are needed as well as assessment scales to develop a plan for intervention. Objective assessment scales are useful for measuring the effects of intervention.

Methods to improve neurocognitive impairments are of important research interest. This study sought to examine the synergistic effects of neurocognitive rehabilitation and antipsychotics for schizophrenia.Subjects were 43 patients diagnosed with schizophrenia or schizoaffective disorder in a randomized trial of the effects of neurocognitive rehabilitation or a quasi-randomized experimental trial of supported employment with neurocognitive rehabilitation. We compared the effects of risperidone and aripiprazole in neurocognitive rehabilitation for schizophrenia. Subjects were divided into the following groups: (i) the control-risperidone group (CR group) (n = 13); (ii) the rehabilitation-risperidone group (RR group) (n = 9); (iii) the control-aripiprazole group (CA group) (n = 10); and (iv) the rehabilitation-aripiprazole group (RA group) (n = 11). Subjects in the rehabilitation group were engaged in computer-based cognitive exercises (24 sessions) with bridging group (12 sessions) over 12 weeks. Psychiatric symptoms, neurocognitive functioning and social functioning assessments were evaluated at baseline and at 12 weeks.A two-way anova with neurocognitive rehabilitation and antipsychotic medication as factors revealed a significant interaction effect on motor speed. Working memory and motor speed significantly improved in the RA group compared with the CA group. We found no significant improvements between the CR group and the RR group.A synergistic effect of neurocognitive rehabilitation and aripiprazole was observed as improvement of motor speed. In patients treated with aripiprazole, neurocognitive rehabilitation appeared to improve working memory and motor speed. Further studies of synergistic effects of neurocognitive rehabilitation and antipsychotic medication are necessary to verify these findings.

The aims of the present study were to revise the Community Re-entry Program-Japanese version and to review the effectiveness of the revised Program, named the Discharge Preparation Program.This study was a randomized controlled trial. The Discharge Preparation Program (DPP) was the intervention condition (n = 26), and the usual rehabilitation program was the control condition (n = 23). Outcome indicators included factors that make patient discharge difficult (which nurses evaluated), psychiatric symptom, knowledge about the illness or medication, and the number of patients who were discharged within 6 months after the end of a program.Significant improvements were found in the score of the 'Issues on treatment compliance' factor and the score of the 'Autistic life' factor, which are subscales of the Discharge Difficulty Scale, for the DPP group, on two-way ANOVA ('Issues on treatment compliance': F = 3.818, P0.10; 'Autistic life': F = 4.155, P0.05) These factors affected discharge outcome. Thus, the program may be capable of promoting discharge of long-term hospitalized psychiatric patients. With regard to the number of patients discharged in 6 months after the end of a program, there was no significant difference between both groups.The present result is in agreement with past studies, and the DPP is useful in discharge support for patients with schizophrenia in Japan.

The concept and assessment tools for social cognition of schizophrenia were reviewed in order to bridge the gap between brain cognitive science and psycho-social intervention. Social cognition as well as neuro-cognition strongly influences social functioning, and the impact of neuro-cognition is mediated by social cognition. Neuronal networks of personal identification, facial perception, emotional identification, eye contact, "theory of mind", mutual communication, and the decision-making process have been clarified recently. The results of face discrimination and emotion recognition tasks show impairment in persons with schizophrenia as compared with healthy controls, especially fear, dislike, and sad recognition tasks. It might be difficult for them to link ambiguous stimuli with specific emotions, and they have a tendency to recognize uncomfortable emotions easily. "Jumping to conclusions" tendency (JTC) was identified in previous research on delusion. JTC develops from information uptake bias and confidence bias, and they might be thought to be trait and state. Social problem-solving is the skill to use social cognition to comprehensively adjust to specific social situations, and processing skills of social problem-solving are related to divergent thinking. Rating scales and the results of previous studies on emotion recognition, social perception, attribution style, and "theory of mind" were summarized. Furthermore, psycho-social interventions to improve emotion recognition directly, JTC, and divergent thinking were reported. Interventions aiming at improving social cognition or meta-cognition directly have been recently developed, which might improve some components of social functioning that used to be difficult to improve. These concepts of social cognition and researches on brain science, assessment tools, and intervention methods would clarify the mechanisms of the effects of psycho-social interventions, improve their methodology, and help to develop new aspects of intervention.

The intermediate and long-term supports for suffered places of the Higashi-Nihon Huge Earthquake were discussed from the viewpoint of the community living and psychiatric rehabilitation. It might be useful to prevent from exacerbation of psychiatric disorders that gathering information, communication skills, relation with neighborhood, and joining training for disaster defense, and so on are acquired by persons with psychiatric disorders in the community living. If persons with psychiatric disorders are cared as disabled against disaster without empowering them with these skills, they cannot contribute to new society after disaster and worse estrangement from the society might appear. The Japanese Association of Psychiatric Rehabilitation proposed two models of one-stop service combining psychiatric service, mental health, and welfare from the viewpoint to support the community living; multi-disciplinary outreach team based temporary psychiatric clinic focusing psychiatric services, and comprehensive community living support center focusing mental health and welfare. It depends on demands of the suffered places which model is better adjusted, and hybrid model is possible. The important need to build long-term support system for people of supporting suffered persons from this huge earthquake was mentioned.

The model program of psycho-social treatment and staff training were reported in this issue. The mission of model program is supporting recovery of persons with mental illness and their family as well as empowering their hope and sense of values. The personal support specialists belonging to multi-disciplinary team have responsibility to support life-long process of recovery across hospitalization, out-patients clinic, day treatment, and outreach service. The shared value of multi-disciplinary team (the community life supporting team) is recovery so that the team renders self directive life, various alternatives of their lives, and peer group with models of recovery to persons with mental illness. There should be several technologies which are used in the team such as engagement, psycho-education, cognitive-behavior therapy, care-management, cooperating with other resources. The responsibility, assessment and evaluation techniques, guarantee of opportunities for training, and auditing system of the team and process of treatment are important factors to educate team staff. Raising effective multi-disciplinary team requires existence of a mentor or good model near the team.

Introduction by the column editors: Despite the worldwide shift from inpatient to community-based treatment for individuals with severe mental illness, Japanese psychiatric services remain hospital based. In 1998, Japan had 29 psychiatric beds per 10,000 persons, twice as many as in most European countries and five times as many as in the United States (1).The reasons for Japan's slow transition to a community-based mental health system are both economic and cultural. For instance, 90 percent of psychiatric beds are in private for-profit hospitals. There is little incentive for inpatient facilities to discharge patients promptly, because the Japanese health care system provides universal coverage with virtually unlimited reimbursement for inpatient services, and the government does not have a mechanism for financing the relocation of resources from hospitals to communities (2). In addition, the stigma associated with mental illness in Japanese families is high (3). Thus a patient's primary residence is th...

This study examines the factors that may impede discharge support for persons with schizophrenia who are receiving standard psychiatric services in Japan.Two hundred and ninety-two in-patients from nine psychiatric hospitals diagnosed with schizophrenia agreed to participate in this study. The mean duration of hospitalization at the time of the survey was approximately 10 years.Variables that were evaluated in the baseline assessment were as follows: demographic features such as age and duration of hospitalization, primary psychiatrist's evaluation (the Brief Psychiatric Rating Scale, Global Assessment of Functioning, Assessing List of Patients' Needs of Psychiatric Rehabilitation, and so on), ward nurses' evaluation (the Discharge Difficulty Scale and the Hall and Baker's Rehabilitation Evaluation), and self administered questionnaires (the Self-Efficacy for Community Life Scale, Client Satisfaction Questionnaire, MOS Short-Form 36-Item Health Survey, and Drug Attitude Inventory Short Form). In the follow-up one year later, the subjects were divided into two groups: patients discharged and patients still hospitalized.Eight factors were identified by factor analysis of the Discharge Difficulty Scale. They were insight and treatment compliances, anxieties over discharge, activities of daily living (ADL), problem behaviors, autistic behaviors, medical complications, suicidal behaviors, and family problems. Five clusters were found on cluster analysis; cluster 1 (multiple factors of discharge difficulty), cluster 2 (insight, adherence, and autistic behavior factors of discharge difficulty), cluster 3 (few factors of discharge difficulty), cluster 4 (anxiety and autistic behavior of discharge difficulty), and cluster 5 (insight and adherence, anxiety, and deviant behavior factors of discharge difficulty). In the follow-up one year later, 60 and 157 subjects were divided into the discharge and continued-hospitalization groups, respectively. Six factors were detected by factor analysis that examined the variables which showed significant differences between the two groups in the baseline assessment: 1) discharge difficulties observed by ward nurses, 2) interpersonal difficulties attributed to negative symptoms, 3) hostility, excitement, and suspiciousness, 4) self-efficacy of patients in the community, 5) possible exacerbation of medical diseases, and 6) physical complaints related to the adverse effects of medication. On logistic regression analysis, the hostility, excitement, and suspiciousness and self-efficacy of patients in the community were found to be the two significant contributing factors to the outcome.Effective treatments promoting discharge support for long-term in-patients with schizophrenia are discussed according to the five clusters found. By clustering discharge difficulties, the treatment team will be provided with the necessary medical and social resources. In conclusion, a desirable supportive relation between patients and the team, basic skills to motivate the patients, and cooperative relations among the members of the treatment team are crucial in order to improve the outcomes of patients with discharge difficulties.

The aim of this study was to review the theories and methodologies for helping persons with schizophrenia to gain employment because working is one of the important factors for normalizing lives. The rate of employment among schizophrenics is determined by several factors including the unemployment rate of the nation, the date, sampling method and so on. However, persons with schizophrenia generally have had a lower employment rate around 20%, calculated as the rate of competitive employment compared to other psychiatric disorders both in the U.S. and Japan. Because traditional vocational rehabilitation did not lead to a good vocational outcome, supported employment has been developed over the last 20 years. Many studies clarified that supported employment led to a better outcome in the competitive employment, especially "Individual Placement and Support (IPS)". The systematic review of the Cochrane database, the Treatment Guideline of Schizophrenia of APA, and the PORT Treatment Guideline of Schizophrenia recommended the use of supported employment. Supplementary programs such as cognitive rehabilitation have been recently developed because psychiatric symptoms and social functioning were not improved and income and tenure of employment were not sufficient, even with supported employment. Cognitive functioning, attention, learning, memory, and executive functioning were verified to have influences on vocational functioning in many studies, and cognitive rehabilitation with supported employment was verified to improve vocational outcome. Six evidence based technologies of vocational rehabilitation were discussed. Vocational rehabilitation centers, day treatment centers aiming at competitive employment, and NPOs for employment of disabled persons are recommended as good clinical models of evidence based vocational rehabilitation. Professionals of the same agency in these models help people concerning both working and independent living, which is one of the important principles of IPS. Finally, we discussed several issues about methodologies and social framework which need further research and social agreement.

Social dysfunction of schizophrenia is observed in many domains including social skills, ability to conduct tasks, attention/durability, volition/motivation, stability of social life, and insight of dysfunction. These dysfunctions have been found to relate to non-social cognitive functioning to some extent. Social skills may have a strong relationship with social cognition. The intervention technique of cognitive functioning of schizophrenia, known as cognitive rehabilitation or cognitive remediation, has its main target as non-social cognition. Cognitive behavior therapy focuses on the contents of the cognitive process, while cognitive rehabilitation focuses on the cognitive process (information process) or thinking skills. Which cognitive functioning should be targeted was revealed as were theoretical models of cognitive rehabilitation, and various intervention techniques and their usefulness. It has been found that some elements of cognitive functioning, such as executive functioning, could be improved in experimental settings in efficacy studies. However, comprehensive rehabilitation including cognitive rehabilitation should be used in order to relieve social dysfunctioning or psychiatric symptoms. Some experts insisted that an individualized program with several steps, along with cognitive abilities, is required to enhance usefulness and effectiveness. Other experts said more complex cognitive functioning profoundly associated with social life should be targeted, rather than elementary cognitive functioning. The conclusions of meta-analyses of randomized controlled trails were not consistent until now, because inclusion criteria of meta-analysis was different. Finally, it was discussed how the theory and techniques of cognitive rehabilitation should be implemented in traditional rehabilitation.

In this report, we describe a case of Neuro-Behçet's disease with early onset of bipolar mood disorder. A 53-year-old man with neuropathy including dysphasia and dyslalia developed bipolar mood disorder with anxiety, agitation, depressive mood, talkativeness, hyperkinesias, and appetite rise, and soon exhibited severe personality deterioration. Oral aphthae, cell proliferation and elevated IL-6 levels in spinal fluid, and the patient's clinical downhill course with remission and relapse in spite of good reaction to steroid preparation indicated the possibility of Neuro-Behçet's disease. Brain MRI showed clear swelling of the brain stem area, especially in the pons, in the active phase with low signal in T1-weighted images contrasting with clear high signal in T2-weighted images and FLAIR. At the time of remission, atrophy of the brain stem was shown. These findings were consistent with the view reported in recent years concerning the brain image of Neuro-Behçet's disease, which seemed to be useful for the differential diagnosis. This case manifested two outstanding clinical features. First, it showed bipolar mood swing or mixed state distinguishable from disinhibition or euphoria in deteriorated personality, which is common in this condition. A clear bipolar mood disorder has not been described until now in Neuro-Behçet's disease. Second, subclinical dysthymia or hypomanic phase occurred before clear onset of the disease. In Neuro-Behçet's disease, it is currently considered that psychiatric symptoms may appear in the early stage, but there is controversy as to whether they can precede the other symptoms. Our case indicated very early onset of psychiatric symptoms in this condition.