Daisuke Nishi

Nutritional medicine as mainstream in psychiatry

Psychiatry is at an important juncture, with the current pharmacologically focused model having achieved modest benefits in addressing the burden of poor mental health worldwide. Although the determinants of mental health are complex, the emerging and compelling evidence for nutrition as a crucial factor in the high prevalence and incidence of mental disorders suggests that diet is as important to psychiatry as it is to cardiology, endocrinology, and gastroenterology. Evidence is steadily growing for the relation between dietary quality (and potential nutritional deficiencies) and mental health, and for the select use of nutrient-based supplements to address deficiencies, or as monotherapies or augmentation therapies. We present a viewpoint from an international collaboration of academics (members of the International Society for Nutritional Psychiatry Research), in which we provide a context and overview of the current evidence in this emerging field of research, and discuss the future direction. We advocate recognition of diet and nutrition as central determinants of both physical and mental health.

Reliability and validity of the Japanese version of the Resilience Scale and its short version

BackgroundThe clinical relevance of resilience has received considerable attention in recent years. The aim of this study is to demonstrate the reliability and validity of the Japanese version of the Resilience Scale (RS) and short version of the RS (RS-14).FindingsThe original English version of RS was translated to Japanese and the Japanese version was confirmed by back-translation. Participants were 430 nursing and university psychology students. The RS, Center for Epidemiologic Studies Depression Scale (CES-D), Rosenberg Self-Esteem Scale (RSES), Social Support Questionnaire (SSQ), Perceived Stress Scale (PSS), and Sheehan Disability Scale (SDS) were administered. Internal consistency, convergent validity and factor loadings were assessed at initial assessment. Test-retest reliability was assessed using data collected from 107 students at 3 months after baseline. Mean score on the RS was 111.19. Cronbachs alpha coefficients for the RS and RS-14 were 0.90 and 0.88, respectively. The test-retest correlation coefficients for the RS and RS-14 were 0.83 and 0.84, respectively. Both the RS and RS-14 were negatively correlated with the CES-D and SDS, and positively correlated with the RSES, SSQ and PSS (all p < 0.05), although the correlation between the RS and CES-D was somewhat lower than that in previous studies. Factor analyses indicated a one-factor solution for RS-14, but as for RS, the result was not consistent with previous studies.ConclusionsThis study demonstrates that the Japanese version of RS has psychometric properties with high degrees of internal consistency, high test-retest reliability, and relatively low concurrent validity. RS-14 was equivalent to the RS in internal consistency, test-retest reliability, and concurrent validity. Low scores on the RS, a positive correlation between the RS and perceived stress, and a relatively low correlation between the RS and depressive symptoms in this study suggest that validity of the Japanese version of the RS might be relatively low compared with the original English version.

Peritraumatic Distress, Watching Television, and Posttraumatic Stress Symptoms among Rescue Workers after the Great East Japan Earthquake

Background The Great East Japan Earthquake of March 11, 2001 left around 20,000 dead or missing. Previous studies showed that rescue workers, as well as survivors, of disasters are at high risk for posttraumatic stress disorder (PTSD). This study examined the predictive usefulness of the Peritraumatic Distress Inventory (PDI) among rescue workers of Disaster Medical Assistance Teams (DMATs) deployed during the acute disaster phase of the Great East Japan Earthquake. Methodology/Principal Findings In this prospective observational study, the DMAT members recruited were assessed 1 month after the earthquake on the PDI and 4 months after the earthquake on the Impact of Event Scale-Revised to determine PTSD symptoms. The predictive value of the PDI at initial assessment for PTSD symptoms at the follow-up assessment was examined by univariate and multiple linear regression analysis. Of the 254 rescue workers who participated in the initial assessment, 173 completed the follow-up assessment. Univariate regression analysis revealed that PDI total score and most individual item scores predicted PTSD symptoms. In particular, high predictive values were seen for peritraumatic emotional distress such as losing control of emotions and being ashamed of emotional reactions. In multiple linear regression analysis, PDI total score was an independent predictor for PTSD symptoms after adjusting for covariates. As for covariates specifically, watching earthquake television news reports for more than 4 hours per day predicted PTSD symptoms. Conclusions/Significance The PDI predicted PTSD symptoms in rescue workers after the Great East Japan Earthquake. Peritraumatic emotional distress appears to be an important factor to screen for individuals at risk for developing PTSD among medical rescue workers. In addition, watching television for extended period of time might require attention at a time of crisis.

Incidence and prediction of psychiatric morbidity after a motor vehicle accident in Japan: the Tachikawa Cohort of Motor Vehicle Accident Study.

Objectives:To assess both the incidence of new-onset psychiatric illness after involvement in a motor vehicle accident in Japan for comparison with Western data and the predictors of psychiatric morbidity and posttraumatic stress disorder (PTSD) evaluated immediately after the accident. Design:Prospective cohort study of injured patients assessed immediately and 4–6 wks after involvement in a motor vehicle accident. Setting:Intensive care unit in a teaching hospital in Tokyo, Japan. Patients:Total of 100 consecutive patients with motor vehicle accident–related injuries (mean Injury Severity Score, 11.2; mean Glasgow Coma Scale, 14.5; age, 18–69 yrs) admitted to the intensive care unit. Patients with traumatic brain injury, suicidality, current psychiatric or neurologic illness, or cognitive impairment were excluded. Measurements:An extensive clinical interview and evaluation of vital signs, sociodemographic variables, previous traumatic events, family history of psychopathology, Impact of Event Scale–Revised, Hospital Anxiety and Depression Scale, Clinician-Administered PTSD Scale, and Mini-International Neuropsychiatric Interview. Results:A total of 31 patients showed some form of new-onset psychiatric illness at the 4- to 6-wk follow-up. The majority of illnesses consisted of depression (major depression, n = 16; minor depression, n = 7) and PTSD (full PTSD, n = 8; partial PTSD, n = 16). Other illnesses included alcohol dependence (n = 3), obsessive–compulsive disorder (n = 2), agoraphobia (n = 2), and social phobia (n = 1). Both psychiatric morbidity and PTSD were predicted by a sense of life threat (odds ratio, 4.2 and 6.2, respectively), elevated heart rate (odds ratio, 1.6 and 1.7), and higher Impact of Event Scale–Revised intrusion subscale score (odds ratio, 1.1 and 1.1). Conclusion:This study showed that psychopathology and PTSD after a motor vehicle accident in Japan is common and that the incidence is within the range of that in Western countries. A combination of a sense of life threat, heart rate, and Impact of Event Scale–Revised intrusion subscale allowed for significant prediction of psychiatric morbidity and PTSD.

Concern over radiation exposure and psychological distress among rescue workers following the Great East Japan Earthquake Concern over radiation exposure and distress

BackgroundOn March 11, 2011, the Great East Japan Earthquake and tsunami that followed caused severe damage along Japan’s northeastern coastline and to the Fukushima Daiichi nuclear power plant. To date, there are few reports specifically examining psychological distress in rescue workers in Japan. Moreover, it is unclear to what extent concern over radiation exposure has caused psychological distress to such workers deployed in the disaster area.MethodsOne month after the disaster, 424 of 1816 (24%) disaster medical assistance team workers deployed to the disaster area were assessed. Concern over radiation exposure was evaluated by a single self-reported question. General psychological distress was assessed with the Kessler 6 scale (K6), depressive symptoms with the Center for Epidemiologic Studies Depression Scale (CES-D), fear and sense of helplessness with the Peritraumatic Distress Inventory (PDI), and posttraumatic stress symptoms with the Impact of Event Scale-Revised (IES-R).ResultsRadiation exposure was a concern for 39 (9.2%) respondents. Concern over radiation exposure was significantly associated with higher scores on the K6, CES-D, PDI, and IES-R. After controlling for age, occupation, disaster operation experience, duration of time spent watching earthquake news, and past history of psychiatric illness, these associations remained significant in men, but did not remain significant in women for the CES-D and PDI scores.ConclusionThe findings suggest that concern over radiation exposure was strongly associated with psychological distress. Reliable, accurate information on radiation exposure might reduce deployment-related distress in disaster rescue workers.

Reliability and validity of the Japanese version of the Peritraumatic Distress Inventory

OBJECTIVE To assess the reliability and validity of the Japanese version of the Peritraumatic Distress Inventory (PDI). METHOD One hundred thirty-five participants with physical injury resulting from motor vehicle accidents were consecutively recruited in this cross-sectional study, from Aug. 18, 2005, to Jan. 8, 2008. A subsample (n=71) were retested on the PDI an average of 96.4 days after initial measure completion. RESULTS Correlational analyses revealed an overall Cronbachs alpha coefficient of 0.83. The item-total correlations for the 13 items ranged from 0.29 to 0.75. The test-retest correlation coefficient was 0.61. The PDI was significantly correlated with the external validators such as peritraumatic dissociation as measured by the Peritraumatic Dissociative Experiences Questionnaire (PDEQ); the intrusion, avoidance and hyperarousal scores of the Impact of Events Scale-Revised (IES-R); and the depression and anxiety subscales of the Hospital Anxiety Depression Scale (HADS) (P<.01). CONCLUSION The present study indicated that the Japanese version of the PDI has a high degree of internal consistency, acceptable reliability and a high degree of concurrent validity with measures of peritraumatic dissociation and posttraumatic symptoms. The Japanese version of the PDI can be used as a validated instrument in future research.

International Society for Nutritional Psychiatry Research consensus position statement: nutritional medicine in modern psychiatry

In recent years, there has been an unprecedented growth in both the quantity and methodological quality of research directed at exploring the relationship between nutrition and mental health. Indeed, the strength of data has now afforded nutritional medicine a place in the mainstream psychiatric discourse (1). Robust associations have been established between nutritional quality and mental health, with the bulk of this evidence indicating a protective effect of healthy diets on depressed mood (2), and the newest research supporting a detrimental impact of unhealthy diets on the mental health of young people (3,4) and adults (5,7). There are also convincing data supporting the application of certain nutrient-based supplements (nutraceuticals) as monotherapy or combined therapy (8), or as augmentation therapy (9). Although the growth in scientific research related to nutrition in psychiatry may be recent, it is now at a stage where it can no longer be ignored. In light of this, we aim to provide a platform to move towards a new integrated paradigm in psychiatry whereby nutritional considerations (both educational and prescriptive) can be considered “mainstream” (1). To this end, we present a consensus position statement from the International Society for Nutritional Psychiatry Research (ISNPR). In brief, the ISNPR was formed in 2013 with the aim to advance research and communication on nutritional medicine in the field of psychiatry. One of its first goals was to formulate a position statement that embodied the principles of the organization, allowing for codification of the society’s underpinning tenets. In order to develop this, we employed a Delphi-based model by which ISNPR researcher and clinician members could vote on a select list of 110 statements created by an expert steering committee. The committee provided a list of sub-statements concerning three main topics/areas: the current general needs and challenges in psychiatry; key elements of diet and nutraceutical evidence related to mental health/psychiatry; potential public health and clinical applications. These were transcribed and tabulated in Survey Monkey for online voting by the wider ISNPR membership. A Likert scale (0–10) was used for each statement (0=don’t include, 5=don’t know/depends, 10=definitely include), and statements that received a mean score of >6.5/10 by ISNPR members were reviewed by the steering committee for inclusion in the position statement, which is presented below. Present treatment of mental disorders is achieving sub-optimal outcomes; in addition little attention is given to preventative efforts. Due to the immense burden of mental disorders, there is now an urgent need to identify modifiable targets to reduce the incidence of these disorders. Diet and nutrition offer key modifiable targets for the prevention of mental disorders and have a fundamental role in the promotion of mental health. Epidemiological data, basic science, and clinical evidence suggest that diet influences both the risk for and outcomes of mental disorders. As such, we advocate that evidence-based nutritional change should be regarded as an efficacious and cost-effective means to improve mental health. In addition to dietary modification, we recognize that nutrient-based (nutraceutical) prescription has the potential to assist in the management of mental disorders at the individual and population level. Many of these nutrients have a clear link to brain health, including: omega-3s, B vitamins (particularly folate and B12), choline, iron, zinc, magnesium, S-adenosyl methionine (SAMe), vitamin D, and amino acids. While we advocate for these to be consumed in the diet where possible, additional select prescription of these as nutraceuticals may also be justified. Ongoing research (including randomized controlled trials) in the area is recognized as critical, using methodologically rigorous designs. Further explication of the biological pathways affected by nutritional modification is also required. Clinical trials of nutraceuticals should include assessment of biomarkers in tandem with clinical outcomes. Global research and health promotion activities focused on improving population health should also include mental health parameters as priority targets and measured outcomes. Importantly, the activities of the food industry need to be examined at a governmental level and relevant policies designed to reduce the global burden of physical and mental ill-health attributable to poor diet. Such policies are advised to stimulate significant public change in dietary habits back towards a traditional wholefood diet (dependent on the culture). Further, there is now a vital need for better public and clinician education to communicate current research findings from the field. In summary, nutrition and nutraceuticals should now be considered as mainstream elements of psychiatric practice, with research, education, policy, and health promotion reflecting this new paradigm. As detailed in our consensus statement, we advocate for the pursuit of an integrative psychiatric model, with diet as a key element. Further, the select use of evidence-based nutraceuticals should be a mainstay of treatment as either stand-alone therapies (mainly in cases of less severe mental disorders, non-tolerance to medication, nutrient deficiencies, or patient choice), or as adjunctive interventions with psychotropic medications to augment treatment efficacy. We recognize the importance of clinician and public education regarding evidence-based nutrition and nutraceuticals to drive mainstream acknowledgement of their impact on mental health. It is the intention that this position statement and the ongoing work of ISNPR will assist in facilitating a transformation in psychiatry to better address the substantial global burden of mental illness, recognizing and embracing diet and nutrition as central determinants of both physical and mental health.

Longitudinal Changes in Serum Brain-Derived Neurotrophic Factor in Accident Survivors with Posttraumatic Stress Disorder

Background: This prospective cohort study investigated the serum levels of brain-derived neurotrophic factor (BDNF), which mediates synaptic plasticity crucial for fear memory extinction, in patients severely injured in motor vehicle accidents (MVAs). Method: A nested, case-controlled study was conducted with 103 MVA survivors: 8 medication-naïve patients who met the criteria for full diagnosis of posttraumatic stress disorder (PTSD) at 6 months after MVA, 10 medication-naïve patients with partial PTSD and 85 patients with no PTSD. PTSD was evaluated by the Clinician-Administered PTSD Scale (CAPS). Serum BDNF levels were measured shortly after the MVA (baseline) and at 6-month follow-up. Results: Posttrauma serum BDNF levels differed between the 3 groups after controlling for age and sex (F = 3.41, p = 0.04), with unexpectedly higher serum BDNF levels seen in the full-PTSD group compared with the no-PTSD group. Additional analysis of patients with serum samples taken at baseline and at 6 months revealed the full-PTSD group had significantly higher serum BDNF levels over the 6 months than the no-PTSD group after controlling for age and sex (F = 6.44, p < 0.01). A positive correlation was seen between changes in serum BDNF levels over 6 months and the CAPS score at 6 months (r = 0.26, p = 0.014). Conclusions: The findings of this study, the first to report longitudinal serum BDNF levels in MVA survivors, suggest that elevated serum BDNF levels could be a biomarker of PTSD after a traumatic event.

Associations between Disaster Exposures, Peritraumatic Distress, and Posttraumatic Stress Responses in Fukushima Nuclear Plant Workers following the 2011 Nuclear Accident: The Fukushima NEWS Project Study

Background The 2011 Fukushima Daiichi Nuclear Power Plant accident was the worst nuclear disaster since Chernobyl. The nearby Daini plant also experienced substantial damage but remained intact. Workers for the both plants experienced multiple stressors as disaster victims and workers, as well as the criticism from the public due to their companys post-disaster management. Little is known about the psychological pathway mechanism from nuclear disaster exposures, distress during and immediately after the event (peritraumatic distress; PD), to posttraumatic stress responses (PTSR). Methods A self-report questionnaire was administered to 1,411 plant employees (Daiichi, n = 831; Daini, n = 580) 2–3 months post-disaster (total response rate: 80.2%). The socio-demographic characteristics and disaster-related experiences were assessed as independent variables. PD and PTSR were measured by the Japanese versions of Peritraumatic Distress Inventory and the Impact of Event Scale-Revised, respectively. The analysis was conducted separately for the two groups. Bivariate regression analyses were performed to assess the relationships between independent variables, PD, and PTSR. Significant variables were subsequently entered in the multiple regression analyses to explore the pathway mechanism for development of PTSR. Results For both groups, PTSR highly associated with PD (Daiichi: adjusted β, 0.66; p<0.001; vs. Daini: adjusted β, 0.67; p<0.001). PTSR also associated with discrimination/slurs experience (Daiichi: 0.11; p<0.001; vs. Daini, 0.09; p = 0.005) and presence of preexisting illness(es) (Daiichi: 0.07; p = 0.005; vs. Daini: 0.15; p<.0001). Other disaster-related variables were likely to be associated with PD than PTSR. Conclusion Among the Fukushima nuclear plant workers, disaster exposures associated with PD. PTSR was highly affected by PD along with discrimination/slurs experience.

Fish Oil for Attenuating Posttraumatic Stress Symptoms among Rescue Workers after the Great East Japan Earthquake: A Randomized Controlled Trial

quake. Disaster Medical Assistance Team members are doctors, nurses, and operational coordination staff (medical or clerical staff who are neither doctors nor nurses) who are dispatched as a mobile medical team with specialized training that is capable of acting during the acute phase of a large-scale disaster. This single-blind, randomized, parallel-group trial was approved by the Ethics Committee of the National Disaster Medical Center, Tokyo, Japan, on April 1, 2011, and registered at UMIN Clinical Trials Registry as UMIN 000005367. The detailed trial procedures and baseline assessment have been reported elsewhere [6] . Participants provided informed consent and were randomly assigned to either the fish oil supplementation plus psychoeducation group or the psychoeducation alone group. For participants allocated to the fish oil plus psychoeducation group, 7 capsules per day, each containing 320 mg of fish oil, were provided in line with previous research [7] . The fish oil composition of each capsule was 70% DHA and 7% eicosapentaenoic acid (EPA). For participants of both groups, a leaflet on psychoeducation about posttraumatic distress focusing on critical incident stress was provided. The primary outcome was a total score on the Impact of Event Scale-Revised (IES-R) at 12 weeks after shipment of the supplements on April 19, 2011. The IES-R is a self-reporting questionnaire about PTSD symptoms and is the most widely used measure in all forms of disaster area research [8] . Safety of the intervention was evaluated by the presence of adverse events during the observation period, by asking the participants about the presence of such events at 2, 4, 8, and 12 weeks after the start of fish oil supplementation. All analyses were conducted according to the intention-totreat principle. Analysis of covariance was used to investigate the significance of the differences in the initial values as well as of the net changes after the intervention among the 2 groups. Covariates for the analysis of covariance were sex, age, and IES-R score at baseline. We examined the impact of sex difference for fish oil supplementation on PTSD symptoms as scheduled, because previous studies showed that the prevalence of PTSD was higher in women than in men [9] . All statistical analyses used two-tailed tests. For all statistical evaluations, p values less than 0.05 were considered indicative of significant differences. All data analyses were performed using SAS version 9.1 (SAS Institute Inc., Cary, N.C., USA). Of the 1,816 Disaster Medical Assistance Team workers deployed to the disaster areas, 172 participated in the study between April 2 and 12, 2011. The participants did not differ significantly from nonparticipants in terms of occupation. The two groups were well balanced with respect to baseline characteristics. Primary outcome data were available for all participants except one. A sensitivity analysis was performed using a multiple imputation The Great East Japan Earthquake and tsunami that occurred on March 11, 2011 devastated the northeastern coast of Japan, and left about 20,000 dead or missing. Many rescue workers, as well as survivors, were exposed to traumatic experiences. An appropriate strategy for the attenuation of posttraumatic stress disorder (PTSD) symptoms is therefore clearly required. In the pathogenesis of PTSD, fear memory becomes excessively consolidated and extinction learning does not progress [1] . Kitamura et al. [2] indicated that the level of hippocampal neurogenesis is a crucial factor in determining the period of hippocampal-dependent fear memory. This finding suggested that the fear memory, which is a characteristic of PTSD, might be controlled by appropriately regulating hippocampal neurogenesis [3] . Based on the animal research conducted to date, fish oil is the most promising candidate for dietary intervention to facilitate adult hippocampal neurogenesis [4] . In an open-label trial in patients with physical injury, we previously found that PTSD symptoms at 12 weeks after injury were significantly alleviated by taking fish oil containing mainly docosahexaenoic acid (DHA) [5] . Against this background, this study aimed to determine whether fish oil supplementation can attenuate PTSD symptoms among Disaster Medical Assistance Team members who were deployed during the acute disaster phase of the Great East Japan EarthReceived: December 14, 2011 Accepted after revision: January 20, 2012 Published online: August 1, 2012