Masafumi Mizuno

Duration of untreated psychosis and pathways to psychiatric services in first-episode schizophrenia

Abstract  The aim of the present study was to examine the duration of untreated psychosis (DUP) in first‐episode schizophrenia patients in Japan and to investigate the available pathways to psychiatric services. Eighty‐three patients who visited Keio University Hospital (n = 54) or Oizumi Mental Hospital (n = 29) were evaluated retrospectively with regard to their DUP, living situation, social participation level, referral pathway, reason for seeking treatment, and their global assessment of functioning (GAF) score. The mean DUP was 13.7 months (median, 5.0 months) overall. No significant difference in DUP was found between subjects living alone and those living with others; however, employed patients had a significantly shorter DUP (8.1 months) than unemployed patients (18.7 months). Pathways to psychiatric services were totally different between the two institutions. Fifty‐two subjects (62.7%) came to the services directly: 40 patients (74.1%) came to the university hospital and 12 patients (41.4%) came to the mental hospital. At the mental hospital, nine patients (31.0%) had been admitted because of a legal obligation, and six (20.7%) had been referred through public health centers. None of the patients had been referred to either of the services by general practitioners. The main reason for seeking treatment was psychiatric symptom aggravation (59.3%) at the university hospital and acting out (64.3%) at the mental hospital. Some universal psychosocial factors appear to influence the DUP but the characteristics of specific psychiatric services may also affect treatment delays.

Social cognitive problem-solving in schizophrenia: Associations with fluency and verbal memory

This study assessed the relationship between social functioning and neurocognitive function in individuals with schizophrenia. Social cognitive problem-solving (SCPS) is a significant contributor to social competence and is an aspect of information processing that is involved in the identification and resolution of interpersonal or social problems. We examined 49 schizophrenia patients and 28 healthy controls using the means-ends problem-solving procedure (MEPS) for SCPS, the Rey Auditory Verbal Learning Test (RAVLT), the Wisconsin Card Sorting Test (WCST), and a series of fluency tests for neurocognitive assessment, as well as the Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning (GAF). Fluency tests can be used to evaluate divergent thinking, and a qualitative analysis was done of the fluency test responses. The results suggest that patients with schizophrenia have a significantly poorer MEPS performance than normal controls. In patients with normal RAVLT scores, MEPS scores were correlated with task-modified responses on the fluency test but not with any of the WCST scores. This suggests that SCPS is related to divergent thinking that requires concept flexibility and/or the conversion of viewpoint in patients with schizophrenia in whom verbal memory function is preserved.

Relation between social functioning and neurocognitive test results using the Optional Thinking Test in schizophrenia

Abstract  The current study investigated the relationship between clinical evaluations of social functioning and neurocognitive test results, including various fluency tests for assessing divergent thinking, in patients with schizophrenia. The Optional Thinking Test (OTT) was used to measure the ability of individuals to conceive of alternatives. This test assesses alternative thinking, or the capacity to generate solutions to problems. The current study examined 36 schizophrenia patients and 25 normal subjects using the Mini‐Mental State Examination (MMSE), the Rey Auditory Verbal Learning Test (RAVLT), the Letter Cancellation Test (LCT), the Letter and Category Fluency Tests, and the OTT for neurocognitive assessment, as well as the Positive and Negative Syndrome Scale (PANSS), the Global Assessment of Functioning (GAF), the Social Functioning Scale (SFS), and the Life Assessment Scale for the Mentally Ill – Interpersonal Relations (LASMI‐I) for clinical measures. The schizophrenia patients had significantly poorer performances on the MMSE, RAVLT, LCT (time), fluency tests, and OTT than the controls. In the OTT, the proportions of classified strategies were indistinguishable between the schizophrenia patients and the controls. Alternative thinking, as measured by the OTT, was correlated with verbal fluency and attention but was not correlated with the social functioning scores (GAF, SFS, LASMI‐I), whereas the Means‐Ends Problem‐Solving was correlated with the GAF in schizophrenia. Patients with schizophrenia could conceive of the same categories of alternatives as healthy people, but could not conceive as many alternatives.

Impaired Development of Rat Cerebellum Induced by Neonatal Injection of the Glycoprotein Synthesis Inhibitor, Tunicamycin

Abstract: The effects of the protein glycosylation inhibitor tunicamycin on the postnatal development of the rat cerebellum were examined in vivo. Tunicamycin (0.2 μg) was injected intracranially into 1‐day‐old rats. Inhibition of glycosylation of the macromolecules in the cerebellum by tunicamycin treatment was suggested by a reduced incorporation of [3H]glucosamine into the trichloroacetic acid (TCA)‐insoluble fraction. The tunicamycin treatment did not affect gain in body weight significantly. However the cerebellar weight was significantly reduced by 30–40% compared with that of the controls. Development of GABAergic and cholinergic innervations in the hypoplastic cerebellum was examined by measuring the activities of glutamate decarboxylase (GAD) and choline acetyltransferase (ChAT). The specific activity and the total activity of GAD were significantly reduced in the tunicamycin‐treated cerebellum. In contrast the specific activity of ChAT was significantly increased, whereas the total activity of ChAT per cerebellum was identical with that of the controls. These results suggest that the intracranial injection of tunicamycin affects the postnatal development of rat cerebellum, such as GABAergic and cholinergic innervations.

‘Alice in Wonderland’ Syndrome as a Precursor of Depressive Disorder

A 54-year-old Japanese businessman who was found to exhibit the ‘Alice in Wonderland’ syndrome and went on to develop a depressive disorder is described. Lengthening and shortening of time experience continued intermittently for about 3 months, and metamorphopsia, distortion of body image, and the quick-motion phenomenon (alteration in time sense) persisted for almost 2 days without interruption. There were no abnormal physical findings. The authors review studies on ‘Alice in Wonderland’ syndrome and suggest that depressive illness may be a causal factor.

Neuropsychological Investigation of the Effects of Psychiatric Rehabilitation Strategies for Schizophrenia

Several studies have found a relationship between cognitive functioning and social skills in schizophrenia. The results are generally consistent with the hypothesis that poor cognitive functioning contributes to social skill impairment. In a series of studies on the efficacy of social skill training, improvement by training was stressed, but the difficulty of generalization of skills inquired by training is still controversial. The impairments not improved through skill training, however, may provide cues or hints for additional rehabilitation strategies. Several clinical neuropsychological tests, behavioral assessment by rehabilitation evaluation (REHAB), and psychiatric symptoms assessment by the Brief Psychiatric Rating Scale (BPRS) were administered to patients with schizophrenia before and after 22 hours of social skill training (SST) sessions. SST was performed in a day treatment program for outpatients with stable psychiatric symptoms. Trained staffs conducted a 1-hour program every week for a total 22 sessions, in addition to standard psychiatric treatment. The results show that performance on the Idea Fluency Test, which requests as many responses as possible on the uses of objects, was significantly better after the sessions than before the sessions. However, further qualitative analysis of the responses showed that the improvement of the total score on the Idea Fluency Test was due to the increase of task-dependent form responses connected with the regular uses and shapes of the object. Task modification form responses in the Idea Fluency Test that required conversion of viewpoint did not improve. This may in part explain the difficulty of escaping from stereotyped thinking by patients with schizophrenia.

Implementing Community-Based Psychiatry in an Urban District of Tokyo: Report on Minato Net 21

There has been a rapid growth of community-based psychiatric treatment in many countries, owing to the worldwide movement of deinstitutionalization. This chapter reports on the activities of Minato Net 21 in Tokyo. Japan had a long history of long-term hospital care in mental health, starting from the Mental Hygiene Law (1950). However, the emphasis was changing from relying on long-term institutional care towards protecting human rights and establishing social rehabilitation facilities in the late 1980s. The Japanese government set up the target figures of rehabilitation facilities for the mentally disordered to be constructed from 1995 to 2002. However, the major characteristics of the Japanese health delivery system, such as the national insurance system, which covers most of the hospital charges, and the private psychiatric hospitals, which own 90% of beds, are not much in favor of community-based treatment. Recently the government has been trying to change this situation gradually by supporting community-based psychiatry. Although the network systems that support community-based treatment are not yet well constructed, partly due to the lack of availability informal social resources, Minato Net 21, a comprehensive community care program for people with mental disorders, has started to work on implementing community-based psychiatry in an urban area of Tokyo, where very few social resources for the mentally disordered exist. A multidisciplinary team consisting of medical doctors, nurses, social workers, and a clinical psychologist was organized. They work with the mentally disordered and the family members in order to improve their problem-solving abilities. They are also trying to develop a network system by integrating information. Minato Net 21 is an innovative clinical model that will promote community-based psychiatry, even in an area where informal social resources are scarce.

Social Cognitive Problem-Solving Skills in Schizophrenia

Social cognitive problem-solving skills (SCPS) were studied in patients with schizophrenia and normal volunteers using various measures. The means-ends problem solving procedure (MEPS) was used to assess SCPS; the mini-mental state examination, the Rey auditory verbal learning test (RAVLT), and fluency tests were used to assess molecular neuro cognitive deficits. Psychiatric symptoms and general functioning were assessed with the Positive and Negative Symptoms Scale (PANSS) and Global Assessment of Function (GAF), respectively. Fluency tests are measures to evaluate divergent thinking and include the Word Fluency Test and the Idea Fluency Test. Qualitative analysis of responses to the Idea Fluency Test was also conducted. In the entire group with schizophrenia, the relationships among SCPS and symptoms and general functioning were studied. The relationship between SCPS and molecular neurocognitive deficits was studied in patients with higher RAVLT scores. The results indicate that patients with schizophrenia had statistically poorer performance on MEPS. MEPS scores were correlated with GAF but not with any subcategory of PANSS. Regarding molecular neurocognitive deficits, the task-modified responses to the Idea Fluency Test were correlated with MEPS scores in patients with higher RAVLT scores. This suggests that SCPS is related to divergent thinking requiring concept flexibility or conversion of viewpoint in schizophrenia.

Factors Affecting Drug Compliance Among Patients in Japan with Schizophrenia

Factors affecting Japanese patients with schizophrenia in terms of their drug compliance were investigated. Subjects were patients with schizophrenia who were discharged from a psychiatric hospital for he first time. The target period was 24 months after discharge. Positive and Negative Symptoms Scale (PANSS), Clinical Global Impression (CGI), Global Assessment of Functioning (GAF), Drug Attitude Inventory (DAI), and The Schedule for Assessment of Insight (SAI) were adopted as rating scales. To define drug noncompliance, patients satisfying either of two criteria were chosen: an indication of “not taking medications appropriately” entered in the medical record, or inconsistency in the periods of prescription and visiting the outpatient clinic. There were 58 subjects (48.3% male), of whom 51.7% were fully compliant for 24 months after discharge. Significant factors among the good compliance group were found to be “lack of spontaneity and flow of conversation,” “depression,” and “emotional withdrawal” at discharge on PANSS subscales; a diagnosis of hebephrenic and residual schizophrenia, longer hospitalization and longer time from first treatment to admission, and positive attitde toward antipsychotics on the DAI scale; and “insight for treatment and drug compliance” on the SAI scale. Factors for noncompliance, on the other hand, were “uncooperativeness” and “lack of judgment and insight” in PANSS subscales at discharge, as well as gastrointestinal symptoms and drowsiness as side-effects, and less complete education.

DUP in first‐episode schizophrenia and its early prognosis in Japan

DUP of first‐episode schizophrenia patients has recently been drawing a lot of attention, but there is no investigation in relation to early prognosis in Japan. The duration of first admission and neuroleptic dosage in 1 year after prescribing first neuroleptics have been studied.