The number of stroke patients in Japan continues to increase because of decreasing mortality and progress of aging. Depression and apathy after stroke occur frequently and have a significant influence on quality of life in stroke patients. Pathophysiological mechanisms lesion locations which cause psychiatric disorders are important issues still being debated. The antidepressant treatment of post-stroke depression (PSD) has been shown to improve activities of daily living, cognitive function and survival rate. Thus, appropriate diagnosis and treatment of PSD are very important. Apathy without depressed mood means true apathy, in which case, it is more effective than dopamine agonists in comparison to antidepressants such as SSRI. Patients with depression need rest, in contrast to patients with non-depressed apathy who need activity behavioral therapy. In the future, it is very important for post-stroke patients to be managed by a medical team and to establish a community network providing them with care and support.

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Depression is highly prevalent in patients with ischemic heart disease, and the presence of depression increases the risk of mortality. Mechanisms underlying cardiovascular disease and depression include health-related behavior and biological factors such as autonomic nervous system functioning, platelet activity, endothelial dysfunction, and inflammation. Antipsychotics such as SSRIs are the first line treatment for patients with coronary heart disease and moderate or severe depression. Previous studies have shown that antidepressants and cognitive behavioral therapy are safe and effective to improve depressive symptoms of patients with coronary heart disease, but significant improvements in cardiovascular outcomes or mortality of the patients have not been observed yet. Several recent studies suggest that collaborative care improves both depressive symptoms and cardiovascular outcomes. In 2008, the American Heart Association formally recommended routine screening for clinical depression in patients with coronary heart disease. These trends suggest that it is important to establish a care network between cardiology and psychiatry.

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In this paper, pharmacotherapy for BPSD is described. Therapy for BPSD consists of two types, non-pharmacotherapy and pharmacotherapy. Non-pharmacological therapy is a first line therapy and can often ameliorate BPSD. If non-pharmacological therapy is ineffective, pharmacotherapy is required as a supplemental therapy. In pharmacotherapy, safety is most important. We should avoid deteriorate cognitive and physical functions by pharmacotherapy. The medications often used for depression, apathy, hallucination, delusion, agitation and irritability, are illustrated here. Appropriate pharmacotherapy is effective and useful for improving patient’s BPSD as well as reducing caregiver’s burden.

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Epilepsy has recently been drawn away from the clinical interest of Japanese psychiatrists. However, psychiatric symptoms such as anxiety, depression and schizophrenia-like psychosis are common clinical presentations in people with epilepsy, which largely affect their quality of life. Considering that suicide is also more frequent in populations with epilepsy, it is undoubtedly important to carefully diagnose and treat the psychiatric implications. Unfortunately, not many psychiatrists appear to have clear and precise comprehension of the psychiatric issues in this area. This article reviews various psychiatric symptoms accompanying epilepsy itself as well as those induced by the treatment such as antiepileptic medications in order that psychiatrists practicing in general hospitals might pay more attention to the importance of their role in the treatment of epilepsy.

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The first recognized cases of acquired immunodeficiency syndrome (AIDS) occurred in the USA in 1981, and it has been 28 years since the discovery of the human immunodeficiency virus (HIV). Since the middle of the 1990s, the era of highly active antiretroviral therapy (HAART), the prognosis of HIV infection has remarkably improved, and this disease has been regarded as a “chronic disease.”
Despite the progress of HIV treatment, psychiatric disorders are still common with this disease. Some previous studies suggested psychiatric comorbidity rates of 50% and more. Psychiatric disorders (e.g. adjustment disorder, substance-related disorders, depression and other mood disorders) and cognitive dysfunction (e.g. HIV encephalopathy) in people with HIV infection are associated with decreased quality of life, decreased adherence to care, faster disease progression, and increased mortality. HIV/AIDS psychiatry plays an important role in improving adherence to self-care behaviors and treatment with HAART. Pharmacological treatment is necessary for the successful treatment of relieving psychiatric symptoms of HIV-infected individuals, but it should be done with a great deal of caution because many psychotropic drugs have cytochrome P450 3A4-dependent metabolism that can be blocked by many HAART regimens. Non-pharmacological treatment modalities (e.g. psychotherapy and social support) are helpful to deal with psychosocial factors and behavioral problems endured by HIV-infected individuals.

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Neuropsychiatric manifestations are common in patients with systemic lupus erythematosus (SLE) and are associated with a worsening prognosis, more cumulative organ damage, and decreased quality of life (QOL). The pathogenic mechanisms underlying neuropsychiatric manifestations of SLE (NPSLE) are likely to be multifactorial and may involve vasculopathy of predominantly small intracranial blood vessels, autoantibody production, and intrathecal production of proinflammatory cytokines. No disease-specific diagnostic markers or diagnostic gold standard is known for NPSLE. Thus, the first step of the diagnostic work-up is to exclude non-SLE-related conditions. The correct diagnosis is derived from careful analysis of the clinical, laboratory, and imaging data on a case-by-case basis. This article reviews the current literature, especially related to the diagnostic and management aspects of NPSLE, which will be useful for consultation-liaison psychiatrists.

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For development of a system to assess and care for outpatients with mental disorders who underwent chemotherapy against their cancer, the usefulness of a program combining a distress and impact thermometer (DIT) used by nurses as well as interviews by psychiatrists were examined. The subjects were outpatients who came to the Hiroshima University Hospital to begin or continue chemotherapy from the end of June to December in 2007. One hundred and thirty patients agreed with this research. Of the 38 participants whose DIT scores were beyond the cutoff scores, 4 for distress and 3 for impact, only 6 preferred being interviewed by a psychiatrist. Two of them were diagnosed with major depressive disorder, and the others with adjustment disorders. However, only three of the six continued to use clinical psychiatric service. Among these who did not prefer the interview assessment, the DIT scores of half of them were under the cutoff scores. The degree of the participants’ satisfaction for the interview approach was not so low. The results suggest the potential needs of psychological support and the effectiveness of this program on certain subjects. For further development, it is important to weaken the psychological stress of patients to provide the necessary mental care and to strengthen the continuous supporting system for outpatients with cancer.

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Patients with adjustment disorders due to physical diseases who were involved in the consultation-liaison area in a general hospital were subclassified into three groups according to their experimental reaction patterns in the process of accepting their diseases. A total of 71 subjects with adjustment disorders due to physical diseases, who were newly referred to the Department of Psychiatry from another department between April 2004 and December 2006, were evaluated. They were classified into three groups (simple type, release type, and conflict-displaying type) according to their experimental reaction patterns in the process of accepting their diseases, and representative cases were presented. The age, sex, symptoms, time from the onset to admission, duration of hospitalization, and prognosis were compared between the groups, and the clinical characteristics were described. Based on the features of each disease type, the clinical characteristics appeared to exhibit a close relationship with each other, and differ according to the severity of psychological distress involved in accepting diseases. Therefore, it was suggested that such subclassification can provide a useful viewpoint to understand patients going through disease acceptance.

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A woman in her seventies with a history of depression and who also had progressive tongue cancer developed depression again during chemotherapy and radiotherapy. She refused to undergo an operation because of psychiatric symptoms such as suicidal tendencies and rejection although she was administered psychiatric pharmacotherapy such as sertraline and clomipramine. Because electroconvulsive therapy (ECT) was administered for her psychiatric symptoms, she dramatically improved and decided to have the operation. Therefore, the refusal of the operation was thought to be a decision-making disturbance due to depression. This case indicates the possibility of a cancer patient making a normal judgment via treatment with ECT when the patient is affected by drug-resistant depression and has a decision-making disturbance. Further, during a course of treatment, the psychiatrist in attendance expressed impatience and discomfort with this critical situation because psychiatric treatment was involved in the life progress of the cancer. The negative feelings of the psychiatrist may be "counter transference" in the broad sense of the term. Therefore, it is important for psychiatrists to appropriately manage their own feelings with progressive cancer patients.

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