Antipsychotics are used not only to treat psychotic disorders such as schizophrenia and bipolar disorder but also to manage delirium in general hospital settings. Nonetheless, the evidence supporting the use of antipsychotic agents to treat delirium remains limited. An increasing number of observational studies indicate an elevated risk of metabolic disorders, venous thromboembolism, and aspiration pneumonia in antipsychotic drug users. This article reviews current clinical practice to manage antipsychotic-induced adverse events in general hospital settings. Strategies to prevent antipsychotic adverse events are focused on its affinity to various monoamine receptors.

In psychiatric outpatient care at general hospital, treatment for depressed patients is mainly focused, but at the same time, patients with physical disorders are often consulted from other department. It is said that the difference in efficacy between antidepressants is small, rather the difference in side effects is large. In addition to gastrointestinal symptoms, insomnia / irritation and drowsiness, not well-known but severe side effects which can affect QOL, such as bleeding, sexual dysfunction, weight gain, and liver dysfunction were outlined. Regarding drug-drug interactions, several antidepressants might be sometimes problematic and interact with commonly used therapeutic agents for physical disorders such as warfarin, theophylline, tramadol, statin drugs, and steroids. Considering whether a patient is suitable for antidepressant and if the antidepressant does not work, we should think about the merits and demerits for switching vs augmentation/combination. It is desirable to explain to patients about multiple options including risks and to share the decision with patients.

Most general hospitals treat patients with secondary mania and bipolar disorder with various complications. Therefore, clinicians must be aware of the adverse effects and drug-drug interactions. Secondary mania is often observed in elderly patients and usually occurs within 12 months after a head injury. Lithium needs to be administered cautiously in patients with heart failure and renal disorders, and combination therapy with diuretic and anti-inflammatory drugs requires close monitoring. Carbamazepine possesses anticholinergic properties and induces drug metabolizing enzymes. Valproic acid inhibits various drug metabolizing enzymes, and its use is unsafe during pregnancy. Lamotrigine needs to be administered cautiously in combination with inducers and inhibitors of uridine diphosphate glucuronosyltransferase.

Hypnotic drugs are intended to induce sedation and promote sleep for the chronic treatment of insomnia. Hypnotics have the potential to reduce motor and cognitive function as a consequence of their sedative effect. The effects on cognition are relevant to the extent that a drug dose affects daytime performance for patients using hypnotic drugs. Hypnotic medication is associated with increased risk of car accidents and falling. We often encounter medical incidents such as a fracture of a bone, due to falling by hypnotic administration in patients, particularly elderly persons. These incidents lead to decrease quality of life for their patients. Sedation is a major effectiveness of hypnotics, also an important matter of falling down for patients. To enhance safety of hypnotic medication for patients, we have constructed drug formulary system of hypnotics in Tohoku Medical and Pharmaceutical University Hospital. According to evidence-based evaluation using medical and pharmaceutical evaluation documents, two drugs such as suvolrexant (Belsomra^®, a dual orexin receptor antagonist) and eszopiclone (Lunesta^®, non-benzodiazepine hypnotic agent) are chosen by pharmacists for the first tier drug. Formulary of these drugs is authorized by the Committee of Pharmaceutical Affairs in our university hospital. In the formulary list, it is recommended to take once a day at bedtime for suvorexant (15 mg) and eszopiclone (1 mg), respectively.

Activity restriction is when cancer patients restrict various activities in daily living after their cancer diagnosis. In this study, we developed an activity restriction scale for cancer patients (SIP-C) based on the items of chronic pain version SIP and examined the reliability and validity of the SIP-C. One hundred eighteen cancer patients responded to SIP-C, SIP, depression scale and the QOL scale. As a result, 26 items were chosen as the final items for SIP-C. Internal consistency based on the KR-20 α coefficient was 0.88, which was sufficient. Correlation analysis of related factors confirmed the validity of SIP-C. SIP-C is expected to be a useful scale as a tool to evaluate activity restriction in cancer patients.

This study investigated the physical restraint of patients in general hospitals in four prefectures of the Tokai region, and sought to clarify methods for preventing the need for physical restraint from an ethical standpoint and methods for promoting early release from physical restraint. Methods: A survey was mailed to 447 general hospitals in the Tokai region (Shizuoka, Gifu, Aichi, and Mie prefectures), to be completed by nurses in charge of caring for patients. The survey included a request for the number of inpatients under physical restraint as of 12:00 pm on March 1, 2018. Results: Answers were returned from 42 institutions (9.3% recovery rate). The number of physically restrained patients was 552, of whom 33.0% were not diagnosed with dementia, delirium, nor mental disorder. For 55.1% of patients, physical restraint was continuously used from the date of admission to the date of the survey. Nurses made the decision to initiate physical restraint for 96.4% of patients. Discussion: To reduce the need for physical restraint in general hospitals and promote early release, it seems to be important to provide psychiatric knowledge for nurses.

Clozapine, which is the only antipsychotic drug approved for treatment-resistant schizophrenia in Japan, was released ten years ago. Because of the high standards associated with this drug, such as the need for each patient to register in the CPMS (Clozaril Patient Monitoring Service) and the need to administer the drug for longer than eighteen weeks, Clozapine has not been fully introduced for schizophrenia treatment. In our department, seventeen patients with treatment-resistant schizophrenia have been treated with Clozapine, although several patients have been regarded as poor responders. Most patients who receive Clozapine treatment have impaired cognitive function; therefore, a network of specialized hospitals should be established to introduce Clozapine therapy for patients at earlier stages of the disease. This network would maximize the benefit of the drug. In addition, the environment of the patients should be altered before drug initiation to minimize the number of patients who discontinue use. Moreover, ingenuity in a practical setting is needed to avoid severe adverse events, such as neutropenia. Other changes are needed to minimize the differences between institutions such as university hospitals and general psychiatric hospitals. To accommodate the many years of effort required for the adoption of Clozapine in Japan, we must concentrate on practical wisdom to obtain the greatest benefit from this drug.

Electroconvulsive Therapy (ECT) is an effective therapy for patients with schizophrenia, especially those who have catatonic features or treatment-resistant symptoms. Propofol is one of the most commonly used intravenous anesthetics for ECT in Japan, although propofol has the disadvantage of having a strong anticonvulsive effect. For patients with high seizure threshold, ketamine can be an effective anesthetic agent because it does not have anticonvulsant effect. ECT with ketamine anesthesia (ketamine ECT) for patients with depression has been frequently reported. In the case of schizophrenia, ketamine anesthesia could also be an effective method. However, there have been few reports about ketamine anesthesia in schizophrenia patients because ketamine might cause exacerbation of psychotic symptoms of schizophrenia. In the present report, we introduce two patients with schizophrenia who had had difficulty in having effective seizures with propofol anaesthesia and were treated successfully with ketamine ECT in combination with propofol of reduced dasages, without any exacerbation of psychotic symptoms.