There is a large treatment gap (95.4%) of Alcohol Use Disorder (AUD) in Japan and it needs to be addressed. However, many psychiatrists in Japan feel inadequate regarding AUD treatment. At our hospital, we have implemented initial treatment of AUD as part of a liaison service and one-stop-service model practice in general hospitals. A favorable outcome has been achieved. In 2015, among 181 AUD patients (93% with alcohol dependence), 36.5% stopped drinking, 22.1% reduced their consumption, 13.3% continued problem drinking, and 28.1% were unknown. We then searched the negative feelings (1-5 of the Likert scale) of the AUD patients among the health care professionals (doctors and rehabilitation-specialists) at our hospital using questionnaires. The average score decreased from 3.25 to 2.37 (p=0.01) after this implementation. Thus we discuss these results as well as some practical tips for AUD initial treatment in Japanese general hospitals.

There an estimated 1.09 million alcoholics in Japan, and only 40,000 are receiving specialized treatment by psychiatric institutes. In general, medical departments, while understanding that treatment for addiction itself is necessary, report that it was an issue that cooperation did not function sufficiently and did not lead to addiction treatment. Since 2015, our hospital has set up a “Drinking Consultation clinic” in a general hospital to provide early intervention for alcoholics. In this paper, we introduce the contents of our efforts so far, and retrospectively evaluate the prognosis of patients for 5 years before and after setting up this specialized clinic. The number of new patients after the installation was about 10 times higher than before the specialized outpatient setting. Regarding prognosis, the percentage of untreated patients decreased from 67% to 4%, and the percentage of continued treatment increased from about 15% to about 69%. In this paper, we examine the methods of early intervention in psychiatry in general hospitals and the results over the past 10 years, and consider the issues and challenges of expanding psychiatric interventions at general hospitals.

It is clear that many alcoholics and heavy drinkers have been referred to general hospitals, such as our hospital, but successful countermeasures have hardly progressed in our hospital. At our hospital, we conduct liaison activities for inpatients, of which about 60% are consultations on delirium. Based on this, we have prepared an assessment sheet for delirium, focusing on heavy drinking and alcohol dependence as one of the risks of developing delirium. We have also created an assessment sheet showing how to manage alcohol withdrawal syndrome and how to intervene psychosocially in alcohol-related problems. Additionally, we hold study sessions in our hospital. As a result of these efforts, the number of consultations in hospital and outpatient care settings has increased. In this paper, we examined the details of the above-mentioned activities, future issues, and points to consider when intervening with patients with alcohol problems at general hospitals.

A psychiatrist at a psychiatric hospital, a specialist in addiction, has started an alcohol liaison consultation at a general hospital in Japan. The psychiatrist examined outpatients and inpatients twice a month. Patients diagnosed with alcoholism received a motivational interview and were referred to a specialized psychiatric institution. This was followed by a one-year case series study. The study included 47 outpatients and 30 inpatients. The average AUDIT score for inpatients was 22.5, of which 21 (70%) were diagnosed with alcohol dependence based on ICD-10 criteria. Of the inpatients with the addiction, 14 (67%) were referred to a specialized psychiatric hospital. Since the start of the liaison practice, the number of alcoholics who have been referred to the psychiatric institution from the general hospital has more than doubled from 12 to 25 per year. More alcohol dependent patients may be treated by addiction specialists performing alcohol liaison consultations in general hospitals. This collaboration can also be a way to reduce the treatment gap between primary care and specialized medical care for alcoholism.

We have been conducting a short-term inpatient treatment program for Alcohol Use Disorder (AUD) Patients (Tokyo Medical Center Alcoholic Program with Physicians = TAPPY) since November 2017. The three main content topics are as follows: study sessions with interdisciplinary instructors, psychotherapy by psychiatrists, and the creation of connections to self-help groups. All of above are to be completed within a two-week admission period. During the last two years, all patients have been connected to some continued treatments. The number of patients taking TAPPY after being transferred from other departments of wards are increasing due to psychiatric liaison team intervention. In acute general hospitals, the commitment of interdisciplinary members is important in order to motivate patients to enter specialized medical care as early as possible. Psychiatric liaison teams need to promote better coordination with other health care professionals, such as gastroenterology, so that they can better understand addiction and support the recovery of patients.

This study compared depression and delirium in Alzheimer’s Disease (AD) assessed by three cognitive function tests, including the Mini-Mental State Examination, revised Hasegawa Dementia Rating Scale, and Neurobehavioral Cognitive Status Examination. A matched case-control method was used while controlling for sex, age, and cognitive status. No obvious differences were observed between delirium and AD. In contrast, differences between depression and AD in terms of cognitive status were observed, and cognitive functions such as orientation and memory were better retained in depression than in AD, whereas cognitive functions such as attention, understanding, repetition, calculation, and judgment were better retained in AD than in depression. These results suggest that detailed examination of cognitive function can aid in the differentiation between depression and AD.

The standard of the suicidal pathient of our country is very higher than other developed nations. The importance of psychiatrists consulted with suicidal patients has increased. We have considered as the intervention method by investigating the differences of social backgrounds, stress factors and psychological features between secondary and tertiary first aid patients. The tertiary first aid suicidal patients were statistically significant higher rate of a history of suicide attempts than the secondary one, and the result was similar to other reports. About half of both patients, the suicide attempts occurred because of the discord of relations with a family or the partner, and many of them were characterized by impulsive or self-revelation. This study implies that it is difficult to predict suicide attempts of patients due to psychological features, however, family involvement and the establishment of a regional support system to prevent suicides may be important.

In 2014, the Japanese society for dialysis therapy published the "proposal for the shared decision-making process regarding initiation and continuation of maintenance hemodialysis." We recognized the following problems based on our experience of using it in the clinical settings: (1) There is no description about how to evaluate the presence or the absence of competence and about how to record it. (2) Treatment of patients with limited competence is undecided. (3) There is little possibility that a "third party" such as a psychiatrist can intervene when a competent patient wants to discontinue the dialysis. (4) There is a lack of support system for patients, families, and medical staff after the decision to withhold or to withdraw the dialysis. In this report, we presented solutions to these issues based on clinical cases. We hope that the new proposal scheduled to be announced in 2020 can be used immediately in clinical practice by the dialysis physicians as well as by the psychiatrists.

The relapse of catatonia often causes personality deterioration due to cognitive dysfunction, impairment of affection, or other reasons. These changes can lead to a decreasing quality of life for the patients and their families. Consequently, we continuously monitor patients with a history of catatonia, even when they have a good prognosis. Herein we report the case of a 71-year-old male who suffered from catatonia, including stupor and psychomotor excitation and depression following major surgery. He had been in remission for more than 40 years since his admission twice to hospitals because of fulminant catatonia in his twenties prior to the recent surgery. We consider the cause of this clinical course leading to catatonia to be associated with both the strongly invasive surgery and the psychological stress related to the dilemma of drafting and signing his will. We recommend consulting with a psychiatric specialist who has experience with schizophrenic episodes prior to undergoing major surgeries.