Considering the great clinical significance of case reports, we discuss the acceptability of reporting without Informed Consent (IC). Clinical case reports on psychiatry are different in various points from those of other medical specialties. That difference is especially prominent in case reports in relation to psychopathology and psychotherapy. Among various difficulties in reporting clinical cases in these fields, acquiring IC seems to be the most difficult issue. Dr. Kantrowitz, a psychoanalyst argued in her research reports about the difficulty and/or harmfulness of obtaining IC from patients when psychotherapists try to publish clinical cases. Considering the value of case reports in those areas, we tried to find validity of reporting cases without IC from patients. The Health and Labor Ministry of Japan recently provided an ethics guide for medical research on human subjects. According to this guide, clinical case reports are not included in medical research. However, reporting cases without IC may be in opposition to the law regarding protection of personal information. We insist in this paper that Academic Society of Psychiatry and its related journals in this country should study the ethics guide and its requirements in relation to personal information protection from the viewpoint of the specificity of clinical psychiatry. We hope the alternative guideline on publishing case reports in the field of psychiatry is provided soon by the society. Then, we will be able to report clinical cases and share valuable experience and knowledge without excessive concern about IC related to complicated matters. We present some necessary condition and proposals that should be included in the new guide.

The significance of case reports in medicine is obvious: Case reports provide lifelong education of doctors and consequently improve standard of medicine in the community. Recently it has been asserted that case reports require agreement of the patients about presenting and publishing the reports. However the obligation of agreement may restrain case reports of the patients who failed treatment, as well as the patients with severe side effect of the treatment, or the patients having different opinions of doctors regarding the disease models or the meaning of clinical courses. The “Case” in case reports involves medical information without privacy. It is information about the patients and information how therapist think and manage patients as well: it is, in an extreme instance, a sort of fiction reconstructed by the therapist based on facts. The “Case” is information which belongs to the public and which must be shared. Academic societies should promote this position.

Depending on whether case reports are conducted as research or as part of medical care, it is necessary to comply with the Personal Information Protection Act, which has been amended in recent years, and to take into account the purpose of relevant ethical guidelines and guidelines, including the need to obtain the consent of the individual concerned. Nevertheless, the Personal Information Protection Act does not sufficiently reflect the reality of medical and medical research in the field of psychiatry. The academic community needs to continue to raise issues regarding its serious impact on case reports, with an eye to the possibility of enacting new special laws on medical and medical research.

The reperch ethic committee of the Japanese Society of Psychiatry and Neurology published guidelines to protect the privacy of the patients in case reports. Professor Kobayashi objected the policy and content of these guidelines, this issue discussed in the Psychiatria et Nerologia Japonica in 2019. Although the ethical issue of the protection for subjects in both clinical and biological studies would, rightfully, be important, could the point of informed consent for subjects be discussed at a similar level between case reports and clinical studies for both patients and psychiatrists? In this manuscript, I discussed the relationship between medical education and case reports which is often overlooked.

In the 2016 medical fee revision, additional medical fees can be calculated for psychiatric wards of 7: 1, 10: 1, and 13: 1 if certain conditions such as psychiatry liaison teams are met. At the time of this revision, it was very important to grasp the status of psychiatric ward admission fees at general hospitals that have psychiatric beds. We analyzed and examined the results of a basic survey of general hospital psychiatry conducted in 2016 for 237 general hospitals with psychiatric beds operating as of June 2016. Nationwide, 25% of general hospitals had a psychiatric ward of 15: 1. By region, the number of general hospitals with a psychiatric ward of 15: 1 was particularly high in Hokkaido. Regarding the relationship between the management organization and the ratio of psychiatric wards of 15: 1, 35% of municipal and prefectural hospitals had a psychiatric ward of 15: 1, which was higher than other management organizations. It was also found that general hospitals with a psychiatric ward of 15: 1 tended to have more psychiatric beds than the other hospitals.

For prevention of repeated suicide attempts, it is important to provide psychiatric support for the attempters during emergency transportation and following treatment at the Emergency and Critical Care Center (ECCC). However, there are few reports on changes in suicide attempter referrals to psychiatrists in the case of ECCC establishment and expansion. In this study, the background factors of suicide attempters, who were referred to the psychiatric department in our hospital, were compared before and after new establishment of ECCC. When compared with the total number of referred patients, both the rate of total suicide attempters and attempts with low mortality increased significantly after ECCC establishment. On the other hand, when similar surveys were conducted at the other hospital where the existing ECCC was expanded by hospital renovations, there was no significant difference in any background factors. Our results support a previous report indicating that suicide attempters tend to be transported mainly to ECCC where consultation with psychiatrists is available. In order to qualify the suicide attempters’ support at ECCC, it is essential to increase the number of psychiatrists and other specialty teams, and at the same time, to eliminate their burden, in preparation for intensifying consultation services.

It is important for workers to balance occupational life with medical care for physical illness. However, the true impact of occupational stress experienced upon returning to work following a physical illness leave remains unclear. The purpose of the present study is to investigate the occurrence of severe occupational stress and the stress-related factors among workers who have taken work leave because of physical illness. The control group comprised participants who have taken work leave because of mental illness. Questionnaire data from 244 participants were analyzed (127 participants with physical illness, 117 participants with mental illness). All participants completed the Brief Job Stress Questionnaire, the Quick Inventory of Depressive Symptomatology (QIDS), the Work Functioning Impairment Scale (Wfun), and the Nou-hirou Scale. High occupational stress was observed in 15.7% of the physical illness group and in 42.7% of the mental illness group (χ² = 21.68, p <.001). In the physical illness group, both the QIDS (p <.05) and the maladaptive cognitive/behavioral reaction in the Nou-hirou Scale (p <.05) were significantly associated with high occupational stress. In the mental illness group, scores for Wfun and the disturbed social executive functions and impairment of social and daily function subscales of the Nou-hirou Scale were significantly associated with high occupational stress. The results of the present study highlight the importance of stress management for workers returning to work following a physical illness leave.

Hereditary spastic paraplegia (HSP) is a group of neurodegenerative diseases in which genetic mutations cause progressive spastic paraplegia. It is classified into pure and complex forms. Pure HSP presents with only spastic paraplegia, and complex HSP includes other clinical features such as intellectual disability. We report the case of a 33-year-old woman with intellectual disability who was diagnosed with HSP. She presented with psychosis and was initially treated for a stress-related psychiatric disorder. Several years later she developed a gait disturbance, and complex HSP was suspected. Several studies have reported cases of complex HSP accompanied by psychosis and mood disturbances. In this case, hallucinations and delusions recurred repeatedly. Antipsychotic drugs such as olanzapine were effective. It is important to consider the possibility of complex HSP when a patient with intellectual disability presents with psychiatric symptoms and develops progressive gait disturbance.

We present a patient with schizophrenia who was successfully rechallenged with clozapine after discontinuation due to neutropenia. In Japan, clozapine is under-prescribed in comparison to Western countries, and very few cases of clozapine rechallenge have been reported. A 45-year-old man had been diagnosed with schizophrenia at the age of 22. After repeated relapses and hospitalizations, he was considered treatment-resistant. He was started on clozapine at the age of 37, and showed a good response. He was admitted to hospital for agitation and delusions. After admission, he developed aspiration pneumonia and consequently lost his appetite. Twenty-three days after the onset of pneumonia, decreases in white blood cells (3600 cells/mm³) and absolute neutrophil count (1370 cells/mm³) were observed, and clozapine was immediately discontinued. Subsequently, he became paranoid, aggressive, and refused to eat and take medication. After treatment with several other antipsychotics, each of which exerted a poor effect, we rechallenged the treatment with clozapine with the approval of the Expert Committee for Clozaril Patient Monitoring Service. This decision was made because the neutropenia may not have been solely due to clozapine but may have been the result of a combination of manageable factors. After re-initiation of clozapine, the patient’s mental state markedly improved, and he was eventually discharged. He remained mentally stable on clozapine for more than 2 years after the rechallenge, with no recurrence of neutropenia. When rechallenging with clozapine, it is crucial to analyze the possible alternative causes of neutropenia. Further research is required to support the applicability of clozapine rechallenge.