Goldberg P and Huxley described the key features of the model of the pathways to psychiatric care. There are 5 levels from the community to the psychiatric hospital and 4 filters. This framework serves to draw our attention to the "filters" through which depressive patients must pass in order to receive mental health care providers. The 2^<nd> filter is the most important belong to primary care, which includes levels 2 (total depressive patients) and 3 (detected mood disorders). The ability to pass 2^<nd> filter smoothly, depends on detection of mood disorders by primary care physician and makes second prevention for depression. The 3^<rd> filter is also important belong to level 3 and level 4 (all patients treated by mental health services). Screening tests and diagnostic aids for depressive symptoms aim to improve the accuracy with which the primary care physician detects mood disorders. Brief measures are more useful in the busy clinical practice. But they have benefits and limitations. When screening for depression, the cutt-off scores of test should be cautious, and would be connected in a tendency to overdiagnosis. The PRIME-MD PHQ depression scale (PHQ-9) is dual-purpose instrument for making provisional depressive disorder diagnoses and assessing severity for depressive disorders. The PHQ-9 can be administered by the co-medical staffs, and it can be useful clinical tool for screening depression in primary care settings. However, about a screened patient, enough ability for diagnosis and clinical competence are requested for an appropriate diagnosis and treatment strategy of mood disorders.

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Patients with medical illness have a markedly higher rate of comorbid mood disorder than healthy people. However, diagnosis can be difficult as patients with mood disorders will report physical symptoms when examined at regular medical institutions, but rarely mention psychological symptoms. In many cases, the symptoms of the primary illness and those of depression are similar, and thorough medical interviews and careful observation are required. Furthermore, in cases of comorbid mood disorder, many symptoms aside from those of the primary illness are present. If physical symptoms unrelated to the primary illness are observed, it is necessary to be sufficiently aware of the possibility of depression and to make a careful evaluation while also considering and searching for other comorbidities. There may be a relationship between laboratory findings indicating the primary illness and the degree of depression; therefore, for physical management, attention must be paid to depression as well as changes in examination findings. If improvement is poor, patients experience difficulty in treatment. Furthermore, if QOL decreases more than expected despite appropriate medical physical therapy, it is necessary to consider comorbid mood disorder, and depending on the situation, coordinate with medical specialists and perform comprehensive diagnosis and treatment.

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Recent reports indicate that bipolar disorder is frequently misdiagnosed as unipolar depression, leading to inappropriate use of antidepressants. Early identification of bipolar disorder is one of the key points in managing depression in the primary care setting. Although it is difficult to differentiate bipolar and unipolar types of depression due only to depressive symptoms, atypical and manic features in the depressive episode may give some dues to the diagnosis of bipolar disorder. The clinician needs to check carefully evidence of past spontaneous (hypo) mania which is required to diagnose bipolar disorder, because of underreporting or lack of information on the (hypo) manic episodes. Alternatively, some self-reported questionnaires may be also useful in screening patients with bipolar disorder in a primary care practice. Moreover, bipolar disorder commonly has concomitant personality and substance abuse disorders, and is complicated by the presence of one or more comorbid disorders. It is preferable to estimate "bipolarity", especially a family history of bipolar disorder and antidepressant-induced (hypo) mania, from the viewpoint of bipolar spectrum. In the pharmacotherapy of bipolar disorder, mood stabilizer is recommended as a first-line treatment regardless of the types of mood episodes. Despite widespread antidepressant treatment for both unipolar and bipolar depression in a clinical practice, some recent reports suggest that antidepressants are not effective for the treatment of bipolar depression. Considering that antidepressants for bipolar depression may induce a manic switch or rapid cycling, the clinician would have to pay careful attention to the use of antidepressants in bipolar disorder.

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Premorbid personality, environment and life stage contribute to the pathogenesis and development of depression. Depressive patients develop their personality based on concealed mood fluctuation and aspiration for objects. If they give up dependency on their important persons and identify themselves with social norms to form a higher integrated level of personality structure, they develop a melancholic-type personality or an immodithymic personality observed after middle age, manifested with classical-type depression with feelings of guilt. If dependence is oversatisfied, escape-type depression (Hirose) or immature-type depression (Abe et al.) develops with narcissistic tendencies appearing after the second half of the 20s. Whether mood fluctuation is situated within personality traits or one of the symptoms in the case of depressive patients from their late 10s to the first half of their 20s who had a lower integrated level of personality structure and exposed mood fluctuation is unclear. Two of the typical depressive pictures at this life stage are BPD-like bipolar II (Abe) with hypomanic elements that act out easily and dysthymia-type depression (Tarumi) with a marked tendency to avoidance. In summary, the clinical picture of depression varies depending on the integrated level of personality structure, quantity of manic element and life stage.

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Background: Overweight in pregnant women is strongly associated with several perinatal risks. Health guidance focusing on weight control is of interest for reducing perinatal risks. In the present study, we hypothesized that awareness of perinatal risks and health-promoting behaviors in daily life are different between overweight and normal weight pregnant women. Method: One hundred and ten pregnant women from 12 to 40 weeks who did not show severe complications (mean age, 30.7±4.6 years) participated and completed an original questionnaire "Pregnancy Behavior Scale (PBS)" which consists of 10 items for risk recognition and 20 items for health promotion on pregnancy. Results of PBS were confirmed by a personal interview. Subcales for PBS in overweight subjects (body mass index ≧24 at baseline, n=17) or in excess weight gain subjects (increase in over 0.27kg/week, n=33) were compared with those in normal weight subjects (n=93) or in normal (0.17 to 0.27kg/week, n=47) and low (less than 0.17kg/week, n=30) weight gain subjects. Results: Factor analyses of PBS revealed that 2 subscales from risk recognition and 3 subscales from health promotion were classified. Each subscales demonstrated good internal consistency (Cronbach's alpha, from 0.54 to 0.94). A score of optimism on risk recognition in overweight subjects showed significantly higher than that in normal weight subjects (p<0.001). On the other hand, a score of adherence to health guidance on health promotion in excess weight gain subjects was significantly lower compared with that in low weight gain subjects (P<0.05). Conclusion: PBS is a valid and reliable instrument for assessing thought and behaviors in pregnant women. Overweight pregnant women are likely to neglect perinatal risks and health promotion. These results suggest that pregnant women should require health guidance focusing on weight control to reduce perinatal risks.

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Objectives: Recently, an increasing number of Japanese workers have shown signs of stress. A tool to detect the process of worsening of worker's mental health is urgently needed. In 2006, we found five new factors including "self assessment of one's working worth, fulfillment", "decreased will to work", "fatigue/exhaustion", "insufficient inner reserves", "social relationship" in the Burn-Out Scale for Japanese version using structural equation modeling (SEM) with the parceling technique. Then, we developed a new Mental Health Inventory-5 for Workers (MHI-5) after evaluating 18 well-known assessments of Worker's Stress Methods: The subjects were 228 workers (male 124, female 104, 42±12 years). The study was performed between July and September 2006 using an interview or mailed survey. The following data were collected: 1) Job including overwork, autonomy and aptitude for job, 2) Cognition including negative thinking, idealism (self sacrifice) and anxiety regarding insufficiency, 3) Social Relationship including asking someone for advice, help and communication, 4) Psychosomatic Condition including depressive tendency, neurotic tendency, sleep, appetite and general complaints, and 5) MHI-5. The MHI-5 was constructed of five subscales, that is, "working worth, fulfillment"," decreased will to work", "fatigue/exhaustion", "insufficient inner reserves, and "social relationship", as described above, using a total of 30 questions. In this study, we evaluated the reliability, validity and causal model of our MHI-5. Results: The internal consistency of the MHI-5 was very high (α=0.901). The five subscales correlated with each other. An explorative factor analysis showed that five subscales of MHI-5 were coincidental with the five-factor structure obtained by our previous study. The inventory was strongly correlated with certain important occupational stressors. These findings suggested a high criterion-related validity of MHI-5. Furthermore, SEM analysis using the parceling technique showed a good index of fit in a causal model of MHI-5. Conclusion: We found good reliability, validity and a good index of fit in a causal model of the newly developed MHI-5. We emphasize that our inventory is a good generic screening test for assessing problems in worker's mental health easily and quickly.

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