In 2025, when the baby-boom generation will become the late elderly, the number of death per year is presumesd to be 1,530 thousand and regional comprehensive care systems and home care are being promoted in order to establish community based end of life care.

A psychosomatic approach is useful not only for patients and families but also for other occupations in order to smoothly implement collaboration among them in practicing the regional comprehensive care system.

In order to provide “seamless palliative care”, it is important to establish a “regional palliative care network” in cooperation with multiple occupations and in collaboration among medical institutions. I think a palliative care ward could connect these local networks. I would like to introduce my experience of Suwa Central Hospital. This is a unique community-based type of hospital and a palliative care ward was utilized very effectively. I would also like to mention the activities I want to develop in Tokyo from now on.

Spiritual pain is a concept that stands for a kind of suffering that only humankind could have. We humankind have the capacity to handle the meaning and value, so we could have spiritual pain. The four important attitudes or knowledges when offering spiritual care are ①to know all cares can be spiritual care, ②we should interact with patients keeping in mind that they are precious individuals, ③we medical staff should not take their place and ④we should be determined to have com-passion.

Insomnia is the most common sleep complaint across all stages of adulthood. Chronic insomnia is a major public health problem affecting millions of individuals along with their communities. Insomnia disorder is defined as a persistent difficulty with sleep initiation, duration, consolidation or quality that occur despite adequate opportunities and circumstances for sleep and results in some form of daytime impairment. Many symptoms and associated features of primary and secondary insomnias are overlapping, thus making differentiation among such subtypes difficult. The international classification of sleep disorders, 3^rd ed. (ICSD-3) manual includes three diagnostic categories for insomnia : chronic insomnia disorder, short-term insomnia disorder and other insomnia disorders. These diagnoses apply to patients with and without comorbidities regardless of whether those comorbidities are viewed as potentially sleep disruptive. It appears that treatment of insomnia may improve the outcome of both sleep disturbance and comorbid conditions. Evidence supports the efficacy of cognitive-behavioral therapy (CBT) in the treatment of insomnia disorder. CBT is the major forms of psychological treatment that have been systematically evaluated.

Although behavioral interventions are the mainstay of treatment, pharmacologic therapy may be necessary for some patients. A good understanding of the risks and benefits of insomnia medications is critical. Improvement of sleep hygiene and consolidation of circadian rhythm should be achieved before starting the pharmacological treatment. The so-called z-drugs (zolpidem, eszopiclone, and zopiclone) should be reserved for use if the non-pharmacological approaches are ineffective. For the general population with difficulty falling asleep, ramelteon, a melatonin receptor agonist, and the z-drugs can be considered. For those who have difficulty staying asleep, suvolexant, a dual orexin receptor antagonist, should be considered. Usage of high dose of benzodiazepines are not recommended because of their high abuse potential and the availability of better alternatives. Sedating antihistamines, antiepileptics, and atypical antipsychotics are not recommended unless they are used primarily to treat another condition. Persons with sleep apnea or chronic lung disease with nocturnal hypoxia should be evaluated by a sleepspecialist before sedating medications are prescribed.

Chronic Insomnia Disorder is typically treated using sleep medications, and psychological treatment is rarely conducted for this disorder. Cognitive behavioral therapy for insomnia (CBT-I) is a highly effective treatment for insomnia symptoms and for reduction in dosage of hypnotics. It also recommended a well-established standard-level and first choice treatment. Recently, it has been revealed that CBT-I is effective for insomnia comorbid with psychiatric (e.g., depression and PTSD) or physical disorders (e.g., cancer and chronic pain). This paper discusses the components of CBT-I and its effectiveness in treating primary and comorbid insomnia.

This study evaluated the effectiveness of add-on cognitive behavioral therapy for insomnia (CBT-I) and GABA-A receptor agonists (GABAA-RA) dose-tapering in patients with primary insomnia resistant to pharmacotherapy. This randomized, multicenter, two-arm, parallel-group study compared CBT-I and treatment as usual (TAU) in patients with persistent primary insomnia despite GABAA-RA treatment. Primary outcomes were severity of insomnia and GABAA-RA tapering rate. Tapering of GABAA-RA dosing was applied in both groups in Sessions 4 and 5 out of 5 interventions provided once every 2 weeks. A mixed-effects repeated measures model revealed significant improvement in Insomnia Severity Index score during the post-intervention and follow-up (FU) periods in the CBT-I versus the TAU group. GABAA-RA tapering rate approached 30% during FU in the CBT-I group ; no significant intergroup difference was observed. Add-on CBT-I improved insomnia symptoms resistant to GABAA-RA therapy. No effect on tapering rate was observed. CBT-I may promote dose reduction by optimizing the protocol and duration.

Objectives : Sleep problems have been associated with deteriorating health status, depression and reduced quality of life (QOL). An international study indicated that university students in Japan have the shortest sleep durations among those in the 24 countries included in the study. The present study aimed to measure the sleep quality and examine whether it is associated with the perceived deterioration in health status, depressive mood level, or reduced health-related QOL status in physical college freshmen.

Methods : A total of 336 college students (247 males, 89 females) who were enrolled in a physical education program completed self-administered questionnaires, including the Pittsburgh Sleep Quality Index (PSQI), Total Health Index (THI), Beck Depression Inventory-II, and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), on the day following their matriculation. Simple linear regression analyses of the PSQI global clinical score (GCS) on each of the variables were performed. Subsequently, multilinear regression analyses with stepwise selection method were conducted to investigate the effects of those variables that showed a significant relationship with GCS, and a categorical variable classified into two groups according to their engaging in sports (team or non-team sport) on the GCS. The data were analyzed based on sex.

Results : In the simple linear regression analyses, the GCS showed significant correlations to the following variable scores : vague complaints, depression, and irregularity of life for the THI subscales in males and respiratory, mouth and anal symptoms for the THI subscales and bodily pain and general health for the SF-36 subscales in females. The stepwise multilinear regression analyses identified depression and irregularity of life in males and general health in females as independent GCS predictors.

Conclusion : These findings suggest that the sleep quality in physical college freshmen on the day following their matriculation might be associated with the perceived deterioration in health status in males and a reduced health-related QOL in females.