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1.  Internet addiction and self-evaluated attention-deficit hyperactivity disorder traits among Japanese college students 
Internet addiction (IA), also referred to as Internet use disorder, is a serious problem all over the world, especially in Asian countries. Severe IA in students may be linked to academic failure, attention-deficit hyperactivity disorder (ADHD), and forms of social withdrawal, such as hikikomori. In this study, we performed a survey to investigate the relation between IA and ADHD symptoms among college students.
Severity of IA and ADHD traits was assessed by self-report scales. Subjects were 403 college students (response rate 78%) who completed a questionnaire including Young’s Internet Addiction Test (IAT) and the Adult ADHD Self-Report Scale–V1.1.
Out of 403 subjects, 165 were male. The mean age was 18.4 ± 1.2 years, and mean total IAT score was 45.2 ± 12.6. One hundred forty-eight respondents (36.7%) were average Internet users (IAT < 40), 240 (59.6%) had possible addiction (IAT 40–69), and 15 (3.7%) had severe addiction (IAT ≥ 70). Mean length of Internet use was 4.1 ± 2.8 h/day on weekdays and 5.9 ± 3.7 h/day on the weekend. Females used the Internet mainly for social networking services while males preferred online games. Students with a positive ADHD screen scored significantly higher on the IAT than those negative for ADHD screen (50.2 ± 12.9 vs 43.3 ± 12.0).
Our results suggest that Internet misuse may be related to ADHD traits among Japanese youth. Further investigation of the links between IA and ADHD is warranted.
PMCID: PMC5573248  PMID: 27573254
attention-deficit hyperactivity disorder; hikikomori; Internet addiction; Internet use disorder; neurodevelopmental disorders
2.  A 39-Year-Old “Adultolescent”: Understanding Social Withdrawal in Japan 
The American journal of psychiatry  2016;173(2):112-114.
PMCID: PMC5573246  PMID: 26844793
4.  Identification of the hikikomori syndrome of social withdrawal: Psychosocial features and treatment preferences in four countries 
Hikikomori, a form of social withdrawal first reported in Japan, may exist globally but cross-national studies of cases of hikikomori are lacking.
To identify individuals with hikikomori in multiple countries and describe features of the condition.
Participants were recruited from sites in India, Japan, Korea and the United States. Hikikomori was defined as a 6-month or longer period of spending almost all time at home and avoiding social situations and social relationships, associated with significant distress/impairment. Additional measures included the University of California, Los Angeles (UCLA) Loneliness Scale, Lubben Social Network Scale (LSNS-6), Sheehan Disability Scale (SDS) and modified Cornell Treatment Preferences Index.
A total of 36 participants with hikikomori were identified, with cases detected in all four countries. These individuals had high levels of loneliness (UCLA Loneliness Scale M = 55.4, SD = 10.5), limited social networks (LSNS-6 M = 9.7, SD = 5.5) and moderate functional impairment (SDS M = 16.5, SD = 7.9). Of them 28 (78%) desired treatment for their social withdrawal, with a significantly higher preference for psychotherapy over pharmacotherapy, in-person over telepsychiatry treatment and mental health specialists over primary care providers. Across countries, participants with hikikomori had similar generally treatment preferences and psychosocial features.
Hikikomori exists cross-nationally and can be assessed with a standardized assessment tool. Individuals with hikikomori have substantial psychosocial impairment and disability, and some may desire treatment.
PMCID: PMC5573567  PMID: 24869848
Social isolation; cross-national; culture
5.  Use of a public film event to promote understanding and help seeking for social withdrawal 
This study aimed to implement a public film event about mental health aspects of social withdrawal. Secondary aims were to assess participants’ knowledge, attitudes, and intended behaviors related to social withdrawal.
The event, held at three U.S. sites, consisted of a film screening, question-and-answer session, and lecture. Participants completed a post-event survey.
Of the 163 participants, 115 (70.6%) completed surveys. Most of the sample deemed social withdrawal a significant mental health issue. Regarding post-event intended behaviors, 90.2% reported intent to get more information, 48.0% to being vigilant for social withdrawal in others, and 19.6% to talking with a health care professional about concerns for social withdrawal in themselves or someone they knew. Asian participants were significantly more likely than non-Asians to intend to encourage help-seeking for social withdrawal (p = .001).
A public film event may be a creative way to improve mental health awareness and treatment-seeking.
PMCID: PMC5573568  PMID: 25427837
culture; film; Japan; multimedia; social isolation; social psychiatry
6.  Social Support and Health Service Use in Depressed Adults: Findings From the National Health and Nutrition Examination Survey 
We investigated the relationship between social support and health service use among men and women with depression.
Participants were 1379 adults with symptoms of depression (Patient Health Questionnaire-9 score ≥5) in the National Health and Nutrition Examination Survey. Using the framework of the Andersen Behavioral Model of Health Services Use, multivariable regression models used social support, stratified by depression severity, to estimate association with utilization of mental health and nonmental health services. Partial F-tests examined a priori interactions between social support and gender.
Among those with adequate social support, odds of seeing a nonmental health provider were much higher when depression was moderate [Odds Ratio (OR): 2.6 (1.3–5.3)] or severe [OR: 3.2 (1.2–8.7)], compared to those lacking social support. Conversely, odds of mental health service use were 60% lower among those with moderate depression [OR: 0.4 (0.2–1.0)] when social support was adequate as opposed to inadequate. Social support was unrelated to service use when depression was mild. Gender moderated the relationship between social support and health service use among individuals with severe depression.
Social support has opposite associations with mental and nonmental health service use among adults with clinically significant depression. This association is largely attributable to the effect of male gender on the relationship between social support and health service use.
PMCID: PMC5560028  PMID: 26795687
Depression; Social support; Health service use; NHANES; Gender
7.  Multidimensional anatomy of ‘modern type depression’ in Japan: A proposal for a different diagnostic approach to depression beyond the DSM-5 
Japan’s prototype of depression was traditionally a melancholic depression based on the premorbid personality known as shūchaku-kishitsu proposed by Mitsuzo Shimoda in the 1930s. However, since around 2000, a novel form of depression has emerged among Japanese youth. Called ‘modern type depression (MTD)’ by the mass media, the term has quickly gained popularity among the general public, though it has not been regarded as an official medical term. Likewise, lack of consensus guidelines for its diagnosis and treatment, and a dearth of scientific literature on MTD has led to confusion when dealing with it in clinical practice in Japan. In this review article, we summarize and discuss the present situation and issues regarding MTD by focusing on historical, diagnostic, psychosocial, and cultural perspectives. We also draw on international perspectives that begin to suggest that MTD is a phenomenon that may exist not only in Japan but also in many other countries with different sociocultural and historical backgrounds. It is therefore of interest to establish whether MTD is a culture-specific phenomenon in Japan or a syndrome that can be classified using international diagnostic criteria as contained in the ICD or the DSM. We propose a novel diagnostic approach for depression that addresses MTD in order to combat the current confusion about depression under the present diagnostic systems.
PMCID: PMC5560068  PMID: 26350304
atypical depression; depression; DSM-5; dysthymia; major depressive disorder; shūchaku-kishitsu
8.  Brief gatekeeper training for suicide prevention in an ethnic minority population: a controlled intervention 
BMC Psychiatry  2016;16:211.
Suicide is a critical public health problem around the globe. Asian populations are characterized by elevated suicide rates and a tendency to seek social support from family and friends over mental health professionals. Gatekeeper training programs have been developed to train frontline individuals in behaviors that assist at-risk individuals in obtaining mental health treatment. The purpose of this study is to assess the efficacy of a brief, multi-component gatekeeper intervention in promoting suicide prevention in a high-risk Asian community in the United States.
We adapted an evidence-based gatekeeper training into a two-hour, multi-modal and interactive event for Japanese-Americans and related stakeholders. Then we evaluated the intervention compared to an attention control using mixed methods.
A sample of 106 community members participated in the study. Intervention participants (n = 85) showed significant increases in all three types of intended gatekeeper behavior, all four measures of self-efficacy, and both measures of social norms relevant to suicide prevention, while the control group (n = 48) showed no significant improvements. Additional results showed significantly higher satisfaction and no adverse experiences associated with the gatekeeper training. The separate collection of qualitative data, and integration with the quantitative survey constructs confirmed and expanded understanding about the benefits of the intervention.
A brief, multi-modal gatekeeper training is efficacious in promoting positive gatekeeper behaviors and self-efficacy for suicide prevention in an at-risk ethnic minority population of Japanese Americans.
PMCID: PMC4936244  PMID: 27388600
Gatekeeper training; Suicide prevention; Identification and referral; Intervention; Japanese; Asian; Community; Mixed methods
9.  Impact of biopsychosocial factors on psychiatric training in Japan and overseas: Are psychiatrists oriented to mind, brain, or sociocultural issues? 
To clarify the impact of biopsychosocial factors on psychiatric training under the new and traditional postgraduate medical education system in Japan and to compare them with young psychiatrists from other countries.
Psychiatric residents and early-career psychiatrists were recruited in Japan and other countries. Using mail-based and web-based self-administered questionnaires, we evaluated participants' demographic information, motivation to become psychiatrists, interest and commitment to various aspects of psychiatry, and reactions to a case vignette, focusing on biopsychosocial factors.
A total of 137 responses, 81 from Japan and 56 from other countries, were collected. Before starting psychiatric training, Japanese participants showed a strong interest in ‘mind’ and less interest in ‘brain’ and ‘environmental factors’, while the interest in ‘brain’ and ‘environmental factors’ is presently as high as that in ‘mind.’ Japanese participants reported less commitment to their training toward ICD/DSM-based diagnosis, interview, pharmacotherapy, psychosocial treatment and epidemiology, compared with participants from other countries. In particular, Japanese participants showed less commitment to their training in suicide prevention, despite their perception of its high importance due to a high suicide rate in Japan. Suicide risk of a case vignette proved to be differently assessed according to participants' commitment levels to each aspect of psychiatry.
Our results suggest that young psychiatrists' attitudes concerning the biopsychosocial model generally become well-balanced with psychiatric training, however sociocultural factors do not seem to be well represented in the Japanese psychiatric training system. Additional training on sociocultural issues, such as suicide in Japan, should be considered.
PMCID: PMC4932895  PMID: 20923431
biopsychosocial model; postgraduate medical education; psychiatric training; psychotherapy; suicide prevention
10.  Attitudes of early-career psychiatrists in Japan toward child and adolescent psychiatry and their career decision 
To understand the attitude of early-career psychiatrists toward child and adolescent psychiatry (CAP), we performed a national survey. The subjects were 348 early-career psychiatrists. A questionnaire was sent to the subjects and returned anonymously. A total of 234 subjects (67.2%) responded. Ten out of 115 (8.9%) psychiatrists in their first to third year of experience, and 18 of 119 (15.1%) psychiatrists in their fourth to tenth year answered that they had interest in CAP. Psychiatry rotations with adequate CAP cases may be necessary to attract early-career psychiatrists to CAP.
PMCID: PMC4928473  PMID: 20132524
postgraduate medical education; child and adolescent psychiatry; subspecialty
11.  Hikikomori, A Japanese Culture-Bound Syndrome of Social Withdrawal? A Proposal for DSM-V 
A form of severe social withdrawal, called hikikomori, has been frequently described in Japan and is characterized by adolescents and young adults who become recluses in their parents’ homes, unable to work or go to school for months or years. The aim of this study was to review the evidence for hikikomori as a new psychiatric disorder. Electronic and manual literatures searches were used to gather information on social withdrawal and hikikomori, including studies examining case definitions, epidemiology, and diagnosis. A number of recent empiric studies have emerged from Japan. The majority of such cases of hikikomori are classifiable as a variety of existing DSM-IV-TR (or ICD-10) psychiatric disorders. However, a notable subset of cases with substantial psychopathology do not meet criteria for any existing psychiatric disorder. We suggest hikikomori may be considered a culture-bound syndrome and merits further international research into whether it meets accepted criteria as a new psychiatric disorder. Research diagnostic criteria for the condition are proposed.
PMCID: PMC4912003  PMID: 20531124
hikikomori; social withdrawal; diagnosis; culture-bound syndrome
12.  Does the ‘hikikomori’ syndrome of social withdrawal exist outside Japan?: A preliminary international investigation 
To explore whether the ‘hikikomori’ syndrome (social withdrawal) described in Japan exists in other countries, and if so, how patients with the syndrome are diagnosed and treated.
Two hikikomori case vignettes were sent to psychiatrists in Australia, Bangladesh, India, Iran, Japan, Korea, Taiwan, Thailand and the USA. Participants rated the syndrome's prevalence in their country, etiology, diagnosis, suicide risk, and treatment.
Out of 247 responses to the questionnaire (123 from Japan and 124 from other countries), 239 were enrolled in the analysis. Respondents’ felt the hikikomori syndrome is seen in all countries examined and especially in urban areas. Biopsychosocial, cultural, and environmental factors were all listed as probable causes of hikikomori, and differences among countries were not significant. Japanese psychiatrists suggested treatment in outpatient wards and some did not think that psychiatric treatment is necessary. Psychiatrists in other countries opted for more active treatment such as hospitalization.
Patients with the hikikomori syndrome are perceived as occurring across a variety of cultures by psychiatrists in multiple countries. Our results provide a rational basis for study of the existence and epidemiology of hikikomori in clinical or community populations in international settings.
PMCID: PMC4909153  PMID: 21706238
Hikikomori; social withdrawal; taijin kyofusho; amae; Internet addiction
13.  The Relationship Between Level of Training and Accuracy of Violence Risk Assessment 
Although clinical training programs aspire to develop competency in violence risk assessment, little research has examined whether level of training is associated with the accuracy of clinicians’ evaluations of violence potential. This is the first study to compare the accuracy of risk assessments by experienced psychiatrists to those of psychiatric residents. It also examined the potential of a structured decision support tool to improve residents’ violence risk assessments.
Using a retrospective case control design, medical records were reviewed for 151 patients who assaulted staff at a county hospital and 150 comparison patients. At admission, violence risk assessments had been completed by psychiatric residents (N= 38) for 52 patients, and by attending psychiatrists (N = 41) for 249 patients. Trained, blinded research clinicians coded information available at hospital admission with a structured risk assessment tool, the HCR-20 Clinical (HCR-20-C) scale.
Receiver operating characteristic analyses showed that clinical estimates of violence risk by attending psychiatrists had significantly higher predictive validity than those of psychiatric residents. Risk assessments by attending psychiatrists were moderately accurate (AUC = .70), whereas risk assessments by residents were no better than chance (AUC = .52). Incremental validity analyses showed that addition of information from the HCR-20-C had the potential to improve the accuracy of risk assessments by residents to a level (AUC = .67) close to that of attending psychiatrists.
Less training and experience is associated with inaccurate violence risk assessment. Structured methods hold promise for improving training in risk assessment for violence.
PMCID: PMC4907265  PMID: 22948947
14.  A New Form of Social Withdrawal in Japan: A Review of Hikikomori 
The purpose of this article is to provide a clinical review of a unique, emerging form of severe social withdrawal that has described in Japan. It begins with a case vignette, then reviews the case definition, epidemiology, psychopathology, differential diagnosis, and treatment and management of the condition. Called hikikomori, it is well-known to both the psychiatric community and general public there but has never been reviewed in the English medical literature. Patients are mostly adolescent and young adult men who become recluses in their parents’ homes for months or years. They withdraw from contact with family, rarely have friends, and do not attend school or hold a job. Never described before the late 1970s, hikikomori has become a silent epidemic with tens, perhaps hundreds, of thousands of cases now estimated in Japan. The differential diagnosis includes anxiety and personality disorders, but current nosology in the Diagnostic and Statistic Manual of Mental Disorders may not adequately capture the concept of hikikomori. Treatment strategies are varied and lack a solid evidence basis, but often include milieu, family, and exposure therapy. Much more study including population-based and prospective studies need to be conducted to characterize and provide an evidence basis for treatment of this condition.
PMCID: PMC4886853  PMID: 19567455
15.  Social isolation associated with depression: A case report of hikikomori 
Social isolation is associated with significant morbidity and mortality. A severe form of social isolation or social withdrawal, called hikikomori in Japan, has been described, but controversy over the etiology and universality of the phenomenon remains.
Case report.
Diagnostic assessment by structured clinical interview and psychometric tools revealed hikikomori and underlying bipolar disorder, in which the patient's social withdrawal occurred exclusively during major depressive episodes. The patient declined pharmacotherapy, but his hikikomori and depression went into remission after 25 sessions of cognitive behavioural therapy targeting his social isolation.
This is the first reported case of hikikomori in the Americas. It illustrates the association between hikikomori and a mood disorder, and suggests the importance of international study of the prevalence and potential treatment strategies for severe social isolation.
PMCID: PMC4886854  PMID: 22408115
Social isolation; social withdrawal; bipolar disorder; hikikomori
16.  Correlates of Suicide Among Veterans Treated in Primary Care: Case–Control Study of a Nationally Representative Sample 
Journal of General Internal Medicine  2014;29(Suppl 4):853-860.
Veterans receiving Veterans Affairs (VA) healthcare have increased suicide risk compared to the general population. Many patients see primary care clinicians prior to suicide. Yet little is known about the correlates of suicide among patients who receive primary care treatment prior to death.
Our aim was to describe characteristics of veterans who received VA primary care in the 6 months prior to suicide; and to compare these to characteristics of control patients who also received VA primary care.
This was a retrospective case–control study.
The investigators partnered with VA operations leaders to obtain death certificate data from 11 states for veterans who died by suicide in 2009. Cases were matched 1:2 to controls based on age, sex, and clinician.
Demographic, diagnosis, and utilization data were obtained from VA’s Corporate Data Warehouse. Additional clinical and psychosocial context data were collected using manual medical record review. Multivariate conditional logistic regression was used to examine associations between potential predictor variables and suicide.
Two hundred and sixty-nine veteran cases were matched to 538 controls. Average subject age was 63 years; 97 % were male. Rates of mental health conditions, functional decline, sleep disturbance, suicidal ideation, and psychosocial stressors were all significantly greater in cases compared to controls. In the final model describing men in the sample, non-white race (OR = 0.51; 95 % CI = 0.27–0.98) and VA service-connected disability (OR = 0.54; 95 % CI = 0.36–0.80) were associated with decreased odds of suicide, while anxiety disorder (OR = 3.52; 95 % CI = 1.79–6.92), functional decline (OR = 2.52; 95 % CI = 1.55–4.10), depression (OR = 1.82; 95 % CI = 1.07–3.10), and endorsement of suicidal ideation (OR = 2.27; 95 % CI = 1.07–4.83) were associated with greater odds of suicide.
Assessment for anxiety disorders and functional decline in addition to suicidal ideation and depression may be especially important for determining suicide risk in this population. Continued development of interventions that support identifying and addressing these conditions in primary care is indicated.
PMCID: PMC4239287  PMID: 25355088
mental health; veterans; primary care; health services research
17.  Relationship between Trusting Behaviors and Psychometrics Associated with Social Network and Depression among Young Generation: A Pilot Study 
PLoS ONE  2015;10(4):e0120183.
Maladaptive social interaction and its related psychopathology have been highlighted in psychiatry especially among younger generations. In Japan, novel expressive forms of psychiatric phenomena such as “modern-type depression” and “hikikomori” (a syndrome of severe social withdrawal lasting for at least six months) have been reported especially among young people. Economic games such as the trust game have been utilized to evaluate real-world interpersonal relationships as a novel candidate for psychiatric evaluations. To investigate the relationship between trusting behaviors and various psychometric scales, we conducted a trust game experiment with eighty-one Japanese university students as a pilot study. Participants made a risky financial decision about whether to trust each of 40 photographed partners. Participants then answered a set of questionnaires with seven scales including the Lubben Social Network Scale (LSNS)-6 and the Patient Health Questionnaire (PHQ)-9. Consistent with previous research, male participants trusted partners more than female participants. Regression analysis revealed that LSNS-family (perceived support from family) for male participants, and item 8 of PHQ-9 (subjective agitation and/or retardation) for female participants were associated with participants’ trusting behaviors. Consistent with claims by social scientists, our data suggest that, for males, support from family was negatively associated with cooperative behavior toward non-family members. Females with higher subjective agitation (and/or retardation) gave less money toward males and high attractive females, but not toward low attractive females in interpersonal relationships. We believe that our data indicate the possible impact of economic games in psychiatric research and clinical practice, and validation in clinical samples including modern-type depression and hikikomori should be investigated.
PMCID: PMC4383339  PMID: 25836972
18.  Using the mood disorder questionnaire and bipolar spectrum diagnostic scale to detect bipolar disorder and borderline personality disorder among eating disorder patients 
BMC Psychiatry  2013;13:69.
Screening scales for bipolar disorder including the Mood Disorder Questionnaire (MDQ) and Bipolar Spectrum Diagnostic Scale (BSDS) have been plagued by high false positive rates confounded by presence of borderline personality disorder. This study examined the accuracy of these scales for detecting bipolar disorder among patients referred for eating disorders and explored the possibility of simultaneous assessment of co-morbid borderline personality disorder.
Participants were 78 consecutive female patients who were referred for evaluation of an eating disorder. All participants completed the mood and eating disorder sections of the SCID-I/P and the borderline personality disorder section of the SCID-II, in addition to the MDQ and BSDS. Predictive validity of the MDQ and BSDS was evaluated by Receiver Operating Characteristic analysis of the Area Under the Curve (AUC).
Fifteen (19%) and twelve (15%) patients fulfilled criteria for bipolar II disorder and borderline personality disorder, respectively. The AUCs for bipolar II disorder were 0.78 (MDQ) and 0.78 (BDSD), and the AUCs for borderline personality disorder were 0.75 (MDQ) and 0.79 (BSDS).
Among patients being evaluated for eating disorders, the MDQ and BSDS show promise as screening questionnaires for both bipolar disorder and borderline personality disorder.
PMCID: PMC3599106  PMID: 23443034
Bipolar disorder; Borderline personality disorder; Eating disorder; Comorbidity; Screening scale
19.  The Key Role of a Transition Course in Preparing Medical Students for Internship 
Among the core transitions in medical education is the one from medical school to residency. Despite this challenging transition, the final year of medical school is known as lacking structure and clarity. The authors examine the preparation of medical students for the professional and personal challenges of internship in the context of transition courses. They first describe the development of a residency transition course, offered since 2001 at the University of California, San Francisco, School of Medicine (UCSF), exploring aspects of a needs assessment, course goals and content, core competencies, and course implementation. They then critically analyze the course, judging it successful based on high subjective satisfaction scores and increased perceived preparedness data. Next, the authors discuss the national context of transition courses, perspectives of various stakeholders, and lessons learned from the UCSF experience. Finally, they consider future directions, suggesting that internship transition courses be a standard part of the medical school curriculum.
PMCID: PMC3128667  PMID: 21617513

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