05 September Tokyo research symposium slides

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What happens next
Mental Health Matters: What are
the policy priorities for Japan?
Research symposium
National Institute of Mental Health
Thursday 5 September 2024
12.00pm – 4.00pm

Mental health matters:
A global policy agenda
Welcome lunch
12.00pm – 1.00pm

Welcome
introduction
Yoshinori Cho, Director General,

Project overview
Esther McNamara,
Senior Health Policy Lead, ILC-UK

What is this project about?
• Global burden of acute mental health conditions
• Mental healthcare needs currently unmet
• What this means in the context of demographic
change
• Socioeconomic opportunities of managing the
mental health disease burden, and prevention

China Germany Japan UK USA
ILC Index
overall
ranking
49 22 20 14 31
ILC Index
happiness
ranking
52 19 62 25 32
%of
health
spending
on MH
10%
(2020)
2%
(2021)
6%
(FY
2020-
2021)
6.8%
(2020)
Suicide
rate per
100,000 in
2021
5.25 11.16 16.8 10.7 14.5
Global
average
= 9.15
New rankings
from 2024
updated Index

Japan in ILC’s Index

We are looking at this issue through the
lens of the following diagnoses:
• Post-traumatic stress disorder
• Major depressive disorder
• Schizophrenia

Psychiatrists 2.2 13.2 11.8 7.6 10.5
Psychologists 1.89 49.5 3 36 29.8
Mental
health nurses
5.4 56 83.8 56 4.2
Mental health professionals per 100,000
people

Findings so far
• Investment and workforce provision are insufficient
amidst demographic change
• Availability of data on incidence, spending, and
demand for healthcare today, let alone in the future
• Access to appropriate care pathways across longer
lives
• Healthcare system structures and sustainability

Session 1
Management of mental health conditions in
Japan: major depressive disorders, PTSD and
schizophrenia

Presentation 1
Hiroshi Kunugi, Clinical Medicine Professor
and Chairman, Department of
Neuropsychiatry, Teikyo University

Management of mental health conditions
in Japan: major depressive disorders
Hiroshi Kunugi
Department of Psychiatry, Teikyo University School of
Medicine
Department of Mentarl Disorder Research, NCNP
Mental Health Matters: What are the policy priorities for Japan?
Thursday, 5 September 2024 @ NCNP
13

Vascular dementia
Alzheimer disease
Schizophrenia
Mood disorders
Anxiety, stress, somatic disorders
Substance abuse
Others
Epilepsy
2004 2007 2010 2013 2016 2019
Recent changes in number of psychiatric patients under psychiatric treatment by diagnosis
Twelve-month prevalence of any mood disorders: 2.8% (Ishikawa et al, JAD,
2018).
Approximately ¼ of MDD patients are treated in psychiatric clinic/hospital. 14

15
日本の男性について , 完全失業率の 1 ％上昇が 10 万人当たり約 25 人の自殺者数増加と相関
Chen et al, Jap World Economy 21:140-150 、 2009.
2023: 21818 （ M 14854; F 6964)
Number of suicide in
Japan
Total
Male
Female
1978 1998 2003
2022

16
Suicide rates in G7 countries (in 100,000)
US
Japan
France
Germany
Canada
UK
Italy
Japan
US
France
Germany
Canada
UK
Italy
Japan
France
US
Germany
Canada
UK
Italy

• ¾ of MDD patients do not receive psychiatric treatment.
• Relatively high suicide rate in Japan is, due in part to the
untreatment of MDD.
• More public awareness needed?
17

More than half of long-term sick leave workers by
mental disorders
(Nishiura et al, 2021)
西浦千尋ほか：民間企業における長期疾病休業の発生率、復職率、
退職率の記述疫学研究： J-ECOH スタディより
(2012-2014)

Stress Check Program in
Japan
• The Stress Check Program is a mandatory initiative aimed at improving
workplace mental health.
• Instituted by an amendment to the Industrial Safety and Health Law in 2014.
• It requires all workplaces with 50 or more employees to conduct stress
checks at least once a year.
• The program involves:
• Regular Stress Assessments: Employees complete a questionnaire to evaluate their
stress levels.
• Feedback and Counseling: Results are shared with employees, and those identified
with high stress levels are offered counseling.
• Workplace Improvements: Aggregate data is used to identify and address workplace
stressors.
19

Treatment of MDD
• Psychoeducation including reducing stressors by
adjusting environmental factors
• Psychotherapy: CBT
• Pharmacotherapy
• Antidepressants; Anxiolytics, Antipsychotics, Mood
stabilizers, Hypnotics, Chinese herbal medicine, etc
• Brain stimulation
• ECT, rTMS
• Rehabilitation: “Rework” in day care setting
• Others
• Nutrition; Exercise; light therapy, etc
20

Treatment of MDD
• Pharmacotherapy
• ECT, rTMS
• Others
21

CBT in Japan health insurance system
unrewarding, unpractical, and unprevailing
• CBT
￥ 4800 for 30 min by psychiatrist
≧
￥ 3500 for 30 min by nurse & psychiatrist ( 5min)
≧ ≧
Nurse:
• clinical experience 2 years
≧
• Observer 10 cases & 120 hours
≧
• Supervision 5 cases
≧
• Ordinary supportive psychotherapy
￥ 3000 for 5 min by psychiatrist
≧
# Poor time effectiveness in CBT
# Too strict regulation for nurse to participate
# Surprisingly, psychologists are not considered in this
system. 22

Treatment of MDD
• Psychotherapy: supportive psychotherapy/CBT
• Pharmacotherapy
• ECT, rTMS
• CBT is often practiced in this setting.
• Others
23

Duloxetine
17%
Trazodone
13%
Sertraline
12%
Escitalopram
11%
Paroxetine
10%
Mirtazapine
10%
Tri-Cyclic
7%
Fluvoxamine
6%
Vortioxetine
6%
Venlafaxine
5%
Tetra-Cyclic
2%
Milnacipran
1%
2024 年 1 ｰ 6 患者数シェア
Antidepressants’ market share based on number of prescribed patients
(2024 1-6 in Japan)
Lack of bupropion, fluoxetine, etc. 24

Bupropion
• Advantages
• Effect on dopamine reuptake
• No side effect of weight gain
• No side effect of sexual dysfunction
• Possible effect on smoking cessation
• Disadvantage
• No effect on serotonin reuptake
25

Bupropion
• Advantages
• No effect on weight gain
• No side effect on sexual dysfunction
• Disadvantage
26

27
⇒HVA could be a state marker for MDD
CSF HVA levels depend on depression
severity but not on antidepressants
(Yoon et al, J Clin Psychiatry, 2017)

Koslow et al. (1983) - Male -0.69 0.27 -1.22 -0.15 0.012
Koslow et al. (1983) - Female -0.35 0.25 -0.84 0.14 0.16
Asberg et al. (1984) - Male -0.75 0.31 -1.35 -0.14 0.015
Asberg et al. (1984) - Female -0.49 0.27 -1.02 0.040 0.070
Widerlöv et al. (1988) -0.23 0.37 -0.96 0.50 0.54
Molchan et al. (1991) -0.14 0.36 -0.86 0.57 0.69
Reddy et al. (1992) -0.60 0.26 -1.11 -0.087 0.022
De Bellis et al. (1993) -0.35 0.36 -1.06 0.36 0.33
Engström et al. (1999) -0.49 0.22 -0.92 -0.050 0.029
Sher et al. (2005) 0.016 0.21 -0.40 0.43 0.94
Sullivan et al. (2006a) -0.041 0.35 -0.72 0.64 0.91
Sullivan et al. (2006b) 0.25 0.29 -0.32 0.83 0.39
Ogawa et al. (2015) -0.88 0.32 -1.50 -0.27 0.0051
-0.37 0.092 -0.55 -0.19 0.000061
-1.00 -0.50 0.00 0.50 1.00
Low HVA High HVA
Study Statistics Hedges's g and 95% CI
Hedges's
g
Standard
error
Lower
limit
Upper
limit
P-value
Total
HVA （ dopamine metabolite): 11
studies
2024/01/20 28
(Ogawa et al: J Psychiatr Res, 2018; 105: 137-146)

5-HIAA (serotonin metabolite): 11 studies
Koslow et al. (1983) - Male -0.21 0.27 -0.73 0.31 0.44
Koslow et al. (1983) - Female 0.53 0.26 0.016 1.033 0.043
Asberg et al. (1984) - Male -0.53 0.27 -1.06 -0.0072 0.047
Asberg et al. (1984) - Female -0.51 0.25 -1.01 -0.014 0.044
Widerlöv et al. (1988) -0.084 0.37 -0.81 0.64 0.82
Molchan et al. (1991) 0.48 0.37 -0.25 1.20 0.20
Reddy et al. (1992) 0.28 0.26 -0.23 0.78 0.28
De Bellis et al. (1993) -0.36 0.36 -1.07 0.35 0.32
Engström et al. (1999) -0.036 0.22 -0.47 0.39 0.87
Sher et al. (2005) 0.21 0.21 -0.20 0.63 0.32
Sullivan et al. (2006a) -0.16 0.35 -0.84 0.52 0.64
Sullivan et al. (2006b) 0.38 0.29 -0.20 0.96 0.20
Ogawa et al. (2015) -0.61 0.31 -1.22 -0.0020 0.049
-0.042 0.11 -0.26 0.17 0.70
-1.00 -0.50 0.00 0.50 1.00
Low 5-HIAA High 5-HIAA
Hedges's
g
Standard
error
Lower
limit
Upper
limit
P-value
Total
2024/01/20 29

MHPG (noradrenaline metabolite): 11
studies
Koslow et al. (1983) 0.51 0.18 0.16 0.87 0.0050
Asberg et al. (1984) - Male 0.054 0.37 -0.66 0.77 0.88
Asberg et al. (1984) - Female -0.21 0.31 -0.82 0.40 0.50
Widerlöv et al. (1988) 0.00 0.37 -0.73 0.73 1.00
Molchan et al. (1991) 0.50 0.37 -0.22 1.23 0.17
De Bellis et al. (1993) -0.12 0.36 -0.83 0.58 0.73
Engström et al. (1999) -0.41 0.22 -0.84 0.025 0.065
Sher et al. (2005) -0.24 0.21 -0.65 0.18 0.26
Sullivan et al. (2006a) 0.14 0.35 -0.53 0.82 0.68
Sullivan et al. (2006b) -0.19 0.29 -0.76 0.39 0.52
Ogawa et al. (2015) -0.20 0.31 -0.80 0.40 0.51
-0.019 0.11 -0.23 0.20 0.86
-1.00 -0.50 0.00 0.50 1.00
Low MHPG High MHPG
Hedges's
g
Standard
error
Lower
limit
Upper
limit
P-value
Total
2024/01/20 30

Bupropion
• Advantages
• No effect on weight gain
• No side effect on sexual dysfunction
• Disadvantage
31

32
Serretti & Mandelli: J Clin Psychiatry. 2010; 71: 1259-72.
Bupropion was reported to be more effective in obese patients with
MDD than nonobese patients (Jha et al, JAD, 2018).

Arch Gen Psychiatry 2010
N=55387
Obesity increases the risk of
depression (OR 1.55).
33
2022/10/20
Depression increases the
risk of obesity (OR 1.59).
Bidirectional
relationship between
depression and obesity.

0
5
10
15
20
25
30
35
Working
memory
MDD patients Healthy participants
B
*
*
U
(40)
N
(185)
O
(65)
OB
(17)
U
(25)
N
(213)
O
(47)
OB
(9)
0
5
10
15
20
25
30
35
Executive
function
MDD patients Healthy participants
F
U
(40)
N
(185)
O
(65)
OB
(17)
U
(25)
N
(213)
O
(47)
OB
(9)
**
***
*
(Hidese et al, J Affect Disord, 2017)
Obesity is related with cognitive dysfunction in MDD
P A
L R
R
L
L
R
R L
P A
Gray matter volume reductions in the left medial frontal, right
orbitofrontal, bilateral inferior frontal, bilateral middle temporal,
bilateral inferior temporal gyri, and bilateral thalami
White matter FA value reductions in the bilateral internal capsule
and left optic radiation
2017/8/20 34

• Obese patients should receive nutrition guidance to control
weight, which is not mentioned in the guideline of MDD
treatment.
35

Treatment of MDD
• Pharmacotherapy
• ECT, rTMS
• Others
36

37
Biosynthesis of monoamines requires essential amino acids and micronutrients
(Kunugi et al PCN,
2023)
Extracellular zinc binds to dopamine transporter and inhibits reuptake of dopamine (Norregaard et al,
EMBO J 1998; 17: 4266).

38
国立健康・栄養研究所「健康日本 21 （第二次）分析評価事業」栄養摂取状況調査資料より
https://www.ohayo-milk.co.jp/info/column_19ss_fe_yogurt.html
Iron intake is insufficient and rapidly decreasing in Japan
total
male
female
Recommended iron intake for women

• At least iron (ferritin), zinc, folate, vitamin B1, and vitamin D
levels should be routinely monitored in depressed patients,
and supplementation should be provided in case of
insufficiency/deficiency (not mentioned in the Japanese
guideline of MDD).
39

Treatment of MDD
• Pharmacotherapy
• ECT, rTMS
• Others
40

・ Approved by health insurance system in June,
2019
・ Only for treating resistant depression
・ Only one protocol approved (high frequency
stimulation for 40 min on frontal cortex for 6
weeks): very time-consuming
・ Cost and time effectiveness much improved
from June, 2024 ( ￥ 12,000⇒ ￥ 20,000 ）
・ Not yet widespread: only 4 facilities in Tokyo
including 2 university hospital
rTMS

Objective assessment by wearable
devices
42

Mean 24 h activity rhythms
43
(a) Depressed patients (n=20; solid
line) and controls (n=20; dotted
line)
(b) Patients with major depressive
disorder (MDD) (n=14; blue line),
patients with bipolar disorder (BP)
(n=6; red line) and controls (n=20;
dotted line)
• For sleep parameters, patients showed
significantly increased total sleep time, wake
after sleep onset, and sleep fragmentation
index.
• For activity rhythm parameters, patients
showed significantly decreased MESOR and
amplitude.
• Acrophase tended to be delayed in the
patients

2022/11/19
活動量計付き
心拍センサー
うつ病患者の活動量と心拍変動を同時計測
44

Simultaneous monitoring of activity and autonomic
nervous system
2022/11/19
Koga N et al. Neuropsychopharmacol Rep. 2022. 45
Reduced activity in the daytime and increased activity during sleeping
Dampened parasympathetic nervous system in depressed patients
● male controls
〇 male patients

Summary
• ¾ of MDD patients do not receive psychiatric treatment.
• Relatively high suicide rate in Japan is, due in part to the untreatment of
MDD.
• More public awareness needed?
• Stress Check Program may be useful to enhance public awareness and
prevent the development depression.
• CBT in Japan health insurance system is unrewarding, unpractical, and
thus unprevailing, although it is often practiced in “rework” program.
• Some major antidepressants including bupropion and fluoxetine, are
unavailable in Japan.
• rTMS has recently been introduced in the health insurance system;
however, its application is still limited.
• Nutritional approaches such as nutrition guidance and supplementation
is not well recognized.
• Objective assessment by wearable devices is expected to be introduced
in the daily clinical setting.
46

Presentation 2
Yoshiharu Kim, Director Emeritus,

Management of PTSD and trauma in
Japan
Yoshiharu Kim
Emeritus Director General
National Institute of Neurology and Psychiatry
National Center of Neurology and Psychiatry
2024.9.5
Research symposium: Mental Health Matters – what are the
policy priorities for Japan?
---ILC-UK and NCNP Japan---

Yoshiharu Kim National Center of Neurology and Psychiatry
COI to be disclosed in connection with this presentation
① Advisor : None
② Shareholding/Profit : None
③ Patent royalty fee ： None
④ Lecture fee : None
⑤ Manuscript Fee : None
⑥ Funded research, joint research expenses : None
⑦ Scholarship donation : None
⑧ Endowed Chair Affiliation : None
⑨ Gifts and other rewards : None

Progress in disaster psychiatric
countermeasures (pre-311)
• Sarin gas attack on the subway (1995)
• Great Hanshin-Awaji Earthquake (1995)
• Hostage-taking at the Peruvian Ambassador's Residence(1996-97)
• Wakayama curry poisoning case (1998)
• Ikeda Elementary School child murder case (2001)
• Health and Labor Science Research Group (1998-2014)
• Specialized training program for PTSD measures (2002)
• Japanese Society for Traumatic Stress Studies (2002)
• Guidelines for Community Mental Health Care Activities in
Disasters (2003)
• Hyogo Psychological Care Center established (2004)
• Basic Law for Victims of Crime (2004)

National Information Center for Post disaster mental
health; In NCNP
③Policy for post-disaster mental heath care centers
As some vicitms may manifest chronic mood and anxiety symptoms after the great East Japan Earthquake, including PTSD
symptoms; 、
1 Aid the establishment of mental health care center in the affected prefectures
2 Establish National Information Center for Post disaster mental health; overall accommodation of mental health care teams ,
provide professional advice, analyse data & information.
3 Monitor the treatment of severe cases of psychiatric disorders precipitated by the disaster trauma, such as PTSD, and contribute to
the improvement of the community mental health in affected sites. Improve the nationwidel preparedness for mental health care
after future disasters.
Aim
Mental Health
Care Center
Affected
prefectures
Common
Database
Common
Database
Advice
Support;
screening
Victims Victims Victims
Date &
Information
・ Date analysis
・ professional
advice
To improve
National
system of
post-disaster
mental health
care &
treatment
Mental Health
Care Center
Mental Health
Care Center
○Advice for mental health care teams
○Information; collection & provision
○Research supervision
○Policy making for mental health care in
affected sites
52
Support;
screening
Support;
screening Advice
Advice

PFA Guide for Field
Workers
• WHO publication
www.who.int
• Collaborative effort:
– World Health Organization
– War Trauma Foundation
– World Vision International
• Endorsed by 24 UN/NGO
international agencies
• Available in several
languages
Q
uickTime™anda
decompressor
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Dissemination of PFA in Japan
• Translation
– National Center of Neurology and
Psychiatry (Kim & Suzuki)
– Plan Japan & Care Miyagi
• TOT
– 9-12, December, 2013 &
8-11, October, 2012, Tokyo Japan
– National Center of Neurology and
Psychiatry & Global Health Institute,
UN University
– War Trauma Foundation
• Collaboration & 1 day training
– Ministry of Health, Labor and Welfare
– Ministry of Foreign Affaires
– Ministry of Police
– Japanese Self Defense Force
– National Institute of Public Health
– Japanese Association of Clinical
Psychotherapy
– Japanese Association of Primary Care
Medicine
– Disaster Mental Assistant Teams
– University Education of Psychology
Yoshiharu Kim
Ryoko Ohtaki
Asami Ohnuma

The Flow of the TCOM Study
T1 (Baseline) (n = 300)
Eligible Participants (n = 344)
Refused
(n = 44)
T2 (1 Month) (n = 190)
Newly admitted patients due to MVAs (n = 886)
Ineligible Participants (n
=386)
≧69 years old (n = 62),
≦18 years old (n = 134)
Head injury (n = 115)
Decreased cognitive functions (n = 7)
Psychiatric disorders (n = 13)
Impaired physical function (n = 6)
Unable to communicate in Japanese (n
= 9)
Severe psychiatric symptoms (n = 4)
Outdwellers (n = 36)
NA (n = 156)
Died (n = 76)
Discharged/
Transferred (n = 80)
T3 (3 Month) (n = 155)
T4 (6 Month) (n = 139)
T5 (9 Month) (n = 133)
T6 (1.5 Years) (n = 119)
T7 (3 Years) (n = 103~)

A month after an accident - 30% of patients
were suffering from mental illness
Major Mental Illness Comorbidity
Diagnosis N PTSD Partial Major Minor
PTSD Depression Depressive
Disorder
PTSD 8 -- -- 7 0
Partial PTSD※ 16 -- -- 5 5
Major Depression 16 7 5 -- --
Minor Depressive Disorder 7 0 5 -- --
Alcohol-related Disorders 3 1 1 1 1
Other Disorder 3 1 1 2 0
Some Disorder 31
※Partial PTSD diagnosis was made if two diagnostic criteria in each B, C, D category were met. For an
interview, Mini-International Neuropsychiatric Interview (MINI) and Clinician Administered PTSD Scale
(CAPS) were used.
（ n=100)
Matsuoka Y, Nishi D….KimY. Crit Care Med, 2008

Acute and chronic radiological effects
• Deterministic Effects
– Acute, hemopoietic, gastrointestinal, central nervous, intensity, high
dose, threshold(+), severity correlates with the dose
• Stochastic Effects
– Chronic, cancer and genetic defects, time course, low dose, threshold(-),
frequency correlates with time course ? : much controversy
• No inhabitant has been yet confirmed to suffer from acute and
deterministic radiological effects, except those who worked
within the power plant

Table 1. Characteristics of the groups (Demographics)
Sample (n=347) Control (n=288) Both groups
high vs. low risk
Agea
66.3 ( 6.7) 70.3 (6.4) <0.001 <0.01
Sex (male)b
131 (37.8) 104 (36.1) N.S. N.S.
Smoking (yes)b
54 (15.6) 42 (14.6) N.S. N.S.
Drinking (yes)b
147 (42.4) 116 (40.3) N.S. N.S.
Years of educationa
9.4 ( 2.4) 10.0 (2.5) <0.001 <0.05
Employment historyb
Office worker/civil servant 91 (26.2) 84 (29.2) N.S. N.S.
Farmer/fishery 132 (38.0) 102 (35.4) N.S. <0.05
Industry worker 42 (12.1) 37 (12.8) N.S. N.S.
Self-employed 59 (17.0) 39 (13.5) N.S. N.S.
Others 22 ( 6.3) 30 (10.4) N.S. N.S.
Never employed 39 (11.2) 26 (9.0) N.S. N.S.
# of family members living witha
3.2 ( 1.7) 3.6 (2.1) N.S. <0.05
# of non-atomic traumatic eventsa
4.0 ( 2.1) 4.1 (2.0) N.S. <0.01
Loss of spouse/ relative within
3°due to atomic bombb
160 (46.1) 67 (23.3) <0.001 <0.001

Table 1. Cont’d
Characteristics of the groups (Physical & mental health findings)
Sample
(n=347)
Control (n=288) Both groups
high vs. low risk
Physical health findingb
Presence of physical disease
(past 6mo.)
267 (76.9) 223 (77.4) N.S. <0.01
Mental health findings (GHQ28)
High risksb,d
255 (73.5) 114 (39.6) <0.001
Total scorea
10.6 (5.7 ) 6.5 (5.4 ) <0.001
Physical 4.2 (2.0 ) 2.4 (2.0 ) <0.001
Social 1.9 (1.8 ) 1.1 (1.4 ) <0.001
Depressive 1.0 (1.6 ) 0.6 (1.5 ) <0.001
Anxious 3.5 (2.0 ) 2.3 (1.8 ) <0.001

correct knowledge on atomic bomb
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Exp
Cont

Table 2. Contribution of variables to poorer mental health
Adjusted odds ratio 95% CI p
Sample groupb
5.26 2.56 11.11 <0.001
Age 0.98 0.93 1.04 N.S.
# of family members living with 0.91 0.76 1.10 N.S.
Years of education 1.06 0.90 1.24 N.S.
Job history of farmer/ fishery 2.11 0.95 4.66 N.S.
Loss of spouse/ relative within 3°due to
atomic bomb
1.75 0.89 3.44 N.S.
Presence of physical disease within 6 mo. b
1.77 0.82 3.80 N.S.
# of non-atomic traumatic events 1.18 0.99 1.41 N.S.
Erroneous knowledge on radiationc
Radioactivity is different from
lightening
2.14 1.05 4.33 <0.05
Radioactivity decreases over time 1.94 0.85 4.41 N.S.
Natural exposure to radiation occurs 2.37 1.16 4.84 <0.05

Nagasaki PTSD Project (Research Project on the Psychological Effects of A-bomb Survivors)
PTSD, depression, panic disorder, insomnia,
alcoholism, etc.
complications (in an illness)
Diseases, etc. for which benefits are provided
Angina pectoris, myocardial infarction, arrhythmia,
essential hypertension, asthma, chronic gastritis,
arthritis, chronic rheumatoid arthritis, diabetes,
hyperthyroidism, allergic rhinitis, menopausal disorders,
etc.
In response to the report of the "Study Group on the Report on the Testimonies from Undesignated Areas Exposed to the Atomic
Bombings" (August 2001), which reported that the A-bomb experience had a negative impact on mental health, medical expenses
are paid for mental illness (PTSD, etc.) and its complications caused by the A-bomb experience in the Special Zone for Type 2
Health Examination (FY 2002-) *Number of eligible persons at the end of H28: 6,438 (Nagasaki residents) ～ Number of eligible
persons at the end of H28: 6,438 (Nagasaki Prefecture residents only)
＋
From H30 "Complications of diabetes mellitus
(nephropathy, retinopathy, etc.)" was added.
H30 budget amount
794,621 thousand yen
(795,489 thousand
yen)
uncovered: Cancer, pneumonia, anemia, hyperlipidemia
From the
hypocenter
5km
From the
hypocenter
12km
Type 1 Health
Examination
Special exception
area (S49)
Class 1 Health
Examination
Special Exception
Area (S51)
Second-Class
Health
Examination
Special exception
area (H14)
area exposed
to radiation
from the
atomic bomb
Type 2 Health Examination Special Exception Area
Areas where annual medical examinations are available if
you were living at the time of the atomic bombings
Dementia" was added in FY 2008.
Cerebrovascular Disorders" was added in FY 2009.

Traumatic Experiences and PTSD in Japan
Lifetime prevalence of traumatic experiences and PTSD
in Japan: from the WMH survey
Kawakami et. al, 2014 J Psychiatr Res. 2014 June ; 53: 157-165
Frequency
(%)
戦
争
関
連
身
体
的
暴
行
性
的
暴
行
自
然
災
害
人
為
災
害
事
故
生
命
に
関
わ
る
病
気
ト
ラ
ウ
マ
的
死
別
そ
の
他
0
5
10
15
20
25
Series1
Lifetime prevalence
PTSD 1.3%
Panic disorder 1.0%
PTSD is common
mental illness.
Traumatic experience of some kind 60.7
(past 12 months)
PTSD 0.7
Panic disorder 0.5

Brain pathology of PTSD
Yehuda et al. 2015. Nature Reviews Disease Primers
• (left panel) Typically, PTSD is manifested by re-experiencing and hyperarousal,
with amygdala/island hyperactivity and showing low activity in the medial
frontal lobe
• (right panel) Some PTSD patients show symptoms of dissociation and
Brain pathology related to decreased emotional
suppression and increased emotional suppression
in PTSD

Fear response
Helplessness
Phobias, panic
PTSD
dissociative disorder

psychologica
l support
Support and stand
by the person's
ability to get back
on his/her feet.
Respect for
natural recovery.
Trained.
Supporter
Mental Health Care: stepwise model
Level 1
guide
Recovery Skills
Coach. Improving
conditions and
preventing
chronicity.
Guided by.
supporter
Level 2 Level 3
therapeuti
c
interventio
ni
beyond the
control of the
individual
help (a person)
out of the way
Medical care,
strong crisis
intervention
outreach
Medical

Approved treatment of PTSD.
1. drug therapy
Sertraline, Paroxetine
2. Psychotherapy
Prolonged Exposure Therapy

CME plus extras, slide 73
Functional Neuroanatomy of Traumatic Stress
Amygdala
Hippocampus
Locus Coeruleus
Pituitary
Hypothalamus
Orbitofrontal
Cortex
Cerebral Cortex
Adrenal
CRF
ACTH
NE
Extinction to fear
through amygdala
inhibition
Long-term storage of
traumatic memories
Conditioned fear
Cortisol
Output to
cardiovascular
system
Prefrontal
Cortex
Parietal Cortex
Stress
Attention and vigilance-fear behavior
Dose response effect on metabolism
Glutamate
Revised, Bremner D. Neurobiology of PTSD. In:Posttraumatic Stress Disorder, eds. Saigh & Bremner, 1999, Allyn

Paroxetine in PTSD
*p<0.001; †
Adjusted for center and covariates; GlaxoSmithKline, 2000—Study 651 (Data on file)
0 4 8 12
CAPS-2 Total Score
Placebo
Paroxetine 20 mg
Paroxetine 40 mg
Weeks
Adjusted
Mean
Change
from
Baseline
(ITT/LOCF)
†
0
-10
-20
-30
-40
*
*
*
*
*
*

Confidential
0 4 8 12 24 36 52
-35
-30
-25
-20
-15
-10
-5
0
Clinical evaluation of paroxetine in PTSD:
52 week, open-label study in Japan
reduction
in
CAPS
score
weeks
Kim Y et al. Clinical evaluation of paroxetine in post-traumatic stress disorder
(PTSD): 52-week, non-comparative open-label study for clinical use experience.
PCN 2008 62:646-52

Childhood Experiences
Underlie Chronic
Depression
Well-being

Childhood Experiences
Underlie Later
Suicide
1
0
3
2
4+
Death

mental disorder
gene
Brain
function/structure
Immunology/
Endocrinology
Cognitive
function/biases/personality traits
coping behavior
resilience
No
No
No
Etiological Models of
Mental Illness
Childhood
Life
Events
gene expression
Epigenetic
changes
Adult
Stress
vulnerability
intermediate
phenotype
Trauma
(Prepared by Hiroaki Hori)

History of Establishment of Diagnostic
Criteria for Complex PTSD
● Until formal diagnostic criteria
● PTSD diagnosis was first proposed in DSM-III (1980)
● (The core model is the reaction that occurs in adult soldiers who have experienced combat, such
as the Vietnam War.)
● In cases of child abuse and prolonged incarceration in incarceration camps, it has been noted
that severe effects on emotional control, interpersonal relationships, and sense of self can occur
● Complex PTSD" Herman; different from ICD-11 complex PTSD
Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Traumatic Stress, 1992.
● Extreme Stress Disorder Not Otherwise Specified (DESNOS)." van der Kolk
Disorders of Extreme Stress: The Empirical Foundation. J Traumatic Stress, 2005
● ICD-11 (International Classification of Diseases, 11th Revision) 2018
● Complex PTSD was first adopted as an official diagnostic criterion.
● First major revision of ICD in nearly 30 years
● Emphasis in the revision was placed on having clinical utility, focusing on core symptoms, and
international applicability (Keeley et al., 2016).

ICD-11 Complex PTSD (CPTSD) https://icd.who.int/en
Event Criteria:
Definition "Extremely threatening and frightening event" = same as PTSD event criteria
Description "Most commonly, a sustained or recurring event from which escape is difficult or
impossible, such as (e.g., torture, childhood sexual or physical abuse, domestic violence, prisoner of
war, civil war (genocide) experiences, prostitution/trafficking, sustained violence)
PTSD symptoms:
Re-experiencing, hyperarousal, and avoidance paralysis symptoms.
Severe and persistent DSO symptoms (difficulty in self-organization)
– Affective dysregulation (AD): excess or lack of emotional control
– Negative self-concept (NSC): belief that one is weak, defeated, and unworthy
– Interpersonal difficultiesDisturbed relationship (DR): difficulty in maintaining interpersonal relationships
and intimacy with others
Common with PTSD
Specific to CPTSD: DSO
symptoms
Behavior Division, National Institute of Mental Health, National
Center of Neurology and Psychiatry
Fear response + Helplessness
Helplessness, Social defeat

Investigating the Efficacy of STAIR Narrative
Therapy for Complex PTSD in Japan
Yoshiharu Kim, Madoka Niwa
The content of this presentation is based on the following paper published online on June 8
Niwa M, Kato T, ... Kim Y. (2022) Skills Training in Affective and Interpersonal Regulation Narrative Therapy for
Women with ICD-11 Complex European Journal of Psychotraumatology. doi: 10.1080/20008198.2022.2080933
National Center of Neurology and Psychiatry
Tomoko Kato, Ryoko Otaki, Rieko Otomo, and Kaesuke Suga,
Mayumi Sugawara, Mizuki Narita, Hiroaki Hori, Toshiko Kamo,

Results and Discussion (treatment outcome: primary endpoint)
• CPTSD severity significantly improved 3 months after treatment (p < .001)
• Effect size large (d=1.69 after treatment, d=2.14 after 3 months)
• CPTSD diagnosis: 6 of 7 no longer meet diagnostic criteria for CPTSD (and
PTSD) on ITI after treatment, all 7 after 3 months
ITI
Score
Rang
e
Point of measurement
Effect size d
(completers)
Pre (n = 10) Post (n = 7) FU (n = 7) Pre to Post Pre to FU
CPTSD Severity (0-48) 30.60 (6.90) 15.43 (9.74) ** 13.29 (8.20) ** 1.69 2.14
PTSD Severity (0-24) 13.80 (4.18) 6.86 (6.26) ** 5.14 (4.34) ** 1.30 1.96
DSO Severity (0-24) 16.80 (3.79) 8.57 (4.65) ** 8.14 (4.60) ** 1.77 1.88
Table 1 Mean (SD) and effect size of ITI severity scores by time point
Note: Linear mixed model including interrupted cases *p < .05, **p < .01
➡︎Significant improvement in CPTSD symptoms after treatment, maintained
after 3 months
Effect size d
0.2 to small
0.5 to
medium
0.8 to large

scale
Score
Range
Point of measurement
Pre (n = 10) Mid (n = 9) Post (n = 7) FU (n = 7)
CPTSD (ITQ) (0-48) 35.10 (8.99) 28.67 (13.89) 22.00 (14.17) ** 19.71 (14.81) **
PTSD (PDS) (0-51) 31.40 (8.57) 26.33 (14.34) 18.43 (13.59) ** 17.29 (14.42) **
Dissociation (DES-
II)
(0-100) 36.00 (18.85) 25.67 (22.94) 21.89 (26.72) * 15.87 (19.33) **
Emotional
Regulation (DERS)
(36-180) 135.50 (15.75) 121.44 (27.11) 99.00 (25.36) ** 98.86 (25.63) **
Emotional
regulation (NMR)
(25-125) 44.10 (7.19) 58.22 (15.58) * 70.86 (15.96) ** 73.57 (17.15) **
Interpersonal
Relations (IIP-32)
(0-4) 2.18 (0.56) 2.04 (0.49) 1.63 (0.42) * 1.47 (0.28) **
Depression (BDI-II) (0-63) 39.90 (12.37) 34.56 (11.85) 19.57 (12.46) ** 20.14 (16.16) **
State Anxiety (STAI-
S)
(20-80) 44.20 (8.08) 37.67 (10.30) 37.00 (6.88) 40.29 (7.67)
Characteristic
Anxiety (STAI-T)
(20-80) 65.80 (6.91) 65.44 (8.03) 54.86 (9.06) * 54.86 (13.93) *
Quality of life
(WHOQOL26)
(1-5) 2.37 (0.71) 2.58 (0.68) 2.98 (0.46) ** 3.17 (0.67) **
Negative
perception (PTCI)
(36-252) 178.90 (33.02) 167.22 (33.93) 122.14 (44.56) ** 127.71 (54.02) **
Results and Discussion (Treatment Outcomes: Secondary Endpoints)
Table 2 Mean (SD) per time point for each rating scale

Underdiagnosis of PTSD (in Japan)
• Based on a 12-month prevalence of PTSD of 0.7% (standard error of 0.2), we estimate that
there are 700,000 (95% confidence interval 300,000 to 1.1 million) PTSD patients per year
• 7,000 patients come to clinic in the 2020 patient survey.
• According to the National Database of Medical Institution Receipt Information (NDB), the
total number of patients in 2019 was 18,131 (17,662 outpatients and 756 inpatients in
psychiatric beds: with duplicates).
- Department of Public Mental Health and Medical Research. From Mental Health and Welfare
Resources (https://www.ncnp.go.jp/nimh/seisaku/data/)
Stigma against victimization
Lack of reliable assessment or treatment
Trauma focused psychotherapy has high effect size, >1.5,
but needs 90 minituts × 10−20 sessions
SSRIs’ are easy to presbcibe but their effect size < 0.5
• Strong need for robust assessment, new medication with larger
effect size

Current PTSD phase Past PTSD phase
ASD
phase
Severity of the Symptoms
Above Criteria of PTSD
Event
24 hr Urinary Cortisol
NK activity ? ? ?
Time
a
b
a: Yehuda R Am J Psychiatry 1995 b:Laudenslager ML Brain Behav Immun 1998
a

Trauma and Cellular Immunity
Suppression of the cellular immunity
CD3+, CD4+, CD8+ cell
NK cell activity
IL-4, IFN-g
→ existing in the subjects
with past history of PTSD
Kawamura, Kim, Asukai (2002) American Journal of Psychiatry

Registry studies (cross-sectional studies)
Trauma history+.
PTSD+.
Trauma history+.
PTSD-.
healthy control
Brain MRI, cognitive and physiological functions, blood biomarkers, genomics
trauma history specific
• pattern of brain activity
• cognitive-behavioral index
• Gene (expression) pattern
Characteristics of
Conventional
Depression
Diverse
• pattern of brain activity
• cognitive-behavioral index
• Gene (expression) pattern

Indicators to be measured in clinical research
This clinical study will measure the following biomarkers (including genomic)
These markers are essentially used in both cross-sectional and longitudinal studies
cognitive
function
brain image
autonomic
nerves
blood
Cognitive and
physiological indicators
Immune and
inflammatory
systems
•IL-1β
•IL-6
•TNF-alpha
•Interferon-γ
•CRP
HPA system
•Cortisol ACTH DHEA-S
DNA
mRNA
(exhaustive)
microRNA
(exhaustive)

0
50
100
150
200
250
past PTSD control
N=12 N=48
pg/ml
IL- 4
0
500
1000
1500
2000
2500
past PTSD control
N=12 N=48
INF-g
pg/ml
0
50
100
150
past PTSD control
N=12 N=48
pg/10
6
IL- 4/ T cell
500
1000
1500
past PTSD control
N=12 N=48
pg/10
6 IFN-g/ T cell
0
**
** **
**
Comparisons between Past PTSD and healthy Controls
Kawamura, Kim, Asukai (2002) American Journal of Psychiatry

Itoh et al. 2019. modified from J Affect
Disord
Memory Bias in PTSD Patients - Association with BDNF Gene
Val66Met Polymorphism-.
PTSD patients compared to healthy
controls,
Negative memory bias is significant.
Negative memory bias in 46
female PTSD patients and 68
healthy control women
*
p < 0.05,***
p < 0.001 (post test of Kruskal-Wallis test). The dashed asterisk (*
) indicates that the negative
memory bias becomes significantly stronger as the number of Met alleles increases in the group of PTSD patients
(Jonckheere-Terpstra trend test).
BDNF gene in 50 female patients with PTSD and 70 healthy
controls
Comparison of negative memory bias stratified by Val66Met
polymorphism
The more met alleles in PTSD patients, the greater the negative
memory bias. Modified from Hori et al., 2020. Sci Rep
Memory bias: the memory bias of remembering negative or positive information better than emotionally neutral information
Negative
memory
bias
PTSD
sufferer
healthy
controls
p = 0.01 (Mann-Whitney U test)

Childhood Abuse Experiences and Attention Bias Variability:
Association with BDNF Val66Met Polymorphism
Hori et al. 2021. modified from Transl Psychiatry
Met allele of the Val66Met polymorphism is associated with increased attention
bias variability and dose dependence
Attention bias variability is further increased when Met allele holders are
subjected to childhood emotional abuse
Emotional abuse in childhood leads to unstable
attention to negative information in adulthood
A study of 128 healthy adult
women
p = 0.021 (Jonckheere-Terpstra trend test) p = 0.022 (2-way ANOVA)
Attention bias: the bias to pay more attention to negative
or positive information compared to emotionally neutral
information.

Suicidal risk in PTSD ： predictive model
Stepwise multiple regression analysis for suicidal ideation/risk in PTSD patients from CRP rs2794520 and IL6 rs1800796
genotypes, CRP and IL-6 protein levels, age, BMI, smoking, PTSD severity, and comorbid MDD/anxiety disorders.
R-squared
Adjusted
R-squared
Analysis of variance for
regression
B Standardized β t p
Suicidal ideation 0.29 0.25 F = 9.4, p < 0.001
(Constant) (0.95) (6.0) (< 0.001)
CRP rs2794520 -0.34 -0.51 -4.0 < 0.001
Comorbid MDD 0.41 0.36 2.8 0.008
Suicide risk 0.16 0.14 F = 8.0, p = 0.007
(Constant) (2.4) (15.9) (< 0.001)
IL6 rs1800796 -0.47 -0.40 -2.8 0.007
Notes: Suicidal ideation and risk were assessed with BDI-II item-9 and MINI suicide risk weighted score, respectively.
CRP and IL-6 protein levels were included in this model after log-transformation.
Rs2794520 was coded as 0: "CC", 1: "CT", and 2: "TT"; rs1800796 was coded as 0: "CC", 1: "CG", and 2: "GG".
Bold p values represent significant results.
Kawanishi et al., 2023 Brain Behav Immun Health を改変

4 weeks
Forgetting of
fear memory
Recent fear memory
Remote fear memory
4 weeks 〜 4 weeks
Enhancing neurogenesis
10 min
Hippocampus
-dependent state
Forgetting of
fear memory
MEM (50 mg/kg b.w.)
MEM (50 mg/kg b.w.)
1. Contextual fear memory
Model of PTSD
4
weeks
MEM (50 mg/kg b.w.)
SD Test 1
10 days
Test 2
2. Social defeat stress
1) Forgetting of traumatic
memory
2) Improvement of PTSD-like
behaviors

Clinical Trial Outline
Memantine Dose: 5mg /day, increased 5mg every week, until
20mg/day, wit modification due to side-effects, for 12 weeks. The same
protocol of the use for Alzheimer disease.
PTSD patients between 20 and 60 years
old
No specific procedure for
activation of traumatic
memory, as the participants
are spontaneously
confronted to trauma
(Once / Day)
Dose (mg)
※Except for the case which has difficulty to increase the amount.
Trial (Medication) period = 12 weeks
post-treatment
observation period
Informed
Consent
Pre-dose
evaluation
Start
of
dosing
Medical
interview,
etc.
Medical
interview,
etc.
Medical
interview,
etc.
4-week
post-evaluation
8-week
post-evaluation
12-week
post-evaluation
Medical
interview,
etc.
5
10
15
20

Total score Intrusion Avoidance Hyperarousal
0
5
10
15
20
25
30
35 Baseline Endpoint
Baseline 12week
PTSD diagnosis
(+)
n = 10
(+)
n = 4
(-)
n = 6
(b)
Baseline 4 week 8 week 12 week
0
5
10
15
20
25
30
35
40
45
50 PDS total score over time
P1 P2 P3 P4 P5
P6 P7 P8 P10 P13
Baseline Endpoint
(a)
(c)
PDS score
**
**
**
**
Completer analysis (t = 4.3, df = 9, p = 0.002, d = 1.35)
Hori, Kim et al., 2021 Eur J Psychotraumatol

Toward additional indications: RCT
No need to talk about trauma!

Underdiagnosis of PTSD (in Japan)
• Based on a 12-month prevalence of PTSD of 0.7% (standard error of 0.2), we estimate that there are
700,000 (95% confidence interval 300,000 to 1.1 million) PTSD patients per year
• 7,000 patients come to clinic in the 2020 patient survey.
• According to the National Database of Medical Institution Receipt Information (NDB), the total number of
patients in 2019 was 18,131 (17,662 outpatients and 756 inpatients in psychiatric beds: with duplicates).
- Department of Public Mental Health and Medical Research. From Mental Health and Welfare Resources (
https://www.ncnp.go.jp/nimh/seisaku/data/)
Stigma against victimization
Lack of reliable assessment or treatment
Trauma focused psychotherapy has high effect size, >1.5,
but needs 90 minituts × 10−20 sessions
SSRIs’ are easy to presbcibe but their effect size < 0.5
• Strong need for robust assessment, new medication with
larger effect size

PDE4B mRNA expression 、 DNA methylation and PTSD symptoms
PDE4B mRNA expression, re-experience symptoms, PTSD diagnosis, level of anxiety, DNA methylation in PTSD
patients
→ PDE4B mRNA
expression, lower in
PTSD patients than in
healthy volunteers,
showed negative and
significant relation with
re-experience and trait
anxiety.
Hori et al., Mol Psychiatry (in press)
A background factor
could be the DAN
methylation

Transcriptome analysis of PTSD patients and PTSD model mouse
• Through comparison of gene expression between PTSD patients and PTSD
mouse models we newly found phosphodiesterase 4B (PDE4B), a negative
regulator of the cAMP signaling pathway, as a gene with decreased
expression in common between the two groups
• In PTSD patients, the lower the expression level of PDE4B, i.e., the higher
the activation of the cAMP signaling pathway, the more severe the re-
experiencing symptoms
• The association between PTSD re-experiencing symptoms and cAMP
signaling pathway hyperactivation opens the way for the development of
new diagnostic and therapeutic methods for PTSD

Thank you very much for your
attention.

Presentation 3
Zui Narita, Chief, Department of Behavioral
Medicine, National Institute of Mental
Health

Schizophrenia: a public
health perspective
Zui C. Narita, MD, PhD, MHS
Department of Behavioral Medicine
NIMH Japan

“Dementia praecox” to “schizophrenia”
(1908)
• Was considered as earlier mental
deterioration.
• Dr. Eugen Bleuler introduced
“schizophrenia.”
-Splitting of integration of thoughts.
Fusar-Poli P, Politi P. Paul Eugen Bleuler and the birth of schizophrenia (1908). Am
J Psychiatry. 2008 Nov;165(11):1407. doi: 10.1176/appi.ajp.2008.08050714. PMID:
18981075.

Reischauer Incident (1964)
• U.S. Ambassador Edwin O. Reischauer
stabbed by a young Japanese man with
schizophrenia.
• Negative and stigmatized perception
towards patients with mental disorders.
• 1965 revision of the Mental Hygiene
Law
-Emergency Admission System ( 緊措 )
Image: Reischauer Institute of Japanese Studies

Psychiatric hospitalization
Number of psych beds
per 1k people
Average length of stay
(d)
Belgium 1.7 10.1
France 0.9 5.8
Germany 1.3 24.2
Italy 0.1 13.9
Japan 2.7 285
Korea 0.9 124.9
Switzerland 0.9 29.4
UK 0.5 42.3 https://www.mhlw.go.jp/content/12200000/000462293.pdf

“Mind-split disease” to “integration
disorder” in Japan (2002)
• Dr. Yoshiharu Kim
• Reduce stigma and reflect a more modern
understanding of the disorder.
• Especially important in IC as many patients
were not informed of the diagnosis.
-Motivating the treatment.
Image: National Institute of Mental Health 2022

Schizophrenia: Prevalence
• Empirical knowledge: 1%
• World: 0.33% to 0.75%
• US: 0.25% and 0.64%
• Japan: 0.7%
• Quite susceptible to measurement bias, so the actual prevalence
might be even higher. Adobe Stock
https://www.nimh.nih.gov/health/statistics/schizophreniahttps://www.mhlw.go.jp/
kokoro/youth/stress/know/know_03.html

Heritability of schizophrenia in Asians,
age, sex, SES-adjusted
Chou IJ, Kuo CF, Huang YS, Grainge MJ, Valdes AM, See LC, Yu KH, Luo SF, Huang LS, Tseng WY, Zhang W, Doherty M. Familial Aggregation and Heritability of
Schizophrenia and Co-aggregation of Psychiatric Illnesses in Affected Families. Schizophr Bull. 2017 Sep 1;43(5):1070-1078. doi: 10.1093/schbul/sbw159. PMID:
27872260; PMCID: PMC5581894.

Heritability of schizophrenia in Asians,
age, sex, SES-adjusted
Chou IJ, Kuo CF, Huang YS, Grainge MJ, Valdes AM, See LC, Yu KH, Luo SF, Huang LS, Tseng WY, Zhang W, Doherty M. Familial Aggregation and Heritability of
Schizophrenia and Co-aggregation of Psychiatric Illnesses in Affected Families. Schizophr Bull. 2017 Sep 1;43(5):1070-1078. doi: 10.1093/schbul/sbw159. PMID:
27872260; PMCID: PMC5581894.
• If the heritability is not that high, where is the rest coming from?

Why do we always have schizophrenia?
• Ancient Egyptian texts (BC 1550)
• Herodotus’s The Histories (BC 500)
• Why doesn’t the prevalence shrink
over time?
https://mru.ink/ja/the-ebers-papyrus-ancient-egypt/
https://ja.m.wikipedia.org/wiki/%E3%83%95%E3%82%A1%E3%82%A4%E3%83%AB:Herodotus_-_Historiae,_1908_-
_2734989_pagina1.jpg

Schizophrenia: Development
Image: Ministry of Land, Infrastructure, Transport and Tourism
Psychotic experiences (PEs)
Schizophreni
a
Genes Environment
s
Diminished wellbeing
Suicidal outcomes
What clinicians see
Prevention should
happen upstream

PEs: Overview
• Hallucination-like or delusion-like symptoms.
• Potential precursor to schizophrenia.
• Lesser intensity, persistence, or impairment than those of
schizophrenia.
Linscott RJ, van Os J. An updated and conservative systematic review and meta-analysis of
epidemiological evidence on psychotic experiences in children and adults: on the pathway
from proneness to persistence to dimensional expression across mental disorders. Psychol
Med. 2013 Jun;43(6):1133-49. doi: 10.1017/S0033291712001626. Epub 2012 Jul 31. PMID:
22850401.

PEs: Prevalence
Narita Z, Hazumi M, Kataoka M, Usuda K, Nishi D. Association between discrimination and subsequent psychotic experiences in
patients with COVID-19: A cohort study. Schizophr Res. 2024 May;267:107-112. doi: 10.1016/j.schres.2024.03.027. Epub 2024 Mar 25.
PMID: 38531157.
Narita Z, Wilcox HC, DeVylder J. Psychotic experiences and suicidal outcomes in a general population sample. Schizophr Res. 2020

PEs: Prevalence in adults
McGrath JJ, Saha S, Al-Hamzawi A, Alonso J, Bromet EJ, Bruffaerts R, Caldas-de-
Almeida JM, Chiu WT, de Jonge P, Fayyad J, Florescu S, Gureje O, Haro JM, Hu C,
Kovess-Masfety V, Lepine JP, Lim CC, Mora ME, Navarro-Mateu F, Ochoa S,
Sampson N, Scott K, Viana MC, Kessler RC. Psychotic Experiences in the General
Population: A Cross-National Analysis Based on 31,261 Respondents From 18
Countries. JAMA Psychiatry. 2015 Jul;72(7):697-705. doi:
10.1001/jamapsychiatry.2015.0575. PMID: 26018466; PMCID: PMC5120396.

PEs: Prevalence in adolescents
Kelleher I, Connor D, Clarke MC, Devlin N, Harley M, Cannon M. Prevalence of
psychotic symptoms in childhood and adolescence: a systematic review and
meta-analysis of population-based studies. Psychol Med. 2012 Sep;42(9):1857-
63. doi: 10.1017/S0033291711002960. Epub 2012 Jan 9. PMID: 22225730.

PEs: Trajectory examples of 3
individuals.
van Os J, Linscott RJ, Myin-Germeys I, Delespaul P, Krabbendam L. A systematic
review and meta-analysis of the psychosis continuum: evidence for a psychosis
proneness-persistence-impairment model of psychotic disorder. Psychol Med. 2009
Feb;39(2):179-95. doi: 10.1017/S0033291708003814. Epub 2008 Jul 8. PMID:
PEs persist as a psychotic
disorder in certain people

PEs: Social context
Please PubMed me for more papers.

Policy perspective: Crucial factors for
PEs from what I have published.
• Race
• Gender nonconformity
-Not modifiable.
• Loneliness
• Bullying victimization
• Relationship with others
• Physical injuries
• Childhood maltreatment
• Neighborhood environments
• Problematic internet use
• Discrimination
• Social withdrawal (hikikomori)
-Might be a target of intervention.

Summary
• In Japan, patients with schizophrenia have historically been
stigmatized.
• The heritability of schizophrenia is not as high as commonly
believed.
• Prevention should happen in the upstream like PEs.
• From a policy perspective, modifiable social/environmental
factors are potential targets.

Audience discussion
2.00pm – 2.20pm

Coffee break
2.20pm – 2.30pm

Session 2
What lessons can be learnt from Japan, what
works well, and how do we best manage
mental health across the life course?

Presentation 1
Jun Saito, Senior Research Fellow,
Japan Centre for Economic Research

Importance of Preserving Mental Health for the
Japanese Economy
ILC Research Symposium:
Mental Health Matters-what are the policy priorities for Japan?
Held on 5th
September 2024
At National Institute of Mental Health, Tokyo
Japan Center for Economic Research
Senior Research Fellow
Jun Saito

Today’s Plan
• Mental health situation in Japan
• Causes of mental disorders
• Economic consequences of mental disorders
• Importance of preserving mental health for the economy
• Measures to preserve mental health in Japan
• Remaining task to achieve the goal
128

Mental Health Situation in Japan

Patients with Mental Disorder
130
(Note) * Excluding Fukushima and a part of Miyagi prefectures.
** Estimation method has been revised.
(Data Source) Patient Survey, Ministry of Health, Labour and Welfare,

Claims for Industrial Accident Insurance by
Persons with Mental Disorder
Total (Of Which) Suicide
131
(Data Source) Ministry of Health, Labour and Welfare

Number of Outpatients by Age
132
(Data Source) Comprehensive Survey of Living Conditions. Ministry of Health, Labour and Welfare

Causes of Mental Disorder
• Having to work long hours
– Working more than desired (Kuroda and Yamamoto, 2014)
– Working more than 50 hours a week (Kuroda and Yamamoto, 2016)
• Having peers who work long hours (Kurokawa et al., 2017)
• Having a demanding job with an inflexible workstyle (Kuroda and
Yamamoto, 2016)
134

Causes of Mental Disorder
• Working under a boss who is not capable and is not good at
communicating (Kuroda and Yamamoto, 2018)
• Being a non-regular worker against one’s will (Takahashi et al, 2014)
• Having to lose a job against one’s will
– Involuntary unemployment (Takahashi et al, 2014)
– Mandatory retirement (Okamoto et al., 2018)
135

Total Working Hours
136
(Data Source) Monthly Labour Survey, Ministry of Health, Labour and Welfare

Number of Employed by
Weekly Working Hours
137
(Data Source) Labour Force Survey, Ministry of Internal Affairs and Communications

Share of Non-Regular Workers
138
(Percent)
(Data source) Labour Force Survey, Ministry of General Affairs and Communications

Non-Regular Workers Who are Working Unwillingly
139

Unemployed Who Quitted a Job Involuntary
140

Reasons for Strong Anxiety, Anguish, and Stress Among
Workers (2020)
141
There are reasons to feel strong
anxiety, anguish, or stress
(Data Source) Special Survey on Industrial Safety and Health, Ministry of Health, Labour and Welfare

Economic Consequences of Mental
Disorders

Economic Consequences
• Increase in health-care cost
– Become an outpatient
– Become an inpatient
• Increase in welfare benefit and public service
– Public support of medical payments paid by persons with disabilities
– Disability pension system
– Public assistance program
143

• Decline in employment rate
– Detached from the labour market (early retirement) (Inui et al., 2019)
– Become unemployed
– Commit suicide
• Reduction in working hours
– Take a sick leave (absenteeism) (Inui et al., 2019)
• Decline in productivity
– Work with health problems (presenteeism) (Suzuki et al., 2015)
– Worsen firm performance (Wada et al., 2007; Kuroda and Yamamoto, 2016)
144

• Increase in family care-givers (including young carers)
– Decline in productivity (schoolwork)
– Reducing working hours (study hours)
– Quitting jobs (give up schooling)
• Difficulty in mobilizing financial assets
– Financial institutions find difficulty in confirming transactions
• Increased interest in financial gerontology
145

Cost for the Japanese Economy
• Cost of absenteeism and presenteeism is large in the case of
mental disorders. (Keio University, 2011; Juntendo University, 2011; Okumura and Higuchi, 2011;
Wada et al, 2013)
• Cost of presenteeism is larger than the cost of health-care and
medicine, and absenteeism. Mental disorder is one of the
chronic illness with the highest total cost. (Nagata et al., 2018)
• Long-term cost of loss of life is huge.(Juntendo University, 2011)
146

Share of Mental Disorder in National Medical Care
Expenditure by Age
147
(Age)

Workers Who Leave their Jobs for Caregiving to the Elderly
and the Sick
148
(Age)
(Data Source) Employment Status Survey, Ministry of Internal Affairs and Communications

Young Carers
Percent of the Total Care Given to Persons with Mental Disorders
149
(Note) Survey conducted during the period between December 2020 and February 2021.
(Data Source) Mitsubishi UFJ Research and Consulting

Financial Assets and Liabilities by Age of the Head of
Households (2019)
150
(Data Source) Ministry of Internal Affairs and Communications

Importance of Preserving Mental Health for
the Japanese Economy

Significance for the Economy
• Aging and shrinking of the population is expected to proceed
further in Japan.
• Aging and shrinking of the population will:
– Lower economic growth,
– Worsen the sustainability of the social security system, and
– Worsen the sustainability of the fiscal situation.
152

Population Projection
153
(Note) Projection is for the medium fertility/medium mortality scenario.
（ Data Source) National Institute of Population and Social Security Research, Population Projection for Japan, April 2023.

Aging Rate
154
Lon-term reference
projection
(Note) Projection is for the medium fertility/medium mortality scenario.
（ Data Source) National Institute of Population and Social Security Research, Population Projection for Japan, April 2023.

Potential GDP Growth Rate
155
(Data Source) Cabinet Office

Total Debt of the Central and Local Governments
156
(Data Source) Cabinet Office
Projection

Measures to Preserve Mental Health in
Japan

Measures to Preserve Mental Health
• Obligate employers to strengthen health management
– Amendment of Industrial Safety and Health Act
• Introducing stress check (2015).
• Requiring employers to comprehend the working hours of their employees
(2019).
• Providing their employees opportunities to consult with doctors and take
necessary actions to maintain mental health (2006).
158

– Amendment of Labour Standards Act
• Capping overtime working hours at 45 hours a month, 360 hours a year. Even
under special condition where both employers and employees agree,
overtime working hours must be under 720 hours a year, less than 100 hours
a months, and the average for multiple months needs to be less than 80 hours
(2019/2020).
159

– Amendment of Labour Standards Act
• Raising extra pay rate for overtime exceeding 60 hours a month to 50 percent
from 25 percent (2010/2023).
• More than 5 days of annual paid leave must be taken by the workers who are
eligible to more than 10 days of annual paid leave (2019).
160

• Introduce incentives for the employers to preserve mental
health of their workers
– Health and Productivity Management Initiative (METI) asks firms to
recognize that cost of health management is an investment for raising
productivity in the future (2014).
– Rewards outstanding firms engaged in the program by recognizing
them as “Certified Outstanding Organizations” (2016).
161

Measures to Support (Re)Employment
• Support mentally handicapped to get a job
– Provide information, advice, and assistance at job placement offices (Hello-
Work) and regional vocational centres for persons with disabilities.
• Provide firms with financial incentives to hire mentally handicapped
– Provide subsidies to the employers for hiring and training the handicapped,
and for appointing assistants at the workplace.
• Promote Rework (return to work)programs
– Provide rehabilitation programs to the mentally handicapped who are on
leave from work.
162

Number of Employed by
Weekly Working Hours
163
(Data Source) Labour Force Survey, Ministry of Health, Labour and Welfare

Acquisition Rate of Annual Paid Leave
164

Job Placement of Mentally Handicapped
165

Limitation of the Measures
• Raising extra pay for overtime work may incentivize workers to work
longer hours.
• Regulation on working hours still has exceptions which allows long
working hours.
• Regulation on working hours may intensify job density (or encourage
take-home work) and increase pressure on mental health.
• Raising cost of health management may encourage firms to hire
more non-regular workers who are not subject to health
management of the firms.
166

Remaining Tasks to Achieve
the Goal

Remaining Task to Achieve the Goal
• Long working hours can be considered as an essential element of
the Japanese employment system consisting of lifetime employment
and seniority-based wage system.
– Since the firms have to maintain employment and basic pay even in
recessions, they regard overtime working hours as adjustment factors of
labour cost; increasing them in expansions and reducing them in recessions
(Kuroda and Yamamoto, 2011).
• It implies that long working hours may be difficult to get rid of
altogether unless the Japanese employment system itself is
reformed.
168

Overtime Working Hours of
Full-Time Workers
169
(Note) Shadows show recessions.
(Data Source) Monthly Labour Survey, Ministry of Health, Labour and Welfare

Thank you for your attention!
Japan Center for Economic Research
Senior Research Fellow
Jun Saito

Presentation 2
Favour Omileke, Project Specialist,
Health and Global Policy Institute

ILC RESEARCH SYMPOSIUM
Mental Health Matters
September 5th
2024
Favour Omileke
Project Specialist (HGPI)
• Confidential (Reproducing all or any part of the contents is prohibited without the author's permission).
• Opinions expressed here do not represent the views of Health and Global Policy Institute as an organization.

173
• Current situation regarding Mental Healthcare in Japan
• Current Challenges
• What Japan has to offer to other countries
• What Japan can learn from other countries
Overview

174
Historical Background to Mental Health in Japan
Home Confinement
(1900-1950)
Hospitalization
(1950-2004)
1950: Mental Hygiene Act
1987: Mental Health Act Enacted
Community-Centered
Care (2004-Present)
2004: Vision for Reform of Mental Health
and Welfare
2022: Act on Mental Health and Welfare
2022: Act on Mental Health and Welfare
Aims: promote health and well-being; support individuals with mental illness; facilitate
access to mental health services
Key Actions:
Enhanced mental health services
Integration of mental health and general healthcare
Crisis management and suicide prevention
Reducing stigma and raising public awareness
Legal and institutional reforms
Kurita et al., 2024

175
Current Situation regarding Mental Health in Japan
Increased prevalence of mental health
disorders
• 4% experience depression (5% in
women/ 3% in men)
• 3-4% experience anxiety disorders
• Decreasing suicide rates (15.5 per
100,000 people)
Low treatment prevalence
• Stigma due to cultural and social
factors
• Systemic issues – fragmentation of
services
• Barriers to accessing treatment
• Awareness and education
Accessibility of mental health services
In rural areas:
• Limited availability of services
• Restricted integration with general healthcare
• Distance to services and limited transportation
• Limited funding
Iwatani et al., 2022; Miura et al., 2023

176
Current Challenges
Stigma and unchanging social attitudes
Insufficient number of mental healthcare professionals
Workplace mental healthcare reform
Youth mental healthcare reform
Digital healthcare lacking especially in rural areas

177
What Japan has to offer to other countries
Management of mental illness resulting from natural disasters
Disaster Psychiatric Assistance Team (DPAT)
Role and function:
•Specialized: specialized team of mental health professionals, including psychiatrists, psychologists,
social workers, and nurses, trained to respond to mental health crises caused by disasters.
•Deployment: DPATs are deployed to disaster areas to provide immediate psychological support,
conduct mental health assessments, and offer interventions. Their role is crucial in addressing both
the psychological and emotional needs of disaster survivors.
Field-operation:
•Crisis Intervention – on-site intervention (trauma therapy and counselling)
•Collaboration with Local Services – local mental health services and communities
•Post-deployment activities -
Debriefing and Support: Feedback and Improvement:
Miura et al., 2023; Kawakami et al., 2012

178
What Japan has to offer to other countries
Holistic Approach to Mental Health
Holistic approach to mental healthcare through the integrated care community-based system (ICCS):
ICCS Main Components:
•Community-based services
•Coordination and collaboration
•Continuity of Care
•Early Detection and Intervention
•Support for Families and Caregivers
•Accessibility and Inclusivity
Implementation
•Local governments actively implementing ICCS by developing and managing community
health and welfare services.
•Public and private sector collaboration
•Case management
•Innovative practices
Ishikawa et al., 2016; Iwatani et al., 2022

179
What Japan can learn from other countries
Sweden: Workplace mental health
programs
• Mental health sickness borne by the
government.
• Strategic mental health initiatives
implemented at work – mental health
budget, mental health leads.
• Focus on holistic well-being at work
• Mental health agenda is embedded in
Swedish firms – prioritized at a senior
level within the company
New Zealand: Youth mental health
programs
• Different mental health associations
that support youth (Mental Health
Foundation, Cure Kids, Healthify)
• Making mental health solutions
relevant and accessible for young
people – Sparx e-therapy
• School based health services
• Provide online courses and training
courses
Hetrick et al., 2017; Jonsdottir er al., 2012

180
What Japan can learn from other countries
Thailand: Integration of traditional and
modern approach
• Embracing global trends and keeping
key cultural aspects to mental
healthcare
• Focus on expanding mental healthcare
and services.
• Nationwide mental healthcare,
accessibility and decentralized
services.
• Integrated community care
• National mental health development
plan (2018 – 2037)
• Promote well-being across all age
groups.
• Enhancing mental health and
psychiatric services.
Singapore: Digital health solutions and
cross-sector collaboration
• Mindline – digital mental health
platform aimed at equipping
individuals with tools, knowledge to
take care of their mental health.
• Digital local connect (DLC) – platform
for service providers.
• Digital Mental Health Connect
Platform (DMHC) – integrate and
coordinate mental health support
services across health and social
service agencies.
• MarCo – emotional support robot
friend online to talk to about mental
health issues.
Ho et al., 2020; Zhang et al., 2020

181
Moving Forward
Long-term hospitalization to community-based care
Focus on improving access to mental health services especially in rural areas
Patient and public involvement, engagement and collaboration in health
policy elaboration, research and development.
Focus on improving workplace mental healthcare and youth mental
healthcare programs
Digital healthcare promotion

183
References
• Hetrick, S. E., Bailey, A. P., Smith, K. E., Malla, A., Mathias, S., Singh, S. P., ... & McGorry, P. D. (2017). Integrated (one stop shop)
‐
youth health care: Best available evidence and future directions. Medical Journal of Australia, 207(S10), S5-S18.
• Ho, C. S., Chee, C. Y., & Ho, R. C. (2020). Mental health strategies to combat the psychological impact of COVID-19 beyond
paranoia and panic. Ann Acad Med Singapore, 49(1), 1-3.
• Ishikawa, H., et al., Lifetime and 12-month prevalence, severity and unmet need for treatment of common mental disorders in
Japan: results from the final dataset of World Mental Health Japan Survey. Epidemiol Psychiatr Sci, 2016. 25(3): p. 217-29.
• Iwatani J., Ito J., Taguchi Y., Akiyama T. Recent Developments in Community-Based Mental Health Care in Japan: A Narrative
Review // Consortium Psychiatricum. - 2022. - Vol. 3. - N. 4. - P. 63-74. doi: 10.17816/CP199
• Jonsdottir, I. H., Rödjer, L., Hadzibajramovic, E., Börjesson, M., & Ahlborg Jr, G. (2010). A prospective study of leisure-time
physical activity and mental health in Swedish health care workers and social insurance officers. Preventive medicine, 51(5),
373-377.
Kido, Y., N. Kawakami, and W.H.O.W.M.H.J.S. Group, Sociodemographic determinants of attitudinal barriers in the use of
mental health services in Japan: findings from the World Mental Health Japan Survey 2002-2006. Psychiatry Clin Neurosci,
2013. 67(2): p. 101-9.
Umeda, M., N. Kawakami, and G. World Mental Health Japan Survey, Association of childhood family environments with the
risk of social withdrawal ('hikikomori') in the community population in Japan. Psychiatry Clin Neurosci, 2012. 66(2): p. 121-9.
Kawakami, N., et al., Early-life mental disorders and adult household income in the World Mental Health Surveys. Biol
Psychiatry, 2012. 72(3): p. 228-37.
• Weng JH, Hu Y, Heaukulani C, Tan C, Chang JK, Phang YS, Rajendram P, Tan WM, Loke WC, Morris RJT Mental Wellness Self-
Care in Singapore With mindline.sg: A Tutorial on the Development of a Digital Mental Health Platform for Behavior Change J
Med Internet Res 2024;26:e44443
• Zhang, Z., Sun, K., Jatchavala, C., Koh, J., Chia, Y., Bose, J., ... & Ho, R. (2020). Overview of stigma against psychiatric illnesses
and advancements of anti-stigma activities in six Asian societies. International journal of environmental research and public
health, 17(1), 280.

Presentation 3
Ryoma Kayano, Technical Officer,
WHO Centre for Health Development

NCNP & ILC research symposium
Ryoma Kayano
Technical Officer
WHO Centre for Health Development
WHO Kobe Centre’s mental
health research in collaboration
with Japanese experts

186 |
WHO Centre for Health Development (WHO Kobe Centre):
An outposted office of WHO Headquarters (HQ)
HQ department with a mandate
for policy research
To conduct research and synthesize evidence
about health systems and innovations, particularly
in light of achieving Universal Health Coverage in
the context of population ageing, and Health
Emergency and Disaster Risk Management
(Health EDRM)

187 |
WHO Kobe Centre’s mandate on local engagement
Uniquely funded by local municipalities
Global mandate as HQ department and local mandate for host
municipalities and communities
Exchange evidence and knowledge between Japan and other
regions and countries
Promote research collaboration between local and global
research institutes

188 |
Relevant research topics for
global and local research collaboration
Ageing and dementia Health emergency and disaster
risk management (Health EDRM)

Global Ageing
2015
2020
2025
2030
2035
2040
2045
2050
Source: WHO

NCD Epidemic
Heart disease
Cancer
Lung diseases
Diabetes
Tobacco Use
Unhealthy Diet
Lack of Physical
Exercise
Harmful use of Alcohol

191 |
Expanding population with dementia
Source: WHO Infographic 20 September 2017

192 |
Huge economic and social burden
Source: WHO Infographic 20 September 2017

193 |
Situation in Japan
Dementia: 4 million / MCI: 4 million(1/4 of 65+ population)
Total economic impact : 145 Billion USD
－ Medical cost: 20 Billion USD
－ Social sector cost 65 Billion USD
(institution : 30 Billion USD, home-based : 35 Billion USD)
－ Informal care cost 60 Billion USD
Expected to be more than 250 Billion USD in 2025
Source: MHLW report on dementia SBD 2015

195 |
Modifiable Risk
Factors of Dementia
Early life less education (9%)
Middle life hearing loss (8%), hypertension
(2%), obesity (1%)
Late life smoking (5%), depression (4%),
physical inactivity (3%), social isolation (2%),
diabetes (1%)
Source: the Lancet Commission for Dementia
prevention, intervention, and care, 2017

196 |
Global Action Plan on the Public Health Response to
Dementia (2017 WHA)
7 Action Areas
1. Dementia as a public health priority
2. Dementia awareness and friendliness
3. Dementia risk reduction
4. Dementia Diagnosis, treatment and support
5. Support for dementia carers
6. Information systems for dementia
7. Dementia research and innovation

Kobe Dementia Project
Devising New Strategies to Strengthen Health Systems
Kobe University Hospital
Collaborative Research of Kobe Univ., WHO and FBRI*,
with supports from Kobe City
FBRI* : Foundation for Biomedical
Research & Innovation

198 |
What are the gaps?
Actual local model and good practice for implementation of the global action
plan including early detection and prevention (correspond to action area 3
(risk reduction) and 4(diagnosis)).
This research project aims at proposing a successful local model in a city
with 1.6 million population, for effective early detection of high risk
population for dementia or MCI, as well as evaluates a possible cost-
effective prevention of cognitive decline.

199
Key Concept for dementia early
detection and intervention
Identification of individuals at risk
Effective intervention
Efficient diagnosis
Effective intervention
1. Prevention of
Dementia
2. Prevention of
Long-Term Care
Not to be Demented, not to be in Need of Care!
Normal
MCI
Dementia
Care Need
Community
Clinics

Community
Clinics
Risk Assessment by
“Basic Checklist”
(Citizens over 70)
Home Doctor / Support Doctor
(MCI/Dementia diagnosis)
University Hospital
Previous Program for Dementia in Kobe
Risk is not
stratified.
Questionnaires
are not
quantitative.
Brain Health Class
Program
Other Public Health
Programs
Efficacy is not evaluated.
Therapeutic
Intervention
Other Long-Term Care
Prevention Programs
Local Elderly Care Management
Center (Life Guidance)
200
Effects are not adequately evaluated, hampering improvements
Long-Term
Care
Need
Certification
Dementia
diagnosis

Home Doctor / Support Doctor
Community
Elderly General Population
Health Checkup Participants
Possible future Kobe System Dementia Management
Effective Cognitive
Training Programs
Effective Public Health
Programs
Therapeutic Intervention
Low Risk
MCI
High Risk Effective Long-Term Care
Prevention Programs
Local Elderly Care Management
Center (Life Guidance)
201
Realization of quantitative feedback mechanism in local governmental services
Risk Assessment by Basic
Checklist, CFI, EQ5D, etc
(Older General Population)
Demented
Long-Term
Care
Need
Certification
Continuous and Quantitative Link
University Hospital
Clinics

203 |
Key findings of Kobe Dementia Study
Three simple
questions
delivered through
administrative
campaign
questionnaire may
help identifying
high risk
populations for
intervention and
service provision

204 |
Increasing mental health issues in LMICs

205 |
WHO Mental Health Atlas 2020
Key findings
– 171 of WHO’s 194 Member States at least partially completed
the Mental Health Atlas 2020 questionnaire
– 15% of Member States reported no mental health data
– 57% of Member States have a stand-alone mental health law
– 2.1% of government health expenditure for mental health
– Two mental health workers per 100 000 population in LIC,
while 60 workers per 100 000 in HIC
– Limited child and adolescent mental health facilities
– 0.1 psychiatrist and 0.9 nurses per 100 000 population in the
African Region (9.7 and 25.2 in European Region)

206 |
“Community for All Ages”

207 |
Mental health and psychosocial support (MHPSS)
for emergencies and disasters

208 |
WHO Health EDRM Research Network
Over 400 experts from 59 countries involved
Co-chairs to support facilitation (Prof Virginia
Murray UK, Prof Jonathan Abrahams Australia)
WHO HQ (DRR unit, WKC), and Regional
Offices discuss the strategy
WHO Kobe Centre: Secretariat of the network
Facilitate global / regional collaborative research
and activities

209 |
Health EDRM research priority setting in 2018
Area 1. Health
data
management and
disasters
Area 2. Mental
health and
psychosocial
support (MHPSS)
Area 3.
Addressing
needs of sub-
populations
Area 4. Health
workforce
development
Area 5. Research
methods and
ethics

210 |
WHO Research Method Guidance for
Health research before, during, after disaster
 Developed by WHO Kobe Centre with 164
experts from 30 countries – published in 2021
 Regular update – living reference
 Online learning materials on WKC website
 Global dissemination initiatives underway

Kyoto University Medical Student
07 March 2016
211 |
Source: Kobe City

212 |
Disaster Medical Assistance Team
(DMAT)
Established in 2005 (lessons from GHAE)
Focus on emergency medicine for patients in fatal, critical, and/or
serious conditions
Support medical facilities through triage, emergency treatment
and operation
Support disaster survivors to evacuate
Transport severe patients by aircrafts

213 |
Great East Japan Earthquake (GEJE)
after tsunami
before tsunami
Otsuchi Town, Iwate Prefecture, Japan

214 |
Disaster Psychiatric Assistance Team
(DPAT)
Established for broad psycho-social response after disaster
(through lessons from GEJE).
DPAT provides a) support for local mental health providers, b)
acute mental health first aid for disaster survivors, c) mental
health support for evacuation site and patient at home, d) care for
supporters, as well as conduct data collection and assessment in
collaboration with public health sectors

215 |
Mental Health Care Center
for Disaster Survivors
Established for the victims of a large-scale natural disaster (e.g.
GHAE, GEJE)
Dedicated to long-term mental health follow-up and consultation
for disaster survivors
Challenges in a) setting criteria, b) long-term budget allocation, c)
capacity building

Case study: Iwanuma Project on Great East Japan
Earthquake 2011
• Seven months before the 2011 GEJE,
a survey was conducted by the Japan
Gerontological Evaluation Study
(JAGES) on the relationship between
social capital and health in Iwanuma
City, Miyagi Prefecture, Japan.
• Data collected before and after GEJE
provided implications about disaster
preparedness, response and
recovery by over 50 scientific journal
papers
Source: Iwanuma Project Research Results
https://www.jages.net/project/jititaijointresearch/iwa
numa/?
action=common_download_main&upload_id=15260

Case study: Iwanuma Project on Great East Japan
Earthquake 2011
• The study results provided evidence on possible measure to reduce
the risk for post-disaster negative health consequences including:
• Increased participation in exercise and hobby groups help to reduce
depressive symptoms in disaster survivors
• Community-level social capital mitigates progression of cognitive disability
after the disaster
• Positive effects on mental health of group relocation into temporary
housing
• Risk of increased BMI and cardiometabolic diseases due to relocation to
temporary housing
Source: Iwanuma Project Research Results https://www.jages.net/project/jititaijointresearch/iwanuma/?
action=common_download_main&upload_id=15260

218 |
WKC funded research on MHPSS
2016-2018 research project with NCNP and Hyogo Institute for
Traumatic Stress: Synthesizing knowledge on long-term mental
health care for disaster survivors in Japan
2019-2021 research project with Curtin University, NCNP and
HITS research team: Systematic review on long-term mental
health effects on disaster survivors
2022-23 research project with Kyoto University: investigating
digital CBT intervention effects on preventing mental health
issues of university students during COVID-19

219 |
Key messages
Unique local mandate created opportunities to promote research
collaboration between Japan and other regions and countries
Strong engagement of local municipalities and local research
institutes helped producing evidence to inform local
implementation of research findings
Global, national, and local relevance on some research areas
Multi-national and multidisciplinary collaboration enabled global
initiatives to develop WHO publication on research methods

Thank you
Ryoma Kayano
kayanor@who.int

Audience discussion
3.30pm – 3.50pm

Conclusions
Patrick Swain,
Research and Development Manager, ILC-UK

Thank you
ありがとう

05 September Tokyo research symposium slides

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