05 September Tokyo research symposium slides

Slides from the ILC's Mental health matters research symposium on 5 September 2024 at the National Institute of Mental Health in Tokyo, Japan.

1. ilcuk.org.uk 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

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

3. Mental health matters : A global policy agenda Welcome introduction Yoshinori Cho, Director General, National Institute of Mental Health

4. Mental health matters : A global policy agenda Project overview Esther McNamara, Senior Health Policy Lead, ILC-UK

5. Mental health matters : A global policy agenda 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

6. Global average = 9.15 New rankings from 2024 updated Index Mental health matters : A global policy agenda

7. Mental health matters : A global policy agenda Japan in ILC’s Index

8. Mental health matters : A global policy agenda We are looking at this issue through the lens of the following diagnoses: Post-traumatic stress disorder Major depressive disorder Schizophrenia

9. Mental health matters : A global policy agenda Mental health professionals per 100,000 people

10. Mental health matters : A global policy agenda 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

11. Mental health matters : A global policy agenda Session 1 Management of mental health conditions in Japan: major depressive disorders, PTSD and schizophrenia

12. Mental health matters : A global policy agenda Presentation 1 Hiroshi Kunugi , Clinical Medicine Professor and Chairman, Department of Neuropsychiatry, Teikyo University

13. 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

14. 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. 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. 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

17. 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

18. 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)

19. Stress Check Program in Japan T he 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. I t 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

20. 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

21. 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 21

22. 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: clinic al 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

23. Treatment of MDD Psychoeducation including reducing stressors by adjusting environmental factors Psychotherapy: supportive psychotherapy/CBT Pharmacotherapy Antidepressants; Anxiolytics, Antipsychotics, Mood stabilizers, Hypnotics, Chinese herbal medicine, etc Brain stimulation ECT, rTMS Rehabilitation: “Rework” in day care setting CBT is often practiced in this setting. Others Nutrition; Exercise; light therapy, etc 23

24. Antidepressants’ market share based on number of prescribed patients (2024 1-6 in Japan) Lack of bupropion, fluoxetine, etc. 24

25. 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

26. Bupropion Advantages Effect on dopamine reuptake No effect on weight gain No side effect on sexual dysfunction Possible effect on smoking cessation Disadvantage No effect on serotonin reuptake 26

27. 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)

28. Koslow et al. (1983) - Male -0.6 9 0.27 -1.22 -0.15 0.01 2 Koslow et al. (1983) - Female -0.35 0.2 5 -0.84 0.1 4 0.1 6 Asberg et al. (1984) - Male -0.7 5 0.3 1 -1.35 -0.14 0.015 Asberg et al. (1984) - Female -0.49 0.27 -1.0 2 0.040 0.0 70 Widerl ö v et al. (1988) -0.2 3 0.37 -0.9 6 0.50 0.54 Molchan et al. (1991) -0.14 0.36 -0.8 6 0.5 7 0.69 Reddy et al. (1992) -0. 60 0.26 -1.1 1 -0.087 0.02 2 De Bellis et al. (1993) -0.35 0.36 -1.0 6 0.3 6 0.33 Engstr ö m et al. (1999) -0.4 9 0.22 -0.92 -0.050 0.029 Sher et al. (2005) 0.016 0.21 -0. 40 0.43 0.9 4 Sullivan et al. (2006a) -0.041 0.35 -0.7 2 0.6 4 0.9 1 Sullivan et al. (2006b) 0.25 0.29 -0.32 0.8 3 0.39 Ogawa et al. (2015) -0.88 0.3 2 -1. 50 -0.2 7 0.005 1 -0.37 0.092 -0.5 5 -0.1 9 0.00006 1 -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 - v alue Total HVA （ dopamine metabolite): 11 studies 2024/01/20 28 (Ogawa et al: J Psychiatr Res, 2018; 105: 137-146)

29. 5-HIAA (serotonin metabolite): 11 studies Koslow et al. (1983) - Male -0.2 1 0.27 -0.73 0.31 0.4 4 Koslow et al. (1983) - Female 0.5 3 0.2 6 0.016 1.033 0.043 Asberg et al. (1984) - Male -0.53 0.2 7 -1.06 -0.0072 0.04 7 Asberg et al. (1984) - Female -0.51 0.25 -1.0 1 -0.014 0.04 4 Widerl ö v et al. (1988) -0.084 0.37 -0.81 0.64 0.82 Molchan et al. (1991) 0.4 8 0.3 7 -0.25 1. 20 0. 20 Reddy et al. (1992) 0.2 8 0.26 -0.2 3 0.78 0.28 De Bellis et al. (1993) -0.3 6 0.36 -1.0 7 0.3 5 0.32 Engstr ö m et al. (1999) -0.036 0.2 2 -0.4 7 0.39 0.8 7 Sher et al. (2005) 0.21 0.21 -0.20 0.6 3 0.3 2 Sullivan et al. (2006a) -0.1 6 0.3 5 -0.8 4 0.5 2 0.64 Sullivan et al. (2006b) 0.3 8 0.29 -0. 20 0.9 6 0. 20 Ogawa et al. (2015) -0.6 1 0.31 -1.2 2 -0.00 20 0.049 -0.042 0.1 1 -0.2 6 0.17 0. 70 -1.00 -0.50 0.00 0.50 1.00 Low 5-HIAA High 5-HIAA Study Statistics Hedges's g and 95% CI Hedges's g Standard error Lower limit Upper limit P - v alue Total 2024/01/20 29 (Ogawa et al: J Psychiatr Res, 2018; 105: 137-146)

30. MHPG (noradrenaline metabolite): 11 studies Koslow et al. (1983) 0.51 0.18 0.1 6 0.87 0.0050 Asberg et al. (1984) - Male 0.05 4 0.3 7 -0.66 0.77 0.88 Asberg et al. (1984) - Female -0.21 0.31 -0.82 0. 40 0. 50 Widerl ö v et al. (1988) 0.00 0.37 -0.7 3 0.7 3 1.00 Molchan et al. (1991) 0.50 0.3 7 -0.2 2 1.2 3 0.17 De Bellis et al. (1993) -0.12 0.3 6 -0.8 3 0.58 0.73 Engstr ö m et al. (1999) -0.4 1 0.22 -0.84 0.025 0.065 Sher et al. (2005) -0.2 4 0.21 -0.65 0.1 8 0.26 Sullivan et al. (2006a) 0.14 0.3 5 -0.53 0.82 0.68 Sullivan et al. (2006b) -0.1 9 0.29 -0.76 0.3 9 0.5 2 Ogawa et al. (2015) -0.20 0.3 1 -0.80 0. 40 0.5 1 -0.019 0.11 -0.23 0. 20 0.86 -1.00 -0.50 0.00 0.50 1.00 Low MHPG High MHPG Study Statistics Hedges's g and 95% CI Hedges's g Standard error Lower limit Upper limit P - v alue Total 2024/01/20 30 (Ogawa et al: J Psychiatr Res, 2018; 105: 137-146)

31. Bupropion Advantages Effect on dopamine reuptake No effect on weight gain No side effect on sexual dysfunction Possible effect on smoking cessation Disadvantage No effect on serotonin reuptake 31

32. 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) .

33. 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.

34. ( 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

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

36. 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 36

37. 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. 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

39. 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

40. 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 40

41. ・ 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

42. Objective assessment by wearable devices 42

43. Mean 24 h activity rhythms 43 Depressed patients (n=20; solid line) and controls (n=20; dotted line) 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

44. 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

45. 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

46. 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. Nutrition al 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

47. Mental health matters : A global policy agenda Presentation 2 Yoshiharu Kim, Director Emeritus, National Institute of Mental Health

48. 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---

49. Yoshiharu Kim National Center of Neurology and Psychiatry COI to be disclosed in connection with this presentation Advisor : None Shareholding/Profit : None Patent royalty fee ：None Lecture fee : None Manuscript Fee : None Funded research, joint research expenses : None Scholarship donation : None Endowed Chair Affiliation : None Gifts and other rewards : None

50. 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)

51. National Information Center for Post disaster mental health; In NCNP ③ Policy 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

52. 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

53. 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

54. The Flow of the TCOM Study T 1 (Baseline) (n = 300) Eligible Participants (n = 344) Refused (n = 44) T 2 (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) T 3 (3 Month) (n = 155) T 4 (6 Month) (n = 139) T 5 (9 Month) (n = 133) T 6 (1.5 Years) (n = 119) T 7 (3 Years) (n = 103~)

55. 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

56. 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

57. Table 1. Characteristics of the groups 　 (Demographics) Sample (n=347) Control (n=288) Both groups 　 high vs. low risk Age a 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 education a 9.4 ( 2.4) 10.0 (2.5) <0.001 <0.05 Employment history b 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 with a 3.2 ( 1.7) 3.6 (2.1) N.S. <0.05 # of non-atomic traumatic events a 4.0 ( 2.1) 4.1 (2.0) N.S. <0.01 Loss of spouse/ relative within 3°due to atomic bomb b 160 (46.1) 67 (23.3) <0.001 <0.001

58. 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 finding b Presence of physical disease (past 6mo.) 267 (76.9) 223 (77.4) N.S. <0.01 Mental health findings (GHQ28) High risks b,d 255 (73.5) 114 (39.6) <0.001 Total score a 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

59. correct knowledge on atomic bomb

60. 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 finding b Presence of physical disease (past 6mo.) 267 (76.9) 223 (77.4) N.S. <0.01 Mental health findings (GHQ28) High risks b,d 255 (73.5) 114 (39.6) <0.001 Total score a 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

61. Table 2. Contribution of variables to poorer mental health Adjusted odds ratio 95% CI p Sample group b 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 radiation c 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

62. 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 .

63. 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 (%) 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

64. Fear Conditioning

65. Learned helplessness

66. 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 s howing low activity in the 　　medial frontal lobe (right panel) Some PTSD patients show symptoms of dissociation and hypoarousal, with low activity in the amygdala and insula and　 Medial frontal lobe hyperactivity is present Brain pathology related to decreased emotional suppression and increased emotional suppression in PTSD

67. F ear response Helplessness Phobias , panic PTSD dissociative disorder

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

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

70. 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 Bacon.

71. 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) † -10 -20 -30 -40 * * * * * *

72. 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

73. CME plus extras, slide 76

74. C h il dhoo d Expe r i ences U nde r li e C h r on i c D ep r e ss i on W e ll - b e ing

75. Childhood Experiences Unde r lie L a ter Suicide 1 3 2 4+ De a t h

76. 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)

77. 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 ).

78. 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

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

80. 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 Institute of Mental Health National Center of Neurology and Psychiatry Tomoko Kato, Ryoko Otaki, Rieko Otomo, and Kaesuke Suga, Mayumi Sugawara, Mizuki Narita, Hiroaki Hori, Toshiko Kamo ,

81. 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 Range 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

82. 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 ➡︎ CPTSD-related symptoms, dissociation, depression, quality of life , and negative cognitions also significantly improved , 　　Maintained after 3 months

83. 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

84. 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

85. 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

86. 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

87. 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)

88. 50 100 150 200 250 past PTSD control N=12 N=48 pg/ m l IL- 4 500 1000 1500 2000 2500 past PTSD control N=12 N=48 INF- g pg/ m l 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 ** ** ** ** Comparisons between Past PTSD and healthy Controls Kawamura, Kim, Asukai (2002) American Journal of Psychiatry

89. 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 )

90. 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.

91. 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

92. 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 Enhancing neurogenesis 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 Enhancing neurogenesis 1) Forgetting of traumatic memory 2) Improvement of PTSD-like behaviors

93. 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

94. (+) n = 10 (+) n = 4 ( - ) n = 6 (b) 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

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

96. 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

97. 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

98. 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

99. Thank you very much for your attention.

100. Mental health matters : A global policy agenda Presentation 3 Zui Narita, Chief, Department of Behavioral Medicine, National Institute of Mental Health

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

102. “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.

103. 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 Admissio n System ( 緊措 ) Image: Reischauer Institute of Japanese Studies

104. 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

105. “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 wer e not informed of the diagnosis. -Motivating the treatment. Image: National Institute of Mental Health 2022

106. 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

107. 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.

108. 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, w here is the rest coming from?

109. 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

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

111. 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.

112. 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 Jan;215:223-228. doi : 10.1016/j.schres.2019.10.024. Epub 2019 Oct 23. PMID: 31668492.

113. 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.

114. 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.

115. 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: 18606047. PEs persist as a psychotic disorder in certain people

116. PEs: Social context

117. PEs: Social context Please PubMed me for more papers.

118. 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.

119. 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.

120. Mental health matters : A global policy agenda Audience discussion 2.00pm – 2.20pm

121. Mental health matters : A global policy agenda Coffee break 2.20pm – 2.30pm

122. Mental health matters : A global policy agenda Session 2 What lessons can be learnt from Japan, what works well, and how do we best manage mental health across the life course?

123. Mental health matters : A global policy agenda Presentation 1 Jun Saito, Senior Research Fellow, Japan Centre for Economic Research

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

125. 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

126. Mental Health Situation in Japan

127. 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,

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

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

130. Causes of Mental Disorder

131. 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

132. 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

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

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

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

136. Non-Regular Workers Who are Working Unwillingly 139 (Data Source) Labour Force Survey, Ministry of Internal Affairs and Communications

137. Unemployed Who Quitted a Job Involuntary 140 (Data Source) Labour Force Survey, Ministry of Internal Affairs and Communications

138. 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

139. Economic Consequences of Mental Disorders

140. 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 D isability pension system P ublic assistance program 143

141. Economic Consequences 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

142. Economic Consequences 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

143. 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

144. Share of Mental Disorder in National Medical Care Expenditure by Age 147 (Data Source) Ministry of Health, Labour and Welfare (Age)

145. 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

146. 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

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

148. Importance of Preserving Mental Health for the Japanese Economy

149. 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

150. 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.

151. 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.

152. Potential GDP Growth Rate 155 (Data Source) Cabinet Office

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

154. Measures to Preserve Mental Health in Japan

155. 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

156. Measures to Preserve Mental Health Obligate employers to strengthen health management 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

157. Measures to Preserve Mental Health Obligate employers to strengthen health management 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

158. Measures to Preserve Mental Health 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

159. Measures to Support (Re)Employment Support mentally handicapped to ge t 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

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

161. Acquisition Rate of Annual Paid Leave 164 (Data Source) Ministry of Health, Labour and Welfare

162. Job Placement of Mentally Handicapped 165 (Data Source) Ministry of Health, Labour and Welfare

163. 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

164. Remaining Tasks to Achieve the Goal

165. 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

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

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

168. Mental health matters : A global policy agenda Presentation 2 Favour Omileke, Project Specialist, Health and Global Policy Institute

169. ILC RESEARCH SYMPOSIUM Mental Health Matters September 5 th 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 .

170. 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

171. 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

172. 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

173. 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

174. 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

175. 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

176. 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

177. 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

178. 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

179. 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.

180. Mental health matters : A global policy agenda Presentation 3 Ryoma Kayano , Technical Officer, WHO Centre for Health Development

181. 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

182. 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)

183. 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

184. Relevant research topics for global and local research collaboration Ageing and dementia Health emergency and disaster risk management (Health EDRM)

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

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

187. Expanding population with dementia Source: WHO Infographic 20 September 2017

188. Huge economic and social burden Source: WHO Infographic 20 September 2017

189. 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

190. Complexity of Dementia

191. 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

192. Global Action Plan on the Public Health Response to Dementia (2017 WHA) 7 Action Areas Dementia as a public health priority Dementia awareness and friendliness Dementia risk reduction Dementia Diagnosis, treatment and support Support for dementia carers Information systems for dementia Dementia research and innovation

193. 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

194. 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.

195. 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

196. Community Clinics Risk Assessment by “Basic Checklist” (Citizens over 70) Home Doctor / Support Doctor ( MCI/Dementia diagnosis) University Hospital (MCI/Dementia diagnosis) 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) Efficacy is not evaluated. Efficacy is not evaluated. 200 Effects are not adequately evaluated, hampering improvements Long-Term Care Need Certification Dementia diagnosis

197. Home Doctor / Support Doctor ( MCI/Dementia diagnosis) 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 (MCI/Dementia diagnosis) Clinics

198. 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

199. Increasing mental health issues in LMICs

200. 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)

201. “ Community for All Ages ”  

202. Mental health and psychosocial support (MHPSS) for emergencies and disasters

203. 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

204. Health EDRM research priority setting in 2018

205. 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

206. Source: Kobe City

207. 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

208. Great East Japan Earthquake (GEJE) after tsunami before tsunami Otsuchi Town, Iwate Prefecture, Japan

209. 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

210. 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

211. C a se s t u d y : 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/iwanuma/?action=common_download_main&upload_id=15260

212. C a se s t u d y : 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

213. 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

214. 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

215. Thank you Ryoma Kayano [email protected]

216. Mental health matters : A global policy agenda Audience discussion 3.30pm – 3.50pm

217. Mental health matters : A global policy agenda Conclusions Patrick Swain, Research and Development Manager, ILC-UK

218. Mental health matters : A global policy agenda Thank you ありがとう