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A social issue that will substantially impact Japan 20 years later: Measures to address social withdrawal need to be promptly promoted

Ken Inoue, Doctor, Research and Education Faculty, Medical Sciences Cluster, Health Service Center, Kochi University, Japan
Tsuyoshi Miyaoka, Doctor, Department of Psychiatry, Faculty of Medicine, Shimane University, Japan
Sadayuki Hashioka, Doctor, Department of Psychiatry, Faculty of Medicine, Shimane University, Japan
Jun Horiguchi, Doctor, Department of Psychiatry, Faculty of Medicine, Shimane University, Japan
29 November 2017

Social withdrawal refers to “staying at home for 6 months or longer without going to school or work and interacting little with anyone other than family members”.1 The 2004 survey reported that about 320,000 households in Japan include an individual who is socially withdrawn1, and 1.18% of individuals ages 20–49 indicated that they had become socially withdrawn at some point. Various factors underlie social withdrawal. Over the past few years, the issue of social withdrawal has garnered considerable attention in Japan of all 47 prefectures nationwide.

The 2016 survey by the Cabinet Office suggested that about 540,000 individuals ages 15–39 were socially withdrawn nationwide.2 According to the survey to ascertain the extent of social withdrawal in each prefecture, individual surveys have been conducted or the extent of social withdrawal has been determined in 18 of 47 prefectures nationwide, surveys are underway in 2 prefectures, and plans are to conduct the survey (it has already been planned) in 1 prefecture. The number of individuals who were socially withdrawn was specifically estimated in 12 of those prefectures, and the number of individuals age 40 or over who were socially withdrawn was estimated in 9 of the 12 prefectures mentioned. In 5 of those 9 prefectures, individuals age 40 or over who were socially withdrawn outnumbered individuals age 39 or younger who were socially withdrawn.2

According to one study of 150 municipal offices that provided counseling regarding social withdrawal, most offices (62%) had provided advice regarding individuals in their 40s who were socially withdrawn.3 Fifty-two percent of offices had provided advice regarding individuals in their 30s who were socially withdrawn, 46% had provided advice regarding individuals in their 20s who were socially withdrawn, and 45% had provided advice regarding individuals in their 50s who were socially withdrawn.3

Based on these findings, individuals age 40 or over who are socially withdrawn need to receive more social resources and increased outreach to encourage their interaction with the rest of society. Experts in different fields and different bodies dealing with individuals who are socially withdrawn need to address individual situations and they need to consider coordinating their efforts when necessary.4 Moreover, measures to address social withdrawal need to be analyzed and response options need to be considered in accordance with local conditions rather than formulating a uniform action plan for the country as a whole.5 At the current point in time, there is a lack of data and research with which to examine social withdrawal from various perspectives, so efforts to ascertain the specifics of that issue must be promoted.2,3

1.Ministry of Health, Labour and Welfare. [Hikikomorisesakunituite]. Last accessed 25 September 2017.

2.Shakai. [Hikikomorikounenreika]. Saninchuousinbun (Newspaper) No.27 on 25 September, 2017, 2017 (in Japanese).

3.Nihonkeizaisinbun. Last accessed 11 September 2017.

4.Inoue K, Fukunaga T, Fujita Y, Ono Y. Future proposals in light of the current status of suicide prevention measures for the young and middle-aged in Japan. West Ind Med J 2011; 60: 374.

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How physical is reality?

Saad F Ghalib, Consultant Old Age Psychiatrist, Behavioral Sciences Pavilion, SKMC, Abu Dhabi,UAE
12 November 2017

An argument repeatedly leveled against psychiatry as a proper science can be summarized in the following statement:" psychiatry deals with the realm of the subjective which invariably and often synonymously taken to indicate the realms of the nonphysical". However, advances in modern science no longer supports a Newtonian type physical reality or a Cartesian object-subject duality which often referred to as common wisdom!

To most people, reality is made of stuff, that is matter, and matter is made of elementary particles. However, when physicists looked into the behavior of these particles, they were up for a surprise! Electrons for example treated in quantum mechanics as point particles with mass and charge. This notwithstanding, an electrons' position(alternatively speed) is theoretically meaningless as its potentially spread out everywhere in the universe! Moreover, and despite its corpuscular nature, an electron can behave like a wave, but unlike sound waves, an electron wave is a probability wave whereby a high amplitude provides a higher chance of finding the electron once subject to an act of measurement. Furthermore, and in another blow to physical reality, it was found that when two elementary particles interact and then go separate ways, they nevertheless remain in contact, so that measurement on particle A will instantly influence the results we obtain from measurement on particle B no matter how far apart they are in the universe! Surprisingly, the choice of experiment would end up influencing the reality of the phenomenon under study, for example: the position of an electron does not exist prior to an observer making a decision to look! It is in this sense that the subject cannot be disentangled from the object in the overall description of the phenomenon.

If one thing, advances in modern science have shown beyond doubt that reality is not a physical thing but the potential or probability for certain relations to unfold in time. Moreover, attempts to separate the object from the subject are doomed to failure. Subjectivity and physical reality, concepts that we take for granted in our daily life, yet they are far from straight forward and the source of so much muddle!
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Effects of Stigma on caregivers - An Inconvenient Truth

Jens Peter Eckardt, chief analyst, MSc, BEDRE PSYKIATRI (Better Psychiatry) Research Unit, Copenhagen, Denmark. Website:
31 October 2017

New research once again underlines the importance of further investigations of the consequences of stigma attached to mental illness, namely stigma such as prejudice and discrimination experienced by caregivers of people with mental illness. In this case the considerable economic implications for caregivers, who often make up informal means of support for people with mental illness, are commonly ignored (1) (2) (3). According to the authors, caregivers who experience stigma may take time off work, give up employment, or forego leisure to provide support; to overlook these economic effects would be serious, given that many people with mental illness rely on families, friends and others for support (1).

Evidence from around the world shows that stigma on caregivers affects heavily and do not differ significantly from country to country or from one society to another (2) (3) (4) (5) (8). The interest in stigma of caregivers appeared in early publications from the 60s by which a person is stigmatized by virtue of association with another stigmatized individual, which has been referred to as ‘courtesy’ or ‘associative’ stigma (6) According to Larson et al., family stigma contains the stereotypes of blame, shame, and contamination where e.g. public attitudes which the blame is attributed to poor parenting skills which led to the child’s mental illness (7). In turn he concludes, the stigma process negatively impacts individuals in numerous ways in which family members may avoid social situations, spend energy and resources on hiding the secret, and experience discrimination within employment and/or housing situations (7).

Effects of stigma on caregivers has received very little attention in research and despite increasing awareness and discussions, no studies have estimated these costs (e. g. absenteeism, premature

retirement, productivity loss) where stigma on caregivers has been reported (1). Future research may as well explore the breadth and depth of the problems and identify interventions that effectively reduce stigma on caregivers (7). Interventions and strategies to change the public attitude, perspectives of media and well-educated clinicians are especially needed to reduce the negative effects of psychological factors related to stigma on caregivers. But in words of Khurshudyan, “the results of stigma are much broader than personal drama for mental health patients or their close relatives. The adaptive response to private and public shame is secrecy. Secrecy acts as an obstacle to the presentation and treatment of mental illness at all stages.” (5)

I therefore call on the international community to pay urgent attention and exploration on this topic and start recognizing the need of more research and education to end this damaging mark that distinguishes someone as discredited - and in the end lead to a significantly amount of discrimination, stereotypes and prejudices within a society. To put it in other words by reformulate an old classic saying; ‘If you think research and education in mental health is expensive, Try stigma and ignorance.’ It’s inconvenient but true.


(1)Paul McCrone, and Graham Thornicroft (2017) The Economic Impact of Mental Health Stigma. In Mental Health Economics. The Costs and Bene¬fits of Psychiatric Care, Denise Razzouk Editor. Springer.

(2)Lia Fernandes (2017) Mental Health and Carers. In Sabine Bährer-Kohler Francisco Javier Carod-Artal Editors Global ‘Mental Health Prevention and Promotion’. Springer

(3)Armen Soghoyan and Khachatur Gasparyan (2017) Mental Health and Stigma. In Sabine Bährer-Kohler Francisco Javier Carod-Artal Editors Global ‘Mental Health Prevention and Promotion’. Springer

(4)Eshetu Girma et al (2014) Self-stigma among caregivers of people with mental illness: toward caregivers’ empowerment. Journal of Multidisciplinary Healthcare

(5)Khurshudyan (2015) Stigma among mental health patient’s family members in Armenia. The personality and Mental Health.

(6)Margareta Ostman and Lars Kjellin (2002) Stigma by association. Psychological factors in relatives of people with mental illness. BRITISH JOURNAL OF PSYCHIATRY

(7)Jon E. Larson, Ed.D., Patrick Corrigan, Psy.D. (2008) The Stigma of Families with Mental Illness. Academic Psychiatry

(8)Singh A, Mattoo SK, Grover S. (2016) Stigma and its correlates among caregivers of schizophrenia: A study from North India. Psychiatry Res

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On the edge of a total collapse.

Jakub S. Bil, Phd, Adjunct Prof. Faculty Member., Andrzej Frycz Modrzewski Kraków University, Faculty of Medicine and Health Sciences
28 October 2017

In many countries, inequalities in mental health services and infrastructure are enormous. Flawed management of mental health facilities, reduction of the number of beds, and insufficient financing has created a situation in which the architecture of existing mental health hospitals often resembles that of first asylums, rather than places dedicated to treatment. Programs and reforms aimed at the improvement of mental healthcare consistently omit issues that could lead to the upgrading of the infrastructure of mental health services(1).

The ongoing reforms of mental healthcare services include the decentralisation and dissemination of resources. All the issues covered by the reforms represent a huge step forward. Unfortunately, all these attempts might be undermined by the current state of existing mental health infrastructure(2). Patients are mostly hospitalised in conditions that do not provide for basic needs. Therapy is carried out in unsuitable buildings such as former military barracks, palaces, warehouses, or historical buildings which need renovation or immediate closure.

Facilities used by psychiatric units that have been adapted to human occupation or not were originally intended for therapeutic functions often do not meet statutory act requirements for medical entities. Many have rooms which act as passages between other rooms, which is unacceptable from both the perspective of hospital design practice. In many cases it is not possible to allocate sufficient space or isolate agitated patients. Due to frequent overcrowding, patients occupy storage rooms, corridors, or niches in corridors which were originally intended for relaxation zones.

This results in problems such as the use of inappropriate spaces for patients and can lead to aggressive behaviour and sentinel events including, homicide, escape, theft, sexual relations and sexual abuse, injuries, lack of intimacy, privacy, violation of patients’ dignity, and lack of appropriate forms of isolation when required. Also inpatient suicide attempts are sentinel events in mental health wards that occur in almost every facility worldwide(3). They are a consequence of multiple factors that originate from both the patient’s mental health issues and the consequences of structural problems in mental healthcare systems(4).

Globally there is a significant problem with the reporting of such events, which are still considered taboo, and the lack of action to improve the poor quality of mental health facilities. In many countries the legal system does not require anti-suicide measures, safety designs, or the use of environmental anti-ligature assessment scales in mental health hospitals. What is more, ver often there are almost no legal regulations regarding the design of mental health units. In addition, these inadequate environments are full of ligature points that are improperly secured, if at all.

Mental health patients, just like others, deserve high quality healthcare institutions with financing that would guarantee appropriate conditions of hospitalisation and observe their needs and dignity. The reforms of the mental health system will not succeed unless the very basic needs are covered. A key factor in any healthcare system is its infrastructure and, without that, there is a probability of total collapse.

1. Bhugra, Dinesh et al. The WPA-Lancet Psychiatry Commission on the Future of Psychiatry The Lancet Psychiatry 2017;4(10):775 - 818.

2. Cohen, A.; Minas, H. Global mental health and psychiatric institutions in the 21st century. Epidemiology and psychiatric sciences, 2017;26(1): 4-9.

3. Mills, Inpatient suicide on mental health units in Veteran Affairs (VA) hospitals: avoiding environmental hazards. General Hospital Psychiatry 2013, 35:528-36.

4. Corrigan,P.W., Markowitz, F. E.,& Watson, A.C. Structural Levels of Mental Illness Stigma and Discrimination. Schizophrenia Bulletin,2004:30(3),481–491.

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Suggestions for improvements to undergraduate psychiatric education, from a recent MBChB graduate

Tom R Dalton, Academic FY2 Doctor, University Hospitals Bristol NHSFT
27 October 2017

As someone who was keen on psychiatry from the start of medical school, I recall looking forward to the handful of preclinical psychiatry lectures with great anticipation. Finally, I would find answers to questions which had plagued me since secondary school: why don’t people with eating disorders just eat normally? Why do people deliberately injure themselves? Why can’t substance addicts just stop using? What is it that prevents someone with OCD leaving their house?

The undergraduate psychiatry curriculum covered the risk factors, prevalence and impacts of psychiatric disorders, formal lists of the criteria by which we define them, a basic introduction to the neurobiological processes thought to underpin them, and the principles of treatment. However, my most urgent questions about what the patients may be thinking, and what might be driving some of their most puzzling symptoms went unanswered. The patients remained something of a ‘black box’, difficult to understand and even harder to empathise with.

I found that the greatest leaps forward in understanding came from other sources entirely. A short discussion with an insightful friend and eating disorder sufferer introduced to me the idea that extreme diet restriction is often a way to feel safe and in control of something when everything feels frightening. Undertaking a library project on non-suicidal self-injury I encountered the putative mechanisms by which it temporarily reduces aversive mental states. A chance conversation with a leading expert in obsessive-compulsive disorder elucidated what it must feel like to experience intrusive obsessions and how this tension can drive compulsive neutralising rituals. During clinical attachments it was then possible to map service users’ individual accounts onto these basic concepts, which had been crucially lacking from undergraduate curriculum, adding phenomenological colour and personal detail.

These were key moments when it was finally possible to understand something of why patients enact such behavioural symptoms. As Jaspers may have put it, there was a move from Erklären (a dry explanation comprising only risk factors and neurobiology) to Verstehen (an empathic understanding of the phenomena). It was possible to imagine what they may be thinking, and realise that anyone might do the same under those conditions.

The question remained of why this had been absent from the psychiatry curriculum. How could a doctor be expected to empathise effectively with a patient when they have not been fortunate enough to encounter these ideas?

I proceeded to investigate whether it would be practicable to teach these experientially learned but relatively simple concepts to medical students. Assembling a series of simplistic and uncontroversial models to describe the development and function of common behavioural symptoms in terms of a sequence of subjective experiences which students can (to an extent) imagine and relate to, it was possible to produce teaching materials which attempt fill the conceptual void between abstract risk factors or neurobiological events and the list of symptoms experienced by the patient. Clinical experience and literature point to the central role of the drive to escape from aversive mental states (be it craving for nicotine(1,2,3), the tension of not-just-right experiences or distressing intrusive thoughts in OCD(4,5), the desperate fear of food or weight gain symbolising failure and loss of control in eating disorders(6,7,8,9), or the overwhelming self-loathing, anxiety or dissociative states which may drive somebody to repeatedly injure themselves(10,11,12)), whereby the behaviours in question are negatively reinforced. Flow-diagrams to simplistically illustrate the spirals into compulsive behaviours were constructed, populated throughout with descriptions of the patient’s subjective experience, attempting to demonstrate some of the ways in which someone’s ability to resist enacting the behaviour becomes eroded to the point where it is hardly a choice. The aim is not to supply a complete explanation of the phenomenon’s aetiology (and this is explicitly emphasised), but rather to provide the missing starting-point from which to try and make sense of the latent processes underlying these baffling and unintuitive symptoms.

Whilst these explanatory models instil only a basic level of understanding, feedback on the teaching materials (delivered to 74 medical students over 3 lectures and evaluated using 5-point Likert scales) has been very positive. Asked whether the lecture improved their understanding of the conditions covered, 50 (68%) of students responded “definitely yes”, and 22 (30%) responded “mostly yes”. When students were asked whether they feel they would have more empathy towards patients with these conditions following the lecture, 55 (74%) responded “definitely more empathy” and 14 (19%) responded “a little more empathy”. Also encouraging were the written comments: “all topics very accessible with good ways to help us empathise with Psych conditions (cannot emphasise this enough - we get teaching on symptoms but not what it actually feels like)”; “Really good way of explaining how disorders arise, which helped me understand the experience the experience of those affected, and will hopefully help me empathise with patients in the future”.

It could be argued that students should encounter service users’ own accounts of the functions of their behavioural symptoms, and that the answer is to increase their clinical exposure. Whilst I agree with the literature that including lived experience in psychiatry teaching is key(13,14), I would argue that it is crucial (not to mention time-efficient in already full curricula) to teach the salient concepts, so that all students are exposed to a basic explanatory framework without relying on having chance discussions with particularly insightful service users. As it is, many clinicians may have left medical school with the expected factual knowledge of many psychiatric conditions, but significant blanks in their understanding of the reasons people might self-injure, use, restrict, purge or repeatedly check. Filling these blanks, stigmatising and misinformed assumptions and stereotypes can remain unchallenged.

Could exploring some of the common functions of behavioural symptoms, such as the examples given, be an invaluable missing component of psychiatry teaching, and a key step in enabling students to make sense of these disorders?


1.Hatsukami DK, Stead LF, Gupta PC. Tobacco addiction. The Lancet. 2008 Jun 20;371(9629):2027-38.

2.Koob GF, Sanna PP, Bloom FE. Neuroscience of addiction. Neuron. 1998 Sep 30;21(3):467-76.

3.Difranza J. A new approach to the diagnosis of tobacco addiction. Addiction. 2010 Mar 1;105(3):381-2.

4.Gillan CM, Fineberg NA, Robbins TW. A trans-diagnostic perspective on obsessive-compulsive disorder. Psychological Medicine. 2017 Jul;47(9):1528-48.

5.Aouizerate B, Guehl D, Cuny E, Rougier A, Bioulac B, Tignol J, Burbaud P. Pathophysiology of obsessive–compulsive disorder: a necessary link between phenomenology, neuropsychology, imagery and physiology. Progress in neurobiology. 2004 Feb 29;72(3):195-221.

6.Crilly L. Hope with eating disorders. Hay House, Inc; 2012 Apr 2.

7.Fairburn CG, Harrison PJ. Eating disorders. The Lancet. 2003 Feb 1;361(9355):407-16.

8.Fairburn CG, Shafran R, Cooper Z. A cognitive behavioural theory of anorexia nervosa. Behaviour research and therapy. 1999 Jan 31;37(1):1-3.

9.Godier LR, Park RJ. Compulsivity in anorexia nervosa: a transdiagnostic concept. Frontiers in psychology. 2014;5.

10.Chapman AL, Gratz KL, Brown MZ. Solving the puzzle of deliberate self-harm: The experiential avoidance model. Behaviour research and therapy. 2006 Mar 31;44(3):371-94.

11.Gratz KL. Risk factors for and functions of deliberate self‐harm: An empirical and conceptual review. Clinical Psychology: Science and Practice. 2003 Jun 1;10(2):192-205.

12.McAllister M. Multiple meanings of self harm: A critical review. International journal of mental health nursing. 2003 Sep 1;12(3):177-85.

13.Livingston G, Cooper C. User and carer involvement in mental health training. Advances in Psychiatric Treatment. 2004 Mar 1;10(2):85-92.

14.Ikkos G. Mental health service user involvement: teaching doctors successfully. Primary Care Mental Health. 2005 Jun 1;3(2):139-44.
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The sanitised public face of mental illness

Killian Donovan, Foundation doctor, Oxford University Hospitals
Gavinda K Sangha, Foundation doctor, Oxford University Hospitals
06 October 2017

Dear Editor,

Psychiatry has reached a turning point in recent years with the huge increase in public discussion of mental illness, and the normalisation of talking about emotional difficulties. For the most part, this has been a positive move, giving a vocabulary to those experiencing psychological distress to share their problems. However I believe that as a profession, we have stood by and allowed this change to develop in a way that actually does a disservice to our most vulnerable patients.

Mental illness is now understood by most of the public through the lens of the celebrity confessional. This has become so prevalent that it is by now almost a cliché – the celebrity who superficially appears to have all their ducks in a row reveals their struggles with mental illness in an autobiographical interview, and is then widely praised for raising awareness. Many people identify with the difficulties expressed by these celebrities, and I do not doubt that these people are helped hugely by the discovery that they are not alone. However the reality is that many people with mental illness, particularly the most vulnerable, are not at-all represented by the celebrity-confessional. There is no space in the current public discourse for the middle-aged patient with schizophrenia who cannot live independently and has been too unwell to hold down a job for twenty years. There is no space for the elderly patient with severe depression for whom even eating is a struggle.

I believe that we have a responsibility to these patients to ensure that they are represented in the public discourse. The fact that the media and general public are discussing mental illness is a good thing, but we must not stand by and praise from the sideline, especially when we know that the sanitised image of mental illness is inaccurate and actually doing a disservice to our most vulnerable patients.

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Burnout syndrome and depression are not the same thing

Francesco Chirico, Occupational Physician, Health Service Department, State Police, Ministry of Interior, Italy
02 October 2017

Bianchi et al. commented on my e-letter in which I affirmed that ‘Burnout syndrome (BOS) is distinct from depression and should be elevated to the status of an occupational disease’ [2], claiming that it is important to distinguish ‘published opinion’ from ‘scientific evidence’ [1]. Based on their own studies, they argue in support of their personal theory, confuting the burnout construct and suggesting an overlap between burnout and depression, that burnout is not a specifically job-related phenomenon and that it is simply a depressive condition [1]. To promote this personal theory, Bianchi et al. have repeatedly criticised several researchers whose counterclaims are based on scientific evidence from over 40 years of literature on BOS. In response, Maslach and Leiter wrote: ‘Research has demonstrated that the two constructs are distinct: burnout is job-related and situation-specific, as opposed to depression, which is more general and context-free’ [3]. Contrasting Bianchi, Maslach and Leiter maintained that ‘studies confirm that burnout and depression are not independent. Each state has implications for the other. However, that relationship is far from saying that burnout and depression are the same mental illness’ [3]. The difference between burnout and depression is an ancient and well-known problem. Indeed, when the construct of burnout first appeared in the 1970s, it was defined under the label ‘old wine in a new bottle’. Therefore, much past research had raised the question of whether burnout was a precipitating factor in depression, or whether the two were coterminous, and the conclusion was that burnout was a distinct construct [4]. The fact that BOS was never entered as a depressive disorder in the DSM or the ICD confirms this conclusion [2]. Therefore, as Epstein and Privitera replied in their debate with Bianchi et al. in The Lancet, ‘a person may have one condition without having the other’ [5]. Bianchi criticised my e-letter, claiming that cynicism, one of the typical dimensions of BOS, can also be observed in depression. However, although BOS shares symptoms with depression, they are not the same mental disorder. According to Maslach and Leiter, cynicism may be ‘more of a core part of burnout than exhaustion’ [3]. Moreover, Bianchi et al. neglect that work-related mental disorders should be diagnosed under the DSM 5 chapter ‘Trauma and Stressor-related Disorders’ (e.g. as ‘chronic adjustment disorders’) and through different diagnostic criteria for every depressive condition included in the ‘Depressive Disorders’ chapter. Moreover, ‘especially in the helping professions, cynicism toward one’s own patients is the distinguishing feature of burned-out workers that is absent in depression, adjustment disorders and other types of work-related strain’ [2]. Finally, the International Labour Organization’s (2016) report showed that many countries recognise BOS as a specific occupational disease, in addition to chronic adjustment disorders and depression [2]. The Dutch diagnosis of BOS as ‘neurasthenia’ [1] resulted from the international disagreement on the aetiology of burnout. Perhaps most importantly, ‘The lack of an official diagnosis of burnout limits access to treatment, disability coverage, and workplace accommodations’ [3].


1 Bianchi R, Schonfeld IS, Laurent E. ‘Burnout syndrome’: distinguishing published opinion from scientific evidence. Br J Psychiatry, eLetter, Aug 07, 2017.

2 Chirico F. Is it time to consider burnout syndrome an occupational disease? Br J Psychiatry, eLetter, July 17, 2017.

3. Maslach, C. and Leiter, M.P. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry. 2016; 15: 103–111.

4 Schaufeli WB, Enzmann D. The burnout companion to study and practice: a critical analysis. London: Taylor & Francis, 1998.

5 Epstein, R.M. and Privitera, M.R. Physician burnout is better conceptualised as depression—Authors' reply. Lancet. 2017; 389: 1398.

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A potential medication for Cannabis Use Disorder in Adolescents

Sadiq Naveed, Associate Medical Director, KVC Hospitals, Kansas
Mandy Yates, Nurse Practitioner Student, University of Missouri- Kansas City
25 September 2017

Cannabis is the most frequently used recreational substance among adolescents in the United States [1]. About 2.7% of adolescents met the diagnostic criteria for cannabis use disorder during 2014 [1]. Effective treatment modalities can positively affect the prognosis of cannabis use disorder. While the efficacy of psychosocial interventions has been reported in previous studies, there are only limited psychopharmacological options for cannabis use disorder. N-acetylcysteine is a pro-drug which has been considered in clinical trials for its efficacy for cannabis use disorder [2]. N-acetylcysteine (NAC) causes the reverse drug-induced down-regulation of the cysteine-glutamate exchanger which reduces compulsive behaviors related to addiction in animal studies [2]. Glutamate plays an important role in the addiction disorders which suggests that the focus should be on restoring the glutamatergic function [3]. Abstinence is encouraged in those who abuse cannabis but general ly have poor outcomes [3]. With NAC, there is less abuse potential and better outcomes have been reported in those who have reduced cannabis cravings after having NAC [3]. In a 4-week trial conducted by Gray et al., (2010), 24 participants were given NAC 1200 mg twice daily and had four weekly visits to assess efficacy and safety. The participants were encouraged to gradually decrease their marijuana use without any additional psychosocial interventions [2]. A daily marijuana use diary was completed and turned in weekly by the participants in this study. Additionally, a semi-quantitative urine cannabinoid levels and urine creatinine were used to determine levels [2]. Participants were asked to return one month after the trial for follow up. It led to significant reduction in self-reported resources of cannabis use and cravings [2]. A marijuana craving questionnaire was used to measure cravings and the four domains included compulsivity, emotionality, expectancy, and purposefulness in this study. The outcome measures improved in three of the four domains over the course of treatment in those who used NAC [2]. The most common adverse events were abdominal discomfort, muscle pains/aches, insomnia, headache, nasal congestion/runny nose, nausea, weight loss, restlessness, and dizziness [2]. The limitations of this study included an open-label study without a control group and semi-quantitative urine drug testing [2]. In another study, 116 adolescents were randomized to the receive NAC (1200 mg) or placebo twice daily along with contingency management intervention and brief weekly cessation counseling [4]. The efficacy was assessed through weekly urine cannabinoid test results in this study. After an 8-week double-blind randomized controlled trial (RCT), participants receiving NAC were more twice likely to have negative urine cannabinoid test results than placebo group [4]. It was well tolerated with minimal adverse effects [4]. Clinicians should consider it as a potential treatment option considering its effectiveness in an open-label and RCT. However, they should carefully consider the benefits, risk factors, and alternative while recommending it as a treatment option.


1. Hedden S, Kennet J, Lipari R, Medley G, Nice P. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. Samhsagov. 2017. Available at: Accessed August 4, 2017.

2. Gray KM, Watson NL, Carpenter MJ, LaRowe SD. N-Acetylcysteine (NAC) in Young Marijuana Users: An Open-Label Pilot Study. The American Journal on Addictions. 2010;19(2):187-189. doi:10.1111/j.1521-0391.2009.00027.x.

3. McClure EA, Gipson CD, Malcolm RJ, Kalivas PW, Gray KM. Potential Role of N-Acetylcysteine in the Management of Substance Use Disorders. CNS Drugs. 2014;28(2):95-106. doi:10.1007/s40263-014-0142-x.

4. Gray KM, Carpenter MJ, Baker NL et al. A Double-Blind Randomized Controlled Trial ofN-Acetylcysteine in Cannabis-Dependent Adolescents. American Journal of Psychiatry. 2012;169(8):805-812. doi:10.1176/appi.ajp.2012.12010055.
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Haloperidol-induced acute liver injury: Letter to editor

Sadiq Naveed, Child & Adolescent Psychiatrist, KVC Hospitals, Kansas
Quentin Bylund, Medical Student, Kansas City University of Medicine and Biosciences
Amna M D Chaudhary, Physician, Nishtar Medical College, Multan, Pakistan
20 September 2017

Delirium is an acute failure of brain function, characterized by fluctuating level of consciousness, necessitating integrated supportive care along with identification and treatment of underlying cause [1-2]. The Confusion Assessment Method (CAM) is a tool to diagnose these patients [2]. Antipsychotics are used to target the combative and psychotic symptoms of delirium but requires cautious monitoring due to heightened risk of side effects [1-2].

We present the case of 53-year-old Caucasian male brought with altered mental status, hypotension and incomprehensible speech. The patient was found unresponsive following wellness check request placed by neighbors who had not seen him for several days. Patient was found emaciated, dehydrated, and mute with erythematous rash in his mouth. Patient was oriented only to himself but not to time and place. Chest x-ray revealed bilateral pulmonary infiltrates and abnormal renal function tests were observed. Both legs had gangrenous ulcers, more severe on right foot. Past medical history was notable for peripheral vascular disease, requiring recent vascular surgery on both legs. Liver function tests (LFTs) upon presentation were, aspartate aminotransferase (AST): 166, alanine transaminase (ALT): 102, alkaline phosphatase: 111, and albumin: 2.2. Immediate treatment was focused on hydration, antibiotics, and initiation of alcohol withdrawal protocol due to suspected alcohol use.

During hospital stay, he had disorganized thoughts process, increased physical aggression, and visual hallucinations, often grabbing invisible things in the air with a fluctuating course of the illness. He was diagnosed with delirium due to general medical condition. The patient was started on 5 mg of Haldoperidone twice daily as needed to target his combative behaviors with a gradual titration to 5mg, 4 times per day.

With increase in the dose of haloperidol, there was an improvement in symptoms of psychosis and agitation. However, within a day after the titration of the dose of haloperidol from 5 mg twice a day to 5 mg four times a day, there was a rapid increase in his LFTs, yielding levels; AST: 109, ALT: 189, alkaline Phosphatase: 130 and albumin dropped to 1.8. However, total bilirubin was 0.3 at baseline and at follow-up assessments. Considering the Haloperidol as a possible cause of this acute liver injury, it was discontinued and his LFTs returned back to the normal range.

The differential diagnosis of transaminitis in this patient was extensive that was narrowed down to haloperidol-induced hepatotoxicity. The association was temporal, dose-dependent and reversible. The precise mechanism of liver damage is unknown and is hypothesized to be due to a toxic metabolic intermediate. Mild transaminitis occurs in in 20% of patients on long term therapy with haloperidol but values greater than 3 times the upper limit of normal are uncommon [3]. The pattern of transaminitis is mostly cholestatic. The aminotransferase abnormalities are usually asymptomatic and transient, reversing even with continuation of medication [4]. In a study of 5300 patients on Haloperidol, 13 cases of acute liver injury were reported whereas 9 cases developed jaundice [5]. Clinicians should be aware of acute liver injury as a rare but important side effect of haloperidol and a low index of suspicion should be kept to monitor liver function tests and signs of toxicity.


1. Beach, S. R., Celano, C. M., Noseworthy, P. A., Januzzi, J. L., & Huffman, J. C. (2013). QTc prolongation, torsades de pointes, and psychotropic medications. Psychosomatics, 54(1), 1-13.

2. Waszynski, C. M. (2007). How to try this: detecting delirium. AJN The American Journal of Nursing, 107(12), 50-59.

3. Zimmerman, H. J. (1999). Hepatotoxicity: the adverse effects of drugs and other chemicals on the liver. Lippincott Williams & Wilkins.

4. Fuller, C. M., Yassinger, S., Donlon, P., Imperato, T. J., & Ruebner, B. (1977). Haloperidol-induced liver disease. Western Journal of Medicine, 127(6), 515.

5. Crane, G. E. (1967). A review of clinical literature on haloperidol. International journal of neuropsychiatry, 3, Suppl-1.
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Conflict of interest: None Declared

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Decriminalization of Suicide: A Letter to Editor

Sadiq Naveed, Child & Adolescent Psychiatrist, KVC Hospitals, Kansas
Ahmed Waqas, Research Assistant, CMH Lahore Medical College & Institute of Dentistry, Lahore Cantt, Pakistan
Tayyaba Afzaal, Psychologist, Government College University, Lahore, Pakistan
06 September 2017

Suicide is a public health concern which continues to plague people around the globe [1]. It is prevalent among all geographies, ethnicities, and religions. Suicide is the second leading cause of death among persons aged 15-29-years-olds globally [1]. About 78% of suicides occur in low and middle-income countries (LMIC) [2]. Numerous risk factors have been associated with suicidal behaviors including the previous history of the suicidal attempt, mental health disorders, substance use, disaster, exposure to violence and abuse, and sense of isolations [2].

Tackling the stigma [3] associated with suicidal behavior is one of the key challenges in helping people struggling with suicidal behaviors. Moreover, in contrast to the high income countries, LMIC exhibit disproportionate access to psychotherapeutic and counseling services owing to poor understanding of suicide, a lack of infrastructure and poor treatment seeking behaviors. In addition to aforementioned reasons, criminalization of suicidal behaviors among many nations, also contributes to the complexity of this issue [3]. This criminalization of suicide is a topic of debate among the key stakeholders such as the health care providers, advocacy groups, law makers, and governments. There are still countries around the globe which continue to legalize suicide attempt as a criminal offense [4]. These countries are mainly from the African and South Asian regions including Kenya, Malawi, Rwanda, Nigeria, Tanzania, Ghana, Uganda, Pakistan, Malaysia, Singapore, and Bangladesh [4]. However, there are 59 countries which made strides towards the decriminalization of suicide. These countries belong to Europe, North America, a majority of South America, and few part of Asia [4].

There can be numerous arguments against the decriminalization of suicidal attempts. However, the authors will like to focus on two key reasons in favor of decriminalization. Religion can play a key role in shaping the life of an individual and can act as a code of conduct for its followers. Religious beliefs can be protective against the suicidal behaviors but lawmakers and stake holders should carefully approach legalization based on the religious beliefs. Suicide attempts and behaviors are related to the complex interplay of biological, psychological, social and environmental factors. The criminal prosecution creates a stigma and fear of legal consequences which prohibits these individuals from seeking help.

Furthermore, there is recently more focus on understanding the genetic factors affecting the pathophysiology of suicide. Several biological factors including dysregulated hypothalamic-pituitary-adrenal (HPA) axis, inflammatory cytokines, and minerals have been associated with an increased risk of suicide [5]. An abnormal HPA axis, low plasma interleukin (IL)-2, tumor necrosis factor-α, interferon-γ, transforming growth factor-β, IL-4, and soluble Il-2 receptors have been linked to an increased suicide with variable results [5]. Considering the above-mentioned reasons, there should be an international advocacy effort to decriminalize suicide attempt.


Centers for Disease Control and Prevention. (2015). Understanding suicide fact sheet. Retrieved June 14, 2015.

World Health Organization. (2017). Suicide. World Health Organization. Retrieved 6 September 2017, from

Waqas, A., Zubair, M., Ghulam, H., Ullah, M. W., & Tariq, M. Z. (2014). Public stigma associated with mental illnesses in Pakistani university students: a cross sectional survey. PeerJ, 2, e698.

Ranjan, R., Kumar, S., Pattanayak, R. D., Dhawan, A., & Sagar, R. (2014). (De-) criminalization of attempted suicide in India: A review. Industrial Psychiatry Journal, 23(1), 4–9.

Ganança, L., Oquendo, M. A., Tyrka, A. R., Cisneros-Trujillo, S., Mann, J. J., & Sublette, M. E. (2016). The role of cytokines in the pathophysiology of suicidal behavior. Psychoneuroendocrinology, 63, 296-310.
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