Yusuke Arai

Background: The Effectiveness of Guidelines for Dissemination and Education in Psychiatric Treatment (EGUIDE) project is a nationwide Japanese educational program promoting guideline‐concordant pharmacotherapy for schizophrenia and major depressive disorder (MDD). Psychiatrists' self‐reported clinical behavior (CB) scores after EGUIDE training are partially associated with objective quality indicators of specific practices. However, their association with comprehensive objective measures of overall guideline adherence remains unclear. Methods: This multicenter observational study included 1897 EGUIDE‐trained psychiatrists. CB was assessed online immediately after training. The Guideline Adherence Rate (GAR) was calculated for 5328 patients with schizophrenia and 3538 patients with MDD whose discharge records were linked to their psychiatrist's CB score. Associations were evaluated using unadjusted patient‐level Spearman correlations, without modeling clustering within psychiatrists or institutions. Sensitivity analyses aggregated the data to the psychiatrist‐year level, adjusted for institution type, psychiatrist experience, and patient age, and used generalized estimating equations (GEE) to correct the patient‐level inference for clustering. Results: CB scores showed positive but very weak correlations with GAR (schizophrenia, ρ = 0.09–0.14; MDD, ρ = 0.08–0.11; all p < 0.001). Squared coefficients (approximately 0.006–0.020) indicated that CB scores accounted for < 2% of the rank‐order variation in GAR. These associations remained statistically significant in psychiatrist‐year‐level, covariate‐adjusted, and clustering‐corrected (GEE) sensitivity analyses. Conclusions: Post‐training self‐reported CB scores were weakly associated with patient‐level GAR. Given the cross‐sectional, unadjusted analysis and the non‐independence of patients treated by the same psychiatrist, these findings do not establish CB as a reliable proxy for actual clinical practice. Trial Registration: University Hospital Medical Information Network Clinical Trials Registry, UMIN000022645

Aim: Psychiatric comorbidities are common among patients admitted to the intensive care unit (ICU), but findings regarding their impact on clinical outcomes remain inconsistent. Additionally, existing studies have often included patients admitted for suicide attempts or self‐harm, leaving insufficient evidence about the independent effects of psychiatric comorbidity on clinical outcomes. To address this gap, this study investigated the independent association of psychiatric comorbidity with ICU length of stay, hospital length of stay, and in‐hospital mortality among patients admitted to the ICU, excluding those admitted for suicide attempts or self‐harm. Methods: Of the 2599 patients admitted to the ICU of a university hospital, 2192 were included in the analysis. After adjusting for age, sex, body mass index, admission category, and severity score, generalized linear models were used to evaluate ICU and hospital length of stay, and logistic regression analysis was used to assess in‐hospital mortality. Results: Among the 2192 patients included in the analysis, 75 had psychiatric comorbidity. In adjusted analyses, psychiatric comorbidity was not significantly associated with ICU length of stay, hospital length of stay, or in‐hospital mortality. Conclusion: No participants were admitted to the ICU for suicide attempts or self‐harm, and psychiatric comorbidity was not an independent predictor of ICU length of stay, hospital length of stay, or in‐hospital mortality. Thus, in this ICU population, no statistically significant association was detected between psychiatric comorbidity and short‐term clinical outcomes. Therefore, caution is needed when estimating ICU outcomes based solely on the presence of psychiatric comorbidity.

Background: Schizophrenia is characterized by positive symptoms, negative symptoms, and cognitive impairment and is primarily treated with antipsychotic medications. However, a subset of patients responds inadequately to treatment and is classified as having treatment‐resistant schizophrenia (TRS). The prevalence of TRS among patients with schizophrenia remains insufficiently characterized. This study aimed to determine the prevalence of TRS using nationwide data and standardized diagnostic criteria. Methods: This study included patients with schizophrenia who were discharged between 2016 and 2024 from 205 institutions participating in the Effectiveness of Guidelines for Dissemination and Education in Psychiatric Treatment (EGUIDE) project and authorized to prescribe clozapine. TRS was defined according to standardized diagnostic criteria used in Japan. The prevalence of TRS was calculated among patients who underwent a TRS examination by their treating psychiatrist. Results: Among 18 914 patients, 9870 (52.2%) underwent a TRS examination. Among these 9870 patients, 2819 were classified as having TRS, corresponding to a prevalence of 28.6%. Among the 2819 patients with TRS, 1307 were prescribed clozapine at discharge, corresponding to a clozapine treatment rate of 46.4%. Conclusions: This study had the largest sample size among single‐cohort studies investigating the prevalence of TRS. The prevalence of TRS was 28.6% among patients with schizophrenia who underwent a TRS examination and was nearly identical to the pooled prevalence reported in studies at low risk of bias in a previous meta‐analysis. These findings may provide important evidence regarding the prevalence of TRS in routine clinical practice.

Aim: This study aimed to describe the nationwide reach, longitudinal growth, and geographic dissemination of the Effectiveness of Guideline for Dissemination and Education in Psychiatric Treatment (EGUIDE) project in Japan from 2016 to 2024. Methods: The EGUIDE project is a nationwide, multicenter implementation initiative designed to promote the dissemination of clinical practice guidelines, specifically the Guidelines for Pharmacological Treatment of Schizophrenia and the Treatment Guidelines II: Major Depressive Disorder. The project provides educational lectures primarily for psychiatrists and other mental health professionals. We descriptively summarized the cumulative numbers of lectures delivered, participants enrolled, and participating institutions from 2016 to 2024. In addition, we calculated the proportion of hospitals with psychiatric departments that participated in each prefecture. Results: Between 2016 and 2024, a total of 194 guideline lectures on schizophrenia and major depressive disorder were conducted. The cumulative number of participants reached 4785 across 763 institutions, of which 592 were hospitals with psychiatric departments, corresponding to approximately 20% of all such hospitals nationwide. Participating hospitals were distributed across most prefectures in Japan, indicating broad geographic coverage. Conclusion: Over the 9‐year period, the EGUIDE project continuously delivered guideline lectures and steadily expanded its participant and institutional base. The nationwide distribution of participating institutions suggests that the project has established a broad implementation platform for psychiatric guideline dissemination in Japan. Continued efforts may further strengthen this dissemination network and support future evaluations of its impact on psychiatric practice.

Background: Educational interventions are widely used to promote guideline‐concordant psychiatric practice. However, it remains unclear whether participants' subjective satisfaction translates into actual changes in clinical behavior (CB). This study examined the association between subjective assessment (SA) scores of the EGUIDE training programs for schizophrenia and major depressive disorder (MDD) and CB. Methods: In this multicenter observational study, we analyzed data from psychiatrists who participated in the EGUIDE training program. SA scores were obtained immediately after training using standardized questionnaires assessing satisfaction with program content, knowledge, skills, and future clinical intentions. CB was evaluated using self‐report measures of guideline‐concordant practice in general, schizophrenia‐specific, and MDD‐specific domains. Associations between SA and CB scores were examined using Spearman's rank correlation coefficients. Results: A total of 1399 psychiatrists were included in the analysis. The comprehensive SA score showed a significant positive correlation with the comprehensive CB score ( r = 0.19, p < 0.001). Likewise, schizophrenia‐ and MDD‐specific SA scores were positively correlated with all CB domains, including general guideline use and disorder‐specific practices ( ρ = 0.14–0.19, all p < 0.001). Although effect sizes were small, the associations were consistent across disorders and clinical domains. Conclusions: Higher satisfaction with guideline‐based educational programs was associated with greater self‐reported guideline‐concordant CBs, suggesting that positive educational experiences may support improvements in psychiatric practice at the national level.

Aim: Psychiatrists often perceive their clinical practices as guideline‐concordant; however, discrepancies frequently exist between perceived and actual prescribing behaviors. To explore this gap, we examined the association between self‐assessed clinical behavior scores (CBs) and prescribing practices objectively evaluated using quality indicators (QIs) within the EGUIDE educational program framework for schizophrenia and major depressive disorder. Identifying such associations is essential for improving care quality and developing interventions fostering evidence‐based practice. Methods: A prospective observational multicenter study was conducted across Japan involving 820 psychiatrists from university, public, and private hospitals participating in EGUIDE, along with patients diagnosed with schizophrenia ( n = 6714) or major depressive disorder ( n = 3692) treated at these institutions. The outcome measures were associations between psychiatrists' CB scores and quality indicators (QIs) based on discharge prescriptions; these were analyzed using logistic regression adjusted for age, sex, and institution type. Results: For schizophrenia, CBs were significantly associated with 8 of 11 QIs, including treatment‐resistant assessment, antipsychotic monotherapy (with/without other psychotropics), absence of anxiolytics/hypnotics, mood stabilizers, anticholinergics, PRN psychotropics, and clozapine use. For major depressive disorder, 3 of 7 QIs showed significant associations: severity assessment, no anxiolytic/hypnotic prescriptions, and use of modified electroconvulsive therapy. Conclusion: Self‐assessed clinical behavior scores partially reflect actual prescribing practices. These findings highlight the value of incorporating subjective evaluations into clinical performance assessment tools to promote guideline adherence. Moreover, our results suggest that collecting self‐assessments may offer a feasible and scalable strategy for identifying areas where additional education or system‐level support is needed to enhance evidence‐based prescribing in diverse clinical settings. Trial Registration: University Hospital Medical Information Network registry identifier: UMIN000022645

Aim: Clinical practice guidelines have improved the quality and standardization of psychiatric care; however, their long‐term implementation in real‐world settings remains limited. The Effectiveness of the Guidelines for Dissemination and Education (EGUIDE) project was established to promote sustained evidence‐based practice through a multilayered educational program for psychiatrists in Japan. Methods: This multicenter observational study longitudinally tracked psychiatrists' self‐rated clinical behavior (CB) scores related to guideline adherence for up to 8 years after initial EGUIDE participation. CB was assessed using a validated questionnaire covering general guideline use (CB‐G), schizophrenia (CB‐S), and major depressive disorder (CB‐D), with a comprehensive index (CB‐C) representing the mean of all domains. Data were analyzed using the Kruskal–Wallis test, the Mann–Whitney U test, and the Bonferroni correction (two‐tailed p < 0.05). Results: A total of 1562 psychiatrists (mean age, 32.7 ± 7.1 years) were included. All CB indices (CB‐C, CB‐G, CB‐S, and CB‐D) significantly improved post training compared with the baseline (H = 831.2–984.0; all p < 10 ⁻⁷² ), with small‐to‐moderate effect sizes ( r = 0.09–0.29). These improvements were maintained throughout the 8‐year follow‐up, with no significant decline, and several domains showed small but continued increases between 3 and 7 years post training. Conclusion: The EGUIDE program achieved long‐term, sustained improvements in psychiatrists' guideline‐adherent clinical behaviors through an integrated system combining education, supervision, feedback, and follow‐up. This autonomous, cyclical framework represents a high‐impact model for continuous quality improvement and may be adaptable to other medical specialties.

Aim: Orexin‐A (OXA) is a neuropeptide that regulates arousal, behavior, and sleep–wake rhythms. While altered OXA levels have been observed in schizophrenia, longitudinal data are limited. This study examined the relationship between changes in serum OXA levels and physical activity, sleep, and psychiatric symptoms in patients with chronic schizophrenia. Methods: Seventeen long‐term inpatients with schizophrenia underwent assessments at baseline (T1) and again after 6 months (T2). Serum OXA levels, sleep and activity parameters derived from actigraphy, and psychiatric symptoms (evaluated with the Positive and Negative Syndrome Scale [PANSS]) were collected at both time points. Spearman's correlations were used to analyze associations between the T2–T1 change in serum OXA (ΔOXA) and the corresponding Δ values of each sleep, activity, and PANSS measure, to explore longitudinal associations among these variables. Results: ΔOXA was positively correlated with Δ step count ( ρ = 0.53, p = 0.03) and negatively correlated with Δ time in bed ( ρ = −0.50, p = 0.04). No significant associations were found with PANSS scores, other sleep parameters, pharmacotherapy, or body mass index. Conclusion: In this preliminary longitudinal sample, increases in serum OXA were linked to greater daytime activity and reduced time in bed, suggesting that orexinergic signaling may modulate behavioral regulation in schizophrenia beyond its established role in sleep–wake control. Larger studies, with adjustment for multiple comparisons, are warranted to evaluate OXA as a candidate biomarker or therapeutic target.

Objective: The Effectiveness Research on the Dissemination and Education of Psychiatric Clinical Practice Guidelines (EGUIDE Project) was launched in Japan to promote guideline‐adherent treatment for schizophrenia and major depressive disorder (MDD) through educational outreach programs. Although short‐term effects on participating physicians have been reported, the long‐term and facility‐wide effects remain unclear. This study evaluated whether guideline‐compliant treatment behaviors improved across institutions over time, indicating potential diffusion or spillover effects. Methods: We conducted a prospective observational study involving 298 psychiatric facilities between 2016 and 2023. Discharge prescriptions and treatment data were collected for 19 623 patients with schizophrenia and 9805 patients with MDD. Adherence to the guidelines was assessed using 11 schizophrenia quality indicators (QI‐S) and seven MDD quality indicators (QI‐D). We performed logistic regression analyses, adjusting for age, sex, and facility type, with Bonferroni correction for multiple comparisons. Results: For schizophrenia, significant year‐on‐year improvements were observed in seven of the 11 QI‐S, including assessment of treatment‐resistant schizophrenia (TRS) diagnosis (from 42.2% to 62.5%), use of modified electroconvulsive therapy (mECT; from 6.1% to 11.8%), and nonprescription of anticholinergics (from 70.7% to 81.7%). For MDD, three of the seven QI‐D showed improvement, including assessment of severity diagnosis (from 51.2% to 77.0%) and use of mECT (from 12.8% to 26.6%). Notably, the implementation of cognitive behavioral therapy (CBT) decreased. These findings suggest long‐term behavioral changes across all facilities, extending even to nonparticipating clinicians. Conclusion: The presence of EGUIDE‐trained psychiatrists was associated with sustained improvements in guideline‐compliant treatments at the institutional level. These results imply not only individual educational benefits but also a diffusion of practice culture—that is, a spillover effect—leading to enhanced quality of psychiatric care. Continued educational efforts are essential to improving treatment practices at scale. Trial Registration: The protocol for the EGUIDE Project is registered with the University Hospital Medical Information Network Registry (UMIN000022645)