Medical Information Distribution Service: Minds defines a clinical guideline as “a document that evaluates the total body of evidence through a systematic review and presents recommendations that are considered optimal, taking into account the balance of benefits and harms, in order to support decision making by healthcare users and providers on important health issues.” Minds also presents a series of guideline development methods, from the formulation of the clinical question, systematic review, synthesis and evaluation of evidence, and development of the recommendation statement. While this method is extremely useful for clinical questions for which high quality evidence can be obtained through systematic review, it is difficult to apply to clinical questions for which high quality evidence is difficult to obtain. Alternative methods include summarizing expert consensus or consensus statements, or describing narrative reviews. Regardless of the method used, the guideline development process should specify the purpose of the guideline development, the members who will develop it, how it will be developed, and how it will be published.

We often come across difficult-to-treat cases with Electroconvulsive Therapy (ECT). This article aims to review and summarize the evidence to resolve these difficult cases, with a focus on changing the stimulus parameters of the ECT device. As electrode placement, right unilateral ECT is more likely to induce seizures than conventional bilateral ECT, and is the most recommended in terms of cognitive deficit. Furthermore, right unilateral ECT with ultra-brief pulse widths would make it easy to induce appropriate seizure. On the other hand, to elongate pulse width might possibly be more effective for difficult cases. Only the case series which resulted in lower pulse settings could resolve seizure induction difficulties. The mechanism to induce or miss seizure is not well known. We have to provide a better way of augmentation for each patient, referring to limited evidence.

Among the factors affecting the efficacy of electroconvulsive therapy (ECT), the most important and widely recognized is the occurrence of generalized seizures. In clinical practice, there are patients who reach the upper limit of the amount of electricity that can be delivered by ECT devices without inducing generalized convulsive seizures, so-called “Difficult-to-induce-seizures ECT cases.” In this article, we would like to present some anesthetic measures to be taken in such cases. The main approaches are divided into two types of anesthetic agents and anesthetic techniques. The former includes information on approaches to propofol, barbiturate anesthetics, ketamine, sevoflurane, remifentanil, dexmedetomidine, and flumazenil, and the latter includes information on adjusting the timing of induction and hyperventilation. The latter includes timing of electrical current and implementation of hyperventilation.

In the field of electroconvulsive therapy (ECT), various techniques have been proposed to address situations where therapeutic seizures cannot be induced even after maximum stimulation (504 mC) with Japanese therapeutic devices. The ECT Committee of the Japanese Society of General Hospital Psychiatry, has been actively developing guidelines for the treatment of difficult-to-induce seizure cases. This report serves as a preliminary literature review of these various techniques. The paper discusses the utility and specific methods of each technique, which are categorized into three groups: 1) drug modification, 2) anesthesia-related approaches, and 3) other ECT techniques.

Nalmefene, when combined with psychosocial treatment, is used to decrease alcohol consumption in patients diagnosed with alcohol use disorder. In our study, we assessed the efficacy and safety of nalmefene based on medication status during a multidisciplinary intervention at the Department of Hepatology of a general hospital, which lacks a specialized outpatient alcohol clinic system. We included 17 patients in our study. They were categorized based on the frequency of nalmefene use: four patients were nalmefene-interruption, nine used nalmefene as-needed, and four received regular doses of nalmefene. We calculated the Alcohol Use Disorders Identification Test (AUDIT) scores and the number of drinking days per week before and after nalmefene administration. Both the AUDIT scores and the number of drinking days per week showed a decreasing trend in some patients across all groups. Three patients experienced side effects, and only one had an adverse reaction that necessitated the discontinuation of medication. This study examined the use of nalmefene in the Department of Hepatology of a general hospital. Further studies are expected to clarify the efficacy and safety of nalmefene.

Chronic pain reduces the quality of life (QOL) of the patient; therefore, psychosocial support is required. In this study, we report a case of cognitive behavioral therapy for a patient with poor satisfaction owing to pervasive pain-coping behaviors. Notably, the vicious cycle was reviewed and replaced by goal-directed behaviors. In the early part of the therapy, the patient recognized that her pain-coping behavior was interfering with her future goals and increasing her depressive mood. Later in the therapy, she gradually and systematically practiced goal-directed behaviors without attachment to pain. The relocation of the patient left the long-term effects of the treatment unclear because it ended without sufficient recurrence prevention. Opportunities to experience feelings of pleasure and mastery increased during the treatment period, and depressive symptoms and QOL improved. Pain is experienced and understood polymorphically; therefore, treatment targets may differ in each department. Overall, this case is an example of an approach focused on decreasing pain behaviors rather than pain and may facilitate multidisciplinary understanding.

Recently, obsessive-compulsive disorder (OCD) has been reported to co-occur with various diseases, particularly autoimmune diseases. In this study, we report a case of neuromyelitis optica (NMO), an autoimmune disease characterized by optic and central neuritis, accompanied by anti-AQP4 antibodies, and OCD symptoms that appeared during NMO relapse. Once the patient developed OCD, symptoms of OCD persisted regardless of NMO progression and developed autonomously; OCD symptoms that appeared during NMO exacerbation were not related to NMO status. The OCD symptoms improved with SSRI administration. These results suggest that the patient’s development of OCD was triggered by NMO, however, the disease course was not associated with NMO, and the results also that SSRIs and other pharmacotherapy may be effective in addressing this condition.