Alone Together

How one U-M researcher is raising global awareness of the hikikomori phenomenon

Mr. H didn’t leave his apartment for three years. For the first year, he sequestered himself in a walk-in closet. A housemate supplied him with junk food, and he passed the time surfing the internet and playing video games. And while Mr. H. said disdain for society drove him to seclusion, it was also a source of distress. One day, the 30-year-old reached out to psychiatrist Alan Teo, M.D.

In 2009, Teo, a Robert Wood Johnson Foundation Clinical Scholar at the U-M, was the first physician to publish a review in English medical literature of hikikomori, a phenomenon of severe social withdrawal gaining prevalence among young adults in Japan; government estimates place the number of hikikomori in the island nation around 700,000 — more than the population of Seattle, Washington. Mr. H. had come across Teo’s work and sought his help reentering society.

This chance encounter led this year to the publication of a report about Mr. H., who became the first documented case of hikikomori in the Americas. Others have been reported in Spain, Italy, Oman and Korea.

Factors in Japanese society and family structure are often highlighted as major contributors to the disorder, but whether it’s unique to the Japanese culture is not merely an academic question, says Teo. “It’s clearly most prevalent in Japan, but there’s growing evidence that hikikomori exist all over the world,” he adds, noting that social isolation can be as deadly as smoking or excessive alcohol consumption. In May, Teo participated in a symposium at the Japanese Society of Psychiatry and Neurology’s 108th annual meeting that explored the international nature of the disorder.

Becoming a recluse is nothing new, but it’s a question of prevalence and degree, says Teo. “We’re not pathologizing or creating illnesses,” he says. “These are people who are no longer able to function in their daily lives, and who are extremely troubled by their isolation and loneliness. Everyone goes through periods of relative withdrawal, but for these individuals it becomes a way of life.” A 2010 epidemiologic study found that one out of every 100 Japanese adults between the ages of 20 and 49 reported experiencing a hikikomori episode — defined as withdrawal lasting at least six months — with about half of them showing no indication of additional mental health conditions.

Some scientists hypothesize that the isolating effects of modern technology may be driving the phenomenon, at least in part. “Researchers in Korea have found a link between hikikomori and Internet addiction, which the national government is already treating as a significant public health problem,” says Teo.

Internet addiction is just one of the areas Teo and colleagues from India, Japan and Korea are examining in an ongoing study that will for the first time analyze the disorder cross-culturally.

By raising awareness about hikikomori, Teo hopes people like Mr. H. may be able to get help earlier. “The data indicate that people don’t come in for treatment until they have been suffering for a year or more,” he says. “It’s like if a person waits until they’re 300 pounds before they try to lose weight; it’s going to be really hard to get back to a healthy state. We need the public to keep an eye out for their loved ones and friends, so that they’re able to recognize a problem before months or years have gone by.” —IAN DEMSKY

 

Hospitals Eye U-M Program for Patients on Ventilators

Just because a patient is on a ventilator doesn’t mean she should be confined to bed. The U-M Health System’s Early Mobility Program has been helping to get critically ill patients up and about sooner — a countermeasure against ills of extended immobility like bed sores, pneumonia and weakness.

“Bed rest orders have been replaced with progressive mobility orders,” says Sharon Dickinson, a critical nurse specialist in the Surgical Intensive Care Unit. As a result of the protocol, which Dickinson has dubbed “moving and grooving,” pressure ulcers have been drastically reduced. And at the Critical Care Medical Unit, patients spent an average of a day and a half less on the ventilator, while the length of their typical hospital stay dropped by six days — from 22.3 to 16.4.

These successes have led to the program’s expansion to units across the Health System. Other hospitals are taking note as well. Beaumont Hospital and the Detroit Medical Center have made site visits to the U-M to learn about the program, and the “lean thinking” approach has been shared at national conferences.

“It may look awkward, but it works,” says physical therapist Don Packard, a lecturer in the Department of Physical Medicine and Rehabilitation. “Many patients actually prefer it. They don’t want to be tied down.” —ID

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A Helping Hand

Electrocardiography routinely is used in clinics and hospitals, yet the ECG’s central leads can easily be placed incorrectly, potentially resulting in false findings of ischemia and infarction. Misdiagnoses can have consequences for patients, like delaying surgery or botching pre-employment health screenings.

A simple technique to ensure correct placement of the V1 and V2 leads was successfully piloted by Michael Lehmann, M.D., a professor of internal medicine in the Division of Cardiovascular Medicine, and U-M physiologist Aimee M. Katona. Their three-step maneuver (“Hand-down-2 for V1V2”) starts with the patient placing his hand around the base of his neck; one then counts downward from a spot near the patient’s wrist to locate the correct intercostal space for placement. A detailed description of the method was made available online ahead of print publication in the Journal of Emergency Medicine. —ID

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Longer CPR Attempts May Benefit Some Patients

Only 1 of every 5 hospitalized patients who go into cardiac arrest survives to be discharged. For physicians, the challenge becomes one of assessing the point at which resuscitation efforts cross the line into futility.

When it’s effective, CPR often restores circulation fairly quickly, with a median duration of 12 minutes, according to a U-M analysis of data from 435 U.S. hospitals. However, the study of more than 64,000 patients found that hospitals where resuscitation efforts are generally continued for longer periods of time had better outcomes than those making shorter attempts, suggesting there may be some benefit in continuing efforts under certain circumstances.

Concerns about harming patients with long efforts were also considered. About 15 percent of survivors needed at least 30 minutes to restore their pulse, according to the findings, which were published in The Lancet, and importantly, they did not have substantially worse neurological function at discharge than those who survived less prolonged efforts.

The study, however, does not pinpoint an optimal length for CPR efforts, says senior study author Brahmajee K. Nallamothu, M.D., M.P.H. (Fellowship 2004), an associate professor of cardiology.

Co-author Steven L. Kronick, M.D., M.S. (Residency 1989), an emergency physician who heads U-M’s CPR committee, says that while care for individual patients should remain a bedside decision based on clinical judgment, the analysis suggests opportunities for system-level improvements.

The study indicates that extending the minimum duration of CPR efforts by 10 or 15 minutes might save lives with only a minimum investment of additional resources, the authors say, cautioning that further study is still needed. —ID

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Health Briefs

Often pregnant women are reluctant to take medication for depression, but doctors at U-M may have an alternative to recommend. A 10-week mindfulness-based yoga intervention significantly reduced symptoms in psychiatrically high-risk women, a recent pilot study found. Mindfulness-based yoga incorporates exercise with meditative awareness of the body.

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A small group of glaucoma patients accounts for a large percentage of care expenditures, according to a new study by researchers at the U-M Kellogg Eye Center and colleagues. Analyzing data from a large U.S. managed care network, they found that a 5 percent subset of patients accounted for 24 percent of spending. Better understanding of patient characteristics may help lower overall costs.

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When a patient’s blood pressure remains uncontrolled, it may indicate the current treatment isn’t aggressive enough, but it also can mean the patient isn’t taking his medicine as prescribed. A study by researchers at the U-M and VA Ann Arbor Healthcare System found providers recognized non-adherence less than half of the time in patients with significant refill gaps, and frequently chose to intensify their medications. Incorporating objective measurements of drug adherence into patient visits could help providers make better decisions, the authors report. —ID

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