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Yoshiteru Sato,1 Norio Sugawara,1 Yasushi Kawamata,1 Kazutaka Shimoda,1 Norio Yasui-Furukori1,2 1Department of Psychiatry, Dokkyo Medical University School of Medicine, Mibu, Japan; 2Department of Neuropsychiatry, Hirosaki Medical University, Graduate School of Medicine, Hirosaki, JapanCorrespondence: Norio Yasui-Furukori, Department of Psychiatry, Dokkyo Medical University School of Medicine, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan, Tel +81-28-287-2153, Fax +81-28-286-5187, Email furukori@dokkyomed.ac.jpPurpose: Low health literacy has been associated with adverse outcomes in health maintenance and the course of chronic physical illness. In particular, anxiety disorders can also affect one’s physical health, causing issues including cardiovascular, respiratory, gastrointestinal and immune system disorders. However, there are no reports on physical health literacy among Japanese patients with mental illness.Patients and Methods: A patient background questionnaire, the Japanese version of the Ten-Item Personality Inventory, and the Japanese version of the Health Literacy Scale (HLS-EU-Q47; European Health Literacy Survey Questionnaire) were distributed face to face to 1000 psychiatric outpatients. A total of 785 valid responses including 211 patients with schizophrenia, 261 patients with mood disorders, and 234 patients with anxiety disorders were obtained by mail.Results: Health literacy was “limited” in 52% of patients with schizophrenia, 51% of those with mood disorders, and 38% of those with anxiety disorders. Among patients with mood disorders, there were no differences between those with major depressive disorder and those with bipolar disorder. Anxiety disorders were associated with higher health literacy than schizophrenia and mood disorders (odds ratio (OR) 1.85, 95% confidence interval (95% CI) 1.07, 3.34), and in terms of personality, neuroticism (OR 0.85, 95% CI 0.75, 0.97) and openness (OR 0.85, 95% CI 0.74, 0.98) were associated with limited health literacy, while agreeableness (OR 1.36, 95% CI 1.18, 1.57) and extraversion OR 1.34, 95% CI 1.17, 1.52) were associated with higher health literacy.Conclusion: The results of this study indicate limited health literacy in patients with mental illness, in particular, limited health literacy in outpatients with schizophrenia and mood disorders. In addition, gender and some personality traits were associated with physical health literacy. Based on these results, physical health education should be individualized.Keywords: health literacy, mental illness, anxiety disorders, personality traits

Norio Yasui-Furukori,1,2 Yasushi Kawamata,1,3 Taro Sasaki,1,4 Saaya Yokoyama,1,5 Hiroaki Okayasu,1,6 Masataka Shinozaki,1,7 Yoshitaka Takeuchi,1,8 Aoi Sato,1,9 Takaaki Ishikawa,1,10 Hazuki Komahashi-Sasaki,1,11 Kensuke Miyazaki,12 Takashi Fukasawa,13 Hanako Furukori,14 Norio Sugawara,1,2 Kazutaka Shimoda1 1Department of Psychiatry, Dokkyo Medical University, School of Medicine, Tochigi, Japan; 2Department of Psychiatry, TMC Shimotsuga, Tochigi, Japan; 3Department of Psychiatry, Kikuchi Hospital, Tochigi, Japan; 4Department of Psychiatry, Asahi Hospital, Tochigi, Japan; 5Department of Psychiatry, Aoki Hospital, Tochigi, Japan; 6Department of Psychiatry, Fudogaoka Hospital, Saitama, Japan; 7Department of Psychiatry, Takizawa Hospital, Tochigi, Japan; 8Department of Psychiatry, Okamotodai Hospital, Tochigi, Japan; 9Department of Psychiatry, Muroi Hospital, Tochigi, Japan; 10Department of Psychiatry, Saitama-Konan Hospital, Saitama, Japan; 11Department of Psychiatry, Kanuma Hospital, Tochigi, Japan; 12Department of Neuropsychiatry, Hirosaki-Aiseikai Hospital, Aomori, Japan; 13Department of Psychiatry, Seinan Hospital, Aomori, Japan; 14Department of Neuropsychiatry, Kuroichi-Akebono Hospital, Aomori, JapanCorrespondence: Norio Yasui-Furukori, Department of Psychiatry, Dokkyo Medical University, School of Medicine, Mibu, Shimotsuga, Tochigi, 321-0293, Japan, Tel +81-282-86-1111, Fax +81-282-86-5187, Email furukori@dokkyomed.ac.jpBackground: Recent pharmacoepidemiology data show an increase in the proportion of patients receiving second-generation antipsychotic (SGA) monotherapy, but no studies have analyzed the same patients over a long period of time. Therefore, in this study, we retrospectively evaluated schizophrenia patients with available data for 20 years to determine whether the drug treatments in the same patients have changed in the past 20 years.Methods: The study began in April 2021 and was conducted in 15 psychiatric hospitals in Japan. Schizophrenia patients treated in the same hospital for 20 years were retrospectively examined for all prescriptions in 2016, 2011, 2006, and 2001 (ie, every 5 years).Results: The mean age of the 716 patients surveyed in 2021 was 61.7 years, with 49.0% being female. The rate of antipsychotic monotherapy use showed a slight increasing trend over the past 20 years; the rate of SGA use showed a marked increasing trend from 28.9% to 70.3% over the past 20 years, while the rate of SGA monotherapy use showed a gradual increasing trend over the past 20 years. The rates of concomitant use of anticholinergics, antidepressants, anxiolytics/sleep medications, and mood stabilizers showed decreasing, flat, flat, and flat trends over the past 20 years, respectively.Conclusion: The results of this study showed a slow but steady substitution of SGAs for first-generation antipsychotics (FGAs) over time, even in the same patients.Keywords: pharmacoepidemiology, prescription, antipsychotics, trends, schizophrenia

Norio Sugawara,1– 3 Norio Yasui-Furukori,1,3 Sonoko Yamada,3 Mei Aoki,3 Yoshitaka Takeuchi,1,4 Kensuke Miyazaki,5 Kazutaka Shimoda1 1Department of Psychiatry, Dokkyo Medical University School of Medicine, Tochigi, Japan; 2Department of Clinical Epidemiology, Translational Medical Center, National Center of Neurology and Psychiatry, Tokyo, Japan; 3Department of Neuropsychiatry, Hirosaki University, School of Medicine, Aomori, Japan; 4Shiseikai, Takizawa Hospital, Tochigi, Japan; 5Department of Neuropsychiatry, Hirosaki-Aiseikai Hospital, Aomori, JapanCorrespondence: Norio Sugawara, Department of Psychiatry, Dokkyo Medical University School of Medicine, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan, Tel +81-28-287-2153, Fax +81-28-286-5187, Email nsuga3@dokkyomed.ac.jpBackground: Decision-making capacity for patients with psychiatric disorders is an important and controversial issue in clinical care settings. The aim of this study was to (1) evaluate the level of decision-making capacity of older institutionalized patients suffering from schizophrenia and (2) determine whether their diminished capacity is associated with specific aspects of cognitive impairment.Methods: Using a cross-sectional design, we recruited 48 older institutionalized patients (mean age ± standard deviation: 60.0 ± 14.0 years) who were diagnosed with schizophrenia. Participants underwent the assessments by the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) and the Japanese version of the Brief Assessment of Cognition in Schizophrenia (Japanese-BACS).Results: The understanding summary scores of the MacCAT were found to have a significant positive correlation with the attention and verbal fluency subscale scores of the Japanese-BACS and negative correlations with age and duration of illness. In addition, the appreciation and reasoning summary scores had a significant negative correlation with age. In a linear regression model with a stepwise selection procedure, age, sex, and verbal fluency subscale scores were associated with understanding summary scores.Conclusion: The generally poor cognitive performance of inpatients with chronic schizophrenia indicated that the informed consent process for their treatment might pressure these patients on the basis of cognitive demands. It is necessary for psychiatrists to assess individual decision-making capacity and to increase their patients’ involvement in the treatment process.Keywords: cognitive function, competence to consent, decision-making capacity, schizophrenia

Yasushi Kawamata,1 Norio Sugawara,1,2 Masamichi Ishioka,3 Kazutoshi Kubo,4 Katsuji Suzuki,5 Akira Fujii,6 Hanako Furukori,7 Taku Nakagami,8 Norio Yasui-Furukori,1,2 Kazutaka Shimoda1 1Department of Psychiatry, Dokkyo Medical University School of Medicine, Mibu, Japan; 2Department of Neuropsychiatry, Hirosaki University Graduate School of Medicine, Hirosaki, Japan; 3Department of Psychiatry, Minato Hospital, Hachinohe, Japan; 4Department of Neuropsychiatry, Hirosaki-Aiseikai Hospital, Hirosaki, Japan; 5Department of Psychiatry, Aomori Central Hospital, Aomori, Japan; 6Department of Neuropsychiatry, Mutsu General Hospital, Mutsu, Japan; 7Department of Neuropsychiatry, Kuroishi-Akebono Hospital, Kuroishi, Japan; 8Department of Psychiatry, Nakagami Mental Clinic, Ohdate, JapanCorrespondence: Norio Yasui-FurukoriDepartment of Psychiatry, Dokkyo Medical University School of Medicine, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, JapanTel +81-28-287-2153Fax +81-28-286-5187Email furukori@dokkyomed.ac.jpBackground: Concern regarding the benefit/risk ratio of the long-term use of benzodiazepines (BDZs) and Z-drugs is increasing. To prevent the risk of dependence in BDZ long-term use, it is essential to understand the attitudes of patients and psychiatrists toward BDZ treatment. The aims of this investigation were to 1) obtain information on patients’ attitudes with long-term BDZ use and their referring psychiatrists’ attitudes toward BDZ treatment, including their perception of the difficulty of reducing the dose of BDZs, and 2) identify discrepancies between patients’ and psychiatrists’ perceptions.Methods: A brief questionnaire was constructed to investigate the attitudes of patients receiving BDZ treatment and their referring psychiatrists. Our sample comprised 155 patients who received BDZ treatment for more than one year and their referring eight psychiatrists. Both the patients and their psychiatrists completed our questionnaire between August 2017 and December 2017.Results: Of the patients, 13% felt that it was more difficult to reduce the dose of BDZs than their referring psychiatrists (type A discrepancy), while 25% felt that it was less difficult (type B discrepancy). In the multivariate logistic regression analysis, the female sex and both the patients’ (“psychotherapy plus BDZs was necessary” and “it was necessary to increase the dose of BDZs”) and psychiatrists’ beliefs (“short-term prescription was justified”) were associated with type A discrepancies. Type B discrepancies were associated with psychiatrists’ beliefs that the patient’s wishes justified the use of BDZs and that the cessation of treatment with BDZs would lead to the deterioration of their rapport with their patients.Conclusion: To overcome the discrepancies in the attitudes of patients and psychiatrists toward the cessation of BDZ treatment, it is necessary to promote patient-centered care involving patient psychoeducation and practice guidelines for the decision-making process. Further studies investigating the promotion of patient-centered care to reduce BDZ use are needed.Keywords: dependence, benzodiazepine receptor agonist, anxiolytics, hypnotics, belief

Hiroaki Okayasu,1 Takahiro Shinozaki,1 Yumiko Takano,1 Norio Sugawara,1 Kumiko Fujii,2 Norio Yasui-Furukori,1 Yuji Ozeki,2 Kazutaka Shimoda1 1Department of Psychiatry, Dokkyo Medical University, Tochigi, Japan; 2Department of Psychiatry, Shiga University of Medical Science, Shiga, JapanCorrespondence: Hiroaki Okayasu Tel +81 282-86-1111Email hokayasu@dokkyomed.ac.jpPurpose: Antipsychotic drugs have been implicated as risk factors for QT prolongation, which is a predictor of sudden cardiac death. However, the QT interval is considered an imperfect marker for proarrhythmic risk. Recently, improved methods, namely, QT dispersion (QTD), QTD ratio (QTDR), T wave peak-to-end interval (Tp-e), Tp-e/QT ratio and Tp-e/QTc ratio, have been regarded as proarrhythmic risk markers. We attempted to reevaluate the risk of sudden cardiac death due to antipsychotics use by measuring these improved evaluation methods.Patients and Methods: We retrospectively evaluated QTc, QTD, QTDR, Tp-e, Tp-e/QT ratio and Tp-e/QTc ratio from the medical records of 410 patients with schizophrenia diagnosed by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, or 5th Edition. Information on drugs administered was obtained from medical records. We investigated the correlation between each index on ECG and medication, such as antipsychotics, prescribed to participants with linear regression analysis. We also compared each index between 235 healthy controls and 235 patients matched for age and sex.Results: Positive correlations between QTc and levomepromazine and brexpiprazole were identified. Levomepromazine and lithium were positively correlated with QTD. Levomepromazine, quetiapine, asenapine, clozapine and carbamazepine were positively correlated with QTDR. Levomepromazine, olanzapine, brexpiprazole and lithium were positively correlated with Tp-e. Olanzapine, brexpiprazole and lithium were positively correlated with the Tp-e/QT ratio. Olanzapine, brexpiprazole and lithium were positively correlated with Tp-e/QTc ratio. Significant differences in all indexes were noted between the patients and healthy controls.Conclusion: According to our results, the prediction of the risk of sudden cardiac death by each index was inconsistent. We should evaluate the predictive factor of ventricular arrhythmia according to various electrocardiogram indexes because QTc alone could not identify the risk of sudden cardiac death.Keywords: antipsychotic drugs, sudden cardiac death, electrocardiogram, QT prolongation, QT dispersion, T peak-to-end interval

Norio Sugawara,1,* Norio Yasui-Furukori,1,* Toshinaga Tsuji,2 Shinji Hayashi,2 Yoshikazu Ajisawa,3 Toshimitsu Ochiai,3 Hideyuki Imagawa,4 Kazutaka Shimoda1 1Department of Psychiatry, Dokkyo Medical University School of Medicine, Tochigi, Japan; 2Medical Affairs Department, Shionogi & Co., Ltd., Osaka, Japan; 3Biostatistics Center, Shionogi & Co., Ltd., Osaka, Japan; 4Medicines Development Unit Japan, Eli Lilly Japan K.K., Kobe, Japan*These authors contributed equally to this workCorrespondence: Norio SugawaraDepartment of Psychiatry, Dokkyo Medical University School of Medicine, 880 Kitakobayashi, Mibu, Shimotsugagun, Tochigi 321-0293, JapanTel +81-28-287-2153Fax +81-28-286-5187Email nsuga3@dokkyomed.ac.jpPurpose: The objective of this post hoc analysis was to explore the relationship, including changes over time, between baseline clinical symptom characteristics and working ability, judged by investigators, after 12 weeks of antidepressant monotherapy in Japanese patients with major depressive disorder (MDD) and painful physical symptoms (PPS) in a real-world clinical setting.Patients and Methods: This prospective, observational study in patients treated with duloxetine or selective serotonin reuptake inhibitors was conducted from 2014 to 2016. Both treatment groups were pooled and divided into 2 groups, “working ability recovered” or “working ability not recovered,” based on working ability at the end of the study. Patients were also divided into 4 subgroups by the presence or absence of previous depressive episodes and working ability. Main outcome measures included baseline demographics and clinical characteristics, and the 17-item Hamilton Rating Scale for Depression (HAM-D17).Results: Comparison between “working ability recovered” (n=122) and “working ability not recovered” (n=91) showed that the percentage of patients with complications and psychotherapy at baseline, and baseline HAM-D17 total, insomnia, somatic, and anxiety scores, were significantly different. The results of subgroup analyses were mostly the same as the results analyzed by working ability alone. Although statistical differences were observed for some outcome measures, the differences at baseline, except use of psychotherapy, may not be applicable clinically, and there were no specific trends observed that could predict working ability.Conclusion: This post hoc analysis suggested that most baseline clinical characteristics, including the presence or absence of previous depressive episodes, were not predictive of working ability recovery. However, the use of psychotherapy in parallel with antidepressant monotherapy may be positively associated with working ability recovery. All outcome measures improved over time, reinforcing the importance of continuous treatment and observation to improve and accurately judge working ability in patients with MDD and PPS.Keywords: ability to work, antidepressants, depressive disorder, major, observational study, painful physical symptoms

Norio Sugawara,1,2 Norio Yasui-Furukori,1,2 Manabu Yamazaki,3 Kazutaka Shimoda,1,2 Takao Mori,3 Takuro Sugai,2,4 Hiroshi Matsuda,3 Yutaro Suzuki,2,4 Yuji Ozeki,2,5 Kurefu Okamoto,3 Toyoaki Sagae,3,6 Toshiyuki Someya2,4 1Department of Psychiatry, Dokkyo Medical University School of Medicine, Mibu, Tochigi 321-0293, Japan; 2Japanese Society of Clinical Neuropsychopharmacology, Chiyoda-ku, Tokyo 101-0003, Japan; 3Japan Psychiatric Hospital Association, Minato-ku, Tokyo 108-8554, Japan; 4Department of Psychiatry, Graduate School of Medical and Dental Sciences, Niigata University, Chuo-ku, Niigata 951-8510, Japan; 5Department of Psychiatry, Shiga University of Medical Science, Otsu, Shiga 520-2134, Japan; 6Department of Health and Nutrition, Yamagata Prefectural Yonezawa University of Nutrition Sciences, Yonezawa, Yamagata 992-0025, JapanCorrespondence: Norio SugawaraDepartment of Psychiatry, Dokkyo Medical University School of Medicine, 880 Kitakobayashi, Mibu, Tochigi 321-0293, JapanTel +81-28-287-2153 (extension: 7141)Fax +81-28-286-5187Email nsuga3@dokkyomed.ac.jpBackground: Reliable and easy screening for metabolic syndrome (MetS) is important for patients with schizophrenia. The aim of this study was to assess the predictive utility of body mass index (BMI) for MetS among patients with schizophrenia in Japan.Methods: In total, 8468 patients (4705 males, 3763 females) with schizophrenia or schizoaffective disorders based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), or the International Classification of Diseases, tenth revision (ICD-10), were assessed for MetS using the criteria of the National Cholesterol Education Program Adult Treatment Panel III (ATP III-A). We applied a stratum-specific likelihood ratio (SSLR) analysis, which is independent of the prevalence of the target disease.Results: The mean (± standard deviation) age of these patients was 57.4 ± 13.5 years. The prevalence of MetS was 20.4%. Among males, the SSLRs predicting MetS were 0.03 (95% CI 0.02– 0.06), 0.54 (95% CI 0.48– 0.60), 2.77 (95% CI 2.44– 3.14) and 8.75 (95% CI 7.40– 10.36) for BMI < 20 kg/m2, 20 kg/m2 ≤ BMI < 25 kg/m2, 25 kg/m2≤ BMI < 28 kg/m2, and 28 kg/m2≤BMI, respectively. For females, the SSLRs predicting MetS were 0.08 (95% CI 0.05– 0.12), 0.73 (95% CI 0.66– 0.82), 2.50 (95% CI 2.16– 2.90) and 4.83 (95% CI 4.12– 5.67) for the same BMI categories, respectively.Conclusion: The predictive utility of BMI is confirmed, and BMI has more predictive value in males than in females. Patients with a BMI of 28 kg/m2 or greater had a significantly higher SSLR than those with a BMI less than 28 kg/m2.Keywords: body mass index, metabolic syndrome, schizoaffective disorder, schizophrenia

Hiroaki Okayasu,1 Norio Yasui-Furukori,1 Taro Kadowaki,2 Kei Funakoshi,2 Koichi Hirata,2 Kazutaka Shimoda1 1Department of Psychiatry, Dokkyo Medical University, Tochigi, Japan; 2Department of Neurology, Dokkyo Medical University, Tochigi, JapanCorrespondence: Hiroaki Okayasu Tel +81-282-86-1111Email hokayasu@dokkyomed.ac.jpAbstract: Functional neurologic disorders feature nervous system symptoms that cannot be explained by a neurological disease or other medical condition. The patient described here was a 21-year-old Japanese woman who was initially diagnosed with a functional neurologic disorder based on numbness and weakness of the limbs with no abnormalities in routine examinations. Further detailed examinations revealed monocytes in cerebrospinal fluid (CSF), and electroencephalography revealed widespread, low-voltage, slow waves with concentrated spindle waves. Thus, encephalitis was suspected, and steroid pulse therapy was initiated. Her symptoms subsequently improved. Afterward, CSF analysis was positive for serum anti-GQ1b IgG antibodies. We made a final diagnosis of Bickerstaff’s brainstem encephalitis (BBE). Our report describes the difficult differentiation of functional neurologic disorders from BBE. Physicians and psychiatrists should be aware of BBE.Keywords: Bickerstaff’s brainstem encephalitis, functional neurologic disorder, Guillain-Barré syndrome, Miller Fisher syndrome, consciousness disturbance

Kenji Tsuchiya,1 Shinichi Mitsui,1 Ryuji Fukuyama,2 Noriki Yamaya,3 Takaaki Fujita,4 Kaori Shimoda,1 Fusae Tozato1 1Department of Rehabilitation Sciences, Gunma University Graduate School of Health Sciences, Gunma, 2Department of Rehabilitation, Gunma Seishi Ryougoen, Gunma, 3Department of Health Sciences, Gunma University School of Medicine, Gunma, 4Department of Rehabilitation, Faculty of Health Sciences, Tohoku Fukushi University, Miyagi, Japan Purpose: Although acute bouts of exercise reportedly have beneficial effects on executive function, inactive people may find it difficult to start exercising. In this study, we focused on housework activities (HAs) that generate a sense of accomplishment and require a mild intensity of physical activity. We examined the impact of an acute bout of HA on executive function and oxygenated hemoglobin (oxy-Hb) flow to related cortical regions. Materials and methods: Twenty-five participants (age, 18–21 years; mean, 19.88±0.60 years; six males and 19 females) underwent two experiments, ie, HA and control experiments, which were conducted on different days. Participants vacuumed a dirty floor in the HA experiment and mimicked the same motion with an unplugged vacuum cleaner on a clean floor in the control experiment.Results: Heart rate recorded during the experiments showed no significant difference in the intensity of physical activity between control and HA groups. A questionnaire revealed a sense of accomplishment after completing the HA experiment. Participants performed the Stroop color–word task (SCWT) pre- and post-experiments; cortical hemodynamic changes were simultaneously monitored using functional near-infrared spectroscopy. Variation in Stroop interference scores for SCWT total response between pre- and post-experiments was significantly higher in the HA group than in the control group, and that for SCWT correct response showed a similar trend. Variation in the Stroop interference score for oxy-Hb flow to the right ventrolateral prefrontal cortex (R-VLPFC) showed the same trend.Conclusion: Thus, HAs may have a greater beneficial effect on executive function than other physical activities through the activation of PFC, including R-VLPFC. Keywords: cognitive function, near-infrared spectroscopy, cleaning, stroop interference, positive emotion, prefrontal cortex

Akiko Aoki,1 Shin Ishiguro,1 Takashi Watanabe,1 Mikito Ueda,1 Yuki Hayashi,1 Kazufumi Akiyama,2 Kazuko Kato,3 Yoshimasa Inoue,1 Shoko Tsuchimine,4 Norio Yasui-Furukori,4 Kazutaka Shimoda11Department of Psychiatry, 2Department of Biological Psychiatry and Neuroscience, Dokkyo Medical University School of Medicine, Tochigi, Japan; 3Sakura La Mental Clinic, Tochigi, Japan; 4Department of Neuropsychiatry, Hirosaki University Graduate School of Medicine, Aomori, Japan Objective: The aims of the present study were to analyze the association between discontinuation of paroxetine (PAX) and the genetic variants of the polymorphism in the serotonin ­transporter gene-linked polymorphic region (5-HTTLPR) in Japanese patients with panic disorder (PD) and major depressive disorder (MDD).Methods: The 5-HTTLPR genotype was determined by polymerase chain reaction method. PAX plasma concentration was measured by high-performance liquid chromatography to confirm adherence.Results: When comparing between the PD and MDD patients with the chi-square test and Fisher’s exact test, the PD patients had a significant and higher discontinuation rate due to nonadherence than did the MDD patients (13.5% [7/52] versus 0% [0/88], respectively; P

Kengo Shimoda, Mahito Kimura Nippon Medical School Department of Psychiatry, Nippon Medical School, Chiba Hokusou Hospital, Chiba, Japan Abstract: Many emotional disturbances such as post-stroke depression (PSD) and emotional incontinence (EI) commonly occur following cerebrovascular events. The efficacy of antidepressants for these conditions has been established but their comorbid treatment has not been well characterized. In the current study, the authors describe two cases of post-stroke emotional dysregulation; one case with EI; and the other with EI complicated by PSD. The authors describe their differential responses to treatment. Case 1 developed EI after an infarct due to occlusion of the penetrating branches of the left middle cerebral artery (MCA). Case 2 developed both PSD and EI after right MCA stem occlusion. Both patients were initially treated with the selective serotonin reuptake inhibitor (SSRI) paroxetine. Case 1 reacted promptly to SSRI treatment. However, Case 2 had only a partial response to paroxetine, even after many months of treatment. Adjunctive therapy with low-dose aripiprazole was eventually added, resulting in complete improvement of both EI and PSD after 2 additional months of treatment. Thus, Case 2 required a different treatment strategy than Case 1. These findings suggest that aripiprazole adjunctive therapy could be effective for some complex post-stroke emotional disorders. Keywords: post-stroke disorder, post-stroke depression, emotional incontinence, antidepressants, aripiprazole adjunctive therapy