Background and Objectives The efficacy and safety of lemborexant, a dual orexin receptor antagonist, for treating insomnia associated with depressive episodes remain unclear. This pilot study aimed to evaluate the changes in clinical symptoms following the initiation of lemborexant treatment and its safety in patients with insomnia comorbid with depressive episodes. Methods The inclusion criteria for this multicenter, prospective, interventional, open-label pilot study conducted in Japan were adults (≥ 18 years) diagnosed with insomnia and either major depressive disorder (MDD) or bipolar disorder (BD) according to DSM-5, receiving treatment for a depressive episode for ≥ 4 weeks, and having a baseline Hamilton Depression Rating Scale (HAM-D-17) score of ≥ 8. Patients were classified into four cohorts on the basis of their MDD or BD diagnosis and concomitant insomnia medication use (lemborexant add-on or monotherapy). After a 2-week lead-in period with unchanged prior medications for insomnia MDD or BD, 12-week lemborexant treatment was administered. The primary endpoint was the change from baseline in the Insomnia Severity Index (ISI) total score at week 4, which was analyzed using paired t-tests with a two-sided significance level of 5%. For other endpoints, summary statistics and 95% confidence intervals (CIs) for observed values and changes from baseline were calculated by cohort. Safety outcomes included the evaluation of the safety and tolerability of lemborexant during the treatment period. Results A total of 83 patients with comorbid insomnia and depressive episodes were enrolled (MDD add-on cohort, n = 29; MDD monotherapy, n = 23; BD add-on, n = 16; and BD monotherapy, n = 15). The average age was 47.2 years and 64.6% were female. Mean baseline ISI total score (SD) was 14.5 (4.8), 13.2 (5.5), 13.5 (6.0), and 11.8 (4.6), respectively. At week 4, mean change from baseline in the ISI total score [95% CI, p-value] was − 2.3 [− 3.9, − 0.7, p = 0.0065], − 3.2 [− 5.0, − 1.3, p = 0.0018], − 5.2 [− 7.9, − 2.5, p = 0.0012], − 4.5 [− 6.3, − 2.6, p = 0.0001], respectively. Improvements were sustained through week 12. Sleep diary measures such as sleep onset latency and total sleep time improved in some cohorts, but the results were inconsistent. Mean baseline HAM-D-17 scores were 13.6 (5.1), 12.6 (5.1), 13.9 (4.3), and 11.4 (3.4), respectively, with mean changes at week 12 of − 6.4 [− 7.8, − 4.9], − 6.2 [− 7.7, − 4.6], − 5.2 [− 8.4, − 2.1], and − 5.4 [− 7.2, − 3.5], respectively. No serious treatment-emergent adverse events (TEAEs) were reported, with TEAE incidence ranging from 30% to 40%, all mild to moderate in severity. Somnolence was the most common adverse reaction, reported in 10.3–25.0% of cohorts except BD monotherapy. Nightmare followed, occurring in 4.3–12.5% across cohorts. Conclusions Lemborexant was associated with improvements in insomnia severity and depressive symptoms related to MDD or BD, with no new safety concerns. It may be a treatment option for residual insomnia following treatment for depression associated with MDD or BD, though somnolence and nightmares warrant attention. Confirmatory studies are needed to establish its therapeutic value. Study Registration Japan registry of clinical trials (jRCTs071220037; registered on 4 August 2022)

Background: Sleep quality and mental health are important concerns for esports competitors. However, epidemiological data regarding sleep quality and psychological distress among high-level esports players remain limited. Objective: This study aimed to examine sleep quality and mental health status among high-level esports competitors in Japan and to identify factors associated with psychological distress. Methods: This cross-sectional study included 275 competitors (269 males, 3 females, and 3 who did not report sex) participating in the 2023 National Prefectural Esports Championship. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI), psychological distress using the Kessler Psychological Distress Scale (K6), and depressive symptoms using the Patient Health Questionnaire-9 (PHQ-9). Multivariable logistic regression analyses were performed to identify associated factors. Results: The response rate was 61.8% (275/445). Poor sleep quality (PSQI > cut-off) was observed in 38.5% of competitors. Based on the K6, 24.4% reported psychological distress above the mild threshold, and 29.5% reported mild or greater depressive symptoms according to the PHQ-9. Overall mental health levels were comparable to those reported in previous studies of general populations. Nighttime esports training was significantly associated with psychological distress (adjusted odds ratio 3.80; 95% confidence interval 1.50–9.64; p = 0.005). Conclusions: More than one-third of Japanese esports competitors experience poor sleep quality, and approximately one-quarter report mild or greater psychological distress. Nighttime esports training may be an important factor associated with mental health among competitors. Further longitudinal studies are warranted to clarify temporal relationships and to examine whether reducing nighttime training is associated with improved mental health outcomes among esports competitors.

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: To describe clinical characteristics associated with antidepressant non‐use among patients presenting with depressive states in routine psychiatric practice and to explore factors associated with antidepressant prescription among patients with high diagnostic certainty for major depressive disorder (MDD). Methods: This multicenter cross‐sectional observational study used retrospectively collected routine clinical data from 35 psychiatric facilities in Japan. Eligible patients were those who attended participating facilities during March 2023 and were considered by their treating psychiatrist to be under clinical management for a depressive presentation or depressive episode at the index clinical assessment. All variables, including antidepressant use, current clinical state, symptom severity, and diagnostic certainty, were assessed at that single time point. At each site, when a patient not receiving antidepressants was identified, the next consecutively seen patient receiving antidepressants was enrolled as a comparator to facilitate contemporaneous between‐group comparison. Physicians completed a standardized case report form including demographics, current clinical state, depressive symptom severity, and diagnostic certainty ratings for MDD and alternative diagnoses. Group comparisons were performed in the full cohort. Analyses restricted to patients with high diagnostic certainty for MDD were prespecified as exploratory, and a multivariable logistic regression model was fitted within this subgroup to examine factors associated with antidepressant prescription. Results: A total of 1342 patients were enrolled (antidepressant use, n = 669; no antidepressant use, n = 673). High diagnostic certainty for MDD was less frequent in the no‐antidepressant group than in the antidepressant group (22.1% vs. 38.5%). In the no‐antidepressant group, commonly reported reasons for non‐prescription included lack of diagnostic certainty (74.0%), clinical stability or absence of current symptoms (60.3%), and concerns about adverse effects (17.7%) (multiple responses allowed). In exploratory analyses restricted to patients with high diagnostic certainty for MDD ( n = 400), remitted status and less severe symptom profiles were more frequent in the no‐antidepressant group. In the multivariable model within this subgroup, severe or very severe symptoms (vs. no symptoms) were associated with higher odds of antidepressant prescription (odds ratio [OR] = 4.317, 95% CI 1.067–17.462, p = 4.0 × 10 ⁻² ), whereas age, sex, current state, and developmental disorder certainty were not statistically associated. Conclusion: In this multicenter observational sample, antidepressant non‐use among patients presenting with depressive states was associated with lower diagnostic certainty for MDD and with lower current symptom burden at the time of observation. Among patients with high diagnostic certainty for MDD, greater symptom severity was associated with antidepressant prescription. These findings may help contextualize conservative treatment decisions under diagnostic uncertainty in routine psychiatric practice.