Mental Health

Read about the fascinating history of psychiatry.


Psychiatry got its name as a medical specialty in the early 1800s. For the first century of its existence, the field concerned itself with severely disordered individuals confined to asylums or hospitals. These patients were generally psychotic, severely depressed or manic, or suffered conditions we would now recognize as medical: dementia, brain tumors, seizures, hypothyroidism, etc. As was true of much of medicine at the time, treatment was rudimentary, often harsh, and generally ineffective. Psychiatrists did not treat outpatients, i.e., anyone who functioned even minimally in everyday society. Instead, neurologists treated “nervous” conditions, so named for their presumed origin in disordered nerves.

Read Article:

Mental Health

Doug Berger – Tokyo Psychiatrist on Single-Parent Homes

Dr. Doug Berger, a psychiatrist in Tokyo, has written before on marriage and divorce in Japan. Here we ask him to elaborate on a few questions.

1. How are children affected by living in a single parent home?
This will necessarily depend on a number of factors, the age of the child, the time and quality of the ability of the parent to provide love, affection, and a protective environment, the socioeconomic environment of the family, and the ability of the parent and child to be flexible and reasonable with this situation.

Naturally, the more time and quality of the parent’s ability to provide love and security, and the more inherent mental stability both the child and parent have, the better off they will be. The age of the child when the single-parent home was created, and the circumstances around this creation will be of importance, more on that below.

2. Are abandonment issues more prevalent in children from single parent homes?

I don’t think it is a valid use of statistics to make a blanket statement and say yes or no. For each home, there is either more or less time alone on the part of the child. One could argue that the chances of having a difficult parent are 50% less than a 2-parent home, and while being alone seems better than being with a difficult parent, we would not advocate single parent homes over 2-parent homes of course.

If there is a child that is alone or feels abandoned then we need to engage some kind of social intervention and help this child integrate with some social activities. If the community the family lives in has good infrastructure and a close-knit community with families that participate in many activities where many same-age friendships can be grown then this may be enough in of itself to make a child from a single-parent household feel social and happy. If it is not a community like this, then social services need to have a bigger role to provide some alternative.

3. Are children raised in single parent homes from birth less affected than children whose parents divorced in their teens?

It is common to meet children raised in single parent homes from birth who state they did not know any other kind of family structure so that the single parent situation seemed entirely normal to them and they had no problem with it.

Divorce of one’s parents in adolescence is usually not a great thing, but might be worse for a child who is between 5 and 12 years-old because they usually more connected to their parents then teenagers. However, this all depends on how bitter the divorce, how many friends the teen has, the inherent mental stability of the child and parents, and the ability of the parents to be reasonable in ensuring that divorce will lead to a smooth transition for the child to continue the same lifestyle and with frequent visits and access to each parent, and this is more important for young teens than older teens.

4. What are some tips for children that may blame themselves for their parents’ separation or divorce?

This is not easy to clear up and sometimes takes years to run its course because a course of events has already unfolded once the child has started to think like this. Coaching and psychotherapy may help these children, but probably the best way is to avoid this happening to begin with.

Reasonable parents who can continue to work together as parents and a family will help decrease the risk of this outcome. Sometimes, we recommend that the parents move to a partial separation where one of the spouses has a separate living space, but where the family is together often, or at least one parent is visiting the child’s living space regularly.

The partial separation may be enough to give the parents space but allow them to continue the family in some way. Then the parents can actually be divorced on paper without telling the children-depending on their age or the parents can go to full divorce in stages as the children get older. It may be easier to acclimate to stressful events unfolding in slow stages.

5. How can parents ease the transition into a single parent household for children?

Continuing the ideas presented in question 4, I would say that if for example the father is moving out, he can present the idea to his children that he is getting an “office” to stay in so that he can do work in a quiet place, but he will still spend time at the home and that the children can also visit him. The wife may take the opportunity to have her own social life on days the husband, or ex-husband if they have signed divorce papers, is at the home watching the children.

For many couples in conflict, one partner having a separate living space can be enough to decrease the stress in the relationship enough to the point where they can be reasonable with each other. As the children get older, they will not need both parents around so often and the parents can begin to build their lives independently from the ex-spouse both socially and occupationally.

Read more on Dr. Doug Berger‘s comments as it relates to single-parent households here:

Mental Health

Tests, testing, and tested – we need to critically evaluate the meaning of tests in psychiatry

Douglas M. Berger
Meguro Counseling Center, Tokyo, Japan

A recent article entitled, “Perils of Newborn Screening”[1] led me to think of how we in psychiatry and our patients also have some perilous ideas about screening and testing. The article describes testing initiated in 2006 in New York State for Krabbe disease of the nervous system. Krabbe disease is a rare inherited disorder where lack of the enzyme galactocerebrosidase causes the myelin coating on the nerves to break down. Mental and motor development are affected, and muscle weakness, deafness, and blindness may occur.[2]

Out of the total one-million babies tested, 24 tested positive and out of 24, 4 developed symptoms. One family refused treatment and subsequently the child died; another child died from complications of the treatment; another’s illness is progressing despite treatment, and one baby who had been treated successfully has recently lost his ability to walk. Parents of babies who test positive, are described to be in a constant state of worry, some pursue risky tests, and the emotional trauma (not to mention the cost) incurred is likely to outweigh the benefits.

This example illustrates how one kind of test may have pros and cons. The pros and cons of ‘testing’ can also be seen in one’s daily practice of psychiatry. The following are personal experiences of my practice in Tokyo.


“My 8-year-old child is depressed, should they have psychological (psych) testing to determine if antidepressants are warranted?” A woman I have been treating for a few years for major depression told me about her 8-year-old son who is irritable, has been crying more, and has written some notes contemplating suicide. She first brought her son to a large local counseling center where they recommended in-person counseling with their staff psychologist, school observations, and psych testing (costing about $4,500), and told the mother that they could not recommend starting antidepressants until the psych testing was complete. The son could not finish the testing because he was unable to maintain concentration.

The mother eventually decided she couldn’t wait anymore and asked me to evaluate the child who clearly looked depressed. I explained that if the psych testing assessed the son having a depression, this affirms the obvious. If the psych testing assessed the son without a depression, we are still left with a depressed-looking child who is writing suicide notes, and with an anti-depressant responsive depression in his mother. Neither family dynamics nor school issues could explain the child’s depression.

We agreed that there was no logic for psych testing in terms of, ‘to treat’ or ‘not to treat’; and in tandem to a medical work-up for depression, we initiated 2.5 mg of escitalopram a day with a good response. Scales and tests for depression may indeed provide some helpful information; however, predictive value, sensitivity, and specificity are still far from perfect,[3] and the National Institute of Mental Health (NIMH) guidance only mentions medical examination and history of symptoms in the evaluation of depression.[4]

While no test can fully prove a psychiatric diagnosis, we understood that the medication can be construed to be both a treatment as well as a kind of diagnostic test, i.e., improvement on administration, and relapse on discontinuation would support the diagnosis of a major depression.

In addition, while the son was ill with depression, the other aspects of psych testing, i.e., personality or intellectual testing, would not properly reflect these areas of functioning. It would be like asking a person with pneumonia to run around a track, time them, and then make an interpretation of this person’s ability to run (not to mention the cost saving of the psych testing).

The next peril is the way the school authorities may use the results of his psychological testing, which may have a negative impact on the child’s education in the future. I opined that the school only needed to know that the son would get help, but did not need to know the diagnostic or treatment details.

“My 4-year-old has been tested and diagnosed with Asperger’s Disorder, can you counsel him?” This has been a more frequent inquiry in recent years. Some parents or adult patients almost seem to be proud to have this diagnosis, thinking that it portends high intelligence, but it may actually be a way to avoid a more uncomfortable mental illness diagnosis. Most of these parents do not realize that there is no test to prove that someone has Asperger’s, (the criteria for Asperger’s includes: Marked impairment in social relations, often with stereotyped motor movements, and a vast knowledge of some topic of esoteric or impractical value),[5] and that the incidence of Asperger’s is thought to be extremely low (about three in 10,000)[6] when compared with other disorders whose symptoms overlap with Asperger’s (i.e., attention deficit disorder/ attention deficit hyperactivity disorder (ADD/ADHD), which may affect up to 10% of children.[7]) Few of the patients who come in with a supposed diagnosis of Asperger’s actually fulfill the criteria for Asperger’s.

On examination, most of these children have symptoms suggesting ADD or ADHD; some have depression or anxiety, and others a shyness or awkwardness that may be normal or may evolve into social anxiety disorder later in life. On rare occasion some do look like high-functioning autistic children, although it seems parsimonious and logical to assume that these children have the far more common diagnosis rather than a rare diagnosis if the symptoms overlap significantly.

The peril here is when the parents or an adult patient does not accept having a diagnosis or treatment other than that for Asperger’s. If a child also seems to have a comorbid ADD or ADHD, it needs to be treated first; to ascertain what Asperger’s symptoms may be left. Otherwise, it would be like making a diagnosis of asthma in a child with pneumonia (i.e., it is impossible to see if Asperger’s is there while the person is clearly impaired with ADD or ADHD).

In addition, once a child gets a diagnosis in their educational record, it tends to have a life of its own as definitive, and neither parents, educators, nor even psychologists or psychiatrists, endeavor to change the record.

“Cognitive behavioral therapy has been tested and proven to be effective for depression; can you give it to me?”

This is another situation where the use of the word ‘tested’ comes in and is an inquiry that can be a challenge for the psychiatrist to handle when the patient has vegetative symptoms, a strong family history, and a chronic course of depression because these patients usually require antidepressant medication in addition to any therapy.

Cognitive behavioral therapy (CBT) aims at repairing negative thoughts that are thought to cause depression.[8] Clinically, it is easy to observe; however, that negative cognitions improve when depressed mood improves, be it with antidepressants or the natural cycling course out of depression.[9] This is analogous to delusions improving, when one is given an antipsychotic, so that negative thoughts are more likely the result of depression rather than the cause, just like a runny nose and a cough are the result of a cold. If negative thoughts were the cause of depression, then this would be the only Diagnostic and Statistical Manual of Mental Disorders (DSM) Axis I condition where the symptoms are also construed to be the cause.

However, it can often be seen that CBT may help persons with depression function better. Degree of depression is usually evaluated by a rating scale that assesses both neuro-vegetative symptoms as well as misery (i.e., cognitive symptoms such as despair and helplessness). Giving persons hope and support can alleviate some of the misery symptoms decreasing depression scores. Allowing some time to pass where the persons improve by themselves or cycle out of depression can also decrease scores. In either case, the person functions better and their depression scores decrease over time. Even a few points lower on a depression test can result in a call of a “statistically significant difference” compared to a supportive therapy control group, but that does not mean the illness is really treated. For example, I broke my arm by falling on the ice. I had real pain and also misery because I couldn’t do things I normally liked to do. When my orthopedist told me, “I see many fractures like this, you will be fine in a few months,” all my misery disappeared, but the fracture did not change. Patients in misery can respond well to an authority figure which gives them hope.

A more important problem with using the word ‘tested’ is that it is not easy to study psychotherapy as a modality of treatment because the studies cannot be double blinded like a drug study that has a placebo arm—an extremely crucial point. A study on bias in treatment outcome studies concluded that the results of unblinded randomized clinical trials (RCTs) tended to be biased toward beneficial effects if the RCTs’ outcomes were subjective (as they are in psychotherapy studies) contrary to being objective.[10]

Patients and even professionals assume that the words “randomized and controlled” mean that the studies looking at a therapeutic modality are fully evidence based, even if they are not double blind. They may be single blinded, i.e., the rater may not know the treatment the patient received, but the patient themselves cannot be blinded to the type of therapy, thus potentially biasing the results. Depression studies notoriously have large random errors due to the wide variety of subjects many of which have mild forms of low mood, investigator and patient preference and economic incentive, or non perfect rating instruments, etc. Bias can lead to a result very far from the true value.[11]

A recent meta analysis[12] examined how effective CBT is when placebo control and blindedness are factored in. Pooled data from published trials of CBT in schizophrenia, major depression, and bipolar disorder that used controls for non-specific effects of intervention were analyzed. This study concluded that CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates, treatment effects are small in treatment studies of major depression, and it is not an effective treatment strategy for prevention of relapse in bipolar disorder.

This does not mean that CBT has no value, it only means that we need to consider CBT as an adjunctive modality to help functional impairment and suffering vs. an illness course-changing intervention. It is imperative that our field does not allow studies that are unblinded to be called “evidence based tests.” They need to be in a different category, i.e., “uncontrolled clinical data”, or “clinical impressions” (of CBT practitioners and/or their patients).


To the lay-person, the word “test” implies some absolute truth. The value of a test or a diagnosis given by an authority is very hard to evaluate by the average lay-person, and when it comes to testing of a therapeutic intervention, even most mental health professionals do not understand why it is crucial to control bias by double-blinding in a clinical trial of an intervention, whether psychotherapy or drug. The words “controlled” or “randomized” seem to carry more weight than they are worth if there is no placebo or double blind to back them up. We must also not avoid a critical discussion of the economic incentive to do a test or to “prove” the evidence base of a certain therapy.

{Ed.: Dr. Berger is in private practice in Japan and consultant on pharmaceutical clinical trials. Web page is at: www. japanpsychiatrist. com. This article is intended as a personal opinion piece and not a scientific analysis.}


1. Bleicher A. Perils of newborn screening: Doctors may be testing infants for too many diseases. Sci Am 2012;307:16-7.

2. Pastores GM. Krabbe disease: An overview. Int J Clin Pharmacol Ther 2009;47(Suppl 1):S75-81.

3. Rivera CL, Bernal G, Rossello J. The Children’s Depression Inventory (CDI) and The Beck Depression Inventory (BDI): Their validity as screening measures for major depression in a group of Puerto Rican adolescents. Int J Clin Health Psychol 2005;5:485-98.

4. Available from: [Last Accessed on 2013 Mar 30].

5. F84. Pervasive developmental disorder. International Statistical &ODVVL¿FDWLRQRI’LVHDVHVDQG5HODWHG+HDOWK3UREOHPVth (ICD-10) ed. World Health Organization (2006).

6. Fombonne E. Epidemiological surveys of pervasive developmental disorders. In: Volkmar FR, editor. Autism and Pervasive Developmental Disorders. 2nd ed. Cambridge: Cambridge University Press; 2007. p. 33-68.

7. Centers for Disease Control and Prevention. Summary Health Statistics for U.S. Children. National Health Interview Survey, 2002. March 2004, Series 10, No. 221.

8. Burns, David. Feeling Good, The New Mood Therapy. Avon Books; 1980.

9. Fava M, Davidson K, Alpert JE, Nierenberg AA, Worthington J, O’Sullivan R, et al. Hostility changes following antidepressant treatment: Relationship to stress and negative thinking. J Psychiatr Res 1996;30:459-67.

10. Wood L, Egger M, Gluud LL, Schulz KF, Jüni P, Altman DG, et al. Empirical evidence of bias in treatment effect estimates in controlled trials with different interventions and outcomes: Meta-epidemiological study. BMJ 2008;336:601-5.

11. Steven Piantadosi. Clinical Trials: A Methodologic Perspective. 2nd ed. Hoboken: Wiley-Interscience; 2005.

12. Lynch D, Laws KR, McKenna PJ. Cognitive behavioural therapy for major psychiatric disorder: Does it really work? A meta-analytical review of well-controlled trials. Psychological Medicine 2010;40:9-24.

Mental Health

Helpful advice about soothing anxiety.



With global anxiety and depression rates at an all-time high, what can people do to combat these mental health issues?

Since 1940 the amount of people suffering from anxiety and depression has been steadily increasing. Classified as a spectrum disorder, anxiety can manifest in various forms and severity, and no one is immune to this mental health issue that plagues millions of men, women, youth and even children.

Thanks to the prevalence of digital culture, anxiety is even getting catchy buzzwords and anagrams, like FOMO, better known as Fear of Missing Out, which has been associated with social anxiety and guilt. Not only does this indicate the changing face of anxiety, it is proof that anxiety which was once considered a mental health issue for older people is increasingly becoming an issue amongst all demographics and cultures.

A 2013, mental health report published in the Australian journal Psychological Medicine, found that as many as 1 in every 10 people suffer from some type of anxiety, which can present as panic attacks, heart palpitations, sweats, lightheadedness and a host of other ailments.

The report went on to state that clinical anxiety and depression are serious health issues all around the world, however, anxiety disorders are more commonly reported in Western societies than in non-western societies.

This presents a unique problem for Westerners living abroad in need of anxiety treatment, as well as people in countries where discussing mental health is still considered taboo.

Dr. Doug Berger, a psychiatrist in Tokyo, is working to help erase the stigma associated with anxiety and mental health, while simultaneously using his American and Japanese expertise to treat a diverse array of people living in and around Tokyo.

We asked Dr. Doug Berger about his thoughts around the steady increase of anxiety and depression, as well as some tips to combat anxiety in various age groups.

Thank you for your time Dr. Doug Berger. What do you think is behind the growing number of patients suffering from anxiety?

Anxiety has always existed in various forms, but the ability of mental health professionals to understand anxiety-related conditions is greater due to increased professional awareness. Romantic troubles, economic uncertainty, and other factors including worry how one is viewed by many others on social media, as well as greater access to the news media that continually barrages us with scary stories can all contribute to increased anxiety.

Can you describe what spectrum disorder means and why it applies to anxiety?

The term “spectrum disorder” is just a complicated term to express that the severity of a symptom like anxiety may go from transient to chronic, and mild to severe. It may be part of another problem such as adjusting to a life stressor, it may be a symptom of another psychiatric problem such as depression, or it might be a stand-alone problem as is seen in Generalized Anxiety Disorder, Social Anxiety, Panic Disorder, and others.

What separates general anxiety from an anxiety disorder?

“General anxiety” may refer to anxiety from everyday life problems; i.e., fear of losing one’s job, a romantic relationship, being ostracized from friends, etc., or it can mean Generalized Anxiety Disorder which includes constant worry, muscle tension, possible insomnia etc., that has no specific obvious cause. Sometimes Generalized Anxiety Disorder can be genetic.

What are the types of maladaptive defense mechanisms that can limit a person who is suffering from anxiety or an anxiety disorder?

Persons with anxiety may shrink from social interaction as a reaction or defense to ward off anxiety. They may have mild social fears causing them to seem introverted and quiet, or they may have more severe anxiety in social situations limiting health social and occupational functioning. Mildly introverted persons may be liked because of their non-confrontational demeanor in spite of having significant subjective distress. “Binding one’s anxiety” is another form of defensive reaction wherein a person engages in specific activities or behaviors to decrease tension. For example, a person anxious about an upcoming surgery may begin to organize their affairs and take care of many tasks they fear will be difficult to do after surgery. Persons with anxiety disorder and no specific feared event may show the same behaviors.

In general, what can people do to calm an anxious mind?

Avoiding anxiety-provoking situations may not be a maladaptive behavior depending on the situation or severity as described above. Avoiding, caffeine (which can provoke anxiety), tobacco and alcohol (which can make persons anxious when they come off the substance), drugs (especially drugs with stimulant effects, i.e., drugs for ADHD, cocaine, etc.) is a good idea. Some persons prefer sports, meditation, or yoga to help them, although these may have limited effect if the severity and chronicity of anxiety is great and they should also receive medical help.

Do you have advice for parents whose children suffer from anxiety?

This really depends on the age of the child. For children under five or six years old it is very difficult to pinpoint what is an anxiety disorder from normal or transient developmentally-related anxiety that usually shows up as anxiety on separation from parents. Generally, I would advise providing as much love and care as possible while gently training the child that the parents can not be continually be by their side. Social introversion and avoidance should also patiently be followed over the years by giving both love along with nudging children to take steps to be friendly and social with others. Night terrors and panic in children requires a nuanced evaluation of family dynamics, genetic, and medical/psychiatric issues.

For older children, social-skills training and integrating into peer-group activities if possible is important. Some children really do better with more solitary hobbies such as musical instruments, programming, math, etc., and there is a grey zone where we worry about the child on the one hand, but need to foster acceptance of socially-hesitant children on the part of the parents. Older children with panic, generalized anxiety, social anxiety disorder, and other disorders need to be evaluated by a professional.

Article Link:

Mental Health

Tokyo psychiatrist, Dr. Douglas Berger, comments on “Why We Have Free Will” by Eddy Nahmias January 1, 2015, Scientific American:

In “Why we have free will”, Eddy Nahmias opines that brain-imaging technology does not prove there is no free will. He cites his study on the opinions of students that they had free will when they could deliberate on a choice. It seems obvious, however, that people seem limited to a repertoire choices that fit their default thinking style. The article does not operationally define free will, whether it is limited to any choice, or a repertoire of limited choices, so that the argument is confusing.

Douglas M. Berger, M.D., Ph.D.

U.S. Board-Certified Psychiatrist

Tokyo, Japan

Mental Health

8 Reasons a Psychotropic Medication May Be Discontinued


1. Iatrogenic mental status change
• A new medication is either directly or indirectly responsible for an acute change in mental status
• An acute confusional state after starting an anticholinergic medication could be due to anticholinergic delirium
• A drug-drug interaction may significantly elevate the serum level of the new medication, or the new medication may significantly raise the serum level of a drug the patient has been previously taking without incident

Read Entire Article:

Mental Health

Ask the Expert: Prolonged use of electronic devices

By Douglas Berger, M.D., Ph.D. on January 22, 2015

However vital the use of electronic devices is in children’s lives, prolonged hours of use can have a negative impact on their health and behavior. You can reduce the risk with help from the experts.

How do you draw the line between a healthy use of electronic devices and addiction?

When persons are using a device to an extent that it impairs their ability to spend time with people important to them or to do important activities. For example to study important things or to do work-related things, or to relate to people without frequently being on the device. When grades or work performance falter or persons around them frequently get aggravated with them for being on a device then it is clearly “unhealthy”. If the person is on a device “a lot” but there is no obvious impairment it may not be “unhealthy”, but may still be “wasting time” in some sense.

Most parents create house rules regarding the use of electronic devices at home which eventually creates anxiety in children that later leads to bad behavior. What type of behavior should parents be worried about?  First there is the spending too much time on a device leading to impairment in scholastic or social function as noted above. Next is if the child is getting involved with a social network on line that may include receiving or giving cyber-bulling, bad-mouthing, meeting inappropriate people, or lewd activities etc. These problems require individualized investigation, discussion, and intervention.

What specific situations should children be seen by a psychiatrist? Impairment in scholastic or social function, on-line social problems (that may spill-over into the real world), “zoning-in” to being on a device, depression, truancy, and any other concerning mental or behavioral issue.

Dr. Douglas Berger and his staff at the Meguro Counseling Center in the Shibuya-Ebisu area provide mental health care for individuals, couples, and families, in both English and Japanese.

Link to Original Article:



Mental Health

Advice for parents of children with ADD/ADHD.


One of the most frequently diagnosed learning disability is Attention Deficit Disorder (ADD), a condition that is often accompanied by Hyperactivity Disorder (HD), called ADD if inattention predominates, and ADHD if hyperactivity predominates. Indeed, it is estimated that the prevalence of ADHD has increased tenfold around the globe in the last five years, with the reported number of cases in the United States far outpacing other countries. This increased prevalence is probably due to increased awareness coupled with increased marketing by pharmaceutical companies.

Read Entire Article:

Mental Health

Douglas Berger Psychiatrist Tokyo, writes a Letter to the Editor in Psychiatric Times, RE: ” A ‘Simple’ Way To End Terrorism”

I enjoyed Dr. Pie’s interesting article ” A ‘Simple’ Way To End Terrorism” in the December issue of the Psychiatric Times (P.1) where he discusses the role of paradoxical narcissism and projective identification as defenses of the mind of the terrorist. I’m sure these mechanisms are active, especially in the leaders, but wonder whether the mind-set of the leaders might be different from the followers. In the followers, I imagine there is a considerable amount of attachment dependency as well as transference to the leaders and the icons of worship as parental figures. In either case, I’m also sure simple classifications will not explain the entire phenomena.

Doug Berger, M.D., Ph.D.
US Board Certified Psychiatrist
Tokyo, Japan

For more information about Douglas Berger Psychiatrist Tokyo visit the following website:

Mental Health

A fascinating article about the amazing properties of artificial spider silk

spider silk.jpg

Possibly the strongest hybrid silk fibers yet have been created by scientists using all renewable resources. Combining spider silk proteins with nanocellulose from wood, the process offers a low-cost and scalable way to make bioactive materials for a wide range of medical uses.

Read Entire Article: