Text Messaging for Psychiatric Outpatients Effect on Help-Seeking and Self-Harming Behaviors

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1 2016 Shutterstock.com/zf Ern Contct Hours Text Messging for Psychitric Outptients Effect on Help-Seeking nd Self-Hrming Behviors Toyohiko Kodm, RN, MS; Hiroko Syouji, RN, MS; Schiko Tkki, RN, MS; Hirokzu Fujimoto, RN, MS; Shinichi Ishikw, MD; Mski Fukutke, PhD, MD; Msru Tir, PhD, MD; nd Tkeshi Hshimoto, PhD, MD ABSTRACT A mobile phone intervention ws developed nd tested with 30 psychitric outptients with mentl illness, who hd high idetion for suicide. The intervention involved promoting helpseeking behviors by sending text messges, including informtion bout socil welfre services nd reminders bout medicl ppointments, for 6 months. After the intervention period, the number of prticipnts who used socil services significntly incresed, nd more thn 80% of prticipnts reported tht the text messging service ws helpful nd useful. Compred to bseline, prticipnts self-hrming behviors decresed nd the ttending psychitrists rted their suicide idetion s weker. This is the first intervention study to promote psychitric ptients help-seeking using text messging, nd lthough it ws not rndomized controlled tril, this intervention hs prcticl vlue nd my led to the prevention of suicide. [Journl of Psychosocil Nursing nd Mentl Helth Services, 54(4), ] 2016 Kodm, Syouji, Tkki, Fujimoto, Ishikw, Fukutke, Tir, nd Hshimoto; licensee SLACK Incorported. This is n Open Access rticle distributed under the terms of the Cretive Commons Attribution-NonCommercil 4.0 Interntionl ( This license llows users to copy nd distribute, to remix, trnsform, nd build upon the rticle non-commercilly, provided the uthor is ttributed nd the new work be non-commercil. Journl of Psychosocil Nursing Vol. 54, No. 4,

2 When viewed globlly, mentl illness is n immedite nd serious issue, with the Orgnistion for Economic Coopertion nd Development (2014) reporting tht one in two individuls will experience mentl illness t some point in their lives. Mentl illness is known to be risk fctor for suicide (Cho, N, Cho, Im, & Kng, 2016), nd it hs been reported tht help-seeking behviors reduce the risk of suicide (Moskos, Olson, Hlbern, & Gry, 2007; Owens, Lmbert, Donovn, & Lloyd, 2005). Therefore, the current uthors developed nd tested the effectiveness of mobile phone (text messging) progrm promoting psychitric outptients help seeking. To the uthors knowledge, this is the first study tht promotes psychitric outptients help seeking nd reduction of self-hrm nd suicide using text messging intervention. Previous studies hve found few methods tht significntly reduced the risk of suicide (Brown et l., 2005; Fleischmnn et l., 2008). Brown et l. (2005) rndomly ssigned suicide ttempters (N = 120) to usul cre group or usul cre plus cognitive therpy group nd found significntly reduced rettempted suicide rte in the intervention group. In five countries, Fleischmnn et l. (2008) conducted rndomized controlled trils with suicide ttempters (N = 1,867), in which prticipnts received either tretment s usul, or tretment s usul plus brief intervention nd contct (BIC), including ptient eduction nd follow up. Significntly fewer deths from suicide occurred in the BIC group thn in the tretment-s-usul group (0.2% versus 2.2%) (Fleischmnn et l., 2008). These interventions re effective, nd specilist cn provide cognitive therpy for n individul who presents high risk of suicide; however, highly skilled specilists re costly, so it is hrd to provide follow-up cre for ll suicide ttempters. The Interntionl Telecommuniction Union (2014) reported high penetrtion rtes for mobile devices round the world. Mobile phone technologies cn enble intervention with lrge numbers of individuls t low cost nd hve the potentil to effect behvior chnge. In review of text messging used for behviorl interventions, Wei, Hollin, nd Kchnowski (2011) found tht, mong 16 rndomized controlled trils, 10 reported significnt improvement with the interventions nd six reported differences, suggesting positive trends. Mobile phone technologies offer the possibility of mnging noncriticl cre within the community, thus improving ptients qulity of life nd controlling costs (d Cost, Slomão, Mrth, Pis, & Sigulem, 2010). Therefore, the current study focused on suicide interventions sent vi mobile phone text messging technologies. METHOD Prticipnts nd Ethics Prticipnts were 30 psychitric outptients. Before the study, the current uthors consulted with psychitrists t medicl fcilities to secure their greement to ssist with their reserch. The smple size ws determined to be pproprite to conduct this pilot experiment sfely under the mngement of nd with the opertionl coopertion of relevnt medicl fcilities. Ptient prticipnts stisfied the following inclusion criteri: ge 18; dignosed with mentl disorder (Interntionl Clssifiction for Diseses-10); hving hd suicidl idetion ccording to evlution by the ttending psychitrist; hving competency to join the study, which ws judged by the physicin; nd possessing mobile phone or smrtphone. Prticipnts were recruited from university hospitl, psychitric hospitl in Hyogo Prefecture, three medicl center hospitls in Kobe City, privte psychitric hospitl, nd three psychitric clinics in Kobe City, Jpn (popultion pproximtely 1.5 million). Written informed consent ws obtined from ech ptient. Ptients received ll services s usul whether they chose to prticipte. The recruitment period ws between Februry 2013 nd November The text messging intervention ws conducted up to My The study protocol ws pproved by the Kobe University Reserch Ethics Committee, Kobe City Medicl Center Hospitls nd Hyogo Prefecturl Psychitric Hospitl. Procedure Prticipnts received on their own mobile phone or smrtphone two text messges per week for 6 months from the study reserchers mil server nd did not receive ny pyment for joining the progrm. The messges were sent utomticlly by computer progrm t 12:30 p.m. every Mondy nd Thursdy so tht working prticipnts could view the text messges t Mobile phone technologies cn enble intervention with lrge numbers of individuls t low cost nd hve the potentil to effect behvior chnge. convenient time. Moreover, to prevent prticipnts from being surprised by hving the regulr text messges stop suddenly, the uthors grdully extended the intervl period between messges fter the fourth month. There were 52 messges tht were developed by psychitric specilists, including three psychitric nurses nd two psychitrists. Two psychitric outptients checked the messges, 32

3 which were 150 to 250 Jpnese lnguge chrcters in length nd specificlly designed round the themes of mnging stress, mintining good mentl well-being, promoting dherence to mediction, methods of sleep improvement, the importnce of consulting with someone bout their problem, nd informtion bout locl services (e.g., consulttion services). Locl service informtion messges were linked to website ddress or phone number so prticipnts could contct the services esily. When events such s symposium for prevention of depression were held in Kobe City, prticipnts received messge bout the event pproximtely 2 weeks prior. In ddition, to support the continution of tretment, the uthors sent text messges informing prticipnts of medicl ppointments on the dy before ppointments. If prticipnts were seen t the medicl fcility s scheduled, they received positive feedbck text messge bout their consulttion behvior the next dy. Prticipnts informed the study reserchers of the nme they wnted to be clled, which ws registered on the computer by the resercher, nd tht nme ws displyed on the text messges prticipnts received. No content ws duplicted within 6-month period, so tht prticipnts did not lose interest in the messges. Although they could not reply vi their mobile phone to the text messge, the progrm stff held monthly meetings where prticipnts could sk questions bout the messges. Mesures Prticipnts demogrphic nd clinicl dt were obtined from their ttending psychitrists vi questionnire. In ddition, psychitrists reported t bseline on the presence or bsence of prticipnts self-hrm nd intensity of suicidl idetion (0 = no suicidl idetion to 5 = extremely intense suicidl idetion) during the pst 6 months. To ssess prticipnts bseline problems/troubles nd their use of TABLE 1 PARTICIPANTS CHARACTERISTICS AT BASELINE (N = 30) Chrcteristic n (%) Age (yers) (men, SD) 38.4 (11.4) Sex Mle 15 (50) Femle 15 (50) Psychitric dignosis Mood disorders 19 (63.3) Schizophreni, schizotypl, nd delusionl disorders 8 (26.7) Neurotic, stress-relted, nd somtoform disorders 3 (10) Employment sttus Unemployed 15 (50) Student 3 (10) Compny employee 2 (6.7) Other 10 (33.3) Mritl sttus Unmrried 20 (66.7) Mrried 8 (26.7) Divorced 2 (6.7) Household composition Live with someone 24 (80) Live lone 5 (16.7) Other 1 (3.3) Dignosis ccording to Interntionl Clssifiction for Diseses-10. socil/personnel resources in their dily life, the following questions were sked: 1. Wht problems or troubles re you experiencing now? 2. Did you consult with someone bout your problems or troubles during the pst 6 months? With whom did you consult? 3. Did you use socil service, such s job ssistnce fcility or self-help group, during the pst 6 months? 4. Wht service or support did you use? For Questions 2 nd 4, multiple choice response method ws used nd multiple nswers were llowed. Prticipnts were ssessed t 3 months into the intervention using the following questions: 1. Did you consult with someone bout your problems or troubles during the pst 3 months? 2. With whom did you consult? 3. Did you use socil service, such s job ssistnce fcility or self-help group, during the pst 3 months? 4. Wht service or support did you use? 5. Ws our text messge helpful? 6. Wht is the reson for its being helpful? 7. Wht do you wnt from our text messge? Multiple nswers were llowed for Questions 2, 4, 6, nd 7. For Questions 3 nd 5, 4-point Likert response scle ws used, where 1 = helpful, 2 = little helpful, 3 = not too helpful, nd 4 = not helpful. Journl of Psychosocil Nursing Vol. 54, No. 4,

4 TABLE 2 STUDY PARTICIPANTS (N = 30) REPORTED PROBLEMS OR TROUBLES AT BASELINE Problem/Trouble n (%) Illness 26 (86.7) Economic 24 (80) Work 21 (70) Fmily 18 (60) Interpersonl reltionship 14 (46.7) Romnce 8 (26.7) I hve no mentor 6 (20) I don t know where to go for help 6 (20) School life 4 (13.3) Burden of cring 2 (6.7) Bullying or hrssment 1 (3.3) Other 5 (16.7) Multiple nswers were llowed. TABLE 3 STUDY PARTICIPANTS (N = 28) WHO CONSULTED SOMEONE IN THE 6 MONTHS BEFORE AND DURING THE STUDY, AND WITH WHOM THEY CONSULTED Consulttion I consulted someone bout my problem or trouble. Individul with whom the prticipnt consulted 6 Months Before the Study (n, %) After Study Completion (n, %) p Vlue 24 (85.7) 26 (92.9) 0.63 Psychitrist 18 (64.2) 23 (82.1) 0.18 Fmily 12 (42.9) 15 (53.6) 0.38 Friend 9 (32.1) 12 (42.9) 0.45 Physicin 3 (10.7) 3 (10.7) 1.00 Specilist or consulttion services stff 1 (3.6) 8 (28.6) 0.02 * Internet 1 (3.6) 0 (0) 1.00 Telephone counselor 0 (0) 2 (7.1) 0.50 Other 8 (28.6) 1 (3.6) 0.02 * Multiple nswers were llowed. *p < The sme ssessments were then repeted fter 6 months of the progrm were completed, nd prticipnts psychitrists were sked bout their hospitl ttendnce, presence or bsence of self-hrm, nd intensity of suicidl idetion during the pst 6 months compred with tht t the end of the intervention. Becuse ptients who hve committed self-hrm in the pst re t prticulrly high risk for suicide, sfety of the prticipnts ws top priority. To void possible upset when reclling pst self-hrm, n evlution scle sking prticipnts bout suicidl idetion ws not used. Sttisticl Anlysis Dt were nlyzed using SPSS version 22 for Windows. Vribles relted to help seeking nd self-hrm were compred with McNemr s test. Intensity of suicidl idetion ws mesured with the Wilcoxon signed-rnk test. RESULTS All prticipnts received ll text messges, nd no one refused receipt of messges. One prticipnt did not complete the questionnire t 3 months nd nother t 6 months into the intervention. Tble 1 shows bseline demogrphic nd clinicl chrcteristics. Prticipnts men ge ws 38.4 yers, 50% were femle, nd the lrgest number hd been dignosed with mood disorders. Tble 2 shows tht more thn one hlf of prticipnts hd problems or trouble with illness, economic issues, work, nd fmily reltions t bseline. These problems/troubles were similr to those found in previous report (Onishi, 2015) nd were relted to the text messges focusing points. Tble 3 shows the proportion of prticipnts who consulted with someone in the 6 months before nd during the 6-month study period. There ws no significnt difference before nd fter the intervention in terms of the proportion of prticipnts who consulted someone bout their problems or troubles; however, the proportion of prticipnts who consulted specilists or consulttion services stff ws significntly higher fter the intervention. As cn be seen in Tble 4, the proportion of prticipnts who used some type of socil service significntly incresed over the intervention period. At the 3- nd 6-month time points of the intervention, more thn 85% of prticipnts reported tht the text messges were helpful or little helpful. Regrding their resons, more thn one hlf nswered, Receiving the text messge itself plesed me. In response to the question Wht do you 34

5 TABLE 4 STUDY PARTICIPANTS WHO USED SOCIAL SERVICES (N = 28) Socil Service Use Bseline (n, %) Post-Intervention (n, %) p Vlue I used some form of socil service 5 (17.9) 11 (39.3) 0.03 * Form of socil service Consulttion service 0 (0) 2 (6.9) 0.50 Telephone consulttion service 0 (0) 2 (6.9) 0.50 Socil welfre fcility 4 (14.3) 5 (17.9) 1.00 Self-help group 1 (3.6) 0 (0) 1.00 Symposium or workshop 2 (7.1) 4 (14.3) 0.50 Other 2 (7.1) 6 (21.4) 0.22 Multiple nswers were llowed. *p < TABLE 5 STUDY PARTICIPANTS WHO ENGAGED IN SELF-HARM AND MEAN INTENSITY OF SUICIDAL IDEATION BEFORE AND DURING THE 6 MONTHS OF THE STUDY (N = 29) Vrible Bseline Post-Intervention p Vlue Engged in self-hrm (n, %) 8 (27.6) 2 (6.9) 0.03 * Intensity of suicidl idetion (men, SD) 2.00 (1.18) 0.83 (1.00) <0.001 ** Dt were obtined from ttending psychitrists. *p < 0.05; **p < wnt from our text messges?, the highest number of prticipnts nswered tht they were Fully stisfied with the text messging service nd content. Outcome dt were obtined from prticipnts physicins (Tble 5). Prticipnts who hd committed selfhrm during the previous 6 months t bseline ccounted for 27.6% of the smple (n = 8), wheres the proportion t 6 months significntly decresed to 6.9% (n = 2, p = 0.03). Further, the intensity of suicidl idetion ws significntly reduced fter the intervention period (p = 0.001). There were no significnt reltionships between self-hrm or suicidl idetion nd prticipnts demogrphic dt (p > 0.05, ssessed with logistic regression nlyses). One prticipnt did not visit medicl fcility but did not refuse to receive the text messges. All others received ongoing outptient cre (96.7%). DISCUSSION To the current uthors knowledge, this is the first intervention study to promote psychitric ptients help seeking using text messging. In the current study, prticipnts consulted with specilists or consulttion services stff nd used socil services more ctively thn before they enrolled in the study. The incidence of self-hrm nd prticipnts intensity of suicidl idetion significntly decresed. All prticipnts received ll text messges nd the mjority believed the text messging ws helpful nd were stisfied with the messges. Thus, becuse the study ws completed sfely, the intervention method hs prcticl vlue nd might led to the prevention of suicide. During the tril, consulttion with specilists or stff bout problems or troubles incresed, suggesting tht text messging led prticipnts to contct more specilized personnel. Although there ws no significnt difference, the number of prticipnts who consulted with fmily members, friends, nd/or their psychitrist incresed; thus, it my be rgued tht their psychologicl resistnce to consulttion Journl of Psychosocil Nursing Vol. 54, No. 4,

6 KEYPOINTS Kodm, T., Syouji, H., Tkki, S., Fujimoto, H., Ishikw, S., Fukutke, M.,...Hshimoto, T. (2016). Text Messging for Psychitric Outptients: Effect on Help-Seeking nd Self- Hrming Behviors. Journl of Psychosocil Nursing nd Mentl Helth Services, 54(4), Individuls who prtke in self-hrming behvior re t high risk for suicide; however, help-seeking behviors reduce the risk of suicide. 2. Text messging using mobile phones reduced self-hrm nd incresed helpseeking behviors mong individuls with mentl illness. 3. Text messging interventions cn contribute to the prevention of suicide. Do you gree with this rticle? Disgree? Hve comment or questions? Send n e-mil to the Journl t jpn@helio.com. lso decresed. The use of socil services incresed cross five of six items, which indictes the text messges promoted wider use of these services mong prticipnts. When prticipnts who did not use socil services were sked to explin their resoning (dt not shown), the most common reson t bseline ws I didn t know how to use it. However, t 6 months, the number of prticipnts who gve tht sme nswer decresed; thus, the text messging might hve given them the required informtion to mke use of socil services. The uthors believe tht use of consulttion nd socil services not only solves problems but lso enhnces the feeling of connectedness, resulting in decresed incidence of self-hrm nd intensity of suicidl idetion. An importnt strength of the current study is tht there ws high follow-up rte (>96%). As previous studies hve shown, prticipnts who receive text messging intervention re less likely to drop out of study compred to other forms of intervention (Agypong, Ahern, McLoughlin, & Frren, 2012; Free et l., 2011). Prticipnts in the current study reported high level of stisfction, which might be one of the resons for the high follow-up rte. The text messging intervention hs mny dvntges, including delivery of support to ny loction without the individul hving to visit n institution (Free et l., 2009). The intervention lso llows for substntil numbers of messges to be sent simultneously nd independently, with the benefit of further reducing lbor expenditure nd costs. Becuse text messge cn be kept on their mobile devices, recipients cn rered messges t ny time. In ddition, the text messge ws linked to website ddress or phone number for services, so prticipnts could ccess socil services more esily. Mobile phone technology hs the potentil to provide support to those with other helth problems. There is evidence tht using text messges cn support smoking cesstion (Free et l., 2011), remind generl medicl ptients of scheduled medicl ppointments (d Cost et l., 2010), nd improve complince with mediction (Strndbygrd, Thomsen, & Bcker, 2010). Currently, severl smrtphone pplictions re vilble for improvement of mentl helth problems, such s posttrumtic stress disorder (Elis, Fogger, McGuinness, & D Alessndro, 2014). With the current progrm, the content of the text messges nd time t which text messges re sent cn be chnged ccording to client preferences. Moreover, the study ws completed sfely in smple of severely mentlly ill ptients with suicidl idetion. Therefore, the uthors believe this pproch could be pplied to individuls other thn psychitric ptients. There re some limittions to the current study. The smple of 30 prticipnts ws smll, nd the inclusion of ptients depended on their psychitrists subjective opinion; however, these were necessry spects for conducting the pilot study. The influences of other tretments, including mediction or spontneous recovery, lso cnnot be ruled out in regrd to study prticipnts reported helpseeking nd self-hrming behviors. To confirm the effectiveness of the current pproch, it will be necessry to conduct rndomized controlled tril using lrger smple nd complete dditionl follow up to determine how long the effect of the text messging intervention is sustined. CONCLUSION The current study ws sfely completed in ptients with severe mentl illness with suicidl idetion, nd prticipnts were stisfied with the text messging intervention. This is the first study tht promotes psychitric outptients help-seeking nd reduction of self-hrm using text messging. This intervention hs prcticl vlue nd my led to the prevention of suicide in psychitric outptients. REFERENCES Agypong, V.I., Ahern, S., McLoughlin, D.M., & Frren, C.K. (2012). Supportive text messging for depression nd comorbid lcohol use disorder: Single-blind rndomised tril. Journl of Affective Disorders, 141, doi: /j.jd Brown, G.K., Ten Hve, T., Henriques, G.R., Xie, S.X., Hollnder, J.E., & Beck, A.T. (2005). Cognitive therpy for the prevention of suicide ttempts: A rndomized controlled tril. Journl of the Americn Medicl Assocition, 294, doi: / jm Cho, S.-E., N, K.-S., Cho, S.-J., Im, J.-S., & Kng, S.-G. (2016). Geogrphicl nd temporl vritions in the prevlence of mentl disorders in suicide: Systemtic review nd met-nlysis. Journl of Affective Disorders, 190, doi: /j. jd

7 d Cost, T.M., Slomão, P.L., Mrth, A.S., Pis, I.T., & Sigulem, D. (2010). The impct of short messge service text messges sent s ppointment reminders to ptients cell phones t outptient clinics in So Pulo, Brzil. Interntionl Journl of Medicl Informtics, 79, doi: /j. ijmedinf Elis, B.L., Fogger, S.A., McGuinness, T.M., & D Alessndro, K.R. (2014). Mobile pps for psychitric nurses. Journl of Psychosocil Nursing nd Mentl Helth Services, 52(4), doi: / Fleischmnn, A., Bertolote, J.M., Wssermn, D., De Leo, D., Bolhri, J., Boteg., Thnh, H.T. (2008). Effectiveness of brief intervention nd contct for suicide ttempters: A rndomized controlled tril in five countries. Bulletin of the World Helth Orgniztion, 86, doi: / S Free, C., Knight, R., Robertson, S., Whittker, R., Edwrds, P., Zhou, W., Roberts, I. (2011). Smoking cesstion support delivered vi mobile phone text messging (txt2stop): A single-blind, rndomised tril. Lncet, 378, doi: /s (11) Free, C., Whittker, R., Knight, R., Abrmsky, T., Rodgers, A., & Roberts, I.G. (2009). Txt2stop: A pilot rndomised controlled tril of mobile phone-bsed smoking cesstion support. Tobcco Control, 18, doi: /tc Interntionl Telecommuniction Union. (2014). The world in 2014: ICT fcts nd figures. Retrieved from en/itu-d/sttistics/documents/fcts/ict- FctsFigures2014-e.pdf Moskos, M.A., Olson, L., Hlbern, S.R., & Gry, D. (2007). Uth youth suicide study: Brriers to mentl helth tretment for dolescents. Suicide nd Life-Thretening Behvior, 37, doi: / suli Onishi, K. (2015). Risk fctors nd socil bckground ssocited with suicide in Jpn: A review. Jpn Hospitls: The Journl of the Jpn Hospitl Assocition, 34, Orgnistion for Economic Co-opertion nd Development. (2014). Mking mentl helth count: The socil nd economic costs of neglecting mentl helth cre. Pris, Frnce: Author. Owens, C., Lmbert, H., Donovn, J., & Lloyd, K.R. (2005). A qulittive study of help seeking nd primry cre consulttion prior to suicide. British Journl of Generl Prctice, 55, Strndbygrd, U., Thomsen, S.F., & Bcker, V. (2010). A dily SMS reminder increses dherence to sthm tretment: A three-month follow-up study. Respirtory Medicine, 104, doi: /j. rmed Wei, J., Hollin, I., & Kchnowski, S. (2011). A review of the use of mobile phone text messging in clinicl nd helthy behviour interventions. Journl of Telemedicine nd Telecre, 17, doi: / jtt Mr. Kodm is Psychitric Socil Worker nd Cre Mnger nd Doctorl Course Student, Dr. Hshimoto is Professor, Deprtment of Rehbilittion Science, nd Mr. Fujimoto is Assistnt Professor, Deprtment of Nursing, Kobe University Grdute School of Helth Sciences, Kobe; Ms. Syouji is Public Helth Nurse nd Certified Nurse Specilist, Koui Hospitl, Osk; Ms. Tkki is Industril Counselor, Komzw Kei Clinic, Tokyo; Dr. Ishikw is Chief Psychitrist, Division of Psychitry, Nishi Kobe Medicl Center, Kobe; Dr. Fukutke is Chief Psychitrist, Deprtment of Psychitry nd Neurology, Kobe City Medicl Center Generl Hospitl, Kobe; Dr. Tir is Chief Psychitrist, Kofu Hospitl of Hyogo Prefecture, Kobe, nd Clinicl Resercher, Deprtment of Psychitry, Kobe University Grdute School of Medicine, Kobe, Jpn. Mr. Kodm is lso Lecturer, Deprtment of Adult Helth nd Psychitric Nursing, School of Nursing, Fculty of Medicine, Mie University, Tsu, Jpn. The uthors hve disclosed no potentil conflicts of interest, finncil or otherwise. This work ws supported by Kobe City nd the Jpn Society for the Promotion of Science KAKENHI (grnts nd ). The uthors thnk Kyno Yotsumoto, PhD, OTR, Associte Professor, Kobe University School of Helth Sciences, for his encourgement nd scientific discussions; Ttsuzou Asno, MD, Toshiki Ishi, MD, nd Yuichi Kkimoto, MD, for their guidnce nd helpful suggestions concerning the study; Mrs. Kzuko Kno for her vluble ssistnce s secretry; nd the numerous hospitl stff members who ssisted throughout the dt collection process. They lso recognize Editge ( for help with English lnguge editing Kodm, Syouji, Tkki, Fujimoto, Ishikw, Fukutke, Tir, nd Hshimoto; licensee SLACK Incorported. This is n Open Access rticle distributed under the terms of the Cretive Commons Attribution-NonCommercil 4.0 Interntionl ( licenses/by-nc/4.0). This license llows users to copy nd distribute, to remix, trnsform, nd build upon the rticle non-commercilly, provided the new work be non-commericl. Address correspondence to Toyohiko Kodm, RN, MS, Psychitric Socil Worker nd Cre Mnger, Lecturer, School of Nursing, Fculty of Medicine, Mie University, 2-174, Edobshi, Tsu, Mie , Jpn; e-mil: t-kodm@nurse.medic.mie-u.c.jp. Received: September 7, 2015 Accepted: Jnury 5, 2016 doi: / Journl of Psychosocil Nursing Vol. 54, No. 4,