Psychiatric comorbidity among patients with gender identity disorder

Aims: Psychiatric comorbidity and mental instability seem to be important unfavorable prognostic factors for long‐term psychosocial adjustment in gender identity disorder (GID). However, psychiatric comorbidity in patients with GID has rarely been assessed. In this study, we investigated the psychiatric comorbidity and life events of patients with GID in Japan. Methods: A total of 603 consecutive patients were evaluated independently by at least two senior psychiatrists at the GID clinic using clinical information and results of examinations. Results: Using DSM‐IV criteria, 579 patients (96.0%) were diagnosed with GID. Among the GID patients, 349 (60.3%) were the female‐to‐male (FTM) type, and 230 (39.7%) were the male‐to‐female (MTF) type. Current psychiatric comorbidity was 19.1% (44/230) among MTF patients and 12.0% (42/349) among FTM patients. The lifetime positive history of suicidal ideation and self mutilation was 76.1% and 31.7% among MTF patients, and 71.9% and 32.7% among FTM patients. Among current psychiatric diagnoses, adjustment disorder (6.7%, 38/579) and anxiety disorder (3.6%, 21/579) were relatively frequent. Mood disorder was the third most frequent (1.4%, 8/579). Conclusions: Comparison with previous reports on the psychiatric comorbidity among GID patients revealed that the majority of GID patients had no psychiatric comorbidity. GID is a diagnostic entity in its own right, not necessarily associated with severe comorbid psychological findings.     

Regional cerebral blood flow changes in female to male gender identity disorder

Aims: Despite a range of research on gender identity disorder (GID), at present there is no scientific consensus on whether the etiology of GID is mental or physical. In particular recent advances in the technology of neuroimaging research have led to an increased understanding of the biological basis of various mental disorders. GID also should be evaluated from this perspective. The aim of the present study was therefore to do the first trial to examine the regional cerebral blood flow (rCBF) in GID. Methods: Persons considered biologically male fulfilling the GID criteria are termed male to female (MTF) and, conversely, persons considered biological female are termed female to male (FTM). We compared 11 FTM subjects and nine age‐ and handedness‐matched female control subjects. None of the subjects was regularly taking medication and none had any kind of physical or psychiatric comorbidity. To evaluate rCBF in GID subjects and control subjects, statistical parametric mapping analysis of ^99mTc‐ethyl‐cysteinate dimer single‐photon emission computed tomography was used. Results: GID subjects had a significant decrease in rCBF in the left anterior cingulate cortex (ACC) and a significant increase in the right insula compared to control subjects. Conclusions: The ACC and insula are regions that have been noted as being related to human sexual behavior and consciousness. From these findings, useful insights into the biological basis of GID were suggested.     

Clinical characteristics of patients with gender identity disorder at a Japanese gender identity disorder clinic

The aim of this study was to examine the clinical characteristics of patients with gender identity disorder (GID) at a GID clinic in Japan. A total of 603 consecutive patients were evaluated at the GID clinic using clinical information and results of physical and neurological examinations. Using DSM-IV criteria, 579 patients (96.0%) were diagnosed with GID. Four patients were excluded for transvestic fetishism, eight for homosexuality, five for schizophrenia, three for personality disorders, and four for other psychiatric disorders. Among the GID patients, 349 (60.3%) were the female-to-male (FTM) type, and 230 (39.7%) were the male-to-female (MTF) type. Almost all FTM-type GID patients started to feel discomfort with their sex before puberty and were sexually attracted to females. The proportion of FTM patients who had experienced marriage as a female was very low, and very few had children. Therefore, FTM-type GID patients seem to be highly homogeneous. On the other hand, various patterns of age at onset and sexual attraction existed among MTF patients. Among the MTF-type GID patients, 28.3% had married as males and 18.7% had sired children. Thus, MTF-type GID patients seem to be more heterogeneous.     

Speech rate in males,females, and male‐to‐female transsexuals

For clinicians treating transsexual clients it is important to address primarily those characteristics whose modification is most relevant to the creation of the desired gender presentation. The present study investigated the extent to which a modification of speech rate is warranted in male‐to‐female transsexuals. Comparison of speech rate measured in 100 non‐transsexual males, 100 non‐transsexual females, and 28 individuals with a confirmed diagnosis of male‐to‐female gender dysphoria showed no significant differences. This result suggests that a modification of overall speech rate in male‐to‐female transsexuals is not really indicated but does not exclude that speech rate in males and females is perceived differently by listeners or that gender differences exist in temporal aspects of speech at a micro‐level.     

Suicidal ideation among patients with gender identity disorder

In this study, we tried to clarify the prevalence of suicidal ideation and self-mutilation including suicide attempts among patients with gender identity disorder (GID) and the relationship of those behaviors to demographic characteristics. A total of 500 consecutive Japanese GID patients without any other psychiatric comorbidity were evaluated at the outpatient GID Clinic of Okayama University Hospital. The lifetime rate of suicidal ideation was 72.0% of the total sample. There were no significant differences in the prevalence of suicidal ideation among groups divided by sex, age, age at onset or education. The lifetime prevalence of self-mutilation including suicide attempts was 31.8% of the total sample. Low level of education was significantly related to self-mutilation among both male-to-female and female-to-male GID patients. Younger age at onset was a significant factor affecting self-mutilation only among MTF GID patients. A lack of strategies to cope with severe distress among persons with lower education might induce a high frequency of self-mutilation including suicidal attempt. GID patients with a low level education might be at high risk of self-mutilation and should be watched with special attention to self-mutilation.     

Amyotrophic lateral sclerosis: gender differences in the use of mechanical ventilation

Background and purpose: Invasive and non‐invasive mechanical ventilation are therapeutic options in patients with amyotrophic lateral sclerosis (ALS). Related to known national ALS incidence figures, the study aims to examine gender aspects versus physiological data in patients with ALS commencing mechanical ventilation. Methods: Data from two nationwide registers involving all patients with ALS in Norway and Sweden who started invasive and non‐invasive mechanical ventilation during 2002–2007. Results: The total ALS population on invasive and non‐invasive mechanical ventilation comprised n = 308 subjects [Norway n = 96 (72% men), Sweden n = 212 (69% men)]. Compared to Swedish ALS incidence figures, our finding of a male/female ratio of 2.3/1 in patients with ALS on invasive and non‐invasive mechanical ventilation shows a statistically significant male predominance in the use of mechanical ventilation (P‐value 0.0084 Chi square). Only 6.7% of men and 3.8% of women had invasive (via tracheotomy) ventilation (P = 0.344). Initiation of mechanical ventilation was acute (not planned) in 18% of patients (no gender difference). Age distribution (mean age 62), pulmonary function tests (FVC%pred, FEV₁%pred), daytime blood gas analyses (PaO₂, PaCO₂) and survival revealed no statistically significant gender differences. Conclusion: In Norwegian and Swedish patients with ALS on invasive and non‐invasive mechanical ventilation, two‐thirds were men. Associated with known national ALS male/female incidence figures, our finding shows that statistically significantly more men than women with ALS are using mechanical ventilation. Physiological data and survival were equal in both genders. This may indicate the need for a more aggressive approach to stimulate mechanical ventilation in female patients with ALS.     

Adolescents with gender identity disorder: reconsideration of the age limits for endocrine treatment and surgery

The third versions of the guideline for treatment of people with gender identity disorder (GID) of the Japanese Society of Psychiatry and Neurology does not include puberty-delaying hormone therapy. It is recommended that feminizing/masculinizing hormone therapy and genital surgery should not be carried out until 18 year old and 20 year old, respectively. On the other hand, the sixth (2001) and the seventh (2011) versions of the standards of care for the health of transsexual, transgender, and gender nonconforming people of World Professional Association for Transgender Health (WPATH) recommend that transsexual adolescents (Tanner stage 2, [mainly 12-13 years of age]) are treated by the endocrinologists to suppress puberty with gonadotropin-releasing hormone (GnRH) agonists until age 16 years old, after which cross-sex hormones may be given. A questionnairing on 181 people with GID diagnosed in the Okayama University Hospital (Japan) showed that female to male (FTM) transsexuals hoped to begin masculinizing hormone therapy at age of 15.6 +/- 4.0 (mean +/- S.D.) whereas male to female (MTF) transsexuals hoped to begin feminizing hormone therapy as early as age 12.5 +/- 4.0, before presenting secondary sex characters. After confirmation of strong and persistent cross-gender identification, adolescents with GID should be treated with cross-gender hormone or puberty-delaying hormone to prevent developing undesired sex characters. These treatments may prevent transsexual adolescents from attempting suicide, being depressive, and refusing to attend school. Subsequent early breast and genital surgery may help being employed in desired sexuality.     

Association study of gender identity disorder and sex hormone-related genes

To investigate the biological mechanism of gender identity disorder (GID), five candidate sex hormone-related genes, encoding androgen receptor (AR), estrogen receptors α (ERα) and β (ERβ), aromatase (CYP19), and progesterone receptor (PGR) were analyzed by a case–control association study. Subjects were 242 transsexuals (74 male-to-female patients (MTF) and 168 female-to-male patients (FTM)), and 275 healthy age- and geographical origin-matched controls (106 males and 169 females). The distributions of CAG repeat numbers in exon 1 of AR, TA repeat numbers in the promoter region of ERα, CA repeat numbers in intron 5 of ERβ, TTTA repeat numbers in intron 4 of CYP19, and six polymorphisms (rs2008112, rs508653, V660L, H770H, rs572698 and PROGINS) of PGR were analyzed. No significant difference in allelic or genotypic distribution of any gene examined was found between MTFs and control males or between FTMs and control females. The present findings do not provide any evidence that genetic variants of sex hormone-related genes confer individual susceptibility to MTF or FTM transsexualism.     

To what extent does frontal type executive impairment affect coping strategies in Parkinson’s disease?

Background and purpose: Given the frequency of executive dysfunction in Parkinson’s disease (PD), we wonder to what extent this fact might influence the coping strategies which are used. Methods: A total of 135 PD patients with no dementia were divided into two groups according to their cognitive status (‘with frontal type executive impairment’ or ‘without frontal type executive executive impairment’). All patients were seen for a semi‐structured interview to collect sociodemographic and clinical information and to assess their cognitive and mental states (DSM‐IV‐TR, frontal assessment battery and Montgomery and Asberg Depression Rating Scale). Then, all patients completed two self‐report questionnaires concerning their coping strategies (Ways of Coping Checklist and Coping with Health, Injuries and Problems Scale). Results: After controlling the depression, we noticed a significant effect of cognitive status on positive re‐evaluation (P = 0.02). Interestingly, except for instrumental strategies, patients with frontal type executive impairment used significantly more coping strategies than did patients without frontal type executive impairment. Conclusion: Our results suggest that neither executive impairment nor depression prevents patients from using coping strategies extensively.     

Clinical features of childhood onset essential tremor

Childhood onset essential tremor (ET) is uncommon. It is not clear as to whether ethnicity-specific differences may influence the phenotypic features. To determine the frequency and clinical characteristics of childhood ET in a tertiary referral center. In a prospective evaluation of 120 consecutive ET patients in a movement disorders clinic, we found a 15.5% (19) frequency of childhood onset ET patients. The mean age of onset and mean age was 10.8 ± 4.1 (6–16) years and 25.7 ± 15.0 (16–73) years consisting of 73.6% (14/19) men and 26.4% (5/19) women. A positive family history of ET was present in 11 of 19 (52.6%). Presence of a head tremor was observed in 2/19 (10.5%). We highlighted a relatively high frequency (15,5%) of childhood ET in our Asian cohort. In addition, we drew attention to the male preponderance and the low frequency of head tremor in childhood ET corroborating study findings in white ET patients. These observations appear to transcend ethnic and cultural differences and lend further support that gender difference may play a role in the pathogenesis and expression of ET.     

Gender dysphoria in pervasive developmental disorders

Pervasive developmental disorders (PDD) are characterized by two essential symptoms: impairment in social interaction, and restricted, repetitive, and stereotyped patterns of behavior, interests, and activities. PDD include autistic disorder, Asperger's disorder, and PDD-Not Otherwise Specified (PDD-NOS). These three disorders are sometimes termed autism spectrum disorders. A recent epidemiological survey demonstrated that the rate of PDD may be almost 1% and that many PDD cases might not be diagnosed properly in childhood. Erik Erikson described eight stages of psychosocial development through which a normally developing human should pass from infancy to adulthood. In the theory, an adolescent shows 'Identity vs. Role Confusion'. It has been reported that individuals with PDD often have identity crises which sometimes include gender dysphoria. This phenomenon might be related to the so-called identity diffusion in youth. When they reach their young youth, it has been said that subjects with PDD realize their uniqueness and differences compared to others, and, as a result, they may develop confusion of identity which could be exhibited as gender identity disorder. A recent study demonstrated that, amongst 204 children and adolescents who visited a GID clinic in the Netherlands, 7.8% were diagnosed with autism spectrum disorders after a careful diagnostic procedure by a multi-disciplinary team. Taken together, PDD and GID seem closely related to each other. In this paper, we present four PDD cases with gender dysphoria and related symptoms: 1) a girl with PDD who repeatedly asserted gender identity disorder (GID) symptoms in response to social isolation at school, 2) a junior high school boy with PDD and transvestism, 3) a boy diagnosed with Asperger's disorder who developed a disturbance of sexual orientation, and 4) a boy with Asperger's disorder and comorbid childhood GID. Many of the clinical symptoms related to gender dysphoria might be explained by the cognitive characteristics and psychopathology of PDD. The Japanese Society of Psychiatry and Neurology published guidelines for the assessment and treatment of GID in 1997, and revised them in 2006. As a result, GID has become well known as a clinical entity in Japan, and there have been an increasing number of Japanese patients complaining of gender dysphoria. It is important to consider an underlying diagnosis of PDD when encountering patients with gender dysphoria.     

Cognitive emotion regulation strategies contributing to resilience in patients with depression and/or anxiety disorders

Objective

Research suggests that resilience is associated with favorable treatment outcome in patients with depression and/or anxiety disorders. In this regard, the identification of specific characteristics related to resilience that could provide targets for resilience-enhancement interventions is needed. Since the type of cognitive coping strategies is a possible marker of resilience, we investigated adaptive and maladaptive cognitive emotion regulation strategies contributing to resilience in patients with depression and/or anxiety disorders.

Methods

A total of 230 outpatients with depression and anxiety disorders were consecutively recruited and completed the Cognitive Emotion Regulation Questionnaire, the Connor–Davidson Resilience Scale, the Beck Depression Inventory, and the State Anxiety Inventory. A linear regression model was used to determine which cognitive emotion regulation strategies predicted resilience after controlling for relevant covariates. Additionally, this model of resilience was compared with those of depression and anxiety symptoms.

Results

Adaptive strategies were more strongly correlated with resilience than maladaptive strategies. In the regression model, more use of refocus on planning and positive reappraisal as well as less use of rumination predicted high resilience after controlling for age, gender, marital status, depression, and anxiety. Among these strategies, refocus on planning was the common strategy contributing to resilience and depression.

Conclusion

These results suggested that the cognitive emotion regulation strategies of refocus on planning, positive reappraisal, and less rumination contribute to resilience in patients with depression and anxiety disorders. It might provide potential targets for psychotherapeutic intervention to improve resilience in these patients.     

Coping strategies as related to medical and demographic data in amyotrophic lateral sclerosis

Montel S, Albertini L, Spitz E. Coping strategies as related to medical and demographic data in amyotrophic lateral sclerosis.
Acta Neurol Scand: 2012: 125: 135–141.
© 2011 John Wiley & Sons A/S. Introduction – The aim of this study was to examine the coping strategies of 49 patients with amyotrophic lateral sclerosis (ALS) and their relationships with medical and demographic data. Methods – A total of 49 subjects were asked to fill out a document that would provide their demographic and medical data. Then, each one was asked to complete a questionnaire of coping strategies called the Brief COPE. Results – Regarding age groups, we noticed several significant differences concerning emotional support, venting, positive reframing, planning and humour. All these strategies were used significantly more often by younger patients. As for medical variables, the clinical form (bulbar vs spinal ALS), and participation or non‐participation in a clinical trial proved to affect the coping style. The correlation analysis showed that disease duration was positively and significantly related to acceptance, positive reframing and humour. Only one significant correlation was observed between coping strategies and ALS Functional Rating Scale (ALSFRS) scores. It concerned blame, which was negatively correlated with ALSFRS scores. Discussion – Our study clearly demonstrated the relationships between coping strategies and medical as well as demographic variables. These results encourage us to develop further investigations to better understand these relationships and to offer better adapted psychological interventions for patients with ALS.     

Cognitive coping strategies and symptoms of depression and anxiety: a comparison between adolescents and adults

The present study focused on comparability of adolescents and adults in the reporting of cognitive coping strategies and their relationship to symptoms of depression and anxiety. Two samples were included: 487 adolescents attending a secondary school and 630 adults from a general practitioners practice. Data were obtained on symptoms of depression and anxiety and the use of nine cognitive coping strategies: acceptance, catastrophizing, other-blame, positive reappraisal, putting into perspective, refocus on planning, positive refocusing, rumination and self-blame.The results showed that all cognitive coping strategies were reported by adolescents to a significantly lesser extent than by adults. Further, it was shown that both in adolescents and adults a considerable percentage of the variance in symptomatology was explained by the use of cognitive coping strategies. Although adolescents and adults differed in relative strength of the relationships, generally speaking, conclusions were the same: in both groups, the cognitive coping strategies self-blame, rumination, catastrophizing and positive reappraisal were shown to play the most important role in the reporting of symptoms of psychopathology, showing the importance of introducing prevention and intervention programmes at an early stage.     

Event-Related Potentials for Gender Discrimination: An Examination Between Differences in Gender Discrimination Between Males and Females

The event-related potentials (ERP) following presentation of male and female faces were investigated to study differences in the gender discrimination process. Visual stimuli from four categories including male and female faces were presented. For the male subjects, the P220 amplitude of the T5 area following viewing of a female face was significantly larger than that following viewing of a male face. On the other hand for female subjects, the P170 amplitude of the Cz area following observation of a male face was larger than that for a female face. The results indicate that the neural processes, including responsive brain areas used for gender discrimination by observing faces, are different between males and females.     

Coping styles in prodromes of bipolar mania

OBJECTIVES: Psychological studies have identified that different coping strategies affect outcome in bipolar disorder (BD), with the possibility of preventing mania by effective coping with prodromes. This study seeks to examine coping mechanisms using a recently developed scale to clarify the relationship of coping styles to clinical and demographic characteristics, and to identify coping differences between bipolar I and II subjects. METHODS: The Coping Inventory for Prodromes of Mania (CIPM) was completed by 203 bipolar patients, along with other diagnostic and clinical measures. The CIPM is organized into four factors of coping including: stimulation reduction (SR), problem-oriented coping (PR), seeking professional help (SPH), denial and blame (DB). CIPM psychometric properties and its relationship to demographic and clinical factors, dysfunctional attitudes, and mood symptoms were examined. Coping profiles were generated by BD subtype (I versus II). RESULTS: The CIPM displayed psychometric properties consistent with the single previous study with this instrument. Neither demographic/clinical characteristics nor mood symptoms showed any particular relationship with the CIPM. Clear differences in coping also emerged between BD I and BD II subjects. BD I tended to use a wider range of coping strategies and scored highly on the SPH factor as compared to BD II subjects. BD II participants preferred to use DB and PR, but were less likely to use SPH and SR. CONCLUSIONS: The CIPM appears to be a valid measure of coping. Coping style preferences appear to differ according to bipolar subtype.     

Cross-sex hormone treatment does not change sex-sensitive cognitive performance in gender identity disorder patients

Cognitive performance in untreated early onset gender identity disorder (GID) patients might correspond to their born sex and not to their perceived gender. As a current mode of intervention, cross-sex hormone treatment causes considerable physical changes in GID patients. We asked, as has been suggested, whether this treatment skews cognitive performance towards that of the acquired sex. Somatically healthy male and female early onset GID patients were neuropsychologically tested before, 3 and 12 months after initiating cross-sex hormone treatment, whereas untreated healthy subjects without GID served as controls (C). Performance was assessed by testing six cognitive abilities (perception, arithmetic, rotation, visualization, logic, and verbalization), and controlled for age, education, born sex, endocrine differences and treatment by means of repeated measures analysis of variance. GID patients and controls showed an identical time-dependent improvement in cognitive performance. The slopes were essentially parallel for males and females. There was no significant three-way interaction of born sex by group by time for the six investigated cognitive abilities. Only education and age significantly influenced this improvement. Despite the substantial somatic cross-sex changes in GID patients, no differential effect on cognition over time was found between C and GID participants. The cognitive performance of cross-sex hormone-treated GID patients was virtually identical to that of the control group. The documented test–retest effect should be taken into consideration when evaluating treatment effects generally in psychiatry.     

Psychosexual outcome of gender-dysphoric children

ObjectiveTo establish the psychosexual outcome of gender-dysphoric children at 16 years or older and to examine childhood characteristics related to psychosexual outcome.MethodWe studied 77 children who had been referred in childhood to our clinic because of gender dysphoria (59 boys, 18 girls; mean age 8.4 years, age range 5–12 years). In childhood, we measured the children's cross-gender identification and discomfort with their own sex and gender roles. At follow-up 10.4 ± 3.4 years later, 54 children (mean age 18.9 years, age range 16–28 years) agreed to participate. In this group, we assessed gender dysphoria and sexual orientation.ResultsAt follow-up, 30% of the 77 participants (19 boys and 4 girls) did not respond to our recruiting letter or were not traceable; 27% (12 boys and 9 girls) were still gender dysphoric (persistence group), and 43% (desistance group: 28 boys and 5 girls) were no longer gender dysphoric. Both boys and girls in the persistence group were more extremely cross-gendered in behavior and feelings and were more likely to fulfill gender identity disorder (GID) criteria in childhood than the children in the other two groups. At follow-up, nearly all male and female participants in the persistence group reported having a homosexual or bisexual sexual orientation. In the desistance group, all of the girls and half of the boys reported having a heterosexual orientation. The other half of the boys in the desistance group had a homosexual or bisexual sexual orientation.ConclusionsMost children with gender dysphoria will not remain gender dysphoric after puberty. Children with persistent GID are characterized by more extreme gender dysphoria in childhood than children with desisting gender dysphoria. With regard to sexual orientation, the most likely outcome of childhood GID is homosexuality or bisexuality. J. Am. Acad. Child and Adolesc. Psychiatry, 2008;47(12):1413–1423.     

Gender differences in bipolar disorder type I and II

Objective: We investigated gender differences in bipolar disorder (BD) type I and II in a representative cohort of secondary care psychiatric in‐ and out‐patients. Method: In the prospective, naturalistic Jorvi Bipolar Study of 191 secondary care psychiatric in‐ and out‐patients, 160 patients (85.1%) could be followed up for 18 months with a life chart. Results: After adjusting for confounders, no marked differences in illness‐related characteristics were found. However, female patients with BD had more lifetime comorbid eating disorders (P < 0.001, OR = 5.99, 95% CI 2.12–16.93) but less substance use disorders (P < 0.001, OR = 0.29, 95% CI 0.16–0.56) than males. Median time to recurrence after remission was 3.1 months longer among men than women, female gender carrying a higher hazard of recurrence (P = 0.006, HR = 2.00, 95% CI 1.22–3.27). Conclusion: Men and women with type I and II BD have fairly similar illness‐related clinical characteristics, but their profile of comorbid disorders may differ significantly, particularly regarding substance use and eating disorders. In medium‐term follow‐up, females appear to have a higher hazard of recurrence than males.     

Evaluation of gender differences in caregiver burden in home care: Nagoya Longitudinal Study of the Frail Elderly (NLS-FE)

Background: Japan is presently experiencing a growth in the number of male caregivers and this situation has given rise to some concerns over gender differences. Previous studies have suggested that there are gender differences in caregiver burden in home care, however, it is still unclear whether or not gender differences exist. We therefore conducted this study to attain a better understanding of the Japanese male caregiver burden in home care, using data from the Nagoya Longitudinal Study of Frail Elderly (NLS‐FE). Methods: NLS‐FE is a large prospective study of community‐dwelling elderly persons eligible for public long‐term care insurance who live in Nagoya city and use the services of the Nagoya City Health Care Service Foundation for Older People, which comprises 17 visiting nursing stations and corresponding care‐managing centers, from November to December 2003. Data used in this study included the Japanese version of the Zarit Caregiver Burden Interview, caregivers’ and dependents’ characteristics, and the caregiving situation. The differences in dependent and caregiver characteristics between male and female caregiver groups were assessed using the χ²‐test for categorical variables or the unpaired t‐test for continuous variables. Multiple logistic regression was used to examine the association between dependent and caregiver characteristics and caregiver burden. Results: A total of 399 male caregivers and 1193 female caregivers were included in our analysis. Before and after controlling baseline variables, we did not detect a difference between male and female caregivers with respect to caregiver burden. Conclusion: Our study suggests that differences in caregiver burden may not necessarily exist between male and female caregivers in Japan.