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2014 Volume 26 Issue 5
In this issue
Systematic review and meta-analysis
Appraisal of the methodological quality and summary of the findings of systematic reviews on the relationship between SSRIs and suicidality Wei LI, Yumei WAN, Juanjuan REN, Ting LI, Chunbo LI Background: Several systematic reviews have been published about the relationship of the use of selective serotonin reuptake inhibitors (SSRIs) and risk of suicidal ideation or behavior but there has been no formal assessment of the quality of these reports. 
Aim: Assess the methodological quality of systematic reviews about the relationship of SSRI use and suicidal ideation and behavior; and provide overall conclusions based on this assessment. 
Methods: Systematic reviews of RCTs that compared SSRIs to placebo and used suicidal ideation or behavior as a key outcome variable were identified by searching Pubmed, Embase, The Cochrane Library, EBSCO, PsycINFO, Chinese National Knowledge Infrastructure, Chongqing VIP database for Chinese Technical Periodicals, WANFANG DATA, and the Chinese Biological Medical Literature Database. The methodological quality of included reviews was independently assessed by two expert raters using the 11-item Assessment of Multiple Systematic Reviews (AMSTAR) scale. 
Results: Twelve systematic reviews and meta-analyses were identified. The inter-rater reliability of the overall AMSTAR quality score was excellent (ICC=0.86) but the inter-rater reliability of 5 of the 11 AMSTAR items was poor (Kappa
Conclusions: The available evidence suggests that adolescents may experience an increase in suicidal ideation and behavior with SSRI use, particularly those who have a depressive disorder and those treated with paroxetine. However, there are few high-quality reviews on this issue, so some doubt about the evidence remains. The AMSTAR scale may be useful in the ongoing efforts to improve the quality of systematic reviews, but further work is needed on tightening the operational criteria for some of the items in the scale. 
Keywords: systematic reviews, methodological quality, AMSTAR, selective serotonin reuptake inhibitors, suicidal ideation, suicidal behavior [Shanghai Arch Psychiatry. 2014; 26(5): 248-258. doi: http://dx.doi.org/10.11919/j.issn.1002-0829.214080]
Prevalence of antisocial personality disorder among Chinese individuals receiving treatment for heroin dependence: a meta-analysis Baoliang ZHONG, Yutao XIANG, Xiaolan CAO, Yan LI, Junhong ZHU, Helen F. K. CHIU Background: Studies from Western countries consistently report very high rates of comorbid Antisocial Personality Disorder (ASPD) among individuals with heroin addiction, but the reported proportion of Chinese individuals with heroin addiction who have co-morbid ASPD varies widely, possibly because Chinese clinicians do not consider personality issues when treating substance abuse problems.
Aim: Conduct a meta-analysis of studies that assessed the proportion of Chinese individuals with heroin dependence who have comorbid ASPD. 
Methods: We searched for relevant studies in both Chinese databases (China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform, Taiwan Electronic Periodical Services) and western databases (PubMed, EMBASE, and PsycInfo). Two authors independently retrieved the literature, identified studies that met pre-defined inclusion and exclusion criteria, assessed the quality of included studies, and extracted the data used in the analysis. Statistical analysis was performed using StatsDirect 3.0 and R software. 
Results: The search yielded 15 eligible studies with a total of 3692 individuals with heroin dependence. Only 2 of the studies were rated as high-quality studies. All studies were conducted in rehabilitation centers or hospitals. The pooled lifetime prevalence of ASPD in these subjects was 30% (95%CI: 23%-38%), but the heterogeneity of results across studies was great (I2=95%, p
Conclusions There are substantial methodological problems in the available literature about ASPD in Chinese individuals receiving treatment for heroin dependence, but we estimate that about one-third of them meet criteria for ASPD. Further work is needed to increase clinicians’ awareness of this issue; to compare the pathogenesis, treatment responsiveness and recidivism of those with and without ASPD; and to develop and test targeted interventions for this difficult-to-treat subgroup of individuals with heroin dependence. 
Keywords: Antisocial personality disorder, Heroin dependence, prevalence, meta-analysis, China [Shanghai Arch Psychiatry. 2014; 26(5): 259-271. doi: http://dx.doi.org/10.11919/j.issn.1002-0829.214091]
Original research article
Case control study of association between the ANK3 rs10761482 polymorphism and schizophrenia in persons of Uyghur nationality living in Xinjiang China Xianjiang ZHONG, Lili ZHANG , Shuxian HAN, Xiao LUO, Zhiguo AN, Qizhong YI Background: The rs10761482 polymorphism of the ANK3 gene has been associated with the occurrence of schizophrenia. 
Aim: Assess the relationship between the ANK3 gene and schizophrenia in individuals of Uyghurian descent. 
Methods: A total of 630 patients with schizophrenia and 535 healthy controls of Uyghur descent were genotyped for the ANK3 gene rs10761482 locus using Taqman probe technology. SHEsis and SPSS17.0 software were used for data analysis. 
Results: There were no significant differences in the genotype or allele frequencies between the case group and control group. Within the case group there was no relationship between gender or age of onset of schizophrenia and the genotype or allele frequencies. Separate analyses among men and among women also failed to identify significant differences in the allele and genotype frequencies between cases and controls or between patients with adolescent-onset schizophrenia and those with adult-onset schizophrenia. 
Conclusions: Our findings do not support previous reports about the relationship of the ANK3 gene and schizophrenia. In the Uyghur nationality group recruited for this study there was no significant association between the ANK3 gene rs10761482 polymorphism and schizophrenia. If these results are replicated in further studies, then the focus should change to understanding why this widely acknowledged association does not exist in this particular ethnic group. 
Keywords: schizophrenia; ANK3 gene; rs10761482 polymorphism, association studies, Uyghur nationality, China [Shanghai Arch Psychiatry. 2014; 26(5): 288-293. Epub 2014 Sept 29. doi: http://dx.doi.org/10.11919/ j.issn.1002-0829.214033]
Randomized controlled trial of adjunctive EEG-biofeedback treatment of obsessive-compulsive disorder Xiaopeng DENG, Gaohua WANG, Lifang ZHOU, Xinfeng ZHANG, Mei YANG, Gangya HAN Background: Current interventions for obsessive-compulsive disorder (OCD) are often of limited benefit. 
Aim: To evaluate the effect of adjunctive treatment with EEG biofeedback training on the symptoms and cognitive functioning of individuals with OCD. 
Methods: A total of 79 individuals with OCD were randomly assigned to the study group (n=40) or the control group (n=39). The control group was treated using a combination of sertraline (50 to 200 mg/d) and weekly cognitive behavioral therapy sessions by trained therapists for 8 weeks; the study group was treated using the same regimen plus EEG biofeedback sessions 5 times per week. The Yale Brown Obsessive Compulsive Scale (YBOCS) was administered by a psychiatrist who was blind to patients’ treatment status before treatment and at the end of the 2nd, 4th, 6th and 8th week for treatment; the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) was administered before and after the 8-week trial.
Results: Three individuals dropped out of the study group and four dropped out of the control group (χ2=0.186, p=0.712). At the end of the study, treatment was considered effective in 32 of the 37 (86.5%) participants in the study group and in 22 of the 35 (62.9%) participants in the control group (χ2=5.36, p=0.021). Repeated measures analysis of variance showed that the improvement in OCD symptoms was greater in the study group than the control group by the 6th week of treatment. At the end of the trial all 5 cognitive dimensions assessed by the RBANS were significantly better in study groups subjects than in control group subjects and the changes in the YBOCS score were significantly correlated with changes in the RBANS overall score in the study group (r=0.43, p=0.007), but not in the control group (r=0.171, p=0.327). 
Conclusions: This methodologically rigorous study demonstrates that 8 weeks of adjunctive treatment with EEG biofeedback training can significantly improve the clinical symptoms and cognitive functioning of OCD patients being treated with medication and psychotherapy. Further work is needed to assess the long-term effects of biofeedback training and the need for booster sessions after an initial period of training. 
Keywords: Obsessive compulsive disorder; EEG biofeedback; cognitive function, China [Shanghai Arch Psychiatry. 2014; 26(5): 272-279. doi: http://dx.doi.org/10.11919/j.issn.1002-0829.214067]
Cross-sectional study of the association of cognitive function and hippocampal volume among healthy elderly adults Lijuan JIANG, Yan CHENG, Qingwei LI, Yingying TANG, Yuan SHEN, Ting LI, Wei FENG, Xinyi CAO,Wenyuan Background: Cognitive impairment and dementia among elderly adults is a pressing public health issue in China but research on biomarkers of cognitive decline has been limited. 
Aim: Explore the relationship between multiple domains of cognitive functioning and the volume of the left and right hippocampus in healthy elderly adults. 
Methods: Structural MRI scanning was performed on 65 community-dwelling healthy participants 65 to 75 years of age using the Siemens 3.0 T Trio Tim with the MPRAGE sequence. The volumes of the left and right hippocampus were determined using Freesurfer software. Cognitive functioning was evaluated using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Both unadjusted and adjusted associations between the hippocampal volumes and cognitive functioning were estimated. 
Results: Within this relatively narrow age range, age was significantly associated with most of the cognitive measures assessed in women but was not significantly associated with any of the cognitive measures in men. In both men and women right hippocampal volume was positively associated with delayed memory and left hippocampal volume was positively associated with both immediate memory and delayed memory (though the relationship with delayed memory in women was only at a trend level). After adjustment for age, gender, and years of formal education (the variable that was most strongly associated with all of the cognitive measures), both left hippocampal volume and right hippocampal volume were positively associated with delayed memory, but not with immediate memory. Interestingly, the difference in the volumes of the left and right hippocampi was negatively associated with the score of the RBANS attention subscale, a relationship that was stronger in women than in men. 
Conclusions: This study confirms previous work about the relationship of hippocampal volume and memory, identifies a possible relationship between attention and the difference in size of the two hippocampi, and suggests that there may be some differences in these relationships by gender. 
Keywords: elderly adults, executive function, hippocampal volume, China [Shanghai Arch Psychiatry. 2014; 26(5): 280-287. Epub 2014 Sep 29. doi: http://dx.doi.org/10.11919/ j.issn.1002-0829.214036]
Forum
Should major depressive disorder with mixed features be classified as a bipolar disorder? Xiaohua LIU, Kaida JIANG Summary: The new diagnostic category in the Depressive Disorders chapter of DSM-5 entitled ‘Major Depressive Disorder With Mixed Features’ is applied to individuals who meet criteria for Major Depressive Disorder and have concurrent subsyndromal hypomanic or manic symptoms. But the operational definition of this new specifier is much closer to that of hypomania and mania than to the definition of atypical depression or the older ‘mixed depression.’ Moreover, multiple studies have shown that the characteristics of individuals with this condition and the clinical trajectory of their illness is much closer to that of bipolar patients than to that of depressed individuals without comorbid hypomanic or manic symptoms. Thus we believe that this condition would be more appropriately placed in the Bipolar Disorders chapter of DSM-5. We also believe that this blurring of the depressive disorder- bipolar disorder boundary is one cause for the low inter-rater reliability in the diagnosis of Major Depressive Disorder. 
Keywords: major depressive disorder, depression with mixed features, mixed depression, bipolar disorder, DSM-5 [Shanghai Arch Psychiatry. 2014; 26(5): 294-296. doi: http://dx.doi.org/10.11919/j.issn.1002-0829.214146]
Case report
Case report on Tourette syndrome treated successfully with aripiprazole M.S. BHATIA, Priyanka GAUTAM, Jaswinder KAUR Summary: Tourette syndrome is a childhood-onset neuropsychiatric disorder characterized by multiple motor and vocal tics of at least one year in duration. This case report describes the history of a 16-year-old boy with a 6-year history of Tourette syndrome who was seriously disabled by his symptoms. Treatment with aripiprazole 10mg/d completely resolved his symptoms in about a month allowing him to return to the life that he had been missing because of his illness. In such cases the potential long-term negative effects of using antipsychotic medications need to weighed against the disruptive effects persistent Tourette symptoms can have on patient’s lives. 
Keywords: Tourette syndrome, aripiprazole, case report, India [Shanghai Arch Psychiatry. 2014; 26(5): 297-299. doi: http://dx.doi.org/10.11919/j.issn.1002-0829.214120]
Research methods in psychiatry
Internal consistency and test-retest reliability of the Chinese version of the 5-item Duke University Religion Index Hanhui CHEN, Zhizhong WANG, Michael R. PHILLIPS, Yanli SUN, Hui G. CHENG Background: The Duke University Religion Index (DUREL) is a widely-used 5-item scale assessing religiosity. 
Aim: Assess the internal consistency, reliability, and factor structure of the revised Chinese version of DUREL. 
Methods: Using probability proportionate to size (PPS) methods we randomly identified 3981 households with eligible occupants in 20 primary sampling sites in Ningxia Hui Autonomous Region, a province in northwest China in which 34% of the population are Muslims of the Hui ethnic group. In 3054 households a screening interview was completed and an adult family member was randomly selected; 2425 respondents completed the survey (including the DUREL) and 188 randomly selected individuals repeated the survey an average of 2.5 days later. 
Results: The internal consistency (Cronbach’s α) of the 5 items in the full sample was 0.90; it ranged from 0.70 to 0.90 in various subgroups of subjects stratified by ethnicity, urban versus rural residence, and above versus below median education. The test-retest reliability (intraclass correlation coefficient) for the total score in the full sample was 0.87; it ranged from 0.63 to 0.90 in the different subgroups of subjects. Exploratory factor analysis in a random half of the sample identified a single factor (eigen value=4.21) that explained 84% of the total variance. Confirmatory factor analysis in the second half of the sample confirmed the unidimensional model; the model fit measures of the one-factor model using the 5 item scores as observed variables were acceptable (comparative fit index [CFI] and Tucker-Lewis index [TLI]>0.99; root mean square error of approximation [RMSEA]=0.105; χ2=70.49, df=5), but the model fit improved after adding the correlation between items 1 and 2 (that assess organized and personal religious activities, respectively) as a sixth observed variable(CFI and TLI>0.99; RMSEA=0.046; χ2=14.32, df=4). 
Conclusions: The Chinese version of the DUREL is a reliable and valid measure of religiosity that can be used to assess the relationship of religiosity/spirituality to physical and psychological wellbeing in Chinese respondents. As suggested by other authors, our factor analysis results indicate that the overall score is the best measure derived from the scale, not the three dimensional scores recommended by the original authors. 
Keywords: religiosity, reliability, validity, explanatory factor analysis, confirmatory factor analysis, Hui ethnic group, China [Shanghai Arch Psychiatry. 2014; 26(5): 300-309. Epub 2014 Sep 29. doi: http://dx.doi.org/10.11919/ j.issn.1002-0829.214088]
Biostatistics in psychiatry
Rank regression: an alternative regression approach for data with outliers Tian CHEN, Wan TANG, Ying LU, Xin TU Summary: Linear regression models are widely used in mental health and related health services research. However, the classic linear regression analysis assumes that the data are normally distributed, an assumption that is not met by the data obtained in many studies. One method of dealing with this problem is to use semi-parametric models, which do not require that the data be normally distributed. But semi-parametric models are quite sensitive to outlying observations, so the generated estimates are unreliable when study data includes outliers. In this situation, some researchers trim the extreme values prior to conducting the analysis, but the ad-hoc rules used for data trimming are based on subjective criteria so different methods of adjustment can yield different results. Rank regression provides a more objective approach to dealing with non-normal data that includes outliers. This paper uses simulated and real data to illustrate this useful regression approach for dealing with outliers and compares it to the results generated using classical regression models and semi-parametric regression models. 
Keywords: normal distribution, non-normal distribution, linear regression, semi-parametric regression models, rank regression, sexual health [Shanghai Arch Psychiatry. 2014; 26(5): 310-316. doi: http://dx.doi.org/10.11919/j.issn.1002-0829.214148]