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2013 Volume 25 Issue 4
In this issue
Systematic review and meta-analysis
Advances in genetic studies of substance abuse in China Yan SUN, Shiqiu MENG, Jiali LI, Jie SHI, Lin LU Summary: The importance of genetic factors in substance addiction has long been established. The rationale for this work is that understanding of the function of addiction genes and delineation of the key molecular pathways of these genes would enhance the development of novel therapeutic targets and biomarkers that could be used in the prevention and management of substance abuse. Over the past few years, there has been a substantial increase in the number of genetic studies conducted on addiction in China; these studies have primarily focused on heroin, alcohol, and nicotine dependence. Most studies of candidate genes have concentrated on the dopamine, opioid, and serotonin systems. A number of genes associated with substance abuse in Caucasians are also risk factors in Chinese, but several novel genes and genetic risk factors associated with substance abuse in Chinese subjects have also been identified. This paper reviews the genetic studies of substance abuse performed by Chinese researchers. Genotypes and alleles related to addictive behavior in Chinese individuals are discussed and the contributions of Chinese researchers to the international corpus of knowledge about the genetic understanding of substance abuse are described.
Prevalence of eating disorders in the general population: a systematic review Jie QIAN, Qiang HU, Yumei WAN, Ting LI, Mudan WU, Zhiqun REN, Dehua YU Background: The estimated prevalence of eating disorders reported in community surveys from different parts of the world varies widely but there has been no systematic attempt to identify the reasons for these differences. 
Objective: Use meta-analysis methods to pool data from community surveys about the prevalence of eating disorders in different locations and to identify the factors that are associated with the reported prevalence of eating disorders. 
Methods: Based on pre-defined inclusion and exclusion criteria, studies were identified from the following databases: PubMed/Medline, PsycINFO, ISI web of knowledge, Ovid, Chinese National Knowledge Infrastructure, Chongqing VIP database for Chinese Technical Periodicals, WANFANG DATA, and Chinese Biological Literature Service System. Statistical analysis was conducted using R software. 
Results: Among the 9315 unduplicated reports reviewed (one-fourth of which were published in Chinese) only 15 – with a pooled sample size of 72,961 individuals – met the inclusion criteria for the analysis. None of the included studies were from China and only one Asian country (South Korea) was included in the analysis. The estimated lifetime prevalence, 12-month prevalence, and 4-week prevalence of any eating disorder was 1.01% (95% confidence interval [CI], 0.54-1.89), 0.37% (CI, 0.22-0.63), and 0.21% (CI, 0.15-0.28), respectively. Estimated lifetime prevalence of anorexia nervosa, bulimia nervosa, and binge eating disorder was 0.21% (CI, 0.11-0.38), 0.81% (CI, 0.59-1.09), and 2.22% (CI, 1.78-2.76), respectively. The estimated female-male ratio for lifetime prevalence of any eating disorder was 4.2. The lifetime prevalence of any eating disorder reported from studies conducted in Western countries was 6.1-fold greater than that reported in a single study from South Korea. Over time there has been a non-significant increase in reported prevalence of any eating disorder and a significant increase in reported prevalence of anorexia nervosa. 
Conclusions: Eating disorders are common in the general population, more common in women than men, and more common in Western countries than in Asian countries.The reported prevalence is increasing over time, but this may be due to changes in diagnostic criteria. There are serious limitations in the available epidemiological data, primarily differences in the conditions included among eating disorders and the lack of acceptable epidemiological studies from low- and middle-income countries (including China).
Original research article
Effectiveness and safety of generic memantine hydrochloride manufactured in China in the treatment of moderate to severe Alzheimer’s disease: a multicenter, double-blind randomizedcontrolled trial Minjie ZHU, Shifu XIAO, Guanjun LI, Xia LI, Mouni TANG, Siming YANG, Xiufeng XU, Lianyuan FENG, Kaix Background: Memantine hydrochloride is a N-methyl-D-aspartate (NMDA) antagonist that may be useful in the treatment of Alzheimer’s disease. 
Aim: Compare the efficacy and safety of generic memantine hydrochloride produced in China to that of the imported proprietary version of the medication (Ebixa) in the treatment of moderate to severe Alzheimer’s disease (AD). 
Methods: In this multicenter, double-blind randomized controlled trial 229 patients with moderate to severe AD were randomly assigned to a 16-week trial of either the generic preparation or the proprietary preparation of memantine hydrochloride. All participants were assessed at baseline and at 4, 8, 12 and 16 weeks after enrolment. The primary outcome variable was the Alzheimer Disease Assessment Scale-cognition (ADAS-Cog) score. Secondary outcomes were scores in the Mini-Mental State Examination (MMSE), the Activities of Daily Living (ADL) scale and the Clinical Global Impression (CGI) scale. 
Results: Sample sizes for the safety set (SS) analysis, full analysis set (FAS) and per protocol set (PPS) analysis were 112, 109 and 103 in the generic medication group, and 111, 107 and 101 in the proprietary medication group, respectively. The ADAS-Cog and ADL total scores at the end of weeks 4, 8, 12, and 16 decreased significantly compared with baseline for both groups (p
Conclusion: There are no significant differences in the effectiveness or safety between memantine that is generically produced in China and imported proprietary memantine in the treatment of individuals with moderate and severe AD during the first 16 weeks of treatment.
Mental health literacy among residents in Shanghai Jingyi WANG1, Yanling HE1*, Qing JIANG1, Jun CAI1, Weiling WANG, Qingzhi ZENG, Juming MIAO, Xuejun Q Background: The recent adoption of China’s new national mental health law provides a good opportunity to obtain baseline information about community mental health literacy in the country. 
Aim: Assess knowledge and attitudes about mental disorders among residents in Shanghai. 
Methods: A total of 1953 residents aged 15 or above selected from all 19 districts in Shanghai completed two self-report questionnaires – the Mental Health Knowledge Questionnaire (MHKQ) and the Case Assessment Questionnaire (CAQ). MHKQ total scores range from 0 to 20 (higher scores indicate better mental health literacy). The CAQ presents respondents with five case vignettes and possesses nine questions after each vignette measuring respondents’ knowledge and attitudes towards these mental illnesses. 
Results: Correct response rates for the 20 MHKQ items ranged from 26 to 98%, with a mean rate of 72%. The internal consistency (alpha) of the 20 items on the MHKQ was 0.69, but this decreased to 0.59 after removing four items about mental health promotion. A 5-factor model for the 20 items in the MHKQ was identified using exploratory factor analysis on one-half of the surveys, but the model was only partially validated in the confirmatory factor analysis using the second half of the surveys. On the CAQ, rates of correct recognition of mania, depression, schizophrenia with positive symptoms, schizophrenia with negative symptoms and anxiety were 42%, 35%, 30%, 19% and 21%, respectively. Work stress (37.3%), problems with thinking (30.0%) and negative life events (24.4%) were reported to be the three main causes of mental disorders. Seeing a counselor (34.2%) or a psychiatrist (33.3%) were the two most common suggestions for help-seeking. Higher education and younger age were related with better mental health literacy and higher rates of recognition of common mental disorders. 
Conclusions: Mental health literacy in Shanghai appears to be increasing, but the reliability and validity of the instruments used to assess mental health literacy (MHKQ and CAQ) have not been adequately assessed so this result must be considered preliminary. Further work, preferably including both qualitative and quantitative components, is needed to revise these instruments before they can be used to assess the effectiveness of mental health promotion campaigns.
Twelve-year retrospective analysis of outpatients with Attention-Deficit/Hyperactivity Disorder in Shanghai Lingxiao JIANG, Yan LI, Xiyan ZHANG, Wenqing JIANG, Caohua YANG, Nan HAO, Lili HAO, Mengyao LI, Wenw treated in outpatient psychiatric clinics in China, accounting for up to 50% of all patients. 
Objective: Understand changes over time in the characteristics and treatment of children with ADHD seen at specialty psychiatric clinics in China. 
Methods: For each year from 2000 through 2011, 250 charts of patients who made their initial visit to the Child and Adolescent Psychological Counseling Clinic of the Shanghai Mental Health Center were randomly selected. Among the 3000 selected patients, 998 (33%) had a diagnosis of ADHD. 
Results: About 80% of the ADHD patients were male and the majority of them fell ill prior to the age of seven. The mean (sd) age at the time of first attendance at the clinic was 10.0 (2.6) years and the mean duration of illness at the time of the initial visit was 2.9 (1.2) years; both of these values decreased significantly over time. About 20% of them were non-residents of Shanghai and about 11% had comorbid psychiatric diagnoses (primarily depression and tic disorder); both of these proportions increased significantly over time. Among the 576 (58%) who visited the clinic more than once, 77% were treated with central nervous system stimulants, but the proportion administered behavioral treatments (either solely on in combination with medications) increased significantly over time. 
Conclusion: ADHD remains the most common diagnosis of children seen in specialty psychiatric clinics in China but the proportion of clinic attendees with ADHD is gradually declining as non-specialty treatment services expand and other diagnoses become more prominent. There are encouraging trends of earlier identification and treatment of ADHD and of increasing use of non-pharmacological interventions. Nevertheless, most children with ADHD have been ill for at least two years at the time of the initial diagnosis, so continued research efforts are needed to identify the best ways to speed up the recognition and treatment of this disabling condition.
Forum
Should repetitive Transcranial Magnetic Stimulation (rTMS) be considered an effective adjunctive treatment for auditory hallucinations in patients with schizophrenia? Jijun WANG, Yifeng XU
Case report
A case of recurrent neuroleptic malignant syndrome Zexiang OUYANG, Li CHU Summary: Neuroleptic malignant syndrome (NMS) is a life-threatening neurologic complication associated with the use of neuroleptic agents and characterized by a distinctive clinical syndrome of fever, rigidity, autonomic nervous system dysfunction and mental status change. This report discusses the clinical presentation, possible etiology, pathogenesis and treatment of one case of recurrent NMS in a middle-aged woman with schizophrenia. NMS occurred after combined treatment with haloperidol and aripiprazole (the first episode) and, four years later, after combined treatment with haloperidol and clozapine (the second episode). This case highlights the need to be particularly cautious in the use of antipsychotic medications in patients with a history of NMS and, whenever possible, to avoid combined treatment with multiple antipsychotic medications in these patients.
Biostatistics in psychiatry
Power analysis for cross-sectional and longitudinal study designs Naiji LU, Yu HAN, Tian CHEN, Douglas D. GUNZLER, Yinglin XIA, Julia Y. LIN, Xin M. TU