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2015 Volume 27 Issue 1
In this issue
Systematic review and meta-analysis
Using aripiprazole to reduce antipsychotic-induced hyperprolactinemia: meta-analysis of currently available randomized controlled trials Meiling MENG, Wei LI, Shaowei ZHANG, Hongyan WANG, Jianhua SHENG, Jijun WANG, Chunbo LI Background: Hyperprolactinemia (HPL) is a common side effect of antipsychotic medications.Recent reports suggest that aripiprazole can ameliorate antipsychotic-induced HPL, but results are inconsistent and the single available systematic review only considered five studies. 
Aim: Conduct an updated meta-analysis of all randomized controlled trials (RCTs) about the efficacy and safety of aripiprazole as an adjunctive treatment for antipsychotic-induced hyperprolactinemia. 
Methods: English and Chinese databases were searched for RCTs about the use of aripiprazole in treating antipsychotic-induced HPL published by January 20, 2015. Studies were selected using pre-defined inclusion and exclusion criteria. The Cochrane Risk of Bias tool was used to evaluate risk of biases, the Cochrane GRADE measure was used to assess the quality of evidence, and Review Manager 5.3 software was used for data analysis. 
Results: A total of 21 studies, 19 of which were conducted in mainland China, were included in the analysis. Meta-analysis of data from 8 of the studies with a pooled sample of 604 individuals found that compared to the control condition adjunctive aripiprazole significantly increased the proportion of participants who experienced HPL recovery (risk ratio [RR]=19.2, 95%CI=11.0-33.5). The proportion who experienced any adverse effect during follow-up did not differ between the two groups, but the aripiprazole group was more likely to report somnolence(RR=2.76, 95%CI=1.34-5.69) and headaches (RR=2.31, 95%CI=1.08-4.92). High-dose aripiprazole (>5mg/day) was more effective than low-dose (
Conclusions: This study systematically reviewed and evaluated all relevant RCTs and found that adjunctive aripiprazole is effective and safe to use in the treatment of antipsychotic-induced HPL. However, the low quality of some of the studies, the incomplete methodological information provided for most of the studies, and the relatively short follow-up time of the studies raises question about the validity of the results. Further work that resolves these methodological and reporting issues is needed. 
Keywords: aripiprazole; hyperprolactinemia; randomized controlled trial; meta-analysis
Original research article
Social media and suicide prevention: findings from a stakeholder survey Jo ROBINSON, Maria RODRIGUES, Steve FISHER, Eleanor BAILEY, Helen HERRMAN Background: Suicide is a leading cause of death, particularly among young adults. The rapid growth of social media and its heavy use by young adults presents new challenges and opportunities for suicide prevention. Social media sites are commonly used for communicating about suicide-related behavior with others, which raises the possibility of using social media to help prevent suicide. However, the use of social media varies widely between different suicide prevention advocates. The role this type of intervention should play in a community’s overall suicide prevention strategy remains a matter of debate. 
Aim: Explore the ways in which stakeholders use social media for suicide prevention and assess their views about the potential utility of social media as a suicide prevention tool. 
Methods: A 12-week stakeholder consultation that involved the online administration and completion of surveys by 10 individuals who conduct research about suicide and social media, 13 organizations that use social media for suicide prevention purposes, and 64 users of social media. 
Results: Social media was seen as a useful means of delivering a range of suicide prevention activities. Respondents reported that the key benefits of social media were the opportunity to obtain emotional support from others, to express one’s feelings, to talk to others with similar problems, and to provide help to others. The social media site believed to hold most potential for delivering suicide prevention activities was Facebook. There were concerns about potential risks of social media, but respondents felt the potential benefits outweighed the risks. 
Conclusions: Social media was recognized by different types of stakeholders as holding potential for delivering suicide prevention activities. More research is required to establish the efficacy and safety of potential social media-based interventions and ethical standards and protocols to ensure that such interventions are delivered safely need to be developed and implemented. 
Keywords: suicide; social media; internet-based survey; suicide prevention organizations; Australia
Cross-sectional evaluation of the adequacy of guardianship by family members of community-residing persons with mental disorders in Changning District, Shanghai Qiongting ZHANG, Hao CHEN, Kang JU, Xin NIU, Lanjun SONG, Jia CHUI Background: The disease burden associated with chronic psychiatric illnesses is high and is projected to grow rapidly. A community-based management system for persons with mental illness was established in Shanghai in 2012 based on the Shanghai Mental Health Regulations that were developed to conform with China’s new mental health law.
Aim: Evaluate the guardianship services provided by family members to persons with mental illnesses living in the Changning District of Shanghai.
Methods: The legal guardians of 4034 of the 4283 community-dwelling persons with psychiatric disorders living in Changning District who are registered in the Shanghai Information Management System of Mental Health were interviewed by local community health doctors and local neighborhood committee officials. The adequacy of guardianship was assessed based on standardized criteria (including the guardian’s regular attendance at mental health training sessions, and their level of assistance in the treatment, daily life, and rehabilitation of the patient) and the main reasons for inadequate guardianship were recorded.
Results: The majority of guardians (3331, 83.6%) adequately fulfilled their guardianship duties. Advanced age and ill-health of the guardian was the main contributing factor in 87% of the 703 cases in which the guardianship was classified as inadequate. Other factors associated with inadequate guardianship included the patient’s unstable clinical condition or failure to adhere to medication, and when the guardian did not live in the same household as the patient. The patient’s diagnosis, the guardian’s level of education, and the relationship between the guardian and patient were also associated with the adequacy of guardianship.
Conclusions: The guardianship-based community services for mentally ill individuals in urban China works reasonably well. But the rapid aging of China’s population may gradually decrease the ability of China’s families to continue to assume this heavy burden. Alternative models of providing high-quality, community-based services for persons with mental disorders need to be developed as part of the roll-out of China’s new mental health law.
Key words: psychiatric patients; guardianship; community care; mental health law; China
Comparison of the personality and other psychological factors of students with internet addiction who do and do not have associated social dysfunction Qiang CHEN, Xing QUAN, Huimin LU, Pei FEI, Ming LI Background: There is ongoing controversy about whether or not internet addiction should be considered a non-substance behavioral addiction (like gambling disorder) and, if so, what diagnostic criteria should be used to define the condition. Current criteria for internet addiction give equal diagnostic weight to the physiological symptoms and the social consequences of internet addiction.
Aim: Assess the psychological correlates of social dysfunction among individuals with internet addiction.
Methods: A total of 133 students who sought treatment at the Guangji Psychiatric Hospital from July 2011 to December 2013 for psychological problems related to excessive internet use and who currently met Young criteria for internet addiction were identified; 31 of the 38 students who meet rigorous criteria for concurrent internet-related social dysfunction and a random sample of 44 of the 95 students without concurrent social dysfunction completed a battery of psychosocial measures: seven supplementary scales of the Minnesota Multiphasic Personality Inventory (MMPI), the Egna Minnen av Barndoms Uppfostran perceived parenting scale, the Perceived Social Support Scale, the Trait Coping Style Questionnaire, and the Symptom Checklist 90.
Results: Compared to persons with internet addiction without accompanying social dysfunction, those with social dysfunction had higher levels of interpersonal sensitivity, hostility, and paranoia; lower levels of social responsibility, anxiety, self-control, and family social support; and they were more likely to employ negative coping strategies. There were however, no differences in perceived parenting styles between the two groups.
Conclusions: A relatively small proportion of individuals who meet the physiological markers of internet addiction simultaneously report significant internet-related social dysfunction. There are several psychosocial measures that distinguish persons with internet addiction who do or do not have concurrent social dysfunction. Further research is needed to determine whether or not these are two distinct subtypes of internet addiction and whether or not persons with internet addiction without concurrent social dysfunction should be classified as suffering from a ‘mental disorder’.
Keywords: addictive behavior; internet addiction; social function; mental disorder; students; China
Forum
Attenuated psychosis syndrome: benefits of explicit recognition Jason SCHIFFMAN, William T. CARPENTER Summary: Given the unique characteristics of people who meet criteria for attenuated psychosis syndrome (APS) and the growing literature on the clinical benefits of providing services to individuals who meet these criteria, the APS diagnosis serves an important, and previously missing, role in psychiatry. The promotion of the APS diagnosis should help reduce the over-diagnosis and over-treatment of individuals with prodromal psychotic conditions and it should also encourage expanded training about attenuated psychosis among clinicians who primarily provide services to youth (a primary group who are diagnosed with APS). Only some of the individuals with APS subsequently develop psychosis, but all have existing clinical needs – regardless of subsequent conversion. The formal recognition of APS in DSM-5 will facilitate the research needed to identify and meet those needs. 
Keywords: attenuated psychosis syndrome; schizophrenia; diagnosis; mental disorder; DSM-5
Psychosis risk syndrome is not prodromal psychosis Lihua XU, Tianhong ZHANG, Jijun WANG Summary: One of the most exciting trends in schizophrenia research is the shift in focus from treatment studies to studies about the early identification and prevention of schizophrenia. These studies have primarily focused on adolescents or young adults with prodromal symptoms or on clinically high-risk individuals who show similar impairments in cognitive and social functioning to those seen in individuals with schizophrenia and, thus, are considered at high risk of developing schizophrenia or other psychotic disorders. Some researchers have labeled this condition as psychosis risk syndrome (PRS). There are moves in some circles to re-define the condition as a disorder in its own right: the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5), lists ‘attenuated psychosis syndrome’ (APS) in the appendix as a condition for further study. Individuals with PRS are certainly at higher risk of developing a psychotic disorder than those without PRS, but the majority of those with PRS do not subsequently develop a psychotic disorder, so we argue against the inclusion of PRS or APS as a subtype of schizophrenia spectrum disorder. 
Keywords: psychosis risk syndrome; attenuated psychosis syndrome; schizophrenia spectrum disorder
Case report
Case report of rabies-induced persistent mental symptoms Xiaoqing WANG, Xiaowen YU, Yangtai GUAN Summary: Rabies is a viral infection with a high case fatality rate. Typical symptoms of rabies include hydrophobia, pharynx muscle spasms, and progressive paralysis. Rabies-induced persistent mental disturbances are rare. Here we report a 22-year-old male who was infected with rabies after being attacked by a dog. He did not receive rabies vaccine immediately after the incident and was only provided with non-standard treatment at a local clinic. A week later he became disorientated, paranoid, and aggressive. One month after the attack, rabies antibody was found in his cerebrospinal fluid and a Magnetic Resonance Imaging (MRI) examination of his head revealed abnormal signals in the putamina, caudate nucleus, and insula. His mental symptoms persisted for six years and his daily functioning was severely impaired, but his vital signs were stable without signs of brain stem damage. Six years after the incident, a repeat MRI showed brain atrophy. 
Key words: Rabies; mental symptoms; brain atrophy; China
Research methods in psychiatry
Brief Chinese version of the Family Experience Interview Schedule to assess caregiver burden of family members of individuals with mental disorders Hongbo HE, Yanling ZHOU, Bin SUN, Yaoguang GUO, Robert A. ROSENHECK Background: Caregiver burden is an important issue that needs to be addressed when developing management programs for persons with chronic mental illnesses, but there is, as yet, no reliable way for assessing this in China. 
Aim: Assess the validity and reliability of a brief adapted Chinese version of the Family Experience Interview Schedule (FEIS) among caregivers of inpatients with mental disorders in China. 
Methods: We first translated and back-translated the original 114-item FEIS and administered it to 606 primary caregivers of psychiatric inpatients. After excluding 9 items about sociodemographic variables and 9 items that over 15% of respondents were unable to answer, we conducted an exploratory factor analysis using a random half of the sample on the remaining 96 items and, based on the results of the factor analysis, selected the items to be included in the final shortened scale. Correlation analysis, confirmatory factor analysis, and internal consistency measures were used to assess the reliability and validity of the final scale using data from the second half of the sample. 
Results: The final scale included 28 items that loaded on five dimensions: (a) patients’ violent behavior; (b) patients’ suicidal tendency; (c) caregivers’ depression and anxiety; (d)disruption of caregivers’ daily routines; and (e) caregivers’ satisfaction with health services. These five dimensions explained 50.5% of the total variance. Confirmatory factor analysis found reasonable fit of this 5-factor model (χ2/df=2.94, p
Conclusions: The five dimensions of family burden assessed by the 28-item brief Chinese version of FEIS have good internal consistency and, thus, appear to assess valid dimensions of family burden in Chinese care-givers of persons with serious mental illnesses. Further work is needed to assess the test-retest reliability of this scale and its sensitivity to change over time. 
Key words: family burden; mental disorders; reliability; validity; Family Experience Interview Schedule; China
Biostatistics in psychiatry
Kappa coefficient: a popular measure of rater agreement Wan TANG, Jun HU, Hui ZHANG, Pan WU, Hua HE Summary: In mental health and psychosocial studies it is often necessary to report on the between-rater agreement of measures used in the study. This paper discusses the concept of agreement, highlighting its fundamental difference from correlation. Several examples demonstrate how to compute the kappa coefficient – a popular statistic for measuring agreement – both by hand and by using statistical software packages such as SAS and SPSS. Real study data are used to illustrate how to use and interpret this coefficient in clinical research and practice. The article concludes with a discussion of the limitations of the coefficient. 
Keywords: interrater agreement; kappa coefficient; weighted kappa; correlation