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2017 Volume 29 Issue 3
Systematic review and meta-analysis
Adjunctive melatonin for tardive dyskinesia in patients with schizophrenia: a meta-analysis Chen-Hui SUN, Wei ZHENG, Xin-Hu YANG, Dong-Bin CAI, Chee H. NG, Gabor S. UNGVARI, Hai-Yan LI, Yu-Jie Background: Tardive dyskinesia (TD) is characterized by abnormal and involuntary movements. Importantly,TD could cause considerable personal suffering and social and physical disabilities.
Aims: This meta-analysis based on randomized controlled trials (RCTs) systematically assessed the therapeutic effect and tolerability of melatonin for TD in schizophrenia.
Methods: A computerized and systematical search of both Chinese (Wanfang Data, Chinese National Knowledge Infrastructure (CNKI), SINOMED) and English (PubMed, PsycINFO, Embase, Cochrane Library databases) databases, from their inception until June 8, 2017, was conducted by two independent authors.The severity of TD symptoms were the primary outcome measure and analyzed using a random effects model by the Review Manager (RevMan) Version 5.3. Quality evaluation of included RCTs was conducted using the Cochrane risk of bias and Jadad scale. The GRADE (Grades of Recommendation, Assessment,Development, and Evaluation) system recommendation grading method was used to assess the overall quality level of meta-analytic outcomes.
Results: Four RCTs (n=130) were identified and analyzed. Three RCTs used double blind and 1 RCT used masked assessors using the Cochrane risk of bias, and 3 RCTs were rated as high quality based on Jadad scale. Compared with the control group, adjunctive melatonin was superior in reducing the severity of TD as measured by the Abnormal Involuntary Movement Scale (AIMS) (4 RCTs, n=130, weighted mean difference (WMD): -1.52 (95% confidence intervals (CI): -3.24, 0.20), p=0.08; I2=0%) although the improvement did not reach a significant level. The overall evidence quality of the improvement of TD symptoms, according to GRADE approach, was rated as “Low”. The data on the ADRs and cognitive effect were limited.
Conclusions: This meta-analysis shows that melatonin has potential for improving TD symptoms in schizophrenia. Future higher quality and larger RCTs are warranted to confirm the findings.
Key words: Tardive dyskinesia; antipsychotic; melatonin; meta-analysis
Original research article
Changes in cognitive function in patients with primary insomnia Hui GUO, Meijie WEI, Wantao DING Background: Neuropsychological evidence is not sufficient concerning whether there is cognitive impairment in patients with primary insomnia. Further study is needed in this regard. 
Aims: To measure the changes in cognitive functioning in patients with primary insomnia. 
Methods: 40 patients with insomnia (insomnia group) and 48 normal sleepers (control group) were tested using the Pittsburgh Sleep Quality Index (PSQI), episodic memory test, and Montreal Cognitive Assessment(MoCA).
Results: The insomnia group had significantly lower scores than the control group in the naming (t=3.17,p=0.002), immediate memory (t=3.33, p=0.001), and delayed recall (t=6.05, p=0.001) sections of the MoCA,as well as a lower overall score on the MoCA (t=3.24, p=0.002). Participants with different degrees of insomnia also had significantly different scores in naming (F=7.56, p=0.001), language (F=3.22, p=0.045), total score (F=6.72, p=0.002), delayed memory (F=8.41, p=0.001), and delayed recall (F=22.67, p=0.001) sections of the MoCA. The age of primary insomnia patients was correlated to MoCA total score, immediate memory,delayed recall, and delayed recognition function, also with statistical significance. The years of education of primary insomnia patients was also significantly correlated to overall MoCA score, as well as visuospatial and executive function, naming, attention, language, and abstraction sections of the MoCA.
Conclusion: Primary insomnia patients have cognitive impairment. The more severe the insomnia is, the wider the range of and the more serious the degree of cognitive impairment is.
Key words: primary insomnia, cognitive function, episodic memory, influencing factors
Peripheral SLC6A4 gene expression in obsessive-compulsive disorder in the Han Chinese population Xuemei WANG, Qing ZHAO, Wen CHEN, Shunying YU, Zhen WANG, Zeping XIAO Background: Serotonergic system dysfunction has been implicated in obsessive-compulsive disorder (OCD).This study examined peripheral SLC6A4 gene expression in OCD patients and healthy controls to explore the relationship between SLC6A4 and OCD. 
Methods: Participants included 50 first episode OCD patients and 60 age and gender-matched healthy controls. Relative SLC6A4 gene expression were examined by real-time quantitative reverse transcription polymerase chain reaction (RT-PCR) in peripheral leukocytes of all the subjects. The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was used to assess the severity and subtype of OCD. 
Results: SLC6A4 gene expression, normalized by glyceraldehyde-3-phosphate dehydrogenase (GAPDH), were not significantly different between the OCD patients and healthy controls(z=-0.79,p=0.428). Male OCD patients showed a tendency of low gene expression of SLC6A4 in peripheral blood (z=-1.66, p=0.096). We did not find a significant correlation between SLC6A4 expression and the severity and subtype of OCD. 
Conclusion: There is no correlation between SLC6A4 expression levels and the severity and subtype of OCD,but male OCD patients showed a tendency of low gene expression of SLC6A4 in peripheral blood. These results suggest that gene expression of SLC6A4 in peripheral blood may not be a useful biomarker of OCD in the Han Chinese population. 
Key words: OCD, SLC6A4, gene expression, RT-PCR, Yale–Brown Obsessive-Compulsive Scale score(Y-BOCS).
Dysfunction of cognition patterns measured by MATRICS Consensus Cognitive Battery (MCCB) among first episode schizophrenia patients and their biological parents Aiai CAO, Ting SHEN, Haibin LI, Chuangxin WU, Marita MCCABE, David MELLOR, Linda BYRNE, Jie ZHANG, J Background: Schizophrenia is characterized by abnormal perception, thinking, emotions, and behaviors.Cognitive dysfunction is acknowledged as one of the most pivotal symptoms in schizophrenia. In addition to positive or negative symptoms, which had been proposed by Gallhofer in the early 1970s, schizophrenia patients suffered from cognitive impairments as well. Many studies show that there is genetic susceptibility in the first grading kinship of patients with schizophrenia. Patients with schizophrenia have cognitive impairment not only in the acute phase but also in the stable phase. Studies also show that the healthy first-grading relatives of patients with schizophrenia suffer from cognitive defects. However, there is still a lack of studies about the cognitive features of biological parents of those with schizophrenia. In this study,we speculate the biological parents of schizophrenia patients have specific cognitive dysfunction. And we explore the patterns of cognition among both schizophrenia patients and their biological parents using the Chinese version of MATRICS Consensus Cognitive Battery (MCCB). 
Aims: Cognitive features of patients with schizophrenia might be affected by the cognition mode of patients'biological parents. The dysfunctional cognitive patterns need to be characterized among the patients with schizophrenia and their parents. 
Methods: We applied the MATRICS Consensus Cognitive Battery (MCCB, a novel measurement tool) to evaluate the cognitive function of 29 first-episode patients with schizophrenia (meeting ICD-10 diagnostic criteria for schizophrenia, aged between 17-45 years old), 58 cases of biological parents of schizophrenia patients (aged between 40-70 years old) and 46 healthy controls (aged between 40-70 years old).Furthermore, we explored the relationship between the cognitive dysfunction in patients with schizophrenia and their biological parents. All data were analyzed using SPSS18.0 statistical software. 
Results: 1) Male patients with schizophrenia had obvious cognitive defects in six domains of cognitive function as measured by the MCCB (all except the social cognition domain) compared to their male parents.Female patients showed lower ability on both working memory and problem reasoning than their female parents. 2) The significant differences of both working memory and reasoning problems also existed between the patients' fathers and matched healthy controls. 3) Patients' mothers didn't show any significant difference on the problem reasoning domain compared with healthy controls. However, the visual learning domain appeared abnormal in patients' mothers compared with healthy controls. 
Conclusion: There are six dimensions of cognitive impairments in both first-episode schizophrenia patients and their biological parents. Compared with healthy controls, patients’ biological parents have conspicuous dysfunction in domains of working memory, problem reasoning and visual learning as well. Further study is needed to explore the underlying mechanisms of similar cognitive dysfunction between first-episode schizophrenia patients and their biological parents. 
Key words: first-episode schizophrenia, cognitive function, biological parents, MCCB
The fantasmatic and imaginary child of the pregnant woman Simone SETTERBERG Background: Pregnancy is a period of transition, which makes women more vulnerable and in unfavorable conditions may lead to psychopathology in both mother and infant. It is essential to outline factors adversely affecting the resolution of this period. Early interventions and why they matter: Interventions during pregnancy can provide important improvement in the outcome for both maternal and infant mental health. 
Aim: The aim of the study is to evaluate the risk factors of antenatal anxiety and depression focusing particularly on maternal representations of the relationship towards the fetus and her own parents during pregnancy and the early postpartum period. 
Methods: The study is outlined using a quantifiable interview during pregnancy to evaluate the woman’s ability to keep her child in mind, measured by reflective functioning. Reflective functioning provides information regarding the pregnant woman’s relationship quality to her fetus and important people in her life. Primiparae in Stockholm around gestation week 20 are asked about their experience with respect to pregnancy, their relationship to their family, partner, and their unborn child. The women selected to the study are an at risk population, with high levels of stress, childhood adversity, and/or history of mental health. These women are more vulnerable to develop perinatal anxiety and depression. 
Results: The pregnancy interview provides valuable insight into the pregnant women’s psychic constitution.The quantifiable measure of their mental state, reflective functioning, serves as measure of quality of the mother’s parenting capacity. The countertransference and transference of the interviewer towards the women during the interview enables a more profound understanding of the underlying dynamics and constructs of repression, aggression, mourning, and narcissistic defenses. 
Conclusion: A better understanding of the underlying mechanisms of the pregnant women’s intrapsychic reorganization of motherhood and her relation to the unborn child shall facilitate specific early interventions.These interventions shall be targeted to specific risk groups and enable the prevention of adverse child outcomes. 
Key words: pregnancy; intervention; mothers; infants; perinatal anxiety; depression; reproduction
Forum
Is depression the result of immune system abnormalities? Xiaoyun GUO, Kaida JIANG Summary: The etiology of Major Depressive Disorder (MDD) is still unclear. We reviewed the literature for the relationship between inflammatory signaling and cytokines in the pathogenesis of MDD. In addition, we provid evidence for adjunctive treatment using anti-inflammatory drugs to improve the therapeutic effect and prognosis. Finally, we explore the possible relationship between the pathogenesis of MDD and immune disturbances. 
Key words: major depressive disorder; cytokines; neuroimmunology; China
Case report
Psychogenic Polydipsia – management challenges M.S. BHATIA, Aparna GOYAL, Rashmita SAHA, Nimisha DOVAL Summary: Compulsive water drinking or psychogenic polydipsia is now increasingly seen in psychiatric populations. Effects of increased water intake can lead to hyponatremia causing symptoms of nausea,vomiting , seizures, delirium and can even be life threatening if not recognized and managed early. Here we present a 35-year old adult who was diagnosed with psychogenic polydipsia and was successfully managed with a combination of pharmacotherapy, fluid restriction and psychosocial management. 
Key words: psychogenic polydipsia, hyponatremia, seizure, psychiatric sequelae, anxiety symptoms
Autoimmune thyroiditis presenting as psychosis Soumitra DAS, Nimisha DOVAL, Vikas MOUN Summary: Hashimoto’s thyroiditis is a rare condition associated mainly with neurological symptoms. It contains an abundant amount of auto-antibodies in the blood. Only a few cases of behavioral symptoms without significant neurological disturbances have been recorded in the literature. In this view, our case is unique as it was not associated with overt hypothyroid manifestations. 
Key words: Thyroiditis, psychosis, antibodies, autoimmune encephalitis.
Hyponatremia with olanzapine - A suspected association Ankur SACHDEVA, Mona CHOUDHARY Summary: Hyponatremia is a rare, yet potentially life threatening complication of antipsychotics. Here,we report a case of a 45-year-old female diagnosed with schizophrenia who developed hyponatremia soon after addition of olanzapine to the existing treatment. This prompted us to evaluate the relationship between hyponatremia and olanzapine, as timely management is crucial. Naranjo algorithm established a “probable” causal relation between olanzapine and hyponatremia. Possible etiological reasons of this clinically significant and life threatening adverse event have been discussed. We report the case and the literature focusing on hyponatremia as a possible adverse event of olanzapine. Medical illnesses are often ignored or missed in patients with psychiatric disorders either due to patients’ inability to report complaints or non-serious attitude of physicians towards such patients. A high index of suspicion should be kept while dealing with this probable complication. 
Key words: Hyponatremia, Olanzapine, Antipsychotics, India
Biostatistics in psychiatry
The differences and similarities between two-sample t-test and paired t-test Manfei XU, Drew FRALICK, Julia Z. ZHENG, Bokai Wang, Xin M. TU, Changyong FENG Summary: In clinical research, comparisons of the results from experimental and control groups are often encountered. The two-sample t-test (also called independent samples t-test) and the paired t-test are probably the most widely used tests in statistics for the comparison of mean values between two samples.However, confusion exists with regard to the use of the two test methods, resulting in their inappropriate use. In this paper, we discuss the differences and similarities between these two t-tests. Three examples are used to illustrate the calculation procedures of the two-sample t-test and paired t-test.
Key words: independent t-test; paired t-test; pre- and post- treatment; matched paired data