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2018 volume 30 Issue 2
In this issue
In this issue Daihui Peng
Systematic review and meta-analysis
Mechanism of Repetitive Transcranial Magnetic Stimulation for Depression Zhengwu PENG, Cuihong ZHOU, Shanshan XUE, Jie BAI, Shoufen YU, Xiaosa LI, Huaning WANG, Qingrong TAN Summary: Depressive disorder is one of the most common mental health problems currently. However, the mechanism-based treatments for this disorder remain elusive. Repetitive transcranial magnetic stimulation (rTMS), a non-invasive procedure that could stimulate electrical activity by a pulsed magnetic field in the brain, is considered to be an effective treatment for depression. Here, we review the main findings from both clinical and basic research on rTMS for depression, including its antidepressant efficacy, basic principles,
as well as its ability to regulate neural circuits, neurotransmitters and brain networks, neurogenesis in hippocampus, and synaptic, and molecular pathways.
Key words: RepetitiveTranscranial Magnetic Stimulation; Depression; Neurophysiology
Original research article
Analysis of Misdiagnosis of Bipolar Disorder in An Outpatient Setting Hui SHEN, Li ZHANG, Chuchen XU, Jinling ZHU, Meijuan CHEN, Yiru FANG Background: Bipolar disorder is a mental illness with a high misdiagnosis rate and commonly misdiagnosed as other mental disorders including depression, schizophrenia, anxiety disorders, obsessive-compulsive disorders, and personality disorders, resulting in the mistreatment of clinical symptoms and increasing of recurrent episodes.
Aims: To understand the reasons for misdiagnosis of bipolar disorder in an outpatient setting in order to help clinicians more clearly identify the disease and avoid diagnostic errors.
Methods: Data from an outpatient clinic included two groups: those with a confirmed diagnosis of bipolar disorder (CD group) and those who were misdiagnosed (i.e. those who did in fact have bipolar disorder but received a different diagnoses and those without bipolar disorder who received a bipolar diagnosis [MD group]). Information between these two groups was compared.
Results: There were a total of 177 cases that met the inclusion criteria for this study. Among them, 136 cases (76.8%) were in the MD group and 41 cases (23.2%) were in the CD group. Patients with depression had the most cases of misdiagnosis (70.6%). The first episode of the patients in the MD group was more likely to be a depressive episode (χ2=5.206, p=0.023) and these patients had a greater number of depressive episodes during the course of the disease (Z=-2.268, p=0.023); the time from the onset of the disease to
the first treatment was comparatively short (Z=-2.612, p=0.009) in the group with misdiagnosis; the time from the onset of disease to a confirmed diagnosis was longer (Z=-3.685, p
Conclusions: The rate of misdiagnosis of patients with bipolar receiving outpatient treatment was quite high and they often received a misdiagnosis of depression. In the misdiagnosis group the first episode tended to manifest as a depressive episode. In this group there were also a greater number of depressive episodes over the course of illness, accompanied by more psychotic symptoms and a higher incidence of comorbidity. Moreover, these patients apparently lacked insight into their own mania and hypomania symptoms, resulting
in difficulties in early diagnosis, longer time needed to confirm the diagnosis, higher rate of hospitalization, and greater number of hospitalizations.
Key words: bipolar disorder; outpatient department; psychiatry; misdiagnosis
The Association of Insight and Change in Insight with Clinical Symptoms in Depressed Inpatients Hongbo HE, Qing CHANG, Yarong MA Background: Lack of insight has been extensively studied and was found to be adversely correlated with impaired treatment compliance and worse long term clinical outcomes among patients with schizophrenia, while not much is known about this phenonmenon in patients with severe depression.
Aim: To explore the correlates of insight and its relation to symptom changes among the most seriously ill patients with affective disorders, those who require hospitalization.
Methods: Patients hospitalized in a large psychiatric hospital in south China with either major depressive disorder (MDD)(N=55) or bipolar depression (BD) (N=85) based on ICD-10 diagnostic criteria were assessed with the Insight and Treatment Attitudes Questionnaire (ITAQ) one week after admission and at the time of discharge. Clinical symptoms were measured at the same time with the Hamilton Rating Scale for Depression (HAMD-17) and the Depression subscale of the Symptom Check list-90 (SCL-90). Length of stay (LOS), duration of illness, duration of untreated mood disorder, number of previous episodes of depression and previous admissions for depression were documented during interviews with patients and their families and from a review of medical records. Bivariate correlations and multiple regression analysis were used to examine the relationship of sociodemographic characteristics, clinical symptomatology and clinical history, to insight at the time of admission. The relationships between change in clinical symptoms and change in insight from admission to discharge were also examined.
Results: Stepwise multiple regression models suggested that any previous admissions for depression and higher anxiety factor scores on the HAMD-17 are significant independent predictors of insight accounting for 22.9% of the variance. Multiple regression analysis residual change scores (change scores adjusted for baseline values) on the ITAQ showed that improved insight over average stays of 51 days were inversely related to the residual psychomotor retardation factor on the HAMD-17 accounting for 9.1% of the
variance.
Conclusions: More severe anxiety symptoms and previous hospitalization for depression were associated with greater insight into illness at admission. Reduction of motor retardation symptoms during treatment was associated with greater improvement in insight to the time of discharge. The patients who are sicker at admission and who show more improvement in psycho-motor retardation show the greatest insight.
Key words: insight; clinical symptoms; depressive
The Level of Nesfatin-1 in a Mouse Gastric Cancer Model and Its Role in Gastric Cancer Comorbid with Depression Nan ZHANG, Jiangbo LI, Huiling WANG, Ling XIAO, Yanyan WEI, Jing HE, Gaohua WANG Background: The incidence of depressive symptoms is higher in cancer patients. And depression can also affect the occurrence, development and outcome of cancer through the neuroendocrine-immune network system.
Objective: To study the level of Nesfatin-1 in the plasma and brain tissue and its role in the pathogenesis in gastric cancer comorbid with depression using a mouse gastric cancer model.
Methods: 18 mice were randomly divided into the normal control group (NCG), gastric cancer without stress model group (GCNS), and gastric cancer combined with stress model group (GCS). The mice of the GCNS group were inoculated subcutaneously with mouse forestomach carcinoma (MFC) after 5 weeks of nomal feeding to establish a model of subcutaneous transplantation tumor. After 5 weeks of chronic unpredicted mild stress (CUMS) in the GCS group, subcutaneous inoculation of MFC was used to establish
a subcutaneous transplantation tumor model for 1 week. Evaluation of mice behavior was performed by open field test, sucrose preference test and forced swimming test (FST). Determination of Nesfatin-1 concentration in plasma and brain tissue was carried out using enzyme linked immunosorbent assay (ELISA) and Western Blot.
Results: The weight increment in the GCS group was significantly lower than that in the GCNS group (t=-3.39, p
Conclusions: There is a decrease of Nesfatin-1 level in brain tissue and plasma in mice with gastric cancer without stress. CUMS stress can induce depressive behavior in gastric cancer mice, and increase the level of Nesfatin-1 in brain tissue and plasma. Therefore, Nesfatin-1 may be related to the pathogenesis of gastric cancer stress related depression.
Key words: Nesfatin-1; gastric cancer; depression; stress
Applicability Evaluation of Simplified Cognitive Behavioral Therapy Li ZHANG, Zhipei ZHU, Fang FANG, Yuan SHEN, Na LIU, Chunbo LI Background: We have developed a structured cognitive behavioral therapy manual for anxiety disorder in China, and the present study evaluated the applicability of simplified cognitive behavioral therapy based on our previous research.
Aims: To evaluate the applicability of simplified cognitive behavioral therapy (SCBT) on generalized anxiety disorder (GAD) by conducting a multi-center controlled clinical trial.
Methods: A multi-center controlled clinical trial of SCBT was conducted on patients with GAD, including institutions specializing in mental health and psychiatry units in general hospitals. The participants were divided into 3 groups: SCBT group, SCBT with medication group and medication group. The drop-out rates of these three groups, the therapy satisfaction of patients who received SCBT and the evaluation of SCBT from therapists were compared.
Results: (1) There was no significant difference among the drop-out rates in the three groups. (2) Only the duration and times of therapy were significantly different between the two groups of patients who received the SCBT, and the therapy satisfaction of the SCBT group was higher than that of the SCBT with medication group. (3) Eighteen therapists who conducted the SCBT indicated that the manual was easy to comprehend and operate, and this therapy could achieve the therapy goals.
Conclusion: The applicability of SCBT for patients with GAD is relatively high, and it is hopeful that SCBT can become a psychological treatment which can be applied in medical institutions of various levels.
Key words: simplified cognitive behavioral therapy; generalized anxiety disorder; manual; evaluation
Forum
Psychiatric Epidemiology and Mental Health Service in the Tibet Autonomous Region of the People’s Republic of China Liang XIE, Geng WEI, Yan XU, Yueqin HUANG, Xiehe LIU, Tao Li, Wan-jun Guo Summary: Little is known internationally about the psychiatric epidemiology and mental health services in Tibet. This article reviews the relevant research of psychiatric epidemiology and mental health services in the Tibet Autonomous Region (TAR), P. R. China. There is a substantive number of people suffering from mental disorders and psychological problems in an area with a general lack of modern
mental health institutions and professionals.
Key words: Tibet; Mental health; Psychiatric epidemiology; Service
Commentary
Practical Answers are Needed to Respond to the Myth of Mental Health Services in Tibet Bin XIE
Case report
“The Twisted Mind” - Psychogenic Dystonia in An Adolescent, Responding to Antidepressant Therapy Seshadri Sekhar CHATTERJEE, Soumitra DAS, Sukanya GUPTA, Sanhita BHATTACHARYA Summary: Psychogenic dystonia is one of the most common problems encountered in movement disorder patients and accounted mostly for misdiagnosis, management confusion and treatment resistance. Psychiatric morbidities often are the culprit, hence proper psychiatric history taking is of utmost importance. Here we report one case where dystonia was the main presenting complaint of an underlying depressive episode and discuss how managing the cause alleviated the symptoms.
Key words: Psychogenic dystonia, Depression, Psychosomatic, Movement disorder
A Case of Dissociative Seizures Presented like Myoclonic Epilepsy Balaswamy REDDY, Soumitra DAS, Mustafa ALI, Srinivas GURUPRASAD Summary: Psychogenic seizures are often underdiagnosed and epilepsy is very often over-treated which leads to multiple financial, social and stigma related difficulties. The myoclonic seizure itself is a rare phenomenon and when functional movement disorder presents like myoclonus then it’s extremely difficult to pinpoint the exact cause. Here, we are presenting a case who was misdiagnosed as having a myoclonic seizure disorder and treated in multiple places without any improvement which ultimately turned out to be functional movement disorder of a rare variety.
Key words: seizures; myoclonus; functional; pseudo-seizures; dissociative
Biostatistics in psychiatry
Simpson’s Paradox: Examples Bokai WANG, Pan WU, Brian KWAN, Xin M. TU, Changyong FENG Summary: Simpson’s paradox is very prevalent in many areas. It characterizes the inconsistency between the conditional and marginal interpretations of the data. In this paper, we illustrate through some examples how the Simpson’s paradox can happen in continuous, categorical, and time-to-event data.
Key words: conditional expectation; odd ratio; time-to-event analysis