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2012 Volume 24 Issue 5
In this issue
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Serum brain-derived neurotrophic factor (BDNF) levels in schizophrenia : A systematic review Huiru CUI, Yi JIN, Jijun WANG, Xuchu WENG, Chunbo LI Background: There is increasing interest in the role of brain-derived neurotrophic factor (BDNF) in the onset and course of schizophrenia, but there are conflicting reports about serum levels of BDNF in patients with schizophrenia. 
Aim: Conduct a meta-analysis combining studies from China and other countries that have evaluated the relationship of serum BDNF levels to schizophrenia. 
Methods: We used Cochrane methodology and RevMan 5.1 software to identify and pool the results of studies. Electronic searches of western and Chinese registries and follow-up assessment of references located 268 potential articles. Twenty-five articles (20 in English and 5 in Chinese) published before December 2011 that used case-control methods, included patients with schizophrenia who had no concurrent disorders, and used ELISA technology to assess serum BDNF were included in the analysis. The main outcome was the pooled standardized mean difference (SMD) between cases and controls. The quality of the studies was independently assessed by two raters using the GRADE system. The heterogeneity, sensitivity and potential publication bias of the studies was evaluated using RevMan. 
Results: The pooled sample included 1663 patients with schizophrenia and 1355 controls. Fifteen of the included studies were rated as ‘poor quality’ and 10 were rated as ‘very poor quality’. The results of the studies were quite heterogenous (I2=95%) but subgroup analyses found that the heterogeneity was not related to country of origin, sample size, age, gender, prior use of antipsychotic medication, or study quality. The pooled SMD (computed using a random-effect model because of study heterogeneity) was -0.74 (95% CI, -0.99~-0.50; Z=5.99, p
Conclusion: Despite the robust statistical findings of lower serum BDNF in patients with schizophrenia than in controls, given the low quality of the available studies and the substantial heterogeneity between studies, the evidence of lower serum BDNF in patients with schizophrenia must be considered ‘weak’. The potential use of serum BDNF as a biomarker for schizophrenia must wait until higher-quality prospective studies that follow patients over time and that use uniform selection and monitoring procedures confirm these preliminary results.
Using the conditioned fear stress (CFS) animal model to understand the neurobiological mechanisms and pharmacological treatment of anxiety Xiaobai LI Summary: The mechanisms underlying the etiology and pathophysiology of anxiety disorders — the most prevalent class of mental disorders — remain unclear. Over the last 30 years investigators have used the animal model of conditioned fear stress (CFS) to investigate the brain structures and neurotransmitter systems involved in aversive emotional learning and memory. Recent studies have focused on the neuronal circuitry and cellular mechanisms of fearful emotional experiences. This review describes the CFS paradigm, discusses the neural circuit and neurotransmission underlying CFS, and explains the mechanism of action of pharmacological treatments of CFS. The focus of the review is on the molecular mechanisms of fear extinction, a phenomenon directly implicated in the clinical treatment of anxiety. Based on our assessment of previous work we will conclude by considering potential molecular targets for treating symptoms of anxiety and fear.
Original research article
Long-term follow-up of patients treated for psychotic symptoms that persist after stopping illicit drug use Xianhua DENG, Zhibiao HUANG, Xuewu LI, Yi LI, Yi WANG, Dongling WU, Beiling GAO, Xi YANG Background: The long-term outcome of patients diagnosed with drug-induced psychotic disorders in China is unknown. 
Aim: Assess the course of illness and severity of psychiatric symptoms in patients previously admitted to a psychiatric hospital for treatment of psychotic symptoms that were induced by the use of illicit drugs. 
Methods: Patients with psychotic symptoms at the time of their first psychiatric admission who had used illicit drugs in the month prior to admission were followed up 13 to 108 months after admission. Patients and coresident family members were interviewed about post-discharge drug use and psychotic symptoms. 
Results: The 258 identified patients were primarily young, unemployed males whose most common drug of abuse was methamphetamines and who had been abusing drugs for an average of 7 years at the time of admission. Among these patients 189 (73%) were located and reinterviewed; 168 (89%) had restarted illicit drug use and 25 (13%) had required rehospitalization over the follow-up period. In 114 patients (60%) the psychotic symptoms resolved in less than 1 month after stopping the drugs, in 56 (30%) the symptoms persisted for 1 to 6 months, and in 19 (10%) the symptoms persisted for longer than 6 months (in 8 of these the diagnosis had changed to schizophrenia). Compared to the other two groups, patients whose symptoms persisted more than 6 months were more likely to have a family history of mental illness, an earlier age of onset and a longer duration of drug abuse prior to the index admission; they were also more likely to have been re-hospitalized during the follow-up period and to have psychotic symptoms at the time of follow-up. 
Conclusion: Most patients with substance-induced psychotic disorders in our sample had a good long-term prognosis but those who started illegal drug use early, used drugs for prolonged periods, or had a family history of psychiatric illnesses were more likely to develop a chronic psychosis. Further prospective studies are needed to determine the relationship of the neurotoxic effects of illicit drugs and the predisposing characteristics of the individuals in the development of chronic psychosis in persons who use illicit drugs.
Family dynamics in families with children with Attention Deficit Hyperactivity Disorder Kangkang CHU, Shasha LI, Yixin CHEN, Mingchun WANG Background: Development of adjunctive family therapy for the treatment of children with Attention Deficit Hyperactivity Disorder (ADHD) in China requires a detailed understanding of the family dynamics of these families. 
Aim: Assess the family dynamics of families with children who have ADHD in Nanjing, China. 
Methods: Forty-six children 10 to 17 years of age treated at the Nanjing Brain Hospital for ADHD and 46 control children of the same age and gender from schools in Nanjing completed the 19-item Questionnaire of Systematic Family Dynamics (QSFD) which assesses four dimensions of family functioning: Family Atmosphere, Individuation, Moral Absolutism, and Personal Responsibility for Psychological Problems. 
Results: There were no differences between groups in the perceived causes of psychological problems but the ADHD children reported a poorer family atmosphere, less independence from parents, and more ambiguity about ‘right’ and ‘wrong’ in the family. After adjustment for the potential confounding effects of parental education and family economic status, the findings of poorer family atmosphere and less individuation in the ADHD children remained statistically significant. The internal consistency of the four dimensions of the QSFD as completed by the children were poor (alpha=0.44-0.53). 
Conclusion: This preliminary study on the family dynamics of families with children that have ADHD finds that the ADHD children report a poor family atmosphere and little independence from parents. Further work is needed to validate the methods for assessing family dynamics in Chinese families, particularly when using children as informants, but this method provides valuable information that could be used as the focus of adjunctive family therapy to augment the traditional pharmacological and behavioral approaches to the treatment of ADHD.
Prevalence of osteopenia and osteoporosis and factors associated with decreased bone mineral density in elderly inpatients with psychiatric disordersin Huzhou, China Ping GUO, Shikai WANG, Yiping ZHU, Xinhua SHEN, Xuemin JIN, Mincai QIAN, Hongyu TANG Background: Little is known about the risks of bone fractures in elderly patients with mental disorders in China. 
Aim: Assess the bone mineral density (BMD) of elderly patients with mental disorders in China and identify factors that are associated with low BMD, osteopenia and osteoporosis. 
Methods: one hundred and two psychiatric inpatients 60 years of age or older (including patients with schizophrenia, depression, bipolar disorder and dementia) were randomly selected from patients in the geriatric wards of the Third People’s Hospital of Huzhou. Detailed demographic, clinical and biometric data were obtained and the BMD of the lumbar spine was assessed using standard dual energy X-ray absorptiometry (DXA) procedures. Based on WHO criteria, individuals with BMD 1 to 2.5 standard deviations below the mean value for healthy young adults were diagnosed as osteopenia and those with BMD values 2.5 or more standard deviations below the mean value were diagnosed as osteoporosis. 
Results: The prevalence of osteopenia was 33.3% (95% CI, 24.4%-43.2%) and the prevalence of osteoporosis was 35.3% (26.0%-45.2%) but none of these patients – even the five patients who had had non-traumatic fractures – had ever been treated for these conditions. The prevalence of osteoporosis in females was 10-fold that in males (53% versus 5%). BMD decreased with age and increased with increasing body mass index (a reflection of nutritional status). The prevalence of osteoporosis was much higher in patients with a diagnosis of depression (58%) than in those with schizophrenia (33%), Alzheimer’s disease (30%) or bipolar disorder (13%). Regression analyses found that low BMD and the combined category of osteopenia and osteoporosis were both independently associated with female gender, increasing age, decreasing body mass index, and a diagnosis of depression. BMD and osteoporosis were not significantly associated with regular use of antipsychotic medication. 
Conclusion: Osteopenia and osteoporosis are common conditions in elderly patients with mental disorders that can seriously affect their quality of life but they often go undiagnosed and untreated. Long-term prospective studies are needed to clarify the relative importance of nutritional status, activity level, medication usage, and other factors in the causal pathways that connect mental illnesses to BMD.
Forum
Distinguishing subclinical (subthreshold) depression from the residual symptoms of major depression Jianlin JI*
Differentiation of various forms of depression David L. DUNNER
Understanding subthreshold depression Mario Francisco JURUENA
Are subsyndromal symptomatic depression and major depressive disorder distinct disorders? Zhenghui YI, Yiru FANG
Case report
Narcolepsy induced by chronic heavy alcohol consumption: a case report Xinyuan WANG Summary: Narcolepsy is a chronic neurological disorder, characterized by uncontrollable excessive daytime sleepiness, cataplectic episodes, sleep paralysis, hypnagogic hallucinations, and night time sleep disruption. The paper reviewed the related literature and reported a case of long-term drinking induced narcolepsy which was significantly improved after treatment with paroxetine and dexzopiclone.
Biostatistics in psychiatry
You want me to analyze data I don’t have?Are you insane? Xiao-Li MENG*
Correspondence
Treatment outcome of schizophrenia in Chinese patients Ee Heok KUA