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Systematic review and meta-analysis

Consultation-liaison psychiatry in China

Jianlin JI, Chenyu YE

Abstract: Consultation-liaison psychiatry (CLP) was first established in China after liberation in 1949. It has developed more rapidly over the last two decades but, despite major regional differences in the level of CLP, the overall practice of CLP in the country remains quite basic, largely limited to case-based consultation with other medical departments. There is little ongoing collaboration between departments of psychiatry and other departments, and medical students and nonpsychiatric clinicians rarely get training in CLP.

Original research article

Retrospective analysis of treatment effectiveness among patients in Mianyang Municipality enrolled in the national community management program for schizophrenia

Qingjin LI, Xuanyin HUANG, Hong WEN, Xiaoqiong LIANG, Lei LEI, Junlin WU

Background: Over the last six years China has developed the largest community-based service network for persons with serious mental illness in the world (the ‘686 Project’) but the effectiveness of this program has not been assessed in detail. 

Aim: Compare the characteristics of patients with schizophrenia enrolled in the program whose clinical status has improved with the characteristics of patients whose clinical status has not improved.
Methods: The records of 3090 patients with schizophrenia in Mianyang Municipality, Sichuan (a community with 60% rural residents) who participated in the 686 Project at any time during 2011 were extracted from the national electronic registry system for the project and the demographic and treatment characteristics of individuals rated by treating clinicians as ‘recovered’ or ‘improved’ at the time of their last evaluation in 2011 (n=1866) were compared to those of patients rated as ‘unchanged’ or ‘worsened’ (n=1224). The factors considered included gender, age, ethnicity, occupation, education, family economic status, marital status, family history of mental illness, duration of illness, time of enrolled in the 686 Program, and adherence to medication.
Results: In the univariate analysis there were significant differences between the two groups in all variables considered except for gender, ethnicity, and family history of mental illness. The recorded treatment outcome was better in patients who were younger, who had a shorter duration of illness, who were more educated, who came from better-off families, who were more adherent to treatment and who had participated in the program for a shorter period of time. Logistic regression analysis found that patients classified as unchanged or worsened were more likely to be non-adherent to drug treatment, to come from families living below the local poverty line, and to be enrolled in the 686 Program for a longer period of time.
Conclusion: Poor treatment adherence and poverty seriously limit the effectiveness of the 686 Program. New approaches to improving adherence and for providing basic financial support to families with a mentally ill member will be needed to enhance the efficacy of the program.
Randomized controlled trial on adjunctive cognitive remediation therapy for chronically hospitalized patients with schizophrenia
Hongbo LU, Yuying LI, Feng LI, Xinyi JIAO, Wen SHI, Kanglin GUO, Pengfei LIU

Background: Cognitive remediation therapy (CRT) is one of the promising new non-drug approaches to reducing cognitive deficits of patients with schizophrenia that has not yet been fully evaluated in China. 

Aim: Assess the efficacy of CRT in improving the cognitive functioning, social functioning and insight of patients with chronic schizophrenia.
Methods: 126 clinically stable inpatients with chronic schizophrenia were randomly allocated to an intervention group (with CRT) and a treatment as usual group (TAU) (which used standard occupational and recreational therapy methods). The treatment frequency and duration were the same for the two groups: five times per week for three months. The Wisconsin Card Sorting Test (WCST) was used to evaluate before versus after changes in cognitive function, the Scale of Social Skills of chronic schizophrenia Inpatients (SSSI) was used to assess social functioning, and the Insight and Treatment Attitude Questionnaire (ITAQ) was use to assess insight.
Results: Four patients dropped out during the study leaving 60 in the CRT group and 62 in the TAU group in the final analysis. Both groups showed significant improvement in WCST measures over the three-month trial but the improvement in the CRT group was significantly greater than that for the TAU group on all of the WCST measures assessed. The total SSSI score improved significantly in both groups over the three months, but the improvement in the two groups was not significantly different. The total ITAQ score also showed significant improvement in both groups over the three months and the degree of improvement was significantly greater in the CRT group than in the TAU group.
Conclusions: As an adjunctive treatment to antipsychotic medication, a three month course of CRT is more effective at improving the cognitive functioning and insight of hospitalized patients with chronic schizophrenia than routine occupational and recreational therapy.
Effectiveness of a rehabilitative program that integrates hospital and community services for patients with schizophrenia in one community in Shanghai
Hua TAO, Lanjun SONG, Xin NIU, Xuehai LI, Qiongting ZHANG, Jia CUI, Hao CHEN, Zhenghui FU, Wenli FAN

Background: One possible reason for the less than satisfactory long-term outcomes for schizophrenia is the lack of coordination between inpatient and community-based services. 

Aim: Assess the effectiveness of a rehabilitation model for schizophrenia that integrates hospital and community services.
Methods: Ninety patients with schizophrenia participating in an integrated rehabilitation program at 10 community centers in Changning, Shanghai (intervention group) and 52 community-based patients with schizophrenia randomly selected from all patients in Changning participating in routine outpatient care (control group) were assessed at enrollment using the Positive and Negative Syndrome Scale (PANSS) and the Morningside Rehabilitation Status Scale (MRSS) and then re-assessed 1 year later by clinicians who were blind to the group assignment of the patients. The patients’ registered guardians (the vast majority were co-resident family members) were assessed at the same times using the Family Burden Scale (FBS), the Self-rating Depression Scale (SDS), the Self-rating Anxiety Scale (SAS) and the Social Support Rating Scale (SSRS).
Results: At enrollment the clinical status of patients in the two groups (assessed with PANSS) was similar but the social functioning measures assessed by MRSS were significantly worse in the intervention group than in the control group. After one year the improvement of both clinical symptoms and social functioning measures were significantly greater in the intervention group than in the control group. In the year of follow-up, 3 individuals (3.3%) in the intervention group and 6 individuals (11.5%) in the control group were re-hospitalized (Fisher Exact Test, p=0.074). The feelings of burden, depression, anxiety and reported social support among guardians of patients in the intervention group were not significantly different from those for guardians of patients in the control group either at the time of enrollment or after the 1-year intervention. However, guardians in the intervention group showed a significant decrease in depressive and anxiety symptoms over the one-year follow-up.
Conclusion: Rehabilitative approaches that integrate hospital and community services can improve clinical and social outcomes for patients with schizophrenia. Further development of these programs is needed to increase the proportion of patients who achieve regular employment (i.e., ‘community re-integration’) and to provide family members with better psychosocial support.
Superoxide dismutase activity and malondialdehyde levels in patients with travel-induced psychosis
Yi GONG, Ruolian ZHAO, Baochun YANG

Background: Oxidative stress is a neurotoxic factor that may precipitate acute psychoses. 

Aim: Assess the relationship of travel-induced psychosis and oxidative stress.

Methods: Twenty-one inpatients with travel-induced psychosis related to prolonged train travel were evaluated using the Brief Psychiatric Rating Scale (BPRS) at the time of admission and their plasma superoxide dismutase (SOD) activity and malondialdehyde (MDA) concentrations were assessed on the morning following admission. These assessments were repeated after the psychotic symptoms resolved, which typically occurred after 2-6 days of low-dose antipsychotic treatment. The SOD and MDA results in the patients were compared to those of 21 normal age and gender matched control subjects.
Results: At admission the patient group had significantly higher SOD activity and MDA concentrations than the control group. After resolution of the psychotic symptoms the BPRS scores, SOD activity, and MDA concentrations all showed significant declines but the SOD activity and MDA concentrations remained higher than in the matched control group. At admission there was a non-significant positive correlation of the BPRS total score with SOD activity (r=0.32, p=0.164) and with MDA concentration (r=0.34, p=0.126). The before versus after drop in the BPRS total score was weakly correlated with the drop in the SOD activity (r=0.28, p=0.217) and with the drop in the MDA concentration (r=0.29, p=0.211).
Conclusion: These findings suggest that the neurotoxic effects of oxidative stress are directly related to the development of travel-induced psychosis. This may be relevant to the understanding of other acute psychotic states such as schizophrenia.


Meeting population needs for mental health —the Chinese example
Integration of hospital and community services —the ‘686 Project’—is a crucial component in the reform of China’s mental health services
Hong MA
Significance of the 686 Program for China and for global mental healthByron J. GOOD, Mary-Jo Del
Vecchio GOOD

Biostatistics in psychiatry

How to avoid missing data and the problems they pose: design considerations
Julia Y. LIN, Ying LU, Xin TU