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Systematic review and meta-analysis

Metacognitive training for schizophrenia: a systematic review

Jiangling JIANG, Li ZHANG, Zhipei ZHU, Wei LI, Chunbo LI

Background: Metacognitive training (MCT) is a novel group psychotherapy method for schizophrenia, but there is, as yet, no conclusive evidence of its efficacy. 

Aims: Conduct a meta-analysis to assess the effectiveness of MCT in schizophrenia.
Methods: Electronic and hand searches were conducted to identify randomized controlled trials about the effects of MCT in schizophrenia that met pre-defined inclusion criteria. The Cochrane Risk of Bias tool was employed to assess of risk of biases, and Cochrane Review Manager version 5.3 and R version 3.1.1 were used to conduct the data synthesis.
Results: Ten trials from 54 unduplicated reports were included in the review, but differences in the methods of assessing outcomes limited the number of studies that could be included in the meta-analysis. Pooling four studies that assessed the positive symptom subscale of the Positive and Negative Syndrome Scale (PANSS)at the end of the trial identified a small but statistically significant greater reduction in the MCT group than in the control group. But pooling four studies that assessed the delusion subscale of the Psychotic Symptom Rating Scales (PSYRATS) at the end of the trial found no significant difference between the groups. Results from the qualitative assessment of the other results that could not be pooled across studies were mixed, some showed a trend in favor of MCT but many found no difference between the groups.
Conclusions: The limited number of RCT trials, the variability of the method and time of the outcome evaluation, and methodological problems in the trials make it impossible to come to a conclusion about the effectiveness of MCT for schizophrenia. More randomized trials that use standardized outcome measures,that use intention-to-treat (ITT) analyses, and that follow-up participants at regular intervals after the intervention are needed to determine whether or not MCT should become a recommended adjunctive treatment for schizophrenia.
Key words: metacognitive training; schizophrenia; randomized controlled trials; meta-analysis

Original research article

Abnormal inter- and intra-hemispheric integration in male paranoid schizophrenia: a graph-theoretical analysis
Jianhuai CHEN, Zhijian YAO, Jiaolong QIN, Rui YAN, Lingling HUA, Qing LU

Background: The human brain is a complex network of regions that are structurally interconnected by white matter (WM) tracts. Schizophrenia (SZ) can be conceptualized as a disconnection syndrome characterized by widespread disconnections in WM pathways. Aims: To assess whether or not anatomical disconnections are associated with disruption of the topological properties of inter- and intra-hemispheric networks in SZ. 

Methods: We acquired the diffusion tensor imaging data from 24 male patients with paranoid SZ during an acute phase of their illness and from 24 healthy age-matched male controls. The brain FA-weighted(fractional anisotropy-weighted) structural networks were constructed and the inter- and intra-hemispheric integration was assessed by estimating the average characteristic path lengths (CPLs) between and within the left and right hemisphere networks.

Results: The mean CPLs for all 18 inter- and intra-hemispheric CPLs assessed were longer in the SZ patient group than in the control group, but only some of these differences were significantly different: the CPLs for the overall inter-hemispheric and the left and right intra-hemispheric networks; the CPLs for the interhemisphere subnetworks of the frontal lobes, temporal lobes, and subcortical structures; and the CPL for the intra- frontal subnetwork in the right hemisphere. Among the 24 patients, the CPL of the inter-frontal subnetwork was positively associated with negative symptom severity, but this was the only significant result among 72 assessed correlations, so it may be a statistical artifact.

Conclusions: Our findings suggest that the integrity of intra- and inter-hemispheric WM tracts is disrupted in males with paranoid SZ, supporting the brain network disconnection model (i.e., the ‘connectivity hypothesis’) of schizophrenia. Larger studies with less narrowly defined samples of individuals with schizophrenia are needed to confirm these results.

Key words: paranoid schizophrenia; diffusion tensor imaging; brain mapping; characteristic path length;paxillin; alcohol dependence
Controlled trial of the effectiveness of community rehabilitation for patients with schizophrenia in Shanghai, China
Ying ZHOU, Rongshan ZHOU, Wenjie LI, Yiqiang LIN, Jian YAO*, Jian CHEN, Tao SHEN

Background: The ‘Sunshine Soul Park’ is a network of social welfare institutions that provides communitybased rehabilitation services for individuals with mental illness. 

Aims: Assess the effectiveness of the rehabilitation services provided at the ‘Sunshine Soul Park’ on the psychotic symptoms and social functioning of individuals with schizophrenia and, based on these findings,provide a theoretical model of community-based rehabilitation.
Methods: Sixty individuals with schizophrenia in the Huangpu District of Shanghai volunteered for the rehabilitation training program provided at six ‘Sunshine Soul Park’ community centers that involves day treatment, medication monitoring, biweekly rehabilitation training, and other recreational, social, and intellectual activities. A matched control group was recruited from individuals with schizophrenia registered on the Huangpu District registry of the ‘Severe Mental Illness Prevention and Rehabilitation System’. All participants continued their medication without change for the full year of follow-up. Both groups were assessed at baseline, and 3, 6, and 12 months after enrollment using the Insight and Treatment Attitude Questionnaire (ITAQ), Social Disability Screening Schedule (SDSS), Generic Quality of Life Inventory-74(GQOLI-74), and Positive and Negative Syndrome Scale (PANSS).
Results: In the intervention group the ITAQ, SDSS, GQOLI-74, and PANSS scores showed statistically significant improvement compared to baseline at each follow-up assessment. Moreover, the trend in improvement in the interventions group is significantly faster than that in the control group.
Conclusions: The ‘Sunshine Soul Park’ rehabilitation training program enhances patients’ knowledge about their disorder and improves their social functioning and quality of life. Further studies to assess methods for up-scaling this intervention to other areas of China are warranted.
Key words: schizophrenia; community rehabilitation; ‘Sunshine Soul Garden’; social functioning; quality of life; China
Comparisons of family environment between homeless and non-homeless individuals with schizophrenia in Xiangtan, Hunan
Jinliang CHEN, Jindong CHEN, Shuchun LI, Jun LIU, Guohua OUYANG, Wenxuan LUO, Xiaofeng GUO, Ting LI,

Background: Homelessness is an increasingly important problem for individuals with serious mental illness in China. 

Aims: Identify the characteristics of families that are associated with homelessness among individuals with schizophrenia.
Methods: Participants were 1856 homeless individuals with schizophrenia (defined as those who had no place of residence or involved caregivers for 7 consecutive days) and 1728 non-homeless individuals with schizophrenia from Xiangtan, Hunan. The self-completion Family Environment Scale-Chinese Version (FES-CV)was administered to these participants after their acute psychotic symptoms resolved.
Results: Compared to individuals in the non-homeless group, those in the homeless group were older and more likely to be non-locals (i.e., from outside of Xiangtan), be residents of rural (versus urban)communities, have temporary (versus permanent) jobs, be married, and have a low level of education.After controlling for demographic differences using multivariate logistic regression models, homelessness was independently associated higher scores in the FES-CV intellectual-cultural orientation, organization,achievement orientation, and control subscales and with lower scores in the FES-CV cohesion, moralreligious emphasis, independence, and active-recreational orientation subscales.
Conclusions: After controlling for sociodemographic factors, certain aspects of the family environment are associated with being homeless among patients with schizophrenia in China. Further work is needed to identify interventions that can reduce the risk of homelessness in high-risk individuals.
Key words: homelessness; schizophrenia; family environment; China


Bridging the gap between research into biological and psychosocial models of psychosis
Robin M. MURRAY, Lucia SIDELI, Caterina LA CASCIA, Daniele LA BARBERA
Summary: Paul Bebbington’s recent Special Article provides an excellent synthesis of recent advances in psychosocial research on psychosis. However, we doubt that a model based solely on social epidemiology and cognitive theory can totally describe psychosis, and to be fair, Bebbington does not suggest that it does. A complete model must also incorporate what we have learned from non-social epidemiology,neuroscience, and genetics. Evidence indicates that both the social risk factors that interest Bebbington and biological risk factors, such as abuse of stimulants and cannabis, can provoke psychotic symptoms by dysregulating striatal dopamine. The role of neurodevelopmental deviance also needs to be considered in the etiology of schizophrenia-like psychosis. Moreover, the striking advances in our understanding of the genetic architecture of psychosis open an exciting door into studies examining gene-environment correlation and gene-environment interaction. In short, Bebbington demonstrates the value of cognitive and social researchers talking to each other, but the occasional chat with the more biologically inclined could produce a more comprehensive model. 
Keywords: psychosis; schizophrenia; genetics; neurodevelopment; dopamine; social factors.
Addressing risk of bias in trials of cognitive behavioral therapy
Katherine S. BUTTON, Marcus R. MUNAFÒ

Summary: A recent network meta-analysis by Zhu and colleagues reported in the Shanghai Archives of Psychiatry compared two different comparators (psychological placebo and waitlist control) in trials assessing the effectiveness of cognitive behavioral therapy (CBT) for the treatment of generalized anxiety disorder (GAD). CBT was superior to both of these control conditions, but psychological placebo was superior to waitlist. However, we argue that the term ‘psychological placebo’ is a misnomer because the impossibility of effectively blinding participants to treatment allocation in CBT trials makes it impossible to control for placebo effects. This failure to blind participants and therapists – and the resultant high risk of bias – was the main reason Zhu and colleagues found that the overall quality of the evidence supporting the conclusion that CBT is effective for GAD is poor. This is a general problem in all psychotherapy trials, which suffer from well-documented methodological and conceptual problems that prevent adequate placebo control and undermine casual inference. We discuss these problems and suggest potential solutions. We conclude that,while it may be difficult to remove potential bias in randomized controlled trials of psychotherapy, we can improve on the status quo by integrating basic science within applied trials to adjust for these biases and,thus, improve the strength of the causal inferences. 

Keywords: cognitive behavioral therapy; psychotherapy; generalized anxiety disorder; randomized controlled trial; meta-analysis; network meta-analysis; psychological placebo

Case report

Oligodendroglioma presenting as chronic mania
Rahul SAHA, Kiran JAKHAR

Summary: Oligodendrogliomas may present with a variety of psychological symptoms but it only rarely presents with mania. The patient described in this case report is a 55-year-old man with a three year history of progressive mania who was initially diagnosed as chronic mania but a subsequent MRI identified a brain tumor. This report highlights the importance of considering differential organic diagnosis when patients present with atypical presentations of psychiatric disorders. A brain tumor should be considered and brain imaging studies conducted for patients with a late age of onset who do not respond to appropriate medication. 

Keywords: oligodendrogliomas; tumor; chronic mania; India

Research methods in psychiatry

Development of a checklist of short-term and long-term psychological symptoms associated with ketamine use
Ni FAN, Ke XU, Yuping NING, Daping WANG, Xiaoyin KE, Yi DING, Bin SUN, Chao ZHOU,Xuefeng DENG, Rober

Background: Ketamine is an increasingly popular drug of abuse in China but there is currently no method for classifying the psychological effects of ketamine in individuals with ketamine dependence. 

Aims: Develop a scale that characterizes the acute and long-term psychological effects of ketamine use among persons with ketamine dependence.
Methods: We developed a preliminary symptom checklist with 35 dichotomous (‘yes’ or ‘no’) items about subjective feelings immediately after ketamine use and about perceived long-term effects of ketamine use that was administered to 187 inpatients with ketamine dependence recruited from two large hospitals in Guangzhou, China. Exploratory factor analysis (EFA) was conducted on a randomly selected half of the sample to reduce the items and to identify underlying constructs. Confirmatory factor analysis (CFA) was conducted on the second half of the sample to assess the robustness of the identified factor structure.
Results: Among the 35 symptoms, the most-reported acute effects were ‘floating or circling’ (94%), ‘euphoric when listening to rousing music’ (86%), and ‘feeling excited, talkative, and full of energy’ (67%). The mostreported long-term symptoms were ‘memory impairment’ (93%), ‘personality changes’ (86%), and ‘slowed reactions’ (81%). EFA resulted in a final 22-item scale best modelled by a four-factor model: two factors representing chronic symptoms (social withdrawal and sleep disturbances), one about acute psychoticlike symptoms, and one that combined acute drug-related euphoria and longer-term decreased libido.CFA showed that these 4 factors accounted for 50% of the total variance of the final 22-item scale and that the model fit was fair (Goodness of Fit Index, GIF=83.3%; Root Mean Square Error of Approximation, RMSEA=0.072).
Conclusions: A four-factor model including social withdrawal, sleep disturbance, psychotic-like symptoms,and euphoria at the time of drug use provides a fair description of the short-term and long-term psychological symptoms associated with ketamine use. Future work on the 22-item version of the scale with larger samples is needed to confirm the validity of this 4-factor structure, to assess the scale’s test-retest reliability, and to determine whether or not it can be useful in the differential diagnosis and monitoring of treatment of individuals with ketamine dependence.
Keywords: ketamine; substance-related disorders; signs and symptoms; questionnaire; factor analysis; China

Biostatistics in psychiatry
Meta-analysis for psychiatric research using free software R
Ding-Geng CHEN

Summary: This paper provides a brief overview of meta-analysis (MA) with emphasis on classical fixedeffects and random-effects MA models. It illustrates the application of MA models with the open-source software R using publicly available data from five studies on lamotrigine to treat bipolar depression and finds that meta-analysis identifies a statistically significant advantage of lamotrigine over placebo that was not evident in the individual studies. 

Key words: meta-analysis; fixed-effects model; random-effects model; bipolar disorder;lamotrigine