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Systematic review and meta-analysis

The dopamine system and alcohol dependence

Hui MA , Gang ZHU

Summary: Alcohol dependence is a common mental disorder that is associated with substantial disease burden. Current efforts at prevention and treatment of alcohol dependence are of very limited effectiveness. A better understanding of the biological mechanisms underlying dependence is essential to improving the outcomes of treatment and prevention initiatives. To date, most of the efforts have focused on the key role of the dopamine system in the complex etiological network of alcohol dependence. This review summarizes current research about the relationships between alcohol consumption and the dopaminergic system. We find that many of the currently available studies have contradictory results, presumably due to differences in methodology, non-linear dosage effects, use of different samples, and the possible confounding effects of other neurotransmitter systems. 

Keywords: dopamine, alcohol dependence, neurobiochemistry, review
Suicide in India: a systematic review

Background: Suicide is an important cause of death in India but estimated suicide rates based on data from India’s National Crime Records Bureau are unreliable. 

Aim: Systematically review existing literature on suicide and the factors associated with suicide in India.
Methods: PubMed, PsycINFO, EMBASE, Global Health, Google Scholar and IndMED were searched using appropriate search terms. The abstracts of relevant papers were independently examined by both authors for possible inclusion. A standardized set of data items were abstracted from the full text of the selected papers.
Results: Thirty-six papers met inclusion criteria for the analysis. The heterogeneity of sampling procedures and methods of the studies made meta-analysis of the results infeasible. Verbal autopsy studies in several rural locations in India report high suicide rates, from 82 to 95 per 100,000 population – up to 8-fold higher than the official national suicide rates. Suicide rates are highest in persons 20 to 29 years of age. Female suicide rates are higher than male rates in persons under 30 years of age but the opposite is true in those 30 years of age or older. Hanging and ingestion of organophosphate pesticides are the most common methods of suicide. Among women, self-immolation is also a relatively common method of suicide. Low socioeconomic status, mental illness (especially alcohol misuse) and inter-personal difficulties are the factors that are most closely associated with suicide.
Conclusion: The quality of the information about suicide in India is quite limited, but it is clearly an important and growing public health problem. Compared to suicides in high-income countries, suicide in India is more prevalent in women (particularly young women), is much more likely to involve ingestion of pesticides, is more closely associated with poverty, and is less closely associated with mental illness.
Key words: suicide, India, systematic review, organophosphate pesticide, mental illness

Original research article

Retrospective comparison of cognitive behavioral therapy and symptom-specific medication to treat anxiety and depression in throat cancer patients after laryngectomy
Jing CHEN, Chuancheng CHEN, Shengli ZHI

Background: Laryngectomy, a common treatment for laryngeal cancer, is a disabling operation that can induce tremendous stress, but little is known about how to alleviate the psychological effects of the operation. 

Aim: Compare the effectiveness of cognitive behavioral therapy (CBT) and medication in treating anxiety and depression among throat cancer patients after laryngectomy.
Methods: Review of medical records of the psychological outpatient clinic in the Third People’s Hospital of Huzhou City between March 2009 and May 2013 identified 63 patients with post-laryngectomy depression or anxiety disorders who received 8 weeks of one-on-one treatment with CBT (in which patients responded in writing because they were unable to speak) and 56 patients who received 8 weeks of treatment with buspirone (n=11), sertraline (n=9) or both busipirone and sertraline (n=36). The treatment provided (CBT or medications) was based on the stated preference of the patient. The Zung Self-rating Anxiety Scale (SAS) and the Zung Self-rating Depression Scale (SDS) were administered before and after treatment.
Results: After 8 weeks of treatment the mean SAS and SDS scores had decreased significantly in both groups and the prevalence of clinically significant anxiety and depression (based on SAS and SDS cutoff scores) had dropped dramatically. There were, however, no significant differences between the two treatment methods. In the medication group 32% of participants experienced one or more adverse reactions during treatment, but none of these were severe enough to require withdrawal from treatment.
Conclusions: CBT is an effective, short-term treatment for reducing the anxiety and depressive symptoms that often occur after an individual is diagnosed with cancer or treated for cancer. There is robust evidence that treatment of these psychological symptoms can improve both the quality of life and course of illness in cancer patients, so oncologists and other clinicians need to regularly screen patients with cancer and other chronic life-threatening conditions for anxiety and depression and, if present, actively promote the treatment of these symptoms. This study shows that CBT can be effective for cancer patients even when they are unable to speak.
Keywords: cognitive behavior therapy, laryngectomy, depression, anxiety disorders
Randomized controlled trial comparing changes in serum prolactin and weight among female patients with first-episode schizophrenia over 12 months of treatment with risperidoneor quetiapine
Jianjun LIU, Jushui SUN, Xinghua SHEN, Weigang GUO, Shengli ZHI, Guangming SONG, Qiuxia XU, Juanfen

Background: Increased serum prolactin and weight gain are common side effects of atypical antipsychotics but few studies have assessed the long-term pattern of these adverse effects. 

Aim: Compare the effects of risperidone and quetiapine on serum prolactin and weight over 12 months of treatment among female patients with first-episode schizophrenia.
Methods: Eighty female inpatients with first-episode schizophrenia were randomly assigned to receive risperidone (n=40) or quetiapine (n=40) for 12 months. Prolactin concentration, weight and height were measured one day before starting treatment and 1, 3, 6, 9 and 12 months after initiating treatment. Severity of symptoms was assessed at the same time periods using the Positive and Negative Syndrome Scale (PANSS).
Results: Thirty-one patients in the risperidone group and 33 patients in the quetiapine group completed the 12 months of treatment. PANSS scores decreased at each follow-up assessment for both groups; the improvement was significantly greater in the risperidone group after 3 months and 6 months of treatment but by the 9th month of treatment the level of improvement in the two groups was similar. In the quetiapine group serum prolactin remained stable throughout the 12 months but in the risperidone group the serum prolactin level increased 3.5- to 5.2- fold over the one-year follow-up. Weight gain was seen in both groups, particularly during the first 3 months of treatment: 62% of the increase in BMI in both groups had occurred by the end of the 3rd month of treatment. No between-group differences in weight changes were observed. The correlation between changes in weight and changes in prolactin levels were weakly positive: rs=0.17 (p=0.104) in the risperidone group and r=0.07 (p=0.862) in the quetiapine group.
Conclusions: Risperidone and quetiapine had similar efficacy in the first year of treatment of first-episode schizophrenia though risperidone was more rapidly effective. Use of risperidone was associated with chronic hyperprolactinemia but this did not occur with quetiapine. Long-term use of both drugs was associated with sustained weight gain; the timing and magnitude of the weight gain is similar for the two drugs. Weight gain was not strongly related to changes in prolactin levels.
Key words: schizophrenia, weight gain, first-episode, risperidone, quetiapine, long-term follow-up, China
Effectiveness of self-management training in community residents with chronic schizophrenia: a single-blind randomized controlled trial in Shanghai, China
Bin ZHOU, Pu ZHANG, Yiwei GU

Aim: Evaluate the effectiveness of self-management training in community-dwelling adults with schizophrenia. 

Methods: A total of 201 individuals with chronic schizophrenia (mean duration of illness of 17.4 years) were recruited and randomized into the self-management intervention group (n=103) and treatment-as-usual control group (n=98). The self-management training involved weekly group sessions for 6 months in which basic self-management skills were discussed and modelled followed by monthly group booster sessions for 24 months in which a community health worker reviewed patients’ self-management checklist journals. Two psychiatrists who were blind to group assignment evaluated the symptoms and social functioning of participants at baseline and 6 months and 30 months after enrollment using the Brief Psychiatric Rating Scale (BPRS), Social Disability Screening Schedule (SDSS), and Morningside Rehabilitation Status Scale (MRSS). A total of 194 individuals (99 from the intervention group and 95 from the control group) completed the 2.5-year follow-up. Intention-to-treat analysis with the last observation carried forward method was used for analysis.
Results: Compared to the control group, the intervention group had lower mean scores in the BPRS, SDSS and MRSS at both follow-up points. The scores in the intervention group continued to improve during the maintenance phase of the treatment from 6 months to 30 months after enrollment.
Conclusion: Self-management training is an effective method to improve symptoms and social functioning among individuals with chronic schizophrenia living in the community. After six months of weekly training in self-management skills, monthly booster sessions reviewing patients’ daily checklist of illness-related symptoms events are sufficient to maintain the beneficial effects of the training. Further study of the longterm cost-effectiveness of this method is needed.
Keywords: schizophrenia, community mental health services, self-care, rehabilitation, randomized controlled trial, blind assessment


Providing free treatment for severe mental disorders in China
Yi ZHU, Weibo ZHANG, Yanfeng WANG, Jun CAI

Case report

Case report on lithium intoxication with normal lithium blood levels

Summary: An 18-year old female was admitted to a psychiatric hospital with an initial episode of mania. Treated with routine dosages of lithium bicarbonate, her symptoms resolved after two weeks; she was discharged on a dosage of 750 mg lithium bid. Five days after discharge she was taken to the emergency department of a general hospital with loss of appetite and disturbed consciousness. The general hospital physicians were unable to diagnose the problem so she was transferred back to the psychiatric hospital. At that time she had a lithium blood level of 0.57 mmol/L (i.e., at the lower end of the therapeutic range) but was, nevertheless, clearly experiencing lithium intoxication with anuria, trembling extremities, blurred speech, muscle rigidity and hyperactive tendon reflexes. Treated with intravenous mannitol, her acute symptoms resolved quickly. The case highlights the need to monitor clinical symptoms of intoxication in all patients taking lithium, regardless of their blood level, and to inform patients, family members, and general physicians about the symptoms and management of lithium intoxication. 

Key words: lithium intoxication, lithium serum levels, manic episode, adverse reactions, case report

Biostatistics in psychiatry

Log-transformation and its implications for data analysis
Changyong FENG, Hongyue WANG, Naiji LU, Tian CHEN, Hua HE, Ying LU, Xin M. TU

Summary: The log-transformation is widely used in biomedical and psychosocial research to deal with skewed data. This paper highlights serious problems in this classic approach for dealing with skewed data. Despite the common belief that the log transformation can decrease the variability of data and make data conform more closely to the normal distribution, this is usually not the case. Moreover, the results of standard statistical tests performed on log-transformed data are often not relevant for the original, non-transformed data. We demonstrate these problems by presenting examples that use simulated data. We conclude that if used at all, data transformations must be applied very cautiously. We recommend that in most circumstances researchers abandon these traditional methods of dealing with skewed data and, instead, use newer analytic methods that are not dependent on the distribution the data, such as generalized estimating equations (GEE). 

Key words: hypothesis testing, outliers, log-normal distribution, normal distribution, skewness