Bimonthly, Established in 1959
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Two-year prospective case-controlled study of a case Two-year prospective case-controlled study of a case with schizophrenia

Meijuan CHEN, Guojun WU, Zuowei WANG, Jun YAN, Jianfang ZHOU, Yan DING, Yaqin JIANG,Shunzeng RAO, Qi

Background: A community-based rehabilitation program is an essential element of the comprehensive treatment of individuals with schizophrenia. 

Objective: Assess the long-term effects of a community-based case management program for providing rehabilitations services to individuals with schizophrenia.
Methods: A total of 730 community-residing participants who met ICD-10 diagnostic criteriafor schizophrenia were enrolled, 380 in the case management group and 350 in the control group from two districts in Shanghai. Case management involved monthly training visits with patients and their co-resident family members that focused on encouraging medication adherence. Participants were assessed every three months for 24 months with the Camberwell Assessment of Need (CAN), Positive and Negative Syndrome Scale (PANSS), WHODisability Assessment Scale (WHO-DAS), and the Quality of Life Scale (QOLS). Level of discomfort due to sideeffects was also assessed every three months. Individuals who discontinued their antipsychotic medication without physician approval for one month or longer at any time during follow-up were classified as ‘selfdetermined medication discontinuation’.
Results: Compared to the treatment as usual group (i.e., follow-up management every 3 months), by the end of the two-year follow-up those who participated in the case management program had significantly lower rates of medication discontinuation, significantly less severe negative symptoms, lower relapse rates and lower rehospitalization rates. Other factors that had an independent effect on discontinuation of medication included educational level (those with more education had higher discontinuation rates), lack of family supervision of medication, higher dosages of medication, and greater medication-related discomfort.
Conclusion: Case management is a feasible and effective long-term method for improving the rehabilitation outcomes of community residents with schizophrenia. Our results highlight the need to involve family members in the management of patients’ medication, to use the minimum effective dosage of medication, and to aggressively manage all side-effects.
Keywords: schizophrenia, community-based rehabilitation, case management, discontinuation rate, social function

In this issue

special article
Neuroimaging studies of depressive disorders in China since 2000
Yingying YIN, Yonggui YUAN

Summary: This paper reviews neuroimaging studies of depressive disorders conducted in Chinese populations since 2000. Both cross-sectional and longitudinal studies using structural and functional imaging techniques have compared different types of depressed individuals, with and without specific genotypes, and the characteristics of depressed individuals before and after treatment with antidepressants. Many of the findings are unstable – probably because most of the studies are underpowered – but there have been some important contributions to the international literature. Future studies in China need to use standardized methods, longitudinal designs, and joint application of both structural and functional MRI. 

Key words: neuroimaging, structural imaging, functional imaging, depressive disorder, China, review

Original research article

Retrospective assessment of the prevalence of cardiovascular risk factors among homeless individuals with schizophrenia in Shanghai
Qing CHEN, Min WAN, Chunxia BAN, Yafang GAO

Background: Cardiovascular diseases are increasingly important in China, but the prevalence of risk factors for cardiovascular diseases in the indigent mentally ill are unknown. 

Aim: Assess the prevalence of four key risk factors for cardiovascular disease — hypertension, hyperglycemia, hyperlipidemia and smoking – among homeless patients with schizophrenia and identify factors associated with the presence of these risk factors.
Methods: We reviewed medical charts of 181 homeless and 181 non-homeless patients with schizophrenia or schizophreniform disorder admitted to the Shanghai Jiading Mental Health Center between May 2007 and April 2013. Demographic characteristics and risk factors of cardiovascular events were compared between the two groups. Logistic regression models identified the factors that were associated with the presence of one or more of the four risk factors.
Results: The prevalence of hypertension and hyperlipidemia were 19 to 20% in both males and females in the two groups; these rates are similar to those reported in the general population. The prevalence of hyperglycemia ranged from 11 to 15% among males and females in the two groups. Smoking was highly prevalent in male patients (82% in homeless males and 78% in non-homeless males) but, like in China generally, much less prevalent in female patients (7% in homeless females and 5% in non-homeless females). The logistic regression analysis found that male gender, older age, and urban (vs. rural) residence were independently associated with the presence of one or more of the four cardiovascular risk factors. Homelessness was not associated with the presence of cardiovascular risk factors.
Conclusion: This study is the first known report on cardiovascular risk factors among homeless mentally ill in China. The study did not assess several important factors (such as the type, dose and duration of use of antipsychotic medication) but it was, nevertheless, able to show that, unlike in high-income countries, homelessness is not related to elevated risk of cardiovascular disease in Chinese individuals with mental illnesses. Prospective studies with the growing number of homeless individuals in China will be needed to get a clearer picture of the best ways to provide them with the health care services they need.
Key words: homeless, schizophrenia, cardiovascular risk factor, hyperlipidemia, hypertension, hyperglycemia, smoking, China
Changes in behavior and in brain glucose metabolism in rats after nine weeks on a high fat diet: a randomized controlled trial
Hua HU, Yeqing XU, Chunfeng LIU, Heqing ZHAO, Hong ZHANG, Liwei WANG

Background: A high-fat diet (HFD) is a well-known risk factor for cardio-cerebrovascular disease but the relationship between a HFD and depressive symptoms remains unknown. 

Aim: Compare changes in behavioral and measures of brain glucose metabolism in rats fed a HFD to those of rats fed a standard diet.
Methods: Twenty male Sprague-Dawley rats were randomly assigned to a study group (n=10) that received a high fat diet for 9 weeks or a control group (n=10) that received a standard diet for 9 weeks. At baseline and at the end of the 9-week trial assessments included body weight, serum lipids (total cholesterol, triglycerides, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol), the sucrose preference test, and the open field test. The rate of brain glucose metabolism in different brain regions (assessed using micro-positron emission tomography) at the end of the trial was also compared between the two groups of rats.
Results: Nine weeks of a HFD in rats resulted in the expected increase in weight and changes in serum lipid levels, but it was also associated with a decreased preference for sucrose (which may be due to a loss of interest in pleasurable activities), increased weight-adjusted water intake, and a significant deactivation of the right thalamus and right striatum (based on decreased rates of glucose metabolism). In the HFD group the magnitude of the drop in the sucrose preference was strongly correlated to the magnitude of the deactivation of the right thalamus (r=0.78) and the right striatum (r=0.81).
Conclusion: These findings support hypotheses about the role of a HFD in the causal pathway for depressive symptoms. Further work is needed to clarify the underling mechanism, but it appears that the interaction between the content of the diet and the limbic system-striatum-thalamus circuit plays a role in both eating behavior and depressive symptoms.
Keywords: high-fat diet, depression, animal model, glucose metabolism, micro-PET
Retrospective assessment of factors associated with readmission in a large psychiatric hospital in Guangzhou, China
Yanling ZHOU, Robert A. ROSENHECK, Somaia MOHAMED, Ni FAN, Yuping NING, Hongbo HE

Background: Most psychiatric inpatients in China are involuntarily admitted by their families, resulting in relatively long admissions and relatively low readmission rates. However, this pattern may change after implementation of China’s new national mental health law (promulgated in 2013), which restricts involuntary psychiatric admissions to the small proportion of mentally ill individuals who are a danger to self or others. 

Aim: Assess the factors associated with readmission rates of psychiatric inpatients in Guangzhou, China.

Methods: A retrospective analysis of data from the Guangzhou Psychiatric Hospital, one of the largest psychiatric hospitals in China, used Cox regression models to evaluate the relationship between age, gender, diagnosis, marital status, employment status, relationship with the primary caregiver, type of medical insurance, length of stay of the index admission, and the number of previous admissions to estimate the risk of readmission over the year following discharge. Multivariate regression is used to assess factors associated with the total time of readmission during the year of follow-up.

Results: Among 3455 patients admitted from 1 January 2011 to 31 December 2012 who had a mean (sd) length of stay of 65.7 (66.3) days, 476 (13.8%) were readmitted one or more times within one year of discharge. After considering all potential predictors of readmission in a multivariate survival analysis, the number of previous hospitalizations prior to the index admission was the only statistically significant predictor of readmission. The only factor that was significantly related to the total time of readmission was the duration of the index admission.

Conclusion: Shorter length of stay was not associated with increased readmission rates in patients admitted to a large public psychiatric hospital in southern China. This suggests that the expected decrease in the length of psychiatric inpatient admissions that is likely to occur when, based on China’s new regulations, most patients are admitted voluntarily may not lead to increased rates of readmission. Prospective studies with a more comprehensive set of outcome measures (including patient functioning, medication adherence, and family burden) are needed to monitor the effect of the law on patients and on the distribution of mental health services.

Key words: psychiatric inpatients, readmission, length of stay, survival analysis, mental health law, China


Opportunities and challenges for promoting psychotherapy in contemporary China
Xudong ZHAO

Summary: China’s first mental health law, which went into effect last year, envisages a world in which psychotherapy is an integral part of all levels of medical care. There are many obstacles to achieving this goal. The new law empowers psychiatrists to provide psychotherapy but few of them have the time or inclination to do so because of the lower incomes generated by non-biological treatments. Trained clinical psychologists are in very short supply partly because of the lack of supervised training opportunities and partly because the current medical system – and the new mental health law – does not empower them to diagnose or treat patients without the direct supervision of a physician. Achieving the laudable goals of the new law will require substantial changes in the regulations and, perhaps more importantly, in attitudes about the role and status of psychologists within the medical care delivery system. 

Keywords: psychotherapy, mental health law, China


Use of diplotypes – matched haplotype pairs from homologous chromosomes – in gene-disease association studies
Lingjun ZUO, Kesheng WANG, Xingguang LUO

Summary: Alleles, genotypes and haplotypes (combinations of alleles) have been widely used in gene-disease association studies. More recently, association studies using diplotypes (haplotype pairs on homologous chromosomes) have become increasingly common. This article reviews the rationale of the four types of association analyses and discusses the situations in which diplotype-based analyses are more powerful than the other types of association analyses. Haplotype-based association analyses are more powerful than allele-based association analyses, and diplotype-based association analyses are more powerful than genotype-based analyses. In circumstances where there are no interaction effects between markers and where the criteria for Hardy-Weinberg Equilibrium (HWE) are met, the larger sample size and smaller degrees of freedom of allele-based and haplotype-based association analyses make them more powerful than genotype-based and diplotype-based association analyses, respectively. However, under certain circumstances diplotype-based analyses are more powerful than haplotype-based analysis. 

Key words: diplotype, haplotype, association analysis, genotypes, interaction effects, Hardy-Weinberg equilibrium

Case report

Case report of comorbid alcohol-induced psychotic disorder and Madelung’s disease
Zhenxiao SUN, Huanjun LI

Summary: Madelung’s disease, also known as benign symmetric lipomatosis (BSL), multiple symmetric lipomatosis (MSL), fatty neck syndrome or Launois-Bensaude syndrome, is a rare disease characterized by the presence of multiple, symmetric, loose adipose tissues distributed around the neck, occipitalis, shoulder, back or chest. The fat masses are non-encapsulated and therefore can move freely between adjacent areas. This disease is most commonly seen among middle-aged Caucasian men of Mediterranean origins; it is rarely reported in Asia. Among individuals with Madelung’s syndrome, 60 to 90% have a history of chronic alcohol abuse. We report a case of a 51-year-old Chinese man with a history of alcohol use disorder who had fat masses in his neck which gradually enlarged over a period of three years. Based on the case history and the results of physical examination, neck CT and other routine tests, he was diagnosed with Madelung’s syndrome. 

Key words: alcohol use disorders, Madelung’s syndrome, benign symmetric lipomatosis, China

Biostatistics in psychiatry

Item response theory for measurement validity
Frances M. YANG, Solon T. KAO

Summary: Item response theory (IRT) is an important method of assessing the validity of measurement scales that is underutilized in the field of psychiatry. IRT describes the relationship between a latent trait (e.g., the construct that the scale proposes to assess), the properties of the items in the scale, and respondents’ answers to the individual items. This paper introduces the basic premise, assumptions, and methods of IRT. To help explain these concepts we generate a hypothetical scale using three items from a modified, binary (yes/no) response version of the Center for Epidemiological Studies-Depression scale that was administered to 19,399 respondents. We first conducted a factor analysis to confirm the unidimensionality of the three items and then proceeded with Mplus software to construct the 2-Parameter Logic (2-PL) IRT model of the data, a method which allows for estimates of both item discrimination and item difficulty. The utility of this information both for clinical purposes and for scale construction purposes is discussed. 

Key words: Item Response Theory, Mplus, latent variable modeling, CES-D, Health and Retirement Study