In this issue

In this issue

[Shanghai Arch Psychiatry. 2014; 26(5)∶ 245-247. doi∶ hp∶//dx.doi.org/10.11919/j.issn.1002-0829.214156]

The Shanghai Archives of Psychiatry is committed to continually improving research methods in psychiatry, to promoting the use of evidence-based methods in the treatment of mental disorders, and to introducing novel methodological approaches to the psychiatric research community. To this end, with this issue we are inaugurating a new ‘Research Methods in Psychiatry’section of the journal. These papers will focus on methodological issues related to all types of mental health research including basic animal studies, clinical studies, large-scale epidemiological studies, and policy studies. Arcles about the development and evaluaon of questionnaires or other instruments and articles that present the methodological background for large mul-center studies will also be included in this secon. Authors interested in contribung to this secon of the journal should refer to the corresponding part of the Instructions to Authors on our website or contact the editor for this new section, Hui Cheng (chengyaojin@ yahoo.com).

The lead paper in this issue by Li and colleagues[1]is an assessment of the quality of previous systematic reviews about the contenous issue of the relaonship of the use of selective serotonin reuptake inhibitors (SSRIs) and suicidality. An extensive literature review identified 12 systematic reviews of randomized controlled trials (RCTs) about this issue (none of which came from China). Evaluation of the quality of the reviews using the 11-item Assessment of Multiple Systematic Reviews (AMSTAR) scale[2]found that only 1 of the reviews was considered ‘high-quality’, 8 were rated as ‘moderate quality’, and 3 were rated as ‘low quality’. The weight of the accumulated evidence suggests that use of SSRIs is associated with elevated risk of emergent suicidal ideaon and suicidal behavior, particularly in teenagers who are depressed or using paroxetine. But, given the lack of high-quality reviews on the subject, doubt remains about this conclusion. This study highlights the importance of assessing and upgrading the quality of systematic reviews in mental health. Systematic reviews are the most important information considered when determining clinical guidelines for psychiatric disorders and when promong new mental health policies; this analysis suggests that many such reviews are methodologically weak.

The meta-analysis by Zhong and colleagues[3]estimates the prevalence of antisocial personality disorder (ASPD) in Chinese individuals with heroin dependence. Given the low reported rates of personality disorders in China,[4]it is uncertain whether or not the high rates of antisocial personality disorder among heroin users idenfi ed in Western countries also holds true in China. This meta-analysis identified 15 eligible studies (13 from mainland China and 2 from Taiwan, China) all of which were conducted in rehabilitation centers or hospitals. Only 2 of the studies were evaluated as ‘high-quality’; the reported prevalence of ASPD varied widely across studies. The pooled results for the combined sample of 3692 persons with heroin addicon indicate that about 1/3rdhad comorbid ASPD. Rates were higher in men than in women and higher in those who used intravenous heroin than in those who smoked heroin. This proporon of comorbid ASPD and the predominance of males and of intravenous users is similar to that reported in Western studies. Chinese clinicians treating individuals with heroin dependence do not generally consider personality factors; further work is needed to increase clinicians’ awareness of this issue and to develop and test strategies for managing this difficult-to-treat subgroup of individuals with comorbid heroin dependence and ASPD.

The first original research article in the issue by Deng and colleagues[5]is a RCT about the use of adjunctive EEG-biofeedback in the treatment of obsessive compulsive disorder (OCD). The study randomly assigned 79 OCD patients to a treatmentas-usual group (who received sertraline and cognitive behavioural therapy for 8 weeks) and a study group that also received 40 sessions of EEG-monitored biofeedback over the 8 weeks. Compliance with the treatment was excellent (only 7 subjects dropped out over the 8 weeks). OCD symptoms and cognitive functioning were assessed using standardized instruments at baseline and at 8 weeks by trained raters who were blind to the treatment status of the subjects. Repeated measures analysis of variance clearly showed that the improvement in OCD symptoms and the five cognitive dimensions assessed were significantly greater in the study group. Further work is needed to demonstrate that the improvement is due to the biofeedback sessions themselves (and not due to the addional contact with clinicians), to evaluate the long-term effectiveness of the EEG-biofeedback treatment, and to assess the coste ff ecveness of this fairly intensive intervenon.

The original research article by Jiang and colleagues[6]assesses the relationship of hippocampal volume and cognitive functioning in healthy elderly adults. Given the very rapid aging of the Chinese population,[7]finding biomarkers of dementia that could idenfy individuals who would bene fi t from earlyintervenons is an important research objecve for the country. In this study leand right hippocampal volume, potenally useful biomarkers for early demena, were assessed in 65 healthy community-dwelling adults 65 to 75 years of age using structural MRI scanning and compared with the results for several cognitive domains of the Repeatable Baery for the Assessment of Neuropsychological Status (RBANS). The cognitive domains considered included immediate memory, delayed memory, visuospaal and construconal ability, language, and aenon. As has been reported in earlier studies, right hippocampal volume was positively associated with delayed memory and lehippocampal volume was posively associated with both immediate and delayed memory. Two unexpected findings from this study merit further study∶ the difference in the volume of the leand right hippocampus was negavely associated with aenon, and the relaonship between some variables and hippocampal volume (e.g., age) was di ff erent by gender. Longitudinal follow-up studies with larger samples are needed to compare changes in hippocampal volume overme with changes in di ff erent cognive funcons.

The original research article by Zhong and colleagues[8]aempts to replicate the fi ndings of studies in western samples and in Han Chinese samples that demonstrate a clear associaon between schizophrenia and the rs10761482 polymorphism of the ANK3 gene in a sample of 630 paents and 535 controls of Uyghur naonality - a fairly homogeneous Turkic ethnic group living in the Xinjiang Uyghur Autonomous Region of northwest China. Using standard genotyping protocols they found no differences in the allele or genotype frequencies of this polymorphism between cases and controls. Comparison of male and female paents and between adolescent-onset and adult-onset paents also failed to idenfy di ff erences in the allele frequencies or genotypes. This study highlights the value of replicang studies about widely accepted genetic factors related to psychiatric illnesses in genetically distinct groups. When such studies idenfy ethnic groups in which the previously assumed ‘universal’ genetic factor does not exist or does not have the same phenotypic outcome - and if the results are con fi rmed in mulple studies -this provides a unique opportunity to understand the genec environment in which the presumed risk factor exerts its in fl uence.

The Forum by Liu and Jiang[9]quesons the wisdom of the DSM-5[10]decision to include the ‘With Mixed Features’ specifier within the Depressive Disorders chapter rather than in the Bipolar Disorders chapter. They argue that, unlike the old ‘mixed depression’subtype, the definition of this new specifier is much closer to hypomania and mania than to atypical depression. They support their argument for relocang this condition to the Bipolar Disorders chapter by referring to accumulated research over the last two decades indicating that the family history and longterm trajectory of individuals with depressive disorders comorbid with subsyndromal hypomanic and manic symptoms is much closer to that of bipolar patients than to that of depressed individuals without comorbid hypomanic or manic symptoms. They also suggest that this blurring of the depressive disorder- bipolar disorder boundary may be one of the reasons for the very low inter-rater reliability of Major Depressive Disorder in the DSM-5 fi eld trials.[11]

The case report from India by Bhatia and colleagues[12]discusses treatment of a severe case of Tourette Syndrome using aripiprazole. Many low- and middle-income countries do not have ready access to the newer alpha-2 agonists that are currently considered first-line drugs for Tourette’s (such as pergolide, tetrabenazine and topiramate), so anpsychoc medicaons are the most commonly used drugs for the condition despite the risk of metabolic and other side effects associated with chronic use of these medications. In severe cases such as this these medications can transform the lives of the affected individuals, so they need to be used despite the risks. In most cases the drugs can be tapered or stopped after age 18, so treatment with antipsychotic medications while carefully monitoring for adverse e ff ects is clinically jusfi ed.

The Biostatistics piece by Chen and colleagues[14]discusses the use of a novel approach to the common problem faced by researchers of dealing with outlying values for a variable of interest. Linear regression models used to analyze the data in many research studies assume that the variables are normally distributed, an assumpon that is oen not met. The current method of dealing with outlier data points that undermine the normal distribuon of a variable is to truncate extreme variables (usually at 3 standard deviations above the mean value) and to continue to use linear regression. The authors present a less arbitrary method of dealing with this problem∶ conducting rank regression (on the ranked variable instead of the original variable). They give examples of how this approach is more useful than classical regression. However, this method is computationally more complicated so its widespread use will likely need to wait until popular software packages develop modules for conducng the analysis.

1. Li W, Wan YM, Ren JJ, Li T, Li CB. Appraisal of the methodological quality and summary of the findings of systematic reviews on the relationship between SSRIs and suicidality.Shanghai Arch Psychiatry. 2014; 26(5)∶ 248-258. doi∶ hp∶//dx.doi.org/10.11919/j.issn.1002-0829.214080

2. Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al. Development of AMSTAR∶ a measurement tool to assess the methodological quality of systematic reviews.BMC Med Res Methodol. 2007; 7∶10. doi∶ http∶// dx.doi.org/10.1186/1471-2288-7-10

3. Zhong BL, Xiang YT, Cao XL, Li Y, Zhu JH, Chiu HFK. Prevalence of ansocial personality disorder among Chinese individuals receiving treatment for heroin dependence∶ a meta-analysis.Shanghai Arch Psychiatry. 2014; 26(5)∶ 259-271. doi∶ hp∶// dx.doi.org/10.11919/j.issn.1002-0829.214091

4. Zhang W, Shen Y, Li SR. [Epidemiological investigation on mental disorders in 7 areas of China].Zhonghua Jing Shen Ke Za Zhi. 1998; 31(2)∶ 69-71. Chinese

5. Deng XP, Wang GH, Zhou LF, Zhang XF, Yang M, Han GY, et al. Randomized controlled trial of adjuncve EEG-biofeedback treatment of obsessive-compulsive disorder.Shanghai Arch Psychiatry. 2014; 26(5)∶ 272-279. doi∶ http∶//dx.doi. org/10.11919/j.issn.1002-0829.214067

6. Jiang LJ, Cheng Y, Li QW, Tang YY, Shen Y, Li T, et al. Crossseconal study of the associaon of cognive funcon and hippocampal volume among health elderly adults.Shanghai Arch Psychiatry. 2014; 26(5)∶ 280-287. Epub 2014 Sep 29. doi∶ hp∶//dx.doi.org/10.11919/j.issn.1002-0829.214036

7. Office of the National Committee on Ageing. [Forecasts of aging trends in Chinese populaon].Zhongguo She Hui Bao.2006; 6∶ 1-4. Chinese

8. Zhong XJ, Zhang LL, Han SX, Luo X, An ZG, Yi QZ. Casecontrol study of association betweenANK3rs10761482 polymorphism in persons of Uyghur nationality living in Xinjiang China.Shanghai Arch Psychiatry. 2014; 26(5)∶ 288-293. Epub 2014 Sep 29. doi∶ http∶//dx.doi.org/10.11919/ j.issn.1002-0829.214033

9. Liu XH, Jiang KD. Should major depressive disorder with mixed features be classi fi ed as a bipolar disorder?Shanghai Arch Psychiatry. 2014; 26(5)∶ 294-296. doi∶ http∶//dx.doi. org/10.11919/j.issn.1002-0829.214146

10. American Psychiatric Associaon.Diagnostc and Statstcal Manual of Mental Disorders, Fih Editon (DSM-5). Arlington, VA∶ American Psychiatric Associaon; 2013

11. Regier DA, Narrow WE, Clarke DE, Kraemer HC, Kuramoto SJ, Kuhl EA, et al. DSM-5 fi eld trials in the United States and Canada, Part II∶ test-retest reliability of selected categorical diagnoses.Am J Psychiatry. 2013; 170(1)∶ 59-70.doi∶ hp∶// dx.doi.org/10.1176/appi.ajp.2012.12070999

12. Bhatia MS, Gautam P, Kaur J. Case report on Tourette syndrome treated successfully with aripiprazole.Shanghai Arch Psychiatry.2014; 26(5)∶ 297-299. doi∶ http∶//dx.doi. org/10.11919/j.issn.1002-0829.214120

13. Chen HH, Wang ZZ, Phillips MR, Sun YL, Cheng HG. Internal consistency and test-retest reliability of the Chinese version of the 5-item Duke University Religion Index.Shanghai Arch Psychiatry. 2014; 26(5)∶ 300-309. Epub 2014 Sep 29. doi∶hp∶//dx.doi.org/10.11919/j.issn.1002-0829.214088

14. Chen T, Tang W, Lu Y, Tu X. Rank regression∶ an alternave regression approach for data with outliers.Shanghai Arch Psychiatry. 2014; 26(5)∶ 310-316. doi∶ http∶//dx.doi. org/10.11919/j.issn.1002-0829.214148

A full-text Chinese translaton of this artcle will be available at www.shanghaiarchivesofpsychiatry.org on November 25, 2014.