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Shanghai Archives of Psychiatry, 2014, Vol. 26, No. 5
•In this issue•
[Shanghai Arch Psychiatry. 2014; 26(5): 245-247. doi: http://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. Articles about the development and evaluation
of questionnaires or other instruments and articles
that present the methodological background for large
multi-center studies will also be included in this section.
Authors interested in contributing to this section 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 contentious issue of the relationship
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 ideation 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 promoting
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 identified 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
addiction indicate that about 1/3rd had 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 proportion 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 additional contact with
clinicians), to evaluate the long-term effectiveness of
the EEG-biofeedback treatment, and to assess the costeffectiveness of this fairly intensive intervention.
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 identify individuals who would benefit from early
A full-text Chinese translation of this article will be available at www.shanghaiarchivesofpsychiatry.org on November 25, 2014.
• 246 •
interventions is an important research objective for the
country. In this study left and right hippocampal volume,
potentially useful biomarkers for early dementia, 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 Battery for the Assessment
of Neuropsychological Status (RBANS). The cognitive
domains considered included immediate memory,
delayed memory, visuospatial and constructional ability,
language, and attention. As has been reported in earlier
studies, right hippocampal volume was positively
associated with delayed memory and left hippocampal
volume was positively associated with both immediate
and delayed memory. Two unexpected findings from
this study merit further study: the difference in the
volume of the left and right hippocampus was negatively
associated with attention, and the relationship between
some variables and hippocampal volume (e.g., age)
was different by gender. Longitudinal follow-up studies
with larger samples are needed to compare changes in
hippocampal volume over time with changes in different
cognitive functions.
The original research article by Zhong and
colleagues[8] attempts to replicate the findings of studies
in western samples and in Han Chinese samples that
demonstrate a clear association between schizophrenia
and the rs10761482 polymorphism of the ANK3 gene
in a sample of 630 patients and 535 controls of Uyghur
nationality – 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 patients and
between adolescent-onset and adult-onset patients also
failed to identify differences in the allele frequencies or
genotypes. This study highlights the value of replicating
studies about widely accepted genetic factors related
to psychiatric illnesses in genetically distinct groups.
When such studies identify 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 confirmed in multiple studies –
this provides a unique opportunity to understand the
genetic environment in which the presumed risk factor
exerts its influence.
The Forum by Liu and Jiang[9] questions 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 relocating
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
Shanghai Archives of Psychiatry, 2014, Vol. 26, No. 5
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 field 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
antipsychotic medications 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 effects is clinically
justified.
The article in the Research Methods in Psychiatry
section by Chen and colleagues [13] discusses the
assessment of the internal consistency and testretest reliability of an adapted Chinese version of the
5-item Duke University Religion Index. A study with
2425 randomly selected adult residents of the Ningxia
Autonomous Region (including 188 who repeated the
survey) found that the instrument is a reliable and
valid measure that can be used to assess the level of
religiosity or spirituality in Chinese respondents. Unlike
the original English-language version of the scale (which
reports three dimensions), exploratory and confirmatory
factor analysis found that the Chinese version of the
scale is uni-dimensional.
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
assumption that is often not met. The current method
of dealing with outlier data points that undermine the
normal distribution 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 conducting the analysis.
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Shanghai Archives of Psychiatry, 2014, Vol. 26, No. 5
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