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• 245 • 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. • 247 • Shanghai Archives of Psychiatry, 2014, Vol. 26, No. 5 References 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: http://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 antisocial personality disorder among Chinese individuals receiving treatment for heroin dependence: a meta-analysis. Shanghai Arch Psychiatry. 2014; 26(5): 259-271. doi: http:// 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 adjunctive 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. Crosssectional study of the association of cognitive function and hippocampal volume among health elderly adults. Shanghai Arch Psychiatry. 2014; 26(5): 280-287. Epub 2014 Sep 29. doi: http://dx.doi.org/10.11919/j.issn.1002-0829.214036 7. Office of the National Committee on Ageing. [Forecasts of aging trends in Chinese population]. 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 between ANK3 rs10761482 polymorphism in persons of Uyghur nationality living in Xinjiang China. Shanghai Arch Psychiatry. 2014; 26(5): 288293. 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 classified 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 Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington, VA: American Psychiatric Association; 2013 11. Regier DA, Narrow WE, Clarke DE, Kraemer HC, Kuramoto SJ, Kuhl EA, et al. DSM-5 field 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: http:// 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: http://dx.doi.org/10.11919/j.issn.1002-0829.214088 14. Chen T, Tang W, Lu Y, Tu X. Rank regression: an alternative 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