Comparative study of diagnostic systems: Chinese Classification of Mental Disorders-Second Edition versus DSM-III-R

Association Between Clozapine Plasma Concentrations and Treatment Response: A Systematic Review, Meta-analysis and Individual Participant Data Meta-analysis

BACKGROUND AND OBJECTIVES

Although therapeutic drug monitoring of clozapine is recommended, its optimisation is often adjusted only on the basis of dosage. The aim of this study was to assess the link between clozapine plasma concentrations and clinical response by a meta-analysis of published studies and by an individual participant data meta-analysis.

METHODS

We conducted a computerised search of bibliographic databases (EMBASE, PubMed, Clinical Trials, and Web of Science) to identify studies that assessed the relationship between clozapine serum or plasma concentrations and clinical efficacy. Using pooled data, we investigated the association between improvement of clinical outcome and clozapine or norclozapine plasma concentrations, the sum of clozapine and norclozapine plasma concentrations, and the coefficient of variation of clozapine plasma concentrations. Using available individual data, we assessed the relationship between clozapine plasma concentrations and clinical response (changes in the Brief Psychiatric Rating Scale score) and identified a threshold level for a favourable clinical response.

RESULTS

Fifteen studies satisfied inclusion criteria. Our meta-analysis showed that responders had clozapine plasma concentrations that were, on average, 117 ng/mL higher than non-responders. The patients with plasma clozapine concentrations above the thresholds identified in each study had a higher likelihood of responding (odds ratio = 2.94, p < 0.001). Norclozapine plasma concentrations were not associated with a clinical response. The meta-analysis of individual data supported this result and confirmed the link between clozapine concentrations and a change in the Brief Psychiatric Rating Scale score and/or the probability of clinical response. Finally, with the analysis of the coefficient of variation of clozapine plasma concentrations, we found that a greater inter-individual fluctuation in plasma concentrations was associated with a loss of clinical response.

CONCLUSIONS

Our work confirmed that, in contrast to clozapine doses, clozapine plasma concentrations were related to a favourable clinical response, with a mean difference between responders and non-responders of 117 ng/mL. A threshold for a treatment response of 407 ng/mL was determined, with a high discriminatory capacity, and a sensitivity and specificity of 71% and 89.1%, respectively.

Prevalence of Major Depressive Disorder Among Adults in China: A Systematic Review and Meta-Analysis

Background: Prevalence estimates of major depressive disorder (MDD) among adults in China have varied widely between studies. In this systematic review and meta-analysis, the overall prevalence of MDD in the Chinese population was estimated from published epidemiological studies and potential moderators that account for variability in estimates were assessed. Methods: A systematic literature search was conducted in PubMed, EMBASE, Web of Science, PsycINFO, China National Knowledge Internet (CNKI), and WanFang databases to identify relevant studies. Data analyses were conducted using the Comprehensive Meta-Analysis Version 2.0. Results: Forty studies comprising 1,024,087 subjects were included. The pooled point, 12-month, and lifetime prevalence rates of MDD in China were 1.1% (95% CI: 0.9-1.4%), 1.6% (95% CI: 1.0-2.5%), and 1.8% (95% CI: 1.5-2.2%), respectively. Subgroup and meta-regression analyses revealed gender, marital status, survey year, being published in English language, use of the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic systems and age as significant moderators of MDD prevalence. Conclusion: The overall prevalence of MDD in the Chinese population appears to be lower than that of most countries, but the rates have been increasing over time and are elevated in particular demographic subgroups. Due to the negative consequences of MDD, effective preventive measures, early identification, and timely treatments are still important and should be offered to those in need.

Exercise for patients with major depression: a systematic review with meta-analysis and trial sequential analysis

OBJECTIVES

To assess the benefits and harms of exercise in patients with depression.

DESIGN

Systematic review DATA SOURCES: Bibliographical databases were searched until 20 June 2017.

ELIGIBILITY CRITERIA AND OUTCOMES

Eligible trials were randomised clinical trials assessing the effect of exercise in participants diagnosed with depression. Primary outcomes were depression severity, lack of remission and serious adverse events (eg, suicide) assessed at the end of the intervention. Secondary outcomes were quality of life and adverse events such as injuries, as well as assessment of depression severity and lack of remission during follow-up after the intervention.

RESULTS

Thirty-five trials enrolling 2498 participants were included. The effect of exercise versus control on depression severity was -0.66 standardised mean difference (SMD) (95% CI -0.86 to -0.46; p<0.001; grading of recommendations assessment, development and evaluation (GRADE): very low quality). Restricting this analysis to the four trials that seemed less affected of bias, the effect vanished into -0.11 SMD (-0.41 to 0.18; p=0.45; GRADE: low quality). Exercise decreased the relative risk of no remission to 0.78 (0.68 to 0.90; p<0.001; GRADE: very low quality). Restricting this analysis to the two trials that seemed less affected of bias, the effect vanished into 0.95 (0.74 to 1.23; p=0.78). Trial sequential analysis excluded random error when all trials were analysed, but not if focusing on trials less affected of bias. Subgroup analyses found that trial size and intervention duration were inversely associated with effect size for both depression severity and lack of remission. There was no significant effect of exercise on secondary outcomes.

CONCLUSIONS

Trials with less risk of bias suggested no antidepressant effects of exercise and there were no significant effects of exercise on quality of life, depression severity or lack of remission during follow-up. Data for serious adverse events and adverse events were scarce not allowing conclusions for these outcomes.

SYSTEMATIC REVIEW REGISTRATION

The protocol was published in the journal Systematic Reviews: 2015; 4:40.

Characteristics, experience, and treatment of schizophrenia in China

Assessment of differences in the characteristics, experience, and treatment of schizophrenia between China and the West highlights the importance of the interaction of biological and sociocultural factors in the onset and course of the disorder. China reports a much higher prevalence of schizophrenia in urban areas than in rural areas and, surprisingly a higher prevalence in women than in men. Despite differences in the diagnostic criteria for schizophrenia, the pattern of positive, negative, and cognitive symptoms is similar to that seen in the West. Almost ail medical treatment for schizophrenia is provided from specialized psychiatric hospitals, most of which are situated in urban centers. Antipsychotic medication (often the generic clozapine) is the mainstay of inpatient treatment. China developed a variety of innovative community-based treatment models in the 1980s, but the social and economic changes of the 1990s have made ii difficult to generalize these models. Overall, approximately 70% of the estimated 4.8 million persons with schizophrenia in China do not receive regular treatment.

Clair D, He L. Prenatal malnutrition and adult schizophrenia: further evidence from the 1959-1961 Chinese famine

OBJECTIVE

Evidence from the 1944-1995 Dutch Hunger Winter and the 1959-1961 Chinese famines suggests that those conceived or in early gestation during famines, have a 2-fold increased risk of developing schizophrenia in adult life. We tested the hypothesis in a second Chinese population and also determined whether risk differed between urban and rural areas.

METHOD

The risk of schizophrenia was examined in Liuzhou prefecture of Guangxi autonomous region. Rates were compared among those conceived before, during, and after the famine years. Based on the decline in birth rates, we predicted that those born in 1960 and 1961 would have been exposed to the famine during conception or early gestation. All psychiatric case records in Liuzhou psychiatric hospital for the years 1971 through 2001 were examined and clinical/sociodemographic data extracted by psychiatrists blind to exposure status. Data on births and deaths in the famine years were also available, and cumulative mortality was estimated from later demographic surveys. Evidence of famine was verified, and results were adjusted for mortality. Relative risks (RRs) for schizophrenia were calculated for the region as a whole and for urban and rural areas separately.

RESULTS

Mortality-adjusted RR for schizophrenia was 1.5 (1960) and 2.05 (1961), respectively. However, the effect was exclusively from the rural areas RR = 1.68 (1960) and RR = 2.25 (1961).

CONCLUSIONS

We observe a 2-fold increased risk of schizophrenia among those conceived or in early gestation at the height of famine with risk related to severity of famine conditions.

Pharmacological interventions for clozapine-induced hypersalivation

BACKGROUND

Clozapine is widely used for people with schizophrenia. Although agranulocytosis, weight gain, and cardiac problems are serious problems associated with its use, hypersalivation, sometimes of a gross and socially unacceptable quantity, is also common (30-80%).

OBJECTIVES

To determine the clinical effects of pharmacological interventions for clozapine-induced hypersalivation.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (March 2007), inspected references of all identified studies for further trials, contacted relevant pharmaceutical companies, drug approval agencies and authors of trials.

SELECTION CRITERIA

We included randomised controlled trials comparing pharmacological interventions, at any dose and by any route of administration, for clozapine-induced hypersalivation.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data (homogenous) we calculated relative risk (RR) with 95% confidence intervals (CI) and numbers needed to treat (NNT) on an intention-to-treat basis. We calculated weighted mean difference (WMD) for continuous data.

MAIN RESULTS

Of the 15 trials identified, 14 were conducted in China and 14 in hospitals. The quality of reporting was poor with no studies clearly describing allocation concealment and much data were missing or unusable. All results are vulnerable to considerable bias. Most frequently the primary outcome was the diameter of the wet patch on the pillow. Antimuscarinics (astemizole, diphenhydramine, propantheline, doxepin) were the most commonly evaluated drugs. For the outcome of 'no clinically important improvement' astemizole and diphenhydramine were more effective than placebo (astemizole: n=97, 2 RCTs, RR 0.61 CI 0.47 to 0.81 NNT 3 CI 2 to 5; diphenhydramine: n=131, 2 RCTs, RR 0.43 CI 0.31 to 0.58, NNT 2 CI 1.5 to 2.5), but the doses of astemizole used were those that can cause toxicity. Data involving propantheline were heterogeneous (I2= 86.6%), but both studies showed benefit over placebo. Adverse effects were poorly recorded. Of the other interventions, oryzanol (rice bran oil and rice embryo oil extract) showed benefit over the antimuscarinic doxepin in terms of 'no clinically important change' (n=104, 1 RCT, RR 0.45 CI 0.27 to 0.75, NNT 4 CI 2 to 7). The Chinese medicine suo quo wan (comprises spicebush root, Chinese yam and bitter cardamom) showed benefit over doxepin (n=70, 1 RCT, RR 'no clinically important change' 0.31 CI 0.16 to 0.59, NNT 3 CI 1.5 to 3.7).

AUTHORS' CONCLUSIONS

There are currently insufficient data to confidently inform clinical practice. The limitations of these studies are plentiful and the risk of bias is high. These trials, however, are invaluable guides for current and future study design. Well conducted randomised trials are possible. Some may be underway. Current practice outside of well designed randomised trials should be clearly justified.

A community epidemiological survey of generalized anxiety disorder in Hong Kong

Generalized anxiety disorder (GAD) is understudied in Asian communities. There were 3,304 Chinese subjects (aged 15-60 years) randomly drawn from the general population of Hong Kong and successfully interviewed. The participation rate was 65.8%. The six-month prevalence of DSM-IV GAD was 4.1%. Over half of the GAD subjects reported palpitations and bowel symptoms. Comorbid depressive mood (65%) and substance use (35%) were common. Forty-one percent of GAD subjects sought help, usually from general practitioners who prescribed tranquilizers after negative physical investigations. Telephone-based surveys have limitations but provide an affordable and destigmatizing alternative to face-to-face surveys for communities with limited mental health resources.

A randomized, double-blind and placebo-controlled study of a Ganoderma lucidum polysaccharide extract in neurasthenia

Ganoderma lucidum has been widely used to treat various diseases, including cancer, diabetes, and neurasthenia in many Asian countries. This randomized, double-blind, placebo-controlled parallel study aimed to investigate the efficacy and safety of a polysaccharide extract of G. lucidum (Ganopoly) in Chinese patients with neurasthenia. One hundred thirty-two patients with neurasthenia according to the diagnosis criteria of the 10th International Classification of Diseases were included in this study. Written consents were obtained from the patients, and the study was conducted in accordance with Good Clinical Practice guidelines. Patients were randomized to receive Ganopoly or placebo orally at 1,800 mg three times a day for 8 weeks. Efficacy assessments comprised the Clinical Global Impression (CGI) improvement of severity scale and the Visual Analogues Scales for the sense of fatigue and well-being. In 123 assessable patients in two treatment groups at the end of the study, Ganopoly treatment for 8 weeks resulted in significantly lower scores after 8 weeks in the CGI severity score and sense of fatigue, with a respective reduction of 15.5% and 28.3% from baseline, whereas the reductions in the placebo group were 4.9% and 20.1%, respectively. The score at day 56 in the sense of well-being increased from baseline to 38.7% in the Ganopoly group compared with 29.7% in the placebo group. The distribution of the five possible outcomes from very much improved to minimally worse was significantly different (X (2) = 10.55; df = 4; P = .0322) after treatment with Ganopoly or placebo. There was a percentage of 51.6% (32 of 62) in the Ganopoly group rated as more than minimally improved compared with 24.6% (15 of 61) in the placebo group (X (2) = 9.51; df = 1; P = .002). Ganopoly was well tolerated in the study patients. These findings indicated that Ganopoly was significantly superior to placebo with respect to the clinical improvement of symptoms in neurasthenia.

Psychosocial factors in chronic fatigue syndrome among Chinese Americans: a longitudinal community-based study

Chronic fatigue syndrome (CFS) is a relatively new condition of unknown etiology. Research suggests that psychosocial factors such as perceived social support, life stress, and acculturation may significantly influence individuals who are prone to CFS. For 57 Chinese American individuals initially diagnosed with CFS, those who recovered after one year reported lower levels of life stress than those who did not recover. Effects of changes in perceived social support also appeared to be mediated by life stress.

Dizziness and panic in China: associated sensations of zang fu organ disequilibrium

In China, distress is commonly experienced as dizziness that can develop into acute episodes resembling Western panic attacks. These distressing sensations occur in a unique cultural context with a distinctive set of associated symptoms, beliefs and purported etiologies. The experience of illness is informed by traditional Chinese medicine (TCM), an indigenous theory that elaborates a system of organ functioning called zang fi. Depending on the implicated zang fi organ disequilibrium, dizziness and panic present with a specific constellation of associated physical and mental symptoms. This paper presents a clinical survey of psychiatric disorders that demonstrates dizziness to be characteristic of Chinese anxiety states, most particularly panic. Three specific cases of dizziness-focused panic ascribed to different states of zangfu disequilibrium are described. In a typical pattern, initial dizziness and associated symptoms intensify until they generalize into panic attacks. The degree of dizziness and panic corresponds to the state of disequilibrium of the zang fu organ system as well as instability of the social, interpersonal and environmental context of the patient. This paper elucidates the dynamic interpretants of dizziness in the Chinese context to contribute to a medical anthropology of this sensation.

From diversity to unity. The classification of mental disorders in 21st-century China

Psychiatric disease constructs represent social constructs and genuine states of distress that have biopsychosocial sources. As such, they have social uses peculiar to the social groups in which they are created and legitimized. This is as true in the United States as in the rest of the world. The DSM schema, for instance, is so organized that every possible mental condition is listed as a disease to legitimate remuneration to practitioners from private medical insurance and government programs. This particular social use may be irrelevant to other societies where health care is financed differently. The CCMD-3 system represents an attempt at global unification and preservation of features that are salient for local application. Compared with its previous editions, noticeable changes have been made to render it in tune with international usage. This remarkable speed of adaptation speaks to the global flows of information technology and China's openness under rapid economic reform. It also demonstrates that the middle-aged cohort of more pragmatic Chinese psychiatric leaders who headed the CCMD-3 task force are now less vulnerable to the domination of the most senior generation of Chinese psychiatrists. Having been trained in the Russian system of psychiatry and gone through the various periods of national shame that traumatized China, they used to be very cautious about adopting foreign technology in general. This is why much less harmonization with the ICD-10 occurred with the CCMD-2-R, when the responsible task force was, for better or worse, dominated by these senior psychiatrists. Nonetheless, as Stengel and Sartorius remarked, an international classification must not aim to oust or replace regional classifications that serve valuable functions in the local contexts. No single classificatory system, Kirmayer submits, will suffice for all purposes--the correct diagnostic scheme is the one that accomplishes its explicit pragmatic aim by addressing the relevant level of description. The particular additions (e.g., travelling psychosis, culture-related mental disorders), deletions (e.g., depressive neurosis, pathologic gambling, avoidant and borderline personality disorders), retentions (e.g., unipolar mania, neurosis, hysteria, homosexuality), and epistemologic variations (e.g., somatoform disorder, neurasthenia) of diagnostic categories reflect exactly this simultaneous need to globalize and to take account of the changing reality of illness in contemporary China. Stengel advised that "no psychiatric classification can help being partly etiological and partly symptomatological, because these are the criteria by which psychiatrists distinguish mental disorders from each other." To an extent, the CCMD-3 is a critique of certain nosologic assumptions of Western psychiatry, such as the feasibility of a neo-Kraepelinian taxonomy grounded exclusively in symptomatology across all diagnostic categories, and the validity of syndromic architectures based on a firm adherence to the mind-body dichotomy. From this angle of vision, local systems of classification such as the CCMD-3 may offer an opportunity for needed reflections by North American psychiatrists who have simply taken the DSM-IV schema for granted. Sartorius reckoned that a classification is a way of seeing the world at a point in time. A deep study of the CCMD-3 is thus an avenue for achieving an understanding of the contemporary Chinese mind and the social realities in China. The remarkable diversity of China at present, namely, a Communist Party dominated state socialist political structure but the most rapidly growing capitalist economy in the world, guarantees that Chinese people's social and moral experience of illness will continue to change. The study of such culture-specific categories as travelling psychosis, neurasthenia, qigong-induced mental disorder, and dysfunctional homosexuality sheds light on the larger sociomoral processes and destabilizing changes in subjectivity that are occurring in this most populous country in the world.

Response style and the revised NEO personality inventory: validity scales and spousal ratings in a Chinese psychiatric sample

The effects of response style bias on profile scores from the family of NEO scales and the resultant influence of response style on the predictive capacity of these scales continues to be debated. In this study, a large sample of Chinese psychiatric patients were categorized into four response style groups based on their scores from recently developed "validity" scales for the revised NEO Personality Inventory (NEO PI-R). Mean differences and correlations between self-report and spousal ratings of these patients were examined for the NEO PI-R domain and facet scales. Excessive positive self-presentation bias resulted in mean differences between the self-report and spousal ratings for N and E. Correlations between self-report and spousal ratings were reduced in patients engaging in positive self-presentational bias compared to those who were not so categorized on three of the five NEO PI-R scales. However, these results were manifest only in a sub-sample of psychotic patients. Negative self-presentational bias did not affect mean differences or diminish the correlations between the self-report and spousal ratings.

Qigong-induced mental disorders: a review

OBJECTIVE

This review article aims to explore current opinions on Qigong-induced mental disorders, an entity which is unfamiliar to Western psychiatrists.

METHOD

Relevant literature published in Chinese and English is reviewed.

RESULTS

The review is divided into three sections: first, there is brief consideration of the historical development of Qigong in traditional Chinese medicine and its role in psychiatry; second, there is a review of the literature published on Qigong deviations and Qigong-induced mental disorders; and third, there is a discussion on the aetiological role of Qigong in these conditions.

CONCLUSIONS

Qigong remained veiled in secrecy and available only to the elite until the early 1980s. Despite the widespread use of Qigong, there is a conspicuous lack of controlled data regarding its effects on mental health. Qigong, when practised inappropriately, may induce abnormal psychosomatic responses and even mental disorders. However, the ties between Qigong and mental disorders are manifold, and a causal relationship is difficult to establish. Many so-called 'Qigong-induced psychoses' may be more appropriately labelled 'Qigong-precipitated psychoses', where the practice of Qigong acts as a stressor in vulnerable individuals.

An epidemiological study of neurasthenia in Chinese-Americans in Los Angeles

This study examined the prevalence and clinical features of ICD-10-defined neurasthenia (NT) in Chinese-Americans and its relations to other psychiatric disorders. In this community epidemiological survey, the enhanced Composite International Diagnostic Interview [CIDI], with a supplemental NT module, was administered to 1,747 Chinese-Americans, selected with a stratified cluster sampling method. The SCL-90-R was also used for measuring psychiatric morbidity and symptoms. Dimensions of social stress and social support were measured by established instruments. A total of 112 ICD-10 NT subjects (6.4%) were identified. Of these, 63 (56.3%) did not experience any current and lifetime DSM-III-R diagnoses, yielding a 12-month or lifetime prevalence rate of "pure" NT of 3.61%. This rate was much higher than any of the other psychiatric disorders in this sample. Compared with normal subjects, "pure" NT subjects had significantly higher SCL-90-R total and factor scores, experienced more psychosocial stress, and perceived less social support (P < .05 or .01). Compared with subjects with depression and anxiety disorders, "pure" NT cases reported significantly less SCL-90-R psychological symptoms (P < .05 or .01), but had a strikingly similar elevation in the somatization subscale score. These data suggest that NT is a distinctive clinical condition overlapping only partially with the other better recognized diagnostic entities. In view of its high prevalence and the salience of its impact on the health of those afflicted, it is imperative that concerted research efforts be made to further elucidate the temporal stability, natural course, and outcome of such a condition.

Cultures in psychiatric nosology: the CCMD-2-R and international classification of mental disorders

This essay reviews the Chinese Classification of Mental Disorders, Second Edition, Revised (CCMD-2-R, 1995), by assuming the theoretical stance that symptom recognition, disease construction, and taxonomic strategy in psychiatry reflect, and are constrained by, the cultural norms and values as well as the political and economic organizations of the society in which they are embedded. The CCMD-2-R is an ethnomedical classification grounded in both symptomatology and etiology, in which Chinese psychiatrists seek to conform with international classifications on the one hand, and to sustain a nosology with Chinese cultural characteristics on the other. Although broad similarities between the ICD-10 and CCMD-2-R are evident, their blending is legitimately incomplete. Thus, the particular additions (e.g., travelling psychosis, qigong induced mental disorders), deletions (e.g., somatoform disorders, pathological gambling, a number of personality and sexual disorders), retentions (e.g., unipolar mania, neurosis, hysteria, homosexuality), and variations (e.g., depressive neurosis, neurasthenia) reveal not only the changing notions of illness but also the shifting social realities in contemporary China. The CCMD-2-R will be widely used by Chinese psychiatrists and should standardize diagnostic practice and facilitate research, but its impact on everyday clinical work and psychiatric training remains to be evaluated. For Western researchers, it is one avenue for achieving an understanding of the Chinese social world, and should usefully be contrasted with the ICD-10 and DSM-IV as the move towards an international nosology continues.