· In This Issue ·

· In This Issue ·

The last issue of 2011 starts with a seminar on the diagnosis and management of amphetamine-induced psychoses[1]. Rapid economic change and opening to the West has had many benefits for China, but it has also been associated with several less positive changes.One such problem is the increasing prevalence of drug abuse, a problem that was rarely seen in China 20 years ago. Amphetamine-type stimulants are now a relatively common type of substance abuse in China—particularly among young adults in urban areas.It is still extremely uncommon to see patients with co-morbid schizophrenia and substance abuse, but Chinese psychiatrists will be encountering increasing numbers of cases of amphetamine-induced psychoses as the prevalence of the abuse of amphetaminetype compounds rises. Research with such patients can help to identify the distinct genetic, psychological and social characteristics of persons with substance abuse in China. This information can be used to revise international theories about substance abuse, to test clinical interventions for treating substance-induced psychoses in China, and to develop psychosocial interventions for reducing recidivism of individuals who abuse drugs that are likely to be effective in the dynamic social-cultural environment of modern China.

The first research article in this issue[2]reports on the distribution of costs of psychiatric hospitalization in 2010 in a large, representative sample of discharges from the 42 psychiatric hospitals in Zhejiang Province,a relatively well-to-do province on China’s eastern seaboard with a population of about 54 million.They report that 24% of the 7,684 admissions assessed had medical conditions that required treatment during admission and, surprisingly, that the median cost of non-psychiatric medication (for all admissions) during the admission was more than the median cost of psychiatric medications. Further research is needed to determine what proportion of these conditions and costs are due to chronic physical illness (e.g.,hypertension, diabetes, etc.) that have not received appropriate care and what proportion are acute conditions that have arisen as adverse reactions to treatment with psychiatric drugs (e.g., leucopenia,hypokalemia, etc.). These findings have important implications for the planning of mental health services,the development of reimbursement schemes, and the training of mental health professionals. The takehome message for psychiatrists is that they need to ensure that regular in-service training keeps them upto-date on the current thinking about the diagnosis and treatment of common medical conditions that affect their patients at higher rates than are seen in the community at large.

The second research article[3]reports on a study about immediate-release and extended-release formulations of venlafaxine in 60 women with depression. The clinical efficacy of the two formulations is assessed and compared to changes in the plasma levels of venlafaxine and it active metabolite(O-desmethylvenlafaxine). The authors found both formulations to be equally effective in the treatment of depression. Moreover, the two formulations had similartimes to remission. But there was no clear relationship between changes in the severity of depressive symptoms (as assessed by HAMD) and changes in the serum levels of either venlafaxine or its active metabolite. Thus serum levels of venlafaxine and its active metabolite are not suitable markers for assessing the effectiveness of treatment with venlafaxine.The search for biomarkers of the clinical efficacy of antidepressant medication has had many more failures than successes; new models of the mechanism of action of these compounds that incorporate psychosocial as well as genetic variables may be needed before there can be significant advances in this field.

The third research article[4]is about a study that used self-report scales and clinician-administered instruments to assess psychological symptoms in 60 individuals with chronic hepatitis B (CHB) and 60 individuals with hepatitis B cirrhosis (HBC) at the time of admission for an acute exacerbation of the hepatic disease and then followed their psychological symptoms over an eight-week course of treatment.At admission 40% of CHB patients and 80% of HBC patients had clinically significant anxiety and 78% of CHB patients and 87% of HBC patients had clinical significant depression. By the time of the eightweek follow-up the psychological symptoms in both groups had improved significantly but they were still significantly more severe than in a normal control group: 5% of CHB patients and 28% of HBC still had clinically significant anxiety and 7% of CHB patients and 36% of HBC patients still had clinical significant depression. These findings highlight a difficult issue in the management of the psychological symptoms of patients who have chronic physical illnesses that are subject to acute exacerbations. Psychological symptoms at the time of acute exacerbations of physical illness—when they come to clinical attention—often resolve as the acute physical symptoms remit so basing decisions on which patients need adjunctive psychological or psychopharmacological treatments on the status at thetime of acute physical symptoms may be inappropriate.If the psychological symptoms are not severe or lifethreatening clinicians should probably wait until the physical symptoms have returned to their residual state before deciding which patients to treat for psychological symptoms.

The fourth research article[5]reports on a survey of mental health literacy in a stratified random sample of 1,563 adult residents of Changsha, Hunan.Increasing awareness of mental illnesses, decreasing stigmatization, and increasing care-seeking among individuals with psychological problems are key targets in China’s efforts to improve the mental health of the nation. To achieve this target there need to be effective ways to assess the mental health literacy of community members. These standardized assessments of mental health literacy would provide information about what should be included in the mental health promotion campaigns and, when repeatedly assessed, could be used to evaluate the effectiveness of such campaigns.The reported survey from Changsha used a 20-item,self-report questionnaire that had been recommended by the Chinese Ministry of Health. As expected, the level of mental health literacy was negatively related to age and positively correlated with level of education.Respondents were least well informed about the causes of mental disorders, so the authors recommended that this become a focus of mental health promotion campaigns. However, the internal consistency of the instrument was relatively weak (alpha=0.57) so further development work with the instrument will probably be needed before it can be used on a national basis.One of the key problems in assessing mental health literacy is that the concept of what constitutes a ‘mental illness’ varies widely across different groups in the community so respondents asked about their attitude or knowledge of ‘mental illness’ could be referring to different constructs when they respond; some may limit the construct to psychotic individuals, some may include depressed and anxious individuals, and others may include individuals with personality disorders and substance abuse. Instruments aimed at assessing mental health literacy need to ensure that respondents are considering a similar construct.

The Forum in this issue[6,7]focuses on whether or not antipsychotic medications should be used in elderly demented patients. China’s one-child per family policy and improved longevity has resulted in an extremely rapid increase in the proportion of elderly in the population. At the same time the increased mobilization and urbanization of the population has resulted in a breakdown of the large extended family units that traditionally supported the disabled elderly.In parallel with these trends, over the last two decades the numbers of elderly demented individuals in psychiatric institutions has gradually increased; these numbers are expected to increase much more rapidly in the coming decades. Almost all patients with dementia manifest behavioral and psychological symptoms at some point in the course of their illness and for many patients and their care-givers these are the most distressing symptoms of the illness. In the past the clinical response to these problems was to suppress the symptoms with antipsychotic medications but more recent studies have found that the administration of antipsychotic medication in the elder can have serious consequences, including increased overall mortality.The large CATIE-AD study in the United States[8]found that these adverse effects negated any possible positive effects of using antipsychotic medication in the elderly.Despite these concerns, the authors of the two forum pieces support the positions taken by most treatment guidelines that recommend the judicious use of atypical antipsychotic medications if the symptoms are severe or endanger the safety of the patient or others. We expect that heated debate about this issue will continue.

1. Zhao M, Hao W. Diagnosis and clinical management of amphetamine-induced psychosis. Shanghai Arch Psychiatry,2011, 23 (6):324-328.

2. Yang SL, Qian MC, Lu W, Wang CS, Chen HZ, Fei JF, et al. Cost of treating medical conditions in psychiatric inpatients in Zhejiang,China. Shanghai Arch Psychiatry, 2011, 23(6):329-337.

3. Song BH, Fan ZG, Shen WM, Qian MC, Chen HZ, Dai H, Wang SK.Relationship between blood levels and clinical efficacy of two different formulations of venlafaxine in female patients with depression. Shanghai Arch Psychiatry, 2011, 23(6):338-344.

4. Liu QY, Lu Z, Sun L, Ye J. Eight-week follow-up of depressive and anxiety symptoms in patients with chronic hepatitis B, patients with hepatitis B cirrhosis, and normal control subjects. Shanghai Arch Psychiatry, 2011, 23 (6):345-352.

5. Peng Y, Wang XL, Li PF, Liu K. Mental health literacy in Changsha,China. Shanghai Arch Psychiatry, 2011, 23 (6):353-359.

6. Xiao SF. Treating the behavioral and psychological symptoms of senile dementia with antipsychotic drugs. Shanghai Arch Psychiatry, 2011, 23 (6):376-378.

7. Chiu HFK, Li SW. Management of Behavioral and Psychological Symptoms of Dementia (BPSD)—no easy solution. Shanghai Arch Psychiatry, 2011, 23 (6):378-379.

8. Schneider LS, Tariot PN, Dagerman KS, Davis SM, Hsiao JK, Ismail MS, et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med, 2006, 355:1525-1538.

·本期导读·

本期为2011年的最后一期。首先是关于苯丙胺类兴奋剂所致精神障碍的诊断与治疗的专家论坛［1］。经济的快速发展和向西方开放使中国获益匪浅，但也带来了一些消极的影响，药物滥用增加就是其中的一个问题，而它在20年前的中国却很罕见。目前在中国相对常见的物质滥用是苯丙胺类兴奋剂滥用，尤其是在城市的年轻人中。随着苯丙胺类物质滥用患病率的增加，中国的精神科医生将会面对越来越多苯丙胺所致精神障碍的患者。对中国这类患者进行研究将有助于识别其不同的遗传、心理和社会特征。这些信息可被用于国际上修正物质滥用的理论，检验国内对物质所致精神障碍的临床治疗性干预，发展出减少物质滥用者累犯的心理社会干预措施。

本期第一篇论著［2］报道了2010年浙江省42家精神病院出院患者构成的有代表性的大样本人群的住院费用分布情况，中国东海岸的浙江省有5 400万人口，是相对富裕的省份。作者报道7 684例住院患者中，24%在住院期间有需要治疗的躯体问题，令人吃惊的是住院期间患者非精神病性医疗（所有入院）的平均费用高于精神病性医疗的平均费用。将来的研究需要确定在上述医疗问题和费用中，未得到恰当治疗的慢性躯体疾病（如高血压、糖尿病等）所占的比例及精神科药物急性不良反应（如白细胞减少症、低钾血症等）所占的比例。研究结果对精神卫生服务的规划、补偿方案的制定、精神卫生专业人员的培训具有重要意义。该研究对精神科医生的教益是，要确保他们在常规的在职培训中更新对那些比在社区更为常见的躯体疾病的诊断和治疗的新观点。

第二篇论著［3］报道了在60例女性抑郁症患者中进行的一项有关文拉法辛速释剂与缓释剂的研究。研究者评定了两种剂型的临床疗效，比较了文拉法辛及其活性代谢产物（氧去甲基文拉法辛）血药浓度的变化。作者发现文拉法辛的两种剂型对抑郁症都同样有效。而且，两种剂型的起效时间接近。但抑郁症状的严重程度的变化与文拉法辛或其活性代谢产物血药浓度的变化间无明确的关系。文拉法辛及其活性代谢产物的血药浓度不适于用来评定抑郁症的药物治疗疗效。在寻找抗抑郁剂治疗临床疗效的标记物中遭遇的失败远多过成功；可能需要发展出结合心理社会与遗传因素的新作用机制模式，这一领域的研究才有可能取得进展。

第三篇论著［4］报道了在60例慢性乙肝（chronic hepatitis B，CHB）患者与 60 例乙肝后肝硬化（hepatitis B cirrhosis，HBC）患者中进行的心理状况研究，这些患者因病情加重而入院，采用自评量表和临床医生评定的量表，在入院时和治疗8周后分别予以评定。入院时40%的CHB患者和80%的HBC患者有明显的焦虑，78%的CHB患者和87%的HBC患者有明显的抑郁。治疗8周后，两组的焦虑、抑郁明显改善，但与正常对照相比，这些患者的焦虑、抑郁仍很严重：5%的CHB和28%的HBC患者有明显焦虑，7%的CHB患者和36%的HBC患者仍明显抑郁。躯体疾病病情急性恶化时的心理症状常随急性躯体症状的减轻而改善，因此根据患者的急性躯体症状决定辅助进行心理治疗或精神药物治疗，这样做可能是不恰当的。如果心理症状不严重或未危及生命，临床医生应等患者的躯体症状好转后，再决定其心理症状是否需要治疗。

第四篇论著［5］报道了1 563名随机分层选取的湖南长沙市民的精神卫生知识的知晓情况。增加精神疾病知晓率、降低耻感、增加有心理问题者的就医行为是中国致力于提高国民精神健康的核心目标。为达到这一目标，需要对社区居民精神卫生知识知晓情况进行有效的评定。标准的精神卫生知晓情况评定工具应能提供如下信息：精神卫生促进运动应包括的内容以及当重复评定时，哪些内容可用于评定这些活动的效果。该研究采用中国卫生部推荐的含有20个条目的自评问卷在长沙市民中进行了调查。研究对象对精神卫生的知晓情况与年龄负相关，与教育水平正相关。参与研究的调查对象不太知晓精神疾病的病因，因此作者推荐以此作为精神卫生促进运动的焦点。然而，此工具的内部一致性较弱（alpha=0.57），所以人们还需进一步完善此量表，才能在全国应用。在评定精神卫生知晓率时，核心问题之一是有关“精神疾病”的概念随社区人群不同而不同，参与研究的人会考虑到不同结构的精神疾病，可能有的会把它局限为精神病性障碍，有的会想到抑郁、焦虑，有的会想到人格障碍和物质滥用。旨在评定精神知晓情况的工具需要确保调查对象构想出相似的疾病内容。

《论坛》文章［6，7］聚焦于抗精神病药是否应用于老年期痴呆患者。中国的独生子女政策及人均寿命延长导致老龄化人口比例快速增加，与此同时，人口流动与城市化进程使传统上的大家庭解体。与这种趋势平行进展的是过去20年中精神病院老年期痴呆患者逐步增加；在随后的几十年中这样的患者人数还会更快速地增长。几乎所有的痴呆患者都会在某个时期表现出精神行为症状。对许多患者及其照料者来说，它们是最令人痛苦的症状。过去临床医生对这些症状的处理是用抗精神病药来控制症状，但老年人使用抗精神病药会产生严重的后果，包括死亡率增加。美国大型的抗精神病药物临床疗效—阿尔茨海默病研究（CATIE-AD［8］）发现老年人使用抗精神病药，其不良反应抵消了药物可能会有的疗效。除了上述考虑，两篇论坛文章的作者支持大多数治疗指南推荐的方案，即症状严重或危及患者或他人的安全时才谨慎使用非典型抗精神病药。我们期望读者对此问题展开热烈的讨论。

参考文献

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