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In this issue (October 2015).

In recognition of the rapidly increasing economic and social importance of dementia as a global health problem [1,2] and of its impact on public health in China's rapidly aging population, the first three manuscripts in this issue focus on cognitive decline in the elderly.

The issue starts with a meta-analysis by Wang and colleagues [3] about the association of cognitive impairment in elderly individuals with the thickness of the peripheral retinal nerve fiber layer (RNFL). Previous studies have had varying results, but assessing RNFL is a simple, non-invasive procedure, so it is potentially a valuable method for screening elderly individuals for pre-clinical dementia. Review of the literature identified 19 cross-sectional studies--6 of which were conducted in mainland China--that compared RNFL in elderly individuals with no cognitive impairment to those with Alzheimer's disease (AD) or mild cognitive impairment (MCI). The results of the studies were quite heterogeneous, but when limiting the analysis to methodologically stronger studies, the results were sufficiently homogeneous to merit pooling studies in a series of meta-analyses. These analyses found that RNFL was thinner in persons with AD than in those with MCI and thinner in persons with MCI than in healthy controls, particularly in the superior and inferior quadrants of the optic nerve. The result suggest progressive thinning of RNFL as cognitive functioning declines and, thus, support the idea that RNFL could be a biomarker for individuals at high risk of developing AD. Further high-quality prospective studies are needed to test this possibility.

The first original research article by Wu and colleagues [4] assesses the usefulness of repetitive transcranial magnetic stimulation (rTMS) as an adjunctive treatment with low-dose antipsychotic medication for the management of the distressing behavioral symptoms that often accompany Alzheimer's disease. This is a randomized, double-blind trial in which 27 intervention group patients received 20Hz rTMS five days a week for four weeks and 27 control group patients received the same number of sessions with sham rTMS. At the end of the trial both groups showed improvement in cognition and in behavioral symptoms (assessed using the Behavioral Pathology in Alzheimer's Disease Rating Scale, BEHAVE-AD [5]), but the improvement was significantly greater among patients who received adjunctive rTMS. This result suggests that rTMS can become an important part of the therapeutic toolkit for dementia, particularly for patients who cannot tolerate antipsychotic medications. Further work is needed to assess the long-term usefulness of rTMS in dementia and to determine the most suitable frequency, intensity, and location for administering rTMS in individuals with dementia.

The second research article by He and colleagues [6] assessed the effectiveness of a Traditional Chinese Medicine (TCM) intervention on delaying cognitive decline in elderly individuals with mild cognitive impairment and radiological evidence of cerebral white matter lesions. Eighty individuals 65 or older were classified into one of the four main TCM 'constitutions' (qi deficiency, yang deficiency, phlegm dampness, or blood stasis) and then randomly assigned to a treatment-as-usual group or an intervention group. The TCM intervention involved training focused on encouraging changes in diet, lifestyle, and emotional regulation; physical exercises; and six monthly courses of moxibustion (heating acupoints by burning the moxa of dried mugwort on the skin above the points). Based on changes in the Chinese version of the Montreal Cognitive Assessment (MoCA) scale, [7] the intervention group showed significantly greater improvement in cognitive function than the control group over the 6 months of the trial. However, the outcome was not assessed by blinded evaluators and the evidence for the differential effect of the TCM treatment on the four TCM constitutional types was ambiguous, so further research in this area is needed before this TCM intervention can be recommended as a standard treatment for mild cognitive impairment.

The third original research study by Byrne and colleagues [8] is also focused on cognitive deficits, but in this case it is about a subtype of cognitive deficit in chronic schizophrenia that is important but rarely systematically assessed: 'social cognition'. This is a relatively new construct that includes decoding social and emotive information, affect perception and regulation, and causal attribution. [9,10] The extent to which these functions are associated with the more commonly assessed cognitive domains (learning, memory, etc.), with the positive and negative symptoms of schizophrenia, and with overall social functioning remains unclear. The authors report the results of a controlled trial of a 6-week computer-based cognitive remediation program for individuals with chronic schizophrenia. The 20 patients in the control group received treatment-as-usual while the 20 patients in the intervention group received the usual treatment and also completed at least 12 computer-based training sessions over 6 weeks. Each session included a 30-minute computerized drill training (CDT) program involving repetitive exercises in five basic cognitive skills (arithmetic, number lists, pair matching, special working memory, and word lists) and a 10-minute module on facial affect recognition (FAR) that trained respondents to identify 6 different facial emotions using 72 photographs of 36 different Asian individuals. At the end of the 6-week trial there were no significant differences between groups in clinical symptoms or in most cognitive measures, but there was a significantly greater improvement in the intervention group compared to the control group in social functioning (assessed using the Personal and Social Performance scale, [PSP] [11]) and a trend (p=0.09) for greater improvement in the intervention group for facial recognition. Further work is needed in this area both to elaborate the theoretical model of 'social cognition' and to assess the effect of different types of interventions on deficits in social cognition experienced by individuals with severe mental illnesses.

The Forum by Amerio and colleagues [12] is a follow-up to the Forum pieces in the previous issue [13,14] about comorbid bipolar disorder (BD) and obsessive compulsive disorder (OCD). The core question is whether BD-OCD patients have a severe form of BD or concurrently suffer from two clinically and etiologically separate conditions. To address this issue the authors use data from their recently published systematic review [15] to specifically focus on the heritability of BD and OCD in persons with comorbid BD and OCD. Five of the 7 studies they identified that provide data on this question reported that a family history of BD was more common in BD-OCD patients than in non-BDOCD patients and that a family history of OCD was less common. This supports the hypothesis that most BD-OCD patients have a subtype of BD, not two separate co-occurring conditions. Thus treatment for such patients should focus on mood stabilization; clinicians should only consider selective serotonin reuptake inhibitors (SSRIs) if initial strategies prove ineffective.

This issue includes two case reports. The first, by Saha and colleagues, [16] reports on a tragic case from rural India in which a mother of four with a 6-year history of psychosis that never received treatment murdered her 3-month-old infant while under the influence of command hallucinations. This is a somber reminder that basic mental health care is not available in poor rural communities of many low- and middle-income countries. The World Health Organization has developed the Mental Health Gap program [17] for providing basic care in such communities and has promoted the program for over a decade, but local implementation of this program requires political commitment, modest resources, and community-based advocates who champion the cause of the mentally ill.

The second case report by Wang and Wang [18] discusses a cardiac arrest and death in a patient with bipolar disorder one hour after receiving modified electroconvulsive therapy (MECT). The patient was a 58-year-old male with no history of cardiac problems being treated for a recurrent episode of non-psychotic mania. MECT had been effective in the treatment of a manic episode he experienced 6 years previously. In this instance the first session of MECT did not result in a convulsion, but he recovered from the anesthesia and was transferred to the recovery room. However, his condition subsequently deteriorated rapidly; his blood pressure and pulse dropped precipitously over 20 minutes and attempts to resuscitate him failed. The family did not permit an autopsy, but the authors surmise that the use of haloperidol 17 hours prior to the MECT session exacerbated the cardiac effects of the non-convulsive MECT, resulting in death. The take-home message from this case is that taking a detailed cardiac history and, in older patients, conducting a basic cardiac work-up (including cardiac enzymes) should always precede the use of MECT, even in patients who have used it previously.

The Biostatistics in Psychiatry article in this issue by Wang and colleagues [19] discusses the dangers of using common methods for imputing values when they are below (or above) the detection limit of the instrument used to assess the variable in a study. Imputation of undetectable results (i.e., those that are below or above the instrument's threshold) is typically necessary when using physical devices to assess outcomes (e.g., alcohol blood levels), but it can also occur in psychosocial research when an individual falls above or below a certain range of scores on a questionnaire. The authors show that simple methods of imputation (such as replacing unknown results below the detection limit with the mean of the range of values between 0 and the lower detection limit) can dramatically change the reported outcome of a study when the imputed value is treated as if it were real in statistical analyses. Statistical tests based on datasets that use standard methods to impute unknown results are often uninterpretable. This problem is most pronounced when trying to use the estimated geometric mean of a sample to represent the geometric mean of the value in the population from which the sample was selected.


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[2.] Dong YH, Mao XQ, Liu L, He W, Liu Y. [Prevalence of dementia among Chinese people aged 60 years and over: a meta-analysis]. Zhongguo Gong Gong Wei Sheng. 2014; 30(4): 512-514. Chinese.

[3.] Wang MJ, Zhu YB, Shi ZY, Li CB, Shen Y. Meta-analysis of the relationship of peripheral retinal nerve fiber layer thickness to Alzheimer's disease and mild cognitive impairment. Shanghai Arch Psychiatry. 2015; 27(5): 263-279. doi: http://

[4.] Wu Y, Xu WW, Liu XW, Xu Q, Tang L, Wu SY. Adjunctive treatment with high frequency repetitive transcranial magnetic stimulation for the behavioral and psychological symptoms of patients with Alzheimer's disease: a randomized, double-blind, sham-controlled study. Shanghai Arch Psychiatry. 2015; 27(5): 280-288. doi: http://dx.doi. org/10.11919/j.issn.1002-0829.215107

[5.] Reisberg B, Auer SR, Monteiro IM. Behavioral pathology in Alzheimer's disease (BEHAVE-AD) rating scale. Int Psychogeriatr. 1996; 8(suppl 3): 301-308; discussion 351-354. doi:

[6.] He SM, Li LJ, Hu JY, Chen QL, Shu WQ. Effectiveness of Traditional Chinese Medicine (TCM) treatments on the cognitive functioning of elderly persons with mild cognitive impairment associated with white matter lesions. Shanghai Arch Psychiatry. 2015; 27(5): 289-295. doi: http://dx.doi. org/10.11919/j.issn.1002-0829.215109

[7.] Chen H, Yu H, Kong LL, Yi L, Wang JD, Zhou TT, et al. [Reliability and validity of Beijing version of Montreal Cognitive Assessment in the elderly people residing in Qingdao]. Guo Ji Lao Nian Yi Xue Za Zhi. 2015; 36(5): 202-205. Chinese. doi: j.issn.1674-7593.2015.05.004

[8.] Byrne LK, Pan LY, McCabe M, Mellor D, Xu YF. Assessment of a six-week computer-based remediation program for social cognition in chronic schizophrenia. Shanghai Arch Psychiatry. 2015; 27(5): 296-306. doi: j.issn.1002-0829.215095

[9.] Eack SM. Cognitive Remediation: A new generation of psychosocial interventions for people with schizophrenia. Soc Work. 2012; 57(3): 235-246

[10.] Ziv I, Leiser D, Levine J. Social cognition in schizophrenia: Cognitive and affective factors. Cogn Neuropsychiatry. 2011; 16(1): 71-91. doi: .492693

[11.] Si TM, Shu L, Su YA, Tian CH, Yan Y, Cheng J, et al. The Chinese version of the Personal and Social Performance scale (PSP): validity and reliability. Psychiatry Res. 2010; 185: 275-279. doi:

[12.] Amerio A, Tonna M, Odone A, Stubbs B, Ghaemi SN. Heredity in comorbid bipolar disorder and obsessive-compulsive disorder patients. Shanghai Arch Psychiatry. 2015; 27(5): 307-310. doi: j.issn.1002-0829.215123

[13.] Peng DH, Jiang KD. Comorbid bipolar disorder and obsessive-compulsive disorder. Shanghai Arch Psychiatry. 2015; 27(4): 246-248. doi: j.issn.1002-0829.215009

[14.] Shi SX. Obsessive compulsive symptoms in bipolar disorder patients: a comorbid disorder or a subtype of bipolar disorder? Shanghai Arch Psychiatry. 2015; 27(4): 249-251. doi:

[15.] Amerio A, Stubbs B, Odone A, Tonna M, Marchesi C, Ghaemi SN. The prevalence and predictors of comorbid bipolar disorder and obsessive-compulsive disorder: A systematic review and meta-analysis. J Affect Disord. 2015; 186: 99-109. doi:

[16.] Saha R, Singh SM, Nischal A. Infanticide by a mother with untreated schizophrenia. Shanghai Arch Psychiatry. 2015; 27(5): 311-314. doi: j.issn.1002-0829.215058

[17.] World Health Organization. mhGAP Intervention Guide for Mental, Neurological and Substance Use Disorders in Non-specialized Health Settings. Geneva: World Health Organization; 2010

[18.] Wang ZH, Wang JY. Sudden cardiac death after modified electroconvulsive therapy. Shanghai Arch Psychiatry. 2015; 27(5): 315-318. doi: j.issn.1002-0829.214169

[19.] Wang HY, Chen GQ, Lu X, Zhang H, Feng CY. The effect of simple imputation on inferences about population geometric means when data are missing in biomedical research due to dection limits. Shanghai Arch Psychiatry. 2015; 27(5): 319-325. doi: j.issn.1002-0829.215121

[Shanghai Arch Psychiatry. 2015; 27(5): 260-262. doi:
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Publication:Shanghai Archives of Psychiatry
Date:Oct 1, 2015
Previous Article:Introduction to longitudinal data analysis in psychiatric research.
Next Article:Meta-analysis of the relationship of peripheral retinal nerve fiber layer thickness to Alzheimer's disease and mild cognitive impairment.

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