· 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.

·本期導讀·

本期為2011年的最后一期。首先是關(guān)于苯丙胺類興奮劑所致精神障礙的診斷與治療的專家論壇［1］。經(jīng)濟的快速發(fā)展和向西方開放使中國獲益匪淺，但也帶來了一些消極的影響，藥物濫用增加就是其中的一個問題，而它在20年前的中國卻很罕見。目前在中國相對常見的物質(zhì)濫用是苯丙胺類興奮劑濫用，尤其是在城市的年輕人中。隨著苯丙胺類物質(zhì)濫用患病率的增加，中國的精神科醫(yī)生將會面對越來越多苯丙胺所致精神障礙的患者。對中國這類患者進行研究將有助于識別其不同的遺傳、心理和社會特征。這些信息可被用于國際上修正物質(zhì)濫用的理論，檢驗國內(nèi)對物質(zhì)所致精神障礙的臨床治療性干預(yù)，發(fā)展出減少物質(zhì)濫用者累犯的心理社會干預(yù)措施。

本期第一篇論著［2］報道了2010年浙江省42家精神病院出院患者構(gòu)成的有代表性的大樣本人群的住院費用分布情況，中國東海岸的浙江省有5 400萬人口，是相對富裕的省份。作者報道7 684例住院患者中，24%在住院期間有需要治療的軀體問題，令人吃驚的是住院期間患者非精神病性醫(yī)療（所有入院）的平均費用高于精神病性醫(yī)療的平均費用。將來的研究需要確定在上述醫(yī)療問題和費用中，未得到恰當治療的慢性軀體疾病（如高血壓、糖尿病等）所占的比例及精神科藥物急性不良反應(yīng)（如白細胞減少癥、低鉀血癥等）所占的比例。研究結(jié)果對精神衛(wèi)生服務(wù)的規(guī)劃、補償方案的制定、精神衛(wèi)生專業(yè)人員的培訓具有重要意義。該研究對精神科醫(yī)生的教益是，要確保他們在常規(guī)的在職培訓中更新對那些比在社區(qū)更為常見的軀體疾病的診斷和治療的新觀點。

第二篇論著［3］報道了在60例女性抑郁癥患者中進行的一項有關(guān)文拉法辛速釋劑與緩釋劑的研究。研究者評定了兩種劑型的臨床療效，比較了文拉法辛及其活性代謝產(chǎn)物（氧去甲基文拉法辛）血藥濃度的變化。作者發(fā)現(xiàn)文拉法辛的兩種劑型對抑郁癥都同樣有效。而且，兩種劑型的起效時間接近。但抑郁癥狀的嚴重程度的變化與文拉法辛或其活性代謝產(chǎn)物血藥濃度的變化間無明確的關(guān)系。文拉法辛及其活性代謝產(chǎn)物的血藥濃度不適于用來評定抑郁癥的藥物治療療效。在尋找抗抑郁劑治療臨床療效的標記物中遭遇的失敗遠多過成功；可能需要發(fā)展出結(jié)合心理社會與遺傳因素的新作用機制模式，這一領(lǐng)域的研究才有可能取得進展。

第三篇論著［4］報道了在60例慢性乙肝（chronic hepatitis B，CHB）患者與 60 例乙肝后肝硬化（hepatitis B cirrhosis，HBC）患者中進行的心理狀況研究，這些患者因病情加重而入院，采用自評量表和臨床醫(yī)生評定的量表，在入院時和治療8周后分別予以評定。入院時40%的CHB患者和80%的HBC患者有明顯的焦慮，78%的CHB患者和87%的HBC患者有明顯的抑郁。治療8周后，兩組的焦慮、抑郁明顯改善，但與正常對照相比，這些患者的焦慮、抑郁仍很嚴重：5%的CHB和28%的HBC患者有明顯焦慮，7%的CHB患者和36%的HBC患者仍明顯抑郁。軀體疾病病情急性惡化時的心理癥狀常隨急性軀體癥狀的減輕而改善，因此根據(jù)患者的急性軀體癥狀決定輔助進行心理治療或精神藥物治療，這樣做可能是不恰當?shù)?。如果心理癥狀不嚴重或未危及生命，臨床醫(yī)生應(yīng)等患者的軀體癥狀好轉(zhuǎn)后，再決定其心理癥狀是否需要治療。

第四篇論著［5］報道了1 563名隨機分層選取的湖南長沙市民的精神衛(wèi)生知識的知曉情況。增加精神疾病知曉率、降低恥感、增加有心理問題者的就醫(yī)行為是中國致力于提高國民精神健康的核心目標。為達到這一目標，需要對社區(qū)居民精神衛(wèi)生知識知曉情況進行有效的評定。標準的精神衛(wèi)生知曉情況評定工具應(yīng)能提供如下信息：精神衛(wèi)生促進運動應(yīng)包括的內(nèi)容以及當重復評定時，哪些內(nèi)容可用于評定這些活動的效果。該研究采用中國衛(wèi)生部推薦的含有20個條目的自評問卷在長沙市民中進行了調(diào)查。研究對象對精神衛(wèi)生的知曉情況與年齡負相關(guān)，與教育水平正相關(guān)。參與研究的調(diào)查對象不太知曉精神疾病的病因，因此作者推薦以此作為精神衛(wèi)生促進運動的焦點。然而，此工具的內(nèi)部一致性較弱（alpha=0.57），所以人們還需進一步完善此量表，才能在全國應(yīng)用。在評定精神衛(wèi)生知曉率時，核心問題之一是有關(guān)“精神疾病”的概念隨社區(qū)人群不同而不同，參與研究的人會考慮到不同結(jié)構(gòu)的精神疾病，可能有的會把它局限為精神病性障礙，有的會想到抑郁、焦慮，有的會想到人格障礙和物質(zhì)濫用。旨在評定精神知曉情況的工具需要確保調(diào)查對象構(gòu)想出相似的疾病內(nèi)容。

《論壇》文章［6，7］聚焦于抗精神病藥是否應(yīng)用于老年期癡呆患者。中國的獨生子女政策及人均壽命延長導致老齡化人口比例快速增加，與此同時，人口流動與城市化進程使傳統(tǒng)上的大家庭解體。與這種趨勢平行進展的是過去20年中精神病院老年期癡呆患者逐步增加；在隨后的幾十年中這樣的患者人數(shù)還會更快速地增長。幾乎所有的癡呆患者都會在某個時期表現(xiàn)出精神行為癥狀。對許多患者及其照料者來說，它們是最令人痛苦的癥狀。過去臨床醫(yī)生對這些癥狀的處理是用抗精神病藥來控制癥狀，但老年人使用抗精神病藥會產(chǎn)生嚴重的后果，包括死亡率增加。美國大型的抗精神病藥物臨床療效—阿爾茨海默病研究（CATIE-AD［8］）發(fā)現(xiàn)老年人使用抗精神病藥，其不良反應(yīng)抵消了藥物可能會有的療效。除了上述考慮，兩篇論壇文章的作者支持大多數(shù)治療指南推薦的方案，即癥狀嚴重或危及患者或他人的安全時才謹慎使用非典型抗精神病藥。我們期望讀者對此問題展開熱烈的討論。

參考文獻

（此處略，與英文版中的相同）