·In this issue （February 2016）·

·In this issue （February 2016）·

The issue starts with a special article that is an extensively annotated translation of China's 2015-2020 national mental health plan.［1，2］Released in June 2015， this plan outlines the specific steps for implementing the principles enshrined in China's 2012 national mental health law［3］and， thus， serves as the blueprint that provinces throughout China need to adapt for developing and expanding their mental health services. The plan outlines seven specific targets for mental health services over the coming fi ve years （to be achieved by 2020）：

（1） collective management and coordination of mental health work by multiple departments and agencies （including public security， health and family planning，civil affairs， judicial administration，the disabled persons' federation， and the commission on aging） at national，provincial， and prefectural levels；

（2） expansion of specialized psychiatric hospitals or departments of psychiatry within general hospitals at provincial，municipal， and county levels；

（3） a major increase in the number of psychiatrists - reaching 3.8 per 100，000 population in （well-to-do） eastern regions and 2.8 per 100，000 population in （less well-to-do） central and western regions by 2020；

（4） registration， treatment， and support of almost all persons with severe mental illnesses and a substantial reduction in the numbers of civil and criminal ‘incidents or troubles' （i.e.， social disturbances and criminal offenses） caused by such individuals；

（5） improved identification of depression and other common mental illnesses， and establishment of provincial-level crisis hotlines and crisis intervention teams；

（6） provision of psychiatric rehabilitation services in at least 70% of all counties； and

（7） widespread public education about psychological well-being.

The goal of expanding the national registry system for persons with severe mental illnesses［4］and improving the level of services provided to these individuals （goal number 4， above） - a project largely funded by the central government - will be an important target in all jurisdictions， but beyond that there will be major differences in the ways that provinces implement this plan， due to substantial regional differences in economic and social development and in the current availability， comprehensiveness， and quality of mental health services. One important issue raised by the 2012 mental health law - converting the largely involuntary admission system for psychiatric hospitalization to a largely voluntary system - is not addressed in the 2015-2020 plan. Given the Chinese custom of having family members make major health-related decisions for persons with serious illnesses （including hospitalization for both serious physical and mental illnesses）， this change has been one of the more controversial aspects of the new mental health law. There is， as yet， no national consensus about how to make the conversion to a voluntary admission system.

The first original research article by Zhang and colleagues［5］is a randomized， single-blind comparison of combined treatment with standard antidepressants plus 12 weekly sessions of group cognitive behavioral psychotherapy （CBT） （n=32） versus antidepressants alone （n=30） in psychiatric outpatients with mild-tomoderate depression. The authors used a wide range of scales to assess changes in depressive symptoms，quality of life， social support， and functioning at baseline， after the 12-week intervention， and one year after the end of the CBT sessions （during which all participants continued to take antidepressants）.Both groups improved significantly over time， but the antidepressant-plus-CBT group had significantly better outcomes in most of the measures both at the end of the CBT intervention and， somewhat surprisingly， one year after the end of the CBT intervention. If confirmed in larger studies， this long-term benefit of 12 sessions of group-CBT for persons with mild-to-moderate depression being treated with standard antidepressants would be a valuable， cost-effective addition to treatment regimens for depression in low- and middleincome countries where there are few psychotherapists.

The second original article by PAAST and colleagues［6］compared the level of distress and the cognitive functioning of three groups of subjects：20 individuals with obsessive compulsive disorder（OCD） seen at a psychology clinic in Tehran （Iran） who were medication-free at the time of the evaluation；25 individuals with obsessive compulsive personality disorder （OCPD） seen at the clinic； and 25 healthy controls from the community. They use the 28-item General Health Questionnaire （GHQ-28）［7］to assess distress， two measures from the Wisconsin Card Sorting Test （WCST）［8］to assess cognitive flexibility， and three measures from the Tower of London （TOL）［9］test to assess planning ability. As expected， they found that the two patient groups were more distressed than the controls. They also found significant impairments in cognitive flexibility and planning ability in the patient groups， even after adjusting for the severity of distress.Some of the results suggested that the cognitive function of the OCPD patients was less severely affected than that of the OCD patients. Longitudinal studies that monitor fluctuations in cognitive function and obsessive-compulsive symptoms over time are needed to determine whether or not these cognitive changes can serve as diagnostic markers or as indices of illness severity in individuals with OCD or OCPD.

The last original article by Wu and colleagues［10］is a cross-sectional study that combined data from nine voluntary methadone maintenance clinics in three Chinese cities to compare the prevalence， severity，and associated factors of depressive symptoms in 929 heroin users who had been participating in a methadone maintenance treatment program for an average of 9 months to that of 238 heroin users who had enrolled for treatment but had not yet started methadone. Their level of depression was assessed by administering the 13-item Beck Depression Inventory（BDI-13）.［11］The majority of patients in both groups had clinically significant depressive symptoms， but the severity of symptoms was greater in the untreated group than in the treated group， and within the treated group the severity of depressive symptoms decreased as the length of participation in the methadone program increased. However， despite this association of less severe depressive symptoms with methadone treatment， randomized controlled trials will be needed to determine whether or not methadone treatment actually improves depressive symptoms. The authors also found that patients who reported poor family relationships had significantly more severe depressive symptoms， even after adjusting for other factors； this finding highlights the need to include training and support to promote social re-integration as part of methadone maintenance programs.

The two Forum pieces by Zhang［12］and by Wang and Cui［13］discuss the challenges cross-disorder genetic studies are posing for the traditional symptom-based diagnostic system in psychiatry that has been used for more than a century and codified in the WHO's International Classification of Diseases （ICD） and the American Psychiatric Associations' Diagnostic and Statistical Manual of Mental Disorders （DSM）.Both authors agree that genetic studies - several of which report common genetic traits in individuals with diagnostically separate conditions （including schizophrenia， bipolar disorder， depression， attention deficit hyperactivity disorder， and autism spectrum disorder） - suggest a shared pathogenesis of disorders previously thought to be distinct. However， it may be that the genetic commonalities of the disorders that have been identified simply ref l ect some common final（or initial） pathways of conditions that are otherwise genetically quite distinct. The available genetic evidence is too weak and fragmentary to justify abandoning our current symptom-based diagnostic system， especially since there is， as yet， no genetically based diagnostic system that could replace it.

The first case report by Zhang and colleagues［14］describes a 19-year-old boy who was admitted to a psychiatric hospital following a suicide attempt and given an initial diagnosis of depression because of his reports of low self-esteem， social withdrawal， and poor sleep. However， it subsequently became clear that the suicide attempt was secondary to his delusionalintensity beliefs about facial disfigurement that had persisted for more than two years. After re-diagnosis as body dysmorphic disorder， eight weeks of inpatient treatment with fluoxetine and cognitive behavioral therapy resulted in the complete remission of his symptoms and a return to full social functioning. The important lesson from this case is that suicidal behavior can be associated with all types of mental disorders；the presence of some depressive symptoms in a person who has attempted suicide does not necessarily mean that depression is the primary cause of the self-harm behavior.

The second case report by Bhatia and Gautam［15］describes a 10-year-old girl from Delhi with a two-week history of debilitating anxiety symptoms which started after a distant earthquake in Afghanistan （that only resulted in minor tremors in Delhi） received extensive coverage in the local press. She became convinced that Delhi would soon experience a destructive earthquake，refused to leave her home， and became intensely fearful of any moving objects. Two weeks of treatment with a benzodiazepine produced no noticeable improvement，but after the addition of a selective serotonin reuptake inhibitor her symptoms resolved over two weeks and she was able to return to her usual activities. Given the severity of the symptoms， the episode merited a psychiatric diagnosis， but it did not fulfill the criteria of Post Traumatic Stress Disorder or Generalized Anxiety Disorder， so the only suitable DSM-5［16］diagnosis was‘Other Specified Anxiety Disorder'， a non-specific label for episodes of clinically significant anxiety associated with social dysfunction that do not meet the criteria for any other disorder.

The Biostatistics in Psychiatry contribution in this issue by Feng and colleagues［17］discusses some largely unknown limitations of the three main measures of risk used in clinical and epidemiological research： odds ratio，relative risk， and risk difference. Many unsuspecting researchers and clinicians make the assumption that higher or lower values in one of these measures are associated with higher or lower values in the other two measures. This paper demonstrates that this is incorrect. Surprisingly， there is no logical relationship between these measures. This misinterpretation of the relationship of the three measures can lead to incorrect conclusions when comparing the results of different studies or when conducting a meta-analysis that pools results of studies that use different measures of risk.

1. Xiong W， Phillips MR （trans）. Translated and annotated version of the 2015-2020 National Mental Health Work Plan of the People's Republic of China. Shanghai Arch Psychiatry.2016； 28（1）： 4-17. doi： http：//dx.doi.org/10.11919/j.issn.1002-0829.216012

2. Office of the State Council of China. ［National Mental Health Plan （2015-2020）］. Accessed February 10， 2016. Available at： http：//www.gov.cn/zhengce/content/2015-06/18/content_9860.htm. Chinese

3. Chen HH， Phillips MR， Cheng H， Chen QQ， Chen XD，Fralick D， Zhang YE， Liu M， Huang J， Bueber M. Mental health law of the People's Republic of China （English translation with annotations）. Shanghai Arch Psychiatry 2012； 24（6）： 305-321. doi： http：//dx.doi.org/ 10.3969/j.issn.1002-0829.2012.06.001

4. Ma H. Intergration of hospital and community services -the‘686 Project‘ - is a cruicial component in the reform of China's mental health serices. Shanghai Arch Psychiatry.2012； 24（3）： 172-174. doi： http：//dx.doi.org/10.3969/j.issn.1002-0829.2012.03.007

5. Zhang BY， Ding XF， Lu WH， Zhao J， Lv QY， Yi ZH et al. Effect of group cognitive-behavioral therapy on the quality of life and social functioning of patients with mild depression.Shanghai Arch Psychiatry. 2016； 28（1）： 18-27. doi： http：//dx.doi.org/10.11919/j.issn.1002-0829.215116

6. Paast N， Khosravi Z， Memari AH， Shayestehfar M， Arbabi M. Comparison of cognitive flexibility and planning ability in patients with obsessive compulsive disorder， patients with obsessive compulsive personality disorder， and healthy controls. Shanghai Arch Psychiatry. 2016； 28（1）： 28-34. doi：http：//dx.doi.org/10.11919/j.issn.1002-0829.215124

7. Goldberg DP， Hillier VF. A scaled version of the General Health Questionnaire. Psychol Med. 1979； 9（1）： 139-145.doi： http：//dx.doi.org/10.1017/S0033291700021644

8. Heaton SK， Chelune GJ， Talley JL， Kay GG， Curtiss G.Wisconsin Cart Sorting Test Manual： Revised and Expanded.Odessa， FL： Psychological Assessment Resources； 1993

9. Culbertson W， Zillmer E. Tower of London-Drexel University.Technical manual， 2nded. Toronto： Multi-Health Systems；2005

10. Wu YF， Yan SY， Bao YP， Lian Z， Qu Z， Liu ZM. Cross-sectional study of the severity of self-reported depressive symptoms in heroin users who participate in a methadone maintenance treatment. Shanghai Arch Psychiatry. 2016； 28（1）： 35-41.doi： http：//dx.doi.org/10.11919/j.issn.1002-0829.215127

11. Zhang MY. ［Handbook of Psychiatric Rating Scale］. Hunan：Hunan Science and Technology Press； 1998. p. 283， 631， 721.Chinese

12. Zhang C. Genetic findings are challenging the symptombased diagnostic classification system of mental disorders.Shanghai Arch Psychiatry. 2016； 28（1）： 42-44. doi： http：//dx.doi.org/10.11919/j.issn.1002-0829.216015

13. Wang MT， Cui DH. Influence of cross-disorder analyses on the diagnostic criteria of mental illness. Shanghai Arch Psychiatry. 2016； 28（1）： 45-47. doi： http：//dx.doi.org/10.11919/j.issn.1002-0829.216032

14. Zhang YF， Ma HX， Wang YB. Case report of body dysmorphic disorder in a suicidal patient. Shanghai Arch Psychiatry.2016； 28（1）： 48-51. doi： http：//dx.doi.org/10.11919/j.issn.1002-0829.215112

15. Bhatia MS， Gautam P. Case report of a child's anxiety disorder precipitated by tremors from a distant earthquake that was extensively covered in local news stories.Shanghai Arch Psychiatry. 2016； 28（1）： 52-55. doi： http：//dx.doi.org/10.11919/j.issn.1002-0829.215077

16. American Psychiatric Association. Diagnostic and statistical manual of mental disorders： DSM-5. Washington， DC：American Psychiatric Association； 2013

17. Feng CY， Wang HY， Wang BK， Lu X， Sun H， Tu XM.Relationships among three popular measures of differential risks： relative risk， risk difference， and odds ratio. Shanghai Arch Psychiatry. 2016； 28（1）： 56-60. doi： http：//dx.doi.org/10.11919/j.issn.1002-0829.216031

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