OL4 - Open Lecture 4
Chairs: Bruce Singh, Australia
Wen-Shing Tseng, United States

OL4-1

从心理学与神 经生物学关联的角度理解自杀 - Understanding Suicide: Linking Psychology and Neurobiology

Konrad Michel 1
1 University Psychiatric Services Bern , Outpatient Psychiatric Department, Bern , Switzerland

自 杀是个体生活过程中对生命取向的一种选择 ， 这是心理学界的普遍共识。当 与自我相 关的重要因素受到威胁时，自杀的可选性变得突出显著。当重要的生活或工作目标经历严重失败打击时（比如事业失败、人际关系失败、丧失尊严），自杀成为可选的一个方向。此时自杀成为摆脱 “ 糟糕命运 ” 的一 种方法。个体不愿经受的痛苦（如自责、无助、无法忍受的消极情感或心灵煎熬）触发了自我伤害。自我的完整性和连续性被破坏，脆弱的自我不再能维持正常的情绪调整功能。

这些心理过程与大脑功能紧密相关，并依赖于大脑功能。首先我们探讨神经生物学的自我概念的形成。自我完整性的感觉建立在自身成长过程的记忆基础上，这需要前额叶皮质（ PFC ）功能。在 应激状态下， PFC 功能 严重受损，导致事件记忆受损，不能凭借过去经历去规划未来（ “ 对将来缺乏远见 ” ）。 结果，通过皮质活性反映的情感调节功能严重受损，常导致分离状态的出现。

第二点将 讨论神经递质系统功能。尸检研究和 PET 研究提示，自 杀行为 和五 羟色胺（ 5-HT ）代 谢作用密切相关。例如， 5-HT 功能减退及前 额叶功能低下与抑郁症患者的自杀企图的致死性相关。自杀死亡的尸检研究发现，腹内侧 PFC 的 5-HT 受体 转运体位点普遍减少，并且 PFC 的部分区域突触后 5-HT (1A) 受体数增加。

第三点是 对应激事件反应的素质性因素。由于 5-HT 代 谢和自杀行为相关，与 5-HT 功能相 关的各种基因引起了特别关注。几项研究均证实 5-HT 转运体基因启动子的多态性和自杀行为相关，尤其是烈性自杀。表明这些自杀者不仅仅有冲动控制障碍，而且还有较强的攻击性。

早年的 应激性经历可能导致应激轴永久性过度反应，这种情况常见于边缘型人格障碍。药物过量的女性患者经历过儿童期性虐待的比率是正常对照组的 15 倍。延 迟性应激引起 HPA 系 统过度反应，皮质激素释放过多。持续皮质激素增多与 PFC 、 纹状体和海马的萎缩相关，同时皮质 5-HT 利用度下降。 许多研究一致发现，抑郁患者的皮质激素水平增加，且 5-HT 系 统功能障碍。其中有代表性的是：大脑代谢的研究结果显示，抑郁患者的杏仁核活性相对高，而左 PFC 活性 较低。

自 杀企图过后，患者与医师可能都误认为自杀的危机已排除了，患者将回归到 “ 正常 ” 自我。然而，以自 伤解决精神痛苦的行为方式将储存于神经环路中，以应对不能忍受的精神痛苦，在日后出现情感应激情况时将被触发（自杀模式的开关现象）。研究发现，有过自杀企图的患者，其自杀危险性提高了至少 60 倍，并且 这种危险持续存在多年。因此，期望短程治疗能减少自杀行为是不现实的。患者很可能需要长程 “ 治 疗性锚定 ” ， 包括增加行 为治疗次数 ， 和至少继续保持与患者的接触。本讲座还将讨论自杀干预的神经心理学模式的更多内容。

A common denominator of psychological models is the view that suicide is an alternative to life-oriented perspectives in human life, which becomes prominent when important self-relevant issues are threatened. Suicide becomes a possible goal when a person experiences serious failures (occupational failures, relationship failures, personal integrity failures) in important life- or identity goals. Suicide may then emerge as an alternative goal, as a way to end “a bad story”. Self-blame, hopelessness, and unbearable negative affect or mental pain, which the individual seeks to avoid, are triggers for self-harm. The unity and the continuity of the self break down, and the self as a fragile entity is no more able to maintain adequate emotion regulation.

These psychological processes, are intimately dependent on brain function. First, the concept of the neurobiological self will be outlined. A sense of continuity of self requires autobiographical memory and thus prefrontal cortical (PFC) function. Under stress conditions, PFC function is seriously impaired, resulting in impaired episodic memory and in an inability to project from the past into the future (“myopia of the future”). The result is a severely impaired capacity of affect regulation through cortical activity, often resulting in dissociative states.

Secondly, the role of the neurotransmitter systems will be discussed. Post mortem studies and PET studies suggest a strong association between suicidal behaviour and the serotonin metabolism. For instance, impaired serotonergic responsivity and prefrontal hypofunction have been found to be proportional to the lethality of the suicide attempts in depressed patients. Post mortem studies of suicide victims have shown a diffuse reduction in serotonin receptor transporter sites in the ventromedial PFC, and an increase in postsynaptic 5-HT (1A) receptors in localized regions of the PFC.

Thirdly, trait factors responsible for the response to stressful events will be considered. Because of the relationship of serotonin metabolism with suicidal behaviour, variations of genes associated with serotonin function are of special interest. Several studies have demonstrated an association between the polymorphism in the serotonin transporter gene promotor region with suicidal behaviour, particularly with violent suicide, suggesting that these individuals have not only poor impulse control, but high levels of aggression.

Early stressful experiences may result in a permanent overreactivity of the stress axis, a finding which is frequent in borderline personality disorders. Female overdose patients have been found to be 15 times more likely than matched controls to have experienced childhood sexual abuse. Prolonged stress leads to an overreacting HPA system with an excessive release of cortisol. Sustained hypercortisolemia is associated with an atrophy in the PFC, striatum, and hippocampus, as well as with reduced serotonin availability in the cortex. Increased levels of cortisol and a dysfunction of the serotonin system are consistent findings in depressive disorders. Typically, brain metabolic studies of depressed individuals show relative hyperactivation of the amygdala and hypoactivation of the left PFC.

After attempted suicide, patient and therapist may be misled by the impression that the suicidal crisis is now resolved and the person back to his “usual” self. However, the behavioural schema of self-harm as a solution to mental pain will be stored in the neuronal circuitry as a solution to unbearable mental pain, and will be triggered in future situations of emotional stress (the suicidal mode as on/off phenomenon). Consistent with this is the finding, that after attempted suicide, the risk of suicide is increased 60 times or more and remains high for years. Therefore it would be unrealistic to expect that a short time-limited therapy will lead to a long-term reduction of suicidal behaviour. Most likely, a long-term “therapeutic anchoring” is needed, which might include booster sessions of behaviour therapy, and at least some continued offer of contact. Further implications of a neuropsychological model of suicide for therapeutic interventions will be discussed in the lecture.

OL4-2

抑郁症的易感基因 ： 5-HT 转运体基因 - The Serotonin Transporter as a Susceptibility Gene for Depression

Philip B Mitchell 1
1 University of New South Wales , Psychiatry, Sydney , Australia

近年来研究表明 ， 抑郁症 发生与遗传因素密切相关。 Caspi 等在 2003 年 Science 杂志上发表的一篇文章指出 ， 暴露于多种生活事件的人群 ， 其 5-HT 转运体基因多态性与抑郁症发生相关。这是关于抑郁症遗传 - 环境相互作用的首次报道。随后，有 7 项独立研 究 对上述研究进行了重复（包括我们的研究 Wilhelm et al, Br J Psychiatry 2006 ），其中 2 项研究结果为阴性。我们对 128 名教 师进行了 25 年随 访，期间对抑郁症发生相关的心理社会因素进行评估。结果与 Caspi 等一致， 发现 5-HT 转运体基因型为 s/s 的人群更易患抑郁症，随 访人群中，年龄在 40 岁以上的患者这一趋势表现得更加明显。这一结果说明，抑郁症的发病机制为遗传 - 环境相互作用，而与神经质性格、以及正性生活事件无关。

最近，我 们首次 (Wilhelm 等，已投稿 ) 对受试者获知本人 5-HT 转运 体基因型的影响 进行探讨。结果发现大部分受试者乐意知道自己的基因型。在随访第 2 周以及第 12 周后，受 试者很乐意知道自己的基因型。然而，那些基因型为 s/s 的人群在得知 这一信息后情绪更加低落， 3 个月后好 转。

我 们将会针对这一遗传 - 环境相互作用，探讨有效的抑郁症预防方案。

In the last decade it has become apparent that the likelihood of developing depression under adversity is greater in those with a genetic loading to this disorder. It was therefore of particular interest when Caspi et al reported in Science in 2003 that polymorphisms of a specific gene – the serotonin transporter – determined the risk of becoming depressed on exposure to multiple life events. This was the first demonstrated specific gene-environment interaction for depression. Since then, seven other independent replications (including our own – Wilhelm et al, Br J Psychiatry 2006) have been published; there have been two negative studies. In our study, 128 teachers who had been followed up for 25 years - in a longitudinal study of the psychosocial determinants of depression - were genotyped. We found, like Caspi et al, that those with the “risk” s/s genotype of the serotonin transporter gene were more likely to become depressed on exposure to multiple life events. As individuals had been followed into their late 40s, we were able to demonstrate that this gene-environment interaction was responsible for depression onset, was not mediated by neuroticism, and was not related to positive life events.

In a recent study (Wilhelm et al, submitted) we have examined (for the first time) the impact of individual study participants receiving details of their own serotonin transporter genotyping. We found that the majority of participants wished to receive this information. At two and 12 week follow-ups, individuals were pleased that they had received the genotyping information. However, those who had been informed that they were in the high risk (s/s) group were more distressed on receipt of this knowledge, with this distress remaining elevated for 3 months.

The implications of the identification of this gene-environment interaction for potential preventive measures will be discussed.

OL4-3

面 临全球化的儿童和青少年 - Children and Adolescents in a Globalised World

Michel Botbol 1
1 WPA Zone Representative for Western Europe, Judicial Protection of the Youth Governmental Agency, School of Psychology at the Catholic University of Paris, Paris, France

随着世界的全球化 ， 家庭 结构的衍化导致个体概念以及父母 - 孩子 关系的巨大变化 ， 这个现象无处不在。随着夫妇的婚姻危机以及他们建立的不稳定的联盟，亲子关系对建构家庭尤为突出。孩子对家庭的构建具有非常的重要性，并导致父母 - 孩子 关系的 symmetrisation.

随着全球化模式有力地推 动，儿童时代的理想化增长了这种倾向。

我 们从儿童不再是一个不完整的成人这样一个概念中走出来，转而认为成人并不是一个儿童的可怜的翻版。由于这样的转变，孩子这代人现在被促使带领他们父母这代人。

很明 显，这会影响全球化教育模式，特别是在青少年 中 导致严重的社会和心理病理结果。由于对自由，个体价值，自恋成就，共同讨论的规则以及合同化的允诺，甚至家庭核心的亲密等价值体系的过分强调，全球化增强了青春期分离个体化的过程以及对依赖的自恋性防御，这个过程常常激发那些更加脆弱的青少年在面对许多来自这些后果的问题时。会出现强烈的回到过去更强调权威和家长式作风的家庭价值体系的诱惑。我们在本文中描述了这个方案的有限性 ， 并提出其他一些应对儿童青少年全球化焦虑情感的方法。

In the globalised world, that does not have outside, the evolution of family structure induces drastic changes in the conception of person as much as in the parent child relations. With the jeopardizing of the marital couple and the instability of the alliance links on which it was built, the filiations' links becomes prominent to structure the family. The child is then taking a major importance in the construction of the family, leading to a symmetrisation of the child parent's relation.

The idealizations of childhood, strongly promoted by globaliazed models, increase this tendency. We then tend to pass from a conception where the child is no more than an uncompleted adult, to a conception where the adult is no more than a poor version of the child. With this inversion, the children generation are now driven to take the lead upon their parents one.

Obviously this affects the globalised educational model with serious social and psychopathological consequences especially in adolescents. By giving prominent value to freedom, individual pleasure, narcissistic achievement, consensual negotiation of norms and contractual consent, even in the core intimacy of the family, globalization increases the stake of adolescence in its separation individuation processes and the narcissistic defences against the dependency these processes often trigger in the more fragile adolescents In front of the many problems resulting from such consequences there is a strong temptation to return to ancient values giving greater importance to authoritarian models and to paternalistic patterns of family. We will show in this paper the limitation of such projects and will suggest other ways to deal with these worrying effects of globalization on children and adolescents.

OL4-4

中国精神医学培 训 - Psychiatric Training in China

Xin Yu 1
1 Institute of Mental Health, Peking University , Bejing, Chinese Mainland

在人口众多的中国 ， 精神科医 师的数量远远不够。相比于数量之少 ， 中国精神科医师的质量就更为严重。在中国精神病院工作的 16 ， 000 名医 师中，只有三分之一毕业于医科院校。医科院校的各自不同的学制，不同的精神科医师培训标准以及国家精神科医师资格认证系统的缺乏，也使中国不同地区的精神科医师有着不同的资质。为了改善这种状况，中国政府、中国精神科协会会发起一系列活动为不同层次的医师提供培训。同时，开始于 2001 年的国家精神科医 师资格考试作为认证系统也被大家所接受。国家精神科医师培训课程正处于最后的起草阶段。作为示范，一些精 神 卫生机构已经开始执行。然而 ， 为了快而省的改善中国精神科医师的质量 ， 我们还需要一种更全面的方法。

Taking account of the huge population in China , the number of Chinese psychiatrists is too few. Compared to the poor quantity of Chinese psychiatrists, the quality is even worse. Only one third of 16,000 doctors working in Chinese psychiatric institutions are graduates from medical colleges. The various length of curriculum in medical schools, the various standards of psychiatric training, and the lack of national credential system for psychiatrists also make the disparity of qualification of Chinese psychiatrists in various regions. In order to improve this condition, the government, Chinese Society of Psychiatry, and the Chinese Psychiatrist Association initiated a number of activities to provide training for various levels of doctors. Meanwhile, a national certification examination for psychiatrists, which started in the year of 2001, now is becoming a generally accepted credential system. The national curriculum of psychiatrist training is in the final drafting stage and some demonstrating psychiatric institutions begin to implement and recruit residents from local regions. However, a more comprehensive approach is needed to improve the qualification of psychiatrists in China in a quicker and cheaper way.

OL5 - Open Lecture 5
Chairs: Allan Tasman, United States
Helen Chiu, Chinese Hong Kong

OL5-1

资源缺少的国家改善精神卫生状况需要什么 ？ - What is the Need for Mental Health Promotion in Poorly Resourced Countries?

Helen Herrman 1
1 Australian International Health Institute, University of Melbourne , Melbourne , Australia

通 过采用以群体为基础的公共健康措施 ， 同时改变卫生系统 ， 精神卫生得以改善。精神健康和其它方面的健康及生产力相互联系，因此以群体为基础的精神卫生改善在国家中的各个收入阶层都存在必要性，并不像某些人所说，是一项奢侈运动。在高收入国家和低收入国家，精神卫生状况不佳与社会危害、滥用人权、健康水平与生产力水平低下相关，也与精神障碍高风险相关。改善精神卫生状况同时也满足了其它的需求。比如，改善学校精神卫生状况的干预措施也能 促 进学习。

循 证观点表明了在公共卫生中促进精神卫生的功效。促进健康的措施包括宣传、联络、政策法规改变、社区的加入、研究与评估。这些措施在改善躯体健康和促进生产力发展的同时也促进了精神卫生的发展。精神卫生的改善发生在多个层面。有些和个人的关系不大，比如改善住所的政策。有些和个人的关系紧密些，比如将社会心理干预与儿童营养计划及老年人活动安排相结合。有效的干预可能需持续终身。有些社会与卫生特别关注并优先考虑的问题，如 HIV 预防、妇幼健康、暴力、物质滥用和性别歧视，这些干预针对的是特定人群，但最后与精神卫生也是相关 的。本次演 讲将以专业的角度出发 ， 探讨在各国公共卫生中如何促进精神卫生的整合 ， 讨论公共精神卫生干预的进一步研究与评估的必要性。

Mental health is promoted through population-based public health measures, alongside health system change. The interconnections between mental health and other aspects of health and productivity make population-based mental health promotion in countries at all income levels a necessity, rather than a luxury as sometimes portrayed. Poor mental health is associated in high- and low-income countries with social disadvantage, human rights abuses, and poor health and productivity, as well as heightened risk of mental disorders. Promoting mental health also satisfies a range of other needs. For example, interventions to promote mental health in schools can also improve learning.

An evidence base is emerging for the effectiveness of mental health promotion in public health. The health promotion strategies of advocacy, communication, policy and legislative changes, community participation, and research and evaluation can promote mental health together with physical health and productivity. Mental health promotion activities take place at several levels. Some are distal from the individual, such as policies to improve housing; others closer to the individual, such as combining psychosocial interventions with childhood nutrition programs, and activity programs for older adults. Effective interventions are possible across the lifespan. Social and health priorities such as HIV prevention, maternal and child health, violence, substance abuse, and gender equity require interventions focusing on appropriate participation, in turn related to mental health. The presentation will consider the role of the professions in countries in promoting the integration of mental health in public health, and the need for wider research and evaluation of public mental health interventions.

OL5-2

警察中 PTSD 危 险性和康复的前瞻性研究 - Prospective Study of Risk and Resilience for Posttraumatic Stress Disorder in Police

Charles R Marmar 1 , Clare Henn-Haase 1 , Thomas Metzler 1 , Nnamdi Pole 1 , Sabra Inslicht 1 , Shannon McCaslin 1 , Renee Valdez 1 , Susan Meffert 1 , Christian Otte 1 , Thomas Neylan 1
1 University of California , Department of Psychiatry, San Francisco , United States

我 们在一项对纽约和三藩市警察招募报名者中 ， 对 PTSD 症状 发生前和发生后行为、生物学危险因子的影响作前瞻性研究。健康的警察报名者 (n = 180) 在 专业训练是通过自评问卷、对应激的生物学应答进行评估，测定睡眠效率和反应时间，以及一个结构性诊断访谈。在参加警察工作 12 个月后，被 试完成应对突发事件、创伤过程中的分离和抑郁、酒精使用以及 PTSD 症状等一系列 评估。结果显示了经 12 个月警察工作后下列 预测因子对 PTSD 症状的影响：在 专业训练中对模拟突发事件录像以及对标准的和高度恐惧的声音刺激的神经内分泌反应，睡眠效率以及反应时间，精神障碍的家族史以及物质滥用， 14 岁前的虐待经历，愤怒和分离的特征， IQ 和教育程度，性 别和种族，警察服役期间重要的应激事件，面对关键事件时的分离和情感悲伤，常规的工作环境应激，应激性生活事件，社会支持，以及应对策略。还将讨论针对 PTSD 出 现前和出现后的危险因子的预防问题。

We studied the influence of pre-existing and ongoing behavioral and biological risk factors on the development of PTSD symptoms in a prospective study of police academy recruits in New York and San Francisco . Healthy police recruits (n = 180) were assessed during academy training on self-report questionnaires, biological responses to stress challenges, measures of sleep efficiency and reaction time, and a structured diagnostic interview protocol. Twelve months after beginning active duty police service, participants completed assessments on critical incident exposure, peritraumatic dissociation and distress, alcohol use, and PTSD symptoms. Results will be presented on the effects of the following predictors of PTSD symptoms at 12 months of police service: neuroendocrine responses to a critical incident video simulation during academy training, responses to standard and threat enhanced acoustic startle during academy training, sleep efficiency and reaction time, family history of mental disorders and substance abuse, exposure to traumatic events prior to age 14, trait anger and dissociation, I.Q and education, gender and ethnicity, critical incident stress during police service, dissociation and emotional distress during critical incident exposure, routine work environment stress, stressful life events, social support, and coping strategies. Implications for prevention will be discussed with respect to both pre-existing and contextual risk factors.

OL5-3

有 关康宁的科学 ： 精神卫生和相关疾病的整合途径 - The Science of Well-being: An Integrated Approach to Mental Health and its Disorders

Robert Cloninger 1
1 Washington University School of Medicine, Department of Psychiatry, St. Louis , United States

虽然在精神药物和心理治疗指南方面花费巨大 ， 但精神 病学无法提高普通人的快 乐和康宁程度。究其原因是过分关注于精神疾病所导致的病耻感以及对于提高正性情绪 ， 性格发展 ， 生活满意度和灵性等方面的忽视。对于达到康宁的简单而实际途径是整合生物学，心理学，社会和灵性方式来促进精神卫生。有证据显示人们能够通过实际临床模式中依次催化效果的帮助下发展自身的性格和快乐。人们能够通过变得更沉静，接受自身的局限以及顺应自己的恐惧和冲突来认识成功和更具自我指导性。人们也能够通过增加禅定和为他人服务的方法来学会更具合作性。此外通过对于远景的自我意识成长所带来的对于生活造成的负性情绪和正性 情 绪的限制的信念和假设，人们能够更加自我超越。 有 关自我指导，协作以及自我超越的人格特质对于康宁而言是缺一不可的。它们能够被 Cloninger 气 质和性格量表 (http://tci.wustl.edu) 可靠的 测试。一项名为：快乐生活：康宁旅记的有关康宁的心理培训项目业已开展。这是针对任何希望更快乐健康的人通过自我帮助和专业治疗所能达成的一项多层次范围广的干预。

关键词：康宁，性格发展，灵性，快乐，精神生物学

OL5-4

生活模式干 预以及二甲双胍治疗抗精神病药所致体重增加的有效性 ： 随机双盲安慰剂对照研究 - Efficacy of Lifestyle Intervention and Metformin for the Treatment of Antipsychotic-Induced Weight Gain: A Randomized Double-Blind Placebo- Controlled Comparison

Jingping Zhao 1
1 Institute of Mental Health of The Second Xiangya Hospital , Central South University , Changsha , Chinese Mainland

背景 : 体重增加是抗精神病 药物的一个常见副反应 ， 它会增加精神障碍患者共病内科疾病的概率。有研究发现生活模式干预 （ lifestyle intervention ， LI) 或二甲双胍 对治疗抗精神病药所致体重增加有效 ， 然而目前尚没有研究对精神分裂症患者进行生活模式干预、二甲双胍治疗以及两者结合的对照研究。我们进行了 12 周的随机、安慰 剂对照研究来检测 LI 和二甲双胍以及两者 结合治疗抗精神病药所致体重增加和胰岛素敏感性异常的疗效。

方法 : 将 128 名精神分裂症患者随机分成 4 组，分别为安慰剂组、二甲双胍组（ 750mg/ 天）、 LI 结合二甲双胍组、 LI 结合安慰剂组。药物以双盲的形式提供。

结果 : 128 名患者中， 118 人 (92.2%) 完成了 12 周的治 疗。治疗后，体重、体重指数 (BMI) 、腰 围（ WC ）、 胰 岛素水平、空腹血糖（ FG ）、以及胰 岛素抵抗指数（ IRI ）在 LI 结合二甲双胍组、二甲双胍组以及 LI 结合安慰剂组都有显著降低，而在安慰剂对照组有所增加。 LI 结合二甲双胍对体重和体重指数的疗效明显优于二甲双胍，对体重、 BMI 、胰 岛素水平和 IRI 的作用明 显优于 LI 结合安慰剂，对体重、 BMI 、 WC 、 FG 、胰 岛素水平和 IRI 的作用明 显优于安慰剂；二甲双胍对体重、 BMI 、 WC 、 FG 、胰 岛素水平和 IRI 的作用明 显优于 LI 结合安慰剂； LI 结合安慰剂对体重、 BMI 、 WC 、胰 岛素水平和 IRI 的作用明 显优于安慰剂。

结论 : 生活模式干 预、二甲双胍、以及两者结合对抗精神病药所致的体重增加都有疗效，生活模式干预合并二甲双胍治疗对减轻体重的效果最好。生活模式干预合并二甲双胍与单纯二甲双胍治疗对改善胰岛素敏感性的疗效相当。单纯二甲双胍治疗对减轻体重、改善胰岛素敏感性的疗效优于单纯生活模式干预。

关键词： : 体重增加，抗精神病 药，生活模式干预，二甲双胍，随机对照试验，安慰剂

Background: Weight gain is a common side effect of antipsychotics that could be associated with increased medical co-morbidities in psychiatric patients. A few studies have found lifestyle intervention (LI) or metformin was effective for antipsychotic-induced weight gain, but no controlled studies have compared LI to metformin alone or in combination in schizophrenia. We conducted a 12-week randomized, placebo-controlled study to test the efficacy of LI and metformin alone and in combination for antipsychotic-induced weight gain and abnormalities in insulin sensitivity.

Methods: 128 patients with schizophrenia were randomized to placebo, metformin (750mg/day), LI plus metformin (750mg/day) or LI plus placebo. Medications were provided in double-blind fashion.

Results: Of the 128 patients, 118 (92.2%) completed the12-week treatment. After the treatment, weight, body mass index (BMI), waist circumference (WC), insulin, fasting glucose (FG) and insulin resistance index (IRI) levels decreased significantly in the LI plus metformin, metformin and LI plus placebo groups and increased in the placebo group. The LI plus metformin was significantly superior to metformin on weight and BMI, was superior to LI plus placebo on weight, BMI, WC, insulin and IRI, and was superior to placebo on weight, BMI, WC, FG, insulin and IRI; metformin was significantly superior to LI plus placebo and placebo on weight, BMI, WC, FG, insulin and IRI; LI plus placebo was significantly superior to placebo on weight, BMI, WC, insulin and IRI.

Conclusions: Lifestyle intervention and metformin alone and in combination demonstrated efficacy for antipsychotic induced weight gain, and LI plus metformin showed the best effect on weight loss. LI plus metformin and metformin similarly improved the insulin sensitivity. Metformin alone was more effective in weight loss and improving insulin sensitivity than lifestyle intervention alone. Key words: Weight gain, antipsychotic, lifestyle intervention, metformin, randomized controlled trial, placebo

OL6 - Open Lecture 6

Chairs: John Cox, United Kingdom
John Davis, United States

OL6-1

东亚精神病学 ： 过去 ， 现在和挑战 - Psychiatry in East Asia: Past, Present and Challenges

Naotaka Shinfuku 1
1 Seinan Gakuin University, Department of Humand Science, Fukuoka city, Japan

东亚由约 10 个国家和地区 组成 ， 中国的人口最多 ， 其次是日本和韩国。虽然东亚在心灵治愈艺术方面有丰富、宝贵的文化传统，亚洲的观点在现代精神病学中是相当被忽视的。在 20 世 纪之交日本从德国引进了精神病学。日本的精神科医生在殖民时代在台湾和韩国的医科学校教课。美国的传教士在 19 世 纪末开始在中国建立精神病医院。然而，在 20 世 纪的 前部分， 现代精神病学在东亚的发展并不好。在第二次世界大战后 (1941-1945) ，日本效仿美国并 开始建立精神病医院。在三个不同的政府领导下，中国的床位数相对较少。在文革后上个世纪 70 年代末，中国 开始了市场经济和开放政策，这使得中国的精神病学能够与国际进行合作。 WHO 从 1980 年 开始在中国开展精神卫生项目。东亚国家在过去的 20 到 30 年 间经历了非常大的社会经济变化，并被视为国际政治和经济的重要参与者。然而，他们在精神病学的地位是相当低的。希望东亚的国家能开展进一步的合作，并发展出对东亚精神病学的认同，是其变得优 秀、卓越。演 讲者作为 WHO 的地区 顾问在西太平洋地区精神卫生中工作了 13 年， 现在是 WPA 17 区（ 东亚）的地区代表。他将根据自己的经历表述自己的观点。

参考文献

Shinfuku N: Rapid Socioeconmic changes and mental health in Asia and Pacific – Role of Social Psychiatry ,J Bull Soc Psych 23-32,2006 .. Chairman Lecture at 18th World Congress of World Association for Social Psychiatry, October 2006 , Kobe

East Asia is composed of around 10 countries and areas with China having the biggest population followed by Japan and Korea . Though East Asia has had rich cultural heritages in the arts of healing minds, Asian views have been rather neglected in modern psychiatry. Japan imported psychiatry as medical discipline at the turn of the 20th century from Germany . Japanese psychiatrists then taught at medical schools in Taiwan and Korea during the colonial era. American missionary first established psychiatric hospitals in China at the end of 19th century. However, modern psychiatry was poorly developed in East Asia in the former part of the 20th century. After the Second World War (1941-1945), Japan followed USA and started the building of psychiatric hospitals. China has relatively small number of beds under three different ministries. China adopted free market economy and open door policy after the culture revolution at the end of 1970th and this enabled the international collaboration in psychiatry in China . WHO started mental health projects in China from 1980. East Asian countries experienced very rapid socioeconomic changes in the past 20 to 30 years and are ranked as important players in world politics and economy. However, their role in psychiatry is rather low keyed. It is hoped that East Asian countries to further develop collaboration and develop identity and excellence of Asian Psychiatry. The presenter worked as WHO Regional Adviser in Mental Health for the Western Pacific Region for 13 years and now serves as WPA Zonal Representative for the Zone 17 ( East Asia ). He will present his views based on his experiences.

Reference

Shinfuku N: Rapid Socioeconmic changes and mental health in Asia and Pacific – Role of Social Psychiatry ,J Bull Soc Psych 23-32,2006 .. Chairman Lecture at 18th World Congress of World Association for Social Psychiatry, October 2006 , Kobe

OL6-2

中国精神疾病 诊断和分类 ——CCMD-3 - Psychiatric Diagnosis in China and the CCMD-3

Yanfang Chen 1 , Zhong Chen 1 , Chunling Xiao 1 , Haihong Yu 1
1 Beijing Huilonggaun Hospital , Psychiatry, Beijing , Chinese Mainland

目的 ： 评价一种新的诊断工具健康与疾病定量测试法 - 科研版 (RTHD-R) 的可靠性和有效性 ， 并提 议改进 CCMD-3 。

方法 ： 1. 根据 DSM-IV 诊断标准 ， 由 2 名独立的精神科医生分 别用 RTHD-R 和定式 临床检查 - 患者版 （ SCID-P ） 评定 DSM-IV 案例集中的成年病例 （ 指大于等于 18 岁 ）； 2. 以 DSM-IV 案例集中作者的 诊断作为金标准 ， 与上述 2 名精神科医生的 诊断比较 ； 3. 根据 DSM-IV 诊断标准 ， 由 2 名独立的精神科医生分 别用 RTHD-R 和 SCID-P 评定在综合性医院和精神病院就诊的成年精神障碍患者 （ 指大于等于 18 岁 ）； 4. 基于在中国 5 种主要的精神科杂志发表的临床试验中 ， 诊断精神障碍分别使用的 ICD-10 、 DSM-IV 和 CCMD-3 诊断标准的频率 ， 建议改进 CCMD-3 诊断标准。

结果和结论 ： 文章的第一作者将会借 这次机会介绍本次研究的结果。

Aim: To evaluate the reliability and validity of a new diagnostic instrument-- Rating Test of Health and Diseases Research version (RTHD-R) and to make suggestion for the development of CCMD-3 in future.

Methods: 1. Assess the adults cases (at age 18 years old or more)in DSM-IV Case Book with RTHD-R used by one psychiatrist vs. with SCID-P used by the other psychiatrist independently according to the DSM-IV criteria;

2. Take the diagnosis made by the authors of DSM-IV Case Book as golden standard compared with the diagnosis made by the two psychiatrists mentioned above;

3. Assess the adults patients with mental disorders (at age 18 years old or more) both in a general hospital and a psychiatric hospital with RTHD-R by one psychiatrist vs. with SCID-P used by the other psychiatrist independently according to the DSM-IV criteria;

4. Make suggestion for the development of CCMD-3 in future, based on the frequency of subjects' diagnosis of mental disorders in clinical trials of psychiatry in 5 major Chinese journals of psychiatry according to ICD-10, DSM-IV, or CCMD-D3 respectively.

Results and conclusion: The results will be published on this occasion by the first author as one of confirmed speakers.

OL6-3

中国精神 卫生系统的新发展 - The New Development of Mental Health Care System in China Nowadays

Zeping Xiao 1
1 Shanghai Jiaotong University , Shanghai Mental Health Center , Shanghai , Chinese Mainland

本文主要回 顾了中国精神卫生系统的发展史 ， 并以上海模式为例 ， 阐释了三级精神卫生保健体系。作者着重于中国精神卫生系统目前所面临的困难和挑战，并介绍了近 5 年来重要的全国范 围的关于精神卫生的研究。最后，作者对中国今后精神卫生事业的发展给出了一些建议。

The article review briefly the development history of Chinese Mental Health System ， especial took Shanghai Model as an example, to illustrate the tertiary mental health care delivery system. Also, the author gives a big concern on the difficulty and challenge of the mental health system nowadays, introducing the major national wide research on mental health in late 5 years. At last, the author gives some suggestion on mental health development in the future in China .

OL7 - Open Lecture 7
Chairs: Miguel R. Jorge, Brazil
Char-Nie Chan, Chinese Mainland

OL7-1

新加坡精神 卫生保健服务的转变 - Transforming Mental Healthcare Services in Singapore

Yew Meng Leong 1
1 Institute of Mental Health, Woodbridge Hospital , Singapore , Singapore

作 为 Woodbridge 医院和精神 卫生研究所的首席执行官 ， Leong 先生介 绍了新加坡从 1841 年起到 现在精神卫生服务的转变 ， 并提出国家精神卫生保健服务从管理到以社区为基础的治疗服务体系转变的挑战 ， 并就执行体系提出了战略性看法。自从 2000 年， Leong 先生就通 过多元系统 TOPS 提出最初建 议。这包括医院的转变、扩大项目的建立、合作关系的开展和改善服务。本文将介绍这些实践如何为我精神卫生研究所成为亚洲第一家获得 2005 年 Joint Commission International (JCI) 资格的精神病院所做的贡献。并设法就它为促进精神卫生发展和研究所做的显著贡献，建立 WHO 成 员国科威特卫生促进奖。另外 ， 为帮助理解我们的决策 ， 本文将介绍新加坡精神卫生发展蓝图 ， 该蓝图将促使我们精神卫生研究所在 2012 年前从各个方面 处于亚洲精神卫生的领导地位。

As the Chief Executive Officer (CEO) of the Institute of Mental Health (IMH) and Woodbridge Hospital , Mr Leong documents the transformation of mental health services in Singapore from its inception in 1841 to the present. He delineates the challenges and provides a strategic overview of the systems implemented to move national mental healthcare services from custodial management to therapeutic care in community based settings. Through a multiprong system -TOPS, Mr Leong provides insights into the initiatives involved since 2000. These comprise the Transformation of the hospital, the establishment of Outreach Programmes, Partnership and Service Improvement initiatives. The paper discusses how these best practices have contributed to IMH being the first psychiatric hospital in Asia to attain the Joint Commission International (JCI) 2005 accreditation. It also managed to clinch the prestigious WHO State of Kuwait Health Promotion Award for its outstanding contribution to mental health promotion and research. In addition, the paper will showcase the National Mental Health Blueprint to provide an understanding of strategies that will propel IMH towards each vision of becoming a leading mental health centre in Asia by 2012.

OL7-2

对精神卫生政策 ， 计划和组织的回顾 － 国际最新信息 - Review of Mental Health Policies, Planning and Organization - An International Update

Otto W Steenfeldt-Foss 1
1 Emeritas University Health Services of Oslo , Health Services, Oslo , Norway

该演讲将介绍最新的对精神卫生服务进行计划 ， 组织和评估的国际性接受的原则。 重点 强 调流行病学 ， 服务因素和评估程序。 对发展中国家将来的发展和挑战的建议进行评论。

An updated review of the internationally accepted principles for planning, organization and evaluation of mental health services is presented. Epidemiologic aspects, service elements and evaluative procedures are highlighted. Proposals for future challenges and developments with special reference to developing countries are commented.

OL7-3

老年期抑郁症的症状学差异 （ 印度研究 ） - Depression in Old Age: Is it Different Phenomenologicaly? An Indian Experience

Jitendra Kumar Trivedi 1
1 King George Medical University , Department of Psychiatry, Lucknow , India

抑郁症是老年人群最常 见的疾病之一 ， 明显影响患者的生活质量 ， 而诊断率不高。年龄大于 65 岁的社区居民抑郁症的时点患病率是 2-4% ，但症状不 严重的抑郁患病率的范围达到 5-44% 。 虽然发病率高，但 老年抑郁症却常被漏 诊。其原因可能是老年抑郁症的症状表现与青壮年抑郁症有差异。有研究显示，老年抑郁症症状的不同表现在以下方面：激惹症状更多、躯体化症状多见；兴趣减退、负疚感；疑病症状、焦虑。

许多研究指出，老年抑郁症症状具有不同特点、临床表现复杂，并伴随其它症状。正是如此，有必要探讨老年抑郁症患者的症状表现与青壮年患者常见症状的差异，从而提高诊断识别率与治疗率。本研究比较了患抑郁症的老年人与青壮年患者的症状学差异 ， 并对所得结果进行讨论。

Major depression is one of the most prevalent and under diagnosed psychiatric disorders in the geriatric population (Blazer DG, 2003) and significantly decreases quality of life (Wells KB, 1989; Gurland B, 1992) The point prevalence of major depression in community residents of 65 years or older is 2-4%, whereas prevalence of less severe depression ranges from 5 to 44% (Blazer D, 1980). Despite these high rates of occurrences depression in elderly is frequently missed. The reason for this could be a possible phenomenological difference between the depression in the old age and in adulthood. There are studies that have shown a difference in the phenomenology with greater agitation; a high number of somatic symptoms (Saltzman C and Shader R ,1978 ; Nielsen AC and Williams TA,1980; Winokur G, Behar D. et al.: ,1980), loss of interest, guilt (Brodaty H, Breda Cullen et al.,2005; Brodaty H, Luscombe G, Parker G et al.: ,1977) and hypochondriacal worries and anxiety (Gurland B,1976;Goldstein SE,1979;Busse EW and Blazer DG, 1980).

Due to the fact that phenomenology in elderly might present confounding picture due to conditions other than depression and different symptoms reported by this age group as various studies have pointed out , it becomes imperative that these phenomenological differences in presentation of depression as opposed to commonly observed symptoms in adult depression be understood and correct diagnosis of depression be made followed by treatment. The present study explored the phenomenological differences in clinical presentation of depression in geriatric and adult age groups. The findings of the present study will be discussed in the paper.

References:

1. Blazer DG: Depression in late life: review and commentary. Journals of Gerontology Series A: Biological Sciences and Medical Sciences 58(3): 249-265, 2003.

2. Wells KB, Stewart A, Hays RD et al. : The functioning and well-being of depressed patients. Results from the medical outcomes study. Journal of the American Medical Association 262(7): 914-919, 1989

3. Gurland B: The impact of depression on quality of life of the elderly. Clinics in geriatric medicine 8(2): 377-386, 1992

4. Blazer D, Williams C D: Epidemiology of dysphoria and depression in an elderly population. American Journal of Psychiatry, 137: 439-444,1980

5. Saltzman C and Shader R: Depression in elderly I: Relationship between depression, psychologic defense mechanism and physical illness. Comprehensive Psychiatry 14: 99-107, 1978

6. Nielsen AC and Williams TA: Depression in ambulatory medical patients: prevalence by self report questionnaire and recognition by non-psychiatric physicians. Archives of General Psychiatry 37: 999-1004, 1980

7. Winokur G, Behar D. et al.: Clinical and biological aspects of depression in elderly. In Cole Jo, Barrett JE (eds.). Psychopathology in Aged. New York Ray Press. pp 145-153, 1980

8. Brodaty H, Breda Cullen et al.: Age and gender in phenomenology of depression. American Journal of Geriatric Psychiatry. 13: 589-596, 2005 9. Brodaty H, Luscombe G, Parker G et al.: Increased rate of psychosis and psychomotor change in depression with age. Psychological Medicine. 23: 1205- 1213, 1997

10. Gurland B: The comparative frequency of depression in various adult groups. Journal of Gerontology 31: 283-292, 1976

11. Goldstein SE: Depression in the elderly. Journal of the American Geriatrics Society. 27: 38-42, 1979

12. Busse EW and Blazer DG: Disorders related to biological functions: Handbook of Geriatric Psychiatry, New York, Van Nostrand Reinhold Company. 1980

OL7-4

中国 综合医院的精神卫生服务 - Mental Health Service of General Hospital in China

Xueli Sun 1
1 Hau Xi Mental Health Center , Si Chuan University, Chengdu , Sichuan , Chinese Mainland

初 步 调查发现 ， 躯体疾病及中枢神经系统疾病中抑郁、焦虑以及精神病性症状的出现率分别为 29% 、 41% 和 16.9% ； 需求精神 专科医师的会诊率为 5-6% ； 精神 药物 （ 包括抗抑郁剂、抗焦虑剂以及抗精神病药物 ） 的使用率为患者总数的 12% 左右。 说明综合医院精神卫生服务的需求在明显地增长。 中国 综合医院精神卫生服务的形式目前有以下几种情况： ①以二 级学科存在的，具有门诊以及住院病床等设施的完整的精神专科； ② 综合医院精神专科门； ③神 经病学专业人员兼职担任精神卫生服务职能； ④内科和外科医 师承担部分精神卫生服务职能； ⑤非医学背景的心理工作者的精神 卫生服务工作； ⑥ 护理人员的精神卫生服务工作。 中国 综合医院中精神卫生服务所存在的问题是： ①精神 卫生服务机构的健全； ② 综合医院精神卫生服务人员的充实； ③非精神 专业医护人员精神卫生知识的培训； ④ 现从事精神卫生服务工作人员的规范化和专业化； ⑤ 综合医院精神卫生服务体系的完善（如心理工作者制度的建立） ⑥心身疾病的研究。 今后的 发展方向以及需要进行的工作是： ① 强化 医学教育中的精神 卫生教育； ②在 综合医院中建立完善的精神卫生服务机构； ③加 强 对于心身疾病的基础和临床研究； ④加 强精神 卫生专业人员与医学其它专业人员的交流与合作； ⑤在民 间加强心理卫生知识的普及工作。

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