A network model of depressive and anxiety symptoms: a statistical evaluation.

BACKGROUND: Although network analysis studies of psychiatric syndromes have increased in recent years, most have emphasized centrality symptoms and robust edges. Broadening the focus to include bridge symptoms within a systematic review could help to elucidate symptoms having the strongest links in network models of psychiatric syndromes. We conducted this systematic review and statistical evaluation of network analyses on depressive and anxiety symptoms to identify the most central symptoms and bridge symptoms, as well as the most robust edge indices of networks. METHODS: A systematic literature search was performed in PubMed, PsycINFO, Web of Science, and EMBASE databases from their inception to May 25, 2022. To determine the most influential symptoms and connections, we analyzed centrality and bridge centrality rankings and aggregated the most robust symptom connections into a summary network. After determining the most central symptoms and bridge symptoms across network models, heterogeneity across studies was examined using linear logistic regression. RESULTS: Thirty-three studies with 78,721 participants were included in this systematic review. Seventeen studies with 23 cross-sectional networks based on the Patient Health Questionnaire (PHQ) and Generalized Anxiety Disorder (GAD-7) assessments of clinical and community samples were examined using centrality scores. Twelve cross-sectional networks based on the PHQ and GAD-7 assessments were examined using bridge centrality scores. We found substantial variability between study samples and network features. 'Sad mood', 'Uncontrollable worry', and 'Worrying too much' were the most central symptoms, while 'Sad mood', 'Restlessness', and 'Motor disturbance' were the most frequent bridge centrality symptoms. In addition, the connection between 'Sleep' and 'Fatigue' was the most frequent edge for the depressive and anxiety symptoms network model. CONCLUSION: Central symptoms, bridge symptoms and robust edges identified in this systematic review can be viewed as potential intervention targets. We also identified gaps in the literature and future directions for network analysis of comorbid depression and anxiety.

Utilizing plasma drug levels and genetic testing to achieve optimal treatment response in a patient with treatment-resistant schizoaffective disorder.

We report the case of a Chinese male with schizoaffective disorder, an active smoker and a nonresponder to clozapine (600 mg daily). Therapeutic clozapine monitoring was analyzed, revealing a low concentration-dose ratio. A pharmacogenetic test showed that the patient had the CYP1A2*1F/*1F genotype, indicating an ultra-rapid clozapine metabolizer. In combination with fluvoxamine, a CYP1A2 enzyme inhibitor, clozapine plasma concentrations approached the reference range and achieved clinical improvement. This case demonstrates how pharmacogenetics can help understand the value of therapeutic drug monitoring to enhance the treatment of refractory schizoaffective disorder.

COVID-19 and Sleep Problems: A Perspective from Bibliometric Analysis.

OBJECTIVES: The Coronavirus Disease 2019 (COVID-19) pandemic and the containment measures for COVID-19 have affected sleep quality in the population. This study explored sleep-related research from a bibliometric perspective to provide an overview of the research outputs in this field. METHODS: Original and review articles were retrieved from the Web of Science Core Collection (WOSCC) database from December 2019 to 7 Aug 2023. R package "bibliometrix" was used to summarize the number of articles of authors, institutions, and countries; count the citations of the articles, and generate a Three-Fields Plot. VOSviewer software was applied to visualize the collaboration network among authors and institutions, and to conduct a co-occurrence analysis of keywords. RESULTS: A total of 4,499 articles on COVID-19 and sleep, and 25,883 articles on non-COVID-19 and sleep were included. Sleep related articles were mainly published by authors from China, the USA, and Italy. For COVID-19 and sleep research, Huazhong University of Science was the most productive institution. The Psychiatry Research was the most influential journal across the different subject categories of this field. "Mental health", "anxiety", and "depression" were the most common keywords, while "sleep quality" and "quality of life" were the likely topic areas in terms of future research directions. CONCLUSIONS: Our findings provide a comprehensive perspective for researchers to understand the wider landscape of both COVID-19 and non-COVID-19 sleep-related research area.

The association between the adverse event reporting system and burnout and job satisfaction of nurses: Workplace violence as a mediator.

AIMS: This study aims to explore the association between the implementation of the adverse event reporting system (AERS), burnout, and job satisfaction among psychiatric nurses, with a focus on examining the mediating effect of workplace violence from patients. BACKGROUND: Many organizational and personal factors contribute to burnout and job satisfaction experienced by nurses. AERS, serving as a key component of organizational-level quality improvement system, impacts the overall workplace wellness of nurses. METHODS: A national sample of 9,744 psychiatric nurses from 41 psychiatric hospitals across 29 provinces in China participated. Burnout was measured by the Maslach Burnout Inventory. Job satisfaction was measured using the Minnesota Satisfaction Questionnaire. Workplace violence was assessed by nurses' experience of verbal and physical violence. Multilevel linear regression analyses were carried out to examine if AERS impacts burnout and job satisfaction and to identify the mediating role of workplace violence. RESULTS: AERS was positively associated with job satisfaction, but negatively with burnout and workplace violence. Workplace violence exhibited a positive association with burnout and a negative association with job satisfaction. Mediation analyses indicated that the associations between AERS, burnout, and job satisfaction were mediated by workplace violence. CONCLUSIONS: The application of AERS is associated with a reduction in workplace violence in hospitals, which contributes to the diminished burnout and heightened job satisfaction among psychiatric nurses. IMPLICATIONS FOR NURSING PRACTICE AND HEALTH POLICY: The study highlights the importance of organizational efforts and mechanisms in promoting nurses' well-being. It is necessary for hospital management to create a safe workplace through the implementation of AERS.

Medication treatment for alcohol use disorder in special populations.

BACKGROUND AND OBJECTIVES: Alcohol use disorder (AUD) is a significant public health concern, with underutilized effective treatments, particularly in special populations. This article summarizes the current evidence and guidelines for treating AUD in special populations. METHODS: This article is a literature review that synthesizes the latest research on AUD treatment for special populations. We screened 242 articles and included 57 in our final review. RESULTS: There are four food and Drug Administration-approved medications for AUD (MAUD): disulfiram, oral naltrexone, extended-release injectable naltrexone (XR-NTX), and acamprosate. Naltrexone and disulfiram have the potential to cause liver toxicity, and acamprosate should be avoided in patients with severe kidney disease. Psychosocial treatments should be considered first-line for pregnant and nursing patients. Naltrexone is contraindicated in patients on opioids, as it may precipitate acute withdrawal. For patients experiencing homelessness, nonabstinent treatment goals may be more practical, and XR-NTX should be considered to improve adherence. Limited evidence suggests medication can improve AUD treatment outcomes in adolescents and young adults. For patients with poor treatment response despite adequate medication adherence, switching to a different medication and augmentation with psychosocial treatments should be considered. DISCUSSION AND CONCLUSIONS: Understanding the unique considerations for special populations with AUD is crucial, and addressing their special needs may improve their treatment outcomes. SCIENTIFIC SIGNIFICANCE: Our study significantly contributes to the existing literature by summarizing crucial information for the treatment of AUD in special populations, highlighting distinct challenges, and emphasizing tailored approaches to improve overall health and well-being.

Factors Associated With Utilization of Electroconvulsive Therapy During Psychiatric Hospitalization Among Children and Adolescents in China.

PURPOSE: Based on a nationally representative sample in China, we examined the demographic and clinical correlates of utilization of electroconvulsive therapy (ECT) in child and adolescent (C/A) patients younger than 18 years during psychiatric hospitalization. METHODS: As part of a national survey, 41 provincial tertiary psychiatric hospitals in mainland China were selected. Data from 196 C/A patients who were discharged from these psychiatric hospitals from March 19 to 31, 2019, were retrieved and analyzed. RESULTS: (1) The overall rate of ECT among C/A patients during psychiatric hospitalization was 15.6% (n = 30). (2) Between ECT and non-ECT groups, significant differences were found in sex, age, length of stay, Global Assessment of Functioning at admission, treatment outcome, and self-injurious behavior during hospitalization, and the ratio of marked improvement on discharge. (3) Multiple logistic regression analysis revealed that ECT use was independently and positively associated with an older age, male sex, lower Global Assessment of Functioning, and self-injurious behavior during hospitalization. CONCLUSIONS: The frequency of ECT use was relatively frequent in C/A patients during psychiatric hospitalization in our nationally representative sample in China. Developing more specific and operational criteria for the use of ECT for C/A patients is needed to provide guidance for the optimal use of ECT in this patient population.

The effects of childhood trauma on personality in unaffected first-degree relatives of patients with major depressive disorder.

ABSTRAC: OBJECTIVES: This study aimed to preliminarily and exploratorily examine the associations between childhood trauma (CT), its subtypes, and personality traits among unaffected first-degree relatives (FDR, children, or siblings) of patients with major depressive disorder (MDD). METHODS: The study sample included three subgroups: MDD patients (N = 85), Patients' FDRs (N = 35), and healthy control individuals (HC, N = 89). The Childhood Trauma Questionnaire (CTQ) was used to assess childhood trauma and the Eysenck Personality Questionnaire was used to assess personality traits. RESULTS: Significant differences were found in a few personality traits (p < 0.05 for extraversion, neuroticism, and psychoticism) among MDD patients, FDR, and HC, and there were no significant differences between HC and FDR. In the FDR group, compared with those without CT, participants with CT scored significantly higher for neuroticism (N) (F = 3.246, p = 0.046). CT was significantly associated with N, psychoticism (P) and Lie (L), and the strongest association was between CT total score and N. Significantly positive correlations were found between N and sexual abuse (SA) (r = 0.344, p = 0.043), emotional neglect (EN) (r = 0.394, p = 0.019), physical neglect (PN) (r = 0.393, p = 0.019), and CTQ total score (r = 0.452, p = 0.006); between P and CTQ total score (r = 0.336, p = 0.049); and significant negative correlations were found between L and EN (r = -0.446, p = 0.007), CTQ total score (r = -0.375, p = 0.027). CONCLUSION: In unaffected FDRs, there were significant associations between childhood trauma and a few personality traits, including neuroticism, psychoticism, and lie, and emotional neglect was significantly associated with neuroticism.

An International Adult Guideline for Making Clozapine Titration Safer by Using Six Ancestry-Based Personalized Dosing Titrations, CRP, and Clozapine Levels.

This international guideline proposes improving clozapine package inserts worldwide by using ancestry-based dosing and titration. Adverse drug reaction (ADR) databases suggest that clozapine is the third most toxic drug in the United States (US), and it produces four times higher worldwide pneumonia mortality than that by agranulocytosis or myocarditis. For trough steady-state clozapine serum concentrations, the therapeutic reference range is narrow, from 350 to 600 ng/mL with the potential for toxicity and ADRs as concentrations increase. Clozapine is mainly metabolized by CYP1A2 (female non-smokers, the lowest dose; male smokers, the highest dose). Poor metabolizer status through phenotypic conversion is associated with co-prescription of inhibitors (including oral contraceptives and valproate), obesity, or inflammation with C-reactive protein (CRP) elevations. The Asian population (Pakistan to Japan) or the Americas' original inhabitants have lower CYP1A2 activity and require lower clozapine doses to reach concentrations of 350 ng/mL. In the US, daily doses of 300-600 mg/day are recommended. Slow personalized titration may prevent early ADRs (including syncope, myocarditis, and pneumonia). This guideline defines six personalized titration schedules for inpatients: 1) ancestry from Asia or the original people from the Americas with lower metabolism (obesity or valproate) needing minimum therapeutic dosages of 75-150 mg/day, 2) ancestry from Asia or the original people from the Americas with average metabolism needing 175-300 mg/day, 3) European/Western Asian ancestry with lower metabolism (obesity or valproate) needing 100-200 mg/day, 4) European/Western Asian ancestry with average metabolism needing 250-400 mg/day, 5) in the US with ancestries other than from Asia or the original people from the Americas with lower clozapine metabolism (obesity or valproate) needing 150-300 mg/day, and 6) in the US with ancestries other than from Asia or the original people from the Americas with average clozapine metabolism needing 300-600 mg/day. Baseline and weekly CRP monitoring for at least four weeks is required to identify any inflammation, including inflammation secondary to clozapine rapid titration.

Cardiovascular Effects of High-Frequency Magnetic Seizure Therapy Compared With Electroconvulsive Therapy.

BACKGROUND: Magnetic seizure therapy (MST) is a novel convulsive therapy that has been shown to have antidepressant efficacy comparable to electroconvulsive therapy (ECT) with fewer cognitive side effects. However, the cardiovascular (CVS) effects of high frequency MST in comparison to ECT have not been investigated. MATERIALS AND METHODS: Forty-five patients with depression received 6 treatment sessions of 100 Hz MST versus 6 bifrontal ECT treatments in a nonrandomized comparative clinical design. Data on CVS function including heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and rate pressure product (RPP) were collected at baseline (T0), after the induction of anesthesia but before the electrical stimulation (T1), during convulsion (T2), 2 minutes after cessation of motor seizure (T3), 5 minutes after cessation of motor seizure (T4), and 10 minutes after cessation of motor seizure (T5). Comparisons were made with baseline data and between MST and ECT groups. RESULTS: There were statistically significant elevations in the maximum HR, SBP, DBP, and RPP in patients receiving ECT compared with MST both in the initial and sixth treatments (all P < 0.05). Particularly, at T2, the ECT group had significantly higher HR, SBP, DBP, and RPP than those in MST group both in initial and sixth treatment (all P < 0.001). At the sixth treatment, the ECT group had significantly higher SBP, DBP, and RPP during the treatment than in the MST group (all P < 0.001). LIMITATIONS: The anesthetic choices for this study may limit the generalizability of our findings. The sample size was relatively small. CONCLUSIONS: Compared with ECT, high-frequency MST has fewer CVS side effects and may be a safer option for depression patients with CVS disorders.

Burnout and job satisfaction of psychiatrists in China: a nationwide survey.

BACKGROUND: Despite a significant shortage of psychiatrists in China, an ever-increasing number of psychiatrists in China are experiencing burnout and job dissatisfaction and considering leaving their jobs. Yet, to our knowledge, there have been no nationwide studies to date that examined both burnout and job dissatisfaction of psychiatrists in China. Therefore, this study evaluated burnout and job dissatisfaction of psychiatrists in China, and identified relevant characteristics. METHODS: We conducted a nationwide, cross-sectional survey in March 2019. Psychiatrists from all tertiary psychiatric hospitals in China were invited to participate. The Maslach Burnout Inventory-Human Service Survey and the short version of the Minnesota Satisfaction Questionnaire were used to measure burnout and job satisfaction. Data on socio-demographic and occupational characteristics were collected. Multivariate logistic regression was conducted to identify socio-demographic and occupational characteristics associated with burnout and job satisfaction. RESULTS: In total, 4520 psychiatrists from tertiary psychiatric hospitals in China completed the questionnaire. Overall, 38.4% of respondents met the criteria for burnout and 35.6% were dissatisfied with their jobs. Being male, more years of practice, having no leadership role, and longer working hours per week were significantly associated with burnout and job dissatisfaction. Lower monthly pay was significantly associated with job dissatisfaction but not burnout. Moreover, burnout was significantly associated with job dissatisfaction. CONCLUSIONS: Our data suggest a high rate of burnout and job dissatisfaction among psychiatrists in China. In order to preserve and strengthen the mental health workforce, proactive measures are urgently needed to mitigate burnout and job dissatisfaction among psychiatrists in China.

Off-label use of antipsychotic medications in psychiatric inpatients in China: a national real-world survey.

BACKGROUND: The off-label use of antipsychotic medications is common in many countries, and the extent of such use in psychiatric inpatients in China has not been sufficiently studied. The purpose of this study was to survey the incidence and examine the correlates of off-label antipsychotic use in a large, nationally-representative sample in China. METHODS: This study included discharged psychiatric patients between March 19 and 31, 2019 from 41 tertiary psychiatric hospitals across 29 provinces in China. Their socio-demographic and clinical data were collected and analyzed. RESULTS: After excluding patients with schizophrenia spectrum disorder or bipolar disorder, 981 patients were included in the analysis. Overall, antipsychotics were prescribed to 63.2% (95%CI 60.2-66.2%) of the sample. Antipsychotics were used in a wide spectrum of psychiatric disorders, with the rate being the highest among patients with dissociative (conversion) disorders (89.9, 95%CI 83.0-94.8%), organic mental disorders (81.7, 95%CI 73.1-88.7%), dementia (79.0,95%CI 67.8-87.9%), obsessive-compulsive disorder (77.8, 95%CI 55.7-92.5%), mental disorders due to psychoactive substances (75.3,95%CI 64.7-84.2%), behavioural and emotional disorders with onset usually occurring in childhood and adolescence (71.4, 95%CI 45.5-90.1%), somatoform disorders (63.2, 95%CI 40.8%-82..2%), major depression disorder (53.7,95%CI 48.8-58.6%), anxiety disorder (38.8,95%CI 30.5-47.7%), and insomnia (25.0, 95%CI 8.5-28.9%). The top three most commonly used antipsychotics were olanzapine (29.1%), quetiapine (20.3%) and risperidone (6.8%), and their corresponding average doses were 9.04 ± 5.80 mg/day, 185.13 ± 174.72 mg/day, and 2.98 ± 1.71 mg/day, respectively. A binary logistic regression showed that younger age, having the Employee Health Insurance or Residents Health Insurance, having psychotic symptoms and requiring restraint during hospitalization were significantly associated with off-label use of antipsychotics. CONCLUSION: Off-label use of antipsychotics is very common in psychiatric inpatients in China, mainly with moderate-dose use of single agents. However, the efficacy and safety of this practice is uncertain for many diagnoses and for the elderly. Clinicians should be cautious about this practice while waiting for more research data.

Alcohol Use Among Mental Health Professionals in China: A Nationwide Cross-sectional Survey.

AIM: To survey the use of alcohol, and its correlates by mental health professions in China, a nation where there is rapid increase in alcohol consumption and problems. METHODS: As a part of a large-scale, nation-wide online survey of healthcare professionals, we collected demographic variables and other health-related variables anonymously. The Alcohol Use Disorder Identification Test-Concise (AUDIT-C) was used to collect data on alcohol use. RESULTS: 13,980 mental health professionals completed the survey (4382 doctors, 9339 nurses and 259 clinical psychologists), representing 64% of the total targeted. Respondents were predominantly female (75.1%). Alcohol consumption was reported by 41.8% of participants (by 53.9% of doctors, 36.2% of nurses and 40.5% of clinical psychologists). Based on the cut-off scores of the AUDIT-C (≥3 for women and ≥4 for men), 7.5% were classified as probable alcohol misusers in the past year, and the rates were 10.2% in doctors, 6.3% in nurses and 5.8% in clinical psychologists. Multiple logistic regression showed that male sex (OR = 3.772; CI = 3.206-4.439), being a doctor (OR = 1.259; CI = 1.052-1.506), being divorced or widowed (OR = 1.979; CI = 1.467-2.666), having an associate degree or less (OR = 1.809; CI = 1.040-3.147), working in Northeast China (OR = 1.538; CI = 1.281-1.848) and the habit of smoking (OR = 3.345; CI = 2.280-3.967) were significantly associated with alcohol misuse. CONCLUSIONS: Alcohol use and misuse were relatively common among mental health professionals in China, and male sex, being a doctor, with lower education, working in Northeast China and cigarette smoking were significant associations. Awareness and interventions are recommended to promote healthier use of alcohol in this professional group, especially among risk subgroups.

Elevated Rates of Restraint and Seclusion in Child and Adolescent Psychiatric Inpatients in China and Their Associated Factors.

To investigate the rate of restraint and seclusion (R&S) use in child and adolescent psychiatric inpatients in China and to examine factors associated with use of these interventions. As part of an official national survey, 41 provincial tertiary psychiatric hospitals in China were selected. Data from 196 youth inpatients discharged from these hospitals from March 19 to 31, 2019 were retrieved and analyzed. (1) The overall rate of R&S was 29.1% (N = 57) and the rate of restraint was 28.6% (N = 56), and seclusion was 11.7% (N = 23) respectively. (2) Compared to patients who did not require R&S, those who required R&S were more likely to have been hospitalized on an involuntary basis, more likely to present with either manic symptoms or aggressive behavior as primary reason for admission, had more frequent aggressive behaviors during hospitalization, and had a significantly longer length of stay. (3) A logistic regression showed that aggressive behaviors during hospitalization was significantly associated with the use of R&S (OR = 21.277, p < 0.001), along with three other factors: manic symptoms as a reason for admission, involuntary admission and a lower GAF score at admission (all p < 0.01). The rate of R&S is dramatically higher in child and adolescent psychiatric hospitalizations in China compared to other regions. Targeted training of staff, development of precise operational guidelines for appropriate use of R&S, and strict oversight are urgently needed to minimize the inappropriate use of R&S in child and adolescent patients.

Efficacy and Safety of ECT for Behavioral and Psychological Symptoms of Dementia (BPSD): A Retrospective Chart Review.

OBJECTIVE: Much of the functional disturbance in patients with dementia reflects the presence of noncognitive behavioral and psychological symptoms of dementia (BPSD). Agitation is among the most distressing symptoms for patients, clinicians, and caregivers. Currently no pharmacotherapy has clearly been shown to be of value for this condition. This study used a chart review method to examine the safety and efficacy of electroconvulsive therapy (ECT) for patients with dementia receiving ECT for agitation. METHODS: A retrospective chart review was conducted of patients with dementia presenting with symptoms of aggression or agitation and who received ECT treatments. Aggression and agitation were measured by pre- and post-ECT Pittsburg Agitation Scale (PAS) scores. Detailed history of the use of psychotropic medications as well as other clinically relevant variables was analyzed. FINDINGS: Sixty elderly patients (45 women and 15 men, 75% female, mean age 77.5 ± 8.0 years) were included in the analysis. Most patients were treatment resistant to multiple psychotropic medications prior to ECT (mean number 6.1±1.5). The baseline PAS total was 9.3 ± 3.7 and it decreased significantly after three (2.5±2.8) and six (1.5±2.3) ECT treatments. No significant ECT-related medical complications were observed except transient confusion. A decrease in the number of psychotropics prescribed along with an increase in the GAF score was observed after the ECT treatment course. CONCLUSION: ECT was safe in this sample of patients who had co-morbid medical conditions. ECT was associated with the following observations: 1) a reduction in agitation; 2) a reduction in psychotropic polypharmacy; and 3) an improvement in global functioning level. Further research evaluating the effects of ECT in the setting of dementia is warranted.

Psychiatric inpatient beds for youths in China: data from a nation-wide survey.

BACKGROUND: The development of child psychiatric services in China has been slow and very limited resources have been allocated to support its growth. This study set out to investigate the child and adolescent inpatient psychiatric resources currently available in top-tier psychiatric hospitals in China and the characteristics of youth patients hospitalized on an adult unit. METHODS: As part of an official national survey, 29 provincial tertiary psychiatric hospitals in China were selected. Data from 1975 inpatients discharged from these hospitals from March 19 to 31, 2019 were retrieved and analyzed. RESULTS: The mean number of youth psychiatric beds was 27.7 ± 22.9 in these hospitals and 6/29 hospitals had no youth beds. There were significantly more youth beds in developed regions than in less developed regions (P < 0.05). Most of the discharged youth patients were teenagers with severe mental illnesses, including schizophrenia, depressive disorder and bipolar disorder. 7.5% (149) of the 1975 discharged patients were children or adolescents, however youth beds only accounted for 3.2% (804/25,136) of all psychiatric beds. 45.6% (68) of youth patients were discharged from adult psychiatric units. CONCLUSION: Our findings highlight the lack of adequate youth psychiatric inpatient services for children and adolescents living in China, especially in less developed regions. There is an urgent need to build more child and adolescent psychiatric units in provinces where there are none, and to increase the number of beds within the units that exist presently.

Exploring the Prevalence of Clozapine Phenotypic Poor Metabolizers in 4 Asian Samples: They Ranged Between 2% and 13.

PURPOSE/BACKGROUND: Clozapine clearance is influenced by sex, smoking status, ethnicity, coprescription of inducers or inhibitors, obesity, and inflammation. In 126 Beijing inpatients, we measured repeated trough steady-state serum concentrations and identified 4% (5/126) who were phenotypical poor metabolizers (PMs); none were ultrarapid metabolizers (UMs). They were defined as being 2 SDs beyond the means of total clozapine concentration/dose ratios stratified by sex and smoking. Using this definition, this study explores the prevalence of PMs and UMs using data from 4 already published Asian samples. Three samples were East Asian (Beijing 2, Taipei, and Seoul); one was from South India (Vellore). FINDINGS/RESULTS: The prevalence of phenotypical PMs ranged from 2% to 13%, but inflammation was not excluded. The prevalence was 7% (14/191) for Beijing 2, 11% (8/70) for Taipei, 13% (9/67) for Seoul, and 2% (2/101) for the Vellore sample. Five phenotypic PMs appeared to be associated with extreme obesity. Phenotypic UM prevalence ranged from 0% to 1.6% but may be partly explained by lack of adherence. A Vellore phenotypic UM appeared to be associated with induction through high coffee intake. IMPLICATIONS/CONCLUSIONS: Approximately 10% of Asians may be clozapine PMs and may need only 50 to 150 mg/d to get therapeutic concentrations. Future studies combining gene sequencing for new alleles with repeated concentrations and careful control of confounders including inhibitors, inflammation, and obesity should provide better estimations of the prevalence of phenotypic clozapine PMs across races. Clozapine UM studies require excluding potent inducers, careful supervision of compliance in inpatient settings, and multiple serum concentrations.

Satisfaction of psychiatric inpatients in China: clinical and institutional correlates in a national sample.

BACKGROUND: Surveying patients' satisfaction is essential to improve patient-centered care, however, studies on satisfaction and their correlates among psychiatric inpatients are rare in China. This study aimed to measure satisfaction levels of psychiatric inpatients in a national sample and to examine individual and institutional correlates. METHODS: As part of the National Survey for the Evaluation of Psychiatric Hospital Performance, psychiatric inpatients from 32 tertiary psychiatric hospitals in 29 Chinese provinces were interviewed on the day of discharge by trained research staff. Satisfaction was assessed using a five-item questionnaire. Patients' sociodemographic and clinical information were manually retrieved from medical records and institutional data were provided by participating hospitals. Multilevel linear regression was used to assess factors associated with level of satisfaction. RESULTS: Among 1663 inpatients, the reported satisfaction levels were high, with a mean score of 23.3 ± 2.4 out of 25. Education level was positively associated with global satisfaction, satisfaction with costs, and satisfaction with privacy protection. Treatment response was associated with global satisfaction and with the doctor-patient communication subscore. The number of psychotherapy sessions was positively associated with the privacy protection subscore (coefficient = 0.0, P = 0.046). The Global Assessment of Function score was positively associated with the doctor-patient communication subscore (coefficient = 0.0, P = 0.003). Total satisfaction scores and all five subscores were positively associated with hospital-level factors, and patients discharged from hospitals with better staffing and resources reported significantly higher levels of satisfaction. CONCLUSION: Overall, psychiatric inpatients in China were satisfied with the services they received. To further improve patient satisfaction, mental health professionals should optimize their patients' treatment response as much as possible before discharge and provide more psychological treatment during the hospitalization. The government should also provide more resources to increase the number of mental health professionals (nurses, psychologists, and psychiatrists) working in psychiatric hospitals.

Satisfaction of family members with inpatient psychiatric care and its correlates: a national survey in China.

BACKGROUND: Measuring family members' satisfaction with inpatient psychiatric care may help improve the quality of healthcare in psychiatric hospitals. This survey aimed to investigate the satisfaction of family members with inpatient psychiatric care and to explore its associated factors, using a newly-developed 5-item questionnaire. METHODS: This study included 1598 family members of psychiatric inpatients in 32 tertiary public psychiatric hospitals in 29 provinces of China. Satisfaction and demographic data were collected by research staff while patient and hospital data were retrieved separately. RESULTS: We found that the overall satisfaction level was 93.84% (23.46/25). The total satisfaction score in Northeast China was the highest, followed by the East, Middle and West regions (p < 0.001). There was no significant sex difference in total family satisfaction scores. Family members with a lower educational background (elementary school or less) had significantly lower satisfaction. Family members of patients who were diagnosed with schizophrenia were significantly less satisfied with doctor-family communication. In different treatment response subgroups, the marked improvement subgroup had significantly higher total satisfaction scores and subscores. Meanwhile, lower self-payment expenses and a higher number of psychologic treatments offered per day were significantly associated with higher total satisfaction scores and all subscores. Logistic regression showed a higher educational background, more psychologic treatments offered per day, adequacy of professional staffing (higher doctor/bed, nurse/bed and psychologist/bed ratio) were all significantly associated with higher family satisfaction. CONCLUSIONS: We suggest government and hospital managers recruit more mental health professions to improve family satisfaction. If feasible, providing more psychologic treatments to inpatients may also improve families' satisfaction and involvement.

Developing medical record-based, healthcare quality indicators for psychiatric hospitals in China: a modified Delphi-Analytic Hierarchy Process study.

OBJECTIVES: To develop a medical record-based, comprehensive system of healthcare quality indicators for psychiatric hospitals in China. DESIGN: A modified Delphi process with analytic hierarchy process (AHP) was used. PARTICIPANTS: Twenty nationally-recognized experts were invited to participate in two rounds of Delphi expert consultation and AHP. METHODS: Fifty potential indicators were included based on literature review, and 20 experts were asked to rate the importance of each indicator using two rounds of email surveys. The AHP was used to determine the relative importance of the finalized quality indicators. RESULTS: The average authoritative coefficient was 0.92 ± 0.07. After two rounds of Delphi consultation, 47 healthcare quality indicators were identified for Chinese psychiatric hospitals. The mean importance ratings ranged from 7.06 to 8.84 on a nine-point scale, with variation coefficients ranging from 0.04 to 0.22. The percentage of full score for potential indicators ranged from 16% to 74%. In two rounds, the Kendall's W coefficients ranged from 0.423 to 0.535. The weights of structure, process and outcome were 0.175, 0.211 and 0.614, respectively. CONCLUSION: We developed the first set of healthcare quality indicators for psychiatric hospitals in mainland China, and it will provide a standardized and meaningful guide to evaluate the healthcare quality of psychiatric hospitals across the country.

Job satisfaction and associated factors among psychiatric nurses in tertiary psychiatric hospitals: Results from a nationwide cross-sectional study.

AIMS: To investigate the job satisfaction among psychiatric nurses in China and to explore its associated factors. DESIGN: A cross-sectional survey among a nationwide sample from 32 tertiary psychiatric hospitals in 29 provincial capitals in China. METHODS: Nurses (N = 9.907) were targeted for this survey in December 2017. In all, 8,493 responded (response rate = 85.7%) and 7,881 (79.5%) were included in the analysis. An online questionnaire was used to collect demographics and factors related to the work environment. The short version of the Minnesota Satisfaction Questionnaire was used to assess job satisfaction. Multilevel regression was used to examine the association between job satisfaction and these factors. RESULTS: The mean job satisfaction score was 73.7. The multiple regression analysis indicated that self-rated health, monthly income, medical liability insurance coverage, perceived respect from patients, social recognition, nurse-physician collaboration, and trust were significantly associated with higher job satisfaction scores, while age, work hours, and directly experiencing patient-initiated violence were negatively associated with job satisfaction (p < .05). CONCLUSION: Overall, Chinese psychiatric nurses are closer to satisfied than neutral and some demographics and factors related to stressful work environments were associated with nurses' job satisfaction scores. IMPACT: This study examined factors associated with the job satisfaction of Chinese psychiatric nurses in a nationwide sample and indicated that to improve nurses' job satisfaction, the government and hospital administrators could consider ways to promote nurses' personal health and to modify the stressful work environments, such as improving income, reducing work hours, promoting the psychiatric nursing specialty in ways that increase the public's respect for it, increasing awareness of medical liability insurance coverage, and protecting nurses from patients' violence.