Repetitive transcranial magnetic stimulation for the treatment of negative symptoms in residual schizophrenia: rationale and design of a sham-controlled, randomized multicenter study

Current meta-analysis revealed small, but significant effects of repetitive transcranial magnetic stimulation (rTMS) on negative symptoms in patients with schizophrenia. There is a need for further controlled, multicenter trials to assess the clinical efficacy of rTMS on negative symptoms in schizophrenia in a larger sample of patients. The objective of this multicenter, randomized, sham-controlled, rater- and patient-blind clinical trial is to investigate the efficacy of 3-week 10-Hz high frequency rTMS add on to antipsychotic therapy, 15 sessions per 3 weeks, 1,000 stimuli per session, stimulation intensity 110% of the individual motor threshold) of the left dorsolateral prefrontal cortex for treating negative symptoms in schizophrenia, and to evaluate the effect during a 12 weeks of follow-up. The primary efficacy endpoint is a reduction of negative symptoms as assessed by the negative sum score of the positive and negative symptom score (PANSS). A sample size of 63 in each group will have 80% power to detect an effect size of 0.50. Data analysis will be based on the intention to treat population. The study will be conducted at three university hospitals in Germany. This study will provide information about the efficacy of rTMS in the treatment of negative symptoms. In addition to psychopathology, other outcome measures such as neurocognition, social functioning, quality of life and neurobiological parameters will be assessed to investigate basic mechanisms of rTMS in schizophrenia. Main limitations of the trial are the potential influence of antipsychotic dosage changes and the difficulty to ensure adequate blinding.

Gender moderates the relationship between mania spectrum and serotonin transporter polymorphisms in depression

The short (s) variant of the serotonin transporter gene linked functional polymorphic region (5-HTTLPR) is associated with depression. Stressful life events, gender, and race have been shown to moderate this association. Because features of mania/hypomania seem to constitute an indicator of higher severity of depression, we examined the relationship between 5-HTTLPR genotype and symptoms of mania-hypomania spectrum occurring over the lifetime in patients with major depression. The possible moderating role of gender in this relationship was taken into account. Two hundred twenty-two patients with unipolar major depression were genotyped for 5-HTTLPR and nine other representative polymorphisms, and were administered the Mood Spectrum Questionnaire, Lifetime Version (MOODS-SR). The manic-hypomanic (MH) component score was used for analysis. Using a linear model of the MH score as a function of genotypes and gender, controlling for age, severity of depression, and site, we found significant effects of gender (F = 8.003, df = 1, P = 0.005), of the interaction gender x genotype (F = 4.505, df = 2, P = 0.012), and of the baseline Hamilton score (F = 5.404, df = 1, P = 0.021), non-significant effects of genotype (F = 1.298, df = 2, P = 0.275), age (F = 0.310, df = 1, P = 0.578) site (F = 0.504, df = 1, P = 0.479). Significant associations were also detected at three other SNPs. The association between the manic/hypomanic component of the MOODS-SR and the polymorphisms of the 5-HTTLPR is moderated by gender. This finding is intriguing from a clinical point of view because women with unipolar disorder and the "ss" genotype seem to constitute a sub-group with higher severity of depression. These results should be considered tentative pending replication in other samples.

Clinical characteristics and treatment outcome of depression in patients with and without a history of emotional and physical abuse

Clinical features and treatment outcome were compared in depressed outpatients with and without a history of emotional and physical abuse (EPA), including childhood maltreatment. Patients were initially randomized to IPT or SSRI and then augmented with the second treatment if they did not remit with monotherapy. Assessments included the SCID-I, the SCID-II for DSM-IV diagnoses, the HRSD, the QIDS and the Mood Spectrum Self-Report (MOODS-SR). Seventy-eight (25%) patients reported a history of EPA; 60 (76.9%) were women. Patients with a history of EPA did not differ from those without on HRSD scores at baseline, but showed an earlier age at onset of depression and a longer duration of illness. The two groups differed on several mood spectrum factors, namely: 'depressivemood' (15.6+/-4.9 vs. 13.5+/-5.4; p<0.004), 'psychomotorretardation' (11.7+/-4.5 vs. 9.6+/-4.7; p<0.001), 'drugandillness-relateddepression' (1.3+/-1.3 vs. 0.6+/-1.0; p<0.0001), and 'neurovegetativesymptoms' (8.3+/-2.6 vs. 6.9+/-2.9; p<0.0001). Patients with EPA had also a significantly longer time to remission (89 vs. 67days, log-rank test, p=0.035). The need for augmentation treatment was significantly more frequent among patients with EPA than in those without. The present study suggests that patients with a history of EPA show a subtype of depression characterized by poor treatment response and more severe neurovegetative and psychomotor symptoms.

Green Foxtail (Setaria viridis), A Naturally Infected Grass Host of Iris yellow spot virus in Utah

Iris yellow spot virus (IYSV; family Bunyaviridae, genus Tospovirus) is a serious virus pathogen in onion bulb and seed crops in the United States and several parts of the world (1). The virus is exclusively transmitted by onion thrips (Thrips tabaci). Besides onion and other susceptible crops such as garlic, leek, chives, and several ornamentals, weeds could be serving as potential reservoir sources of virus inoculum. There are reports of several weeds found naturally infected with IYSV (1,2,4). However, there is no report of IYSV infection of a grass species. Leaves of green foxtail (Setaria viridis (L.) Beauv.) were collected from two naturally occurring plants approximately 30 m apart in a weed trial conducted in commercial onions grown in Box Elder County, UT on 24 September 2008. Notes of IYSV symptoms on green foxtail were made only on the two grass plants sampled. Density of green foxtail in the weed trial was low and was not recorded. Leaves on both plants displayed a range of symptoms that included streaking, purpling, and chlorotic and necrotic lesions along leaf margins oriented along the axis of longitudinal venation. Samples were positive for IYSV by double-antibody sandwich-ELISA with a commercially available kit (Agdia Inc., Elkhart, IN). ELISA values of the grass samples were 2.64 and 2.23 for each plant sampled. Negative and positive control readings were 0.24 and 4.33, respectively. All absorbance readings were made at 405 nm. To provide a contrast of the grass data in context to the onion field where the weed trial was located, final visual assessments of onions in the field were made on 4 September 2009. Approximately 300 onion plants were assessed for incidence and severity of disease. Incidence of the disease among onions was 100% and the severity of iris yellow spot on leaves was 20 lesions per leaf. The average ELISA value over 30 individual onions arbitrarily sampled from the field on the same day was 3.50, and the ELISA values among the samples ranged from 1.37 to 4.38. The negative and positive controls were 0.19 and 4.40, respectively. To further verify the presence of IYSV in the grass specimen, reverse transcription-PCR was performed on total nucleic acid extracts obtained from the symptomatic parts of the leaves. Primers specific to the nucleocapsid (N) gene coded by the small (S)-RNA of IYSV were used (3). The forward and reverse primer pairs, 5'-TCAGAAATCGAGAAACTT-3' and 5'-CACCAATGTCTTCAACAATCTT-3', respectively, amplify a 751-nt fragment of the N gene (3). An amplicon of expected size was obtained, cloned, and sequenced. The nucleotide sequence analysis and comparison with known IYSV S-RNA sequences showed that the amplicon from foxtail (GenBank Accession No. FJ652594) samples had the highest nucleotide sequence identity (98%) with the corresponding region of an IYSV isolate from Jefferson County, OR (GenBank Accession No. DQ233479). To our knowledge, this is the first report of natural infection of a grass species by IYSV and the first report of a Tospovirus infecting a grass species. The data suggests grasses may serve as a new host reservoir for IYSV. The increasing number of weed hosts of IYSV warrants further study on the role of these weeds as hosts for onion thrips and in IYSV epidemiology. References: (1) D. Gent et al. Plant Dis. 90:1468, 2006. (2) C. Nischwitz et al. Plant Dis. 91:1518, 2007. (3) H. R. Pappu et al. Arch. Virol. 151:1015, 2006. (4) R. Sampangi et al. Plant Dis. 91:1683, 2007.

The factor structure of lifetime depressive spectrum in patients with unipolar depression

BACKGROUND

While previous attempts to elucidate the factor structure of depression tended to agree on a central focus on depressed mood, other factors were not replicated across studies. By examining data from a large number of items covering the range of depressive symptoms, the aim of the present study is to contribute to the identification of the structure of depression on a lifetime perspective.

METHODS

The study sample consisted of 598 patients with unipolar depression who were administered the Mood Spectrum Self-Report (lifetime version) in Italian (N=415) or English (N=183). In addition to classical exploratory factor analysis using tetrachoric correlation coefficients, an IRT-based factor analysis approach was adopted to analyze the data on 74 items of the instrument that explore cognitive, mood and energy/activity features associated with depression.

RESULTS

Six factors were identified, including 'Depressive Mood', 'Psychomotor Retardation', 'Suicidality', 'Drug/Illness related depression', 'Psychotic Features' and 'Neurovegetative Symptoms', accounting overall for 48.3% of the variance of items.

LIMITATIONS

Clinical information on onset of depression and duration of illness is available only for 350 subjects. Therefore, differences between sites can only be partially accounted using available data.

CONCLUSIONS

Our study confirms the central role of depressed mood, psychomotor retardation and suicidality and identifies the factors 'Drug/Illness related depression', 'Psychotic features' and the neurovegetative dysregulation not captured by the instruments most frequently used in previous studies. The identification of patients with specific profiles on multiple factors may be useful in achieving greater precision in neuroimaging studies and in informing treatment selection.

Natural Infection of Iris yellow spot virus in Twoscale Saltbush (Atriplex micrantha) Growing in Utah

Iris yellow spot virus (IYSV; family Bunyaviridae, genus Tospovirus) continues to be an economically important pathogen affecting onion bulb and seed production in several parts of the world and the United States (1). Several weeds were reported naturally infected with IYSV (1,2,4). Leaves of Atriplex micrantha Ledeb. (synonym A. heterosperma Bunge) were collected from naturally occurring plants in a weed trial conducted in commercial onions grown in Box Elder County, UT on 24 September 2008. Leaves displayed a range of symptoms including spotting, chlorosis, and necrosis. Symptomatic leaves were preferentially selected for subsequent diagnostic analyses. Samples were positive for IYSV when tested by double-antibody sandwich-ELISA using a commercially available kit (Agdia Inc., Elkhart, IN). For further confirmation, total nucleic acid extracts from the symptomatic parts of the leaves were prepared and tested for the presence of IYSV by reverse transcription-PCR with primers specific to the nucleocapsid (N) gene coded by the small (S)-RNA of IYSV. The forward and reverse primer pair, 5'-TCAGAAATCGAGAAACTT-3' and 5'-CACCAATGTCTTCAACAATCTT-3', respectively, amplifies a 751-nt fragment of the N gene (3). An amplicon of expected size was obtained, cloned, and sequenced. The nucleotide sequence analysis and comparison with known IYSV S-RNA sequences showed that the sequence of the amplicon from A. micrantha (GenBank Accession No. FJ493541) shared more than 84% nt sequence identity with the corresponding region of IYSV isolates available in GenBank, confirming the IYSV infection of the new host weed. The highest sequence identity (98%) was with an IYSV isolate from Jefferson County, OR (GenBank Accession No. DQ233479). To our knowledge, this is the first report of IYSV infection of A. micrantha under natural conditions. The role of A. micrantha and other weeds in IYSV epidemiology needs further investigation. References: (1) D. Gent et al. Plant Dis. 90:1468, 2006. (2) C. Nischwitz et al. Plant Dis. 91:1518, 2007. (3) H. R. Pappu et al. Arch. Virol. 151:1015, 2006. (4) R. Sampangi et al. Plant Dis. 91:1683, 2007.

The structure of lifetime manic-hypomanic spectrum

BACKGROUND

The observation that bipolar disorders frequently go unrecognized has prompted the development of screening instruments designed to improve the identification of bipolarity in clinical and non-clinical samples. Starting from a lifetime approach, researchers of the Spectrum Project developed the Mood Spectrum Self-Report (MOODS-SR) that assesses threshold-level manifestations of unipolar and bipolar mood psychopathology, but also atypical symptoms, behavioral traits and temperamental features. The aim of the present study is to examine the structure of mania/hypomania using 68 items of the MOODS-SR that explore cognitive, mood and energy/activity features associated with mania/hypomania.

METHODS

A data pool of 617 patients with bipolar disorders, recruited at Pittsburgh and Pisa, Italy was used for this purpose. Classical exploratory factor analysis, based on a tetrachoric matrix, was carried out on the 68 items, followed by an Item Response Theory (IRT)-based factor analytic approach.

RESULTS

Nine factors were initially identified, that include Psychomotor Activation, Creativity, Mixed Instability, Sociability/Extraversion, Spirituality/Mysticism/Psychoticism, Mixed Irritability, Inflated Self-esteem, Euphoria, Wastefulness/Recklessness, and account overall for 56.4% of the variance of items. In a subsequent IRT-based bi-factor analysis, only five of them (Psychomotor Activation, Mixed Instability, Spirituality/Mysticism/Psychoticism, Mixed Irritability, Euphoria) were retained.

CONCLUSIONS

Our data confirm the central role of Psychomotor Activation in mania/hypomania and support the definitions of pure manic (Psychomotor Activation and Euphoria) and mixed manic (Mixed Instability and Mixed Irritability) components, bearing the opportunity to identify patients with specific profiles for a better clinical and neurobiological definition.

The structure of lifetime panic-agoraphobic spectrum

The heterogeneity of the clinical presentation of panic disorder (PD) has prompted researchers to describe different subtypes of PD, on the basis of the observed predominant symptoms constellation. Starting from a dimensional approach to panic disorder, an instrument to assess lifetime panic-agoraphobic spectrum (PAS) available in interview or self-report form (SCI-PAS, PAS-SR) was developed which proved to have sound psychometric properties and the ability to predict delayed response to treatment in patients with mood disorders. However, the structure of the instrument was defined a priori and an examination of its empirical structure is still lacking. Aim of the present report is to analyse the factor structure of the PAS taking advantage of a large database of subjects with panic disorders (N=630) assessed in the framework of different studies. Using a classical exploratory factor analysis based on a tetrachoric correlation matrix and oblique rotation, 10 factors were extracted, accounting overall for 66.3% of the variance of the questionnaire: panic symptoms, agoraphobia, claustrophobia, separation anxiety, fear of losing control, drug sensitivity and phobia, medical reassurance, rescue object, loss sensitivity, reassurance from family members. The first two factors comprise the DSM-IV criteria for panic disorder and agoraphobia. The other factors had received limited empirical support to date. We submit that these symptoms profiles might be clinically relevant for tailoring drug treatments or psychotherapeutic approaches to specific needs. Future perspectives might include the use of these factors to select homogeneous subgroups of patients for brain-imaging studies and to contribute to elucidating the causes and pathophysiology of panic disorder at molecular level.