Persistent negative symptoms in youth at clinical high risk for psychosis: A longitudinal study

BACKGROUND

Severity of negative symptoms has been associated with poor functioning, cognitive deficits, and defeatist beliefs in schizophrenia patients. However, one area that remains understudied is persistent negative symptoms (PNS). Negative symptoms, including PNS, have been observed in those at clinical high-risk (CHR) for psychosis. The aim of this study was to determine if PNS were associated with functioning, neurocognition, and defeatist beliefs in a CHR sample.

METHOD

CHR participants (n = 764) were recruited for the North American Prodrome Longitudinal Study. Negative symptoms were rated on the Scale of Psychosis-risk Symptoms. Generalized linear mixed models for repeated measures were used to examine changes over time between and within groups (PNS vs non-PNS).

RESULTS

The PNS group (n = 67) had significant deficits in functioning at baseline, 6, 12, 18, and 24-months compared to the non-PNS group (n = 673). Functioning improved over time in the non-PNS group, while functioning in the PNS group remained relatively stable and poor over a two-year period. A consistent trend emerged demonstrating higher defeatist beliefs in the PNS group; however, this result was lost when controlling for persistent depressive symptoms. There were no significant differences between the groups on neurocognition, social cognition, and transition to psychosis.

CONCLUSIONS

PNS exist in youth at CHR for psychosis, resulting in significant and persistent functional impairment, which remains when controlling for persistent depressive symptoms. PNS remain even in CHR youth who do not transition to psychosis. Thus, PNS may represent an unmet therapeutic need in CHR populations for which there are currently no effective treatments.

The Early Psychosis Screener for Internet (EPSI)-SR: Predicting 12 month psychotic conversion using machine learning

INTRODUCTION

A faster and more accurate self-report screener for early psychosis is needed to promote early identification and intervention.

METHODS

Self-report Likert-scale survey items were administered to individuals being screened with the Structured Interview for Psychosis-risk Syndromes (SIPS) and followed at eight early psychosis clinics. An a priori analytic plan included Spectral Clustering Analysis to reduce the item pool, followed by development of Support Vector Machine (SVM) classifiers.

RESULTS

The cross-validated positive predictive value (PPV) of the EPSI at the default cut-off (76.5%) exceeded that of the clinician-administered SIPS (68.5%) at separating individuals who would not convert to psychosis within 12 months from those who either would convert within 12 months or who had already experienced a first episode psychosis (FEP). When used in tandem with the SIPS on clinical high risk participants, the EPSI increased the combined PPV to 86.6%. The SVM classified as FEP/converters only 1% of individuals in non-clinical and 4% of clinical low risk populations. Sensitivity of the EPSI, however, was 51% at the default cut-off.

DISCUSSION

The EPSI identifies, comparably to the SIPS but in less time and with fewer resources, individuals who are either at very high risk to develop a psychotic disorder within 12 months or who are already psychotic. At its default cut-off, EPSI misses 49% of current or future psychotic cases. The cut-off can, however, be adjusted based on purpose. The EPSI is the first validated assessment to predict 12-month psychotic conversion. An online screening system, www.eps.telesage.org, is under development.

The Early Psychosis Screener (EPS): Item development and qualitative validation

A panel of experts assembled and analyzed a comprehensive item bank from which a highly sensitive and specific early psychosis screener could be developed. Twenty well-established assessments relating to the prodromal stage, early psychosis, and psychosis were identified. Using DSM-5 criteria, we identified the core concepts represented by each of the items in each of the assessments. These granular core concepts were converted into a uniform set of 490 self-report items using a Likert scale and a 'past 30days' time frame. Partial redundancy was allowed to assure adequate concept coverage. A panel of experts and TeleSage staff rated these items and eliminated 189 items, resulting in 301 items. The items were subjected to five rounds of cognitive interviewing with 16 individuals at clinically high risk for psychosis and 26 community mental health center patients. After each round, the expert panel iteratively reviewed, rated, revised, added, or deleted items to maximize clarity and centrality to the concept. As a result of the interviews, 36 items were revised, 52 items were added, and 205 items were deleted. By the last round of cognitive interviewing, all of the items were clearly understood by all participants. In future work, responses to the final set of 148 items and machine learning techniques will be used to quantitatively identify the subset of items that will best predict clinical high-risk status and conversion.

The Early Psychosis Screener (EPS): Quantitative validation against the SIPS using machine learning

Machine learning techniques were used to identify highly informative early psychosis self-report items and to validate an early psychosis screener (EPS) against the Structured Interview for Psychosis-risk Syndromes (SIPS). The Prodromal Questionnaire-Brief Version (PQ-B) and 148 additional items were administered to 229 individuals being screened with the SIPS at 7 North American Prodrome Longitudinal Study sites and at Columbia University. Fifty individuals were found to have SIPS scores of 0, 1, or 2, making them clinically low risk (CLR) controls; 144 were classified as clinically high risk (CHR) (SIPS 3-5) and 35 were found to have first episode psychosis (FEP) (SIPS 6). Spectral clustering analysis, performed on 124 of the items, yielded two cohesive item groups, the first mostly related to psychosis and mania, the second mostly related to depression, anxiety, and social and general work/school functioning. Items within each group were sorted according to their usefulness in distinguishing between CLR and CHR individuals using the Minimum Redundancy Maximum Relevance procedure. A receiver operating characteristic area under the curve (AUC) analysis indicated that maximal differentiation of CLR and CHR participants was achieved with a 26-item solution (AUC=0.899±0.001). The EPS-26 outperformed the PQ-B (AUC=0.834±0.001). For screening purposes, the self-report EPS-26 appeared to differentiate individuals who are either CLR or CHR approximately as well as the clinician-administered SIPS. The EPS-26 may prove useful as a self-report screener and may lead to a decrease in the duration of untreated psychosis. A validation of the EPS-26 against actual conversion is underway.

Premorbid social adjustment and association with attenuated psychotic symptoms in clinical high-risk and help-seeking youth

BACKGROUND

Attenuated positive symptom syndrome (APSS), characterized by 'putatively prodromal' attenuated psychotic-like pathology, indicates increased risk for psychosis. Poor premorbid social adjustment predicts severity of APSS symptoms and predicts subsequent psychosis in APSS-diagnosed individuals, suggesting application for improving detection of 'true' prodromal youth who will transition to psychosis. However, these predictive associations have not been tested in controls and therefore may be independent of the APSS diagnosis, negating utility for improving prediction in APSS-diagnosed individuals.

METHOD

Association between premorbid social maladjustment and severity of positive, negative, disorganized, and general APSS symptoms was tested in 156 individuals diagnosed with APSS and 76 help-seeking (non-APSS) controls enrolled in the Enhancing the Prospective Prediction of Psychosis (PREDICT) study using prediction analysis.

RESULTS

Premorbid social maladjustment was associated with social anhedonia, reduced expression of emotion, restricted ideational richness, and deficits in occupational functioning, independent of the APSS diagnosis. Associations between social maladjustment and suspiciousness, unusual thought content, avolition, dysphoric mood, and impaired tolerance to normal stress were uniquely present in participants meeting APSS criteria. Social maladjustment was associated with odd behavior/appearance and diminished experience of emotions and self only in participants who did not meet APSS criteria.

CONCLUSIONS

Predictive associations between poor premorbid social adjustment and attenuated psychotic-like pathology were identified, a subset of which were indicative of high risk for psychosis. This study offers a method for improving risk identification while ruling out low-risk individuals.

Evidence for genetic heterogeneity between clinical subtypes of bipolar disorder

We performed a genome-wide association study of 6447 bipolar disorder (BD) cases and 12 639 controls from the International Cohort Collection for Bipolar Disorder (ICCBD). Meta-analysis was performed with prior results from the Psychiatric Genomics Consortium Bipolar Disorder Working Group for a combined sample of 13 902 cases and 19 279 controls. We identified eight genome-wide significant, associated regions, including a novel associated region on chromosome 10 (rs10884920; P=3.28 × 10-8) that includes the brain-enriched cytoskeleton protein adducin 3 (ADD3), a non-coding RNA, and a neuropeptide-specific aminopeptidase P (XPNPEP1). Our large sample size allowed us to test the heritability and genetic correlation of BD subtypes and investigate their genetic overlap with schizophrenia and major depressive disorder. We found a significant difference in heritability of the two most common forms of BD (BD I SNP-h2=0.35; BD II SNP-h2=0.25; P=0.02). The genetic correlation between BD I and BD II was 0.78, whereas the genetic correlation was 0.97 when BD cohorts containing both types were compared. In addition, we demonstrated a significantly greater load of polygenic risk alleles for schizophrenia and BD in patients with BD I compared with patients with BD II, and a greater load of schizophrenia risk alleles in patients with the bipolar type of schizoaffective disorder compared with patients with either BD I or BD II. These results point to a partial difference in the genetic architecture of BD subtypes as currently defined.

Relationship of low vitamin D status with positive, negative and cognitive symptom domains in people with first-episode schizophrenia

AIM

Deficient vitamin D levels are very common among Americans of all ages and ethnicities, but little is known about its prevalence or associated problems among those with schizophrenia.

METHODS

Stored plasma from 20 recent onset schizophrenia subjects and 20 matched healthy comparison subjects were analysed for 25 OH vitamin D, and related to measures of symptom severity and neurocognition.

RESULTS

There was no significant difference in mean 25 OH vitamin D between the schizophrenia and the healthy comparison subjects (28.2 standard deviation (SD) 12.6 ng mL(-1) vs. 29.9 SD 14.3 ng mL(-1) ), and about half the subjects in each group had insufficient levels (<30 ng mL(-1) ). Among psychosis subjects, greater severity of negative symptoms was correlated with lower vitamin D status (r = -0.55, P = 0.012); the correlations of overall symptom severity and positive symptom severity with 25 OH vitamin D levels approached significance (r = -0.42, P = 0.07 and r = -0.36, P = 0.12, respectively). There was no relationship of vitamin D with depressive symptoms. Among the schizophrenia subjects, lower 25 OH vitamin D levels were associated with more severe overall cognitive deficits (r = 0.56, P = 0.019).

CONCLUSION

This study found that lower vitamin D levels in schizophrenia subjects were associated with more severe negative symptoms and overall cognitive deficits. However, the cross-sectional design precludes any conclusions about whether low vitamin D status in fact causes more severe negative symptoms and cognitive impairments. No relationship was found between lower vitamin D levels and depressive symptoms.

Substance use in individuals at clinical high risk of psychosis

BACKGROUND

A series of research reports has indicated that the use of substances such as cannabis, alcohol and tobacco are higher in youth at clinical high risk (CHR) of developing psychosis than in controls. Little is known about the longitudinal trajectory of substance use, and findings on the relationship between substance use and later transition to psychosis in CHR individuals are mixed.

METHOD

At baseline and 6- and 12-month follow-ups, 735 CHR and 278 control participants completed the Alcohol and Drug Use Scale and a cannabis use questionnaire. The longitudinal trajectory of substance use was evaluated with linear mixed models.

RESULTS

CHR participants endorsed significantly higher cannabis and tobacco use severity, and lower alcohol use severity, at baseline and over a 1-year period compared with controls. CHR youth had higher lifetime prevalence and frequency of cannabis, and were significantly younger upon first use, and were more likely to use alone and during the day. Baseline substance use did not differentiate participants who later transitioned to psychosis (n = 90) from those who did not transition (n = 272). Controls had lower tobacco use than CHR participants with a prodromal progression clinical outcome and lower cannabis use than those with a psychotic clinical outcome at the 2-year assessment.

CONCLUSIONS

In CHR individuals cannabis and tobacco use is higher than in controls and this pattern persists across 1 year. Evaluation of clinical outcome may provide additional information on the longitudinal impact of substance use that cannot be detected through evaluation of transition/non-transition to psychosis alone.

Alcohol confounds relationship between cannabis misuse and psychosis conversion in a high-risk sample

OBJECTIVE

Cannabis use has been examined as a predictor of psychosis in clinical high-risk (CHR) samples, but little is known about the impact of other substances on this relationship.

METHOD

Substance use was assessed in a large sample of CHR participants (N = 370, mean age = 18.3) enrolled in the multisite North American Prodrome Longitudinal Study Phase 1 project. Three hundred and forty-one participants with cannabis use data were divided into groups: No Use (NU, N = 211); Cannabis Use without impairment (CU, N = 63); Cannabis Abuse/Dependence (CA/CD, N = 67). Participants (N = 283) were followed for ≥2 years to determine psychosis conversion.

RESULTS

Alcohol (45.3%) and cannabis (38.1%) were the most common substances. Cannabis use groups did not differ on baseline attenuated positive symptoms. Seventy-nine of 283 participants with cannabis and follow-up data converted to psychosis. Survival analysis revealed significant differences between conversion rates in the CA/CD group compared with the No Use (P = 0.031) and CU group (P = 0.027). CA/CD also significantly predicted psychosis in a regression analysis, but adjusting for alcohol use weakened this relationship.

CONCLUSION

The cannabis misuse and psychosis association was confounded by alcohol use. Non-impairing cannabis use was not related to psychosis. Results highlight the need to control for other substance use, so as to not overstate the cannabis/psychosis connection.

Genome-wide pharmacogenomic analysis of response to treatment with antipsychotics

Schizophrenia is an often devastating neuropsychiatric illness. Understanding the genetic variation affecting response to antipsychotics is important to develop novel diagnostic tests to match individual schizophrenia patients to the most effective and safe medication. In this study, we use a genome-wide approach to detect genetic variation underlying individual differences in response to treatment with the antipsychotics olanzapine, quetiapine, risperidone, ziprasidone and perphenazine. Our sample consisted of 738 subjects with DSM-IV schizophrenia who took part in the Clinical Antipsychotic Trials of Intervention Effectiveness. Subjects were genotyped using the Affymetrix 500 K genotyping platform plus a custom 164 K chip to improve genome-wide coverage. Treatment outcome was measured using the Positive and Negative Syndrome Scale. Our criterion for genome-wide significance was a prespecified threshold that ensures that, on an average, only 10% of the significant findings are false discoveries. The top statistical result reached significance at our prespecified threshold and involved a single-nucleotide polymorphism (SNP) in an intergenic region on chromosome 4p15. In addition, SNPs in Ankyrin Repeat and Sterile Alpha Motif Domain-Containing Protein 1B (ANKS1B) and in the Contactin-Associated Protein-Like 5 gene (CNTNAP5), which mediated the effects of olanzapine and risperidone on Negative symptoms, were very close to our threshold for declaring significance. The most significant SNP in CNTNAP5 is nonsynonymous, giving rise to an amino-acid substitution. In addition to highlighting our top results, we provide all P-values for download as a resource for investigators with the requisite samples to carry out replication. This study demonstrates the potential of genome-wide association studies to discover novel genes that mediate the effects of antipsychotics, which could eventually help to tailor drug treatment to schizophrenic patients.

Olanzapine and haloperidol in first episode psychosis: two-year data

Few studies have assessed the comparative efficacy and safety of atypical and typical antipsychotic medications in patients within their first episode of psychosis. This study examined the effectiveness of the atypical antipsychotic olanzapine and the typical antipsychotic haloperidol in patients experiencing their first episode of a schizophrenia-related psychotic disorder over a 2-year treatment period. Two hundred and sixty-three patients were randomized to olanzapine or haloperidol in a doubleblind, multisite, international 2-year study. Clinical symptoms and side effects were assessed at baseline and longitudinally following randomization for the duration of the study. Olanzapine and haloperidol treatment were both associated with substantial and comparable reductions in symptom severity (the primary outcome measure) over the course of the study. However, the treatment groups differed on two secondary efficacy measures. Patients were less likely to discontinue treatment with olanzapine than with haloperidol: mean time (in days) in the study was significantly greater for those treated with olanzapine compared to haloperidol (322.09 vs. 230.38, p<0.0085). Moreover, remission rates were greater in patients treated with olanzapine as compared to those treated with haloperidol (57.25% vs. 43.94%, p<0.036). While extrapyramidal side effects were greater in those treated with haloperidol, weight gain, cholesterol level and liver function values were greater in patients treated with olanzapine. The data from this study suggest some clinical benefits for olanzapine as compared to haloperidol in first episode patients, which must be weighed against those adverse effects that are more likely with olanzapine.

Expanding the 'central dogma': the regulatory role of nonprotein coding genes and implications for the genetic liability to schizophrenia

It is now evident that nonprotein coding RNA (ncRNA) plays a critical role in regulating the timing and rate of protein translation. The potential importance of ncRNAs is suggested by the observation that the complexity of an organism is poorly correlated with its number of protein coding genes, yet highly correlated with its number of ncRNA genes, and that in the human genome only a small fraction (2-3%) of genetic transcripts are actually translated into proteins. In this review, we discuss several examples of known RNA mechanisms for the regulation of protein synthesis. We then discuss the possibility that ncRNA regulation of schizophrenia risk genes may underlie the diverse findings of genetic linkage studies including that protein-altering gene polymorphisms are not generally found in schizophrenia. Thus, inadequate or mistimed expression of a functional protein may occur either due to mutation or other dysfunction of the DNA coding base pair sequence, leading to a dysfunctional protein, or due to post-transcriptional events such as abnormal ncRNA regulation of a normal gene. One or more 'schizophrenia disease genes' may turn out to include abnormal transcriptional units that code for RNA regulators of protein coding gene expression or to be proximal to such units, rather than to be abnormalities in the protein coding gene itself. Understanding the genetics of schizophrenia and other complex neuropsychiatric disorders might very well include consideration of RNA and epigenetic regulation of protein expression in addition to polymorphisms of the protein coding gene.

Factorial structure of the Scale of Prodromal Symptoms

Data from the Scale of Prodromal Symptoms (SOPS) [Early Intervention in Psychotic Disorders, pp. 135-150] on 94 hitherto never-psychotic individuals were entered into a principal components analysis, revealing six components with an eigenvalue greater than 1.0. Based upon scree-plot analysis, further extractions were limited to three, then two, factors. Varimax rotation of the three-component extraction revealed factors with reasonable congruence with a priori content areas. All symptoms labeled as negative in the SOPS loaded on one factor, and four of five symptoms labeled as positive loaded on another. The remaining positive symptom, conceptual disorganization, has been found not to load with other positive-labeled symptoms in studies of schizophrenia using applicable instruments. All symptoms labeled as "general" in the SOPS loaded on a third factor, which appears to reflect the nonspecific psychological distress that might be expected in psychosis-naïve individuals experiencing the preliminary stages of a serious psychiatric disorder. The independence of this component from the positive and negative symptom factors suggests that the structure obtained suggests a clinical continuity between the at-risk presentations seen in this sample and established schizophrenia.

Neuropsychological status of subjects at high risk for a first episode of psychosis

Thirty-six subjects aged 16 years or older judged at risk for a first episode of psychosis within a North American multi-site study of the schizophrenia prodrome [McGlashan et al., Schizophr. Res. (2003); Miller et al., Schizophr. Res. (2003)] performed at levels intermediate to population norms and data reported for schizophrenia samples on a comprehensive neuropsychological exam. In the context of normal intelligence, this intermediate status suggests that, as a group, these subjects are not fully normal in neuropsychological functioning. Conversely, the finding that they do not show the levels of impairment commonly observed in schizophrenia, including within the first episode, suggests that prodromal interventions might conceivably prevent, delay, or lessen the severity of declines associated with first psychotic episodes.

Informed Consent in Early Psychosis Research: National Institute of Mental Health workshop, November 15, 2000

Recent research on the early detection and treatment of schizophrenia has generated significant scientific interest along with considerable controversy and debate. Because our ability to alleviate fully the symptoms and deficits of established schizophrenia is limited, the prospect of interrupting disease progression early is compelling. At the same time, in the absence of an infallible marker of disease risk, there are serious questions about the safety, feasibility, and ethics of intervention research on "at-risk" or putatively prodromal individuals. A workshop, Informed Consent in Early Psychosis Research, was convened by the National Institute of Mental Health (NIMH) on November 15, 2000, to review the results of recent research on early detection and intervention in schizophrenia. Beginning with the assumptions that (1) treatment of asymptomatic individuals with antipsychotic medication is not appropriate in research or clinical care, and (2) neither data nor clinical consensus defines optimal intervention for symptomatic at-risk individuals, workshop participants-including clinical researchers, mental health consumers and family members, bioethicists, community health care providers, and NIMH staff-systematically reviewed available data on the potential risks and benefits of alternate approaches to the management of prodromal states. Ethical issues involved in early detection and intervention studies were discussed. Workshop participants summarized information presented during the meeting into informed consent "bullets" that must be communicated to, and understood and appreciated by, potential research participants.

Progression to AIDS, a clinical AIDS condition and mortality: psychosocial and physiological predictors

BACKGROUND

The primary aim of this study is to examine prospectively the association of stressful life events, social support, depressive symptoms, anger, serum cortisol and lymphocyte subsets with changes in multiple measures of human immunodeficiency virus (HIV) disease progression.

METHODS

Ninety-six HIV-infected gay men without symptoms or anti-retroviral medication use at baseline were studied every 6 months for up to 9 years. Disease progression was defined in three ways using the Centers for Disease Control (CDC) classifications (e.g. AIDS, clinical AIDS condition and mortality). Cox regression models with time-dependent covariates were used, adjusting for control variables (e.g. race, age, baseline, CD4 T cells and viral load, number of anti-retroviral medications).

RESULTS

Higher cumulative average stressful life events and lower cumulative average social support predicted faster progression to both the CDC AIDS classification and a clinical AIDS condition. Higher anger scores and CD8 T cells were associated with faster progression to AIDS, and depressive symptoms were associated with faster development of an AIDS clinical condition. Higher levels of serum cortisol predicted all three measures of disease progression.

CONCLUSIONS

These results suggest that stressful life events, dysphoric mood and limited social support are associated with more rapid clinical progression in HIV infection, with serum cortisol also exerting an independent effect on disease progression.

Impact of stressful life events, depression, social support, coping, and cortisol on progression to AIDS

OBJECTIVE

This study examined prospectively the effects of stressful events, depressive symptoms, social support, coping methods, and cortisol levels on progression of HIV-1 infection.

METHOD

Eighty-two homosexual men with HIV type-1 infection without AIDS or symptoms at baseline were studied every 6 months for up to 7. 5 years. Men were recruited from rural and urban areas in North Carolina, and none was using antiretroviral medications at entry. Disease progression was defined as CD4(+) lymphocyte count <200/microl or the presence of an AIDS indicator condition.

RESULTS

Cox regression models with time-dependent covariates were used adjusting for race, baseline CD4(+) count and viral load, and cumulative average antiretroviral medications. Faster progression to AIDS was associated with higher cumulative average stressful life events, coping by means of denial, and higher serum cortisol as well as with lower cumulative average satisfaction with social support. Other background (e.g., age, education) and health habit variables (e.g., tobacco use, risky sexual behavior) did not significantly predict disease progression. The risk of AIDS was approximately doubled for every 1.5-unit decrease in cumulative average support satisfaction and for every cumulative average increase of one severe stressor, one unit of denial, and 5 mg/dl of cortisol.

CONCLUSIONS

Further research is needed to determine if treatments based on these findings might alter the clinical course of HIV-1 infection.

High versus low basal cortisol secretion in asymptomatic, medication-free HIV-infected men: differential effects of severe life stress on parameters of immune status

The authors hypothesized that HIV-infected men with high basal cortisol secretion would exhibit greater stress-related reductions in the ratio of Th1/Th2 cell-derived cytokines and numbers of CD8+ T and NK lymphocytes than low basal cortisol secretors. A semistructured interview was used to assess life stress during the preceding 6 months of 94 HIV-infected men classified as high and low cortisol secretors (n = 47/group). Increased levels of severe life stress were highly correlated with lower numbers of CD8+ T cells, CD16+ and CD56+ NK cells, CD57+ cells, and higher DHEA-S concentrations in the high cortisol group. Conversely, no significant correlations were found in the low cortisol group. No correlations were found between stress and CD4+ T helper/inducer cell counts, cytokine production, or testosterone levels in either participating group. These data suggest that severe stress in combination with high glucocorticoid activity may modify select parameters of immune status in HIV-infected men.

Characterizing and dating the onset of symptoms in psychotic illness: the Symptom Onset in Schizophrenia (SOS) inventory

Prodromal symptoms, including disturbances of perceptions, beliefs, cognition, affect, and behavior, are often the first symptoms of schizophrenia. Little is understood about the initial, prodromal stage of schizophrenia, despite the compelling research and clinical need. The development and psychometric properties of a new, time-efficient instrument to characterize and date the initial symptoms of a psychotic illnesses, the Symptom Onset in Schizophrenia (SOS) scale, is described in this paper. The SOS rates the presence and dates the onset of 16 general prodromal, positive, negative, and disorganizational symptoms, as well as a clinician, family, and patient global rating of onset of illness. Inter-rater reliability for the presence of each symptom in 35 patients with schizophrenia, schizoaffective, or schizophreniform disorder was good to excellent, with kappa coefficient >0.7 for 12 items, and >0. 5 for all items. Agreement on symptom duration was good to excellent for individual items (ICC=0.7-1.0) and for global rating of duration of illness (ICC=0.97). Our data indicate that the SOS is a reliable, valid, time-efficient tool useful to retrospectively assess the onset of schizophrenia and related psychotic disorders. Further study is underway to evaluate other psychometric properties of the SOS, including test-retest reliability and predictive validity.

Penny-wise and pound-foolish: the impact of measurement error on sample size requirements in clinical trials

BACKGROUND

Clinical research studies must compensate for measurement error by increasing the number of subjects that are studied, thereby increasing the financial costs of research and exposing greater numbers of subjects to study risks. In this article, we model the relationship between reliability and sample-size requirements and consider the potential tangible cost savings resulting from the decreased number of subjects needed when reliability of raters is improved or multiple ratings are used.

METHODS

Standard methods are used to model reliability based on the intraclass correlation coefficient (R) and to perform power calculations. The impact of multiple raters on reliability for a given baseline level of reliability is modeled according to the Spearman Brown formula.

RESULTS

Our models demonstrate that meaningful reductions in sample size requirements are gained from improvements in reliability. For example, improving reliability from R = .7 to R = .9 will decreases sample size requirements by 22%. Reliability is improved by training and by the use of the mean of multiple ratings. For example, if the reliability of a single rating is 0.7, the reliability of the mean of two ratings will be 0.8.

CONCLUSIONS

The costs to improve reliability either through rater training efforts or use of the mean of multiple ratings is cost effective because of the consequent reduction in number of subjects needed. Efforts to improve reliability and thus reduce subject requirements in a study also may lead to fewer patients bearing the burden of research participation and to a shortening of the duration of studies.

Adherence to antipsychotic medications

Taking antipsychotic medication as prescribed is one of the best means patients have of managing psychotic symptoms and preventing relapse. Yet, for various reasons, patients may discontinue taking their medication or skip doses, either occasionally or frequently. Among patients treated with conventional neuroleptics, approximately 40% stop taking their antipsychotic medication within 1 year, and about 75% stop taking the medication within 2 years. Although adverse effects play a large role in a patient's decision to discontinue antipsychotic therapy, other factors also have an effect. Using the health belief model, clinicians can assess the relative impact of various factors on medication adherence. This model posits that adherence to treatment is determined by the patient's assessment of the perceived benefits of treatment and risks of illness versus the costs of treatment (including adverse effects such as weight gain). Other factors in the decision are barriers to adherence and cues to act (i.e., reminders to take medication). Patients who believe the risks of treatment outweigh the benefits are likely to discontinue their medication and are candidates for intervention to increase adherence.

The effects of atypical antipsychotic drugs on neurocognitive impairment in schizophrenia: a review and meta-analysis

Cognitive deficits are a fundamental feature of the psychopathology of schizophrenia. Yet the effect of treatment on this dimension of the illness has been unclear. Atypical antipsychotic medications have been reported to reduce the neurocognitive impairment associated with schizophrenia. However, studies of the pattern and degree of cognitive improvement with these compounds have been methodologically limited and have produced variable results, and few findings have been replicated. To clarify our understanding of the effects of atypical antipsychotic drugs on neurocognitive deficits in patients with schizophrenia, we have (1) reported on newly established standards for research design in studies of treatment effects on cognitive function in schizophrenia, (2) reviewed the literature on this topic and determined the extent to which 15 studies on the effect of atypical antipsychotics met these standards, (3) performed a meta-analysis of the 15 studies, which suggested general cognitive enhancement with atypical antipsychotics, and (4) described the pharmacological profile of these agents and considered the pharmacological basis for their effects on neurocognition. Finally, we suggest directions for the development of new therapeutic strategies.

Progression to AIDS: the effects of stress, depressive symptoms, and social support

OBJECTIVE

We examined the effects of stress, depressive symptoms, and social support on the progression of HIV infection.

METHODS

Eighty-two HIV-infected gay men without symptoms or AIDS at baseline were followed up every 6 months for up to 5.5 years. Men were recruited from rural and urban areas in North Carolina as part of the Coping in Health and Illness Project. Disease progression was defined using criteria for AIDS (CD4+ lymphocyte count of <200/microl and/or an AIDS-indicator condition).

RESULTS

We used Cox regression models with time-dependent covariates, adjusting for age, education, race, baseline CD4+ count, tobacco use, and number of antiretroviral medications. Faster progression to AIDS was associated with more cumulative stressful life events (p = .002), more cumulative depressive symptoms (p = .008), and less cumulative social support (p = .0002). When all three variables were analyzed together, stress and social support remained significant in the model. At 5.5 years, the probability of getting AIDS was about two to three times as high among those above the median on stress or below the median on social support compared with those below the median on stress or above the median on support, respectively.

CONCLUSIONS

These data are among the first to demonstrate that more stress and less social support may accelerate the course of HIV disease progression. Additional study will be necessary to elucidate the mechanisms that underlie these relationships and to determine whether interventions that address stress and social support can alter the course of HIV infection.

Severe life stress as a predictor of early disease progression in HIV infection

OBJECTIVE

Although there is evidence that stress is associated with alterations in immunity, the role of emotional factors in the onset and course of immune-based diseases such as cancer and AIDS has not been established. This prospective study was designed to test the hypothesis that stressful life events accelerate the course of HIV disease.

METHOD

Ninety-three HIV-positive homosexual men who were without clinical symptoms at the time of entry into the study were studied for up to 42 months. Subjects received comprehensive medical, neurological, neuropsychological, and psychiatric assessments every 6 months, including assessment of stressful life events during the preceding 6-month interval. Several statistical approaches were used to assess the relation between stress and disease progression.

RESULTS

The time of the first disease progression was analyzed with a proportional hazard survival method, which demonstrated that the more severe the life stress experienced, the greater the risk of early HIV disease progression. Specifically, for every one severe stress per 6-month study interval, the risk of early disease progression was doubled. Among a subset of 66 subjects who had been in the study for at least 24 months, logistic regression analyses showed that higher severe life stress increased the odds of developing HIV disease progression nearly fourfold. the degree of disease progression was also predicted by severe life stress when a proportional odds logistic regression model was used for analysis.

CONCLUSIONS

This report presents the first evidence from a prospective research study that severe life event stress is associated with an increased rate of early HIV disease progression.

Severe stress, depressive symptoms, and changes in lymphocyte subsets in human immunodeficiency virus-infected men. A 2-year follow-up study

BACKGROUND

This study examined how severe stress and depressive symptoms were related to changes in immune measures during a 2-year period in a sample of gay men with human immunodeficiency virus (HIV) infection. These analyses follow up our initial cross-sectional observations that severe stress was correlated with lower levels of natural killer (NK) cells and CD8+ T lymphocytes in these men.

METHODS

Data were collected in North Carolina as part of an ongoing, longitudinal study, the Coping in Health and Illness Project. Sixty-six HIV-infected gay men, who were asymptomatic at baseline, were assessed systematically at 6-month intervals.

RESULTS

Severe stress and depressive symptoms were independently related to decreases on immune measures from entry to 2-year follow-up, that is, declines in CD8+ T cells and CD56+ and CD16+ NK cell subsets. Subjects most likely to have decreases on these immune measures were those who scored above the median on both stress and depressive symptoms.

CONCLUSIONS

Our findings are among the first prospective data showing that stress and depressive symptoms, especially when they occur jointly, are associated with decreased number of NK and CD8+ T lymphocytes in HIV-infected men. Since these immune cells may play a protective role in the progression of HIV infection, our data suggest that stress and depressive symptoms may have clinical implications for the course of this disease.

Fetal brain development of twins assessed in utero by ultrasound: implications for schizophrenia

There is evidence that some forms of schizophrenia are due to alterations of in utero brain development. Given the concordance rate for schizophrenia in monozygotic twins is approx. 45%, it is not clear how a shared genetic predisposition for schizophrenia and a shared in utero environment might selectively lead to schizophrenia in one but not the other twin in a monozygotic twin pair. This study was undertaken to test the hypothesis that there is a difference in brain development between twins in a monozygotic twin pair that may contribute to the observed concordance rates for schizophrenia. Fetal ultrasound measures of brain (biparietal diameter, head circumference, ventricular width) and body size (femur length, abdominal circumference) obtained during the second trimester of fetal development were retrospectively analyzed in 41 monozygotic and 103 dizygotic twin pairs. In monozygotic twin pairs, there was a significant difference in measures of biparietal diameter, head circumference, and ventricular width, as well as in femur length and abdominal circumference, between twins. There was a similar difference in dizygotic twin pairs. These results indicate that in monozygotic twins, brain development is not identical. This difference in brain development may contribute to the observed concordance rates in monozygotic twins with schizophrenia.

Depression in the medically ill: management considerations

This article reviews the management of depression in three medical conditions associated with a high frequency of depression: coronary artery disease (CAD), cancer, and human immunodeficiency virus (HIV) infection. Major depression significantly increases mortality in patients with CAD. This effect of depression may be mediated by a decrease in heart rate variability. Tricyclic antidepressants (TCAs) possess Type 1A antiarrhythmic activity, which may increase the risk of sudden death. Initial data suggest that tricyclic antidepressants also may decrease heart rate variability. Antidepressant therapy is effective and can improve quality of life for patients with cancer or HIV infection. Strong social support or psychosocial interventions that improve coping skills may positively affect outcome in HIV infection and cancer. Selective serotonin reuptake inhibitors (SSRIs) and new agents may be well suited for use in depressed patients with medical illnesses because they lack the significant adverse anticholinergic and cardiovascular effects of TCAs and other classes of antidepressants.

Somatic symptoms and HIV infection: relationship to depressive symptoms and indicators of HIV disease

OBJECTIVE

This study examined the relationship of the somatic symptoms fatigue and insomnia with indicators of both psychiatric disturbance and HIV disease severity.

METHOD

Study participants were 98 asymptomatic HIV-infected and 71 uninfected homosexual men; 82 HIV-infected and 64 uninfected men had 6-month follow-up examinations. Scales from the self-reported Profile of Mood States measured fatigue and dysphoric mood. Major depression diagnosis was determined by the Structured Clinical Interview for DSM-III-R. Selected items from the Hamilton depression and anxiety scales measured insomnia and other symptoms of depression. Performance on a battery of standardized tests determined neuropsychological function ratings.

RESULTS

At study entry, complaints of fatigue and insomnia were associated with dysphoric mood, major depression, and other non-HIV-related symptoms of major depression but not with CD4 cell counts or neuropsychological functioning. Increases in levels of fatigue and insomnia over the 6-month follow-up period were associated with increases in non-HIV-related symptoms of depression and in severity of dysphoric mood. Increases in fatigue were also associated with decrements in motor functioning. Otherwise, fatigue or insomnia were not associated with HIV disease progression.

CONCLUSIONS

These findings suggest that complaints of fatigue and insomnia in otherwise asymptomatic HIV-infected patients are likely to be related to psychological disturbances and possibly major depression, which can be treated. HIV-infected patients who complain of fatigue or insomnia should routinely be assessed for major depression.

Stress-associated reductions of cytotoxic T lymphocytes and natural killer cells in asymptomatic HIV infection

OBJECTIVE

Previous research has documented a possible relation of stress and depression to cell-mediated immunity. The authors examined how stressful events and depression may affect key parameters of cellular immunity in subjects with and without HIV infection.

METHOD

Data were collected on 99 asymptomatic HIV-positive and 65 HIV-negative homosexual men as part of an ongoing, longitudinal study. Criticisms of previous studies of psychoimmunity were addressed by 1) using a comprehensive, semistructured interview to measure the objective context of stressful events, 2) double labeling of lymphocytes with monoclonal antibodies to measure subsets of cytotoxic/suppressor T lymphocytes and natural killer (NK) cells, and 3) controlling for circadian effects and methodological factors.

RESULTS

In the HIV-positive men, severe stress was significantly associated with reductions in NK cell populations and a subset of T cells thought to represent cytotoxic T effector cells, particularly the CD8+ T cells expressing the CD57 antigen. In the HIV-negative men, no clear and consistent relation between stress and immune system measures was found. Depression was not correlated with any variables in either of the groups, perhaps due to the low levels of depressive symptoms.

CONCLUSIONS

The findings suggest that stress is associated with reductions in killer lymphocytes (decreased NK cell and cytotoxic T lymphocyte phenotypes). The data provide evidence that stress may alter cell populations that provide cytotoxic defense against infection in HIV-positive men and indicate that the clinical significance of stress-related changes in cytotoxic T lymphocytes and NK cells in HIV infection warrants further study.

Mood disorders in HIV infection: prevalence and risk factors in a nonepicenter of the AIDS epidemic

OBJECTIVE

The authors studied the lifetime, initial cross-sectional, and 6-month follow-up prevalence of mood disorders in asymptomatic HIV-infected and uninfected homosexual men who lived in an area with a low prevalence of HIV. They also determined the relationship between current major depression and potential depression risk factors.

METHOD

Subjects included 98 asymptomatic HIV-infected and 71 uninfected homosexual men. Subjects underwent extensive clinical, psychiatric, neuropsychological, and laboratory evaluations.

RESULTS

Similar proportions of HIV-infected and uninfected subjects reported a lifetime (29% and 45%, respectively), an initial current (8% and 3%), and a 6-month follow-up (9% and 11%) history of major depressive disorder. Anxiety disorders were less common, with similar proportions of HIV-infected and uninfected subjects reporting a lifetime (7% and 13%, respectively), an initial current (3% and 7%), and a 6-month follow-up (2% and 5%) history of anxiety disorders. There were no differences in the severity of mood symptoms between HIV-infected and uninfected subjects. Current major depression at initial visit was significantly associated with lifetime history of major depression but not with neuropsychological function or vitamin B12 level.

CONCLUSIONS

These findings are in agreement with previous studies of areas with a high prevalence of HIV. However, the proportion of subjects with mood disorders is high compared with general population studies. Both HIV-infected and uninfected homosexual men may be at high risk for major depression, especially if they have a past history of depression. Moreover, in the asymptomatic stage of HIV infection, major depression does not appear to be secondary to HIV central nervous system effects or low vitamin B12 levels.

Vitamin B12 deficiency and nervous system disease in HIV infection

BACKGROUND

Vitamin B12 deficiency may result in a number of neurological and neuropsychiatric disorders. Patients with human immunodeficiency virus type 1 (HIV-1) infection may have a high rate of vitamin B12 deficiency and nervous system disease. Vitamin B12 deficiency may contribute to neurological disease in HIV-1-infected individuals.

OBJECTIVE

To evaluate the possible contribution of vitamin B12 deficiency to neurological disease in HIV-1-infected individuals.

MAIN OUTCOME MEASURES

Comparison of serum vitamin B12 levels with neurological, neuropsychological, and mood state abnormalities in 153 HIV-1-positive subjects and 57 high-risk seronegative controls. A subgroup of 67 subjects underwent additional extensive clinical neurophysiological, cerebrospinal fluid, and magnetic resonance imaging evaluations.

RESULTS

No statistically significant relationships were noted between vitamin B12 levels and abnormalities on any of the measures examined.

CONCLUSIONS

This study does not indicate an important role for vitamin B12 deficiency in the neurological disease of HIV-1 infection.

Personality disorder in patients infected with HIV: a controlled study with implications for clinical care

OBJECTIVE

Previous studies of psychiatric illness in populations infected with or at risk for HIV have not included systematic evaluation for personality disorders. The authors present the first controlled study of 1) personality disorders in HIV-positive and HIV-negative homosexual men and 2) the impact of personality disorder on coping, social support, and mood in asymptomatic HIV-positive homosexual men.

METHOD

The authors studied 58 asymptomatic HIV-positive and 53 HIV-negative homosexual men living outside the high-prevalence epicenters of the AIDS epidemic. Personality disorder was assessed with a clinician-administered interview, the Structured Clinical Interview for DSM-III-R.

RESULTS

There was a significantly higher prevalence of personality disorder in the HIV-positive (33%) than in the HIV-negative (15%) subjects. In the HIV-positive subjects, those with a personality disorder (compared to those without a personality disorder) showed 1) significantly greater mood disturbance, with higher scores on the Hamilton Rating Scale for Depression, Hamilton Rating Scale for Anxiety, Profile of Mood States Total Mood Dysfunction, and the Beck Hopelessness Scale, 2) greater use of denial and helplessness when coping with the threat of AIDS, and 3) greater social conflict.

CONCLUSIONS

These findings suggest that personality disorder is common in the HIV-positive population. Compared with HIV-infected patients without a personality disorder, patients with a personality disorder may experience greater dysphoria and be more likely to cope with the threat of AIDS in a dysfunctional way. Recognition of the impact of personality disorder on coping with HIV infection is important for comprehensive, sensitive, and effective clinical care.

Psychosocial predictors of high-risk sexual behavior among HIV-negative homosexual men

Despite general awareness that human immunodeficiency virus (HIV) is transmitted sexually, people continue to engage in high-risk behavior. As part of a larger HIV project, the Coping in Health and Illness Project (CHIP), we studied the association of psychosocial factors with sexual risk taking behaviors in 53 HIV-negative gay men residing in a HIV non-epicenter. Risk behavior was measured on a 3-point scale, taking into account condom use, number of sexual partners, and type of sexual activity. Independent variables included mood, coping, history of substance dependence, social support, and acceptance of sexual orientation. Sixty percent of the subjects practiced lower-risk, 17.3% practiced moderate-risk, and 23.1% practiced high-risk behavior. We found that risk behavior was positively correlated with optimism (Life Orientation Test) (OR = 2.7; 95% CI = 1.3-5.5), anger (POMS) (OR = 2.6; 95% CI = 1.2-5.7), and negatively related to emotional control (Courtauld) (OR = 0.5; 95% CI = 0.3-1.0), and gay self-acceptance (OR = 0.35; 95% CI = 0.2-0.8). Further study is needed to determine if sexual risk-taking behavior in HIV-negative gay men will be reduced by enhancing gay self-esteem, increased understanding and adaptive use of anger, and modifying overly optimistic attitudes to increase realism.

Coping with the threat of AIDS: the role of social support

OBJECTIVE

There has been relatively little clinical research on how asymptomatic HIV-positive men cope with the threat of AIDS. The present study was intended to 1) describe the coping strategies used by asymptomatic HIV-positive homosexual men, 2) examine the relationship of coping to dysphoria and self-esteem, and 3) explore how race and social support correlate with coping.

METHOD

The study group was composed of 52 asymptomatic HIV-positive homosexual men. A group of 53 HIV-negative homosexual men was used for descriptive comparison. Data on coping, social support, dysphoria, and self-esteem came from self-report measures; depression was also determined by interviews with the Hamilton Rating Scale for Depression.

RESULTS

The authors found that 1) subjects primarily coped with the threat of AIDS by adopting a fighting spirit, reframing stress to maximize personal growth, planning a course of action, and seeking social support; 2) more helpless coping, less fighting spirit, and less personal growth were related to dysphoria and poor self-esteem, whereas denial was related to more depression, anger, and helpless coping; 3) satisfaction with one's social support networks and participation in the AIDS community were related to more healthy coping strategies (e.g., fighting spirit, personal growth); and 4) black subjects expressed more denial, more helplessness, and less social support.

CONCLUSIONS

These results suggest that health professionals should encourage more adaptive coping strategies, help patients use existing sources of positive social support, and assist patients, particularly black patients, in finding community support networks.

Neurobehavioral functioning in a nonconfounded group of asymptomatic HIV-seropositive homosexual men

Neurobehavioral functioning was tested in 34 asymptomatic HIV-seropositive and 43 HIV-seronegative male homosexual subjects without substance abuse and CNS disorders. The HIV-positive subjects exhibited mild motor slowing compared to the seronegative subjects. These differences remained after controlling for potential cofactors. Early neurobehavioral impairment in HIV infection seems limited to subclinical motor deficits and attributable to HIV rather than possible confounding factors.

Psychiatric disorders in 36 families with Wolfram syndrome

OBJECTIVE

The purpose of this study was to test the hypothesis that heterozygous carriers of the gene for the Wolfram syndrome, who constitute about 1% of the population, are predisposed to significant psychiatric illness. The Wolfram syndrome is an autosomal recessive neurodegenerative syndrome in which 25% of the individuals who are homozygous for the condition have severe psychiatric symptoms that lead to suicide attempts or psychiatric hospitalizations.

METHOD

The authors collected questionnaires, death certificates, and hospital records for blood relatives and their spouses in 36 families of individuals with the Wolfram syndrome and compared the proportion of blood relatives who had had psychiatric hospitalizations, had committed suicide, or had self-reported mental illness to the proportion of spouses with the same manifestations.

RESULTS

The proportion of blood relatives who had had psychiatric hospitalizations, had committed suicide, or had self-reported mental illness significantly exceeded the proportion of spouses with the same manifestations.

CONCLUSIONS

Since heterozygous carriers of the gene for the Wolfram syndrome are 50-fold more common among the blood relatives than among the spouses, the larger proportion among blood relatives is evidence that heterozygous carriers of the gene for the Wolfram syndrome are predisposed to significant psychiatric illness.